Action research in action: reflections on a project to introduce Clinical Practice Facilitators to an acute hospital setting

AIMS OF THE PAPER

The process and philosophical basis of action research are discussed in this article by reviewing the insights that were gained from a study designed to enhance the support available to junior nursing staff in an acute hospital setting.

RATIONALE

It has been well documented that newly qualified nurses require help to develop professional competencies. With this in mind, the role of Clinical Practice Facilitator was established within a National Health Service (NHS) Trust to enhance clinical skill acquisition and the professional development of newly registered nurses and health care assistants.

DESIGN

In order to facilitate the inception, development and subsequent evaluation of these new roles, an action research approach was adopted. Strategies used to encourage collaboration and flexibility during the project are also discussed.

RESULTS

The primary aims of the project were achieved and the authors suggest that the choice of action research was significant to the successful outcome. However, a number of issues arose which deserve more attention including the importance of the interpersonal skills of the action researcher and the value of action research to facilitate change which is relevant at both an individual and organizational level.

A randomised controlled trial to evaluate the effectiveness and cost-effectiveness of counselling patients with chronic depression

OBJECTIVES

To examine the effectiveness and cost-effectiveness of short-term counselling in general practice for patients with chronic depression or combined depression and anxiety, compared with general practitioner (GP) care alone.

DESIGN

A randomised controlled trial and economic evaluation with an initial assessment at randomisation and follow-ups at 6 and 12 months.

SETTING

Nine general practices that were well-established participants of the Derbyshire counselling in general practice scheme, and already had a counsellor in the practice team.

SUBJECTS

Patients were screened at GP practices, and asked to participate if they scored >/= 14 on the Beck Depression Inventory (BDI), had suffered depression or depression/anxiety for 6 months or more, were aged 18-70 and had no history of drug or alcohol abuse, psychoses or suicidal tendencies.

INTERVENTIONS

The experimental group received usual GP treatment and were also referred to an experienced, well-qualified counsellor attached to their general practice. Of the eight counsellors, two practiced cognitive behavioural therapy (CBT) and six had a psychodynamic approach. The controls were referred back to their GP for routine treatment. There were no restrictions regarding the treatment that could be used, except that GPs could not refer controls to practice counsellors.

OUTCOME MEASURES

The main outcome measure was the BDI. Others included the Brief Symptom Inventory, the Inventory of Interpersonal Problems and the Social Adjustment Scale. All tests were given at initial, 6- and 12-month assessments. Comprehensive costs were also estimated, and combined with changes in outcomes to examine between-group differences and whether counselling was more cost-effective than standard GP care.

RESULTS

The trial recruited 181 patients. There was an overall significant improvement in the actual scores over time but no difference between groups or between CBT and psychodynamic counselling approaches at either 6 or 12 months. However, fewer experimental group patients were still 'cases' on the BDI than controls. This difference was statistically significant at 12 months and neared significance at 6 months (using logistic regression with the initial score as a covariate). In addition, most patients were very positive about the counselling and considered it helpful. Visual inspection of the outcomes suggested that more patients with mild or moderate depression at study entry had improved and ceased to be cases, and that more of these patients had become 'non-cases' in the experimental than the control group. However, a multiple regression analysis indicated no significant interactions between group and initial severity of depression. This could be partly due to there being no difference in outcome between the experimental and control group patients who were initially severely depressed and few of these patients ceasing to be cases at follow-up. There were no significant differences in the mean total costs, aggregate costs of services, or any of the service-group costs, except for primary care, between the experimental and control groups over time. The cost-burden to GP practices was significantly higher in the experimental than the control group at 6 months.

CONCLUSIONS

Although patients were generally appreciative of the counselling received, there was only limited evidence of improved outcomes in those referred to counselling. Stricter referral criteria to exclude the severely depressed may have yielded more conclusive results. It is also difficult to estimate the effect of recruitment by screening rather than GP referral, which may limit the applicability of the results to routine clinical practice, and may have interfered with the normal working alliance established between the GP, patient and counsellor. A patient preference trial may, therefore, have been more appropriate. The results indicated that there were similar improvements for both CBT and psychodynamic counselling, but a

Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment

OBJECTIVES

To develop a categorical outcome measure related to clinical decisions and to perform secondary analyses to supplement the primary analyses of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA).

METHOD

End-of-treatment status was summarized by averaging the parent and teacher ratings of attention-deficit/hyperactivity disorder and oppositional defiant disorder symptoms on the Swanson, Nolan, and Pelham, version IV (SNAP-IV) scale, and low symptom-severity ("Just a Little") on this continuous measure was set as a clinical cutoff to form a categorical outcome measure reflecting successful treatment. Three orthogonal comparisons of the treatment groups (combined treatment [Comb], medication management [MedMgt], behavioral treatment [Beh], and community comparison [CC]) evaluated hypotheses about the MTA medication algorithm ("Comb + MedMgt versus Beh + CC"), multimodality superiority ("Comb versus MedMgt"), and psychosocial substitution ("Beh versus CC").

