Shared decision making or paternalism in nursing consultations? A qualitative study of primary care asthma nurses' views on sharing decisions with patients regarding inhaler device selection.

BACKGROUND: Although patients with asthma would like more involvement in the decision-making process, and UK government policy concerning chronic conditions supports shared decision making, it is not widely used in practice. OBJECTIVE: To investigate how nurses approach decision making in relation to inhaler choice and long-term inhaler use within a routine asthma consultation and to better understand the barriers and facilitators to shared decision making in practice. SETTING AND PARTICIPANTS: Semi-structured interviews were conducted with post-registration, qualified nurses who routinely undertook asthma consultations and were registered on a respiratory course. Interviews were recorded, transcribed and analysed using the Framework approach. RESULTS: Twenty participants were interviewed. Despite holding positive views about shared decision making, limited shared decision making was reported. Opportunities for patients to share decisions were only offered in relation to inhaler device, which were based on the nurse's pre-selected recommendations. Giving patients this 'choice' was seen as key to improving adherence. DISCUSSION: There is a discrepancy between nurses' understanding of shared decision making and the depictions of shared decision making presented in the academic literature and NHS policy. In this study, shared decision making was used as a tool to support the nurses' agenda, rather than as a natural expression of equality between the nurse and patient. CONCLUSION: There is a misalignment between the goals of practice nurses and the rhetoric regarding patient empowerment. Shared decision making may therefore only be embraced if it improves patient outcomes. This study indicates attitudinal shifts and improvements in knowledge of 'shared decision-making' are needed if policy dictates are to be realised.

Assessment of psychosocial problems in primary care COPD patients.

The emphasis placed on assessing psychosocial needs in nurse-led practice based consultations for chronic obstructive pulmonary disease (COPD) has not been reported. We investigated the frequency with which nurses performed a range of tasks, and explored if the types of tasks performed were related to levels of training or the setting of clinical consultations. Participants were lead COPD nurses based at 500 randomly selected UK general practices. Respondents completed a questionnaire between February and June 2006. The frequency with which key task were performed - never, sometimes, often or always - was recorded. Follow-up consultations were conducted by 349 of the 368 nurses who responded (74% response rate). Of these, 51% (95% confidence interval (CI):45-56%) reported often or always assessing psychosocial needs, in comparison to 98% (97-99%) who reported often or always checking inhaler technique and 86% (82-89%) who often or always recorded spirometry values. Frequent assessment of psychosocial needs was associated with postregistration COPD education and consultations taking place in designated respiratory clinics. Nurses focus on objective tasks, possibly to the detriment of assessing psychosocial needs. To raise the profile of these aspects of care: updates of the COPD section of the GMS contract should encompass the assessment of patient's psychosocial status and potential impact of this on quality of life; and appropriate education should be provided.

Influence of emotional expression on memory recognition bias in schizophrenia as revealed by fMRI.

We recently showed that, in healthy individuals, emotional expression influences memory for faces both in terms of accuracy and, critically, in memory response bias (tendency to classify stimuli as previously seen or not, regardless of whether this was the case). Although schizophrenia has been shown to be associated with deficit in episodic memory and emotional processing, the relation between these processes in this population remains unclear. Here, we used our previously validated paradigm to directly investigate the modulation of emotion on memory recognition. Twenty patients with schizophrenia and matched healthy controls completed functional magnetic resonance imaging (fMRI) study of recognition memory of happy, sad, and neutral faces. Brain activity associated with the response bias was obtained by correlating this measure with the contrast subjective old (ie, hits and false alarms) minus subjective new (misses and correct rejections) for sad and happy expressions. Although patients exhibited an overall lower memory performance than controls, they showed the same effects of emotion on memory, both in terms of accuracy and bias. For sad faces, the similar behavioral pattern between groups was mirrored by a largely overlapping neural network, mostly involved in familiarity-based judgments (eg, parahippocampal gyrus). In contrast, controls activated a much larger set of regions for happy faces, including areas thought to underlie recollection-based memory retrieval (eg, superior frontal gyrus and hippocampus) and in novelty detection (eg, amygdala). This study demonstrates that, despite an overall lower memory accuracy, emotional memory is intact in schizophrenia, although emotion-specific differences in brain activation exist, possibly reflecting different strategies.

Assessment of key influences on asthma inhaler device selection.

AIM: To identify factors that influenced trained asthma practice nurses' inhaler device selection and the relative importance they placed on these factors in clinical practice. METHOD: Questionnaires were sent to 1,500 randomly selected, trained asthma nurses working in primary care. A second, open-ended questionnaire was sent to 300 of these nurses. RESULTS: The response rate was 38% (573) for the first questionnaire and 21% (64) for the second questionnaire. Patient-related factors had the greatest influence on device selection. Other important factors were ease of inhaler use, the patient's lifestyle and inspiratory flow. Less important considerations were device availability, the size, shape and colour of the inhaler and recommendations from others. CONCLUSION: Many factors influence device selection. Nurses considered some of the factors identified as important when selecting a device, but not others. Nurses should be aware of potential influences on device selection and should consider their professional accountability in all patient interactions.

Structural neural correlates of impairments in social cognition in first episode psychosis.

