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PubMed2004

Understanding the social context of violent and aggressive incidents on an inpatient unit.

The English National Service Framework for Mental Health stipulates that the highest quality of health care should be provided for mental health service users. Incidents of aggression and violence militate against achieving that goal, yet such incidents are frequently reported in inpatient settings. Much research in this area reflects a dualistic, perpetrator/victim conceptualization of incidents. This study aimed to take a more systemic approach by treating violent and aggressive incidents as social interactions and by seeking to understand the social contexts in which they took place. In this paper we describe and discuss the main themes to emerge from 15 staff accounts of 11 incidents on one ward. A striking theme reflected throughout the interview data was the lack of staff engagement with clients, and particularly an inability to look at the world through clients' eyes in interpreting their behaviour. We conclude that the 'zero tolerance' campaigns currently being conducted in the UK in relation to aggression towards NHS staff are unlikely to succeed without attention to understanding why aggressive behaviour arises and identifying features of the caring environment that may contribute to it. Rather than adopting a position of 'zero tolerance', we argue that three steps are required following an aggressive incident: emotional support; critical reflection and learning; and the pursuit of accountability.

Aggression↗

PubMed2004

Education and training in psychosocial interventions: a survey of Thorn Initiative course leaders.

The Thorn Initiative is a prominent education and training programme for psychosocial interventions. The course originated in two centres in the UK in 1992, 10 years on the programme had expanded to 13 centres across England and Wales. A survey of course content and structure was sent out to all 13 sites by email of which eight responded by post. The survey results showed that since 1999 there has been a rapid growth in the number of Thorn sites. There remains a high degree of fidelity to the original courses in mode of delivery, service user and carer participation, and core content. All of the sites were progressing towards providing degree courses, usually in a modular format and with an expanded curriculum. In conclusion, the Thorn Steering Group has been successful in Thorn site expansion and curriculum development. Such success has taken activity away from audit and research in psychosocial interventions, education, training, implementation and fidelity to taught skills. Implementation remains a cause for concern and it is recommended that a focus for Thorn sites should be on creating and evaluating novel solutions to this pervasive problem.

Cooperative Behavior↗

PubMed2005

Launching the Tidal Model: evaluating the evidence.

Launching the Tidal Model: evaluating the evidence This paper reports on two evaluations of the Tidal Model, in the context of two separate acute admission wards, one in Birmingham (2004) and the other in Newcastle (2001), and makes recommendations concerning the criteria and type of reasoning appropriate to evaluating the evidence the two projects have generated. In the Birmingham study, results showed that in the year following the introduction of the Tidal Model, the total number of serious untoward incidents such as physical assault, violence and harassment, decreased by 57%. Nurse satisfaction with their work also improved with nurses rating the model superior to their previous way of working. Inpatient service user assessment of the overall quality of their care was also positive. These findings are then compared with the positive results of an earlier study of the Tidal Model undertaken in Newcastle in 2001. That study was criticized, however, for not showing conclusively that the positive results of the evaluation correlated with the introduction of the Tidal Model. This criticism is briefly examined in the light of both ancient (Aristotle) and modern (Charles Peirce) understandings of the nature of evidence and suggests that such criticism begs the question of the nature of proof. The paper concludes by arguing that, according to both Aristotle and the procedures of abductive reasoning advocated by Charles Peirce, inferring a positive correlation between the results of both studies and the introduction of Tidal Model is a good example of reasonable inference to the best explanation. The available evidence suggests that the results of both studies render the conclusion probable and thus 'good enough' to warrant serious consideration for implementing the Tidal Model more widely within and across Mental Health NHS Trusts.

Humans↗

PubMed2006

An evaluation of a combined education and multi-project practice development programme in mental health.