RESULTS

The summary of SNAP-IV ratings across sources and domains increased the precision of measurement by 30%. The secondary analyses of group differences in success rates (Comb = 68%; MedMgt = 56%; Beh = 34%; CC = 25%) confirmed the large effect of the MTA medication algorithm and a smaller effect of multimodality superiority, which was now statistically significant (p < .05). The psychosocial substitution effect remained negligible and nonsignificant.

CONCLUSION

These secondary analyses confirm the primary findings and clarify clinical decisions about the choice between multimodal and unimodal treatment with medication.

Is the clinical expression of late-life depression influenced by brain changes? MRI subcortical neuroanatomical correlates of depressive symptoms

BACKGROUND

"Vascular depression" has recently been proposed. It is characterized by magnetic resonance imaging (MRI) T2-weighted subcortical lesions, a late onset of first episode of depression, and reduced heritability; a cerebrovascular etiology is suggested. The validity of "vascular depression" might be strengthened if an association was found between the subcortical lesions used to define it and particular depressive symptoms.

METHODS

A blinded cross-sectional examination of DSM-III-R depressive symptoms (American Psychiatric Association, 1987) and MRI T2-weighted subcortical lesions in 44 patients with late-life depression.

RESULTS

Many associations were found; however, because of multiple comparisons, their significance is viewed with caution. The most robust finding was that psychomotor retardation was independently related to total white-matter score. The odds of showing psychomotor retardation was increased 1.9 times for every point increase in severity of white-matter change.

CONCLUSION

In late-life depression the clinical expression of the depression is influenced by the pattern of MRI T2-weighted subcortical lesions. This gives some validity to the concept of an MRI-defined "vascular" subtype of late-life depression and strengthens the argument for including neuroimaging in the classification of late-life depression.

Behavioral versus behavioral and pharmacological treatment in ADHD children attending a summer treatment program

As part of the behavioral treatment in the Multimodal Treatment Study of Children with ADHD (MTA9), children participated in an intensive summer treatment program (STP). This study examined the differences between 57 children in the combined treatment (Comb) group, who were medicated, and 60 children in the behavioral treatment (Beh) group, who were unmedicated throughout the STP. Comb children were significantly better than Beh on 5 measures: rule following, good sportsmanship, peer negative nominations, and STP teacher posttreatment ratings of inattention/overactivity. Groups did not differ on any of the other 30 measures, and responded similarly to the STP over time. Comparisons to normative data revealed that Comb children were more likely to fall within the normative range on 6 measures. The differences between these results and the main MTA results, in which Comb was always superior to Beh, are discussed in terms of the relative intensity of combined treatments. The implications for future studies of pharmacological and behavioral treatment for ADHD are discussed.

Dyslexia: a developmental language disorder

The acquisition of literacy in an alphabetic script such as English makes heavy demands on linguistic skills. The relation between spoken and written language however, is far from straightforward. This article reviews the research that suggests that phonological processing skills are crucial in the translation of symbols to sounds, and the development of rapid and automatic decoding skills. It examines research that indicates that children whose phonological processing skills are compromised in some way, are at-risk of experiencing difficulties in the acquisition of literacy; it supports the suggestion that dyslexia can be viewed as lying on the continuum of developmental language disorders. It goes on to relate theory to practice and discusses the responsibilities of health care professionals in relation to the early identification of dyslexia, and makes suggestions regarding intervention. In particular, it looks at the responsibilities of speech and language therapy services in the care and management of children with dyslexia.

Neural network analysis of oxygenation signals in infants during sleep

The use of artificial neural networks (ANNs) to interpret sleep monitoring signals is described. Recordings from ten infants with apparent life threatening episodes were assigned into training feedforward R-PROP networks. In order to separate good signal from artefact, 60 second time frames of SaO2 and TcPO2 signals were processed and the mean and standard deviation values were used as inputs to the networks. Intra-human errors were minimized using this method whilst inter-human errors remained significant. To decrease the latter, the number of hidden units was increased to eight. Sensitivity figures of the SaO2 network were 0.93 and 0.9 for the training and test sets respectively whilst the specificity figures were 0.7 and 0.65 respectively. For the TcPO2 signals the above figures were 0.92, 0.85, 0.77 and 0.61 respectively.

