A naturalistic inquiry of registered nurses' perspectives and expectations of psychodynamic therapeutic care in acute psychiatric inpatient facilities

Within contemporary inpatient mental health nursing practice, the psychodynamic model of care considered previously to be central to the nurse-patient relationship now seems a radical concept. It appears to exist only within primary care facilities and public health care practice settings. This naturalistic inquiry aimed to explicate mental health nurses' perspectives and expectations of providing psychodynamic therapeutic care in acute inpatient psychiatric facilities. Ten registered nurses working in acute inpatient mental health facilities were interviewed. Five themes emerged: a career for life, relating in a psychodynamic manner, swimming against the current, adopting a position of difference, and hopeful expectancy.

A Sexual Health Programme Implemented in a Psychiatric Inpatient Unit

Research has shown that people with a mental illness are an at-risk group for sexually transmitted infections. A programme for preventing risk behaviours for sexually transmitted infections among people with psychiatric disorder was designed and implemented by mental health occupational therapists. This programme used an interactive didactic approach to provide education and awareness of sexual health issues to acute psychiatric inpatients. Twenty-four participants completed a sexual health questionnaire, which was designed for this study, both before and after attending the programme. They had a higher than expected knowledge of sexually transmitted infections and safe sex practices at pre-test. The education programme resulted in a statistically significant but modest increase in sexual health knowledge. These findings indicate that there are benefits in providing sexual health education to clients with a mental illness. Further programme development should be directed towards sexual health decision-making and behaviour change.

Outcomes following inpatient rehabilitation : a seven year perspective

Introduction: Improving physical and cognitive functioning is a key objective of multi-disciplinary inpatient geriatric rehabilitation. Outcomes relevant to minimum functional ability required for older adults to successfully participate in the community have been reported. However, there has been little investigation reporting outcomes of older inpatients receiving multi-disciplinary rehabilitation being discharged home from geriatric rehabilitation units. This study aims to investigate characteristics and physical and cognitive outcomes of this cohort. Method: The Princess Alexandra Hospital Geriatric and Rehabilitation Unit is the largest rehabilitation unit in Queensland. Multidisciplinary health professionals enter admission and discharge functional and clinical outcomes along with demographic information into a purpose designed database for all patients. Data collected between 2005 and 2011 was analysed using descriptive statistics. Results: During the seven-year period, 4120 patients were admitted for rehabilitation; 2126 (52%) were female, mean age of 74 years (Standard Deviation 14). Primary reasons for admission were for reconditioning post medical illness or surgical admission (n = 1285, 31%), and 30% (n = 1233) admitted for orthopaedic reasons. Of these orthopaedic admissions, 6.6% (n = 82) were for elective surgery, and 46% (n = 565) were for fractured neck-of-femurs. 76% (n = 3130) of patients were discharged home, 13% (n = 552) to residential care facilities and 10% (n = 430) were discharged to an alternative hospital setting or passed away during their admission. Mean length of stay was 44 days (SD 39) Preliminary analysis of FIM outcomes shows a mean motor score of 53 (SD = 19) on admission which significantly improved to 71 (SD = 18) by discharge. There was no change on FIM cognitive score (28 (SD7) vs 29 (SD 6). Conclusion: Geriatric patients have significant functional limitations even on discharge from inpatient rehabilitation; though overall cognition is relatively intact. Orthopaedic conditions and general deconditioning from medical/surgical admissions are the main reasons for admission. The majority of people receiving rehabilitation are discharged home.

Outcomes following inpatient rehabilitation of lower limb amputees

Introduction: Lower-limb amputations are a serious adverse consequence of lifestyle related chronic conditions and a serious concern among the aging population in Australia. Lower limb amputations have severe personal, social and economic impacts on the individual, healthcare system and broader community. This study aimed to address a critical gap in the research literature by investigating the physical functioning and social characteristics of lower limb amputees at discharge from tertiary hospital inpatient rehabilitation. Method: A cohort study was implemented among patients with lower limb amputations admitted to a Geriatric Assessment and Rehabilitation Unit for rehabilitation at a tertiary hospital. Conventional descriptive statistics were used to examine patient demographic, physical functioning and social living outcomes recorded for patients admitted between 2005 and 2011. Results: A total of 423 admissions occurred during the study period, 313 (74%) were male. This sample included admissions for left (n = 189, 45%), right (n = 220, 52%) and bilateral (n = 14, 3%) lower limb amputations, with 15 (3%) patients dying whilst an inpatient. The mean (standard deviation) age was 65 (13.9) years. Amputations attributed to vascular causes accounted for 333 (78%) admissions; 65 (15%) of these had previously had an amputation. The mean (SD) length of stay in the rehabilitation unit was 56 (42) days. Prior to this admission, 123 (29%) patients were living alone, 289 (68%) were living with another and 3 (0.7%) were living in residential care. Following this amputation related admission, 89 (21%) patients did not return to their prior living situation. Of those admitted, 187 (44%) patients were discharged with a lower limb prosthesis. Conclusion: The clinical group is predominately older adults. The ratio of males to females was approximately 3:1. Over half did not return to walking and many were not able to return to their prior accommodation. However, few patients died during their admission.

