Camilla Haw

Introduction: PRN (as required) medication is commonly used in inpatient psychiatry but little is known about staff opinions concerning its use. Aims & objectives: To explore views about PRN medication among nurses and psychiatrists working in PICUs or secure care at a charitable hospital. Method: A structured questionnaire with visual analogue scales was used to examine staff views about PRN medication. Participants were: 21 PICU nurses, 20 nurses working on medium secure admission units (MSAUs) and 27 psychiatrists. Inquiry was made about preferences and avoidance of PRN drugs and when PRN administration becomes rapid tranquillisation (RT). Results: Nurses working in PICUs and MSAUs held similar views about PRN medication. Nurses were more in favour of PRN medication than psychiatrists, whereas psychiatrists felt more strongly that PRN sedation was sometimes over-used. PICU staff favoured promethazine whereas non-PICU staff preferred lorazepam/lorazepam and haloperidol combined. There was no consensus as to when PRN administration becomes RT. Conclusions: Nurses hold more positive views about PRN sedation than psychiatrists. Despite the ECG requirement, many staff favour haloperidol. The NICE definition of RT was not quoted by most participants. RT and PRN medication is a grey area which deserves further exploration.

In October 2013, the Tribunals Judiciary of England issued a new practice direction stipulating how tribunal reports should be completed. This paper aimed to study the quality of nursing tribunal reports in a secure inpatient service before and after the introduction of the latest practice direction and the issuing of a local template to aid report writing. A total of 160 reports (80 written in 2013 and 80 in 2014) were scored on the presence of 24 key items derived from the latest practice direction. The quality of nursing reports improved in the re-audit from an average of 36.3% of key items present to 51.3% but still lagged behind that of medical and social circumstances reports. Even in the second audit, few reports were signed or commented on why the patient should remain detained. Report length increased from a mean of 2.9 to 4.0 pages but only 27.5% of reports used the template despite widespread publicity. Use of the template resulted in better quality reports. Among other interventions, a training programme in report writing is now underway to assist nurses with meeting the new practice direction requirements. Nurses also need supervision, protected time and a quiet area for report writing.

Data from the Oxford Monitoring System for Attempted Suicide (2004–2011) were used to study hospital presentations for self‐harm in which Suicidal Intent Scale (SIS) scores were obtained (N = 4,840). Regression of medians was used to control for the confounding effect of age and gender. Higher estimated median SIS scores were associated with increasing age, male gender, self‐poisoning versus self‐injury, multiple methods of self‐harm versus self‐injury alone, use of gas (mainly carbon monoxide), dangerous methods of self‐injury (including hanging, gunshot), and use of alcohol as part of the act. For self‐poisoning patients, there was a correlation between the number of tablets taken and the total SIS score. Compared with self‐poisoning with paracetamol and paracetamol‐containing compounds, self‐poisoning with antipsychotics was associated with a lower median SIS score while antidepressants had the same estimated median as paracetamol. Use of alcohol within 6 hours of self‐harm was associated with lower SIS scores. In conclusion, certain methods of self‐harm, particularly dangerous methods of self‐injury and self‐poisoning with gas, were associated with high intent and should alert clinicians to potential higher risk of suicide. However, apart from use of gas, suicidal intent cannot be inferred from type of drugs used for self‐poisoning.

Aims: To explore mental health nurses' knowledge, attitudes and clinical judgement concerning medicines management in an inpatient setting with a view to enhancing training.Background: Medicines management is a key role of mental health nurses, but little research has been conducted into their training needs.Design: An exploratory mixed‐methods design was used involving individual interviews with participants to investigate their responses to hypothetical medicine administration scenarios.Methods: Interviews were held with a convenience sample of 50 Registered Nurses working in a specialist mental health hospital between November 2012–February 2013. Participants were presented with clinical vignettes describing eight scenarios they might encounter as part of their medicines management role and asked about how they would respond. Responses were assessed by two independent raters against ten quality standards underpinning the vignettes.Results: The median number of responses that were judged to demonstrate adequate awareness of associated quality standards was 4 (range 1–7), indicating that many participants did not appear to be aware of, or compliant with, currentUKmedicines management guidance and local policy. Many would not report a ‘near miss’ or medicines administration error. There was a lack of awareness of guidance on verbal prescribing, consent to treatment rules and the administration of off‐label/unlicensed drugs. Past year attendance on a medicines management course, time since registration and self‐reported knowledge of national standards for medicines administration did not discriminate between total score on the 10 quality standards.Conclusion: The medicines management training needs of participants appeared not to be fully met by the existing learning sources. The use of vignettes to assess nurses' training needs requires evaluation in other settings.

Background: A growing body of research evidence from countries around the world indicates that economic recession is associated with increases in suicide, particularly in males of working age. Aims: To explore contributory and ameliorating factors associated with economic recession and suicide and thereby stimulate further research in this area and encourage policy makers to consider how best to reduce the impact of recession on mental health and suicidal behaviour. Method: We conducted a selective review of the worldwide literature focusing on possible risk factors, mechanisms and preventative strategies for suicidal behaviour linked to economic recession. Results: A model of how recession might affect suicide rates is presented. A major and often prolonged effect of recession is on unemployment and job insecurity. Other important effects include those exerted by financial loss, bankruptcy and home repossession. It is proposed these factors may lead directly or indirectly to mental health problems such as depression, anxiety and binge drinking and then to suicidal behaviour. Countries with active labour market programmes and sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job-search initiatives for the unemployed. Other measures likely to help include targeted interventions for unemployed people, membership of social organisations and responsible media reporting. Good primary care and mental health services are needed to cope with increased demand in times of economic recession but some governments have in fact reduced healthcare spending as an austerity measure. Conclusion: The research evidence linking recession, unemployment and suicide is substantial, but the evidence for the other mechanisms we have investigated is much more tentative. We describe the limitations of the existing body of research as well as make suggestions for future research into the effects of economic recession on suicidal behaviour.

Suicide clusters, although uncommon, cause great concern in the communities in which they occur. We searched the world literature on suicide clusters and describe the risk factors and proposed psychological mechanisms underlying the spatio‐temporal clustering of suicides (point clusters). Potential risk factors include male gender, being an adolescent or young adult, drug or alcohol abuse, and past history of self‐harm. However, the majority of studies lack methodological rigor. Many different psychological mechanisms are described, including contagion, imitation, suggestion, learning, and assortative relating, but supporting empirical evidence is generally lacking. More scientifically rigorous studies are needed to improve understanding of suicide clusters.

Background: The use of additional sedative psychotropic medication to calm agitated or aggressive patients is known as rapid tranquillisation (RT). Several studies of RT practice have been conducted in psychiatric intensive care units (PICUs) and acute psychiatric settings. Method: We carried out a cross-sectional survey of the use of parental sedation in an English secure hospital using data from medication charts and case notes. Results: We studied the medication charts of 316 patients and found 203 incidents (all involving intramuscular route) of parenteral sedation involving just 35 patients. The vast majority (30; 85.7%) of those administered parenteral sedation were female and most (23; 65.7%) had emotionally unstable personality disorder. The most common indication was self-harm (44; 21.7%). In 24 (11.8%) instances the patient had requested an injection. A single drug was administered in 159 (78.3%) cases. The most commonly administered drug was lorazepam (152 cases) followed by haloperidol (69) and olanzapine (21). Case note documentation was frequently inadequate and in very few cases was there evidence of physical monitoring. Conclusions: The use of parenteral sedation was rather different from that previously described in PICUs. Hospital policy and NICE guidance were not always being followed. Measures to rectify these deficits are being taken.