Annie Altschul's legacy to 20th century British mental health nursing

Being knowledgeable about, learning from and building upon one's history is the hallmark of an enlightened and progressive profession. This includes an appreciation of the work of those who contributed to moulding the profession into what it currently is. Mental health nursing has not distinguished itself by respect for its former leaders. In this paper, the life and times of one of the most outstanding mental health nurses of the century, Professor Annie Altschul, are recalled and examined. She sought constantly to establish what should be the essence of mental health nursing and what its role should be in the alleviation of human suffering. As an outsider herself, she identified strongly with those marginalized by society. Always a spokesperson for the centrality of nursing in patient care, she saw nurses as those best placed to provide holistic care to patients whilst other professionals specialized in their biomedical, social and financial needs. Long after her retirement, Altschul remains active in supervising and examining postgraduate nursing students. She is still a voice in the mental health debate, someone whose opinions are sought and valued.

Practice nurses' perceptions of services for clients with psychological problems in primary care

Over a third of people presenting in primary care in the United Kingdom (UK) have a mental health problem causing some degree of disruption in their lives. Approximately 90% of these are treated and managed by primary care staff without any support from mental health services. Following the White Paper published by the UK Department of Health in 1997 (Department of Health, 1997. The New NHS--Modern and Dependable, HMSO, London), the influence of primary care both in the commissioning and provision of mental health services is likely to increase. By far the largest professional group currently involved in mental health in primary care are practice nurses. Although their numbers have increased dramatically during this decade, little is known of the work they do or of their perceptions of it. The present questionnaire-based study sought to elicit the types of mental health problems encountered by practice nurses in primary care, the interventions they provide and the skills they utilise. The data indicates that practice nurses care for people with a wide variety of mental health problems ranging from mild to severe. Many feel unprepared for this type of work and are reluctant to get too involved with clients in case they uncover problems they are not able to cope with. Lack of access to appropriate educational support is identified as the main problem currently faced by practice nurses alongside poor inter-professional relationships with mental health personnel. This paper discusses ways of meeting the needs of practice nurses and of improving collaboration in primary care settings.

First Report of Entyloma Polysporum on Sunflower (Helianthus annuus) in Southern California

During a period of wet weather from December 1996 to March 1997, commercial plantings of sunflower in San Diego County, CA, were infected by a leaf smut, Entyloma polysporum (Peck) Farl. The fungus was observed on sunflowers grown in a greenhouse in San Diego County and also on sunflowers from nurseries in Ventura and Riverside counties. Although the disease was first noticed in 1996, the infection was not of economic significance so no attempt was made to identify the causal agent. However, with continuous cropping of sunflowers year round significant losses were observed on seedlings that were systemically infected as they emerged. This is the first report of E. polysporum causing economic losses on sunflowers. The distinguishing characteristics of this fungus are masses of globose to subglobose spores, pale green to yellow green in color, approximately 12 μm in diameter, with a double wall consisting of an inner pale green wall and outer hyaline sheath. The spores occur in dense masses called sori that completely replace the leaf cells. Young spores are difficult to distinguish from leaf cells in a cursory examination. Older sori form discolored lesions in the leaf ranging from circular to irregular in shape and replace most of the chlorenchyma tissue in the infected lesions. Identification of species of smut fungi such as Entyloma is based on the location of the sori in the vegetative parts of the host, the identification of the host, and the spore morphology (4). Savile (3) reviewed the genus on North American composites and, based on morphological characteristics, concluded that almost all the pathogens were either E. compositarum or E. polysporum, with a few intermediate forms. E. polysporum is characterized by globose spores 10 to 17 μm in diameter, surrounded by cell walls 1 μm thick encased in a 1.5- to 2.5-μm thick smooth hyaline sheath (1). Spores of E. compositarum are smaller, 9 to 12 μm in diameter, thin walled (1 to 1.5 μm), smooth, and without a sheath (2). Vánky (4) lists 33 different species on composites according to their host. He believes E. polysporum only occurs on Ambrosia spp., and does not include E. compositarum in his list of Entyloma spp. Neither author mentions Entyloma infecting any species of Helianthus. Savile concluded that E. calendulae (Oudem.) de Bary, described in Europe, is very similar morphologically to E. polysporum, and is probably the same species. E. polysporum was first described in 1881 by Peck as Protomyces polysporus infecting Ambrosia trifida in New York State. In 1996, it was described on Ambrosia artemesifolia in Hungary (3). In the United States it has been reported on sunflowers in Montana (1,2). References: (1) D. F. Farr et al. 1989. Fungi on Plants and Plant Products in the United States. American Phytopathological Society, St. Paul, MN. (2) G. W. Fischer. 1953. Manual of the North American Smut Fungi. Ronald Press, New York. (3) D. B. O. Savile. Can. J. Res. 25(C):109, 1947. (4) K. Vánky. 1994. European Smut Fungi. Gustav Fischer, New York.