This paper describes a unique mental health practice development programme, which aims to integrate education, research, clinical practice and culture change, and promote collaboration between academics, researchers and healthcare practitioners to meet current government policy needs. The programme combines academic qualifications within the context of practice development and aims to produce practitioners who are dynamic leaders, capable of critical thinking, influencing culture change and challenging the nature of conventional practice. The aim of the evaluation was to give insight into participants' experience of the programme using a qualitative approach. Open-ended questionnaires obtained participant's views on facilitation and module content. Focus groups discovered the views and experiences of participants of the programme. The findings showed that the programme was well-received and impacted positively on both patient care and the personal and professional development of participants. The findings were used to modify the programme for the next intake of participants. The research complements the existing body of knowledge on practice development and highlights the benefits for staff, nurses and service users, and the challenges of implementation. The framework and design has the potential to be applied to other areas of practice beyond mental health.

Evidence-Based Medicine↗

PubMed2006

A survey of mental health nurses' experiences of stalking.

Although an increasing amount of literature has appeared in recent years on the subject of stalking, little is known about mental health nurses' (MHNs) experiences of this phenomenon. The aims of the study were to investigate: (1) the incidence of stalking among a sample of MHNs in the UK; (2) who the perpetrators were; (3) the impact of stalking on MHNs; and (4) how MHNs manage their experiences. Employing a survey design, the British version of the Rutgers-Penn clinicians and stalking questionnaire was distributed to a convenience sample of 400 MHNs in the UK. Data were analysed by means of descriptive statistics and McNemar test. The findings reveal that: (1) 50% (n = 56) of MHNs who completed the questionnaire had been stalked; (2) on the whole, victims were female (78.6%) and stalkers males (82.1%); (3) stalkers were from a variety of social groups including mental health service users and MHNs; (4) victims were threatened, followed, physically assaulted and received unwanted communication; (5) MHNs reported a variety of stress-related (psychological and behavioural) responses to their experiences; and (6) employed a range of coping strategies. This study serves to raise awareness of a number of issues surrounding an under-reported phenomenon in mental health nursing and points to the need for further research to explore the reliability and consequences of the findings.

Adaptation, Psychological↗

PubMed2006

Closeness, chaos and crisis: the attractions of working in acute mental health care.

This paper makes a case for the attractiveness of acute mental health inpatient nursing (acute nursing) and argues that an altered perception of this work is essential if we are to provide the most acutely mentally ill and vulnerable people with a stable and expert nursing workforce. The discussion draws on an ethnographic study conducted in an inner-city psychiatric unit in England and the advantages of this method for understanding nursing work are described. Within our findings, we set out two overarching themes: the contextual realities of the contemporary acute ward and features of attraction that encourage nurses to work in the acute care setting. The former includes nurses' responsibility for the total ward environment and the latter the 'comfort of closeness' and 'surviving and thriving in chaos and crisis'. In conclusion, we argue that despite the unpopularity of the acute inpatient mental health environment, the highly sophisticated skills employed by acute nurses actually ensure the promotion of health for the majority of service users.

Acute Disease↗

PubMed2006

Can we assess students' awareness of cultural diversity? A qualitative study of stakeholders' views.

CONTEXT: Personal attitudes of doctors towards cultural diversity may influence the delivery of clinical care. Yet whether medical schools should assess a student's cultural awareness and if so, how, has not been specifically debated. OBJECTIVE: To establish the views of key stakeholders in medical education on the assessment of awareness of cultural diversity within the undergraduate curriculum. METHODS: Semi-structured interviews were undertaken, using sampling and snowballing, with 61 stakeholders, including policymakers, teachers of diversity, students, service users and carers. The data were analysed qualitatively using quasi-statistical and template approaches and themes identified. RESULTS: Three main themes emerged. The first was ambivalence over the need to assess students. Most felt students should be assessed to ensure the subject was taken seriously. Some were concerned that assessment might encourage false attitudes. The second theme was uncertainty over the best methodology. Objective structured clinical examinations (OSCEs) were the most favoured method. Significant concern was expressed that this alone was sufficient. The third theme was concern that current assessment methods do not identify students with inappropriate attitudes that are potentially detrimental to patient care. CONCLUSIONS: Assessment of cultural awareness should be attempted but it needs to be multifaceted. The OSCE alone is inadequate. Other tools, such as reflective portfolios, need evaluation.

