Consultation-liaison scheme for self-poisoned patients in a general hospital.

In a prospective clinical trial 276 self-poisoned patients consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision about "disposal." Junior doctors and nurses received instruction in this work. While awaiting the outcome of the trial the randomisation was continued for 13 months and 729 allocations were made altogether. Physicians requested psychiatric opinions for roughly one in five of their patients. In other respects medical teams performed similarly to psychiatrists. Provided that due attention is given to teaching junior staff and to ensuring that psychiatric treatment and social-work support are available once patients have been assessed, such a consultation-liaison scheme could be adopted in other hospitals. This would help to change unfavourable attitudes towards self-poisoned patients and contribute to the general training of doctors and nurses.     

The medical student as behavioural psychotherapist.

A group of medical students were randomly selected from a larger group to carry out behaviour therapy under supervision. Ten patients with phobic disorders and two with obsessive-compulsive neurosis were treated, and the results, assessed by ratings of proved reliability, compared favourably with other studies in which psychiatrists or nurses acted as therapists. A questionnaire survey showed that students involved in therapy had a more favourable opinion about this kind of treatment than those receiving only theoretical instruction. The results suggested not only that medical students make good behavioural psychotherapists but also that the subject is a worthwhile training experience which warrants inclusion in the curriculum.     

Psychiatric Nurse as Therapist

Under supervision five nurse-therapists have treated phobic patients as successfully as have psychiatrists and psychologists using similar psychological treatments in comparable psychiatric populations. Nurses have also had good results in other neurotic disorders. Intensive training is required. Nurse-therapists find their work rewarding, but the present Salmon gradings make no provision for their advancement should they retain their clinical function. Results suggest that the use of selected psychiatric nurses as skilled therapists can ease the current critical shortage of treatment personnel in psychiatry.     

Psychological and social evaluation in cases of deliberate self-poisoning admitted to a general hospital.

In a prospective clinical trial 312 cases of self-poisoning (276 patients) consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision as to "disposal." Junior doctors and nurses received some instruction in this work. Both groups of assessors asked for help from social workers when necessary. Once the medical teams had completed their assessments, psychiatrists provided most of the hospital treatment. Follow-up at one year showed no significant difference between the two groups of patients in the numbers who repeated their self-poisoning or self-injury (or both), or committed suicide. Provided junior doctors and nurses are taught to assess self-poisoned patients, we think medical teams can evaluate the suicidal risk and identify patients requiring psychiatric treatment or help from social workers, or both. Contrary to the Department of Health''s recommendation that all cases of deliberate self-poisoning should be seen by psychiatrists, we have reached the conclusion that physicians should decide for each of their patients if specialist psychiatric advice is necessary.     

Controlled trial of psychiatric nurse therapists in primary care.

In a randomised controlled clinical trial neurotic patients (mainly phobic and obsessive-compulsive) did significantly better up to one year follow up after receiving behavioural psychotherapy from a nurse therapist rather than routine treatment from a general practitioner. At the end of the year control patients who had not improved had crossover behavioural treatment from the nurse and then improved. Those who dropped out or refused therapy did not show worthwhile gains. Patients preferred being treated in the primary care setting rather than in hospital. Placing nurse therapists in primary care is not only viable but may save more health care resources than it consumes.     

Nurse practitioners in primary care III. The southern Ontario randomized trial

A group of nurses who formerly had performed office functions received a special university-based educational program designed to prepare them to assume much of primary care management as nurse practitioners. The associated family physicians would shift their role to general supervision and attention to difficult clinical problems. To test this new form of practice, two complementary randomized trials have been conducted in south-central Ontario. The particular trial reported here was intended to assess the influence of the educational program on the changing roles of the professional personnel. The nurses of 14 family medical practices, with the physicians'' support and commitment to participation, applied for the new training. Seven applicants were randomly selected to receive the training and their corresponding practices became the experimental group, while the remaining nurses and practices were retained as controls. During the subsequent year of investigation important changes occurred in professional roles of the experimental group. Nurse practitioners spent more time in clinical activities than conventional office nurses. The shift was not at the expense of time devoted to clinical work by physicians. Doctors delegated more professional activities to nurse practitioners than to conventional nurses. Except for remuneration (affected by legal constraints) job satisfaction among experimental physicians and nurses remained high after one year of experience with the new method.     

