3583 results in BJPsych Open
Making It PEACHY: Creation of an Innovative Immersive Simulation Day Promoting Empathetic, Attentive Communication for Holistic Care for Year 4 Medical Students
- Vatsala Mishra, Archanaa Elankovan, Ian Winston
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S112
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This team of simulation fellows and a final-year medical student at a London teaching hospital created an innovative simulation course for fourth-year medical students with the aim to supplement existing undergraduate psychiatry teaching by providing additional opportunity to practice clinical skills. The course allowed students to practice and improve advanced communication skills across a range of inpatient and community settings across GP, A&E, medical and psychiatric environments, with themes exploring psychiatry, heightened emotional states and biopsychosocial influences on mental and physical health in a safe, ethical manner, supplementing the teaching provided on clinical placements.
MethodsThe course was fully mapped to the university curriculum as well as the Health Education England Future Doctor Vision and the Medical Licensing Assessment content map. Scenarios were written by trained simulation faculty in conjunction with specialty experts across all core specialties for fourth year medical students including obstetrics and gynaecology, paediatrics, psychiatry, and healthcare of the elderly. Scenarios were created to reflect local demographics with addition of detailed social history and population health information. This involved creation of simulated patients from multicultural backgrounds, with limited English or other communication needs, and representation of numerous gender expressions, sexual orientations, and a range of mental health and neurodevelopmental needs.
ResultsThe pilot course took place on May 2nd with 7 student participants following approval from senior education stakeholders. During debriefs, participants differentiated between psychiatric symptoms and non-pathological human experiences, and reflected on how and why the patient in front of them is presenting the way that they are, with regards to social determinants of physical and mental health. They were also guided to reflect upon the technical and non-technical learning objectives of each scenario including use of Crisis Resource Management principles. Quantitative and qualitative feedback was collected through use of Likert-scales and white space questions; feedback showed heightened confidence and competence in core skills including psychiatric history taking, mental state examination and risk assessment, as well as core communication skills such as explaining a new diagnosis and managing heightened emotion.
ConclusionFeedback shows the pilot successfully met its aims and enhanced undergraduate training, filling an educational need. Next steps would include formally approaching the university to discuss implementation of the course into the core curriculum. Additional refinements would include further consultation with service users and people with lived experience and consideration around use of actors to ensure complex subjects such as immigration and neurodivergence are portrayed ethically and accurately.
Neurodevelopmental Disorders and Their Association With Neurodegenerative Disorders: A Systematic Narrative Review
- Rebecca Restorick, Huw Dunstall, Katja Umla-Runge
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S74
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Neurodevelopmental disorders (NDDs), such as dyslexia, dyspraxia, and dyscalculia affect cognitive function and therefore share symptomology with neurodegenerative disorders, such as Alzheimer's disease, vascular dementia, and frontotemporal lobe dementia. The primary aim of this narrative systematic review is to ascertain if there is an association between NDDs and neurodegenerative disorders. Secondary aims are what the prevalence of NDDs within a dementia population is and what effect these early life learning disorders have on patients as they get older. It was hypothesised that NDDs would overestimate the severity of cognitive impairment, thereby increasing the severity of dementia staging, and impacting patient care.
MethodsUsing a Population, Exposure, Comparator, Outcome, Setting, and Study design (PECOS) framework, keywords of “dementia”, “dyslexia”, “Dyspraxia/clumsy child syndrome/developmental apraxia/motor learning difficulty/disorder of attention and motor perception” and “dyscalculia/mathematical learning disability” were searched for on 4 databases (SCOPUS, OVID, Cochrane Central Register of Controlled Trials and Web of Science) from January 1, 1960 – June 10, 2022. Studies were included if they discussed both neurodegenerative and neurodevelopmental disorders or compared an intervention typically used in one disorder on the other (e.g., dementia intervention being used on neurodevelopmental disorder). Studies were excluded from grey literature articles, or if they only discussed a neurodevelopmental or neurodegenerative disorder without reference to the other, or if it included acquired, rather than neurodevelopmental dyslexia, dyscalculia, or dyspraxia.
ResultsA total of 8 studies were included for narrative synthesis. The main finding was an association between dyslexia and both Alzheimer's disease and frontotemporal dementia. Many studies suggested this was due to a genetic phenotype that caused a vulnerability in the language regions of patients’ cortices. There was also evidence of structural changes associated with NDDs and increased levels of grey and white matter atrophy in dementia subtypes, particularly in the language areas of the brain.
ConclusionDue to screening and consequently formal diagnosis of neurodevelopmental disorders only recently coming into education systems, many adults currently attending memory clinics did not have a formal diagnosis. As there was limited research on dyspraxia and dementia, partly due to limited research into dyspraxia itself and without a standardized diagnostic tool for adolescents and adults, further research is needed in this area. The hypothesis of NDDs increasing the severity of dementia staging was also not supported by the literature results, and on the contrary, some studies suggested greater global preservation of cognitive function in patients with NDDs and dementia.
Living Alongside an Eating Disorder: A Qualitative Exploration of the Experiences of People in the UK Who Have an Adult Family Member Living With an Eating Disorder
- Laura Gill
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S36
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Eating disorders do not only affect the person who is suffering, but also their family. This qualitative study aims to understand the impacts on individuals who have an adult family member with an eating disorder, and what support they seek for their own well-being.
MethodsA convenience sample of 11 volunteer participants (10 family members and 1 charity worker) from the United Kingdom (UK) were recruited for interviews. Four UK eating disorder charities assisted with outreach by sharing the Participant Information Sheet to their service users. Semi-structured interviews were conducted between February and March 2023. Interviews lasted on average 54 minutes and were recorded on video call (n = 9) or face-to-face on the University of Edinburgh campus (n = 2). Transcripts were analysed using thematic analysis, following a grounded-theory constructivist approach.
