Publications by authors named "Mary Lavelle"

20 Publications

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Understanding adaptive teamwork in health care: Progress and future directions.

J Health Serv Res Policy 2021 07 16;26(3):208-214. Epub 2020 Dec 16.

Reader in Clinical Education, Faculty of Life Sciences and Medicine, King's College London, UK.

Health care teamwork is a vital part of clinical work and patient care but is poorly understood. Despite poor teamwork being cited as a major contributory factor to adverse events, we lack vital knowledge about how teamwork can be improved. Teams in health care are diverse in structure and purpose, and most patient care depends on the ability of different professionals to coordinate their actions. Research in this area has narrowly defined health care teams, focused mainly on a small range of settings and activities and addressed a limited range of research questions. We argue that a new approach to teamwork research is needed and make three recommendations. First, the temporal and dynamic features of teamwork should be studied to understand how teamwork unfolds sequentially. Second, contextual influences should be integrated into study designs, including the organization of work, tasks, patients, organisational structures, and health care system factors. Finally, exploratory, rather than confirmatory, research designs are needed to analyse the complex patterns of social interaction inherent in health care work, to build our theoretical understanding of health care teams and their work, and ultimately to develop effective interventions to support better teamwork for the benefit of patients.
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http://dx.doi.org/10.1177/1355819620978436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182291PMC
July 2021

Reflections, impact and recommendations of a co-produced qualitative study with young people who have experience of mental health difficulties.

Health Expect 2021 05 9;24 Suppl 1:134-146. Epub 2020 Jun 9.

NIHR Patient Safety Translational Research Centre, Imperial College London, London, UK.

Background: There is limited evidence of genuine equal partnership where power is shared with young people with mental health difficulties throughout all research stages, particularly in data collection and analysis.

Objective: To describe how our qualitative study, exploring young peoples' perceptions on the feasibility of using technology to detect mental health deterioration, was co-produced using principles of co-production, whilst reflecting on impact, challenges and recommendations.

Methods: Young people with experience of mental health difficulties were appointed and then worked with researchers throughout all research stages. The study was evaluated against the five principles of co-production. Reflections from researchers and young people were collected throughout.

Results: Seven young people formed an initial Young People's Advisory Group (YPAG); three became co-researchers. Reflection was key throughout the process. Sharing power became easier and more evident as trust, confidence and mutual respect grew over time, particularly after a safe space was established. The safe space was crucial for open discussions, and our WhatsApp group enabled continual communication, support and shared decision-making. The resulting co-produced topic guide, coding framework, thematic map, papers and presentations demonstrated significant impact.

Conclusions: To our knowledge, this is the first qualitative mental health study to be co-produced using the principles of co-production. Our rigorous assessment can be utilized as an informative document to help others to produce meaningful co-produced future research. Although co-production takes time, it makes significant impact to the research, researchers and co-researchers. Flexible funding for spontaneous suggestions from co-researchers and more time for interview training is recommended.
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http://dx.doi.org/10.1111/hex.13088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137486PMC
May 2021

Threats to safe transitions from hospital to home: a consensus study in North West London primary care.

Br J Gen Pract 2020 01 26;70(690):e9-e19. Epub 2019 Dec 26.

National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre; Department of Surgery and Cancer, Imperial College London, London.

Background: Transitions between healthcare settings are vulnerable points for patients.

Aim: To identify key threats to safe patient transitions from hospital to primary care settings.

Design And Setting: Three-round web-based Delphi consensus process among clinical and non-clinical staff from 39 primary care practices in North West London, England.

Method: Round 1 was a free-text idea-generating round. Rounds 2 and 3 were consensus-obtaining rating rounds. Practices were encouraged to complete the questionnaires at team meetings. Aggregate ratings of perceived level of importance for each threat were calculated (1-3: , 4-6: , 7-9: ). Percentage of votes cast for each patient or medication group were recorded; consensus was defined as ≥75%.