Referral patterns and proximity to palliative care inpatient services by level of socio-economic disadvantage : a national study using spatial analysis

Background: A range of health outcomes at a population level are related to differences in levels of social disadvantage. Understanding the impact of any such differences in palliative care is important. The aim of this study was to assess, by level of socio-economic disadvantage, referral patterns to specialist palliative care and proximity to inpatient services. Methods: All inpatient and community palliative care services nationally were geocoded (using postcode) to one nationally standardised measure of socio-economic deprivation – Socio-Economic Index for Areas (SEIFA; 2006 census data). Referral to palliative care services and characteristics of referrals were described through data collected routinely at clinical encounters. Inpatient location was measured from each person’s home postcode, and stratified by socio-economic disadvantage. Results: This study covered July – December 2009 with data from 10,064 patients. People from the highest SEIFA group (least disadvantaged) were significantly less likely to be referred to a specialist palliative care service, likely to be referred closer to death and to have more episodes of inpatient care for longer time. Physical proximity of a person’s home to inpatient care showed a gradient with increasing distance by decreasing levels of socio-economic advantage. Conclusion: These data suggest that a simple relationship of low socioeconomic status and poor access to a referral-based specialty such as palliative care does not exist. Different patterns of referral and hence different patterns of care emerge.

P.I.C.U., H.D.U., A.O.A. What treatment do we provide?: Current descriptions of the function of intensive care for inpatient Psychiatric Health Care.

Purpose – This paper adds to growing research of psychiatric intensive care units (PICU) by recounting descriptions of psychiatric intensive care settings and discusses the perceptions held by nurses of the organisational interfaces, arrangements and provisions of care in these settings. Design/methodology/approach – Data gathered from focus groups held with nurses from two PICUs was used to establish terminology, defining attributes, related concepts, antecedents, values, processes and concepts related to current practices. A literature search was conducted to permit a review of the conceptual arrangements and contemporary understanding of intensive care for people experiencing acute psychiatric illness based on the perspectives held by the nurses from the focus groups. Findings – Dissonance between service needs and the needs and management of individual patients overshadow strategies to implement comprehensive recovery-oriented approaches. Three factors are reported in this paper that influence standards and procedural practice in PICU; organisational structures; physical structures; and subtype nomenclature. Practical implications – Acute inpatient care is an important part of a comprehensive approach to mental health services. Commonly intensive acute care is delivered in specialised wards or units co-located with acute mental health inpatient units mostly known as PICU. Evidence of the most effective treatment and approaches in intensive care settings that support comprehensive recovery for improved outcomes is nascent. Originality/value – Current descriptions from nurses substantiate wide variations in the provisions, design and classifications of psychiatric intensive care. Idiosyncratic and localised conceptions of psychiatric intensive care are not adequately entailing effective treatment and methods in support of recovery principles for improved and comprehensive outcomes. The authors suggest that more concrete descriptions, guidelines, training and policies for provision of intensive psychiatric health care encompassing the perspective of nursing professionals, would reinforce conceptual construction and thus optimum treatments within a comprehensive, recovery-oriented approach to mental health services.

Reflections on tomorrow’s menu : evidence for inpatient meal preferences at a large tertiary public hospital

There are limited studies that describe patient meal preferences in hospital; however this data is critical to develop menus that address satisfaction and nutrition whilst balancing resources. This quality study aimed to determine preferences for meals and snacks to inform a comprehensive menu revision in a large (929 bed) tertiary public hospital. The method was based on Vivanti et al. (2008) with data collected by two final year dietetic students. The first survey comprised 72 questions, achieved a response rate of 68% (n = 192), with the second more focused at 47 questions achieving a higher response rate of 93% (n = 212). Findings showed over half the patients reporting poor or less than normal appetite, 20% describing taste issues, over a third with a LOS >7 days, a third with a MST _ 2 and less than half eating only from the general menu. Soup then toast was most frequently reported as eaten at home when unwell, and whilst most reported not missing any foods when in hospital (25%), steak was most commonly missed. Hot breakfasts were desired by the majority (63%), with over half preferring toast (even if cold). In relation to snacks, nearly half (48%) wanted something more substantial than tea/coffee/biscuits, with sandwiches (54%) and soup (33%) being suggested. Sandwiches at the evening meal were not popular (6%). Difficulties with using cutlery and meal size selection were identified as issues. Findings from this study had high utility and supported a collaborative and evidenced based approach to a successful major menu change for the hospital.

