Charlotte Dack

A review and meta‐analysis of the patient factors associated with psychiatric in‐patient aggression

To combine the results of earlier comparison studies of in‐patient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour.

The antecedents of violence and aggression within psychiatric in-patient settings

Papadopoulos C, Ross J, Stewart D, Dack C, James K, Bowers L. The antecedents of violence and aggression within psychiatric in‐patient settings.

Safewards: the empirical basis of the model and a critical appraisal

Accessible summary In the previous paper we described a model explaining differences in rates of conflict and containment between wards, grouping causal factors into six domains: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper reviews and evaluates the evidence for the model from previously published research. The model is supported, but the evidence is not very strong. More research using more rigorous methods is required in order to confirm or improve this model. Abstract In a previous paper, we described a proposed model explaining differences in rates of conflict (aggression, absconding, self-harm, etc.) and containment (seclusion, special observation, manual restraint, etc.). The Safewards Model identified six originating domains as sources of conflict and containment: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment, and outside hospital. In this paper, we assemble the evidence underpinning the inclusion of these six domains, drawing upon a wide ranging review of the literature across all conflict and containment items; our own programme of research; and reasoned thinking. There is good evidence that the six domains are important in conflict and containment generation. Specific claims about single items within those domains are more difficult to support with convincing evidence, although the weight of evidence does vary between items and between different types of conflict behaviour or containment method. The Safewards Model is supported by the evidence, but that evidence is not particularly strong. There is a dearth of rigorous outcome studies and trials in this area, and an excess of descriptive studies. The model allows the generation of a number of different interventions in order to reduce rates of conflict and containment, and properly conducted trials are now needed to test its validity.

Learning from prevented suicide in psychiatric inpatient care: an analysis of data from the National Patient Safety Agency.

BACKGROUND Inpatient suicide is a tragedy, and removal of the means is only a partially effective strategy. OBJECTIVES To identify the mechanisms by which attempted inpatient suicides are prevented, so that their use can become more widespread. METHOD Analysis of one year of nationally reported suicide attempts on inpatient psychiatric wards from the National Patient Safety Agency. RESULTS Patients are discovered in the act by staff checks (medication rounds, meals, routine activities, and intermittent observation) and by staff being caringly vigilant and inquisitive (noticing the absence of patients, their psychological distress, physical state, responding to unusual noises, etc.). CONCLUSIONS The use of intermittent observation and other patient checks should be increased, and particularly directed to private areas of the ward. All staff should act on any sense of unease or feeling that something about a patient, their behaviour, or noises on the ward, are not right.

Patient reactions to a web-based cardiovascular risk calculator in type 2 diabetes: a qualitative study in primary care.

Background Use of risk calculators for specific diseases is increasing, with an underlying assumption that they promote risk reduction as users become better informed and motivated to take preventive action. Empirical data to support this are, however, sparse and contradictory. Aim To explore user reactions to a cardiovascular risk calculator for people with type 2 diabetes. Objectives were to identify cognitive and emotional reactions to the presentation of risk, with a view to understanding whether and how such a calculator could help motivate users to adopt healthier behaviours and/or improve adherence to medication. Design and setting Qualitative study combining data from focus groups and individual user experience. Adults with type 2 diabetes were recruited through website advertisements and posters displayed at local GP practices and diabetes groups. Method Participants used a risk calculator that provided individualised estimates of cardiovascular risk. Estimates were based on UK Prospective Diabetes Study (UKPDS) data, supplemented with data from trials and systematic reviews. Risk information was presented using natural frequencies, visual displays, and a range of formats. Data were recorded and transcribed, then analysed by a multidisciplinary group. Results Thirty-six participants contributed data. Users demonstrated a range of complex cognitive and emotional responses, which might explain the lack of change in health behaviours demonstrated in the literature. Conclusion Cardiovascular risk calculators for people with diabetes may best be used in conjunction with health professionals who can guide the user through the calculator and help them use the resulting risk information as a source of motivation and encouragement.

Generalization of causal efficacy judgments after evaluative learning

In three experiments, we examined the effect of response-outcome relations on human ratings of causal efficacy and demonstrated that such efficacy ratings transfer to novel situations through derived stimulus relations. Causal efficacy ratings were higher, and probability of an outcome given a response was lower, for a differential reinforcement of high rate schedule than for either a differential reinforcement of low rate schedule (Experiment 1) or a variable interval schedule (Experiment 2). In Experiment 3, we employed schedules that were equated for outcome probability and noted that ratings of causal efficacy and the rate of response were higher on a variable ratio than on a variable interval schedule. For participants in all three experiments, causal efficacy ratings transferred to the stimulus present during each schedule and generalized to novel stimuli through derived relations. The results corroborate the view that schedules are a determinant of both response rates and causal efficacy ratings. In addition, the novel demonstration of a mechanism of generalization of these ratings via derived relations has clinical implications.

