Pain Assessment and Pharmacologic Management

Background The Internet and telecommunications technologies contribute to national health care system infrastructures and extend global health care services markets. The Cuban national health care system offers a model to show how a national information portal can contribute to system integration, including research, education, and service delivery as well as international trade in products and services.Objective The objectives of this paper are (1) to present the context of the Cuban national health care system since the revolution in 1959, (2) to identify virtual institutional infrastructures of the system associated with the Cuban National Health Care Telecommunications Network and Portal (INFOMED), and (3) to show how they contribute to Cuban trade in international health care service markets.Methods Qualitative case research methods were used to identify the integrated virtual infrastructure of INFOMED and to show how it reflects socialist ideology. Virtual institutional infrastructures include electronic medical and information services and the structure of national networks linking such services.Results Analysis of INFOMED infrastructures shows integration of health care information, research, and education as well as the interface between Cuban national information networks and the global Internet. System control mechanisms include horizontal integration and coordination through virtual institutions linked through INFOMED, and vertical control through the Ministry of Public Health and the government hierarchy. Telecommunications technology serves as a foundation for a dual market structure differentiating domestic services from international trade.Conclusions INFOMED is a model of interest for integrating health care information, research, education, and services. The virtual infrastructures linked through INFOMED support the diffusion of Cuban health care products and services in global markets. Transferability of this model is contingent upon ideology and interpretation of values such as individual intellectual property and confidentiality of individual health information. Future research should focus on examination of these issues and their consequences for global markets in health care.

Enhancing communication between family members and health care team members within the pediatric intensive care unit (PICU) is a national clinical and research priority. Poor communication can increase patients’ length of stay, hospital costs, and the likelihood of delivering value-discordant care. Family members of PICU patients report numerous communication barriers, such as poor access to members of the health care team, inadequate care coordination, and infrequent clinician-initiated discussions. Despite these rec-ognized barriers, there is a salient lack of interventions to support communication between PICU family members and members of the health care team.To address this issue, the investigators studied the feasibility of implementing a navigator-based communication intervention called PICU Supports and assessed the responses of family members and clinicians to that intervention. PICU Supports comprises specific intervention components for the navigator, patients’ family members, and health care providers. The navigator’s intervention components included a rigorous navigator- training protocol; a standardized meeting-frequency protocol for the navigators, the family members, and the health care team members; tailored PICU-transition support for the family members; and a post-PICU discharge check-in. Family members’ intervention components included a parent-developed PICU information handbook, a bedside communication log, and bereavement packets for family members of decedents. Each week, members of the health care team reviewed a navigator-prepared document that included relevant psychosocial information and identified family needs. The investigators conducted this study at a university-based, tertiary-care children’s hospital with 76 PICU beds.Family members completed the same survey at enrollment, discharge, and 3 to 5 weeks after discharge. Some family members participated in an optional 1-on-1 semistructured audio interview at discharge. Thirty-five family members enrolled in the study. Family members reported that PICU Supports improved communication with members of the health care team, although no family members requested a family meeting. Opinions on the PICU handbook were mixed, as some family members were too overwhelmed to read the material. Family members and health care team members rarely used the bedside communication log. Overall, the health care team members found PICU Supports to be valuable, but they recommended improving the navigator’s integration with members of the health care team. The investigators concluded that PICU Supports was feasible to implement and research