An Investigation into the Implementation of CYP-IAPT Routine Outcome Measures in their First Year of Integration into Child Psychotherapy Practice

This thesis examines the impact on child and adolescent psychotherapists within CAMHS of the introduction of routine outcome measures (ROMs) associated with the Children and Young People’s Improving access to Psychological Therapies programme (CYP-IAPT). All CAMHS therapists working within a particular NHS mental health Trust1 were required to trial CYP-IAPT ROMs as part of their everyday clinical practice from October 2013-September 2014. During this period considerable freedom was allowed as to which of the measures each therapist used and at what frequency. In order to assess the impact of CYP-IAPT ROMs on child psychotherapy, I conducted semi-structured interviews with eight psychotherapists within a particular CAMHS partnership within one NHS Trust. Each statement was coded and grouped according to whether it related to initial (generic) assessment, goal setting / monitoring, monitoring on-going progress, therapeutic alliance, or to issues concerning how data might be used or interpreted by managers and commissioners. Analysis of interviews revealed greatest concern about session-by session ROMs, as these are felt to impact most significantly on psychotherapy; therapists felt that session-by-session ROMs do not take account of negative transference relationships, they are overly repetitive and used to reward / punish the therapist. Measures used at assessment and review were viewed as most compatible with psychotherapy, although often experienced as excessively time consuming. The Goal Based Outcome Measure was generally experienced as compatible with psychotherapy so long as goals are formed collaboratively between therapist and young person. There was considerable anxiety about how data may be (mis)used and (mis)interpreted by managers and commissioners, for example to end treatment prematurely, trigger change of therapist in the face of negative ROMs data, or to damage psychotherapy. Use of ROMs for short term and generic work was experienced as less intrusive and contentious.

Exploring Forensic Nursing Ethics and Practice: Roles, Loyalties and Photodocumentation Practices

Thesis (Ph.D.)--University of Washington, 2016-08

The use of motivational interviews by nurses to promote health behaviors in adolescents: a scoping review protocol

