Cell wall components of Pseudomonas morsprunorum Wormald and their role in pathogenicity

Imperial Users onl

Obstacles to shared decision-making in psychiatric practice: Findings from three observational studies

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.This thesis aims to make contributions at substantive, methodological and theoretical levels. First, the findings from three observational studies are combined to identify obstacles to the use of shared decision-making in modern psychiatric practice. Particular attention is paid to how patients' choices about their treatment are facilitated or constrained by the actions of mental health professionals. A typology of pressure is constructed, based on detailed analyses of how pressure is applied and resisted in routine encounters (outpatient consultations) and "crisis' situations (assessments for compulsory admission to hospital, and ward rounds in acute inpatient care). Findings from two ethnographies and one conversation analysis (CA) study are presented. 'Meaning' is central to the write-up of each set of findings, however while the analytic focus of the ethnographies is 'insider' knowledge and meanings, in the CA study it is gn the activities that make those meanings possible in the first place. The methodological contribution of the thesis stems from its demonstration of how to produce a coherent, unified research account from two very different versions of qualitative inquiry. Despite the potential for analytic inconsistency, the thesis arguably has far greater force and persuasiveness as a result of the attempt to combine, compare and contrast findings from three studies. It is contended that a sound theoretical base for sociological research may be created by combining Goffman's micro-sociology with Foucault's analyses of disciplinary power/knowledge in one of a number of ways. A Goffmanian 'home base' is adopted for this thesis, with Foucauldian thinking applied to add a historical, 'macro' dimension to the analysis that Goffman's work so conspicuously lacks. Foucault's work also provides the conceptual tools for examining the more subtle form of control through expertise that would be missed in a purely Goffmanian study.Department of Health, Eli Lilly, and Dr Jim Birle

Patient preferences and performance bias in a weight loss trial with a usual care arm.

OBJECTIVES: This qualitative study examines performance bias, i.e. unintended differences between groups, in the context of a weight loss trial in which a novel patient counseling program was compared to usual care in general practice. METHODS: 14/381 consecutive interviewees (6 intervention group, 8 control group) within the CAMWEL (Camden Weight Loss) effectiveness trial process study were asked about their engagement with various features of the research study and a thematic content analysis undertaken. RESULTS: Decisions to participate were interwoven with decisions to change behavior, to the extent that for many participants the two were synonymous. The intervention group were satisfied with their allocation. The control group spoke of their disappointment at having been offered usual care when they had taken part in the trial to access new forms of help. Reactions to disappointment involved both movements toward and away from behavior change. CONCLUSION: There is a prima facie case that reactions to disappointment may introduce bias, as they lead the randomized groups to differ in ways other than the intended experimental contrast. PRACTICE IMPLICATIONS: In-depth qualitative studies nested within trials are needed to understand better the processes through which bias may be introduced

Editorial: Shared Decision Making in Mental Health: International Perspectives on Implementation

© 2021 Ramon, Quirk and Zisman-Ilani. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY).While there is an increased acceptance of the potential usefulness of applying share decision making (SDM) in everyday mental health practice, its implementation in practice is still lacking. People who use mental health services often do not know what SDM is; clinicians often have reservations concerning the capacity of service users to make decisions, and fear that SDM may lead to harmful risk taking in increased medication non-adherence. Current research of these issues demonstrates the importance of easy access to information concerning mental health interventions, and the relevance of respect and trust by both clinicians and service users to each other in the process of SDM. Existing research highlights the willingness and ability of most people experiencing mental ill health to reach well- informed decisions alongside their clinicians. The editors of this special issue have therefore invited articles on original research describing SDM projects contributing to advancing the development of SDM and its implementation.Peer reviewedFinal Published versio

Obstacles to shared decision-making in psychiatric practice : findings from three observational studies