Nursing language: uses and abuses

Nurses communicate with a variety of people on many different levels. Yet the full importance of nurse language is not fully appreciated. This article examines the use of nursing language and suggests that nurses can increase their professional potential through using language more consciously.

A comparative study of the perceptions of British mental health nurses and psychiatrists of their work environment

This comparative study of the perceptions of mental health nurses and psychiatrists about aspects of their work environment was undertaken in the West Midlands in England. The aim of the study was to ascertain the extent to which the environment in which mental health professionals' work impacts on their own mental and physical well-being. Seventy-four psychiatrists and 301 mental health nurses responded to a postal questionnaire. Analysis of data indicated that significant differences exist between nurses and psychiatrists in their working conditions, their physical working environment, their sources of support with a work-related problem, and the effects of their work on their own mental and physical health. The main recommendation derived from this study was to improve communication between mental health professionals and their managers by giving more structured feedback and guidance about one's work performance. This may help to alleviate the mental strain many mental health professionals experience in their work.

Predictors of a healthy workplace for Swedish and English psychiatrists

BACKGROUND

Few studies have attempted to analyse the organisational aspects of the workplace that may affect the well-being of psychiatrists and even fewer have offered insights into what a positive workplace might look like. This study provides an outline of such a workplace, with reference to individual and organisational factors. In addition, a comparison is made between two European cities to check for cultural differences.

METHOD

Three hundred and eighty psychiatrists from Stockholm and Birmingham responded to a previously tested questionnaire on their work environment.

RESULTS

Predictors of a positive workplace for psychiatrists were: high self-esteem, satisfactory support with work-related problems, lower perceived workload, positive view of leadership, low work-related exhaustion and having a sense of participation in the organisation. There were few cultural differences.

CONCLUSIONS

Measures should be taken to improve leadership skills for managers, to offer more support for work-related problems, and to allow psychiatrists to participate more in the organisation.

The role of lateral cephalometric radiography and fluoroscopy in assessing mandibular advancement in sleep-related disorders

Mandibular advancement splints are successful in managing obstructive sleep apnoea (OSA) in selected subjects. For these to be effective, some improvement in the dimensions of the oropharyngeal airway must occur. Twenty subjects with proven obstructive sleep apnoea were examined using lateral cephalometric radiography and a fluoroscopic technique. Cephalograms were analysed, and assessed for both skeletal and soft tissue abnormalities known to be present in OSA subjects. On the basis of these, a prediction was made as to whether the subject's oropharyngeal airway would increase during mandibular protrusion. From the fluoroscopic sequences, the narrowest antero-posterior dimensions of the post-palatal and post-lingual airways were recorded as the mandible moved from the intercuspal position into maximal protrusion. The changes in airway size were noted and these were compared with the predictions made from the static films. In nine subjects, fluoroscopy indicated that the airway opened well during mandibular protrusion, seven did not improve and in four the changes were minimal. Post-palatally the mean airway increase was 2.6 mm, whilst behind the tongue a mean improvement of 3.1 mm was seen. In all but two instances, the cephalometric prediction agreed exactly with the outcome demonstrated by fluoroscopy. All subjects whose airways clearly increased were correctly identified by the cephalogram alone. Cephalometric features associated with a good airway response to protrusion were a reduced lower facial height, low maxillomandibular planes angle and a high hyoid position, accompanied by a normal anteroposterior relationship of the jaws, relatively normal mandibular body length and soft palate area. The more abnormal the skeletal and soft tissue dimensions, the poorer the prognosis. Thus, whilst a single radiograph could indicate whether a positive mandibular response to protrusion could be expected, where doubt existed, a fluoroscopic analysis could provide a useful adjunct to diagnosis.