Results: A total of 39 practices completed round 1, 36/39 (92%) completed round 2, and 30/36 (83%) completed round 3. Round 1 identified nine threats encompassing problems involving communication, service organisation, medication provision, and patients who were most at risk. 'Poor quality of handover instructions from secondary to primary care teams' achieved the highest rating (mean rating at round 3 = 8.43) and a 100% consensus that it was a threat. Older individuals (97%) and patients with complex medical problems taking >5 medications (80%) were voted the most vulnerable. Anticoagulants (77%) were considered to pose the greatest risk to patients.

Conclusion: This study identified specific threats to safe patient transitions from hospital to primary care, providing policymakers and healthcare providers with targets for quality improvement strategies. Further work would need to identify factors underpinning these threats so that interventions can be tailored to the relevant behavioural and environmental contexts in which these threats arise.
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http://dx.doi.org/10.3399/bjgp19X707105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6917362PMC
January 2020

Young adults' perceptions of using wearables, social media and other technologies to detect worsening mental health: A qualitative study.

PLoS One 2019 18;14(9):e0222655. Epub 2019 Sep 18.

School of Public Health, Imperial College London, London, United Kingdom.

Background: Technological interventions may help support and improve mental health. However young peoples' perspectives on using different technologies to detect deteriorating mental health in those already diagnosed with a mental health condition is lacking. The study aim was to explore the perspectives of young patients on the feasibility and acceptability of using wearables, social media and technologies to detect mental health deterioration.

Methods: The study was co-produced with young adults with past mental health difficulties. Semi-structured interviews were conducted with young adults with a severe mental health condition in a private room at a community mental health site. Data was triangulated by comparing codes and ideas across the two co-researchers and two researchers over two virtual meetings. Themes were finalised and presented in a thematic map.

Results: Sixteen participants were interviewed (81% female). There were four main themes: dealing with mental health symptoms, signs of mental health deterioration, technology concerns and technological applications to identify worsening mental health. Wearables and mobile apps were considered acceptable and feasible to detect mental health deterioration in real-time if they could measure changes in sleep patterns, mood or activity levels as signs of deterioration. Getting help earlier was deemed essential particularly in reference to dissatisfaction with the current non-technological mental health services. However, patients identified issues to consider before implementation including practicality, safeguarding and patient preference.

Conclusion: Wearables and mobile apps could be viable technological options to help detect deterioration in young people in order to intervene early and avoid delay in accessing mental health services. However, immediate action following detection is required for the patient to trust and use the intervention.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222655PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750581PMC
March 2020

An evidence based framework for the Temporal Observational Analysis of Teamwork in healthcare settings.

Appl Ergon 2020 Jan 15;82:102915. Epub 2019 Aug 15.

The Florence Nightingale Faculty of Nursing, Midwifery and PalliativeCare, King's College London, London, UK.

Objective: Effective teamwork is critical to patient safety across multiple healthcare settings. However, current observational tools assessing teamwork performance tend to be developed for specific settings or tasks and do not capture temporal features of interaction. This study aimed to develop a valid and reliable observational teamwork behaviour framework, which is based on healthcare practice, applicable across a variety of healthcare contexts and can be used to capture temporal team dynamics.

Methods: Team interactions were audio-visually recorded during routine simulation training at two large clinical education centres specialising in physical and mental healthcare. The framework was based on theoretical models of teamwork and was developed in three steps: 1-micro analysis of verbal and nonverbal behaviour during recorded scenarios (n = 20); 2-iterative test and refine cycles; 3-final behavioural framework applied to a cohort of acute emergency scenarios (n = 9) by two raters to assess inter-rater agreement.

Results: The framework contains twenty-three specific verbal and nonverbal behaviours that can be identified during observations. Behaviours are grouped conceptually based on their function resulting in thirteen behavioural functions, which cluster into five overarching teamwork domains. Inter-rater agreement was excellent (Cohen's Kappa = .84, SE = 0.03).

