Recent Submissions

  • An international adult guideline for making clozapine titration safer by using six ancestry-based personalized dosing titrations, CRP, and clozapine levels

    Rajkumar, Anto P. (2021)
    This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.
  • PsychStart: a novel mentoring scheme for supporting and valuing medical students interested in psychiatry

    Thomas, Nikki (2021)
    We describe the establishment and evaluation of a career-based mentoring scheme (PsychStart) for medical students interested in psychiatry. Medical students reported multiple benefits of mentoring, including enhanced personal and professional development, increased career and clinical knowledge, and broadened exposure to psychiatry. The mentoring scheme was also found to promote and sustain interest in the specialty. Further evaluation is required to determine the long-term effects of mentoring and how this may compare with other undergraduate enrichment activities. We conclude that mentoring in psychiatry could offer innovative solutions for improving recruitment and retention, and for supporting and valuing medical students who demonstrate an early interest in the specialty.
  • On the register but 'out of practice'?

    Brennan, Theresa (2019)
    The usual return-to-practice courses don’t apply to registered nurses who want to re-route into clinical practice but lack the experience or confidence – but there is another option When NHS England published the interim NHS People Plan this summer, encouraging nurses who have left the profession to return to practice was identified as a priority in tackling the nursing workforce crisis.
  • Virtual balint group experience due to the COVID-19 pandemic

    Brown, Rebecca; Philips, NIcola (2021)
    Aims In the changes brought about by remote working, the local psychotherapy case discussion group (Balint Group) has developed as a remote service via video consultation. It is important to consider the effect that this change in method of delivery has had on experience. Method An anonymous survey was distributed to determine the benefits and challenges from participants and facilitators with at least a month of virtual Balint Group experience. The open-ended survey questions captured extended answer responses from 16 students and trainees, and 5 (co-)facilitators, within Nottinghamshire Healthcare NHS Foundation Trust. The qualitative feedback was analysed by thematic analysis, identifying three main themes. Result The first theme of practicalities was centred around access to the group. The virtual format had benefits in terms of reducing travel and time commitment and so improving attendance. However, disadvantages were in technological issues and finding a private and safe environment, individuals often not leaving the work environment on which they were reflecting. The second theme of communication identified how virtual methods are a less natural way of interacting (for example sequential point making), losing both immediacy of reactions and non-verbal communication. There was a loss of essential communication cues, with disjointed conversation affecting contribution. The third theme of group dynamics had some advantages, feeling less intimidating virtually. Yet disadvantages included loss of group cohesion, with participants not building the same relationships (on arriving and leaving a group space), and trust. The more subtle emotions in the group might be missed and opinions given less openly. The facilitators needed to be more directive and experienced difficulties maintaining group engagement and managing the frame. Conclusion The advantages of virtual format are more based on accessibility and the disadvantages more experiential. There are elements of being physically remote that lead to a disembodied experience, that might impact on capacity to reflect emotionally. This might make it more difficult to identify unconscious processes and the experience might be more cognitive. There is a risk that virtually participants will feel more alone with difficult feelings and unsupported by the group. When mental health is being affected by social isolation due to the pandemic, having groups virtually can mimic this isolation in working life. Overall the preference remained for an in-person group. However, it was clear that access to some form of a group was important, to contain anxiety during these unprecedented times.
  • Open dialogue and co-production: promoting a dialogical practice culture in the co-production of teaching and learning within nurse education

