Do not ask whether they have a cognitive map, but how they find their way about.

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The social practice of rescue: the safety implications of acute illness trajectories and patient categorisation in medical and maternity settings.

The normative position in acute hospital care when a patient is seriously ill is to resuscitate and rescue. However, a number of UK and international reports have highlighted problems with the lack of timely recognition, treatment and referral of patients whose condition is deteriorating while being cared for on hospital wards. This article explores the social practice of rescue, and the structural and cultural influences that guide the categorisation and ordering of acutely ill patients in different hospital settings. We draw on Strauss et al.'s notion of the patient trajectory and link this with the impact of categorisation practices, thus extending insights beyond those gained from emergency department triage to care management processes further downstream on the hospital ward. Using ethnographic data collected from medical wards and maternity care settings in two UK inner city hospitals, we explore how differences in population, cultural norms, categorisation work and trajectories of clinical deterioration interlink and influence patient safety. An analysis of the variation in findings between care settings and patient groups enables us to consider socio-political influences and the specifics of how staff manage trade-offs linked to the enactment of core values such as safety and equity in practice

Working for patient safety: a qualitative study of women's help-seeking during acute perinatal events.

BACKGROUND: Women and their relatives can play an important role in early detection and help seeking for acute perinatal events. Recent UK reports indicate that patient-professional partnership in 'working for safety' can be difficult to achieve in practice, sometimes with catastrophic consequences. This research explored the experiences of women and relatives who had experienced early warning signs about their condition and sought help in escalating care. METHODS: Secondary analysis of case study data which included qualitative interviews with 22 women purposively sampled on account of experiencing a step up in care and 4 of their relatives from two NHS Trusts in England during 2010. Analysis focused on the type of safety work participants engaged in, and the opportunities and challenges reported by women and family members when negotiating safety at home and in hospital. RESULTS: Women and relatives took on a dual responsibility for self-diagnosis, self-care and seeking triage, whilst trying to avoid overburdening stretched services. Being informed, however, did not necessarily enable engagement from staff and services. The women's narratives highlighted the work that they engaged in to build a case for clinical attention, the negotiations that took place with health care professionals and the strategies women and partners drew on (such as objective signs and symptoms, use of verbal insistence and repetition) to secure clinical help. For some women, the events left them with a lasting feeling that their concerns had been disregarded. Some described a sense of betrayal and loss of trust in an institution they believed had failed to care for them. CONCLUSION: The notion of 'safety partnerships' which suggests a sense of equality and reciprocity was not borne out by our data, especially with regards to the experiences of teenage women. To enable women and families to secure a rapid response in clinical emergencies, strategies need to move beyond the provision of patient information about warning signs. Effective partnerships for safety may be supported by system level change such as improved triage, continuity of care, self-referral pathways and staff training to address asymmetries of power that persist within the health system

A narrative synthesis of factors that affect women speaking up about early warning signs and symptoms of pre-eclampsia and responses of healthcare staff.

BACKGROUND: One of the challenges for treating pre-eclampsia and preventing further deterioration is determining how best to enable early detection. If women or their partners and families are able to raise early warnings about potential signs and symptoms of pre-eclampsia in pregnancy, birth and in the postnatal period, women may be able to receive earlier intervention to prevent severe pre-eclampsia from developing. The aim of this study was to improve understanding of factors affecting the ability of women to recognise symptoms and signs of pre-eclampsia/eclampsia and seek appropriate medical help and factors affecting health care professionals' responses to women and their families who 'speak up' about early warning signs and symptoms. METHODS: A narrative synthesis was conducted of evidence relevant to address the research question. The following electronic data bases were searched for qualitative studies which met inclusion criteria from January 1980 to April 2016; Medline, CINAHL, HMIC, PsycINFO, Embase, BNI, ASSIA, Scopus, Maternity and Infant Care, Web of Science, Google Scholar, Cochrane, JBI and IBSS with the support of an Information Service Consultant. RESULTS: Following thematic analysis, three themes were identified; 1: Women's understanding and knowledge of pre-eclampsia/eclampsia; 2: Factors affecting help seeking behaviour from perspectives of women and their families'; 3: Factors affecting staff response. There was widespread lack of knowledge and understanding of signs and symptoms of pre-eclampsia/eclampsia among women and their families, with some women not exhibiting signs and symptoms of pre-eclampsia or unable to distinguish them from 'normal' pregnancy changes. CONCLUSIONS: Women and their families not only need to be made aware of signs and symptoms of pre-eclampsia/eclampsia but also require information on the most effective ways to seek urgent medical assessment and care. Some women did not experience prodromal signs and symptoms, which raises concerns about how women and families can detect early onset, and is an issue which needs further exploration. There is very limited research exploring clinical staff response to women who raise concerns about their health when experiencing symptoms and signs of pre-eclampsia/eclampsia with further research needed if safety and quality of care are to be improved

