Introduction of routine outcome measures: staff reactions and issues for consideration

The aim of this study was to explore clinician reactions to (i) the introduction of routine outcome measures and (ii) the utility of outcomes data in clinical practice. Focus group discussions (n = 34) were conducted with mental health staff (n = 324) at approximately 8 months post implementation of routine outcome measures. A semi-structured interview schedule was used to collect data on two key issues; reactions to the introduction of outcome measures and factors influencing the utility of outcomes data in clinical practice. Data from the discussion groups were analysed using content analysis to isolate emerging themes. While the majority of participants endorsed the collection and utilization of outcomes data, many raised questions about the merits of the initiative. Ambivalence, competing work demands, lack of support from senior medical staff, questionable evidence to support the use of outcome measures, and fear of how outcomes data might be used emerged as key issues. At 8 months post implementation a significant number of clinical staff remained ambivalent about the benefits of outcome measurement and had not engaged in the process. The shift to a service model driven by outcomes and case-mix data will take time and resources to achieve. Implications for nursing staff are discussed.

Smoking and schizophrenia: is symptom profile related to smoking and which antipsychotic medication is of benefit in reducing cigarette use?

Smoking rate is disproportionately high among patients with schizophrenia, resulting in significant morbidity and mortality. However, cigarette smoking has been reported to have beneficial effects on negative symptoms, extrapyramidal symptoms, cognitive functioning and mood symptoms. Therefore, smoking cessation may worsen disability in schizophrenia. The association between smoking and these key clinical parameters was examined. Additionally, severity of smoking across four different antipsychotic treatment groups was explored. One hundred and forty-six patients with schizophrenia were assessed for smoking using expired carbon monoxide and smoking history. They were administered the Positive and Negative Symptom Scale, The Extrapyramidal Symptom Rating Scale, the Barnes Akathisia Rating Scale, Reitans Trail-making Test (A and B) and General Health Questionnaire-28. There was no difference in the chlorpromazine equivalent dose of any of the medications studied. Atypical agents were associated with significantly lower levels of smoking when compared with typical medications. There was no difference in smoking severity between the individual atypical medications examined. Similarly, there were no significant differences between smoking and non-smoking groups with regard to Positive and Negative Symptom Scale, Extrapyramidal Symptom Rating Scale, Trail-making Test and General Health Questionnaire-28. However, there was a significant difference between these groups with the smoking group demonstrating less akathisia. Smoking is not associated with positive, negative cognitive and mood symptoms in schizophrenia. Smoking is associated with lower levels of antipsychotic induced akathisia. Clinicians should not be discouraged from helping patients stop smoking for fear of worsening symptoms. However, akathisia may emerge upon cessation of smoking. Switching patients from typical to atypical antipsychotics may assist patients with schizophrenia to give up smoking.

Career versus motherhood? A case study describing a cognitive-existential approach to the dilemma

The present paper reports a case study concerning a professional woman in her 30s, who presented to the Occupational Health department of a metropolitan hospital with work stress stemming from accelerating work demands and marital problems related to the decision about whether to start a family or continue her career. No clinical diagnosis was warranted; however, Maslach Burnout Inventory Scores indicated a high degree of emotional exhaustion and moderate levels of depersonalisation, offset by a high sense of personal accomplishment in her work role. The client also demonstrated severe stress and moderate depression on the Depression-Anxiety-Stress Scale (DASS-21). The case was conceptualised from a combined cognitive-existential perspective. The woman's cognitions about her work, relationship, and prospective motherhood roles were identified, as well as underlying existential issues such as finding a meaning in life and a fear of being alone and unloved. Eight sessions of therapy incorporated components of cognitive and existential therapies, aimed at managing stress and improving marital adjustment. Posttreatment results showed substantial reductions in all the measures of distress, while personal accomplishment remained high. The woman and her husband decided to defer starting a family until other issues had been addressed.