    Hendy, Corrine (2021)
    Purpose The evidence base associated with Open dialogue (OD) continues to develop. However, much of the literature associated with this “whole system philosophy” is focussed within therapeutic clinical practice. The purpose of this paper is to explore another key aspect of OD within a higher education context, the creation of “dialogical practice culture” and the application of key OD principles to enable an open, empowering ethos which permeates all aspects of teaching and learning and supports co-production. Design/methodology/approach The authors use a collective auto ethnographic approach to reflect on their experiences of developing and delivering a series of co-produced seminars within pre-registration mental health nurse education over a period of 4 years. This paper explores the data produced through this process focussing on the pedagogical impact and challenges of applying OD principles to teaching and learning practice. Findings The paper highlights the way in which two core principles of OD, resonate with the co-production process within teaching design and delivery. Moreover, the paper illustrates the impact that threading these principles throughout teaching practice can have: enhancing the learning environment and facilitating mutual empowerment, and thus supporting the students’ development of empowering therapeutic practice with service users. A significant theme in these reflections has been the nature of empowerment and the necessity to openly address power differentials and relationships. Originality/value This innovative paper is the first to explore the application of OD principles within a nurse education context; considering how they support co-production and enable an empowering culture. This exploration helps to provide a foundation for further inquiry and research.
  • Survey to evaluate care of complex clients in residential settings

    Sadraei, Rosa; Pathy, Puru; Collins, Michael (2021)
    Aims Delivering a new efficient assessment and shorter term secondary mental Health intervention service for individual sectors Background In November 2015, there was a transition to services with the focus on delivering more efficient service to clients Previously we had been a combined sector Service. This transition, a reduction in resources and a move away from delivering care Through specialist mental health teams created from the national service framework - such as Assertive outreach, early intervention in psychosis and community rehabilitation - to a more Streamlined generic service, catering for these differing groups of people using a “Pathways Model” approach Result Across the two sectors we had 47 clients on CPA Pathway living in 24 hour residential Settings who all had a current care coordinator. These 47 clients represented the workload currently of 2.8 FTE Band 6 care coordinators. There were at Origin, 13 Residential/Nursing/Secure 24 Hour care providers, where clients were residing. However of these 90% of residents lived in one of 5 settings, 3 settings in Ashfield and 2 in Mansfield. Over 50% of individuals residing did not have existing connections with Mansfield or Ashfield before being placed into the area. 18 Clients (%38) were under section of the mental health act and 1client (%2) was on a life-Licence from criminal justice. Conclusion Transfer of CPA Care Coordination Protocol To send paper referral to our Single Point of Access Meeting at the listed address at the earliest point relocation/placement is confirmed.Formal handover meeting for care will be coordinated, not sooner than 3 months after the placement commences. It will be expected that services currently involved in provision of service continue to hold care responsibility in the interim period. As we move to a paperless environment, provision of electronic documentation such has previous CPA documents, Risk assessments, social circumstance reports & Discharge summaries, would be greatly appreciated
  • Junior doctors rate online simulation as 'good enough' but not as good as face to face sessions

    Bachra, Josh; Ludvigsen, Anna; Junaid, Kehinde (2021)
    Aims To compare the feasibility and acceptability of delivering a simulation-based learning (SBL) programme for Junior Doctors virtually versus face to face. Method The Nottinghamshire Healthcare Simulation Centre has been delivering a SBL programme for Foundation Year 2 doctors on behalf of Health Education East Midlands for the past three years. Since face to face teaching was not possible during the COVID-19 pandemic the programme was delivered online using the same content and format as for prior cohorts. Feedback questionnaires from 128 face to face participants (F2F) and 133 virtual participants (V) were compared. Result There was a decrease in Likert scale ratings across all domains in the virtual group. This was most apparent when examining the ‘strongly agreed’ responses: the venue/remote format was suitable for the session 34% decrease, the course length was appropriate 24% decrease, the pace of the course was appropriate 20% decrease, the simulation was helpful and relevant 15% decrease, the content of the course was organised and easy to follow 13% decrease, the learning objectives were met 10% decrease, the presenters were engaging 6% decrease, the trainers were well prepared 3% decrease. The virtual group included responses in the ‘strongly disagree’ and ‘disagree’ categories relating to the virtual format, length and pace, which did not occur in any domain for the F2F group. Combining the ‘strongly agree’ and ‘agree’ statements also showed a decrease in satisfaction with 72.5% of responses falling into this category for the V group and 88.3% for the F2F group. Fewer participants in the V group would recommend the course to a colleague (98% V vs 99% F2F). Conclusion Providing the SBL programme using an online format was feasible while also being acceptable to most participants. However, participants did not rate this experience as highly as face to face teaching. The largest decreases in satisfaction were in areas related to the virtual format. An interesting finding is that participants rated the pace and length of the online course as less agreeable, despite the content and scheduling being the same as for the face to face group. Based on these findings face to face teaching should resume when practicable. In the meantime, the virtual delivery may be improved if the course length was reduced. Analysis of qualitative feedback may provide insights into why participants did not rate the virtual simulation as highly as the face to face equivalent.
  • Dr QI - A quality improvement (QI) approach to designing and delivering QI training

