Gender and mental illness: an Australian overview

This article highlights the centrality of gender to mental health nursing practice by providing evidence that gendered assumptions are embedded in psychiatric knowledge. After a brief account of gendered rates of mental illness, the first two-thirds of this article explores formal psychiatric diagnostic criteria, casebook specificity, and processes involved in gaining a psychiatric diagnosis in relation to gender. In contemporary psychiatric practice the two tendencies of overdiagnosis and underdiagnosis are simultaneously evident, with woman-predominant styles of expressing distress being particularly associated with underdiagnosis. The final sections of the article outline gendered attitudes and expectations that impact on clients and their treatment, along with common gendered differences relevant to mental health nursing and people living with anxiety, depression, substance abuse, psychosis, and dual diagnosis.

An exploratory investigation into the nursing management of aggression in acute psychiatric settings

The management of aggression in inpatient psychiatric facilities is a major concern for nurses. Despite the prevalence of research on aggression within psychiatric settings, very few studies have tracked the clinical management of identified patients in a systematic manner. The overall aim of this study was to explore the clinical management of patients identified as potentially aggressive in psychiatric inpatient settings. A multimethod approach was used to collect the data. This included surveys, focus groups, and a file audit of patients identified from a random sample of completed aggression incident forms. The findings indicated that 88% of nurses who participated in the survey were assaulted and indicated the need for risk assessment; team management and review; and the importance of the first 5 days of admission as crucial for assessment and review. The development of support structures, formal preceptoring and supervisory arrangements and postincident supports were suggested as part of an overall strategy to support nurses working in acute inpatient settings.

Discourse analysis of an 'observation levels' nursing policy

The practice of special observation (or constant observation) is widely used in inpatient psychiatric facilities for the care of people who are suicidal. In this study, the policy of special observation was examined using a discourse analysis method to discern prevailing ideas and practices highlighted within the policy. After reading, studying and analysing the special observation nursing policy, the authors briefly describe the document and outline the terms and phrases prevalent within the document. These recurrent ideas are then organized into five categories: professional responsibilities, suicidality, the patient's immediate context, the patient's observable behaviour and the nursing checklist. In discussion of the policy document, the invisibility of the authors, target audience and patients is noted. The authors attempt to elicit evidence for the therapeutic nurse-patient relationship in the document. In the analysis of patient, nurse and doctor roles and responsibilities, it is evident that the policy document reinforces the traditional medical hierarchy of power relations. Some assumptions that underpin the document are postulated. Questions regarding the nature of risk assessment and the evidence base for the medical prescription of special observation are raised. As well as ideas and themes evident in the document, the absence of some relevant issues is explored. While the need for succinctness and clarity in policy documents is acknowledged, the fact that patient rights, therapeutic processes and ethical dilemmas are absent is deemed significant.

Childbirth and the development of acute trauma symptoms: incidence and contributing factors

BACKGROUND

Little is known about the relationship between women's birthing experiences and the development of trauma symptoms. This study aimed to determine the incidence of acute trauma symptoms and posttraumatic stress disorder in women as a result of their labor and birth experiences, and to identify factors that contributed to the women's psychological distress.

METHOD

Using a prospective, longitudinal design, women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics. Telephone interviews with 499 participants were conducted at 4 to 6 weeks postpartum to explore the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms.

RESULTS

One in three women (33%) identified a traumatic birthing event and reported the presence of at least three trauma symptoms. Twenty-eight women (5.6%) met DSM-IV criteria for acute posttraumatic stress disorder. Antenatal variables did not contribute to the development of acute or chronic trauma symptoms. The level of obstetric intervention experienced during childbirth (beta = 0.351, p < 0.0001) and the perception of inadequate intrapartum care (beta = 0.319, p < 0.0001) during labor were consistently associated with the development of acute trauma symptoms.

CONCLUSIONS

Posttraumatic stress disorder after childbirth is a poorly recognized phenomenon. Women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate. These findings should prompt a serious review of intrusive obstetric intervention during labor and delivery, and the care provided to birthing women.

Towards understanding some complex borderline behaviours

This article aims to explore and explain some possible antecedents to behaviours revealed by consumers in mental health settings who evoke strong and often negative responses in nurses and other health professionals. The contemporary exemplar par excellence is people who are diagnosed as having a borderline personality disorder. The paper discusses four different but overlapping domains that may contribute to understanding the difficulties many nurses face in relation to working with consumers whose behaviours are complex and distressing. Firstly, these begin with a brief discussion of psychiatric labelling and stereotyping associated with borderline personality disorder. Secondly, the connections between trauma in childhood and psychiatric vulnerability are explored, as nurses and other health professionals sometimes do not appreciate the debilitating and long-term consequences of the survival of childhood abuse or sexual assault. Thirdly, some unconscious defence mechanisms are outlined to partly explain behavioural interactions often displayed by people with a diagnosis of borderline personality disorder. Finally, behavioural concomitants of projection, splitting and projective identification are discussed: they include identity diffusion, self-mutilation and suicide attempts. All of these topics are explored to encourage nurses to support consumers to express pain in more constructive ways.

Older women's experience of living with chronic leg ulceration

In this study the authors sought to gain insight into the lives of older women, to focus on the experience of living with leg ulcers and to explore women's views by talking to them about their experiences. Twelve English-speaking women aged over 70 years who had experienced leg ulceration for 3 years or more were interviewed. Analysis of the interview text revealed two overarching themes: (i) gaining and maintaining control over vulnerable limb(s); and (ii) lifestyle consequences of chronic leg ulceration and impaired mobility. These themes contained several subthemes including: (i) nagging pain; (ii) self-expertise and infection; (iii) leakage, smell and embarrassment; (iv) fighting for skin and limb integrity; (v) wearing non-preferred apparel; (vi) loneliness; and (vii) coping, determination and hope. The findings of this research show that elderly women who live with leg ulcers experience multiple consequences. While the everyday problems of living with an unhealed would are addressed by the community nurse, other more subtle consequences may be overlooked. Recognition of the complex and sometimes hidden concerns of these women could help to avert the sense of helplessness which currently exists.