Conclusion: We present a valid and reliable behavioural framework, grounded in teamwork theory and empirical observations of clinical team behaviour. This framework enables analysis of the nuances and temporal features of clinical practice in depth and across a wide range of clinical contexts and settings. Use of this framework will advance our understanding of teamworking in healthcare.
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http://dx.doi.org/10.1016/j.apergo.2019.102915DOI Listing
January 2020

Beyond the clinical team: evaluating the human factors-oriented training of non-clinical professionals working in healthcare contexts.

Adv Simul (Lond) 2019 13;4:11. Epub 2019 Jun 13.

2Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.

Background: As clinical simulation has evolved, it is increasingly used to educate staff who work in healthcare contexts (e.g. hospital administrators) or frequently encounter clinical populations as part of their work (e.g. police officers) but are not healthcare professionals. This is in recognition of the important role such individuals play in the patients' experience of healthcare, frequently being a patients' first point of contact with health services. The aim of the training is to improve the ability of the team to communicate and co-ordinate their actions, but there is no validated instrument to evaluate the human factors learning of non-clinical staff. Our aim was to develop, pilot and evaluate an adapted version of the Human Factors Skills for Healthcare Instrument, for non-clinical professionals.

Method: The 18-item instrument was developed reflecting the human factors skills of situation awareness, decision making, communication, teamwork, leadership, care and compassion and stress and fatigue management. The instrument was piloted pre- and post-training with non-healthcare professionals ( = 188) attending mental health simulation training within an 11-month period (June 2017-April 2018). Trainees were hospital/primary care administrators ( = 53, 28%), police officers ( = 112, 59%), probation officers ( = 13, 7%) and social workers ( = 10, 5%). Most participants were female ( = 110, 59%) and from White ethnic backgrounds ( = 144, 77%).

Results: Six items were removed, five were not sufficiently sensitive to change ( < .3) and one showed poor reliability. The remaining 12 items revealed a Cronbach's alpha of .93. An exploratory factor analysis revealed a one-factor solution, which explained 58.3% of the variance. The final 12-item instrument was sensitive to change post-training ( < .0001) with large effect sizes ( .7). Cluster analysis revealed that participants with lower pre-training scores showed the greatest improvement.

Discussion: The Human Factors Skills for Healthcare Instrument-Auxiliary version (HuFSHI-A) provides a reliable and valid instrument for the evaluation of human factors skills learning following training of non-clinical populations working in healthcare contexts. Although this instrument has been developed and evaluated with training courses specifically focusing on mental health topics, HuFSHI-A is applicable for any training where teamwork and co-ordination between clinical and non-clinical professionals is considered.
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http://dx.doi.org/10.1186/s41077-019-0101-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6567904PMC
June 2019

The physical and mental health of acute psychiatric ward staff, and its relationship to experience of physical violence.

Int J Ment Health Nurs 2019 Feb 27;28(1):268-277. Epub 2018 Aug 27.

Section of Mental Health Nursing, Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK.

To evaluate and describe the physical and mental health of staff on acute psychiatric wards and examine whether violence exposure is linked with health status. We undertook a cross-sectional survey with 564 nursing staff and healthcare assistants from 31 psychiatric wards in nine NHS Trusts using the SF-36, a reliable and valid measure of health status and compared summary scores with national normative data. Additional violence exposure data were collated simultaneously and also compared with health status. The physical health of staff was worse, and their mental health was better than the general population. Physical health data were skewed and showed a small number of staff in relatively poor health while the majority were above average. Better physical health was associated with less time in the current post, a higher pay grade, and less exposure to mild physical violence in the past year. Better mental health was associated with being older and from an ethnic minority background. Violence exposure influenced physical health but not mental health when possible confounders were considered. Mental health was strongly influenced by ethnicity, and further research might highlight the impact on own-group ethnic density on the quality of care. The impact of staff whom are physically unwell or impaired in the workplace needs to be considered as the quality of care may be compromised despite this being an example of inclusiveness, equal opportunities employment, and positive staff motivation.
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http://dx.doi.org/10.1111/inm.12530DOI Listing
February 2019

MBRRACE in simulation: an evaluation of a multi-disciplinary simulation training for medical emergencies in obstetrics (MEmO).