Adolescents - defined as young people between 10 and 19 years of age1 - are, in general, a relatively healthy segment of the population.2 However, the developmental changes that take place during adolescence may affect their subsequent risk for diseases and for a variety of health-related behaviors. In fact, early onset of preventable health problems (e.g. obesity, malnutrition, STDs) and the engagement in health risk behaviors (e.g., sedentary life style, excessive alcohol consumption, unprotected sex) during adolescence, are likely to put them at greater risk for physical and mental health problems at a later stage in life. Moreover, health related problems and health risk behaviors may disrupt adolescents' physical and cognitive development and therefore may affect their ability to think and act in relation to decisions about their health in the future.1 In summary, health-related behaviors in adolescence, apart from their influence on the continuum of "health-disease", they also have the potential to influence future behaviors. In fact, several studies have shown that past behaviors are good predictors of future behaviors .3,4 Thus, promoting healthy practices during adolescence and taking measures to better protect young people from health risks are essential for the prevention of health problems in adulthood.5 According to the World Health Organization, the main problems affecting young people include mental health problems (such as behavioral disorders, eating disorders, suicide, anxiety or depression), the use of substances (illegal substances, alcohol and tobacco), interpersonal violence, nutrition (a proper nutrition consists of healthy eating habits and physical exercise), unintentional injuries (which are a leading cause of death and disability among young people, with road traffic injuries accounting for about 700 deaths per day), sexual and reproductive health (for example, risky sexual behaviors, early pregnancy and childbirth) and HIV (resulting from sexual transmission and drug injection).5,6 On the other hand, the number of children and youth with chronic health conditions has increased dramatically in the past four decades7 as larger numbers of chronically ill children survive beyond the age of 10.8 Despite the lack of data on adolescents' health making it difficult to determine the prevalence of chronic illnesses in this age group9, it is known that one in ten adolescents suffers from a chronic condition worldwide.10 In fact, national population based studies from Western countries show that 20-30% of teenagers have a chronic illness, defined as one that lasts longer than six months.8 The most prevalent chronic illness among adolescents is asthma and the one with the highest incidence is diabetes mellitus, particularly type II.9 Traditionally, healthcare professionals have been mainly investing in health education activities, through the transmission of knowledge with a view to creating habits, customs and behaviors, and promoting healthy lifestyles. However, empowering people does not only consist of giving them the right information11 , i.e. good information is not enough to cause people to make changes.12 The motivation or desire to change unhealthy behaviors and habits depends on many factors, namely intrinsic motivation, control over personal decisions, self-confidence and perception of effectiveness, personal ambivalence, and individualized assistance.12 Many professionals assume that supplying knowledge is sufficient for behavioral changes; however, even very good advice often fails to generate behavioral change. After all, people continue to engage in unhealthy behaviors despite clearly knowing what they should do and how to change. "What is lacking is the motivation to apply that knowledge".13, p.1233 In fact, behavioral change is a complex phenomenon with multiple determinants that also includes motivational variables. It is associated with ambivalent processes expressed in the dilemma between keeping the current status and moving on to new ways of acting. For example, telling adolescents that if they keep on engaging in a certain behavior, they are increasing the risk of developing a long-term condition such as cardiovascular disease, stroke or diabetes is rarely enough to trigger the desired behavioral change; people are more likely to change when they believe that the change is really effective and that they are able to implement it.12 Therefore, it is essential to provide specific training for "healthcare professionals to master motivational techniques, avoid confrontation with the users, and facilitate behavioral changes".14 In this context, motivating patients to make behavioral changes is also an important nursing task where change in lifestyle is a major element of patients' treatment and preventive interventions.15 One of the nurse's goals is to help improve a patient's health or help them to manage existing health conditions. Once nurses are in a position where they have to focus on accomplishing tasks and telling patients what needs to be accomplished16, the role of the nurse is expanding even more into the use of motivational strategies.17 MI is bringing nurses back to therapeutic communication and moving them closer to successful health promotion and disease management, by promoting behavior change and empowering their patients. As the nursing profession evolves, MI is seen as a challenge and the basis of nurse's interactions with individuals, families and communities.16, 17 In the same way, MI may be taken as an essential tool in the provision of nursing care to adolescents, being itself a workspace with possible therapeutic effects