ResultsParticipants discussed how their lives were changed by engaging with the care of their family member, leading to a shift in family dynamics and a change in understanding of what it means to be a ‘normal’ family. Most interviewees perceived their relative's eating disorder as a negative disruption to their own life, however one participant said that it had no negative impact on his well-being at all. Conflict in the household was a regular outcome, with four interviewees all using the phrase “treading on eggshells”. Siblings of adults with an eating disorder were described by their parents as being excluded from the family due to the ongoing parental focus on the healing of their child. Some participants accessed support groups and social media to connect with other families working through similar challenges.
ConclusionHaving an adult family member with an eating disorder impacts the wider social network of the family. This dissertation argues that the socially constructed meanings of ‘care’ and ‘normality’, alongside the social relations with people placed in similar positions, inform the lived experiences of these individuals. This study's newfound illness narrative of ‘normality’ theorises that some people do not strive to help their relative with an eating disorder because it has already constructed the meaning of their normal life. Future research should aim to recruit a greater variation of participants, including more fathers, children, and siblings. This work endeavours to increase awareness of the support which families need during this time. It therefore opens the opportunity to consider how existing resources and services, both in healthcare and the third-sector, can be improved in the future.
One-Off Focused Teaching Can Improve Trainee Confidence, Knowledge and Skillset in Understanding and Therapeutically Engaging People With a Diagnosis of Personality Disorder
- Sil-Jun Lau, Daniel Meek
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S107-S108
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To design, deliver and evaluate teaching for psychiatry trainees on personality disorder (PD) with the following objectives: to promote understanding and empathy for people with a diagnosis of PD; to equip trainees with skills they can immediately use for therapeutically engaging patients with PD; to introduce the evidence-based treatments that underpin these techniques; and to increase confidence in offering therapeutic clinical encounters for patients with PD.
MethodsA single teaching session was designed and delivered to core psychiatry trainees in three components. First, an interactive lecture was delivered on the theory of personality disorder as understood by two evidence-based psychotherapies: Mentalization-Based Treatment (MBT) and Transference-Focused Psychotherapy (TFP). Second, techniques from both were introduced as skills they can readily apply to clinical practice. Lastly, role-play scenarios with original scripts were worked through to highlight theory and techniques. Evaluation was conducted through anonymous participant-rated scores matched to learning objectives pre- and post-delivery of teaching.
Results20 participants (n = 20) completed the evaluation. 90% of respondents agreed/strongly agreed that they frequently encountered patients with PD. There was high pre-existing confidence in recognising PD in clinical practice; this was little changed by the teaching. Before the teaching, 45% of respondents agreed/strongly agreed with the statement saying they are confident offering clinical encounters for patients with PD; this changed to 90% post-delivery. Pre-delivery, 45% agreed/strongly agreed they possessed skills they could use clinically for PD; this increased to 75% post-delivery. Pre-delivery, 60% agreed/strongly agreed that they can generally empathise with people with PD; this increased to 90% post-delivery. Self-rated knowledge of evidence-based treatments for PD increased for both MBT (20% pre-delivery to 85% post-delivery) and TFP (15% to 75%). 95% of respondents agreed/strongly agreed that they will try out new skills learnt from the session. 100% of respondents agreed/strongly agreed that the teaching was overall useful.
ConclusionThis study shows it is possible to make positive effects on trainee confidence, knowledge and skill in relation to PD in a short and one-off timeframe. Future efforts should include attempts to replicate these findings on larger numbers of participants, across different training and non-training medical grades and in non-medical staff. Future evaluation should also observe if positive changes are sustained across time or lead to improvements in clinical outcomes and patient satisfaction.
Prescribing and Monitoring of Pychotropic Medications in a CAMHS Inpatient Service
- Olorunleke Erunkulu, Shermin Imran, Wasim Ashraf
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S230
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To ensure that there is a clear rationale for commencing service users on psychotropic medications.
To ensure that the prescription of psychotropic medications is evidence-based and that they are in line with the Trusts and NICE guidelines.
Ensure that psychotropic medications are regularly reviewed by the managing team.
To ensure that information about medications is adequately shared with patients and carers.
To ensure that service users are well-monitored for side effects.
MethodsA 2-week retrospective audit on Phoenix ward.
Clinical information from all the current service users on psychotropic medication was reviewed.
The clinical information was collated from all 8 service users’ medication cards, ward round documents, MDT reviews, and electronic notes (PARIS), and these were analyzed by the inpatient specialty registrar.
Results1. We attained a 100% mark in some areas of our prescribing such as indicating the rationale, the maximum dose for medication, and also prescribing within BNF limits.
2. We however could not evidence proper information sharing with patients (only 40% documented).
3. We could not evidence sufficient information sharing with carers (only 20% documented).
4. PRN medication was mostly prescribed as a range rather than a clear dose, which gave rise to subjective dispensing bias.
5. Side effect monitoring was documented for 85% of patients, meanwhile, the standard for this is 100%.
ConclusionClinicians are to ensure that medication information is always shared with service users, and their carers, and this is documented.
Clinicians are to also ensure that PRN medications are prescribed as a single dose rather than as a dose range.
Ward staff are to ensure that they are monitoring side effects and documenting these clearly on electronic notes and ward round documents.
The MDT is to ensure that all regular and PRN medications are reviewed regularly during ward rounds.
Present this audit, share relevant findings with the clinical team, and monitor the implementation of the action plans by doing a reaudit in 6 months.