Women's safety alerts in maternity care: is speaking up enough?

Patients’ contributions to safety include speaking up about their perceptions of being at risk. Previous studies have found that dismissive responses from staff discouraged patients from speaking up. A Care Quality Commission investigation of a maternity service where serious incidents occurred found evidence that women had routinely been ignored and left alone in labour. Women using antenatal services hesitated to raise concerns that they felt staff might consider irrelevant. The Birthplace in England programme, which investigated the quality and safety of different places of birth for ‘low-risk’ women, included a qualitative organisational case study in four NHS Trusts. The authors collected documentary, observational and interview data from March to December 2010 including interviews with 58 postnatal women. A framework approach was combined with inductive analysis using NVivo8 software. Speaking up, defined as insistent and vehement communication when faced with failure by staff to listen and respond, was an unexpected finding mentioned in half the women's interviews. Fourteen women reported raising alerts about safety issues they felt to be urgent. The presence of a partner or relative was a facilitating factor for speaking up. Several women described distress and harm that ensued from staff failing to listen. Women are speaking up, but this is not enough: organisation-focused efforts are required to improve staff response. Further research is needed in maternity services and in acute and general healthcare on the effectiveness of safety-promoting interventions, including real-time patient feedback, patient toolkits and patient-activated rapid response calls

Landmark vs. geometry learning: Explaining female rats' selective preference for a landmark

Rats were trained in a triangular-shaped pool to find a hidden platform, whose location was defined in terms of two sources of information, a landmark outside the pool and a particular corner of the pool. Subsequent test trials without the platform pitted these two sources of information against one another. In Experiment 1 this test revealed a clear, although selective, sex difference. As in previous experiments, females spent more time in an area of the pool that corresponded to the landmark, but here only when it was a cone but not when it was a pyramid. Males, on the other hand, always spent more time in the distinctive corner of the pool. Experiments 2 and 3 were only with female rats. In Experiment 2 two identical shaped cylinders were used as landmark cues (one plain white and the other vertically patterned with four different patterns). The results of the preference test revealed that only the females trained and tested with the plain cylinder spent more time in the area of the pool that corresponded to the landmark than in the distinctive corner of the pool. Finally, Experiment 3 replicated the results of Experiment 2 while eliminating an alternative explanation in terms of differential contrast between the two cylinders and the black curtain

Bi-defects of Nematic Surfactant Bilayers

We consider the effects of the coupling between the orientational order of the two monolayers in flat nematic bilayers. We show that the presence of a topological defect on one bilayer generates a nontrivial orientational texture on both monolayers. Therefore, one cannot consider isolated defects on one monolayer, but rather associated pairs of defects on either monolayer, which we call bi-defects. Bi-defects generally produce walls, such that the textures of the two monolayers are identical outside the walls, and different in their interior. We suggest some experimental conditions in which these structures could be observed.Comment: RevTeX, 4 pages, 3 figure

Online resources and apps to aid self-diagnosis and help seeking in the perinatal period: A descriptive survey of women's experiences.