    Krishnan, Deepa B.; Ohize, Victor; Baumber, Luke (2021)
    Aims To develop and implement a QI training programme for trainees, Trust grade doctors and Consultants in Nottinghamshire Healthcare NHS Trust (NHFT) to enable them to deliver change in practice through acquisition of new knowledge and practical application of skills in QI projects using Model for Improvement. Background QI is crucial to improve patient care. Doctors are uniquely placed to input into patient safety and service delivery of healthcare. The skills required to be future clinical leaders and undertake improvement work are not innate and formal teaching and support is required. What is DrQI? DrQI is a trainee-led QI teaching programme developed in collaboration with Trainees improving patient safety through QI (TIPSQI) in North West deanery. Method A pre-implementation survey amongst doctors in NHFT in February 2019 (33 responses) suggested that 90% of doctors were interested in learning QI and about 48% preferred face-face workshops with support from the QI team. A list of change ideas were created using a driver diagram with QI education and project support identified as key primary drivers. PDSA cycles Nine interactive workshops teaching key QI concepts (based on model for improvement) in NHFT, training more than 100 doctors. A workshop in Derbyshire Healthcare NHS Foundation Trust (70 doctors) and Nottingham University Hospital (20 doctors). Workshops were continually adapted based on qualitative and quantitative feedback. Different formats were tried including virtual sessions, game-based and problem-based learning approaches using small group activities. Result Pre-course and post-course questionnaires were used to assess change in understanding of individual components of QI methodology (SMART Aim, Driver diagram, PDSA cycles, outcome and process measures and run charts). Mean pre-course self-assessment score collated from seven QI workshops in NHFT (2019-2020) was 3.3 and mean post-course score was 7.68, showing an improvement in understanding of QI methodology. Participants were asked to score the relevance (8.4) and quality of teaching (8.4) and the support from the QI team (7.4) on a scale of 1-10 (1 = poor and 10 = excellent). Additional free text feedback was obtained to help us improve the teaching programme. Conclusion Collaborative leadership trainee-led initiative to increase the QI capacity. A bottom up approach to complement the top down approach from the Trust QI team. Future steps include further collaboration and expansion of the scheme to other Trusts, Train the trainer sessions and building a network of QI champions.
  • Audit on clozapine dose and plasma level correlation for patients with chronic treatment-resistant psychosis

