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Biomedical subjects

Linda Gask

Publications and source records attributed to Linda Gask.

At least 19 recordsLinked to original sources
PubMed2006

Evaluating STORM skills training for managing people at risk of suicide.

AIM: This paper reports a study evaluating the Skills Training On Risk Management (STORM) training initiative in three mental health services in the North-West of England, UK. BACKGROUND: Training for health workers has been widely advocated as a key route to suicide prevention. However, reports of evaluations are scarce in the literature. In previous research, we have demonstrated that the STORM intervention results in acquisition of new skills and can be disseminated in a community setting. METHOD: The training was delivered during a 6-month period in 2002 by three mental health nurses who were seconded part-time to the project. The quantitative evaluation, which assessed change in attitudes, confidence, acquisition of skills and satisfaction, used a pretest/post-test design, with participants acting as their own controls. Qualitative interviews were conducted with a purposive sample of 16 participants to explore the impact on clinical practice, and with the three trainers at the end of the study. FINDINGS: Data from 458 staff members were collected during a 6-month period. Positive changes in attitudes and confidence were shown, but previous evidence of skill acquisition was not replicated. Qualitative interviews revealed important insights into changes in clinical practice, particularly for less experienced or unqualified nursing staff, but also concerns about the lack of an educational culture to foster and support such interventions in practice within the organizations. CONCLUSION: STORM training for the assessment and management of suicide risk is both feasible and acceptable in mental health trusts. However, we remain uncertain of its longer-term impact, given the lack of engagement of senior staff in the enterprise and the absence of linked supervision and support from the organizational management to reinforce skill acquisition and development. We consider that regular supervision that links STORM training to actual clinical experience would be the ideal.

Adult↗
PubMed2006

Qualitative study of an intervention for depression among patients with diabetes: how can we optimize patient-professional interaction?

OBJECTIVES: To describe the communication between the depression care specialist (DCS) nurses and patients with both depression and diabetes in an intervention study. Our aims were to inform both the quantitative findings of the present trial and the design of future primary care intervention studies. METHODS: Qualitative content analysis of consultations between DCS nurses and patients in nine primary care clinics. RESULTS: Patients experienced a wide range of physical, social and psychological problems. The DCS nurses employed a range of interventions in addition to the problem-solving and case-management skills that formed the basis of this intervention. CONCLUSIONS: Patients sometimes posed difficulties in being unable to understand the treatment, unprepared to engage with a new treatment and unready (or even unable) to acquire new skills. To optimize the interaction between patient and professional in the case management of depression and diabetes, training should provide guidance in the use of different models of care (medical and psychological), help case managers to identify and negotiate problem scenarios and combine an active model of therapy such as problem-solving treatment for primary care (PST-PC) with elements from motivational interviewing, ensure effective engagement in treatment, and specifically explore how interaction between depression and diabetes might result in adverse outcomes.

Case Management↗
PubMed2005

Training professionals to engage with and promote self-management.

We have set out to investigate an approach to improve patients' ability to self-manage chronic illness. For effective health care in chronic disease, we believe patients need to work in partnership with their doctor; patient-centred consultations are one way to achieve this. This report describes our experience of training specialists in gastroenterology to consult in a patient-centred style as part of a complex self-management intervention in a randomized controlled trial (RCT) involving 700 patients with established inflammatory bowel disease (IBD) attending outpatient clinics. The training session aimed to provide specialists from nine randomly selected intervention sites with the basic skills to carry out the intervention. The training lasted 2 hours, and included background on the research and intervention, a demonstration video, role-play, and video-feedback training. The main findings of the RCT are presented (service use, enablement and satisfaction), and discussed in the light of the views of consultants and patients on the experience of putting the training into practice. The findings of our study confirm and highlight the value of training in patient-centred communication and its potential for promoting self-management effects; the training proved effective in enabling consultants in gastroenterology to establish guided self-management in patients with IBD.

Adolescent↗
PubMed2005

The English version of the Verona medical interview classification system (VR-MICS). An assessment of its reliability and a comparative cross-cultural test of its validity.