J Obstet Gynaecol 2018 Aug 21;38(6):781-788. Epub 2018 Mar 21.

d Department of Women's Health, Guy's and St. Thomas' NHS Foundation Trust , London , UK.

The majority of maternal deaths in the UK are due to pre-existing or new-onset medical conditions, known as 'indirect deaths'. The MBRRACE report identified serious gaps in clinicians' human factors skills, including communication, leadership and teamwork, which contributed to maternal death. In response, we developed the first multi-disciplinary simulation-based training programme designed to address Medical Emergencies in Obstetrics (MEmO). Employing a mixed methods design, this study evaluated the educational impact of this training programme on the healthcare staff (n = 140), including the medical doctors (n = 91) and the midwives (n = 49). The training improved participants' clinical management of medical deterioration in pregnancy (p=.003) alongside improving their human factors skills (p=.004). Furthermore, participants reported the translation of these skills to their routine clinical practice. This flexible training is responsive to the changing national needs and contextualises the MBRRACE findings for healthcare staff. It is a promising avenue for reducing the rates of in-direct death in pregnancy. Impact statement What is already known on this subject? The majority of maternal deaths in the UK are due to pre-existing or new-onset medical conditions. The management of medical conditions in pregnancy relies on a multi-professional approach. However, serious gaps in clinicians' human factors skills, highlighted by the MBRRACE report, may contribute to maternal death. What do the results of this study add? This study evaluated the first multi-disciplinary, simulation-based training programme designed to address Medical Emergencies in Obstetrics (MEmO). Training significantly improved participants' management of medical deterioration in pregnancy and human factors skills, particularly in the areas of leadership, communication and teamwork. Moreover, the participants learning translated into their clinical practice. What are the implications of these findings for clinical practice and/or further research? The delivery of multi-disciplinary team training for all healthcare staff involved in the complex management of medical conditions in pregnancy can help develop a greater understanding of others' professional roles, and demonstrate the importance of interprofessional teamwork. Furthermore, it provides the space to reflect on team working approaches, including the leadership and professional autonomy, and their potential impact on patient care. Future research should evaluate the impact of this training on the objective outcome measures of medical emergencies in pregnancy.
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http://dx.doi.org/10.1080/01443615.2017.1419339DOI Listing
August 2018

Development of the Human Factors Skills for Healthcare Instrument: a valid and reliable tool for assessing interprofessional learning across healthcare practice settings.

BMJ Simul Technol Enhanc Learn 2017 Oct 21;3(4):135-141. Epub 2017 Jun 21.

The Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.

Background: A central feature of clinical simulation training is human factors skills, providing staff with the social and cognitive skills to cope with demanding clinical situations. Although these skills are critical to safe patient care, assessing their learning is challenging. This study aimed to develop, pilot and evaluate a valid and reliable structured instrument to assess human factors skills, which can be used pre- and post-simulation training, and is relevant across a range of healthcare professions.

Method: Through consultation with a multi-professional expert group, we developed and piloted a 39-item survey with 272 healthcare professionals attending training courses across two large simulation centres in London, one specialising in acute care and one in mental health, both serving healthcare professionals working across acute and community settings. Following psychometric evaluation, the final 12-item instrument was evaluated with a second sample of 711 trainees.

Results: Exploratory factor analysis revealed a 12-item, one-factor solution with good internal consistency (α=0.92). The instrument had discriminant validity, with newly qualified trainees scoring significantly lower than experienced trainees ((98)=4.88, p<0.001) and was sensitive to change following training in acute and mental health settings, across professional groups (p<0.001). Confirmatory factor analysis revealed an adequate model fit (RMSEA=0.066).

Conclusion: The Human Factors Skills for Healthcare Instrument provides a reliable and valid method of assessing trainees' human factors skills self-efficacy across acute and mental health settings. This instrument has the potential to improve the assessment and evaluation of human factors skills learning in both uniprofessional and interprofessional clinical simulation training.
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http://dx.doi.org/10.1136/bmjstel-2016-000159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765849PMC
October 2017

Managing medical emergencies in mental health settings using an interprofessional in-situ simulation training programme: A mixed methods evaluation study.