    Macnamara, Olivia; Lawton, John D.; Lankappa, Sudheer (2021)
    Aims Clozapine is associated with a risk of severe adverse events for which there are current monitoring systems are in place; however, there are no established regimens for monitoring of clozapine plasma levels. Recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance advises clozapine levels should be monitored in certain clinical situations where toxicity may be suspected. This audit aimed to evaluate current practice of clozapine level monitoring within one Local Mental Health Team (LMHT). Method Electronic (RiO) records of 41 patients (33 male, 8 female; aged from 27 to 76 years; mean age 45 years) registered to the ZTAS system within the Nottingham City Central LMHT were reviewed. 46% had been on clozapine for over 16 years. 73.3% of patients were within clusters 12 and 13; 25.4% of patients were in cluster 11, with one patient in cluster 8. Dates of clozapine plasma level tests for each patient between 2006 and 2020 were found on the electronic NoTIS system, along with clozapine, norclozapine and total clozapine levels. Concurrent clozapine dose and regimens were obtained from pharmacy records from 2018 onwards. Result 273 clozapine plasma levels were conducted between 2006 and 2020. The average interval between levels taken was 10 months, 2 weeks but had a wide range, the shortest interval being 2 days, the longest being 13 years. 88 levels taken were >600 ug/L, suggesting increased toxicity risk. 108 levels were <350 ug/L, suggesting possible sub-optimal dosing or non-compliance. Statistical tests on correlation coefficient, although statistically non-significant (R = 0.37), showed a positive trend between total clozapine dose and the plasma level between all 3 parameters (i.e. clozapine, norclozapine and total clozapine). Conclusion There does not appear to be any routine plasma clozapine level monitoring throughout the LMHT with an average interval between tests of 10 months. There was a non-significant but positive trend between total daily dose of clozapine and clozapine level. 32% of clozapine levels returned were higher than the recommended level. We would recommend as suggested in the guidelines from MHRA, clozapine plasma levels should be monitored in certain clinical situations with increased toxicity risk. Trough levels should be taken with records of time of previous dose taken. Limitations of this study included a small sample size (41 patients) with data collection reliant on electronic systems. It was unclear if these results represent trough levels, making values difficult to interpret. Multifactorial impact on clozapine metabolism causes wide patient variability in plasma levels.
  • Development of a peer support intervention to improve the experience and outcomes of discharge from inpatient mental health care: the role of experiential knowledge in a coproduced approach

    Repper, Julie (2021)
    OBJECTIVES: Peer support is rapidly being introduced into mental health services internationally, yet peer support interventions are often poorly described, limiting the usefulness of research in informing policy and practice. This paper reports the development of a peer support intervention that aims to improve outcomes of discharge from inpatient to community mental health care. People with experiential knowledge of using mental health services-peer workers and service user researchers-were involved in all stages of developing the intervention: generating intervention components; producing the intervention handbook; piloting the intervention. RESULTS: Systematic review and expert panels, including our Lived Experience Advisory Panel, identified 66 candidate intervention components in five domains: Recruitment and Role Description of Peer Workers; Training for Peer Workers; Delivery of Peer Support; Supervision and Support for Peer Workers; Organisation and Team. A series of Local Advisory Groups were used to prioritise components and explore implementation issues using consensus methods, refining an intervention blueprint. A peer support handbook and peer worker training programme were produced by the study team and piloted in two study sites. Feedback workshops were held with peer workers and their supervisors to produce a final handbook and training programme. The ENRICH trial is registered with the ISRCTN clinical trial register, number ISRCTN 10043328, and was overseen by an independent steering committee and a data monitoring committee.
  • A clinical audit to investigate polypharmacy and interactions in inpatients in an old age psychiatric ward