Functional independence following subacute inpatient rehabilitation was not affected by age among older patients recovering from cardiac-related hospital admissions

Introduction Older people recovering from cardiac events requiring an acute hospital admission may experience a decline in physical function limiting their ability to return home to their previous accommodation. Subacute inpatient rehabilitation therapies have potential to assist recovery of physical functioning. However, it is unknown whether age influences the length of stay or physical functioning at discharge from subacute inpatient rehabilitation for this population. Objectives This study examined the outcomes of a cohort of older patients recovering from a cardiac event requiring hospitalisation to investigate the association between age and physical function at discharge, as well as age and length of rehabilitation stay. Methods Participants included 145 consecutive inpatient admissions to a subacute geriatric assessment and rehabilitation unit with a cardiac condition as their primary reason for hospital admission. Participants were required to complete a multi-disciplinary physical functioning assessment within 72 hours of admission to the unit, and again within 72 hours prior to discharge from the unit. The primary outcome measure was the Functional Independence Measure motor score. Demographic and clinical information, including length of stay and discharge destination, were also recorded. Results A total n=126 (87%) participants, with a mean (standard deviation) age of 79 (10) years, had both assessments completed and were included in analyses. Participants who had passed away (n=4, 3%), or did not have both assessments completed per protocol were excluded from analyses. Discharge destinations included home (n=101, 80%), residential aged care (n=17, 13%) and another hospital (n=8, 6%). The (median, interquartile range) Functional Independence Measure motor score was higher at discharge (79, 71 to 84) than admission (61, 48 to 71); z=7.75 p<0.001. Age was not associated with Functional Independence Measure motor score at discharge (t= -0.18, p=0.86), or length of stay in the rehabilitation unit (t= -0.52, 0.60). Conclusion Any perception that age may be associated with longer lengths of stay and reduced physical function outcomes among patients with cardiac conditions admitted for subacute inpatient rehabilitation for older adults is not supported data from this investigation. Older age should not be considered a disincentive when considering the suitability of patients with cardiac diagnoses for this type of inpatient rehabilitation or their potential physical functioning outcome.

Inpatient facial expression recognition with SMS alert

Facial expression recognition (FER) has been dramatically developed in recent years, thanks to the advancements in related fields, especially machine learning, image processing and human recognition. Accordingly, the impact and potential usage of automatic FER have been growing in a wide range of applications, including human-computer interaction, robot control and driver state surveillance. However, to date, robust recognition of facial expressions from images and videos is still a challenging task due to the difficulty in accurately extracting the useful emotional features. These features are often represented in different forms, such as static, dynamic, point-based geometric or region-based appearance. Facial movement features, which include feature position and shape changes, are generally caused by the movements of facial elements and muscles during the course of emotional expression. The facial elements, especially key elements, will constantly change their positions when subjects are expressing emotions. As a consequence, the same feature in different images usually has different positions. In some cases, the shape of the feature may also be distorted due to the subtle facial muscle movements. Therefore, for any feature representing a certain emotion, the geometric-based position and appearance-based shape normally changes from one image to another image in image databases, as well as in videos. This kind of movement features represents a rich pool of both static and dynamic characteristics of expressions, which playa critical role for FER. The vast majority of the past work on FER does not take the dynamics of facial expressions into account. Some efforts have been made on capturing and utilizing facial movement features, and almost all of them are static based. These efforts try to adopt either geometric features of the tracked facial points, or appearance difference between holistic facial regions in consequent frames or texture and motion changes in loca- facial regions. Although achieved promising results, these approaches often require accurate location and tracking of facial points, which remains problematic.