and that further refinement and testing of the intervention are warranted.Kelly N. Michelson, MD, MPH, lead author of the study, cites her prior research and personal clinical experiences as the motivation for the study. Originally, Dr Michelson had planned to develop a standardized approach to address end-of-life decision-making in the PICU. However, her preliminary work “highlighted the individual nuances and contextual issues that often influence decision-making” in the PICU. So rather than creating a standardized intervention, Dr Michelson concluded that critical care providers may benefit from “a malleable approach to decision-making that can easily be adapted to the individual needs of each family, patient, and situation.” She adds, “given the successful implementation of navigators in other settings, introducing a navigator into the PICU setting to individualize decision-making and psychosocial supports seems like the next natural step.”To assemble the team necessary to develop PICU Supports, Dr Michelson used “stakeholder-engaged comparative effectiveness research” as a guiding framework. “We identified 3 groups of stakeholders: parents of previously critically ill children, clinicians who care for and administrators who oversee the care of critically ill children, and clinical trials research experts.” The clinician stakeholder group included representatives from various medical specialties, nursing, social work, palliative care, spiritual care, and administration. Together, these 3 stakeholder groups developed the PICU Supports intervention and helped design the study.Dr Michelson contends that the “value of having such a large, multifaceted group is reflected in the comprehensive nature of the PICU Supports intervention,” and encourages “investigators to make that extra effort to engage” multidisciplinary groups during research. However, she admits that “coordinating such a large group presented some challenges.” Dr Michelson recalls difficulty scheduling meetings and “finding ways to keep the larger team engaged when there were no direct activities for them to comment on or participate in.” Nevertheless, she concludes: “I feel incredibly privileged to have had the opportunity to work with such a diverse and dedicated group of people.”Dr Michelson believes that although “we are still trying to determine the best way to support parents and families of critically ill children … the best approaches will ultimately require a team effort,” as many disciplines and professions influence the family experience within the PICU. She anticipates that “this work will help pediatric critical care teams develop strategies for bringing those group efforts together.” Dr Michelson humbly acknowledges that PICU Supports is “only one approach” that can be used to support families and clinicians and “the impact of this approach is still yet to be determined. But the idea that we need to find better, more efficient ways to individualize care for families, knowing the complexity of the care team and clinical challenges facing those in the PICU, is fundamental.”As clinicians and scientists conduct more research, prominent questions may arise. For example, Dr Michelson shares, “we were surprised to see so few parents interested in having family meetings because many experts tout their value.” She further acknowledges that research within the PICU can be difficult because “it serves a very heterogeneous population with different support needs.” As such, studies may focus on “very specific populations,” which “limits generalizability.” Alternatively, investigators may “create an option that could be adapted to different populations to maximize generalizability and scalability…. Perhaps, the best approach lies somewhere between those two extremes.”This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Kelly N. Michelson, MD, MPH, has been a pediatric critical care specialist for more than 15 years. However, another of her life’s passions is dance: “Dancing and the human body were always my passions.” In fact, she focused on dance between completing her undergraduate degree and entering medical school. “My dance career allowed me to travel nationally and internationally and to fulfill one of my childhood dreams. But I never let go of my dream to become a physician.”During her pediatric and critical care training, Dr Michelson “was drawn to the interesting pathophysiology and fast pace in the PICU.” She “was also amazed by the intense relationships that clinicians develop with parents of critically ill patients … [who are] facing their worst nightmare.” She says that these formative experiences “drove me to do the research that I do now.” Even today, Dr Michelson’s experiences as a pediatric intensivist remain central: “[they] shape how I think about supporting families of critically ill children and about the questions I try to address in my research.”