Making decisions about treatment for localized prostate cancer

Objective To describe the decision-making processes used by men diagnosed with localized prostate cancer who were considering treatment. Patients and methods Men newly diagnosed with localized prostate cancer from outpatient urology clinics and urologist's private practices were approached before treatment. Their decision-making processes and information-seeking behaviour was assessed; demographic information was also obtained. Results Of 119 men approached, 108 (90%) were interviewed; 91% reported non-systematic decision processes, with deferral to the doctor, positive and negative recollections of others' cancer experiences, and the pre-existing belief that surgery is a better cancer treatment being most common. For systematic information processing the mean (SD, range) number of items considered was 4.19 (2.28, 0-11), with 57% of men considering four or fewer treatment/medical aspects of prostate cancer. Men most commonly considered cancer stage (59%), urinary incontinence (55%) and impotence (51%) after surgery, and low overall mortality (45%). Uncertainty about probabilities for cure was reported by 43% of men and fear of cancer spread by 37%. Men also described uncertainty about the probabilities of side-effects (27%), decisional uncertainty (25%) and anticipated decisional regret (18%). Overall, 73% of men sought information about prostate cancer from external sources, most commonly the Internet, followed by family and friends. Conclusions In general, men did not use information about medical treatments comprehensively or systematically when making treatment decisions, and their processing of medical information was biased by their previous beliefs about cancer and health. These findings have implications for the provision of informational and decisional support to men considering prostate cancer treatment.

Trusting technology: Women aged 40-49 years participating in screening for breast cancer - an exploratory study

Objective: This paper reports key findings from an exploratory study of factors associated with women's decision to participate in mass mammography screening in Tasmania. In particular, we explored factors that contribute to the choice to participate in screening by women who are outside the primary target group, and for whom the evidence of benefit remains contentious. Methods: Semi-structured interviews were conducted with a small sample of women aged between 40 and 49 years in rural Tasmania who had participated in mammography screening. Results: Key ideas that appeared to shape participation included the fear of breast cancer, trust in technology, and taking responsibility for health. Information provision is also an important factor in shaping participation patterns. Conclusions and implications: In order to facilitate informed consent, information provision in this area should take account of the dominant ideas that shape the decision to participate in breast cancer screening.

Measuring crime prevention through environmental design

Crime Prevention Through Environmental Design (CPTED) has considerable support among the built environment professions. Yet the underlying assumptions on which it is based have rarely been, effectiveness or efficacy. This paper reports the development and use of a evaluated to assess their of scale that measured the actual levels of incidental CPTED in two residential areas in Gold Coast, Australia. The scale was administered in parallel with a victimization and social attitude survey. Analysis based on the combination of the two suggests that CPTED measures may have some effect on reducing victimization, particularly the kind of CPTED measures that apply to the group of dwellings on a single street, but the effect on fear of crime is surprisingly limited. It also indicates that there is on a single street, but the of potential in the application of such a scale in a wider assessment of the effectiveness of operationalizing CPTED design measures.

Herbs or natural substances as complementary therapies for chronic kidney disease: ideas for future studies

Chronic kidney disease (CKD) is an increasingly common condition with limited treatment options that is placing a major financial and emotional burden on the community. The use of complementary and alternative medicines (CAMS) has increased many-fold over the past decade. Although several compelling studies show renal toxicities and an adverse outcome from use of some CAMS, there is also emerging evidence in the literature that some may be renoprotective. Many nephrologists are unaware of these potential therapeutic benefits in treating CKD, or they are reluctant to consider them in research trials for fear of adverse effects (including nephrotoxicity) or deleterious interaction with co-prescribed, conventional medicines. The increased use of self-prescribed CAMS by their patients suggests that practitioners and researchers should keep abreast of the current information on these agents. A primary goal of this article was to review the available scientific evidence for the use of herbs or natural substances as a complementary treatment for patients with CKD. A further goal was to report the literature on herbs that have been reported to cause kidney failure.

The commentariat and discourse failure: language and atrocity in Cool Britannia

Recent terrorist events in the UK, such as the security alerts at British airports in August 2006 and the London bombings of July 2005 gained extensive media and academic analysis. This study contends, however, that much of the commentary demonstrated a wide degree of failure among government agencies, academic and analytic experts and the wider media, about the nature of the threat and continues to distort comprehension of the extant danger. The principal failure, this argument maintains, was, and continues to be, one of an asymmetry of comprehension that mistakes the still relatively limited means of violent jihadist radicals with limited political ends. The misapprehension often stems from the language that surrounds the idea of 'terrorism', which increasingly restricts debate to an intellectually redundant search for the 'root causes' that give rise to the politics of complacency. In recent times this outlook has consistently underestimated the level of the threat to the security of the UK. This article argues that a more realistic appreciation of the current security condition requires abandoning the prevailing view that the domestic threat is best prosecuted as a criminal conspiracy. It demands instead a total strategy to deal with a totalizing threat. The empirical evidence demonstrates the existence of a physical threat, not merely the political fear of threat. The implementation of a coherent set of social policies for confronting the threat at home recognizes that securing state borders and maintaining internal stability are the first tasks of government. Fundamentally, this requires a return to an understanding of the Hobbesian conditions for sovereignty, which, despite the delusions of post-Cold War cosmopolitan multiculturalism, never went away.