Developing and Delivering a Regional Teaching Programme in Liaison Psychiatry: A Quality Improvement Project
- Sally Tulip, Cara Katona
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S175-S176
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Several sites across the North London Mental Health Partnership (NLMHP) do not have a liaison-specific rolling teaching programme. Best practice standards set by the RCPsych Psychiatric Liaison Accreditation Network (PLAN) are therefore not being met.
The aims of this quality improvement project (QIP) were to: (1) ascertain the perceived need for liaison-specific teaching across NLMHP sites; (2) develop and deliver a teaching programme; and (3) assess attendance, clinician satisfaction and confidence before and after teaching sessions.
MethodsA pre-programme questionnaire on Microsoft Forms was sent to team members across NLMHP sites to assess whether respondents were receiving liaison-specific teaching, the perceived utility of the programme, and suggestions for development.
A cross-site monthly teaching programme was developed. Sessions were presented by liaison clinicians from a list of liaison-specific topics via Microsoft Teams.
A post-session questionnaire was sent to establish session satisfaction, confidence pre- and post-session, and further comments. Mean satisfaction scores were calculated. Percentage change in confidence score was calculated for each session and overall.
Themes were identified from the qualitative data and suggestions implemented.
ResultsOf the 11 professionals who responded to the pre-programme questionnaire, 50% were not receiving any liaison-specific teaching. Respondents agreed the programme would be helpful in improving their knowledge and clinical practice (mean score = 4.9/5).
Attendance for the sessions ranged from 15–27 professionals (mean = 22). A range of 2–10 professionals completed each post-programme questionnaire (mean = 6.3; total responses = 25). Mean satisfaction for each session ranged from 4.3–5/5 (overall mean = 4.7/5). Percentage increase in confidence scores ranged from 4.6–48% (mean = 24%).
Feedback-driven changes made to improve the programme included: making session recordings available; sending reminder emails; creating an online platform and making session feedback available to presenters.
Respondents considered the sessions interesting and informative, that topics provoked good discussion, and that the 'bite-sized' training allowed attendance without interfering with clinical work.
ConclusionThis QIP highlighted the need for a liaison-specific teaching programme across NLMHP. Participants agreed that this would improve their knowledge and practice. The programme was reasonably well-attended across sites. Respondents reported improved confidence and felt the sessions were relevant to their clinical practice.
Limitations included the low and variable questionnaire response rate and limited data on the new programme's utility.
The next stages of the project include wider delivery, involvement of patients and carers, and of specialists in related psychiatric and medical fields.
Do Not Attempt Resuscitation (DNAR) Orders in an Older-Age Psychiatric Hospital
- Sian Thompson, Michael Whybrow
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
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- 01 August 2024, p. S266
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We aim to see whether DNAR discussions are being undertaken at an appropriate time for our patients, as well as seeing whether these are recorded formally and regularly reviewed, as per local protocol. We also aim to see whether the immediate medical/nursing teams are aware of the local guidelines, as well as which of their patients have a DNAR in situ, and how to find this out. As an old-aged psychiatric unit, this is very important.
MethodsWe used 2 methods of data collection. One was questionnaires that we gave out to medics, nurses, and HCAs on our wards. We collected quantitative data from them on whether they knew where DNAR forms were and which of their patients had DNAR forms. We then also collected quantitative data from our online notes, looking into which patients had DNARs, whether these were recorded online and in a physical copy, whether it was discussed on clerking, and whether it was regularly reviewed and documented in MDTs. We used data from 51 inpatients over 3 wards.
ResultsOver 30% of patients have a DNAR in situ across the 3 wards. The dementia-focussed wards have a higher number of DNARs in place. All patients with a DNAR had a purple form completed and kept on the ward. 75% of staff knew where these were. Only 20% of those with DNARs had these documented online as per local guidelines; only 45% of staff knew where to find this information online. Only 8% of patients had their DNAR status discussed on admission, and 10% in their first MDT. Only 60% staff knew which patients had a DNAR in situ.
ConclusionThere is evidence that purple forms are completed appropriately and stored well. The main issue is the online record-keeping; staff either don't know how to or that they can document this online. This is reiterated as many did not know where the information was online. This demonstrates a lack of knowledge and education.
DNAR conversations are not occurring in the first place; the status is not being regularly reviewed, leading to issues where these conversations are rushed during acute events. It is important to think about these things earlier to ensure everyone, patient, family and staff, understands the process and rationale.
Lack of staff knowledge on which patients have DNARs in situ could be a great issue if an acute event were to occur, and compromises patient safety.
A Case for Cerebellar Neuromodulation in Affective Disorders
- Alex O'Neill-Kerr, Harshani Yapa Bandara, Nadia Hristova
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S285
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This case report focuses on a 68-year-old Caucasian female, with long-standing symptoms of executive and cerebellar dysfunction, which responded well to rTMS targeting the prefrontal cortex and cerebellum.
MethodsThis patient was seen in the private sector for long-standing symptoms of low mood, mental fog, unsteady gait, along with slurred speech and poor vision. History indicated the possibility of multiple mini strokes several years earlier, which may have contributed to her current presentation, and MRI Brain confirmed diffuse small vessel disease in periventricular areas and deep white matter, with no atrophy of brainstem or cerebellum. Her medications at the time included venlafaxine 75 mg OD, atorvastatin 20 mg OD, amlodipine 5 mg OD, thiamine HCL 100 mg OD and aspirin 75 mg. She then had a course of standard rTMS (F3 and F4), to which she had no real response. The team then performed a Quantitative Electroencephalography which revealed bilateral prefrontal and cerebellar disconnection, with normal connectivity in the rest of the brain and cortex, which enabled a diagnosis of Organic mood (affective) disorder, F06.3.