Effect of past and present behavioural specialization on brain levels of biogenic amines in workers of the red wood ant Formica polyctena

Social insect workers usually participate first in intranidal tasks (i.e. act as nurses within the nest) and then switch to extranidal tasks and become foragers. However, foragers sometimes switch back again to brood care and become reverted nurses. Behavioural and physiological correlates of the transition nurse–forager (behavioural maturation) and forager–reverted nurse (behavioural reversion) are relatively well known in the honeybee, although they are less explored in ants. To understand better the role of biogenic amines in ant behavioural maturation and behavioural reversion, the levels of octopamine (OA), dopamine (DA) and serotonin (5‐HT) are examined in the brains of nurses, foragers and reverted nurses of the red wood ant Formica polyctena Först. (Hymenoptera: Formicidae). Brain OA levels and the ratios OA : DA and OA : 5‐HT are higher in nurses than in foragers and reverted nurses. Reverted nurses and foragers do not differ significantly with respect to brain biogenic amine levels and amine ratios. Biogenic amine levels in brains of workers of F. polyctena are thus maturation‐related rather than task‐related. This is one of the first studies of neurochemical correlates of ant behavioural maturation and the first attempt to identify neurobiological correlates of ant behavioural reversion. The data obtained provide further evidence that neurobiological processes underlying honeybee and ant behavioural maturation and behavioural reversion reveal important differences.     

Feasibility and Impact of Doctor-Nurse Task Delegation in Preventive Child Health Care in the Netherlands,a Controlled Before-After Study

BackgroundIn the Netherlands a need is felt for more flexible Child Health Care services, both efficient and tailored to needs. We set up a study on impact and feasibility of task delegation to child health care nurses performing all regular checkups on children aged 2 months to 4 years. Abnormal findings were discussed with the attending child health care doctor. This article describes impact and feasibility of this task delegation from four viewpoints: competences of nurses; percentage of children assigned to the nurse; change in abnormal findings and referrals; experiences of professionals and parents.MethodsTwo experiment teams and two control teams were compared before and after starting task delegation. Nurses in the experiment teams were trained to carry out regular checkups on healthy children. Assignment to the experiment schedule was a joint decision by doctor and nurse. Nursing competences were measured by means of questionnaires. Percentage of children assigned to the nurse and screening results of eyes, heart, hips, growth and development were extracted from the electronic health record. Difference in change was compared between experiment and control teams. Mann-Whitney tests and logistic generalized estimating equations were used to test for significance. Experiences of professionals and parents were evaluated through focus group interviews, which were subjected to a qualitative analysis.ResultsNurses in the experiment regions showed improvement in medical screening skills. No difference in change was perceived in general nursing competences. In the experiment group, 69% of all children were assigned to the nurse. There were no significant differences in change in the percentages of abnormal findings or referrals in the experiment teams compared to the control teams, except for hips. Interviews showed that both doctors and nurses thought positively of the new working method, yet made some recommendations for improvements. Parents felt well-informed and experienced an equal level of proficiency but less continuity in person.ConclusionThis experiment shows that task delegation from doctor to nurse in preventive child health care is feasible. It is important to pay attention to the acceptation process of professionals during implementation. More investigation is needed in order to assess effectiveness and efficacy of task delegation.     

WHAT PSYCHIATRISTS THINK ABOUT ALCOHOLISM

The one approach most favored for alcoholism by psychiatrists in Southern California who answered a questionnaire is membership in Alcoholics Anonymous. Ninety-nine per cent of them approved Alcoholics Anonymous, and 80 per cent had referred patients to the organization. Yet they believed only 10 per cent of the persons who join A.A. remain sober for over two years. This against the claim of A.A. that 60 per cent or more of their fellowship are recovered emphasized the pessimism of the psychiatrists questioned.Ninety per cent of the psychiatrists who replied said they do not treat alcoholics or that they limit the number or the type they will accept for treatment. They obtain recovery, they said, of 10 per cent of patients, improvement of 50 per cent, and the rest are unchanged.The emphasis in psychiatry is on elimination of the anxieties leading to alcoholism; in Alcoholics Anonymous the emphasis is on the strength to bear these anxieties. Ninety per cent of the replies received were in favor of clinics for alcoholics, and the respondents felt that governmental agencies should support these clinics. Under such circumstances psychiatrists would combine their abilities with psychologists, social workers and Alcoholics Anonymous. Thirty-five per cent of psychiatrists said they are willing to work in a clinic, the majority without recompense.     

Serum levels of total and free IGF-I and IGFBP-3 are increased and maintained in long-term training.

