Mental health inpatients' and staff members' suggestions for reducing physical restraint: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Restraint has negative psychological, physical and relational consequences for mental health patients and staff. Restraint reduction interventions have been developed (e.g., "Safewards"). Limited qualitative research has explored suggestions on how to reduce physical restraint (and feasibility issues with implementing interventions) from those directly involved. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper explores mental health patients' and staff members' suggestions for reducing physical restraint, whilst addressing barriers to implementing these. Findings centred on four themes: improving communication and relationships; staffing factors; environment and space; and activities and distraction. Not all suggestions are addressed by currently available interventions. Barriers to implementation were identified, centring on a lack of time and/or resources; with the provision of more time for staff to spend with patients and implement interventions seen as essential to reducing physical restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. Fundamental issues related to understaffing, high staff turnover, and lack of time and resources need addressing in order for suggestions to be successfully implemented. ABSTRACT: Introduction Physical restraint has negative consequences for all involved, and international calls for its reduction have emerged. Some restraint reduction interventions have been developed, but limited qualitative research explores suggestions on how to reduce physical restraint (and feasibility issues with implementation) from those directly involved. Aims To explore mental health patients' and staff members' suggestions for reducing physical restraint. Methods Interviews were conducted with 13 inpatients and 22 staff members with experience of restraint on adult mental health inpatient wards in one UK National Health Service Trust. Results Findings centred on four overarching themes: improving communication and relationships between staff/patients; making staff-related changes; improving ward environments/spaces; and having more activities. However, concerns were raised around practicalities/feasibility of their implementation. Discussion Continued research is needed into best ways to reduce physical restraint, with an emphasis on feasibility/practicality and how to make time in busy ward environments. Implications for Practice Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. However, fundamental issues related to understaffing, high staff turnover and lack of time/resources need addressing in order for these suggestions to be successfully implemented.

Utility of electronystagmography in the prediction of post-operative outcome following cochlear implantation.

OBJECTIVE: To examine the relationship between pre-operative electronystagmography and videonystagmography test results and post-operative outcomes in dizziness, auditory sensitivity and speech recognition. METHODS: A retrospective chart review was performed. Auditory sensitivity and speech perception ability were tested pre- and post-operatively in 37 adult cochlear implant recipients. Auditory sensitivity was evaluated using either pure tones (for testing with earphones) or frequency-modulated warble tones (for sound-field testing). Speech perception ability was evaluated using Northwestern University Auditory Test Number 6. RESULTS: No correlation was found between pre-operative electronystagmography test results and post-operative subjective dizziness. However, pre-operative electronystagmography testing and post-operative hearing sensitivity as measured by warble tone average (dB HL) correlated significantly at six months or later after cochlear implant activation (r  ≥  -0.34, n = 34, p < 0.05). CONCLUSION: This study, which has a level of evidence 4, demonstrates that pre-operative electronystagmography testing has a potential use in predicting post-operative outcomes in hearing sensitivity following cochlear implantation. However, larger studies are needed to confirm this novel finding.

The development of a statewide continuous evaluation system for the Texas Children's Mental Health Plan: a total quality management approach.

The article presents a description of processes involved in developing and implementing a statewide continuous evaluation system for the Texas Children's Mental Health Plan (TCMHP) and quality management tools used to approach implementation challenges. Implementation issues are discussed relating to stakeholder involvement, evaluation design evolution, measurement method modification, evaluation integration, staff training, data quality control, communication of results, and use of results in decision making. A review of implementation processes suggests evaluation design and activities should be seen as constantly evolving in response to ongoing stakeholder input. Involving stakeholders in design and implementation can result in increased data quality, data-informed decision making to improve service delivery, and increased public accountability. The TCMHP evaluation system development demonstrates that quality management tools can provide a useful framework to work through design and implementation problems, and a continuous evaluation system can provide an infrastructure for meeting data needs in a managed care environment.

The management of meniscal tears in the ACL-deficient knee.

Concomitant ACL and meniscal tears pose a higher risk for premature osteoarthritis than either condition alone, especially in the active athlete. Given that the ACL-deficient knee is also at risk of initiating tears and propagating smaller tears, ACL reconstruction is advisable. The meniscal repair in the ACL-unstable knee is at a higher risk for retear. Therefore, ACL reconstruction should be considered seriously for the ACL-deficient patient with a reparable meniscal tear, as well as for the irreparable meniscal tear, as long as the patient is an otherwise appropriate reconstruction candidate. The meniscal tear with a vertical longitudinal pattern that is less than 5 mm from the meniscosynovial junction and longer than 10 mm should be repaired. Tears with rim widths greater than 5 mm may be repaired if there is evidence for vascularity. Those tears that have rim widths greater than 5 mm without evidence for significant vascularity may be repaired, but healing enhancement techniques are recommended, including rasping of synovial fringes and insertion of fibrin clot, and both the patient and the surgeon need to be aware of the significantly lower success rates. If repairs of double flap, double longitudinal, or radial tears are performed, then use of the fascia sheath coverage with fibrin clot, as proposed by Henning et al, can be considered. Partial meniscectomy is acceptable for the complex meniscal tear.