Based on the above findings, she was then prescribed a course of rTMS as follows:
1. Bifrontal excitatory Theta burst, at 50–60%, daily for 20 treatments.
2. CB1 and CB2 Cerebellar iTBS (10min) at 50–60%, daily for 20 treatments.
ResultsAlthough long known for its function in fine tuning motor function, emerging research indicates the growing importance of the cerebellum and its neural connections in neuropsychiatric disorders.
Recent studies have shown that those with cerebellar damage show impairments in executive function, and emotional regulation, in addition to language deficits and problems with sensory processing. It is bidirectionally connected with areas associated with processing social salience, including the posterior parietal and prefrontal cortex. With its connections to the prefrontal cortex, limbic structures and monoamine producing brainstem areas, it is likely the cerebellum also plays a key role in fine tuning emotional output, which appears to be corroborated by functional neuroimaging.
ConclusionThis case further supports the emerging evidence base that the cerebellum plays a key role in emotional experience, along with the prospect of using targeted rTMS for therapeutic benefit.
Benefits & Barriers: Improving Medical Handover in a Psychiatric Hospital
- Nina MacKenzie, Callum Cruickshank, Ewan Mahony, Jessica Parker, Robyn Canham
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S150
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Background: Handover aims to achieve the efficient communication of clinical information when responsibility for patients is transferred. The Royal Edinburgh Hospital (REH), a specialist hospital serving the Lothians, has repeatedly received “red flags” (ranked in the bottom 2% of benchmarked areas) on the handover section of the Scottish training survey (STS) and GMC national training survey of doctors in training (DiT).
Aims:
• Survey DiT to understand their experience of handover.
• Introduce a new structured handover process.
• Re-audit parameters after intervention.
MethodsData from REH DiT were extracted from an anonymised handover survey, disseminated to all psychiatry DiT in Scotland in January 2023. Multiple choice and free-text questions covered handover timings, format, structure, and attendance. The survey was repeated after intervention. In addition, data from the STS were analysed. The intervention consisted of altering shift times to include protected time for handover, introducing a dedicated room, training in the use of an electronic system to record tasks, involvement of senior doctors, and dissemination of the new changes to procedure.
ResultsA total of 12 survey responses (25% response rate) pre-intervention (25% FY2s, 17% GPSTs, 58% core trainees) and 14 post-intervention (14% FY2s, 14% GPSTs, 71% core trainees) were analysed. The proportion of respondents reporting that handover always happened at times of shift change increased from 7% to 93% post-intervention. The proportion of those reporting that there was protected time for handover rose from 0% to 50%, and the use of a predetermined structure/format increased from 0% to 43%. After intervention, 86% of DiT felt adequately supported during handover (compared with 17% pre-intervention) and 93% of respondents felt handover ‘allowed for the efficient and effective transfer of information to protect patient safety’ (33% pre-intervention). Prior to the process change, 83% of DiT felt there was no clear senior leadership at handover; this fell to 21%. Post-intervention the use of WhatsApp/texts to hand over information fell by 100%. The new system was welcomed by trainees, but teething problems were identified.
ConclusionThe new process led to improvements in the frequency, consistency, format, recording, and senior support of handover. Issues with the use of video call software and electronic medical records systems have been identified, and work is ongoing to address these in an iterative quality improvement process. Good clinical handover benefits patients (fewer mistakes and increased safety, better continuity of care, improved satisfaction) and clinicians (improved communication skills, increased accountability, feel more informed, improved job satisfaction).
Advice and Guidance in Mental Health: A Transformational Approach
- Viviane Nzouonta Ngwompo, Paul Maddock, Rebecca Harris
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S199-S200
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- To strengthen shared decision making between psychiatrists and general practitioners (GPs) while avoiding needless outpatient activity.
- To promote a seamless partnership between GPs and psychiatrists that will improve efficiency and effectiveness for better patient health outcomes.
- To improve patient journey whilst responding to operational pressures.
- To test GPs engagement and satisfaction.
MethodsFollowing GPs engagement sessions, a 12 weeks pilot was conducted with the Bath and North East Somerset (BaNES) Primary Care Liaison Service (PCLS) and the 6 Primary Care Networks (PCNs) in BaNES. 22 GP surgeries were allowed access to Advice and Guidance (A&G) system using a digital platform. The pilot ran from 3rd April to 25th June 2023, focussing on answering non-urgent queries related to: psychotropic medications, mental health presentations, and the wider mental health system signposting and awareness.
One Consultant Psychiatrist and One Associate Specialist in Psychiatry were involved. The asynchronous system (eOpinion) with an expected response time of 3–5 working days was used.
To allay any governance risks and to act as a backup should the A&G system process fail to record appropriately, a dual recording of the A&G given – both in the A&G digital platform and the patient electronic record was implemented. Further governance structures were built into the project to establish that actions undertaken by the psychiatrists were effective and justifiable.
Results82 requests received over the 12 weeks period.
20 out of 22 surgeries took part.
The Psychiatrists spent on average of 3.5 hours per week answering A&G requests. The administrative team spent on average one hour and three quarter per week processing A&G responses.
Although no significant impact on total referrals was noted, there was indication that demand was moving from the referral to A&G request.
All requests were responded within 2 working days.
Requests from GPs were largely appropriate with 88% resulting in advice and guidance, indicating an improved patient journey.
Minimal impact on the operational processes.
Positive feedback from GPs with 91% finding the A&G system useful or very useful. They were keen for the offer to continue.