Aquisition and extinction of two characteristics consistent with fear relevance

Fear relevance, the potential of a stimulus to become quickly associated with fear, is a characteristic assumed to have an evolutionary basis and to result in preferential processing. Previous research has shown that fear relevant stimuli share a number of characteristics, negative valence and preferential identification in a visual search task, for instance. The present research examined whether these two characteristics can be acquired by non-fear relevant stimuli (geometric shapes) as a result of Pavlovian fear conditioning. Two experiments employed an aversive learning paradigm with geometric shape CSs and a shock US, with stimulus ratings, affective priming and visual search performance assessed before and after acquisition and after extinction. Differential electrodermal responses, larger during CS1 than CS, were present during acquisition but not during extinction. Affective priming results suggest that the CS1 acquired negative valence during acquisition, which was lost during extinction. However, negative valence as indexed by more negative ratings for CS1 than for CS shapes seemed to survive extinction. Preferential attentional processing as indexed by faster detection of CS1 among CS shapes than vice versa on the visual search task also remained. The current research confirmed that characteristics of fear relevant stimuli can be acquired in an aversive learning episode and that they may be extinguished. This supports the proposal that fear relevance may be malleable through learning.

Snakes and kittens in the grass: No evidence for preferential processing of fear-relevant animals in visual search

Ohman and colleagues provided evidence for preferential processing of pictures depicting fear-relevant animals by showing that pictures of snakes and spiders are found faster among pictures of fiowers and mushrooms than vice versa and that the speed of detecting fear-relevant animals was not affected by set size whereas the speed of detecting fiowers/mushrooms was. Experiment 1 replicated this finding. Experiment 2, however, found similar search advantages when pictures of cats and horses or of wolves and big cats were to be found among pictures of flowers and mushrooms. Moreover, Experiment 3, in a within subject comparison, failed to find faster identification of snakes and spiders than of cats and horses among flowers and mushrooms. The present findings seem to indicate that previous reports of preferential processing of pictures of snakes and spiders in a visual search task may reflect a processing advantage for animal pictures in general rather than fear-relevance.

Effect of instructed extinction on verbal and autonomic indices of Pavlovian learning with fear-relevant and fear-irrelevant conditional stimuli

We investigated the effects of conditional stimulus fear-relevance and of instructed extinction on human Pavlovian conditioning as indexed by electrodermal responses and verbal ratings of conditional stimulus unpleasantness. Half of the participants (n = 64) were trained with pictures of snakes and spiders (fear-relevant) as conditional stimuli, whereas the others were trained with pictures of flowers and mushrooms (fear-irrelevant) in a differential aversive Pavlovian conditioning procedure. Half of the participants in each group were instructed after the completion of acquisition that no more unconditional stimuli were to be presented. Extinction of differential electrodermal responses required more trials after training with fear-relevant pictures. Moreover, there was some evidence that verbal instructions did not affect extinction of second interval electrodermal responses to fear-relevant pictures. However, neither fear-relevance nor instructions affected the changes in rated conditional stimulus pleasantness. This dissociation across measures is interpreted as reflecting renewal of Pavlovian learning.

Climate of fear in organisational settings: Construct definition, measurement and a test of theory

This paper reports a study that explored a new construct: climate of fear. We hypothesised that climate of fear would vary across work sites within organisations, but not across organisations. This is in contrast a to measures of organisational culture, which were expected to vary both within and across organisations. To test our hypotheses, we developed a new 13-item measure of perceived fear in organisations and tested it in 20 sites across two organisations (N = 209). Culture variables measured were innovative leadership culture, and communication culture. Results were that climate of fear did vary across sites in both organisations, while differences across organisations were not significant, as we anticipated. Organisational culture, however, varied between the organisations, and within one of the organisations. The climate of fear scale exhibited acceptable psychometric properties.