The goals of this study were to determine whether the long-term training regimens experienced by competitive collegiate swimmers would result in altered levels of total and free serum insulin-like growth factor I (IGF-I) as well as IGF-binding proteins (BP) IGFBP-1 and -3. Two male (Teams 1M and 2M) and one female (Team 2F) teams were studied at the start of training, after 2 mo of training, after 4 mo (2-4 mo had the highest volume of training), after 5 mo (near the end of tapering; only for Team 1M), and several days after training was over. For Team 1M, total IGF-I concentrations were increased by 76% after 4 mo and were subsequently maintained at this level. Total IGF-I responses were more variable for Teams 2F and 2M. Free IGF-I levels were increased nearly twofold for all teams at 2 mo and were maintained or increased further with subsequent training. Only the levels of free IGF-I for Team 1M returned to pretraining values after training had ended. Training had little effect on IGFBP-1 levels. For all teams, serum IGFBP-3 was elevated by 4 mo of training (for Team 2F it was increased at 2 mo) by 30-97% and remained at these higher levels thereafter. The ratio of total IGF-I to IGFBP-3 was not increased by training in any group. These data indicate that serum levels of total and free IGF-I and total IGFBP-3 can be increased with intense training and maintained with reduced training (tapering). The findings show that changes in free IGF-I levels are not accounted for by alterations in the total IGF-I/IGFBP-3 complex or in IGFBP-3 levels and indicate that there are other important determinants of free IGF-I.     

Reliability of video taped interviews with children suspected of being sexually abused.

OBJECTIVE--To determine the reliability of judgments about the likelihood of child sexual abuse based only on video recorded interviews. DESIGN--Blinded rating of likelihood of abuse by seven professional groups and comparison with consensus rating. SETTING--Child and adolescent psychiatry centre. SUBJECTS--Four people from each of seven professional disciplines: specialist psychiatrists, general psychiatrists, experimental psychologists, trainee social workers, trainee clinical psychologists, lawyers, and police. MAIN OUTCOME MEASURE--Rating of 12 recorded interviews. RESULTS--Agreement between the consensus panel and professional groups was 83% (151/183) for high likelihood cases (seven cases) and 89% (118/132) for low likelihood cases (five). Specialist psychiatrists and the police were better able to identify high likelihood cases than were other groups with less experience of interviewing sexually abused children (91% (48/53) v 79% (102/129); p = 0.05). CONCLUSIONS--Raters could accurately distinguish children with low likelihood of abuse on interview evidence alone, but those with more experience of dealing with sexual abuse were better at identifying high likelihood cases.     

The nursing crisis

Three concrete proposals are made for the improvement of the present nursing situation:1. Make nursing education more easily available by holding the prerequisites to a minimum and concentrating upon the real essentials of nursing, granting the student the R.N. degree when she has completed this basic and essential training.2. Utilize more fully the principles of group nursing as applied to "specialing" whether in the home or in the hospital.3. Completely avoid the use of sub-standard nurses, while furnishing to the nurse such non-technical service (through the use of maid assistants or others) as shall make practicable the complete utilization of her skill and training.     

Coronary Care Units—The Status in California

In order to determine the status of Coronary Care Unit activity in California hospitals, especially as it pertains to nurse training, a survery was conducted by the California State Department of Public Health. More than 95 percent of hospitals that were questioned responded. Only one-third of the hospitals reported they neither had a unit nor plans to build one. All units in operation were either directed by an individual medical director or by a Coronary Care Unit Committee.The survey indicated that in some hospitals with operational units, nurses were not permitted to perform life-saving resuscitative procedures. All operational units reported in-service education programs of some type. Many hospitals indicated they would like to have Coronary Care Unit training programs to which they could send nurses. The reasons why nurses may not perform important resuscitative procedures are discussed as well as the need for Coronary Care Unit training programs for both physicians and nurses in California.     

THE “NURSING CRISIS”

Three concrete proposals are made for the improvement of the present nursing situation:1. Make nursing education more easily available by holding the prerequisites to a minimum and concentrating upon the real essentials of nursing, granting the student the R.N. degree when she has completed this basic and essential training.2. Utilize more fully the principles of group nursing as applied to “specialing” whether in the home or in the hospital.3. Completely avoid the use of sub-standard nurses, while furnishing to the nurse such non-technical service (through the use of maid assistants or others) as shall make practicable the complete utilization of her skill and training.     

Integration of mental health into primary care in Kenya

Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in the public health system across Kenya, using a sustainable general health system approach. The content of training was closely aligned to the generic tasks of the health workers. The training delivery was integrated into the normal national training delivery system, and accompanied by capacity building courses for district and provincial level staff to encourage the inclusion of mental health in the district and provincial annual operational plans, and to promote the coordination and supervision of mental health services in primary care by district psychiatric nurses and district public health nurses. The project trained 41 trainers, who have so far trained 1671 primary care staff, achieving a mean change in knowledge score of 42% to 77%. Qualitative observations of subsequent clinical practice have demonstrated improvements in assessment, diagnosis, management, record keeping, medicine supply, intersectoral liaison and public education. Around 200 supervisors (psychiatrists, psychiatric nurses and district public health nurses) have also been trained. The project experience may be useful for other countries also wishing to conduct similar sustainable training and supervision programmes.     

The clinical psychologist in a health centre: one year's work.