Nurse Educ Today 2017 Dec 21;59:103-109. Epub 2017 Sep 21.

Maudsley Simulation, South London & Maudsley NHS Foundation Trust, Lambeth Hospital, SW9 9NT, UK.

Background: In the UK, people with severe mental illness die up to 20years earlier than the general population, prompting increased focus on physical health in mental illness. However, training for mental health inpatient staff to meet patients' physical health needs has not received the same attention, with physical health training often being reactive and lacking evidence of effectiveness.

Objectives: To evaluate an interprofessional, in situ, simulation training intervention for managing medical deterioration in mental health settings. Investigating the impact of training on: 1. Participants' knowledge, confidence, and attitudes towards managing medical deterioration; and 2. Incident reporting, as an objective index of incident management. Participants' perceptions of the impact on their practice were qualitatively explored.

Design: This evaluation employed a mixed-methods pre-post intervention design.

Participants & Settings: Fifty-three healthcare professionals participated including: mental health nurses, psychiatrists, healthcare assistants, and activity co-ordinators from two busy psychiatric triage wards in South London, UK.

Methods: The intervention comprised eight half-day sessions delivered weekly across two wards. Structured surveys assessed participants' knowledge, confidence, and attitudes towards medical deterioration pre and post training. Participants' experience of training was qualitatively captured through post-course surveys and focus groups three months post training. Incident reporting rates for seven-month periods pre and post training were compared.

Results: Following training, participants showed significant improvement in knowledge (p<0.001), confidence (p<0.001), and attitudes towards (p<0.02) managing medical deterioration. Incident reporting increased by 33% following training. Participants' reported improved confidence in managing medical deterioration, better understanding of effective communication, improved self-reflection and team working, and an increased sense of responsibility for patients' physical health.

Conclusions: Interprofessional, in situ simulation training for medical deterioration yielded promising outcomes for individuals and teams. Simulation is an under-used training modality in mental health, offering a holistic training approach with the potential to provide educational and clinical benefits while supporting workforce resilience.
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http://dx.doi.org/10.1016/j.nedt.2017.09.009DOI Listing
December 2017

Patient, caregiver and clinician use of comparative effectiveness research findings in care decisions: results from a national study.

J Comp Eff Res 2017 May 8;6(3):219-229. Epub 2017 Feb 8.

Patient-Centered Outcomes Research Institute, 1828 L Street NW, Suite 900, Washington, DC 20036, USA.

Aim: To assess awareness, use and attitudes concerning comparative effectiveness research (CER) findings.

Materials & Methods: Online surveys of patients and caregivers managing rare (n = 560 patients, n = 609 caregivers) or chronic conditions (n = 762 patients, n = 776 caregivers), and practicing clinicians (n = 638).

Results: Less than half of patients and caregivers reported exposure to any type of CER findings in the past 12 months. Of those, over half identify healthcare professionals as the information source, yet only 10% of clinicians indicated they were 'very familiar' with CER. Clinicians were concerned about the time required to find relevant evidence and the appropriateness of comparisons in available health research.

Conclusion: Clinicians, patients and caregivers indicate unmet need for incorporating CER research findings into clinical decision-making.
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http://dx.doi.org/10.2217/cer-2016-0061DOI Listing
May 2017

Physical injury and workplace assault in UK mental health trusts: An analysis of formal reports.

Int J Ment Health Nurs 2016 Aug 11;25(4):355-66. Epub 2016 May 11.

Institute of Psychiatry.

Workplace violence is a significant problem for health service personnel, with National Health Service (NHS) workers subject to 68 683 physical assaults between 2013 and 2014. Almost 70% of assaults occur in the mental health sector, and although serious, non-fatal injury is rare, the individual and economic impact can be substantial. In the present study, we analysed mandatory incident reports from a national database to examine whether there were identifiable precursors to incidents leading to staff injury, and whether staff characteristics were associated with injury. In line with previous descriptions, we found injury occurred either as a direct result of patient assault or during physical interventions employed by staff to contain aggression. Importantly, we found little evidence from staff reports that patients' symptoms were driving aggression, and we found less evidence of patient perspectives among reports. We make several recommendations regarding the reporting of these events that could inform policy and interventions aimed at minimizing the likelihood of injury.
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http://dx.doi.org/10.1111/inm.12201DOI Listing
August 2016

Predictors of effective de-escalation in acute inpatient psychiatric settings.