Competencies drive decision making

Staff nurses, using the Nursing Interventions Classification, selected the core competencies, performance criteria and interventions relevant to their practice. A performance-based approach highlights performance outcomes and previous experience. A preceptor and self-directed learning activities help apply the knowledge in the work setting.

A survey of patients placed on the supervision register in one mental health trust

Mental health nurses, in common with other health care groups, are charged with monitoring the quality of care for severely mentally ill clients. It is now apparent that improving the social functioning of these clients is far more complex than was previously thought and demands better coordinated services. To improve services is especially challenging at a time when resources are diminishing and existing generic mental health services find themselves under severe pressure. The introduction of the Supervision Register (1994) was one response to a number of high profile incidents in the U.K. which suggested that greater collaboration between health services, social services and voluntary agencies needed to be sought. This study aimed to ascertain the characteristics of clients placed on the Register and the reaction of the mental health professionals who have to implement it. Although the majority of staff interviewed in the course of the study acknowledged that the Register served to highlight and perhaps potentiate the constituents of good practice, a number were concerned that in the absence of appropriate and sufficient community-based resources, procedural mechanisms such as the Supervision Register were merely a cosmetic purpose.

Mental health nursing in the 1950s and 1960s revisited

From the post-War period to the 1960s, immense changes took place in the philosophy, organization and delivery of mental health care in the UK. These changes were driven by the financial burden that Bevan's National Health Service imposed on the British Government, by the dynamism and vision of psychiatrists and mental health nurses returning from the War, and by a new social and cultural consciousness, which put minority groups such as the mentally ill onto the political agenda. This paper seeks to explore some of these complex interactions and to show how the closure of mental hospitals was the inevitable outcome of movements both inside psychiatry and far beyond it. An awareness of the historical context of mental health care can assist planners and providers to avoid the many pitfalls that have been made by our predecessors.

Post polio syndrome. The late sequelae of poliomyelitis

Patients who in earlier life suffered from acute poliomyelitis are reporting new and disabling symptoms that have been variously labelled the 'late sequelae' or 'post polio syndrome'. Systematic review of such patients has identified specific categories of disability. A practical investigation and management plan for such patients presenting to a general practitioner is proposed.

Towards a rhetoric of spirituality in mental health care

The spiritual dimension of care is frequently alluded to in the nursing literature, but rarely examined in terms of what it means in practice or how it might be taught to students entering the profession. Some of those most in need of spiritual care are people suffering from mental illness or psychological distress. The aim of this paper is to explore the different meanings of spirituality and to suggest ways in which the spiritual care of clients can be implemented. It further recommends which aspects of spirituality could usefully be included in nursing curricula. The paper concludes by alerting nurses to the causes and manifestations of spiritual apathy in contemporary health care and calls for a rhetoric that will counter the jargon of cost analysis which currently prevails in the health services.