The Livingston integrated health services project is an attempt to provide a fully integrated area health service with special emphasis on developing multidisciplinary community health teams. As part of this experiment a clinical psychologist was appointed to work in general practice. Ninety-four patients with behavioural, emotional, and cognitive problems were referred in the first year (1% of the 10 000 patients registered at the practice). The psychologist thus provided treatment for some patients who would otherwise have been seen by a general practitioner with neither the time nor the training to deal adequately with their problems.     

Counsellors in English and Welsh general practices: their nature and distribution.

OBJECTIVE--To establish the prevalence of counselling services in English and Welsh general practices and factors associated with their distribution; to describe qualifications, working arrangements, and case mix of "counsellors." DESIGN--Postal questionnaire and telephone interview survey of a sample of about one in 20 general practitioners in England and Wales. SETTING--English and Welsh general practices. SUBJECTS--1880 general practitioners of whom 1542 (82%) completed questionnaires. MAIN OUTCOME MEASURES--Prevalence and distribution of practice counselling services; counsellors'' qualifications and funding; types of patients referred. RESULTS--586 counsellors were distributed among 484 of the 1542 practices. Three types of counsellor predominated: community psychiatric nurses (187); "practice counsellors" (145); and clinical psychologists (95). Practice characteristics which independently predicted the presence of a counsellor were for community psychiatric nurses four or more partners (odds = 1.72, 95% confidence interval 1.18 to 2.26); for practice counsellors stress clinic (odds = 2.22; 1.83 to 2.61), training practice (odds = 1.70; 1.24 to 2.16), and health region (chi 2 = 55.94; df = 14; p < 0.001); and for clinical psychologists list size of > or = 10,500 (odds = 1.79; 1.09 to 2.49), training practice (odds = 1.78; 1.31 to 2.25), health region (chi 2 = 48.31; df = 14; p < 0.001). 197 counsellors had training in counselling. The qualifications of 85 were unknown to the general practitioner. The principal source of funding was the district health authority for community psychiatric nurses (150) and clinical psychologists (58) and the family health services authority for practice counsellors (76). All counsellors were referred a wide range of problems. CONCLUSIONS--Counselling services are wide-spread in general practice, but a high proportion of counsellors lack qualifications, and many may be referred problems outside their knowledge.     

基于"艾宾浩斯理论"骨科实习带教量表的建立及意义

目的：本研究基于艾宾浩斯学习理论,制定一套量化的骨科护理临床教学管理纲要,对临床实习内容进行整理和评估,为实 习人员规范化培训提供参考。方法：通过中国知网数据库检索实习护理人员培训所涵盖的护理操作、心理、教育等方面的内容。采 用德尔菲（Delphi）法进行专家咨询,依据专家意见评估并筛选教学量表内容。基于艾宾浩斯学习理论确定不同科目的权重与频 次,建立临床带教管理量表。结果：临床带教管理量表包括3 项一级项目：基础操作、专科操作和健康宣教;43 项二级项目：静脉输 液、卧换、轴线翻身等。结论：临床带教管理量表的制定为实习人员规范化培训提供了可借鉴的方法,为提升临床带教效果奠定了基础。     

Design of Surgery Premises and Employment of Nurses

The surgery premises of many general practitioners have no accommodation for a nurse. Some have only a nurse/treatment room away from the consulting and examination rooms. Modern designs are no better, and are inadequate in view of the present trend to employ more nurses in group practices. Much of the value of a nurse is lost if she cannot help patient and doctor at the time of examination. The premises described here were designed to enable her to do so by combining the treatment room with a clinical room and a set of examination rooms.     

Does the treatment of maternal attention deficit and hyperactivity disorder (ADHD) enhance the efficacy of a behavioural parent training for the treatment of their children’s ADHD? Study protocol of a randomized controlled multicentre trail

Heritability of deficit and hyperactivity disorder (ADHD) is high. Thus, frequently both children and parents are affected. Parental ADHD often has a negative impact on parent-child interactions and may constitute a significant barrier to a successful treatment of the child's ADHD. The objective of our randomized controlled multicentre trial is to evaluate whether the treatment of maternal ADHD improves the efficacy of a behavioural parent training for children's ADHD. One hundred and forty-four mother-child pairs, both affected by ADHD according to DSM-IV, will be treated at five sites in Germany. Mothers are randomized to manualized cognitive-behavioural group psychotherapy plus open methylphenidate treatment or to control treatment (supportive counselling). After 13 weeks of treatment, manualized behavioural parent training will be administered to all mother-child pairs. Therapists are graduated psychologists or physicians. Treatment integrity will be established by independent supervision. Primary endpoint (child's externalizing symptoms) is rated by interviewers blind to the mother's treatment allocation. Intention-to-treat analysis will be performed within a linear regression model (Current Controlled Trials ISRCTN73911400).