OBJECTIVE:Assess the role of online resources and apps for women's help seeking and staff's response to concerns in the perinatal period. DESIGN:Online survey. Descriptive analysis of women's use and experiences of digital resources for self-diagnosis and help seeking, drawing on numerical and free-text responses. SETTING:Two tertiary referral centres and one district general hospital in two UK geographic locations. PARTICIPANTS:632 postnatal women, surveyed over a 4 month period. MEASUREMENTS:Women's access to digital devices; frequency and type of health concerns experienced after 22 weeks' gestation; variability in use and experiences of websites/apps; perceptions of staff's response to concerns after help-seeking. FINDINGS:1254 women were approached over a 4-month period; 632 participated (response rate: 50%). Women reported a 'mix and match' blended use of digital resources to both learn about, and self-diagnose/self-triage for potential complications in pregnancy as an adjunct to care provided by maternity staff. Over half the participants experienced concerns about themselves or their baby after 22 weeks. The top concern was fetal movements, reported by 62%. Women used 91 different digital resources to help with understanding and decision-making, in addition to seeking support from family, friends and healthcare professionals. Enabling features of staff responses were identified from free-text responses (n = 292) by women who sought professional help regarding their health concerns, and influencing factors at clinical, organisational and digital level. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE:Online information retrieval and digital self-monitoring is increasingly integral to women's self-care during pregnancy and offers opportunities to support escalation of care and shared decision-making. Further work should assess optimal inclusion of this 'digital work' into clinical consultations

Situationally-sensitive knowledge translation and relational decision making in hyperacute stroke: a qualitive study

Stroke is a leading cause of disability. Early treatment of acute ischaemic stroke with rtPA reduces the risk of longer term dependency but carries an increased risk of causing immediate bleeding complications. To understand the challenges of knowledge translation and decision making about treatment with rtPA in hyperacute stroke and hence to inform development of appropriate decision support we interviewed patients, their family and health professionals. The emergency setting and the symptomatic effects of hyper-acute stroke shaped the form, content and manner of knowledge translation to support decision making. Decision making about rtPA in hyperacute stroke presented three conundrums for patients, family and clinicians. 1) How to allow time for reflection in a severely time-limited setting. 2) How to facilitate knowledge translation regarding important treatment risks and benefits when patient and family capacity is blunted by the effects and shock of stroke. 3) How to ensure patient and family views are taken into account when the situation produces reliance on the expertise of clinicians. Strategies adopted to meet these conundrums were fourfold: face to face communication; shaping decisions; incremental provision of information; and communication tailored to the individual patient. Relational forms of interaction were understood to engender trust and allay anxiety. Shaping decisions with patients was understood as an expression of confidence by clinicians that helped alleviate anxiety and offered hope and reassurance to patients and their family experiencing the shock of the stroke event. Neutral presentations of information and treatment options promoted uncertainty and contributed to anxiety. ‘Drip feeding’ information created moments for reflection: clinicians literally made time. Tailoring information to the particular patient and family situation allowed clinicians to account for social and emotional contexts. The principal responses to the challenges of decision making about rtPA in hyperacute stroke were relational decision support and situationally-sensitive knowledge translation

Simulation of associative learning with the replaced elements model

Associative learning theories can be categorised according to whether they treat the representation of stimulus compounds in an elemental or configural manner. Since it is clear that a simple elemental approach to stimulus representation is inadequate there have been several attempts to produce more elaborate elemental models. One recent approach, the Replaced Elements Model (Wagner, 2003), reproduces many results that have until recently been uniquely predicted by Pearce’s Configural Theory (Pearce, 1994). Although it is possible to simulate the Replaced Elements Model using “standard” simulation programs the generation of the correct stimulus representation is complex. The current paper describes a method for simulation of the Replaced Elements Model and presents the results of two example simulations that show differential predictions of Replaced Elements and Pearce’s Configural Theor