Mary Lavelle

Is Nonverbal Communication Disrupted in Interactions Involving Patients With Schizophrenia

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.

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

Abstract 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.

Aggression on inpatient units: Clinical characteristics and consequences

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.

Aggression on inpatient units

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.

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

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.

Participation during first social encounters in schizophrenia.

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.

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

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 (t(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.

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

Abstract 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.

Improving decision-making and cognitive bias using innovative approaches to simulated scenario and debrief design

> The simplest approach to improving doctors’ decision-making is to educate them about the existence of the biases… (Bornstein and Emler, 2001).1 Over the last 20 years, healthcare systems globally have reduced the number of acute inpatient psychiatry beds, diverting resources to community-based teams. This has led to an increased number of patients from all specialities presenting to the emergency department. The Economist Intelligence Unit has projected a global trend of decreases in the number of hospital beds per 1000 population until 2019, despite growing demand from growing and ageing populations as well as the need for community-care and home-care beds.2 This trend is especially noted in mental health. Since 2013, most UK mental health trusts have regularly experienced a lack of inpatient bed availability, with these problems widely described and addressed in national policy and guidance.3 When patients are in crisis, they are assessed by multidisciplinary mental health teams. Mental health professionals must balance the potential costs and benefits of several courses of action. These decisions and their consequences are complex, having significant implications for individuals, families, professionals and healthcare systems. However, clinicians appear not to use the same process to make decisions or agree on treatment options. Clinicians tend to focus on finding the right decision rather than understanding the decision-making process that influences actions. Many different factors, including bias, contribute to variability in clinical decision-making, with some clinical presentations managed more consistently than others.1 To address this subjectivity and bias in practice, bring clinical practice in line with evidence-based guidelines and …