Encyclopedia of Family Health

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

AimThis study aims to explore how nursing services were managed and provided in intensive care units during the COVID‐19 pandemic and clarify the management lessons learned.BackgroundThe surge in the number of patients with COVID‐19 worldwide and the unpredictability of new variants mean the voices of nurse managers who participated in fighting the pandemic in intensive care units must be considered. Health care systems need specific plans to face similar future crises.MethodThis is a descriptive, qualitative, narrative study using indirect content analysis.ResultsWe analysed 37 intensive care unit nurse managers' reflections on lessons learned from the COVID‐19 pandemic. Four themes were extracted: restructuring organisations' resources, issues with family‐centred care, education and training and policy reforms.ConclusionsPromising strategies for Emirati intensive care units in planning for responses to future crises include maximizing organisation resources, boosting family‐centred care, providing in‐service training for nurses and policy reform.Implications for Nursing ManagementOur findings will support health care leaders, educators, policymakers and researchers to improve the management of similar pandemic situations. This study presents fundamental data concerning the subjective experiences of intensive care unit nurse managers. These experiences may inform development of multi‐dimensional strategies including: ensuring the adequacy of projected supplies, space and nursing workforce; establishing communication protocols; and reforming existing policies.

Academic Emergency MedicineVolume 5, Issue 3 p. 269-271 Free Access More on Assessing Outcomes of Emergency Care Alexander K. Ommaya ScD, MA, Corresponding Author Alexander K. Ommaya ScD, MA Agency for Health Care Policy and Research, Rockville, MD Agency for Health Care Policy and Research, 2101 East Jefferson Street, Rockville, MD 20852. Fax: 301–443–0251; e-mail: aommaya@po4.ahcpr.govSearch for more papers by this authorLisa Simpson MB, BCh, Lisa Simpson MB, BCh Agency for Health Care Policy and Research, Rockville, MDSearch for more papers by this authorElinor Walker, Elinor Walker Agency for Health Care Policy and Research, Rockville, MDSearch for more papers by this author Alexander K. Ommaya ScD, MA, Corresponding Author Alexander K. Ommaya ScD, MA Agency for Health Care Policy and Research, Rockville, MD Agency for Health Care Policy and Research, 2101 East Jefferson Street, Rockville, MD 20852. Fax: 301–443–0251; e-mail: aommaya@po4.ahcpr.govSearch for more papers by this authorLisa Simpson MB, BCh, Lisa Simpson MB, BCh Agency for Health Care Policy and Research, Rockville, MDSearch for more papers by this authorElinor Walker, Elinor Walker Agency for Health Care Policy and Research, Rockville, MDSearch for more papers by this author First published: 28 June 2008 https://doi.org/10.1111/j.1553-2712.1998.tb02628.xCitations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume5, Issue3March 1998Pages 269-271 ReferencesRelatedInformation

Management of postpartum perineal pain is essential because untreated pain can interfere with the motherhood experience and might result in various complications. The study aimed to assess postpartum perineal and postpartum pain intensity, pharmacological management and maternal complications after normal vaginal delivery. A prospective observational study was conducted in Obstetrics and Gynaecology among 300 women who underwent normal vaginal delivery. The severity and intensity of the perineal pain in subjects were relatively high, i.e. severe on Day 1, moderate to mild pain on Day 2 and mild pain on Day 3. The overall postpartum pain was mild on all 3 d. Non-steroidal anti-inflammatory drugs (NSAIDs) and analgesic combination drugs were prescribed the most for pain management, which significantly impacted pain reduction. All participants involved in the study had a postpartum haemorrhage and was the most common complication. The study concludes that there was a significant reduction in the overall intensity of pain from Day 1 to Day 3. IMPACT STATEMENT What is already known on this subject? Vaginal delivery is a multidimensional process that causes inflammation of cervical tissue and tears in the birth canal, leading to pain perception. Previous studies reported increased pain intensity on the first day after childbirth and a gradual decrease as the days pass. What do the results of this study add? The well-accepted pain scales, such as faces rating scale (FRS) and verbal numeric scale (VNS) were appropriate for assessing the intensity of perineal pain. Self-developed and validated postpartum pain assessment questionnaire (PPAQ) was beneficial for the assessment of postpartum pain. NSAIDs and analgesics combination was effective in managing the pain. What are the implications of these findings for clinical practice and/future research? Accurate pain assessment is essential for humanising patient care since it helps make a correct plan for required intervention, and its evaluation can help provide appropriate medications and reduce complications. Self-developed and validated PPAQ is easy to use and can be used in clinical studies to assess postpartum pain.

The aim of this study was to identify which pain assessment tools are used in clinical practice. The recognition and assessment of pain is essential to ensure appropriate pain management. There are a number of pain assessment scales and tools available for healthcare professionals to assist patients describe and rate their pain intensity and to help clinicians assess pain, observe behaviours associated with pain and monitor the effectiveness of pain interventions. A short self-administered questionnaire survey of nursing staff was completed by nurses attending a pain management study day at the university and a pain meeting completed the questionnaire. Although no one pain assessment rating scale was used across all the healthcare organisations represented all the nurses indicated that they used one or a number of self-report pain assessment scales in their clinical practice. The Numerical Rating Scales and the Verbal Descriptor Scale were used by the majority of nurses. The use of behavioural pain assessment scales, such as the Abbey pain assessment scale, were used by 42% of the respondents This small survey indicates that verbal self-report pain assessment scales appear to be embedded into clinical practice, but the use of observational pain assessment tools for people with communication difficulties (including dementia) have not been adopted by the majority of organisations represented. This suggests that there is a need toincrease their use in everyday clinical practice. It is important that clinical staff are aware which pain assessment scale is used in their organisation to ensure consistency. Where different pain assessment scales are used for individual patients the scale chosen for an individual patient needs to be documented and communicated to all members of the health care team to ensure consistent use.