ConclusionEffective inter-professional collaboration between GPs and psychiatrists is essential in enhancing patients' overall health outcomes and experiences. For mental health services, this transformational approach should continue to enhance the existing offer. However, we should remain mindful of the potential risk of increased workload burden in General Practices, and the implications of this new clinical model on staff based in specialist services.
The impact of transformational leadership on workers’ personal resources: latent profile analysis and links with physical and psychological health
- Daniel Cortés-Denia, Manuel Pulido-Martos, Janine Bosak, Esther Lopez-Zafra
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- BJPsych Open / Volume 10 / Issue 5 / September 2024
- Published online by Cambridge University Press:
- 01 August 2024, e135
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Background
Several studies have examined the impact of leadership on employee well-being and health. However, this research has focused on a variable-centred approach. By contrast, the present study adopts a person-centred approach.
AimsTo (a) identify latent ‘resources’ profiles among two samples combining vigour at work, work engagement and physical activity levels; (b) examine the link between the identified profiles and indicators of psychological/physical health; and (c) test whether different levels of transformational leadership determine the probability of belonging to a particular profile.
MethodTwo samples of workers, S1 and S2 (NS1 = 354; NS2 = 158), completed a cross-sectional survey before their annual medical examination.
ResultsFor S1, the results of latent profile analysis yielded three profiles: spiritless, spirited and high-spirited. Both high-spirited and spirited profiles showed a positive relationship with mental health, whereas spiritless showed a negative relationship. For S2, two profiles (spirited and spiritless) were replicated, with similar effects on mental health, but none of them was related to total cholesterol. In both samples, transformational leadership determined the probability of belonging to a particular profile.
ConclusionsTransformational leadership increased the probability of belonging to a more positive profile and, therefore, to better workers’ health.
Service Evaluation of Diagnostic Evolution in Psychiatric Patients at Benazir Bhutto Hospital: Comparing OPD and ER Admissions
- Naima Gul, Asad Nizami
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S189
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This project evaluated the accuracy and evolution of psychiatric diagnoses in patients admitted through the Outpatient Department (OPD) and Emergency Room (ER) at Benazir Bhutto Hospital. It aimed to understand the factors contributing to diagnostic changes, especially the impact of comorbid conditions and interdisciplinary discussions.
MethodsOver an eight-month period, this study reviewed 200 patient records from the psychiatric department. It compared initial psychiatric diagnoses from OPD and ER admissions with final diagnoses at discharge. The evaluation examined the influence of ward round discussions, serial mental state examinations, and newly identified comorbid medical conditions, such as thyroid disorders and neurological issues, on diagnostic changes.
ResultsAnalysis showed that 38.2% of ER admissions had a revised diagnosis by discharge, compared with 22.5% from OPD. Initial diagnoses primarily included major depressive disorder (30.1%) and bipolar disorder (27.2%). By discharge, increases were observed in personality disorders (up by 18.3%) and substance use disorders (up by 14.7%). Comorbid medical conditions were newly diagnosed in 26.8% of patients. Factors influencing diagnostic changes included ward round discussions (57.3%), serial mental state examinations (40.2%), lab findings (33.5%), and medical/interdisciplinary consultations (29.6%).
ConclusionThe service evaluation at Benazir Bhutto Hospital reveals significant diagnostic evolution in psychiatric care, more pronounced in ER admissions. The identification of additional disorders and comorbid medical conditions highlights the necessity for comprehensive, ongoing psychiatric assessment. Lab findings and interdisciplinary consultations played a crucial role in refining diagnoses, suggesting the importance of an integrated care approach. Recommendations include improving initial diagnostic processes in ER settings and strengthening interdisciplinary communication to enhance accuracy in psychiatric diagnosis and patient treatment outcomes.
Stakeholder's Views on the Development of Mobile Application (TechCare) for Patients With First Episode With Psychosis: Qualitative Study
- Zaib un Nisa, Nadeem Gire, Ameer Bukhsh Khoso, Imran B. Cahudhry, Nusrat Husain
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S37-S38
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Psychosis is one of the leading causes of disability. First Episode Psychosis (FEP) significantly impacts the long-term course of the disorder. While a majority of FEP service users show signs of ‘recovery' within 12 months of treatment, the early course involves frequent relapses, with up to 80% relapsing within five years. This elevates the risk of persistent psychotic symptoms, affecting cognitive, social, and occupational functioning. Medication, the core treatment, reduces relapse by 75%, necessitating additional psychosocial treatments. Mobile-based interventions are recognized for meeting families' needs in terms of information, guidance, and support. This paper explores stakeholder views on developing mobile interventions for those experiencing their first psychosis episode.
MethodsThis qualitative paper was part of the TechCare app development process in which face-to-face interviews with patients (17), and 4 focus groups with health professionals were carried out. The qualitative interviews and focus groups explored the views of stakeholders on the need for mobile-based treatment, the structure of the application, the content of the application and barriers and challenges were also explored in detail. All the audio-recorded interviews were transcribed and analyzed through a framework approach.
ResultsQualitative analysis revealed three themes. The first theme centers on stakeholders' views about mobile-based treatment. Health professionals reported that app-based treatment enhances help-seeking behavior, reduces societal stigma, and aids in managing treatment and activities. The second theme focuses on suggestions for the Techcare application, emphasizing logical and easy-to-understand content, with a major focus on crisis management, hallucinations, and psycho-education about symptoms. Participants also highlighted the need for a section providing psycho-education for families. Carers emphasized the necessity of an activity plan in the app, including an activity log for medication management and activities. The third theme delves into barriers and challenges in app-based treatment, including difficulty levels and privacy concerns. Stakeholders stressed the importance of content in simple Urdu language for broader understanding.