J Clin Nurs 2016 Aug 3;25(15-16):2180-8. Epub 2016 May 3.

The Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Aims And Objectives: To explore the factors that influence the use of de-escalation and its success in halting conflict in acute psychiatric inpatient setting.

Background: De-escalation is the use of verbal and nonverbal communication to reduce or eliminate aggression and violence during the escalation phase of a patient's behaviour. Although de-escalation is a first-line intervention in aggression management in acute psychiatric settings, little is known about the use or effectiveness of this technique.

Design: A retrospective case note analysis.

Methods: For each patient (n = 522), their involvement in conflict (e.g. aggression) or containment (e.g. coerced medication) during the first two weeks of their admission was recorded. The frequency and order of the conflict and containment events were identified during each shift. The sequences of events occurring in shifts involving de-escalation were analysed. Sequences where de-escalation ended the pattern of conflict or containment were categorised as 'successful', and all others were categorised as 'unsuccessful'.

Results: Over half of patients (53%) experienced de-escalation during the first two weeks of admission, with the majority of these (37%) experiencing multiple episodes. De-escalation was successful in approximately 60% of cases. Successful de-escalations were preceded by fewer, and less aggressive, conflict events, compared with unsuccessful de-escalations, which were most frequently followed by administration of pro re nata medication. Patients with a history of violence were more likely to experience de-escalation, and it was more likely to be unsuccessful.

Conclusions: De-escalation is frequently effective in halting a sequence of conflict in acute inpatient settings, but patients with a history of violence may be specifically challenging.

Relevance To Clinical Practice: These findings provide support for de-escalation in practice but suggest that nurses may lack confidence in using the technique when the risk of violence is greater. Providing evidence-based staff training may improve staff confidence in the use of this potentially powerful technique.
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http://dx.doi.org/10.1111/jocn.13239DOI Listing
August 2016

Aggression on inpatient units: Clinical characteristics and consequences.

Int J Ment Health Nurs 2016 Aug 19;25(4):308-18. Epub 2016 Feb 19.

Institute of Psychiatry, Psychology and Neuroscience, Kings College London.

Aggression and violence are widespread in UK Mental Health Trusts, and are accompanied by negative psychological and physiological consequences for both staff and other patients. Patients who are younger, male, and have a history of substance use and psychosis diagnoses are more likely to display aggression; however, patient factors are not solely responsible for violence, and there are complex circumstances that lead to aggression. Indeed, patient-staff interactions lead to a sizeable portion of aggression and violence on inpatient units, thus they cannot be viewed without considering other forms of conflict and containment that occur before, during, and after the aggressive incident. For this reason, we examined sequences of aggressive incidents in conjunction with other conflict and containment methods used to explore whether there were particular profiles to aggressive incidents. In the present study, 522 adult psychiatric inpatients from 84 acute wards were recruited, and there were 1422 incidents of aggression (verbal, physical against objects, and physical). Cluster analysis revealed that aggressive incident sequences could be classified into four separate groups: solo aggression, aggression-rule breaking, aggression-medication, and aggression-containment. Contrary to our expectations, we did not find physical aggression dominant in the aggression-containment cluster, and while verbal aggression occurred primarily in solo aggression, physical aggression also occurred here. This indicates that the management of aggression is variable, and although some patient factors are linked with different clusters, these do not entirely explain the variation.
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http://dx.doi.org/10.1111/inm.12191DOI Listing
August 2016

Describing the precursors to and management of medication nonadherence on acute psychiatric wards.

Gen Hosp Psychiatry 2015 Nov-Dec;37(6):606-12. Epub 2015 Jul 2.

Section of Mental Health Nursing, Health Services and Population Research, Institute of Psychiatry, King's College London.