Communication: Communication best practices (e.g., teaching goals of care conversations/

What Health Care is Learning From the Aviation Industry

Opiate-Induced Nausea and Vomiting: What Is the Challenge?

<b>MRC-NIHR Efficacy and Mechanism Evaluation (EME) Programme Logic Model</b><br /> <br /> Juliana Callaghan&sup1;, Robert Gray&sup1;, Louise Jones&sup2;, Adam Lockwood&sup1;, Danny McAuley&sup3;, John Norrie⁴, Danielle Preedy&sup1;, Sarah Thomas&sup1;, Insa Wemheuer&sup1;<br /> &sup1;National Institute for Health and Care Research (NIHR), School of Healthcare Enterprise and Innovation, University of Southampton, &sup2;UK Research and Innovation (UKRI) Medical Research Council (MRC), &sup3;Queen's University of Belfast, ⁴The University of Edinburgh<br /> February 2023<br /> <br /> The EME Programme is a partnership between the Medical Research Council (MRC) and the National Institute for Health and Care Research (NIHR). The aim of the programme is to improve the health and wealth of the nation by funding clinical efficacy studies that test if an intervention or technology which has shown early promise in patients works as expected in a well-defined group of patients. This may include using such studies to understand treatment mechanisms. The programme plays a key role in translational research by testing novel or repurposed interventions/technologies and determining whether their development should progress to later-phase clinical trials, or inform new earlier-stage research. <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/efficacy-and-mechanism-evaluation.htm">More information can be found on the programme page on the NIHR website</a>.<br /> <br /> A logic model is a graphical way to show how an activity, programme or intervention is expected to work and bring about the benefits and changes it intends to achieve. By summarising the core elements, a logic model can then be used to support programme planning, implementation and evaluation. NIHR logic models represent in a linear flow diagram the key activities, outputs, outcomes and impacts of each funding programme as a series of logical steps.<br /> <br /> <br /> <br /> <b>Inputs</b><br /> The first step outlined in the logic model focuses on ‘inputs’, i.e., the resources needed to undertake programme activities. The inputs for the EME Programme are: <ul> <li>MRC and NIHR funding</li> <li>funding from the devolved nations</li> <li>NIHR coordinating centre resources</li> <li>stakeholder time</li> <li>the existing UK research infrastructure in terms of expertise, capacity and funding</li> </ul> <br /> <br /> <b>Activities&nbsp; </b><br /> Inputs feed into activities, the second stage of the logic model. Activities are the actions that NIHR and the funded research community undertake to help achieve the programme’s aims and objectives. Together, inputs and activities represent NIHR’s planned work.<br /> <br /> The initial focus for the programme is identification of key research questions, issues and programme priorities. A NIHR team develops targeted <a href="https://www.nihr.ac.uk/researchers/funding-opportunities/">funding opportunities</a> and activities through horizon scanning and collaboration with key stakeholders to stimulate activity or applications in an area of strategic priority. The programme also invites researcher-led proposals, which enables research into investigator-driven areas. All submitted project proposals are reviewed by harnessing detailed feedback from experts, including academics and other professional experts (for example, clinical staff and health care professionals) as well as patients, carers, service users, specific communities and/or members of the general public. A panel recommends high-quality research projects for funding according to set criteria.<br /> <br /> Funded projects are then actively monitored by a NIHR team that supports the project by providing advice and expertise regarding, for example, risks, appropriate methodologies, stakeholder management or patient and public involvement and engagement.<br /> <br /> NIHR support also includes guidance on the dissemination of research outputs. NIHR supports transparent research management and publication of knowledge, with information on and results of projects being openly accessible via the NIHR <a href="https://fundingawards.nihr.ac.uk/">website</a> and <a href="https://www.journalslibrary.nihr.ac.uk/#/">NIHR Journals Library</a> that hosts the <a href="https://www.journalslibrary.nihr.ac.uk/EME/#/">NIHR EME journal</a>.