This thesis aims to make contributions at substantive, methodological and theoretical levels. First, the findings from three observational studies are combined to identify obstacles to the use of shared decision-making in modern psychiatric practice. Particular attention is paid to how patients' choices about their treatment are facilitated or constrained by the actions of mental health professionals. A typology of pressure is constructed, based on detailed analyses of how pressure is applied and resisted in routine encounters (outpatient consultations) and "crisis' situations (assessments for compulsory admission to hospital, and ward rounds in acute inpatient care). Findings from two ethnographies and one conversation analysis (CA) study are presented. 'Meaning' is central to the write-up of each set of findings, however while the analytic focus of the ethnographies is 'insider' knowledge and meanings, in the CA study it is gn the activities that make those meanings possible in the first place. The methodological contribution of the thesis stems from its demonstration of how to produce a coherent, unified research account from two very different versions of qualitative inquiry. Despite the potential for analytic inconsistency, the thesis arguably has far greater force and persuasiveness as a result of the attempt to combine, compare and contrast findings from three studies. It is contended that a sound theoretical base for sociological research may be created by combining Goffman's micro-sociology with Foucault's analyses of disciplinary power/knowledge in one of a number of ways. A Goffmanian 'home base' is adopted for this thesis, with Foucauldian thinking applied to add a historical, 'macro' dimension to the analysis that Goffman's work so conspicuously lacks. Foucault's work also provides the conceptual tools for examining the more subtle form of control through expertise that would be missed in a purely Goffmanian study.EThOS - Electronic Theses Online ServiceDepartment of HealthEli LillyGBUnited Kingdo

Report on the National Audit of Learning Disabilities Feasibility Study (NALD-FS)

Background Concerns have repeatedly been expressed about the quality of healthcare that people with learning disabilities receive in the NHS. Clinical audit can be an effective method for improving the quality of healthcare especially when existing standards are poor. This feasibility study for a national audit of learning disabilities examined the acceptability of data collection methods and the role that audit data could play in raising the standard of care provided. The audit team used these results to recommend how a future national audit should be conducted, including recommendations for standards, recruiting services, data collection methods, and helping services use audit data to improve the quality of care they provide. Findings Results of the study confirm that the quality of care for people with learning disabilities falls below recommended standards. Variation in practice across study sites suggests that it is possible to improve the quality of care people receive. Primary care standards in a national audit should address whether physical and mental health monitoring is adequate for people with learning disabilities. Based on stakeholder feedback, the audit should also collect information about interventions associated with these standards. Audit data should be reported to individual practices as well as at a commissioning level, to maximise engagement with quality improvement. A national audit of secondary care should include acute and mental health providers, as well as specialist learning disability services. Private providers commissioned for NHS patients should also be included within the audit’s remit. Standards in secondary care should be centred on physical and mental health monitoring, staff training, reasonable adjustments and delivery of person-centred care. There should be a core set of standards applying to all types of service, and a subset developed to audit priority issues specific to each service. Experience measures for staff, carers, and patients are necessar

Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia : a mixed-methods study

Background: Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear. Aims: To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay. Design: Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia. Setting: Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit. Participants: Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia. Main outcome measures: Length of stay, quality of assessment and carer-rated experience. Results: People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff. Limitations: The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia. Conclusions: If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised. Future work: Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 22. See the NIHR Journals Library website for further project information

Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES) : Combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services

BackgroundSeclusion (the isolation of a patient in a locked room) and transfer to a psychiatric intensive care unit (PICU; a specialised higher-security ward with higher staffing levels) are two common methods for the management of disturbed patient behaviour within acute psychiatric hospitals. Some hospitals do not have seclusion rooms or easy access to an on-site PICU. It is not known how these differences affect patient management and outcomes.ObjectivesTo (1) assess the factors associated with the use of seclusion and PICU care, (2) estimate the consequences of the use of these on subsequent violence and costs (study 1) and (3) describe differences in the management of disturbed patient behaviour related to differential availability (study 2).DesignThe electronic patient record system at one trust was used to compare outcomes for patients who were and were not subject to seclusion or a PICU, controlling for variables, including recent behaviours. A cost-effectiveness analysis was performed (study 1). Nursing staff at eight hospitals with differing access to seclusion and a PICU completed attitudinal measures, a video test on restraint-use timing and an interview about the escalation pathway for the management of disturbed behaviour at their hospital. Analyses examined how results differed by access to PICU and seclusion (study 2).ParticipantsPatients on acute wards or PICUs in one NHS trust during the period 2008–13 (study 1) and nursing staff at eight randomly selected hospitals in England, with varying access to seclusion and to a PICU (study 2).Main outcome measuresAggression, violence and cost (study 1), and utilisation, speed of use and attitudes to the full range of containment methods (study 2).ResultsPatients subject to seclusion or held in a PICU were more likely than those who were not to be aggressive afterwards, and costs of care were higher, but this was probably because of selection bias. We could not derive satisfactory estimates of the causal effect of either intervention, but it appeared that it would be feasible to do so for seclusion based on an enriched sample of untreated controls (study 1). Hospitals without seclusion rooms used more rapid tranquillisation, nursing of the patient in a side room accompanied by staff and seclusion using an ordinary room (study 2). Staff at hospitals without seclusion rated it as less acceptable and were slower to initiate manual restraint. Hospitals without an on-site PICU used more seclusion, de-escalation and within-eyesight observation.LimitationsOfficial record systems may be subject to recording biases and crucial variables may not be recorded (study 1). Interviews were complex, difficult, constrained by the need for standardisation and collected in small numbers at each hospital (study 2).ConclusionsClosing seclusion rooms and/or restricting PICU access does not appear to reduce the overall levels of containment, as substitution of other methods occurs. Services considering expanding access to seclusion or to a PICU should do so with caution. More evaluative research using stronger designs is required.FundingThe National Institute for Health Research Health Services and Delivery Research programme