Delirium in advanced cancer : screening for the incidence on admission to an inpatient hospice unit

Background Delirium is a common underdiagnosed condition in advanced cancer leading to increased distress, morbidity, and mortality. Screening improves detection but there is no consensus as to the best screening tool to use with patients with advanced cancer. Objective To determine the incidence of delirium in patients with advanced cancer within 72 hours of admission to an acute inpatient hospice using clinical judgement and validated screening tools. Method One hundred consecutive patients with advanced cancer were invited to be screened for delirium within 72 hours of admission to an acute inpatient hospice unit. Two validated tools were used, the Delirium Rating Scale-Revised 98 (DRS-R-98) and the Confusion Assessment Method (CAM) shortened diagnostic algorithm. These results were compared with clinical assessment by review of medical charts. Results Of 100 consecutive admissions 51 participated and of these 22 (43.1%) screened positive for delirium with CAM and/or DRS-R-98 compared to 15 (29.4%) by clinical assessment. Eleven (21.6%) were identified as hypoactive delirium and 5 (9.8%) as subsyndromal delirium. Conclusion This study confirms that delirium is a common condition in patients with advanced cancer.While there remains a lack of consensus regarding the choice of delirium screening tool this study supports theCAMas being appropriate. Further research may determine the optimal screening tool for delirium enabling the development of best practice clinical guidelines for routinemedical practice.

Prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility: a cross-sectional prevalence study

Background Australian subacute inpatient rehabilitation facilities face significant challenges from the ageing population and the increasing burden of chronic disease. Foot disease complications are a negative consequence of many chronic diseases. With the rapid expansion of subacute rehabilitation inpatient services, it seems imperative to investigate the prevalence of foot disease and foot disease risk factors in this population. The primary aim of this cross-sectional study was to determine the prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility. Methods Eligible participants were all adults admitted at least overnight into a large Australian subacute inpatient rehabilitation facility over two different four week periods. Consenting participants underwent a short non-invasive foot examination by a podiatrist utilising the validated Queensland Health High Risk Foot Form to collect data on age, sex, medical co-morbidity history, foot disease risk factor history and clinically diagnosed foot disease complications and foot disease risk factors. Descriptive statistics were used to determine the prevalence of clinically diagnosed foot disease complications, foot disease risk factors and groups of foot disease risk factors. Logistic regression analyses were used to investigate any associations between defined explanatory variables and appropriate foot disease outcome variables. Results Overall, 85 (88%) of 97 people admitted to the facility during the study periods consented; mean age 80 (±9) years and 71% were female. The prevalence (95% confidence interval) of participants with active foot disease was 11.8% (6.3 – 20.5), 32.9% (23.9 – 43.5) had multiple foot disease risk factors, and overall, 56.5% (45.9 – 66.5) had at least one foot disease risk factor. A self-reported history of peripheral neuropathy diagnosis was independently associated with having multiple foot disease risk factors (OR 13.504, p = 0.001). Conclusion This study highlights the potential significance of the burden of foot disease in subacute inpatient rehabilitation facilities. One in eight subacute inpatients were admitted with active foot disease and one in two with at least one foot disease risk factor in this study. It is recommended that further multi-site studies and management guidelines are required to address the foot disease burden in subacute inpatient rehabilitation facilities. Keywords: Subacute; Inpatient; Foot; Complication; Prevalence

How different are complications that affect the older adult inpatient?

Objective: The incidence and cost of complications occurring in older and younger inpatients were compared. Design: Secondary analysis of hospital-recorded diagnosis and costs for multiday-stay inpatients in 68 public hospitals in two Australian states. Main outcome measures: A complication is defined as a hospital-acquired diagnosis that required additional treatment. The Australian Classification of Hospital-Acquired Diagnoses system is used to identify these complications. Results: Inpatients aged >70 years have a 10.9% complication rate, which is not substantially different from the 10.89% complication rate found in patients aged <70 years. Examination of the probability by single years, however, showed that the peak incidence associated with the neonatal period and childbirth is balanced by rates of up to 20% in patients >80 years. Examining the adult patient population (40–70 years), we found that while some common complications are not age specific (electrolyte disorders and cardiac arrhythmias), others (urinary tract and lower respiratory tract infections) are more common in the older adult inpatient. Conclusion: For inpatients aged >70 years, the risks of complications increase. The incidence of hospital-acquired diagnoses in older adults differs significantly from incidence rates found in younger cohorts. Urinary tract infection and alteration to mental state are more common in older adult inpatients. Surprisingly, these complexities do not result in additional costs when compared with costs for the same complications in younger adults. Greater awareness of these differing patterns will allow patient safety efforts for older patients to focus on complications with the highest incidence and cost.