ConclusionIn conclusion, mobile-based treatment contributes to reducing stigma, increasing awareness about the illness in its early stages, and facilitating the management of functional activities for patients. The insights gathered from stakeholders provide valuable guidance for the development of an effective and culturally sensitive mobile-based intervention for individuals experiencing FEP.
Improving the Assessment of Memory and Cognitive Side Effects Post Electroconvulsive Therapy
- Amy-May Garvey, John Brady
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
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- 01 August 2024, pp. S139-S140
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Aims
An April 2022 Electroconvulsive Therapy Accreditation Services (ECTAS) review of electroconvulsive therapy (ECT) services in the Southern Sector of the Western Health and Social Care Trust highlighted that the follow up of service users' memory and cognitive side effects post-ECT needed to be improved to deliver safer and more effective care. The aim of this MDT quality improvement project was to transform the follow-up process from a baseline of 13% of service users receiving memory assessment 1–2 months post ECT to 100% of service users receiving memory assessment 1–2 months post ECT over a 16 month period.
MethodsIn June 2022, an MDT working group was established with key stakeholders from inpatient and community mental health services. Using driver diagrams, opportunities for improvement were collectively identified and innovative ideas proposed to overcome these barriers. The primary drivers for change were communication, resources, and education. Systems were established and PDSA cycles used to review our data and decide whether we needed to make a further change. 17 service users received ECT and were followed up within the 16 month period. Our third change brought about the most significant and sustained improvement to the process; establish ECT champions within community teams. The ECT champion's role was to improve communication between inpatient and community teams in regards to service users needing memory follow up post ECT.
ResultsThe introduction of three ECT champions within the community teams significantly improved communication between the inpatient and outpatient teams resulting in an improvement in the standard of care to our service users. Initial figures show 100% of service users having memory assessment follow up at 1–2 months post ECT in July 2023, October 2023 & December 2023. No service users required follow-up within the service in August/September/November 2023. Performance monitoring is ongoing as part of the service's governance meeting.
ConclusionIn conclusion, by improving communication, utilising resources more effectively and educating through ECT champions, the percentage service users receiving memory assessments at 1–2 months follow up post ECT achieved ECTAS standard of 100%. This will benefit our service users by enabling us to identify those who need further input. Looking into the future, we need to undertake a clinical audit to assess for a sustained improvement and ensure that no unintended consequences have been introduced from this QIP. We have shared our learning within the wider trust and plan to spread and scale our changes across a wider area.
Identifying Molecular Biomarkers in Attention-Deficit/Hyperactivity Disorder (ADHD) – a Systematic Review of Literature and Appraisal of Evidence
- Ayobami Yusuff
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S93-S94
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At the core of medical diagnosis lies specific blood tests, urine analysis, microscopic and histologic examination of tissues, and as well radiological investigations that are usually confirmatory of the presence of a disease. However, the diagnosis of ADHD currently relies on reports of clinical symptoms which is usually subjective, with variable interpretations by different professionals, thus posing issues of misdiagnosis and reliability. This study set out to explore, appraise and summarize molecular biomarkers in literature over the past 30 years, which can be applied for the diagnosis of ADHD.
Attention-deficit/hyperactivity disorder (ADHD) is a common neuropsychiatric and neurobehavioral disorder that affects children and adolescents, and more recently, gaining recognition in adults. It is characterized by a pervasive pattern of inattention, hyperactivity, and impulsivity or a mixture of the three, that cuts across the individual's multiple domains of life.
MethodsOne-thousand articles collated across multiple sources and databases were systematically reviewed and analysed for this project. The keywords for the search criteria in the Boolean operators are “biomarkers and ADHD”, “molecular biomarkers and ADHD” and “biomarkers and ADHD and Diagnosis”.
Results5.6% of the articles from several types of studies were included in the final analysis after the inclusion and exclusion criteria were applied. The results revealed various heterogeneity across age, gender, ethnicity, medication status, comorbidities, and study type, in applying biomarkers to assist in the diagnosis of ADHD. Genetics and epigenetics studies were the most common type of molecular biomarkers studied and identified, accounting for 25% of the results. 80% of the studies analysed blood samples with a few others focusing on saliva, urine, cerebrospinal fluid, hair, and stool samples. All the studies identified focused on diagnostic biomarkers with 25% of them combining either prognostic or response-monitoring subtypes of biomarkers.
ConclusionThis study identified several potential molecular biomarkers in ADHD. However, most of the results showed only associations between the findings and the diagnosis/occurrence of ADHD. It remains a scientific goal to identify a specific and reliable biomarker for ADHD to assist psychiatrists in making accurate diagnosis. Lastly, it would be pragmatic to explore other types of biomarkers such as radiologic and electro-neurologic markers; given that diagnosis is a constellation of signs and symptoms together with appropriate tests. Combining them logically would increase the specificity of diagnosis of ADHD. This study was completed in partial fulfilment of Master of Science (MSc) in Clinical Psychiatry with the University of South Wales.
Monitoring of Sodium Valproate Annual Risk Assessments Within Psychiatric Services
- Melissa Bremner
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S221-S222
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To determine the number of patients within a service on sodium valproate for a psychiatric condition who have updated Annual Risk Acknowledgement forms in place.
MethodsIt was firstly identified that within the NICE guidelines, it is recommended that all patients who are on sodium valproate should have an annual signed risk acknowledgement form in place. Following this, a list of patients was compiled who were currently prescribed this with the local area. Each patient was then checked to see if the valproate was prescribed by psychiatry or by neurology. This was then further divided into general adult and learning disability patients.