    Mokashi, Nisha (2021)
    Aims To identify any problematic polypharmacy in the patient records of those staying in Cherry Ward, an old age psychiatric unit at Highbury Hospital, Nottingham in the calendar year 2018. Background Multi-morbidity is defined as more than one long-term medical condition in a single individual and is a factor that is closely associated with polypharmacy, the use of multiple medications concurrently. Appropriate and Problematic are the two classifications of polypharmacy outlined by the King's Fund report, the first describing optimised evidenced-based pharmacological management of comorbidities and the latter to label prescribed medications whose use is not in the best interests of the patient. The risk of drug interactions and adverse drug reactions is increased with polypharmacy, and frail elderly patients are particularly at risk of the side-effects of psychotropic medications used in the management of mental health disorders. Guidelines highlight this group as a key party to be identified when searching for at-risk people. Method The electronic records of those admitted and discharged from Cherry Ward in 2018 were reviewed in the period spanning January to May 2019, and the first forty-three patients were analysed in Microsoft Excel using criteria based on the King's fund report and the Medscape and BNF (British National Formulary) drug interaction tools. The Medscape drug interaction checker was used for initial screening; the complete medication list for each patient was entered into it and the number of interactions was displayed with advice on severity. If necessary, the individual interactions for each specific medication could also be cross-referenced in the BNF using the extensive lists provided for each drug. These are also graded from mild to severe. Result On discharge, 69.7% (thirty patients) met the criteria for being at higher risk of polypharmacy. One patient became at higher risk of polypharmacy during admission, and another two stepped down from meeting the criteria on admission but not on discharge. Thirty-one of the forty-three patients had at least one interaction recorded; 18.6% (eight patients) had at least one potentially severe interaction. Conclusion A substantial proportion of patients in Cherry ward in 2018 were at a higher risk of polypharmacy, reflecting current practice as outlined in the King's Fund report. Problematic polypharmacy is common among older patients hospitalised with psychiatric illness. Recommendations include use of an automated electronic system to investigate and flag up problematic polypharmacy and severe medication interactions.
  • Assessing the compliance of accurately documenting medication history in CAMHS - completion of the audit cycle

    Guest, Laura; Lankappa, Sudheer (2021)
    Aims To assess the documentation of medication across all Child and Adolescent Mental Health Service (CAMHS) teams in the south region of Derbyshire Healthcare NHS Foundation Trust against a locally agreed protocol. The aim is to ensure accurate and timely documentation of medication history in a standardised way to reduce the risk of medication errors. Method We randomly selected 78 patients across seven teams within CAMHS that were currently prescribed medication as of November 2020. We reviewed each patient to see if medication history had been recorded in the specified section of the trust's patient database PARIS. We then cross referenced this information with the patient notes, clinic letters and prescriptions to review accuracy of information in terms of recording of drug name, dose, frequency, and whether the medication was regular or as required. We compared the data to the results of a previous audit in 2017 which used the same methods. Result Of the 78 patients, 74% (n = 58) had medication recorded in the correct section of PARIS compared to 13% in the 2017 audit. We found that compliance varied between different CAMHS teams ranging from 0% to 100%. Of those with medication history recorded, 86% had all drug names listed correctly, 79% had all drugs listed at the correct dose, 71% had the correct frequency recorded and 81% had whether the medication was regular, or PRN recorded. Conclusion Although we have seen improvement in standardised documentation of medication history since 2017, it remains difficult to rely on this information being up to date and reliable. There was a wide range of compliance in documentation of medication history across different teams, possibly reflecting how effectively the teaching following the previous 2017 audit had been delivered to each team. We have completed more teaching for medical and non-medical prescribers across all localities to highlight the importance of timely and standardised documentation. This is particularly important in CAMHS where the prescribing of medication often remains the responsibility of secondary care, with clinicians regularly prescribing on behalf of colleagues from other teams. Our findings support the move within the Trust towards a system where medication can be both documented and electronically prescribed in the same place (System One).
  • Compliance to completion of sodium valproate annual risk acknowledgement form among women of child-bearing age prescribed sodium valproate in the intellectual disability (ID) services of an NHS trust