Postoperative analgesic requirements in patients undergoing arthroscopic anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) procedures are associated with significant postoperative pain and have traditionally been done on a short-stay hospitalization basis because of concerns for adequate postoperative analgesia. A retrospective chart review was performed to determine postoperative intravenous patient-controlled analgesia (PCA) morphine requirements for 80 patients who had undergone arthroscopically assisted ACL reconstruction under general anesthesia by means of a patellar tendon autograft by 1 of 2 surgeons. The mean +/- SD PCA morphine used after surgery was 20.4+/-20.0 mg. There was a wide interpatient difference in postoperative opioid consumption: the amount of PCA morphine used ranged from 0 mg to 124 mg. A comparison between the surgeons revealed that 1 surgeon had significantly longer intraoperative surgical, tourniquet, and anesthesia times; however, there was no difference in the length of recovery room stay, amount of postoperative PCA morphine used, or time to hospital discharge. Predicting which patients may benefit from short-stay hospitalization after arthroscopic ACL reconstruction may be difficult because of considerable interpatient differences in postoperative analgesic requirements.

Profile of the dentist in the oral healthcare team in countries with developed economies.

This paper confines itself to the description of the profile of a general dentist while outlining where the boundary between specialist and generalist may lie. The profile must reflect the need to recognize that oral health is part of general health. The epidemiological trends and disease variation of a country should inform the profile of the dentist. A particular tension between the provision of oral healthcare in publicly funded and private services may result in dentists practicing dentistry in different ways. However, the curriculum should equip the practitioner for either scenario. A dentist should work to standards appropriate to the needs of the individual and the population within the country's legal and ethical framework. He/she should have communication skills appropriate to ascertain the patient's beliefs and values. A dentist should work within the principles of equity and diversity and have the knowledge and clinical competence for independent general practice, including knowledge of health promotion and prevention. He/she should participate in life-long learning, which should result in a reflective practitioner whose clinical skills reflect the current evidence base, scientific breakthroughs and needs of their patients. Within the 4-5 years of a dental degree it is not possible for a student to achieve proficiency in all areas of dentistry. He/she needs to have the ability to know their own limitations and to access appropriate specialist advice for their patients while taking responsibility for the oral healthcare they provide. The dentist has the role of leader of the oral health team and, in this capacity; he/she is responsible for diagnosis, treatment planning and the quality control of the oral treatment. The dental student on graduation must therefore understand the principles and techniques which enable the dentist to act in this role. He/she should have the abilities to communicate, delegate and collaborate both within the dental team and with other health professionals, to the benefit of the patient. The profile of a dentist should encompass the points raised but will also be based upon competency lists which are published by a variety of countries and organizations. It is important that these lists are dynamic so that they are able to change in light of new evidence and technologies.

Quantitative evaluation of a home exercise program on muscle and functional capacity of patients with osteoarthritis.

Rehabilitation of patients with osteoarthritis of the knees is typically based on home exercise. These programs are believed to benefit patients and have been shown to qualitatively improve strength. The purpose of the present study was to quantify the effects of a 3-mo home exercise program on muscle function and functional capacity. The progressive program included flexibility, strength, endurance, active range of motion and functional activities. Nineteen subjects (67.4 +/- 7.5 yr) with osteoarthritis of the knees began the program, with only nine completing it. The subjects initially had significantly reduced muscle function and functional capacity. Maximal isometric strength of knee extension increased significantly at a knee flexion position of 45 degrees for hip flexion positions of 120 degrees and 60 degrees (35%); however, it failed to increase at longer muscle lengths. There were no significant improvements in hamstring strength. Maximal angular velocity improved after 3 mo of exercise (40%). Muscle endurance did not improve significantly. Although there was a slight increase in functional capacity, these data failed to demonstrate significant clinical or statistical improvement in overall function in patients after home exercise.

Effects of fixed-appliance orthodontic treatment on DMF indices.

An investigation was conducted to clarify the relationship between orthodontic treatment and caries incidence. DMF indices from 308 orthodontically treated and 305 untreated naval recruits were compared. Contrary to expectations, there was no evidence that orthodontic treatment increases caries experience. Orthodontically treated subjects had significantly fewer diseased surfaces--a difference averaging one less diseased surface per patient. Treatment status did not generally affect the number of filled surfaces. Treated subjects had more missing teeth if first premolars were considered, but untreated subjects had more missing teeth if first premolars were not considered. No significant correlation was found between caries incidence and duration of orthodontic treatment. The epidemiologic basis and significance of these findings are discussed.

The diet composition and nutritional knowledge of patients with anorexia nervosa.

A retrospective study of typical 24-h food intake was undertaken of the diets of 17 anorexia nervosa patients during the initial and the most severe phases of their illness. Patients completed a nutritional knowledge questionnaire. Patients' diets were significantly lower in energy and in all major nutrients than those of control subjects. The proportion of energy derived from protein was significantly higher, from fats significantly lower and from carbohydrates not significantly different from that of controls. The mean intake of all nutrients in the more severe phase of illness was lower in the initial phase. Intakes of calcium, retinol activity and ascorbic acid were below RDA levels in the majority of patients, but only a few reported intakes of thiamin, riboflavin and niacin equivalent below RDA values. Most patients scored higher on the nutritional knowledge questionnaire than matched controls, particularly in respect to questions concerning caloric content of food, dieting and roughage. Not all patients obtained high nutritional knowledge scores however, and 25 per cent performed less well than selected controls.

Nutritional knowledge questionnaire. Part two.

An easily administered and scored test of nutritional knowledge was published in the previous issue of the Journal (December 27, 1980). The correct answers to the questionnaire are presented here. The questionnaire has been administered to 2175 subjects. The test was shown to have high reliability and criterion validity, discriminating between educational and occupational groups. There was a significant linear relationship between nutritional knowledge score and age. It is suggested that the test may be of value in the assessment of patients requiring dietetic management.