From this, a list of patients under the care of general adult psychiatry was compiled. The notes for these patients were obtained.
Data collection was then carried out. Each set of notes was reviewed by two individuals for the following:
1. To identify if an annual risk assessment form was carried out.
2. To check if this was within expiry date.
3. To identify patient diagnosis.
4. To identify the dose of sodium valproate.
5. To confirm if these patients were females of childbearing age.
ResultsFrom the initial audit cycle, it was identified that 28 female patients who fell within the inclusion criteria were on valproate, and of these, 6 had forms in place. Of the 6 with forms in place, 50% had expired so needed to be replaced. 17 had no form in place, and for 4 patients it could not be certain if forms were present or not due to unavailability of records. Only 3 patients therefore had the correct form in place which were within expiry date. If we discount those with no data available, only 12% of patients had the correct annual risk acknowledgement form present and within expiry date.
Following the initial audit, two interventions were carried out:
1. The data from the above audit was presented at a consultant meeting, highlighting the importance of ensuring these forms are kept up to date.
2. It was decided that pharmacy would take a leading role in ensuring the annual risk assessment forms are updated.
Following 6 months, this patient cohort was re-audited, with further results obtained.
These results showed a reduction in patients prescribed sodium valproate from 28 to 19. 37% of all patients prescribed sodium valproate had forms, but of these, only 30% were up to date. Therefore, only 11% of patients had correct annual risk acknowledgement forms in place which were up to date.
These results showed an improvement in those who had at one time had a form in place, but roughly similar compliance with availability of up to date forms.
ConclusionOverall it appears that there is a real lack of consistency in ensuring the annual risk assessment forms are in place. A very low percentage of patients have the correct form in place within expiry date, despite interventions which have taken place as part of this audit. Further efforts should therefore be made by teams to ensure that these forms are in place and up to date for all women of childbearing age on valproate.
On a positive note, it may be possible to surmise that the reduction in number of patients on sodium valproate may be linked to raised awareness of the risks to women of childbearing age.
Additionally, a significant number of patients had been sent forms in the post, but had not returned them. Some of these same patients had, in the time that they should have had updated risk forms put in place, been admitted to an inpatient psychiatric hospital. It is therefore important to consider in future if these forms should be updated whilst the patients are admitted to hospital, to increase the number of patients with these forms up to date and therefore improve safety for this cohort of patients. Given that many of these patients have a diagnosis of Bipolar Affective Disorder, they may find it more challenging to return the forms whilst in the community, particularly if unwell; the ICD–11 criteria does note that patients with this condition may suffer from “distractibility, impulsive behaviour and rapid changes in mood state.” Further research could therefore be carried out to determine if utilising inpatient admissions to discuss risks of their medications would be a beneficial way to improve compliance with Annual Risk Assessment Forms.
Lastly, we know that there has been discussion around implementation of such monitoring for men as well as for women. Should this be implemented within the NICE guidelines, further audits should be carried out to determine our compliance with this.
Incorporating Trauma-Informed and Culturally Competent Care Within Domestic Violence Screening Training for Medical Students
- Iyinoluwa Popoola
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S116-S117
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The link between domestic violence and poor mental health outcomes is well-established, with victims often experiencing anxiety, depression, and post-traumatic stress disorder (PTSD). This study aims to evaluate the current state of Domestic Violence (DV) screening training within the medical curriculum at King's College London, focusing on trauma-informed and culturally competent approaches. The objective is to identify gaps and propose recommendations for a comprehensive and inclusive training program.
MethodsApproved by the King's College London Research Ethics Office, this qualitative study was conducted using an online questionnaire that adopted a 5-point Likert-type scale. The study was conducted among KCL Medical Students (n = 25) to gather opinions on DV screening training, and the responses underwent thematic analysis.
ResultsThe survey indicated that 92% of participants had not received formal training on DV screening. In addition, 88% lacked guidance on responding to disclosures in a trauma-informed manner and only 8% believed they had training on responding to DV within diverse cultural contexts. The key themes were ‘Addressing Training Gaps and Challenges’, ‘Practical Skills Enhancement’, ‘Cultural Competency and Diversity' and ‘Comprehensive Understanding of Domestic Violence and Abuse’. Students expressed concerns about the lack of clear, direct education on escalating domestic violence cases. Furthermore, some medical students expressed apprehension about inadvertently re-traumatising or offending patients with a different cultural background.
ConclusionThe study highlights deficiencies in the current domestic violence screening training, emphasizing the urgent need for a more comprehensive, trauma-informed, and culturally sensitive curriculum. Recommendations include the incorporation of domestic violence education within the core curriculum and interprofessional education, survivor engagement, and challenging biases through adopting a critical pedagogy approach. These changes aim to enhance the understanding, attitudes, and practical skills of medical students in addressing domestic violence, ultimately contributing to a more inclusive and responsive medical education system.
Examining Social Touch in Early-Life Stress
- Lena Lim
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S57
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Social contact is crucial for both immediate and later development of adaptive social and emotional behaviour. Tactile experiences during childhood influence the development of the social brain and frequent affectionate touch is associated with secure attachment style. Social touch is an important form of social interaction and plays a significant role in the formation and maintenance of relationships in humans across development, where the hedonic properties of touch are involved in improving the quality of life. However, relatively less research attention has focused on social touch experiences in individuals with a history of early-life interpersonal stress, particularly childhood maltreatment.
MethodsSocial touch pleasantness ratings using a newly developed Social Touch task and attitudes about a variety of social touch behaviours using the Social Touch Questionnaire (STQ) were examined in 40 age- and gender-matched young adults (23 childhood maltreatment, 17 controls).