Attitude of Health Personnel↗

PubMed2006

A pilot project to design, implement and evaluate an electronic integrated care pathway.

The project focused on the design, implementation and evaluation of an electronic integrated care pathway (eICP), within a Mother and Baby Unit. Health care professionals and service users (stakeholders) were involved in the process in order to promote patient centred, co-constructed care. Questionnaire and discussion groups were used for data collection regarding the initial eICP development. Of 15 participants who took part in the design and development of the eICP, seven were able to take part in the evaluation process on the Unit. Results show that 100% (n = 7) of the participants were in agreement with the eICP and the format that was produced and implemented for trial on the Unit. Increased ownership of records, greater multi disciplinary involvement and enhanced patient experience were also reported. Recommendations for clinical practice include resource management, ownership of the research group, holism maintenance and the acquisition of computer skills.

Critical Pathways↗

PubMed2006

'Taking off the suit': engaging the community in primary health care decision-making.

OBJECTIVE: To explore the process of public involvement in planning primary health care. BACKGROUND: Recent policy in the UK promotes public involvement in planning health but there have been difficulties in engaging communities in the process. Surveys of health service organizations have found that there has been a failure to adapt to new approaches. It has become important to understand why this has occurred if policy initiatives to encourage involvement are to succeed. DESIGN: Qualitative study. Data collected through individual interviews and focus groups. SETTING: Two new primary healthcare developments in deprived areas in Bristol and Weston-Super-Mare. PARTICIPANTS: Thirty-six professionals and 23 local residents in Bristol; six professionals and three local residents in Weston-Super-Mare. RESULTS: Three themes were identified: process, partnership and power. The main findings were that exceptional people with a shared commitment to public involvement were necessary to motivate others and develop partnerships. Local people were drawn into the process and with increased confidence became powerful advocates for their community. Creative and varied methods to involve the public were important in achieving balance between professionals and lay people. However, conflicts over practical decisions arose from a lack of clarity over who had power to influence decisions. CONCLUSION: Most of the participants were enthusiastic about their experience of public involvement in planning primary health care. Features crucial to sustainable involvement included a commitment from leaders within statutory agencies, support over a long period to build the confidence of local people, willingness to use informal approaches that are in tune with local culture, and a recognition of the concerns of both service users and providers.

Adult↗

PubMed1997

The specialist learning disability nurse in Wales.

This paper reflects on the development of services for people with learning disabilities within the United Kingdom and focuses on the role of the specialist nurse. The nurse's contribution to the care of this client group has been the subject of debate and controversy for a number of years. Developments within the learning disability filed in Wales in particular are explored, with the All Wales Strategy for People with Learning Disabilities providing the background and context for these developments. An example of how specialist nurses from around Wales came together in order to share good and best practice is discussed. The conclusion is that the specialist learning disability nurse has a great deal to offer, but must be prepared to work together with other professionals as well as service users and their families.

Humans↗

PubMed2005

The intimate mediator: a carer's experience of Alzheimer's.

This research arose out of a collaboration between a service user (M) and two researchers. Following M's invitation to us to explore issues surrounding a carer's experience of Alzheimer's, we jointly agreed a research strategy in which we would engage in a series of interviews with M, with the aim of developing insight into how the intimate carer's complex journey can support and benefit other family caregivers faced with similar challenges. Using a broadly hermeneutic-phenomenological method, three essential themes emerged to describe the carer's journey: (i) something is wrong; (ii) the challenging shared journey: being the carer; (iii) coping through meaning-making: advocacy. We arrive at a position which considers the unique role of an intimate carer as a 'liminal' figure between the private world of an Alzheimer's sufferer and the public world of health and social care systems. The paper concludes with a consideration of how the unique role of the intimate carer as mediator could be more respectfully involved as an ongoing knowledge source for care planning and treatment decisions. Specific areas of consideration in this regard include mechanisms for such user involvement in policy making, day-to-day care delivery, and developments in the support of other carers. We hope to highlight the 'intimacy' of this position and the distinctive benefits and challenges of such intimacy in providing a crucial level of user knowledge and 'evidence' for ongoing treatment decisions. We also hope to highlight the value and power of single-case study in generating useful insights for practice.