Objective: This study aims to (a) describe what conflict (aggression, absconding etc.) and containment (de-escalation, restraining etc.) events occur before and after events of medication nonadherence on acute psychiatric wards and (b) identify which patient characteristics are associated with medication nonadherence.

Method: Conflict and containment events for each shift over the first 2 weeks of admission were coded retrospectively from nursing records for a sample of 522 adult psychiatric inpatients. The frequency and order of the conflict and containment events were identified. Univariate logistic regression models were conducted to examine which patient characteristics were linked with medication noncompliance.

Results: Medication refusals were commonly preceded by aggression whereas demands for pro re nata (PRN) (psychotropic) were commonly preceded by the same patient having been given PRN medication. Refusals and demands for medication were commonly followed by de-escalation and given PRN (psychotropic) medication. Only refusal of PRN medication was commonly followed by forced (intramuscular) medication. Ethnicity, previous self-harm and physical health problems were also linked to nonadherence.

Conclusions: Greater attention to the conflict and containment events that precede and follow medication nonadherence may reduce the likelihood of medication nonadherence.
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http://dx.doi.org/10.1016/j.genhosppsych.2015.06.017DOI Listing
August 2016

Participation during first social encounters in schizophrenia.

PLoS One 2014 20;9(1):e77506. Epub 2014 Jan 20.

University of Exeter Medical School, Exeter, United Kingdom.

Background: Patients with a diagnosis of schizophrenia are socially excluded. The aim of this study was to investigate how patients participate in first encounters with unfamiliar healthy participants, who are unaware of their diagnosis.

Methods: Patterns of participation were investigated during interactions involving three-people. Three conversation roles were analysed: (i) speaker, (ii) primary recipient- focus of the speaker's attention and (iii) secondary recipient- unaddressed individual. Twenty patient interactions (1 patient, 2 healthy controls) and 20 control interactions (3 healthy participants) were recorded and motion captured in 3D. The participation of patients and their partners, in each conversation role, was compared with controls at the start, middle and end of the interaction. The relationship between patients' participation, their symptoms and the rapport others experienced with them was also explored.

Results: At the start of the interaction patients spoke less (ß = -.639, p = .02) and spent more time as secondary recipient (ß = .349, p = .02). Patients' participation at the middle and end of the interaction did not differ from controls. Patients' partners experienced poorer rapport with patients who spent more time as a primary recipient at the start of the interaction (Rho(11) = -.755, p<.01). Patients' participation was not associated with symptoms.

Conclusion: Despite their increased participation over time, patients' initial participation appears to be associated with others' experience of rapport with them. Thus, the opening moments of patients' first encounters appear to be interpersonally significant. Further investigation of patient and others' behaviour during these critical moments is warranted in order to understand, and possibly develop interventions to address, the difficulties schizophrenia patients experience here.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0077506PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3896339PMC
December 2014

Nonverbal behavior during face-to-face social interaction in schizophrenia: a review.

J Nerv Ment Dis 2014 Jan;202(1):47-54

*Institute of Psychiatry, Kings College London, London, UK; †Interaction, Media and Communication Research Group, School of Electronic Engineering & Computer Science, Queen Mary, University of London, London, England; and ‡University of Exeter Medical School, Exeter, UK.

Patients with a diagnosis of schizophrenia display social cognitive deficits. However, little is known about patients' nonverbal communication during their social encounters with others. This review identified 17 studies investigating nonverbal communication in patients' unscripted face-to-face interactions, addressing a) nonverbal differences between patients and others, b) nonverbal behavior of the patients' partners, c) the association between nonverbal behavior and symptoms, and d) the association between nonverbal behavior and social outcomes. Patients displayed fewer nonverbal behaviors inviting interaction, with negative symptoms exacerbating this pattern. Positive symptoms were associated with heightened nonverbal behavior. Patients' partners changed their own nonverbal behavior in response to the patient. Reduced prosocial behaviors, inviting interaction, were associated with poorer social outcomes. The evidence suggests that patients' nonverbal behavior, during face-to-face interaction, is influenced by patients symptoms and impacts the success of their social interactions.
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http://dx.doi.org/10.1097/NMD.0000000000000031DOI Listing
January 2014

Shared understanding in psychiatrist-patient communication: association with treatment adherence in schizophrenia.