    Ohize, Victor; Bagalkote, Deval (2021)
    Aims To determine the proportion of women of child-bearing age prescribed SV who have the SV ARF filled. Background In 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) gave guidance regarding Sodium Valproate (SV) prescription. It acknowledged the significant risk of birth defects and developmental disorders in women of child-bearing age prescribed SV. Consequently, the MHRA recommendation is that SV must not be used in females of child-bearing age unless: conditions of pregnancy prevention programme are met; other treatments are ineffective or not tolerated; and evidence of discussion of risks with patient or carer and annual review of the risks are documented. The evidences of the above criteria are expected to be documented in an Annual Risk Acknowledgement Form (ARF). Method Retrospective study involving systematic search of Trust database to identify women with ID, aged 16–50 years prescribed SV from 2018 to 2019. Result 18 of 28 patients had ARF filled, a 64% compliance. The main indications for SV prescription were epilepsy; challenging behaviour; and mood stabilization. The distribution showed neurology and psychiatrist led prescription initiation equally distributed at 50%. The ARF compliance was higher in the neurology group (93%) compared to 36% in psychiatrist group. A review across the 5 ID teams (A,B,C,D and E) of the trust shows variable compliance to ARF compliance (17%,81%,100%,60%,0% respectively) with teams having higher proportion of neurology led SV prescription initiation also having higher proportion of ARF completion compliance (0%,55%,80%,80%,0% respectively). Conclusion Conclusion / Recommendation ARF compliance is below standard at 64%. Despite the SV prescription being equally distributed between neurology led and psychiatry led, patients whose prescription of SV is neurology led (prescription indication as epilepsy) had better ARF compliance outcome (93%) compared with patients whose prescription is psychiatry led (prescription indication as challenging behaviour or mood stabilization) with 36% ARF compliance. Organizational difference with dedicated epilepsy nurse in the ID service means patients with epilepsy had reviews of medication and compliance to MHRA guidance in completing the ARF. There is need to increase doctors’ awareness to review ARF status during patients’ appointment. Information Technology design to flag up out of date ARF may be helpful. The review of ARF may also flag up consideration of other alternatives: behavioural, psychological, functional and environmental interventions as well as alternative medications like Risperidone for challenging behaviours and other mood stabilizing options. This will minimize SV prescription, which is the original goal of the MHRA guidance.
  • The Mental Health Act 1983 (as amended in 2007) reform – How proposed changes potentially impact personality disorder services

    Mudholkar, Santosh (2021)
    Abstract: At the beginning of this year, the UK government released a White Paper on Reforms of the 1983 Mental Health Act (MHA) aiming to achieve higher quality, accessible mental health care, as well as empowering people detained under MHA during the process and continuation of detention. In this piece, we focus on the potential impact of the proposal around appropriate care, management and detention of people with Personality Disorder (PD) within the criminal justice system (CJS), psychiatric service provision and community routes. We briefly review the historical context of reforms of PD services in the UK and discuss the proposed changes and issues in relation to the criteria of least restriction, detention and therapeutic benefit. We highlight the complexity around referral routes and logistics barriers for secure PD services that might hamper speeded referral routes and raise concerns around responsibility for authorisation of transfers in the context of risk of serious harm to the public. We emphasise the complex treatment needs of individuals with PDs and how these are potentially not met. We also discuss the shift of focus from reactive care to preventative measures and early intervention in the community for individuals with mild-to-moderate levels of PD. We highlight the need for appropriate integrative services in the community to facilitate assessment across services, identification of complex needs and support options including earlier routine screening and potential digital interventions to optimise specialised care for PD.
  • Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

    Drummond, Avril; Thomson, Louise (2020)
    Background: Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients’ needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively. Objectives: To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks. Design: An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process. Setting: Orthopaedic departments in NHS secondary care. Participants: Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers. Interventions: Occupational advice intervention. Main outcome measures: Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost. Results: A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff. Limitations: Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it. Conclusions: The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention. Future work: The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.
  • The transition from children’s services to adult services for young people with attention deficit hyperactivity disorder: the CATCh-uS mixed-methods study