<br /> <br /> Further, the EME Programme’s application and funding process ensures that funded research projects test interventions/technologies independently and rigorously for efficacy, as well as mechanistic insight. The research process often includes collecting samples, for example in the form of biobanks. By funding projects that follow on from clinical studies supported by the NIHR or other funders, the programme also actively supports researchers in reusing data or samples.<br /> <br /> The EME Programme also builds research capacity through initiatives to broaden, strengthen and upskill the translational research community. &nbsp;For example, the programme provides tailored funding opportunities and activities to support the development of early-career clinical trialists and to stimulate cross-sector and international collaboration.<br /> <br /> <br /> <b>Outputs </b><br /> The next step of the flow diagram focuses on the range of ‘outputs’ that result directly from the undertaken activities. For the EME Programme, these include: <ul> <li>academic outputs such as articles in the <a href="https://www.journalslibrary.nihr.ac.uk/eme/#/">NIHR EME journal</a> and other peer-reviewed journals,</li> <li>communications tailored to key audiences (e.g. patient groups, industry, policy-makers and health-care professionals)</li> <li>study data from the testing of interventions/technologies</li> <li>samples collected as part of the research</li> <li>new intellectual property (IP) being registered as a result of the funded research</li> </ul> <br /> <br /> <br /> <b>Cross-cutting activities</b><br /> Some activities that enable the intended change cut across several steps of the logic model: <ul> <li>Stakeholder collaboration: the programme works closely with stakeholders such as other funders, industrial partners, patients, carers, service users, specific communities and the public to support translational research across the ecosystem</li> <li>Targeted knowledge exchange and dissemination takes place across the project lifecycle</li> <li>Activities, outputs and outcomes produced through research contribute to an increasing pool of knowledge which feeds into and influences both the identification of new questions and methods for answering those questions.</li> </ul> <br /> <br /> <b>Outcomes</b><br /> Outcomes are the changes or benefits the programme intends to produce through its activities and by funding a portfolio of research. Due to the programme’s position on the translational pathway and its role being to inform further research, outcomes are typically seen on a short- to medium-term.<br /> <br /> <b>Scientific advancements</b><br /> Research outputs document and disseminate the scientific advancements made by NIHR-funded projects. Scientific advancements include improved knowledge of the potential health benefits of interventions/ technologies and their mechanisms of action. They also include methodological advancements in the field of clinical trials and mechanistic studies. Improved knowledge can also stimulate further research. For research funded by the EME Programme, this can occur in both directions of the research and development pathway, with, for example, research teams continuing to study the tested interventions/ technologies in later-phase clinical trials or the results stimulating further earlier stage research. This all contributes to the UK’s world-leading reputation in delivering translational health research.<br /> <br /> <b>More efficient and effective health research</b><br /> Developing sample banks and establishing the effectiveness of interventions and technologies results in more efficient and effective health research. For example, trials showing ‘no effect’ of the tested intervention/ technology leads to researchers switching to other approaches, which reduces waste in UK scientific research and increases the efficiency of investments in Phase II and Phase III trials. Involving patients, carers, service users, specific communities and/or members of the general public in all steps of the research process results in increased relevance of research to patient and public need. Increased international and cross-sector collaboration in research enables aligned and complementary research aims to be addressed and optimises delivery of the translational research ecosystem.<br /> <br /> <b>De-risking future investment in research</b><br /> In the medium-term, research funded by the EME programme is expected to result in the de-risking of future investment in research by establishing which interventions and technologies are effective, how they work, and progressing those that are effective for practical use as measured on the Technology Readiness Level (TRL) scale. Increased knowledge around interventions/technologies and their mechanisms of action can also enable increased investment in associated development.