Shared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for ...research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption.
Data were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption.
The majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients' treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care.
HCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient's preferences in the care process - preferably before starting treatment through discussions in a multidisciplinary meeting.
Thirty psychiatric patients (aged 18-29) who had attempted suicide were compared with 2 matched control groups, one consisting of nonsuicidal psychiatric patients and the other of normal subjects, ...for personality patterns, parental rearing practices and personal loss before the age of 15. The instruments used were the Eysenck Personality Questionnaire (EPQ), the Lazare-Klerman-Armor Trait Scale (LKAS), the Narcissistic Personality Inventory (NPI) and the Own Memories of Child-Rearing Experiences (EMBU). Patients admitted for suicide attempts differed significantly from normals on several personality dimensions, whereas suicide attempters did not have personality characteristics that made them substantially different from nonsuicidal psychiatric controls. The suicide attempters had experienced significantly more negative and less positive parental rearing factors than normals, but no difference was found between suicidal and nonsuicidal patients for own memories of parental rearing patterns. Parental loss due to divorce had occurred significantly more often among suicide attempters than among both nonsuicidal psychiatric patients and normals.
Primary non-endogenous depression was examined with respect to preceding life stress and instability of personality. A sample of 146 hospitalized patients suffering from primary endogenous ...depression, primary non-endogenous depression or depression secondary to a neurosis was interviewed for preceding personal loss and completed the Eysenck Personality Inventory after recovery. Presence of a preceding personal loss did not discriminate between the three types of depression. Only in personality patterns did primary non-endogenous depressives show features that have been attributed to reactive depression. The primary non-endogenous depressives were significantly more introverted and neurotic than the endogenous depressives, but had lower neuroticism scores than patients with depression secondary to neuroses. Two-thirds of all depressives were found to dissimulate on the Lie scale. Depressives secondary to neuroses showed significantly lower Lie scores than primary endogenous and non-endogenous depressives. High Lie scores were interpreted as expressions of denial or conformity.
Successfully admitted neurotic and non-neurotic depressives were compared with respect to stressful life events experienced in the 6 months before the onset of the illness. Almost equal proportions ...of neurotics and non-neurotics had experienced a single stressful event. Significantly more neurotics than non-neurotics had suffered multiple stressful events. An analysis of the multiple events revealed that many were related and involved a single calamity. For multiple unrelated stressful events no significant difference was found between neurotic and non-neurotic depressions.
Relationships between own memories of parental rearing practices and adult personality features were examined. Two hundred healthy volunteers, 86 males and 114 females, completed the Own Memories of ...Child-Rearing Experiences ( EMBU ), the Eysenck Personality Questionnaire ( EPQ ) and the Lazare - Klerman - Armor Trait Scale ( LKAS ). Relations between two sets of variables were examined by means of Pearson product moment correlation coefficient, and Bonferroni inequalities were applied for each family of hypotheses. For the male sample all correlations were not significant. For females there were several significant correlations. The most consistent finding was that the experience of negative parental rearing factors was associated with pathological features in the personality. About one half of the significant correlations were found between female hysterical scores and EMBU father. The findings support the general assumption that females with hysterical traits have complicated relations to their fathers, which may indicate fixation in the Oedipal stage.
Samples of healthy subjects from Australia, Denmark, Italy, The Netherlands and Sweden completed the EMBU, a Swedish questionnaire aimed at assessing the experience of parental rearing practices. For ...the purpose of comparison three factors - "emotional warmth", "rejection" and "overprotection" - obtained in a previous factor analytic study, have been used. The most pronounced differences occurred between the Dutch and the Swedish sample on the one hand, and the Italian and Australian sample on the other, with the Danish sample in between. Differences in perceived parental rearing should be considered when comparing personality characteristics and/or psychopathological conditions in subjects from different countries.
Violence is commonest in emergency and closed departments. Lack of structure in the department and inactivity together with an authoritarian staff attitude may increase the frequencies of violent ...episodes. Too much therapeutic activity may also cause violence in the department. In order to reduce the frequency of episodes of violence, the staff must be adequate in number. Good contact with the patients may have a preventative effect on violence. The experience of the care staff in the treatment of psychiatric patients is of considerable significance. Massive staff changes with appointment of less experienced care staff and many temporary staff members in the department may increase the extent of violence. Training of the staff in the technique of controlling aggression may improve their ability to cope with violent situations. The effect of staff training may depend upon the content of the training programme. Medical assistance may increase the staff capacity to manage difficult situations such as violent episodes. Leaders have considerable influence on the factors which can reduce the extent of violence. Previous investigations show many methodological defects and new investigations are necessary.
Cardiovascular effects of the tetracyclic antidepressant drug mianserin were examined in a prospective study including ten elderly depressed patients (age 60-77 years). During 1 week on placebo and 5 ...weeks on mianserin, 60 mg per day, orthostatic blood pressure testing, recording of standard electrocardiogram, 24-h electrocardiographic recording and systolic time intervals were carried out along with frequent monitoring of plasma levels of mianserin (13-57 micrograms/l) and the primary metabolite desmethylmianserin (7-27 micrograms/l). Mianserin caused a significant increase in orthostatic systolic blood pressure drop, and this correlated well with the plasma mianserin levels (rs = 0.70). There were no significant changes in supine blood pressure or in orthostatic changes in heart rate. No cardiac conduction disturbances or arrhythmias were provoked, but mianserin caused changes in systolic time intervals indicating impairment of left ventricular contractility and performance. Like tricyclic antidepressants mianserin should thus be used with caution in patients with latent or overt cardiovascular disease.
Three hundred and thirty individuals (80% of the total staff members at a Department of Psychiatry) completed a questionnaire concerning their exposure to patient violence. It was found that over 90% ...of physicians, nurses and nursing aides had been subjected to patient violence at least once during the entire course of their employment in departments of psychiatry. The following percentages were found for incidents of patients violence occurring during a one year period towards staff while employed in departments of psychiatry: residents (17%), nurses (36%), and nursing aides (52%). The highest frequency was found for nursing staff working in closed wards (75%). Length of employment, and thereby the staff's experience, was not related to exposure to patient violence. Neither sex nor age of the nursing staff were significantly associated with their exposure to patient violence. About 1/3 of the nurses and nursing aides had considered changing their job because of patient violence.
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