    Hollis, Chris P.; Sayal, Kapil (2020)
    Background: Attention deficit hyperactivity disorder was previously seen as a childhood developmental disorder, so adult mental health services were not set up to support attention deficit hyperactivity disorder patients who became too old for child services. To our knowledge, this is the first in-depth study of the transition of attention deficit hyperactivity disorder patients from child to adult health services in the UK. Objectives: Our objectives were to explore how many young people with attention deficit hyperactivity disorder are in need of services as an adult, what adult attention deficit hyperactivity disorder services are available and how attention deficit hyperactivity disorder stakeholders experience transition from child to adult services. Design: An interactive mixed-method design was adopted with three study streams: (1) a 12-month surveillance study with 9-month follow-up to find out how many young people required ongoing medication when they were too old for child services (929 surveys completed by children’s clinicians); (2) a mapping study to identify and describe services for young adults with attention deficit hyperactivity disorder (2686 respondents to online surveys for patients and health workers and freedom of information requests to service providers and commissioners); and (3) a qualitative study to explore key stakeholders’ experiences of transition from child to adult services (144 interviews with 64 attention deficit hyperactivity disorder patients, 28 parents and 52 health clinicians; 38 working in child or adult secondary health services and 14 general practitioners). Members of the public advised at each stage of the study. Results: When corrected for non-response and case ascertainment, the annual number of young people with an ongoing need for medication for attention deficit hyperactivity disorder lies between 270 and 599 per 100,000 people aged 17–19 years. Among 315 individuals eligible for transition, 64% were accepted, but only 22% attended their first adult services appointment. Our interactive map describes 294 unique services for adults with attention deficit hyperactivity disorder across the UK, of which 44 are ‘dedicated’ attention deficit hyperactivity disorder services. Few services provide the full range of recommended provision; most focus on diagnosis and medication. Services are unevenly distributed across the UK, with nearly all ‘dedicated’ services being in England. Exploring stakeholders’ experiences revealed how invested the stakeholders are in continuing attention deficit hyperactivity disorder treatment and how the architecture of services affects transition. An association between attention deficit hyperactivity disorder, education and continuance of medication into young adulthood, plus parent involvement and feeling prepared for transition and adult life with attention deficit hyperactivity disorder, influenced investment. However, even with investment, how accessible adult services are, how patient needs fit with the remit of the adult service and the level of patient information available affect transition outcomes. The results also highlight how general practitioners can end up as care co-ordinators during transition by default. Limitations: Transition estimates were based on those who want medication, so these indicate a minimum level of need. Conclusions: Few of those who need ongoing support for attention deficit hyperactivity disorder successfully transfer to adult services, and a small proportion of those who transfer experience optimal transitional care. Adult attention deficit hyperactivity disorder service provision is patchy. Even among ‘dedicated’ services, few provide the whole range of National Institute for Health and Care Excellence-recommended treatments. Future work: We need to evaluate various models of transitional care and adult attention deficit hyperactivity disorder provision, as well as develop and evaluate psychosocial interventions for young people and adults with attention deficit hyperactivity disorder.
  • Race, ethnicity and COVID-19 vaccination: a qualitative study of UK healthcare staff

    Clifford, Naomi (2021)
    OBJECTIVE: COVID-19-related inequities experienced by racial and ethnic minority groups including healthcare professionals mirror wider health inequities, which risk being perpetuated by lower uptake of vaccination. We aim to better understand lower uptake among racial and ethnic minority staff groups to inform initiatives to enhance uptake. DESIGN: Twenty-five semi-structured interviews were conducted (October 2020-January 2021) with UK-based healthcare staff. Data were inductively and thematically analysed. RESULT(S): Vaccine decision-making processes were underpinned by an overarching theme, 'weighing up risks of harm against potential benefits to self and others'. Sub-themes included 'fear of harm', 'moral/ethical objections', 'potential benefits to self and others', 'information and misinformation', and 'institutional or workplace pressure'. We identified ways in which these were weighted more heavily towards vaccine hesitancy for racial and ethnic minority staff groups influenced by perceptions about institutional and structural discrimination. This included suspicions and fear around institutional pressure to be vaccinated, racial injustices in vaccine development and testing, religious or ethical concerns, and legitimacy and accessibility of vaccine messaging and communication. CONCLUSION(S): Drawing on a critical race perspective, we conclude that acknowledging historical and contemporary abuses of power is essential to avoid perpetuating and aggravating mistrust by de-contextualising hesitancy from the social processes affecting hesitancy, undermining efforts to increase vaccine uptake.
  • Cochrane Schizophrenia Group's study-based register of randomized controlled trials: Development and content analysis