OBJECTIVE: This study aimed to assess the inter-rater and intra-rater reliability of the English translation of the original Italian version of the VR-MICS and to evaluate its sensitivity by comparing the coding of English and Italian general practice consultations with emotionally distressed and non-distressed patients, as defined by the 12-item General Health Questionnaire (GHQ-12). METHOD: Six male GPs from Manchester (UK) and six from Verona (Italy) each contributed five consultations, which were coded using the VR-MICS. Intra-rater and inter-rater reliability were assessed both for the division of interviews into speech units and the speech unit coding. Interaction and main effects of GHQ-12 status and nationality on patient and GP expressions were assessed by two-way ANOVA. RESULTS: Agreement indices for the division of speech units varied between 88-96 and 87-93% for GP and patient speech, respectively; those for coding categories between 88-91 and 82-86%, with Cohen's Kappa values between 0.86-0.91 and 0.80-0.85 for GP and patient speech, respectively. Cross-cultural comparisons of patient and GP speech showed no interaction effects between GHQ-12 status and nationality. The Italian GPs were more 'doctor-centred', while the UK GPs tended to use a more 'sharing' consulting style. Independent of nationality, distressed patients talked more, gave more psychosocial cues and increased amounts of positive talk compared to non-distressed patients. GPs in both settings, when interviewing distressed patients, reduced social conversation and increased psychosocial information-giving, checking questions and reassurance. CONCLUSION: The English translation of the VR-MICS showed satisfactory reliability indices and similar sensitivity to patients' verbal behaviours in relation to their emotional state in the two settings. PRACTICE IMPLICATIONS: The VR-MICS may be an useful coding instrument to support collaborative research on doctor-patient communication between the two countries.

Adult↗
PubMed2005

Overt and covert barriers to the integration of primary and specialist mental health care.

This paper is concerned with the historical attempt over the last 20 years to improve integration between primary and specialist mental health care. Semi-structured interviews were carried out during the period December 2000-March 2001 with primary care workers, specialist medical and nursing staff, managers and other key informants in one large group model Health Maintenance Organization in the USA. Both overt (financial) and covert (attitudinal and conceptual) barriers to the integration of mental health and primary care were identified and the impact of these barriers on organizational development is discussed with reference to Activity Theory. The nature and quality of interprofessional conversation in an organization may be important mediating factors in addressing covert barriers to integration between primary and specialist mental health services. There may be insufficient actual contact between different groups of workers in primary and specialist care to enable these professionals to share ideas, challenge mutual assumptions and understand each others' viewpoints about the nature of their work, the covert barriers to integration. Workers may differ in the conceptual models of mental health care they utilize, their views about access to services, and the amount of information they require. In order to integrate services effectively, these issues will require discussion. Financial pressures in the system may lead to failure on the part of management to sanction and encourage opportunities for interprofessional conversation and the geographical distance between places of work may also limit opportunities for contact. However, an alternative explanation might be that attitudinal and other covert barriers to integration effectively prevent, in the first place, the development of such a shared space in which these covert barriers might actually be addressed.

Cooperative Behavior↗
PubMed2005

The effects on suicide rates of an educational intervention for front-line health professionals with suicidal patients (the STORM Project).

BACKGROUND: The opportunity to study district-wide educational interventions on suicide rates is rarely available. In 1997, the authors carried out a district-wide training programme for primary care, accident and emergency, and mental health workers (47% of eligible staff trained), and demonstrated improvements in skills, attitude and confidence among the recipients of the training. METHOD: Suicide rates (including definite suicides and undetermined deaths) and population statistics were collected for a district and region of England from official sources from 1993-2001. A before-and-after (1994-1996 and 1998-2000) training intervention analysis was conducted on suicide rates. RESULTS: The suicide rate in 1994-1996 was 8.8 per 100 000 before our educational intervention and unchanged at 8.6 per 100 000 in 1998-2000 after it (p = 0.783). CONCLUSION: Brief educational interventions to improve the assessment and management of suicide for front-line health professionals in contact with suicidal patients may not be sufficient to reduce the population suicide rate.