Patient Educ Couns 2013 Oct 12;93(1):73-9. Epub 2013 Jul 12.

Unit for Social and Community Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.

Objective: Effective doctor-patient communication, including a shared understanding, is associated with treatment adherence across medicine. However, communication is affected by a diagnosis of schizophrenia and reaching a shared understanding can be challenging. During conversation, people detect and deal with possible misunderstanding using a conversational process called repair. This study tested the hypothesis that more frequent repair in psychiatrist-patient communication is associated with better treatment adherence in schizophrenia.

Methods: Routine psychiatric consultations involving patients with (DSM-IV) schizophrenia or schizoaffective disorder were audio-visually recorded. Consultations were coded for repair and patients' symptoms and insight assessed. Adherence was assessed six months later. A principal components analysis reduced the repair data for further analysis. Random effects models examined the association between repair and adherence, adjusting for symptoms, consultation length and the amount patients spoke.

Results: 138 consultations were recorded, 118 were followed up. Patients requesting clarification of the psychiatrist's talk and the clarification provided by the psychiatrist was associated with adherence six months later (OR 5.82, 95% CI 1.31-25.82, p=0.02).

Conclusion: The quality of doctor-patient communication also appears to influence adherence in schizophrenia.

Practice Implications: Future research should investigate how patient clarification can be encouraged among patients and facilitated by psychiatrists' communication.
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http://dx.doi.org/10.1016/j.pec.2013.05.015DOI Listing
October 2013

Is nonverbal communication disrupted in interactions involving patients with schizophrenia?

Schizophr Bull 2013 Sep 1;39(5):1150-8. Epub 2012 Sep 1.

School of Electronic Engineering & Computer Science, University of London, London, UK.

Background: Nonverbal communication is a critical feature of successful social interaction and interpersonal rapport. Social exclusion is a feature of schizophrenia. This experimental study investigated if the undisclosed presence of a patient with schizophrenia in interaction changes nonverbal communication (ie, speaker gesture and listener nodding).

Method: 3D motion-capture techniques recorded 20 patient (1 patient, 2 healthy participants) and 20 control (3 healthy participants) interactions. Participants rated their experience of rapport with each interacting partner. Patients' symptoms, social cognition, and executive functioning were assessed. Four hypotheses were tested: (1) Compared to controls, patients display less speaking gestures and listener nods. (2) Patients' increased symptom severity and poorer social cognition are associated with patients' reduced gesture and nods. (3) Patients' partners compensate for patients' reduced nonverbal behavior by gesturing more when speaking and nodding more when listening. (4) Patients' reduced nonverbal behavior, increased symptom severity, and poorer social cognition are associated with others experiencing poorer rapport with the patient.

Results: Patients gestured less when speaking. Patients with more negative symptoms nodded less as listeners, while their partners appeared to compensate by gesturing more as speakers. Patients with more negative symptoms also gestured more when speaking, which, alongside increased negative symptoms and poorer social cognition, was associated with others experiencing poorer patient rapport.

Conclusions: Patients' symptoms are associated with the nonverbal behavior of patients and their partners. Patients' increased negative symptoms and gesture use are associated with poorer interpersonal rapport. This study provides specific evidence about how negative symptoms impact patients' social interactions.
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http://dx.doi.org/10.1093/schbul/sbs091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3756773PMC
September 2013

A cross-site qualitative study of physician order entry.

J Am Med Inform Assoc 2003 Mar-Apr;10(2):188-200

Division of Medical Informatics and Outcomes Research, School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA.

Objective: To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals.

Design: A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data.

Measurements: Patterns and themes concerning perceptions of POE were identified.

Results: Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions.

Conclusion: An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC150372PMC
http://dx.doi.org/10.1197/jamia.m770DOI Listing
April 2003
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