Several studies have demonstrated that patients with schizophrenia show impairments in social cognition and current evidence indicate that this deficit is associated with abnormal activity in specific brain regions. In addition to functional imaging studies, we believe that the identification of structural correlates of social cognitive processes may help to better understand the neural underpinnings of these specific skills. The main objective of this study was to investigate the relationship between gray matter density and social cognitive deficits in first episode of schizophrenia spectrum psychosis, using a comprehensive assessment that we previously demonstrated to be a highly sensitive measure of social cognitive deficits in this population. Thirty-eight patients with a first episode of psychosis participated in this study, and the Four Factor Test of Social Intelligence was used as a measure of social cognition. Social cognitive impairments in first episode psychosis were significantly correlated with reduced gray-matter density in the left middle frontal gyrus other regions within the mirror neuron system network (MSN), namely the right supplementary motor cortex, the left superior temporal gyrus and the left inferior parietal lobule. We concluded that structural abnormalities within the MSN may account for the social cognitive deficits present in some psychiatric disorders, such as schizophrenia.

National survey on the roles and training of primary care respiratory nurses in the UK in 2006: are we making progress?

OBJECTIVES: To describe nurse-led UK general practice asthma and chronic obstructive pulmonary disease (COPD) care, and the training undertaken to support it. METHODS: Questionnaires were sent to 500 randomly-selected UK asthma and COPD practice nurses. RESULTS: 382 nurses (76%) completed the practice characteristics section, 389 (78%) described their asthma roles and training, and 368 (74%) described their COPD roles and training. 96 practices (25%; 95%CI 21-29%) ran designated asthma clinics, 87 (23%; 95%CI 19- 27%) ran designated COPD clinics, and 170 (45%; 95%CI 40-49%) did not run designated respiratory clinics. Of the 255 nurses with an advanced asthma role, 51 (20%; 95%CI 15-25%) did not have accredited asthma training. Of the 215 nurses with an advanced COPD role, 111 (52%; 95%CI 45-58%) did not have accredited COPD training. CONCLUSION: Patients are increasingly being seen outside of designated asthma or COPD clinics, often by nurses with an advanced role. It is important that nurses have the training to fulfil this role.

Selective abnormal modulation of hippocampal activity during memory formation in first-episode psychosis.

CONTEXT: Memory is one of the cognitive functions most affected in schizophrenia, with deficits observed from the first episode of psychosis (FEP). Previous studies have indicated that some memory processes may be more affected than others. OBJECTIVE: To examine the neural correlates of 3 specific memory processes in FEP by means of functional magnetic resonance imaging (fMRI). DESIGN: Case-control study. SETTING: Prevention and Early Intervention Program for Psychoses of the Douglas Hospital and Montreal Neurological Institute, McGill University. Subjects Twenty-six patients with FEP and 20 healthy controls. MAIN OUTCOME MEASURES: Behavioral performance and regional brain activity measured during memory encoding by fMRI. Our fMRI design included 3 within-subject contrasts (associative vs item-oriented encoding, encoding of arbitrary vs semantically related image pairs, and successful vs unsuccessful memory encoding) that were then used for group conjunctions and between-group analyses. RESULTS: Patients with FEP showed normal activation of several brain regions, including the prefrontal cortex, hippocampus, and parahippocampal cortex, during successful memory encoding and associative encoding. In contrast, the hippocampus and surrounding medial temporal areas showed reduced activity during the encoding of arbitrary pairs. This selective dysfunction reflected by abnormal brain activation during encoding was accompanied by a greater deficit for subsequent recognition of arbitrary pairs relative to the semantically related pairs. CONCLUSIONS: This study demonstrated that, in the same group of patients with FEP, the hippocampus could show either normal or abnormal modulation of activation depending on the specific cognitive process that was examined. The normal modulation of hippocampal activation observed during successful memory encoding in FEP argues against a general inability to recruit this region. Instead, the dysfunction was specifically linked to semantic relatedness. This selective deficit seems to affect memory performance in FEP and denotes an important representational problem that may confer greater vulnerability to psychotic disorders and would thus be interesting to examine in high-risk populations.

Social cognitive impairments in first episode psychosis.

BACKGROUND: Social cognition is a complex phenomenon involving several distinct processes. Numerous studies have shown that individuals with schizophrenia are largely impaired on this domain of cognition. However, most have focused on a single aspect of social cognition, namely "theory of mind" and/or included patients with long standing illness. OBJECTIVE: The main objective of the present study was to identify social cognition deficits in first episode of schizophrenia spectrum psychosis using a case control design and a comprehensive assessment that allowed the exploration of several dimensions of this phenomenon. SUBJECTS: 36 patients with a first episode of psychosis and 25 healthy controls participated in this study. MATERIAL: Measures of social cognition included the Hinting Task and the Four Factor Test of Social Intelligence. RESULTS: Significant group differences were found on both tasks, but the Four Factor Test of Social Intelligence revealed a stronger group effect and the effects observed remained significant once IQ was covaried. Social cognition did not show any correlations with level of symptoms. CONCLUSION: Social cognition deficits are present during the first episode of psychosis. These impairments do not seem to be a consequence of group differences in overall intellectual functioning and are likely to be state-independent.

Social perspective-taking skills in maltreated children and adolescents.

The primary goal of this study was to assess the ability of maltreated school-age children and adolescents to understand the thoughts, feelings, and points of view of others. Level of egocentrism and social perspective-taking coordination were assessed in a group of 49 maltreated and 49 demographically matched nonmaltreated children. Twenty-six elementary and 23 high school students in each group were individually interviewed and their responses to hypothetical interpersonal situations coded for egocentricity and level of perspective-taking ability. The findings revealed that maltreated children and adolescents were more egocentric and delayed in their social perspective-taking development than their nonmaltreated peers and that they reported lower levels of global self-worth. However, differences within the group of maltreated children and adolescents emerged with regard to negotiating novel relationships, as those with fewer internalizing or externalizing symptoms exhibited better skills in this area than their peers who displayed more symptoms.