Potassium and ventilation during exercise above and below the ventilatory threshold

Increases in arterial plasma potassium during exercise may provide an important drive to ventilation. We examined the changes in arterialized venous plasma potassium concentration ([K +]av) and ventilation that occur during sustained exercise at workloads above and below the ventilatory threshold (Vt) in young health humans. After the onset of exercise at a workload below-Vt, [K +]av rose by 0.3 (+/- 0.1) mmol l-1 (mean +/- SEM). Following 30 min of exercise at this intensity [K +]av had fallen (P < 0.05, ANOVA) by an amount approximately equal to one third of the initial increase. While [K +]av fell, ventilation remained stable. At 5 min after the onset of sustained exercise above the Vt [K +]av had risen by 0.7 (+/- 0.1) mmol l-1 and thereafter remained constant. Ventilation slowly increased throughout the above-Vt protocol. These results show significant differences in the time course of the changes in [K +]av and ventilation. They do not support the hypothesis that changes in [K +]a during moderate exercise cause linearly related changes in ventilation.

A critique of the concept of quality of life

Taking a philosophical approach, ancient Greek philosophers and Christians began to investigate the concept of quality of life. Later, such philisophical pursuit was replaced by the school of positivism, which indicated that science was and still is the only valid form of enquiry. Through such positivistic science, the metaphysical nature of the concept of quality of life is thought to be uncovered. However, the later Wittgensteinian philosophical thoughts demonstrated that there is no metaphysical understanding of any concepts but there is only knowledge of playing language games. In the light of this philosophy, prior to any scientific investigations, researchers have already understood and agreed on the concept of quality of life by playing language games. From the above philosophical analyses, outlines some implications for health care research.

Evaluation of health promotion activities in community nursing practice

The purpose of this research was to study the extent to which community nurses (CNs) were involved in health promotion activities and to investigate whether these activities were meeting the needs of their clients. A cross-sectional survey by multiple methods was designed and carried out in four district health authorities (DHAs) in one regional health authority in England. Two hundred and fifty-one (83.67%) completed questionnaires were returned by CNs working in primary health care (PHC). Sixty sessions with CNs were observed and 249 interviews were conducted with clients. Additionally, as part of the observation 155 clinical records were examined. CNs reported involvement in a wide range of opportunistic and organized health promotion activities. Lifestyle advice and ill-health prevention were most frequently used by all groups. Health visitors (HVs) were involved significantly more in group and community wide activities. District nurses (DNs) were mainly involved in opportunistic health promotion. Practice nurses (PNs) were found to be involved significantly more in health promotion activities organized on an individual basis. Observation revealed that opportunistic health promotion was carried out in almost half of the consultations observed, of which lifestyle advice was the most frequent. Records however showed that this information was rarely recorded. The clients of PNs were mostly aware of other health promotion activities available within the general practice, while almost half of the HVs' clients knew what other health promotion activities were available to them and few DNs' clients were aware of any.

Interaction, language and the "narrative turn" in psychotherapy and psychiatry

The traditional emphasis in psychiatry about "listening to patients" has recently been added to by the development of what we call the "narrative turn" in mental health care where clients' narratives are emphasised. We shall argue however that both approaches tend to embody similar assumptions about therapeutic transactions and roles, and that much work emphasising narratives reveals little about how therapists and researchers work to reconstruct the clients' accounts. It is therefore vital that the emphasis on narratives be supplemented by a more thoroughgoing approach to shared structures of knowledge which act to prefigure clients' distress, how professional records are a profoundly transformative medium, and how therapeutic encounters work to co-construct clients' narratives, rather than simply reflect or explore them. The radical implications of thinking about therapy in terms of narrative and language need to be more fully discussed in the therapy literature, so the narrative turn does not simply reproduce the common-sense assumptions of more conventional approaches.

Chronic lymphatic leukaemia presenting as severe obstructive sleep apnoea

A case of adenotonsillar enlargement from chronic lymphatic leukaemia leading to severe obstructive sleep apnoea (OSA) is described. Nasal continuous positive airway pressure (nCPAP) therapy was poorly tolerated because even at high pressures (+15 cm H2O) obstructive hypopnoeas persisted. Tonsillectomy resulted in significant improvement, though OSA persisted. nCPAP was reintroduced and at low pressures (+6 cm H2O) was efficacious in alleviating the patient's symptoms. This report highlights the need to consider OSA as a cause of constitutional symptoms in adults with lymphoreticular disease, especially where there is involvement of Waldeyer's ring.