<br /> <br /> <b>Enhanced research capacity </b><br /> Research projects funded by the EME Programme also contribute to enhancing research capacity in the form of training and skill-building of project team members through specialist skills and career progression, for example. Working on EME-funded projects is also expected to improve understanding of and interest in translational research for both researchers and trial sites. Collectively, this is expected to result in increased trial activity, capacity and networks, which in turn contributes to international recognition of the UK’s research capabilities.<br /> <br /> <br /> <b>Impacts</b><br /> Impacts, or long-term outcomes, are the anticipated broader (direct and indirect) changes or benefits for organisations, communities, systems and wider society expected to result from the programme's contribution via its activities and portfolio of funded research. These are expected to become apparent in approximately 10-25 years.&nbsp;<br /> For the EME Programme, the overarching long-term benefits are further research and the development of new and repurposed interventions and technologies. These contribute to health benefits through new or repurposed interventions and technologies; improved wealth of the nation through job creation; more effective and efficient use of healthcare resources through targeted investment into promising interventions and technologies; and ultimately, to improving the health and wealth of the nation.&nbsp;<br /> <br /> <br /> <b>Contributions and acknowledgements</b><br /> The NIHR supports the principles of open research, including full and appropriate recognition of the many varied contributions to the creation of knowledge. To support this, we use the<a href="https://credit.niso.org/"> CRediT taxonomy</a> to accurately reflect how each team member has brought their knowledge and skills to the development and delivery of this work. Those that have contributed to this work are listed alphabetically.&nbsp; <ul> <li>Juliana Callaghan:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Writing – review &amp; editing</li> <li>Robert Gray:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Conceptualization, Writing – review &amp; editing&nbsp;</li> <li>Louise Jones:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Conceptualization</li> <li>Adam Lockwood:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Conceptualization, Project administration, Funding acquisition, Methodology, Supervision, Writing – review &amp; editing</li> <li>Danny McAuley:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Conceptualization, Writing – review &amp; editing</li> <li>John Norrie:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Conceptualization, Writing – review &amp; editing</li> <li>Danielle Preedy: &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Conceptualization, Writing – review &amp; editing</li> <li>Sarah Thomas:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Conceptualization, Funding acquisition, Methodology, Supervision</li> <li>Insa Wemheuer:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Project administration, Visualization, Writing – original draft, Writing – review &amp; editing</li> </ul> <br /> In addition, we would specifically like to thank Rebecca Adler, Principal Consultant at NIRAS, and David Salisbury, Independent Consultant and NIRAS Associate, for facilitating the initial development of a Theory of Change for the EME Programme that formed the basis of developing the logic model presented in this document. We would also like to thank the Communications Team at the School of Healthcare Enterprise and Innovation, University of Southampton, for their advice and support in undertaking the visualisation of the model.&nbsp;<br /> <br /> The Logic Model presented in this document also builds on the following document:&nbsp;<br /> <br /> Rentel M C, Simpson K, Dav&eacute; A, Carter S, Blake M, Franke J, <i>et al.</i> A 10-year impact assessment of the Efficacy and Mechanism Evaluation (EME) programme: an independent mixed-method evaluation study. <i>Efficacy Mech Eval</i> 2021;8(20)<br /> <br /> <b>Competing interests&nbsp;</b><br /> This work has been undertaken as part of the delivery of the National Institute for Health and Care Research (NIHR), which is funded by the Department of Health and Social Care. The EME programme is a partnership between the Medical Research Council (MRC) and the NIHR. It is funded by the MRC and the NIHR, with contributions from the CSO in Scotland, Health and Care Research Wales and the HSC R&amp;D Division, Public Health Agency in Northern Ireland. All authors of this document have contributed to it as part of work paid for by the NIHR. No competing interests were disclosed.