regarding problems, clarification of doubts, and development of skills.18 In fact, MI may be particularly applicable in work with adolescents because of their specific developmental stage. Adolescents attempt to establish their own autonomy and identity while struggling with social interactions and moral issues, which leads to ambivalence.19 Consistent with the developmental challenges during adolescence, "MI explicitly honors autonomy, people's right and irrevocable ability to decide about their own behavior"20 while allowing the person to explore possibilities for change of risky or maladaptive behaviours.19 MI can be defined as a directive, client-centred counselling style for eliciting behavior change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style of interpersonal relationship.21 It is a set of strategies and techniques widely used in clinical practice based on the transtheoretical model of change. The Stages of Change model describes five stages of readiness—precontemplation, contemplation, preparation, action, and maintenance—and provides a framework for understanding behavior change.22 The MI has been widely tested and applied in different areas, such as modification of addictive behaviors, interventions with offenders in the context of justice, eating disorders, promotion of therapeutic adherence among chronic patients, promotion of learning in school settings or intervention with adolescents at risk.18,23 In general, clinical practice has been adopting the perspective of motivation as something relatively immutable, i.e., the adolescent is either motivated for change/treatment and, in these conditions, the professional's role is to help him/her, or the adolescent is not motivated and then change/treatment is not feasible. Alternatively the theoretical model underlying the MI technique postulates that the individual's adherence to change/treatment depends on his/her motivation, which can change throughout the therapeutic intervention. As several studies found positive results for effects of MI24-26 and its use by health professionals is encouraged23,27 nurses may play an important role in patients' process of change. As nurses have a crucial role in clinical contexts, they can facilitate the process of ending risk behaviors and/or adopting positive health behaviors through some motivational techniques, namely with adolescents. A considerable number of systematic reviews about MI already exist pointing to some benefits of its use in the treatment of a broad range of behavioral problems and diseases.13,28,29 Some of the current reviews focus on examining the effectiveness of MI for adolescents with diverse health risks/problems 30-32. However, to date there are no reviews that present and assess the evidence for the use of nurse-led MI in adolescents. Therefore, we have little knowledge of what works for whom (which adolescent subpopulation) under what circumstances (in which setting, for what problem) in relation to motivational interviewing by nurses. There is a clear need for scoping or mapping the use of MI by nurses with adolescents to identify evidence gaps and to inform opportunities for future development in nursing practice. On the other hand, information regarding nurse-led implemented and evaluated interventions, techniques and/or strategies used, contexts of application and adolescents subpopulation groups is dispersed in the literature33-36 which impedes the formulation of precise questions about the effectiveness of those interventions conducted by nurses and therefore the realization of a systematic review. In other words, it is known that different kind of motivational interventions have been implemented in different contexts by nurses, however does not exist a map about all the motivational techniques and/or strategies used. Furthermore the literature does not clarify which is the role of nurses at cross professional motivational intervention implemented programs and finally the outcomes and evaluation of interventions are unclear. Thus, the practical implication of this mapping will be clarifying all these aspects. Without this clarification is not possible to proceed to the realization of a systematic review about the effectiveness of the use of motivational interviews by nurses to promote health behaviors in adolescents, in a particular context and/or health risk behavior; or regarding the effectiveness of certain technique and/or strategy of MI. Consequently, there are important questions about the nature of the evidence in this area that need to be answered before formulating a precise question of effectiveness. This scoping review aims to respond to these questions. An initial search of the JBI Database of Systematic Reviews & Implementation Reports, Cochrane Database of Systematic Reviews, , Database of promoting health effectiveness reviews (DoPHER), The Campbell Library, Medline and CINAHL, has revealed that currently there is no Scoping Review (published or in progress) on the subject. In this context, this scoping review will examine and map the published and unpublished research around the use of MI by nurses implemented and evaluated to promote health behaviors in adolescents; to establish its current extent, range and nature and identify its feasibility, outcomes and gaps in the evidence defining research priorities in this field. This scoping review will be informed by the JBI methodology37 that suggests a five stage methodological framework for conducting scoping reviews which includes: identifying the research question, searching for relevant studies, selecting studies, charting data, collating, summarizing and reporting the results.