    Shokraneh, Farhad; Adams, Clive E. (2020)
    Background: Study-based registers facilitate systematic reviews through shortening the process for review team and reducing considerable waste during the review process. Such a register also provides new insights about trends of trials in a sub-specialty. This paper reports development and content analysis of Cochrane Schizophrenia Group’s Study-Based Register. Methods: The randomized controlled trials were collected through systematic searches of major information sources. Data points were extracted, curated and classified in the register. We report trends using regression analyses in Microsoft Excel and we used GIS mapping (GunnMap 2) to visualize the geographical distribution of the origin of schizophrenia trials. Results: Although only 17% of trials were registered, the number of reports form registered trials is steadily increasing and registered trials produce more reports. Clinical trial registers are main source of trial reports followed by sub-specialty journals. Schizophrenia trials have been published in 23 languages from 90 countries while 105 nations do not have any reported schizophrenia trials. Only 9.7% of trials were included in at least one Cochrane review. Pharmacotherapy is the main target of trials while trials targeting psychotherapy are increasing in a continuous rate. The number of people randomized in trials is on average 114 with 60 being the most frequent sample size. Conclusions: Curated datasets within the register uncover new patterns in data that have implications for research, policy, and practice for testing new interventions in trials or systematic reviews.
  • Are researchers getting the terms used to denote different types of recreational cannabis right?-a user perspective

    Sami, Musa (2021)
    BACKGROUND: While current cannabis research has advanced our understanding into the effects of its individual components, there is a pressing need to identify simple terminology that is understood in the same way by researchers and users of cannabis. Current categorisation in research focuses on the two main cannabinoids: delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD); and two different species of cannabis: indica and sativa. Recreational cannabis has also been categorised by researchers as 'skunk' or 'hash'. Focusing on individuals who use cannabis frequently, this study aimed to identify views on current terms used to denote different types of cannabis and to identify terms validated by participants. These views were extracted from responses of the Cannabis Experiences Questionnaire (CEQ), a widely used instrument in the literature. METHODS: We qualitatively analysed 236 free-text responses from Question 23 of the CEQ survey (using Iterative Categorisation) relating to categorization and consumption methods. Data was used from a previous study (Sami et al., Psychol Med 49:103-12, 2019), which recruited a convenience sample of 1231 participants aged 18 years and above who had previously used cannabis. RESULTS: Regarding type of cannabis used, specific strain names (n = 130), concentrates (n = 37), indica/sativa (n = 22) and THC/CBD terms (n = 22) were mentioned. Other terms used were hybrids (n = 10), origins of specific strains (n = 17), edibles (n = 8), and herbal cannabis (n = 7). Regarding problems with specific terms, participants were skeptical about terms such as skunk and super skunk (n = 78) preferring terms like THC/CBD, indica/sativa, specific marketed strains and references to preparation methods. CONCLUSIONS: The results suggest a disparity between the common terms used by researchers in academia and those used by cannabis consumers. While there are advantages and limitations of using these terms to bridge views of researchers and individuals who use cannabis, this study underscores the importance of formally assessing chemical constituents rather than relying on self-report data and of incorporating cannabis user views on current terms used in research, potentially also incorporating descriptors of preparation and consumption methods.
  • Principles for the production and dissemination of recruitment material for three clinical trials of an online intervention

    Rennick-Egglestone, Stefan (2021)
    Some health research studies recruit participants through electronic mechanisms such as the placement of messages on social media platforms. This raises questions for ethics committee oversight, since effective social media campaigns might involve the production and dissemination of hundreds of contemporaneous messages. For the Narrative Experiences Online (NEON) study, we have developed nine principles to control the production and dissemination of promotional material. These have been approved by an ethics committee and enable the audit of our recruitment work. We propose that the drafting for approval of recruitment principles by health research studies may, in many cases, strike an appropriate balance between enabling ethical oversight of online recruitment work and the potential burden of message review.

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