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WHAT IS KNOWN ON THE SUBJECT?: Existing literature provides insight into the general experience of carers of people with a mental illness. Previous studies have found that carers experience a range of emotions when looking after their relatives with a mental illness. However, experiences of carers as they engage with the healthcare system is largely absent from the literature. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper identified the experiences of carers when their relatives are experiencing a crisis or acutely unwell. Carers found themselves in the middle between mental health services and their relatives. Strategies employed by carers to ensure their relatives receive adequate care were identified from this study. This paper identified how carers needed to become more assertive in order to receive adequate care for their relatives, and this finding has implications for any future carer education. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The participants identified the need to work more collaboratively with carers of people with a mental illness as they seek treatment for their relatives in order to achieve better health outcomes for the patients. Improved health service engagement of carers was seen by participants to assist them to better care for their relative. The study also found that there needs to be a clearer definition as to what constitutes mental health crisis and how carers are able to intervene during this period. Services could provide clear information concerning crisis services and in particular triage. ABSTRACT: Aim The literature reporting experiences of relatives of people with mental illness regarding their interactions with mental health services identifies many commonalities. However, the actual experience of carers engaging the services and understanding healthcare systems remains a gap in the literature. The aim of this study was to explore the experiences of carers (of people with a severe mental illness) in a major area mental health service in Victoria Australia as they fulfil their caring role while negotiating support for their relative. A carer is defined as a family member or significant other who is the primary individual who provides informal care for a person with severe mental illness and may or may not be in receipt of income supplement for such a role. Specifically this study has a focus on the experience of the carer when negotiating care needs or admission with a mental health service. Method A qualitative descriptive approach was used with five focus groups as a means of data collection. Ethical approval for the study was obtained from both the hospital and universities ethics committees. Results Key themes identified using thematic analysis are presented in the words of the carers and include: "Juggling" between services; We became assertive and If only they would listen. Often carers were advocating for their relative and needing to negotiate between services (police and crisis assessment teams) to gain any form of assessment or intervention. Carers often spent a great deal of time on the phone to services only to be told that their relative was "not sick enough" to access care or that no response would occur without another service also being involved. Discussion Our research highlights the importance of working collaboratively with informal carers and acknowledging their valuable contribution to the care of their relatives with a severe mental illness. It is very important that adequate support is given to carers especially during the period when their relatives are experiencing a crisis. An understanding of their experiences ensures a more family focused approach towards care. The study findings should enable the healthcare team to focus attention on the issues which are most pertinent to carers. Nurses are advocates not only for the patient but also for their families. Relevance statement Carers supporting a person who experiences mental illness can often find themselves in difficult and emotionally challenging situations such as at times of crisis and admission to mental health services. The fourth and latest Australian National Mental Health Plan (2009-2014) acknowledged these concerns and highlighted the need to recognize the role of carers in promoting well-being and recovery of the relative with a mental illness. The plan acknowledges that families are often best placed to recognize signs of relapse in their family members with a mental illness and discharge planning should include the involvement of family members (Commonwealth of Australia, ). To achieve best care outcomes for consumers, mental health nurses need to recognize the role of the carer and collaborate in care planning.

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Practice development (PD) in mental health nursing has been progressing over the last decade; however, the level and impact of PD activity in the field of mental health remains poorly understood outside localized project impact. More specific reporting and comparative analysis of PD outcomes will improve this situation. In response, this paper presents three case scenarios from work taking place in Australia and New Zealand, as working examples of how PD methodologies have been applied within mental health practice settings. Using a comparative framework that captures the contributing assumptions, practices, processes and conditions imperative to effective PD work within a mental health-care context, three case vignettes are reviewed. The critical question driving this paper is 'what mental health-care services does PD offer in terms of transformational change approaches and the promotion of effective workplace cultures?' Conditions considered necessary for successful PD initiatives within mental health contexts are explored such as how PD converges and diverges with mental health-related theories, plus where and how PD activity best integrates with the specific elements associated with mental health-care provision. The findings are further reviewed in line with reports of PD outcomes from other fields of health care.