A case study of teaching and learning practice in a Chinese adult institution

Résumé: Cette recherche s'est réalisée dans une institution chinoise de formation des adultes. Il existe très peu d'études présentant la pratique de l'enseignement et de l'apprentissage en Chine. Aussi, il semble que cette étude de cas puisse être utile. Elle porte sur le personnel de formation en administration économique dans un centre de formation de Tianjin. Le but premier de cette recherche est de décrire ce qui se fait à cet institut de formation des adultes. Les aspects couverts vont de la sélection du contenu de formation et des modalités d'enseignement jusqu'à la compréhension de l'enseignement et de l'apprentissage. À partir de l'expérience des professeurs de ce centre de Tianjin, cette étude cherche précisément à décrire leurs perceptions et leurs attitudes en regard d'un enseignement centré sur l'apprentissage et développé selon un mode de collaboration. Les fondements théoriques retenus s'inspirent des conceptions andragogiques de Knowles, de celles de Brookfield qui ont trait aux rôles des formateurs et formatrices d'adultes et de Conti qui présente une conception de l'enseignement qui se développe selon un mode de collaboration. Les données sont été retenues à la suite d'interviews et de questionnaires. Ce dernier instrument a été administré à 70 professeurs de formation aux adultes. Les résultats obtenus sont décrits et analysés. Les principaux éléments indiquent que la pratique actuelle de formation des adultes à ce centre de Tianjin ne tient pas compte des principes de l'éducation des adultes présenté selon un mode de collaboration. La formation est centrée sur l'enseignement. Il est à souhaiter que cette recherche contribuera à développer une meilleure compréhension de l'enseignement et de l'apprentissage en Chine tel que perçus par les formateurs et formatrices. Quelques suggestions de recherche complémentaires sont proposées à la fin.||Abstract: The present study grew out of one Chinese adult institute. Relatively few works are available that present a view of what actually happens in Chinese adult teaching and learning practice. Accordingly, it is believed that a case study on Tianjin Institute of Training Economic Management Personnel (TITEMP) which has been working for years in varions forms of adult programs, will be very useful addition to the knowledge of Chinese adult teaching and learning. The primary purpose of the present study is to serve as an introduction to one Chinese adult institute (TITEMP) in terms of characteristics of teaching, including selecting teaching content and teaching pattern, and to expand the understanding of Chinese adult teaching and learning. Based on the experiences of teachers at TITEMP, the study seeks to investigate the issues of teacher's perceptions and attitudes of teaching and learning to obtain implications toward learning-centred and collaborative mode. The theoretical foundations include andragogical conceptions (Knowles), roles of adult teachers (Brookfield), and conceptions of collaborative teaching and learning mode (Conti). The main sources of data are: the interviews and results of the questionnaire. Questionnaire responses from 70 teachers with knowledge of adult teaching and learning are described and interpreted. The general findings of the study are that the existing adult teaching practice at TITEMP does not adequately account for the principles of adult learning in a collaborative mode with adult students. Adult learning is teaching-centred. Some suggestions for further research are offered. It is hoped and believed that this research will contribute to a better understanding of Chinese adult teaching and learning in general, more particularly to the empirical study of the teachers from teaching and learning perspective in a Chinese adult higher learning setting. The research findings will be used as basis for the exploration of Chinese adult teaching.

Human motivation and professional practice: of knights, knaves and social workers

Efforts to improve the efficiency and responsiveness of public services by harnessing the self-interest of professionals in state agencies have been widely debated in the recent literature on welfare state reform. In the context of social services, one way in which British policy-makers have sought to effect such changes has been through the "new community care" of the 1990 NHS and Community Care Act. Key to this is the concept of care management, in which the identification of needs and the provision of services are separated, purportedly with a view to improving advocacy, choice and quality for service users. This paper uses data from a wide-ranging qualitative study of access to social care for older people to examine the success of the policy in these terms, with specific reference to its attempts to harness the rational self-interest of professionals. While care management removes one potential conflict of interests by separating commissioning and provision, the responsibility of social care professionals to comply with organizational priorities conflicts with their role of advocacy for their clients, a tension rendered all the more problematic by the perceived inadequacy of funding. Moreover, the bureaucracy of the care management process itself further negates the approach's supposedly client-centred ethos. The definitive version is available at www.blackwell-synergy.com

Is client-centred care planning for chronic disease sustainable? Experience from rural South Australia

This qualitative evaluation of a chronic disease self-management project in rural South Australia considers the sustainability of client-centred care planning under current organisational and funding arrangements. The study involved consultation with a range of five stakeholder types over two stages (40 in the beginning stage and 39 in the middle stage) about their satisfaction with the care planning and self-management approach used in the project. All stakeholder types valued the client-centred approach because they perceived that clients were better able to accept and deal with the long-term management of their condition. However, this required that care planning should deal with a wider range of issues than just medical management, and so it took longer, which raised its sustainability in general practice under the current funding through the national health insurance programme (Medicare). The study concludes that sustainability may be addressed through further research into the role of and funding for peer-led self-management groups and the employment of care planners in organisational settings that are conducive to a client-centred approach.