Quality of intervention delivery in a cluster randomised controlled trial : a qualitative observational study with lessons for implementation fidelity

Abstract Background Understanding intervention fidelity is an essential part of the evaluation of complex interventions because fidelity not only affects the validity of trial findings, but also because studies of fidelity can be used to identify barriers and facilitators to successful implementation, and so provide important information about factors likely to impact the uptake of the intervention into clinical practice. Participant observation methods have been identified as being particularly valuable in studies of fidelity, yet are rarely used. This study aimed to use these methods to explore the quality of implementation of a complex intervention (Safewards) on mental health wards during a cluster randomised controlled trial. Specific aims were firstly to describe the different ways in which the intervention was implemented, and secondly to explore the contextual factors moderating the quality of intervention delivery, in order to inform ‘real world’ implementation of the intervention. Methods Safewards was implemented on 16 mental health wards in England. We used Research Assistants (RAs) trained in participant observation to record qualitative observational data on the quality of intervention delivery (n = 565 observations). At the end of the trial, two focus groups were conducted with RAs, which were used to develop the coding framework. Data were analysed using thematic analysis. Results There was substantial variation in intervention delivery between wards. We observed modifications to the intervention which were both fidelity consistent and inconsistent, and could enhance or dilute the intervention effects. We used these data to develop a typology which describes the different ways in which the intervention was delivered. This typology could be used as a tool to collect qualitative observational data about fidelity during trials. Moderators of Safewards implementation included systemic, interpersonal, and individual factors and patient responses to the intervention. Conclusions Our study demonstrates how, with appropriate training in participant observation, RAs can collect high-quality observational data about the quality of intervention delivery during a trial, giving a more complete picture of ‘fidelity’ than measurements of adherence alone. Trial registration ISRCTN registry; IRSCTN38001825 . Registered 29 August 201

Study approach and field work procedures of the MentDis_ICF65+ project on the prevalence of mental disorders in the older adult European population

Background This study describes the study approach and field procedures of the MentDis_ICF65+ study, which aims to assess the prevalence of mental disorders in older adults. Methods An age-appropriate version of the Composite International Diagnostic Interview (CIDI65+) was developed and tested with regard to its feasibility and psychometric properties in a pre-test and pilot phase. In the cross-sectional survey an age-stratified, random sample of older adults (65–84 years) living in selected catchment areas of five European countries and Israel was recruited. Results N = 3142 participants (mean age 73.7 years, 50.7% female) took part in face-to-face interviews. The mean response rate was 20% and varied significantly between centres, age and gender groups. Sociodemographic differences between the study centres appeared for the place of birth, number of grandchildren, close significants, retirement and self-rated financial situation. The comparison of the MentDis_ICF65+ sample with the catchment area and country population of the study centres revealed significant differences, although most of these were numerically small. Conclusions The study will generate new information on the prevalence of common mental disorders among older adults across Europe using an age-appropriate, standardized diagnostic instrument and a harmonized approach to sampling. Generalizability of the findings and a potentially limited representativeness are discussed