Alzheimer Disease↗

PubMed2006

Assessing learning needs for breastfeeding: setting the scene.

Breastfeeding has a major contribution to make to public health, yet the UK, like many other developed countries, has low rates of breastfeeding. A contributing factor is that practitioners are ill-prepared to support breastfeeding women. There is a mismatch between the care professionals provide and the support women desire. A national breastfeeding learning needs assessment (LNA) was carried out in England to provide a comprehensive picture of professional and practitioner learning needs and existing training opportunities and resources. The LNA comprised five elements, and sought the views of service users through consumer organizations and voluntary breastfeeding supporters. Two elements of the LNA are reported here. A search of RDLearning, a web-based national resource, provided details of existing accredited courses in the UK for practitioners. Ten short courses provided by higher education institutions were identified, along with a range of courses offered by voluntary and other organizations, such as the National Childbirth Trust and UNICEF Baby Friendly Initiative. Second, an e-mail survey of 28 key stakeholder organizations was undertaken, with a response rate of 68% (n = 18). All but one acknowledged that their members could benefit from further breastfeeding knowledge and expertise and were supportive of a national breastfeeding education initiative. The most popular forms of education provision were workshops and seminars, online and written information. The topic considered most important for all practitioners was the health outcomes of breastfeeding. Other contributions which stakeholder organizations felt they could make were the provision of information resources and setting up specialist interest groups.

Breast Feeding↗

PubMedDate not supplied

The oral health of children with Down syndrome in Ireland.

The authors investigated the oral health of a convenience sample of 71 children with Down syndrome. The study group had a lower caries prevalence but similar levels of unmet treatment needs as children at special and mainstream schools. Treatment experience varied with age: 5-year-olds had more extractions and fewer restorations, and 15-year olds had fewer extractions and more restorations. The number of teeth with fissure sealants was comparable to that of other children in Special Needs Schools. Although the study group had poor oral hygiene, a need for advanced periodontal treatment was not evident. Few had evidence of dental trauma. Malocclusion was prevalent. Through a government-funded program, most of the sample had seen a dentist within the previous year, and few parents reported problems accessing dental care. This study suggests that services targeted toward groups with special needs could generate outcomes comparable to those seen in other service users. A finding that also may hold true for other underserved populations.

Adolescent↗

PubMed2002

Qualitative study of evidence based leaflets in maternity care.

OBJECTIVE: To examine the use of evidence based leaflets on informed choice in maternity services. DESIGN: Non-participant observation of 886 antenatal consultations. 383 in depth interviews with women using maternity services and health professionals providing antenatal care. SETTING: Women's homes; antenatal and ultrasound clinics in 13 maternity units in Wales. PARTICIPANTS: Childbearing women and health professionals who provide antenatal care. INTERVENTION: Provision of 10 pairs of Informed Choice leaflets for service users and staff and a training session in their use. MAIN OUTCOME MEASURES: Participants' views and commonly observed responses during consultations and interviews. RESULTS: Health professionals were positive about the leaflets and their potential to assist women in making informed choices, but competing demands within the clinical environment undermined their effective use. Time pressures limited discussion, and choice was often not available in practice. A widespread belief that technological intervention would be viewed positively in the event of litigation reinforced notions of "right" and "wrong" choices rather than "informed" choices. Hierarchical power structures resulted in obstetricians defining the norms of clinical practice and hence which choices were possible. Women's trust in health professionals ensured their compliance with professionally defined choices, and only rarely were they observed asking questions or making alternative requests. Midwives rarely discussed the contents of the leaflets or distinguished them from other literature related to pregnancy. The visibility and potential of the leaflets as evidence based decision aids was thus greatly reduced. CONCLUSIONS: The way in which the leaflets were disseminated affected promotion of informed choice in maternity care. The culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice.

Adult↗

PubMed1986

An overview of the Canadian health care experience.