A review of the game-centred approaches to teaching and coaching literature since 2006

Background: In 2006, Oslin and Mitchell published a review of the game-centred approaches (GCAs) to teaching and coaching literature highlighting a number of core concepts thought to provide justification for the use of GCAs including (a) its potential to enhance participant motivation, (b) potential for tactical transfer, and (c) development of decision-making skills and effective decision-makers. Oslin and Mitchell also suggested recommendations for future GCA research.Purpose: The purpose of this paper was threefold: (a) to present a review of Anglophone research into GCAs building on the previous review of Oslin and Mitchell published in 2006; (b) to identify new trends in research since 2006; and (c) to investigate the extent to which the initial suggestions and future research directions suggested by Oslin and Mitchell have been addressed.Data collection: GCA literature since 2006 was searched systematically using a three-phase approach. Phase 1 included initial searches of the EBSCO database using terms associated with GCAs and their acronyms (e.g. TGfU (teaching games for understanding), GS (Game Sense), etc.). Phase 2 expanded the search adopting more generic terms from keywords located in the recent literature (e.g. teaching games, tactical development, game performance, etc.). Multiple searches through the EBSCO database were conducted, whereby key terms were cross-referenced until a saturation point was reached. Phase 3 involved removing those publications that were not empirical, peer reviewed, intervention studies or published in English.Findings: Forty-four studies on GCA implementation were identified and the methodological and substantive nature of these studies was examined. The review noted two positive trends: (a) the expansion of research which included the growth of research on GCAs in Europe and Southeast Asia and (b) an increased amount of research in the affective domain. The review found, however, that a number of key challenges remain within GCA research, which include (a) the need for improved articulation of GCA verification procedures; (b) further assessment of tactical awareness development; (c) extended inquiry about GCAs in coaching contexts; (d) more research into ‘newer’ GCAs (i.e. PP (play practice), IGCM (invasion game competence model) and TDLM (tactical decision learning model)); (e) use of longitudinal research designs; (f) inadequate length of GCA induction and training for teachers and coaches, and (g) examination of GCAs in terms of fitness and special populations.Conclusions: GCA pedagogies are of significant importance as they have the potential to promote change within current adult-centric cultures of youth sport and encourage engagement in physical activity over the life course. To meet these needs, it is recommended that GCA research undergo continued expansion with the use of research designs and data collection techniques that aid the examination of different philosophical understandings of GCAs (e.g. ethnographic, phenomenological and psycho-phenomenological). These are paramount to the exploration of ‘who the individual is’ and ‘how the learner is motivated to continue to participate’ and further permit the in-depth, contextual and ecological analysis of GCA interventions that Oslin and Mitchell recommended in their previous review.

Principalship as negotiated practice: a Bourdieuian analysis

 Using a Bourdieuian social analysis the thesis explores the interplay of personal identity formation and system demands captured in the powerful narratives of experienced principals. Astute strategists, they are employing agentic actions centred on learning, democratic practice and social equity that are countering the prevailing logics of the education field.

Creating opportunities for interdisciplinary collaboration and patient-centred care: how nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting.

AIMS AND OBJECTIVES: This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications. BACKGROUND: Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients. DESIGN: A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia. METHODS: A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework. FINDINGS: Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management. CONCLUSIONS: The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication management in an acute hospital setting. Language discourses shaped and were shaped by complex power relations between patients and clinicians and among clinicians themselves. RELEVANCE TO CLINICAL PRACTICE: Clinicians need to be encouraged to have regular conversations to talk about and challenge each other's practices. More emphasis should be placed on ensuring that patients are given opportunities to voice their concerns about how their medications are managed.

Family centred care before and during life-sustaining treatment withdrawal in intensive care: a survey of information provided to families by Australasian critical care nurses

BACKGROUND: A core component of family-centred nursing care during the provision of end-of-life care in intensive care settings is information sharing with families. Yet little is known about information provided in these circumstances.

OBJECTIVE: To identify information most frequently given by critical care nurses to families in preparation for and during withdrawal of life-sustaining treatment.

DESIGN: An online cross-sectional survey.

METHODS: During May 2015, critical care nurses in Australia and New Zealand were invited to complete the Preparing Families for Treatment Withdrawal questionnaire. Data analysis included descriptive statistics to identify areas of information most and least frequently shared with families. Cross tabulations with demographic data were used to explore any associations in the data.