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Women with serious mental illness are frequently on antipsychotic medications to maintain their mental health. During pregnancy there is much debate as to whether to continue or cease these medications. The possibility of adverse effects is of concern to clinicians and the women. This study used a case study methodology to identify the outcomes for 10 babies of women with a history of serious mental illness. The results provide further evidence in regard to women and the use of antipsychotic medications throughout pregnancy and during the first year after birth. Separation of mother and baby occurred in five of the 10 babies. This study identifies the neonatal complications for these vulnerable babies as not outside the norm for births in Australia. The high rate of mother-baby separation is of great concern and needs further longitudinal studies.

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Childbirth involves many psychological and emotional changes for women. The recent Commonwealth Government of Australia, National Perinatal Mental Health Action Plan (in 2008) recommends all pregnant and postnatal women have a psychosocial assessment including completion of the Edinburgh Postnatal Depression Scale. Midwives will assess all women at antenatal 'booking in' to maternity services. Currently, midwives receive little education regarding mental health assessment of women. This study explored the perceptions of midwives of their own mental health skills, knowledge and experiences, when working with women with mental illness in the perinatal period. An exploratory descriptive design was utilized to survey midwives across 19 maternity sites in Victoria, Australia. Clearly, midwives lack mental health skills and knowledge, describing their lack of confidence and feeling uncomfortable and unsafe when providing care for women with mental illness. They also report little knowledge of resources available to provide appropriate services for these women. The future direction for improving maternity care will require midwives to assess mental health needs of women, and refer them on, for timely intervention. It is critical midwives are prepared and able to make this kind of assessment.

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A syncopal episode in an elderly patient with a history of carotid disease, multiple cardiac risk factors, and new onset chest pain presents diagnostic challenges. This case study describes the experience of a woman with coronary vasospasm accompanied by conduction deficits. The patient's history, diagnostic work-up, and treatment program are presented. The relationship between the coronary artery anatomic defects and the conduction abnormalities are discussed.

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This pilot study (N = 20) tested the effects of intravenous midazolam administration on learning retention after pacemaker implantation. Patients were randomized to receive teaching at 1 or 3 hours after the last dose of midazolam. Using a standardized teaching format, one of two study nurses performed the teaching that included incision care, activity restrictions, environmental factors potentially affecting pacemaker function, and follow-up requirements. Learning was evaluated by one of the investigators blinded to teaching time. Subjects in the 1-hour group retained significantly less information than those taught at 3 hours after drug administration. Patients taught later answered similar numbers of questions correctly, whereas there was much more variability in correct responses for the group taught earlier. This article reviews the effects of midazolam on memory and learning as well as provides suggestions for alterations in patient education protocols for patients receiving midazolam for pacemaker implantation. The effect of shortened length of stay on care practices is also discussed.

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This study was a secondary analysis of data collected on 202 patients hospitalized with common medical or surgical cardiac conditions who completed a 24-week postdischarge follow-up program as part of a large-scale randomized clinical trial. Subjects were age 65 years or older, admitted from their homes with one of the following diagnosis-related groups: heart failure, angina, myocardial infarction, coronary artery bypass graft surgery, or cardiac valve replacement. The intervention consisted of comprehensive discharge planning and home follow-up by an advanced practice nurse (APN) for 4 weeks after discharge. Control subjects received usual care. Findings indicated that medical patients in the intervention group had fewer multiple readmissions during the 24 weeks of follow-up and a reduced total number of days of rehospitalization. There were fewer hospital readmissions in the surgical group when measured from discharge to 6 weeks. There were no differences in functional status between intervention and control groups for either population. The findings of this study suggest that high-risk elders with significant cardiac problems may benefit from a care program that emphasizes collaborative, coordinated discharge planning and home follow-up that includes telephone and home visits by APNs.

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This article presents a case study of a 16-year-old male patient with a significant family history for hypercholesterolemia and coronary artery disease, who suffered an anterior lateral myocardial infarction. On admission, his electrocardiograms revealed the classic pattern of an anterior lateral acute myocardial infarction plus a left anterior hemiblock. His cholesterol level was 750 mg/dL, and his low-density lipoprotein was 650 mg/dL. He underwent a cardiac catheterization that revealed an occluded left anterior descending artery requiring a percutaneous transluminal angioplasty and three coronary stents. The 12-lead electrocardiograms on admission and before discharge are analyzed. This article discusses the electrocardiogram characteristics of anterior lateral wall myocardial infarction coupled with a left anterior hemiblock.