Suicidal patients and special observation

Special observation is a nursing practice utilized in in-patient psychiatric facilities for patients who are suicidal. Special observation is carried out by an allocated registered nurse remaining continuously at arms length from, or within sight of (as specified), the patient; or a registered nurse observing the patient within a 30 min interval. In this exploratory study, we investigated the role of the registered nurse when caring for patients on special observation. Semistructured interviews were conducted with 10 randomly selected registered nurses from 4 acute psychiatric wards. The 9 themes that emerged were: 1) Safety; 2) Therapeutic relationships; 3) Supporting patients and carers; 4) Consequences of special observation for nurses; 5) Continuity of care concerns; 6) Peer support; 7) Suicide indicators; 8) Responsibilities and rights: nurses and patients; and 9) Nurses, doctors and the hospital hierarchy. Recommendations for alleviation of the concerns about the practice of special observation are outlined and discussed.

The Mental Health Nursing Clinical Confidence Scale: a tool for measuring undergraduate learning on mental health clinical placements

A significant proportion of the undergraduate preparation of student nurses in the tertiary sector involves the opportunity for experience in a variety of clinical placements. The majority of nursing students in Australian universities spend time in mental health settings. This compulsory clinical experience provides the opportunity for the application of nursing theory and the development of clinical confidence. Whereas there have been attempts to quantify the attainment of confidence to perform skills in general nursing settings, there has been little attention to this issue in mental health settings. The Mental Health Nursing Clinical Confidence Scale was developed as part of a larger study aimed at investigating the impact of mental health clinical placements on undergraduate nurses' attitudes and clinical confidence. Students were surveyed using the scale before and after a mental health nursing placement. The scale revealed robust psychometric properties. Significant changes in the self-reported confidence levels of students were found at the completion of the clinical placement. A number of key factors impacted on student confidence levels both before the clinical and after the placement. The 20 item scale will be a useful instrument in future evaluations of the effectiveness of student learning in mental health settings.

Structural impediments to effective communication

Interestingly, none of the mental health nurse authors that I have consulted, understand the nurse-patient relationship as establishing the parameters for facilitative communication which, to a large extent, opens up or circumscribes further therapeutic possibilities. In other words, the nurse is seen as the initiator of both relationship development and communicative interactions; and the person of the nurse seems irrelevant in that they have skills to learn and techniques to apply. Furthermore, if communication is problematic, it seems to be assumed that such difficulties arise from the patient or from the inadequacy of the nurse's technique, and never from the personal attributes of the nurse.

Women's depression: nursing theory and practice

This theoretical paper argues that a range of social factors are relevant to the genesis of depression in women. These include stressors which particularly pertain to gender, and include poverty, limited practical and social supports and resources, violence against women and childhood sexual assault. After explicating an interpersonal model for the etiology of depression, the paper outlines approaches that nurses can draw on to take sex-based factors into account when assessing and working with women experiencing depression. Nursing strategies which emphasise hope, use group approaches and deal with emotions and unconscious issues are deemed to be especially important.

Psychiatric nursing: epistemological contradictions

This theoretical analysis begins from the premise that the medical specialty of psychiatry is practically and ideologically dominant in relation to psychiatric nursing. To explicate some difficulties within psychiatric nursing from a therapeutic perspective, crucial 19th century European psychiatric epistemological developments are outlined. The article addresses the contemporary problematic of nursing agency in the face of mainstream psychiatry's focus on physical treatments. It is argued that there are intrinsic contradictions for present-day humanistic psychiatric nursing given the theoretical and practical power of the materialist medical model.

'Difference' and nursing research

In recent decades groups of non-mainstream people have named their/our strengths and used the concept of 'difference' to support this position. The pitfalls of radical individualism and of group essentialism which are likely to ensue from this focus on difference are problematic in nursing research. This paper argues that class, ethnicity and gender structure societies in which research takes place; and that common understandings of difference may unwittingly perpetuate and obscure power inequalities. Nursing researchers need to be conscious of these inequalities and ensure that research is oriented towards constructive change for the benefit of health service consumers.

Problem-based learning in nurse education: an Australian view

This paper addresses the need to adopt teaching-learning approaches in nursing education that develop links between theory and clinical practice in a meaningful way. Problem-based learning (PBL) is such an approach and is gaining popularity in tertiary nursing programmes in Australia. PBL, as an example of the constructivist philosophy, focuses on students' existing knowledge as a starting point for conceptual change teaching. The implications for the nurse educator's role when using PBL are discussed in terms of assumptions about the nature of teaching and learning; conceptual change teaching; ability to focus; the role of negotiation; and the ability to analyse student learning. These factors are seen to be critical components of the pedagogy necessary for nurse educators to utilize PBL approaches effectively.

Clinical placement: prebriefing and debriefing as teaching strategies

This paper discusses use of debriefing processes as a teaching strategy. Such an everyday session in the clinical setting is distinguished from conventional debriefing in critical incident or post-trauma emergency situations. The group processes described can also be used to defuse fears before students experience clinical placement. Debriefing sessions are most valuable following the clinical placement day when students' heads may be whirling from over-stimulation of various kinds. The sessions facilitate use of therapeutic communication skills. They work with student emotions and affirm feelings as an integral aspect of teaching-learning. They also provide a forum in which students may practise assertive interventions in role play relevant to specific unsatisfactory interactions experienced on the ward. Positive feedback from the clinical teacher and peers helps build up student confidence.