RESULTS: From the responses of 159 critical care nurses, information related to the emotional care and support of the family was most frequently provided to families in preparation for and during withdrawal of life-sustaining treatment. Variation was noted in the frequency of provision of information across body systems and their associated physical changes during the dying process. Significant associations (p<0.05) were identified between the variables gender, nursing experience and critical care experiences and some of the information items most and least frequently provided.

CONCLUSIONS: The provision of information during end-of-life care reflects a family-centred care approach by critical care nurses with information pertaining to emotional care and support of the family paramount. The findings of this study provide a useful framework for the development of interventions to improve practice and support nurses in communicating with families at this time.

Person, community, Tian: the emergence of order and harmony in Chinese philosophy

This thesis clarifies how the concept of tian functions in Chinese thought, and what tianren heyi (the continuity between tian and humans) means in the Chinese context. With a new interpretation about tianren heyi, I provide a new contribution for understanding these Chinese concepts for an English speaking audience. Tian is not a fixed concept like the idea of heaven, rather, it can be the principle for one’s immanent world. The meaning of the term changes depending on the context it is being used in, and can also be neutral when necessary. Continuity means that there is a resonance and reciprocity in the way these aspects of cosmology emerge together. Humans and tian are not being unified or connected—there is simply continuity between them. What happens is that a productive relationship between them produces depth, harmony, and enhanced significance. Through the interaction between humanity and tian, the human world gains order, and from the perspective of tian, gains harmony. This different understanding the continuity between humanity and tian leads to a new understanding of timing or the appropriateness in li. In the process of practice and self cultivation, it is seen that li is also an idea that is not fixed to one single interpretation as it is connected with timing and appropriateness. The Classical Chinese concept of “Person” (ren 人), as the concrete context of li, is the centre of this practice. Because of the unfixed natures of tian and li, one needs to be flexible in order to cater to their demands. This embodies the freedom of the subject in Chinese thought. As the outcome of li, the social and political structure is shaped in this process, the examples being the models of “great union” and “small tranquillity” (Chapter 3) in Chinese tradition.

Existentialist methodology and perspective: writing the first-person

Without proposing anything quite so grandiose as a return to existentialism, in this paper we aim to articulate and minimally defend certain core existentialist insights concerning the first-person perspective, the relationship between theory and practice, and the mode of philosophical presentation conducive to best making those points. We will do this by considering some of the central methodological objections that have been posed around the role of the first-person perspective and “lived experience” in the contemporary literature, before providing some neo-existentialist rejoinders. We will suggest that the dilemma that contemporary philosophy poses to existentialism, vis-à-vis methodology, is that it is: a) committed to lived experience as some sort of given that might be accessed either introspectively or retrospectively (with empirical science posing prima facie obstacles to the veridicality of each); and/or b) it advocates transformative experiences, and the power of philosophy in connection with such experiences, to radically revise our doxastic and inter-connected web of beliefs. In short, the charge is conservatism on the one hand, radicalism on the other. Each of these concerns will be addressed in turn, utilizing ideas from Kierkegaard (as the source for many existentialist themes, methodological concerns, and formal practices) and from the German and French twentieth century versions of existentialism

Temporal asymmetry and the self/person split

Derek Parfit’s discussion of our bias towards the future has sparked considerable discussion of our pervasively asymmetrical attitudes towards past and future goods. Much of this discussion has centred on whether we can rationally justify such attitudes or whether they are intrinsically irrational. This paper seeks neither to justify nor to reject temporally asymmetrical attitudes, but to explicate the way perspective, and particularly temporal perspective, operates in such biases, in order to show how our temporal biases point to something important about the structure of selfhood. By employing an emerging distinction in the personal identity literature between the ‘self’ as an intrinsically first personal and temporally indexical locus of consciousness, and the ‘person’ as a diachronic bearer of various forms of physical and psychological predicates, we can see that the clash between temporally asymmetrical attitudes and symmetrical welfare judgments is in fact a result of the ways in which selves and persons interact.