Implementing Pressure Ulcer Prevention and Treatment Programs: Using AMDA Clinical Practice Guidelines

Suicide, a major mental and public health problem, is a leading cause of death and a major challenge to mental health professionals worldwide. The World Health Organisation over many years set an explicit target to reduce suicide rates, however, the reality is that the suicide rates continue to increase. It is now the situation that suicide is one of the main causes of death in men in the industrialized world, along with road traffic accidents (Eurostat 2004), yet the amount of government activity and campaigns targeted at increasing road safety and transport initiatives far outweighs efforts to reduce suicide rates. The paper by Sun et al. (2006) in the first instance serves to place a focus on suicide and then goes on to expose some of the attitudes of nurses and patients underpinning the complex dynamics of a therapeutic relationship in the management of suicidal patients. The relationship between suicide and a previous episode of psychiatric inpatient care has been established (Pirkis & Burgess 1998) and this suggests that initiatives to reduce suicide must be primarily located at the suicidal patient's first point of contact with formal health services. Therefore, it is important to focus research efforts on suicide prevention around the area of suicide assessment/screening of patients at the first point of contact with mental health services and conduct longitudinal studies. The initial focus of such research work would be to screen first time attendee's with psychiatric pathology presenting to the health services and investigate suicidal tendency and ideation within a framework of primary care and prevention. Primary care and prevention must be central for research efforts on suicide if we are to redress the problem of suicide in our society. The study by Sun et al. is primarily focused on secondary care and on patients who have already attempted suicide. Sun et al. provide interesting insights into the inpatient management of suicidal patients and the inclusion of patients voicing their opinions and views is a particular strength of the paper. The patient's perception that medication was the most effective treatment from the whole range of treatments and therapies provided does highlight certain failings in the mental health care system as in recent years the mental health professions have targeted considerable efforts on the development of various therapies such as group therapy; psychotherapy; and recreation therapy. The findings of Sun et al. (2006) would support the requirement for rigorous evaluation of available services using patient perception and, in future, the views of service users must become a central pillar directing professional services and treatment regimes. Sun et al. have been quite forthright and honest in acknowledging the limitations of the study. The inclusion of a sample of single sex nurse respondents provides for an unbalanced account of attitudes, given the role of gender in psychiatric therapeutic relationships and their centrality in the reported findings of the study. A further limitation of the study, which is not highlighted clearly by the authors, is the exclusion of other mental health professionals, for example medical staff, from the data collection phase of the study. The authors do highlight the centrality of team work and collaboration in the management of patients who attempt suicide, furthermore direct comments are attributed to other members of the healthcare team. However, the absence of corroboration or any alternative perspective or responses from other members of the healthcare team makes such comments and discussion rather spurious. A selective quotation from a nurse: It is not only psychiatric nurses that can prevent suicide but all members of the team. Consequently we need team co-operation. This may be seen as unbalanced comment in that it portrays an impression that the lack of team work emanates from other members of the health care team. As proposed by the authors, team work is essential for the successful clinical management of suicidal patients therefore every effort must be made to ensure inclusiveness in research efforts. The authors discuss treatment and therapy in suicide as including five main modes, which are conventional including: medication; electroconvulsive therapy; group therapy; psychotherapy and recreation therapy. There is, however, an over simplistic, minimalist, unsubstantiated approach taken in portraying the role of the psychiatric nurse in very traditional terms and this may not be a reflection of the evolving role of the psychiatric nurse in suicide prevention as it evolves internationally. For example, in the article it is suggested that psychiatrists diagnose the condition and prescribe the medications. The psychiatric nurse administers the medication and ensures that the patients receive it. Psychiatric nursing is and has always been more then this rather basic manual intervention and in modern parlance psychiatric nurses are showing leadership in some areas of suicide prevention. It is well established that the expanded and extended role of the psychiatric nurse includes autonomous and independent therapeutic roles (Cowman et al. 2001). Safety and security in acute psychiatric wards is an essential element in the management of suicide. Violent death by suicide is occurring with increasing frequency and within the hospital setting, environmental dangers must be reduced including the absolute requirement for security precautions to protect suicidal patients from themselves. However, there is a wide variation in safety and security procedures in acute psychiatric wards (Cowman & Walsh 2004). A coherent policy and procedure is an essential requirement in ensuring a safe environment for the suicidal patient. Sun et al. (2006) in the paper are quite correct in drawing our attention to the situation of ensuring a safe environment, which may be restrictive and therefore impairing the autonomy and freedom of patients. However, a further dilemma relates to the tension between on the one hand attempting to provide a nursing therapeutic presence and on the other hand operationalising security procedures (Burrows 1991). In the management of suicidal patients the nursing challenge is to ensure an environment where procedures for safety and security are inextricably fused with a caring perspective. An unusual finding was the strength of judgmental attitudes held by psychiatric nurses towards suicidal patients. The extent to which such attitudes may be culturally context dependent and therefore not generalizable to other jurisdictions requires further discussion. Some very unacceptable and unprofessional nursing practices are reported by patients particularly in relation to the ‘protection room’. Such nursing practices are unethical and from a statutory regulatory nursing perspective in the UK and Ireland would not be consistent with a code of professional conduct and would merit attention through Fitness to Practice procedures. Such findings of malpractice create a dilemma for researchers and are worthy of further discussion in the realm of research ethics. In conclusion, the paper does raise awareness and highlight the centrality of the psychiatric nursing role in the management of the suicidal patient in the acute psychiatric ward. The views of patients are an important inclusion in the study, however, in only presenting the views of nurses an opportunity may have been missed by not examining the views of all members of the professional team in the management of suicidal patients.

Disruption of Patient and Family Centered Care Through the COVID-19 Pandemic