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An 82-year-old man was admitted to the hospital with a narrow complex tachycardia. This article presents his case history, examples of the dysrhythmia, and a differential diagnosis approach to identifying the source of the tachycardia. The mechanism of the tachycardia is described and diagrammed and the follow-up care of the patient presented.

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A 75-year-old man developed heart block with intermittent conduction following mitral valve replacement. A simultaneously recorded central venous pressure (CVP) trace revealed evidence of the normal sequence of atrial and ventricular contraction, as well as episodes of ventricular contraction that preceded atrial contraction and episodes of simultaneous atrial and ventricular contraction. The dysrhythmia and CVP trace are analyzed and clinical implications relevant to this case history are discussed.

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This article presents a case study of a patient who required a dual chamber rate responsive pacemaker to assist in managing atrial fibrillation. The patient developed significant bradycardia when treated with the dose of propafenone required to convert atrial fibrillation, so the pacemaker was inserted. An example of a paced rhythm is presented and a differential diagnosis approach is used to discuss the possible interpretations of the rhythm. A brief explanation of the actual cause of the observed paced rhythm is presented.

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This article presents a case study of a patient who required a dual chamber rate responsive pacemaker to assist in managing atrial fibrillation. The patient developed significant bradycardia when treated with the dose of propafenone required to convert atrial fibrillation, so the pacemaker was inserted. An example of a paced rhythm is presented and a differential diagnosis approach is used to discuss the possible interpretations of the rhythm. A brief explanation of the actual cause of the observed paced rhythm is presented.

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An increasingly large body of literature demonstrates the positive effects of social support for patients with all illnesses and cardiovascular disease in particular. However, social support is not the same, nor is it equally beneficial in all circumstances. This article reviews key aspects of the social support literature and presents a model for assessing social networks.

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Hyperthyroidism is a frequently misdiagnosed cause of atrial fibrillation. Difficulties associated with diagnosis are related to physiologic idiosyncrasies, concomitant illnesses, and medication regimens that may alter thyroid function and thyroid function tests. These factors are described. Nurses have a key role in assisting patients to manage hyperthyroidism and atrial fibrillation through case finding, assessment, education, and psychological support.

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This study involves 381 patients who received an implantable cardioverter defibrillator (ICD) for management of serious ventricular dysrhythmias and were followed for up to 9 years. The device was effective in preventing sudden cardiac death (SCD), with survival rates of 97% at 3 years and 94% at 5 years. Complication rates were low. Two hundred and twenty-five patients received at least one shock; 2.3 shocks per patient year were received. Shocks were categorized as appropriate, indeterminate, or inappropriate. Definitions of these categories and their occurrence are discussed and the characteristics and experiences of these patients are described.

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This study investigated whether patients who seek an explanation for their heart attack, as compared to those who do not, differ in their affect, in expectations about their future recovery, and in expectations about coping with their future. Forty-two myocardial infarction patients were interviewed, in both the acute and convalescent stages, as to whether they had thought about "Why me?" Approximately half of the patients at each stage reported searching for an answer to that question. The patients remained generally consistent in their self-reported anxiety, depression, and hostility over time; however, patients who had not thought about "Why me?" reported less anxiety than those who had. No significant differences were found in affect in patients who gave a specific cause for their heart attack and in those who could not. Patients were significantly less optimistic about their future recovery at follow-up than when they were in the hospital, but there were no differences in expectations for future recovery or for future coping of those who had and those who had not thought about "Why me?"

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Research comparing patient and caregiver perceptions suggests that caregivers tend to be negatively biased in their assessment of patients. That is, they are more likely to judge the patients' status more negatively than the patients themselves. The data analyses, however, have not always been as informative about the extent of disagreement. Our data on the extent to which patients who had a myocardial infarction and their nurses' assessments differed suggest that, in the case of the patients' current status, there were no differences in the aggregate between patients' and nurses' assessments. Examination of the discrepancies between the pairs, however, suggests that in some cases nurses are more negative in their assessments than their patients. In the case of beliefs about the future, nurses were significantly more negative, in the aggregate, than patients, and the extent of this difference is further elaborated in the examination of the discrepancies. Nevertheless, with respect to both current and future status, the correlations between patients and nurses were low, indicating little, if any, shared variation. Because this study did not examine the relationship between either patients' or nurses' perceptions of recovery status, and the patients' actual recovery status, further research is needed to further determine the implications of this work. The meaning of these results for clinical nurse specialists (CNS) is discussed.

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