ResultsThe childhood maltreatment group had significantly lower STQ score than the control group, where lower STQ score was furthermore correlated with higher severity of maltreatment, particularly physical neglect. For the social touch task, females who experienced childhood maltreatment had significantly lower mean pleasantness ratings for positive social touch than their male counterparts, and these differences were mainly in response to touch given by stranger and friend of opposite gender.
ConclusionThese preliminary results show that early-life interpersonal stress from caregivers may potentially influence touch processing and pleasantness, particularly for females, and there is a need to further explore the effects of different touch giver role (e.g. friend, stranger, partner).
Prescribing for People With a Personality Disorder
- Arun Kuruppath, Anneke Muller, Alison Fergusson
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S245-S246
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The primary aim was to identify areas where there may be a significant gap in following the NICE recommendations.
To compare how antipsychotic and benzodiazepine prescribing practice in Community mental health team, measures against the national prescribing practices as identified in the POMH-UK Quality Improvement Project (QIP) 12b.
MethodsThe medical secretaries were contacted and asked to provide a list of patients seen as outpatients between March–September 2021 who have a diagnosis of personality disorder.
As there were multiple psychiatrists working in a team the cases to include were taken evenly from each caseload.
ResultsThe frequency of diagnosis of personality disorder was more likely in females (31/40). Most common personality disorder diagnosed was EUPD (88.5%) followed by mixed Personality disorder (11.5%).
Among sample of patients selected, around 75% were prescribed some psychotropic medication including 52.5% (21/40) who were prescribed an antipsychotic medication.
Around 47.6 % (10/21) of the antipsychotic prescriptions were a new recommendation. Out of all the antipsychotic medications prescribed, quetiapine was by far the most common antipsychotic prescribed followed by aripiprazole.
In 38% of cases where antipsychotics were prescribed specifically for the management of Personality Disorder a rationale was given. Predominantly they were prescribed to reduce mood instability and impulsivity, and to aid sleep. Furthermore, none of the rationales given was in line with NICE recommendation.
Only 3.8% (5/21) of those prescribed antipsychotics were given a written information about antipsychotic effectiveness in PD and a plan to reduce antipsychotic medication was documented in only 28.57% (6/21).
A comorbid diagnosis was present in 62.5% (25/40) of the patients and the most common one was complex PTSD. The frequency of antipsychotic prescription was higher in those with a comorbid diagnosis (57.1%) and 42.8% in those without a comorbid diagnosis. However, there were differences in comorbidities present for patients prescribed antipsychotics as compared with those not prescribed antipsychotics. Those on antipsychotics tended to have comorbid diagnoses on the psychosis, bipolar spectrum disorders and PTSD whereas those not on an antipsychotic tended to be on the depressive or anxiety spectrum.
The other psychotropic medications used were antidepressants and benzodiazepines.
ConclusionIn general, the frequency of prescribing antipsychotic medication to patients with personality disorder in the community mental health teams across Cumbria (52.5%) appears to be lower than the national average (57%). However, the prescriptions did not meet the requirements set out by the NICE guidelines. A significant gap between the recommendations and practice was identified.
In 38% of cases, in which antipsychotics had been prescribed specifically for personality disorder there was a rationale given. Even when a rationale was given it was to treat intrinsic features of Personality disorder which is contrary to what NICE recommends. Only 3.8% of prescriptions were supported with written information on the efficacy of antipsychotics in personality disorder.
Carer Engagement and Support in North and West Kent Rehabilitation Services
- Ahmed Elshafei, Martina Heisig, Amanda Fuller
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S229-S230
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To compare current practice in local Rehabilitation in audit across North and West Rehab Kent units against standards of ‘Triangle of Care’.
Standard 1.3:
Carer's views and knowledge are sought throughout the assessment and treatment process.
Standard 5.2:
An early formal appointment is offered to the carer to hear their story, and history and address the carer's concerns.
Standard 5.10:
The carer is involved in the discharge planning process.
A previous audit was conducted in 2019 using Triangle of Care and AIMS standards. We decided to see whether the standards have been upheld.
MethodsWe included all 43 patients admitted over the previous 6-months. No patient had National Opt-Out. The source of information was the RIO system. The data were analysed by 2 investigators.
A data collection form was used:
Question for Standard 1.3: Were the carer's views and knowledge sought throughout the assessment and treatment process? If this was not the case, the reasons were to be specified.
Question for standard Standard 5.2: Was an early formal appointment offered to the carer to hear their story history and address the carer's concerns?
Question for standard Standard 5.10: Was the carer involved in the discharge planning process?
ResultsStandard 1.3:
83.72% had contact with a variety of team members throughout their relative's admission. Reasons for non-involvement included lack of consent, unavailable carers, non-attendance, and carer's preference.
Standard 5.2:
Only 60.53% of carers had an early appointment offer, and the expectation that this should occur in 80% of cases was unmet.
Standard 5.10:
(90%) of the patients had carers involved in the discharge planning process, meeting the required standard.
ConclusionBest Practice:
The audit results demonstrate that carers are involved in their relative's care throughout the admission and discharge process.
Lessons learned:
Compared with the previous audit in 2019, when the criteria for Standard 5.2 were met, carers were offered a formal early meeting significantly less often. Possible reasons could be the pandemic and resulting changes in practice have certainly led to a reduction in face-to-face meetings. Offering individual time to all carers is essential, and efforts should be made to integrate this into practice.
Next steps:
To allocate a team member to offer a meeting with the carer.
To discuss the outcomes with the Carer Champions on each unit, to review what form their support currently takes, and consider how this could link in with the requirements of Standard 5.2.
To re-audit in 1 year.