Investigation of Thin Aqueous Films on Silica Using a Modified Interferometric Technique

The thinning behavior of liquid films between free bubbles and silica is investigated using the interferometric technique. Stable films were obtained at higher salt concentrations compared to previous studies because of the improved cleaning procedure. In contrast to the captive bubble technique used in the past, the free bubble method employed more closely approximates such processes as flotation. The results obtained for aqueous films at low and high ionic strengths are in better agreement with theoretical predictions than those in previous studies. Copyright 2000 Academic Press.

Suggestive evidence of a locus on chromosome 10p using the NIMH genetics initiative bipolar affective disorder pedigrees

As part of a four-center NIMH Genetics Initiative on Bipolar Disorder, a genome screen using 365 markers was performed on 540 DNAs from 97 families, enriched for affected relative pairs. This is the largest uniformly ascertained and assessed linkage sample for this disease, and includes 232 subjects diagnosed with bipolar I (BPI), 32 with schizo-affective, bipolar type (SABP), 72 with bipolar II (BPII), and 88 with unipolar recurrent depression (UPR). A hierarchical set of definitions of affected status was examined. Under Model I, affected individuals were those with a diagnosis of BPI or SABP, Model II included as affected those fitting Model I plus BPII, and Model III included those fitting Model II plus UPR. This data set was previously analyzed using primarily affected sib pair methods. We report the results of nonparametric linkage analyses of the extended pedigree structure using the program Genehunter Plus. The strongest finding was a lod score of 2.5 obtained on chromosome 10 near the marker D10S1423 with diagnosis as defined under Model II. This region has been previously implicated in genome-wide studies of schizophrenia and bipolar disorder. Other chromosomal regions with lod scores over 1.50 for at least one Model Included chromosomes 8 (Model III), 16 (Model III), and 20 (Model I). Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:18-23, 2000

Jaws and teeth of Australopithecus afarensis from Maka, Middle Awash, Ethiopia

The Maka locality in Ethiopia's Middle Awash area has yielded new craniodental remains dated to 3.4 million years (myr) in age. These remains are described and assessed functionally and systematically. The fossils are assigned to Australopithecus afarensis. Maka thus joins Hadar and Laetoli as the third major locality yielding this species. As with previous site samples, the Maka collection displays a wide range of size variation. The nearly complete and undistorted MAK-VP-1/12 adult mandible from Maka is an excellent match for Hadar and Laetoli counterparts, confirming the geographic and temporal distribution of A. afarensis. This specimen shows that this taxon is functionally and developmentally hominid in its incisor/canine/premolar complex. A postulated evolutionary trajectory through A. anamensis to A. afarensis would have involved postcanine megadontia and other adaptations to a more heavily masticated diet relative to the earlier Ardipithecus ramidus.

Personality change in dementia

This study examined the prevalence and nature of personality change in 99 patients with dementia of the Alzheimer type and multi-infarct dementia. Personality was assessed using an informant-rated inventory of the patient's personality before and after the onset of dementia, with the difference equating to a change in personality. Personality characteristics were related to the patients' age and sex, duration of illness, degree of cognitive impairment, the presence of a grasp reflex, and extrapyramidal signs. Personality change was found to be almost universal and negative in nature and was particularly associated with severity of cognitive impairment, longer duration of illness, and neurological signs. The findings reflect those from other studies and emphasize the biological basis of personality changes in dementia.

Neurological correlates of depressive symptoms in Alzheimer's disease and vascular dementia

BACKGROUND

Organic brain disease such as dementia or stroke is associated with depression. In dementia, depressive symptoms are common where there is evidence of vascular disease and in Alzheimer's disease they often coexist with extrapyramidal signs.

METHOD

In a study of 60 patients with Alzheimer's disease and 39 patients with vascular dementia, depressive symptoms were rated using the Cornell Scale for Depression in Dementia. Neurological signs were assessed and severity of cognitive impairment was measured with the Mini-Mental State Examination.

RESULTS

Depressive symptoms were more severe in vascular dementia. Pyramidal tract signs had no relationship to depression in either type of dementia. In vascular dementia, extrapyramidal and grasp reflexes were strongly related to the severity of depression, and were associated with neurovegetative features. In Alzheimer's disease, extrapyramidal signs were the strongest independent predictor of the severity of depression.

CONCLUSION

Depressive symptoms are more severe in vascular dementia compared to Alzheimer's disease and were related to neurological abnormalities.

Australopithecus garhi: a new species of early hominid from Ethiopia

The lack of an adequate hominid fossil record in eastern Africa between 2 and 3 million years ago (Ma) has hampered investigations of early hominid phylogeny. Discovery of 2.5 Ma hominid cranial and dental remains from the Hata beds of Ethiopia's Middle Awash allows recognition of a new species of Australopithecus. This species is descended from Australopithecus afarensis and is a candidate ancestor for early Homo. Contemporary postcranial remains feature a derived humanlike humeral/femoral ratio and an apelike upper arm-to-lower arm ratio.