Canada's universal health insurance system is designed to assure all Canadians access to free hospital and medical treatment. Each province has had considerable latitude in administering the system within its borders. To cope with rising costs, most provinces have adopted policies that limit physician income. Others have instituted fees for service users and have allowed physicians to bill patients for charges above the benefit schedule set by the province. These latter practices have been seen as eroding access to health care, and government funding for provinces that permit them was sharply curtailed by the Canada Health Act of 1984. The law is currently being challenged by the Canadian Medical Association because of the restrictions it places on physicians' freedom of practice. Although the Canadian system has created problems for physicians, the authors believe it provides a benefit no one wants to lose: accessible medical care for all.

Canada↗

PubMed2005

A focus group enquiry into stress experienced by staff working with people with challenging behaviours.

A focus group is a group of people with a shared interest who meet to discuss a particular topic and generate information and opinion. Initially developed for use in market research, focus groups have been widely used in research and are often used in health and social care research. There is an increasing use of focus groups within learning disability settings both with staff and with service users. In this study a series of explorative focus groups gathered information from community staff regarding their experiences of stress when working with people with learning disabilities and challenging behaviours.

Attitude of Health Personnel↗

PubMed2006

Using goal attainment scaling to evaluate a needs-led exercise programme for people with severe and profound intellectual disabilities.

The aim of this study was to evaluate whether involvement in a 16 week exercise programme improved goal attainment in areas of behaviour, access to community-based experiences, health and physical competence. Participants were women with severe intellectual disability and associated challenging behaviour (setting A,N = 14) and male/female service users with profound physical and intellectual disabilities (setting B,N = 8). The exercise programme included active and passive exercise, walking, swimming, hydrotherapy, team games and rebound therapy. Significant gains in aggregated goal attainment were demonstrated by week 16. The reliability and validity of our goal attainment procedures were demonstrated with inter-rater reliabilities exceeding 80 percent. Changes in goal attainment were concurrent with global clinical impression scores in a series of single case studies. Continuing care settings should dedicate care staff to provide routinized, continuing exercise programmes.

Exercise↗

PubMed2004

A web services choreography scenario for interoperating bioinformatics applications.

BACKGROUND: Very often genome-wide data analysis requires the interoperation of multiple databases and analytic tools. A large number of genome databases and bioinformatics applications are available through the web, but it is difficult to automate interoperation because: 1) the platforms on which the applications run are heterogeneous, 2) their web interface is not machine-friendly, 3) they use a non-standard format for data input and output, 4) they do not exploit standards to define application interface and message exchange, and 5) existing protocols for remote messaging are often not firewall-friendly. To overcome these issues, web services have emerged as a standard XML-based model for message exchange between heterogeneous applications. Web services engines have been developed to manage the configuration and execution of a web services workflow. RESULTS: To demonstrate the benefit of using web services over traditional web interfaces, we compare the two implementations of HAPI, a gene expression analysis utility developed by the University of California San Diego (UCSD) that allows visual characterization of groups or clusters of genes based on the biomedical literature. This utility takes a set of microarray spot IDs as input and outputs a hierarchy of MeSH Keywords that correlates to the input and is grouped by Medical Subject Heading (MeSH) category. While the HTML output is easy for humans to visualize, it is difficult for computer applications to interpret semantically. To facilitate the capability of machine processing, we have created a workflow of three web services that replicates the HAPI functionality. These web services use document-style messages, which means that messages are encoded in an XML-based format. We compared three approaches to the implementation of an XML-based workflow: a hard coded Java application, Collaxa BPEL Server and Taverna Workbench. The Java program functions as a web services engine and interoperates with these web services using a web services choreography language (BPEL4WS). CONCLUSION: While it is relatively straightforward to implement and publish web services, the use of web services choreography engines is still in its infancy. However, industry-wide support and push for web services standards is quickly increasing the chance of success in using web services to unify heterogeneous bioinformatics applications. Due to the immaturity of currently available web services engines, it is still most practical to implement a simple, ad-hoc XML-based workflow by hard coding the workflow as a Java application. For advanced web service users the Collaxa BPEL engine facilitates a configuration and management environment that can fully handle XML-based workflow.

Computational Biology↗