Evaluating the implementation of HeLP-Diabetes within NHS services: study protocol

BackgroundSelf-management by people with type 2 diabetes is central to good health outcomes and the prevention of associated complications. Structured education to teach self-management is recommended by the National Institute for Heath and Clinical Excellence; however, only a small proportion of patients report being offered this education and even fewer attend. This study aims to evaluate the implementation of a new internet-based self-management intervention: HeLP-Diabetes (Healthy Living for People with type 2 Diabetes) within the National Health Service. Specific objectives are to a) determine the uptake and use of HeLP-Diabetes by services and patients; b) identify the factors which inhibit or facilitate use; c) identify the resources needed for effective implementation; d) explore possible effects of HeLP-Diabetes use on self-reported patient outcome measures.Methods/DesignThis study will use an iterative design to implement HeLP-Diabetes into existing health services within the National Health Service. A two stage implementation process will be taken, whereby batches of General Practice surgeries and diabetes clinics will be offered HeLP-Diabetes and will subsequently be asked to participate in evaluating the implementation. We will collect data to describe the number of services and patients who sign up to HeLP-Diabetes, the types of services and patients who sign up and the implementation costs. Semi-structured interviews will be conducted with patients and health professionals and cohorts of patient participants will be asked to complete self-report measures at baseline, 3 months, and 12 months.DiscussionThis study will evaluate the implementation of a new online self-management intervention and describe what happens when it is made available to existing National Health Services and patients with type 2 diabetes. We will collect data to describe the uptake and use of the intervention and the resources needed for widespread implementation. We will report on patient benefits from using HeLP-Diabetes and the resources needed to achieve these in routine practice. Interviews with key stake holders will identify, define and explain factors that promote or inhibit the normalization of new patterns of patient and professional activity arising from HeLP-Diabetes.

Web-based self-management support for people with type 2 diabetes (HeLP-Diabetes): randomised controlled trial in English primary care.

Objective To determine the effectiveness of a web-based self-management programme for people with type 2 diabetes in improving glycaemic control and reducing diabetes-related distress. Methods and design Individually randomised two-arm controlled trial. Setting 21 general practices in England. Participants Adults aged 18 or over with a diagnosis of type 2 diabetes registered with participating general practices. Intervention and comparator Usual care plus either Healthy Living for People with Diabetes (HeLP-Diabetes), an interactive, theoretically informed, web-based self-management programme or a simple, text-based website containing basic information only. Outcomes and data collection Joint primary outcomes were glycated haemoglobin (HbA1c) and diabetes-related distress, measured by the Problem Areas in Diabetes (PAID) scale, collected at 3 and 12 months after randomisation, with 12 months the primary outcome point. Research nurses, blind to allocation collected clinical data; participants completed self-report questionnaires online. Analysis The analysis compared groups as randomised (intention to treat) using a linear mixed effects model, adjusted for baseline data with multiple imputation of missing values. Results Of the 374 participants randomised between September 2013 and December 2014, 185 were allocated to the intervention and 189 to the control. Final (12 month) follow-up data for HbA1c were available for 318 (85%) and for PAID 337 (90%) of participants. Of these, 291 (78%) and 321 (86%) responses were recorded within the predefined window of 10–14 months. Participants in the intervention group had lower HbA1c than those in the control (mean difference −0.24%; 95% CI −0.44 to −0.049; p=0.014). There was no significant overall difference between groups in the mean PAID score (p=0.21), but prespecified subgroup analysis of participants who had been more recently diagnosed with diabetes showed a beneficial impact of the intervention in this group (p = 0.004). There were no reported harms. Conclusions Access to HeLP-Diabetes improved glycaemic control over 12 months. Trial registration number ISRCTN02123133.

The transfer of social exclusion and inclusion functions through derived stimulus relations

Previous studies have found that social exclusion can cause distress to those excluded. One method used to study social exclusion is through a virtual ball-toss game known as Cyberball. In this game, participants may be excluded from or included in the ball-toss game and typically report lower feelings of self-esteem, control, belonging, and meaningful existence following exclusion. Experiments 1 and 2 sought to explore the transfer of feelings of exclusion and inclusion through stimulus equivalence classes. In both experiments, participants were trained to form two three-member equivalence classes (e.g., A1–B1, B1–C1; A2–B2, B2–C2) and were tested with novel stimulus combinations (A1–C1, C1–A1, A2–C2, C2–A2). Thereafter, participants were exposed to the Cyberball exclusion and inclusion games. In these games, one stimulus (C1) from one equivalence class was assigned as the Cyberball inclusion game name, whereas one stimulus (C2) from the other equivalence class was assigned as the Cyberball exclusion game name. In Experiment 2, participants were only exposed to the Cyberball exclusion game. During a subsequent transfer test, participants were asked to rate how included in or excluded from they thought they would be in other online games, corresponding to members of both equivalence classes. Participant reported that they felt they would be excluded from online games if the games were members of the same equivalence class as C2. In contrast, participants reported that they felt they would be included in online games if the games were members of the same equivalence class as C1. Results indicated the transfer of feelings of inclusion (Experiment 1) and feelings of exclusion (Experiments 1 and 2) through equivalence classes.

Multiple determinants of transfer of evaluative function after conditioning with free-operant schedules of reinforcement

The aim of the four present experiments was to explore how different schedules of reinforcement influence schedule-induced behavior, their impact on evaluative ratings given to conditioned stimuli associated with each schedule through evaluative conditioning, and the transfer of these evaluations through derived stimulus networks. Experiment 1 compared two contrasting response reinforcement rules (variable ratio [VR], variable interval [VI]). Experiment 2 varied the response to reinforcement rule between two schedules but equated the outcome to response rate (differential reinforcement of high rate [DRH] vs. VR). Experiment 3 compared molar and molecular aspects of contingencies of reinforcement (tandem VIVR vs. tandem VRVI). Finally, Experiment 4 employed schedules that induced low rates of responding to determine whether, under these circumstances, responses were more sensitive to the molecular aspects of a schedule (differential reinforcement of low rate [DRL] vs. VI). The findings suggest that the transfer of evaluative functions is determined mainly by differences in response rate between the schedules and the molar aspects of the schedules. However, when neither schedule was based on a strong response reinforcement rule, the transfer of evaluative judgments came under the control of the molecular aspects of the schedule.