Depression↗
PubMed2005

Qualitative study of an educational intervention for GPs in the assessment and management of depression.

BACKGROUND: Previous research has not shown any significant health gain for patients as a result of providing education about depression for GPs. Reasons for this, however, are unclear. AIMS: To explore relationships between process and outcome in the setting of a randomised controlled trial of a complex educational intervention designed to provide GPs with training in the assessment and management of depression. DESIGN OF STUDY: Qualitative study utilising semi-structured interviews. SETTING: General practice in the northwest of England. METHOD: Semi-structured interviews with 30 GPs in Liverpool and Manchester who participated in a randomised controlled trial. RESULTS: Three major barriers to the effectiveness of the intervention were identified: the lack of the GP's belief that he/she could have an impact on the outcome of depression, the appropriateness of the training, and the organisational context in which doctors had to implement what they had learned. CONCLUSION: Attitudes toward treating depression may need addressing at a much earlier point in medical education. If students are introduced to a biosocial model of depression at an early stage, they may feel more hopeful about their ability to intervene when faced with patients who exhibit significant degrees of functional disability in the context of apparently socially determined disorders. Postgraduate interventions should be tailored to the treatment of depression as a common chronic condition and be focused at the level of the organisation, not the individual practitioner.

Attitude of Health Personnel↗
PubMed2004

Demand and supply for psychological help in general practice in different European countries: access to primary mental health care in six European countries.

BACKGROUND: The general practitioner is usually the first health care contact for mental problems. The position of a general practitioner may vary between health care systems, depending on the referral system (gatekeepers versus directly accessible specialists), presence of fixed lists and the payment system. This may influence patients' expectations and requests for help and GPs' performance. In this paper the effects of working in different health care systems on demand and supply for psychological help were examined. METHODS: Data were collected in six European countries with different health care system characteristics (Belgium, Germany, The Netherlands, Spain, Switzerland and the UK). For 15 consecutive contacts with 190 GPs in the six countries, each patient completed questionnaires concerning reason for visit and expectations (before) and evaluation (after consultation). General practitioners completed registration forms on each consultation, indicating familiarity with the patient and diagnosis. General practitioners completed a general questionnaire about their personal and professional characteristics as well. RESULTS: Practices in different countries differed considerably in the proportion of psychological reasons for the visit by the patient and psychological diagnoses by the GP. Agreement between patients' self-rated problems and GPs' diagnoses also varied. Patients in different countries evaluated their GPs' psychological performance differently as well, but evaluation was not correlated with agreement between request for help and diagosis. In gatekeeping countries, patients had more psycho-social requests, GPs made more psychological diagnoses and agreement between both was relatively high. Evaluation, however, was more positive in non-gatekeeping countries. Individual characteristics of doctors and patients explained only a relatively small part of variance. CONCLUSIONS: Health care system characteristics do affect GPs' performance in psycho-social care.

Europe↗
PubMed2004

Primary care mental health workers: role expectations, conflict and ambiguity.

A number of professionals are involved in mental health in primary care. The NHS Plan proposed the introduction of a new professional, the primary care mental health worker (PCMHW), to improve care in this setting. The present study was conducted to examine pilot PCMHW-type roles currently in existence, to explore staff expectations concerning the new PCMHW role and to consider the issues relating to roles in primary care mental health that are raised by this new worker. The study used a case study design, and involved qualitative interviews with 46 managers and clinicians from primary care and specialist mental health services, including pilot PCMHW-type roles. The key findings were as follows: The pilot PCMHW-type roles were almost exclusively related to client work, whereas respondents had far wider role expectations of the new PCMHWs, relating to perceived gaps in current service provision. This highlights the potential for role conflict. Secondly, there was disagreement and ambiguity among some respondents as to the nature of the new PCMHW's role in client work, and its relationship with the work undertaken by other mental health professionals such as counsellors, psychologists and nurses. Given that multiple professionals are involved in mental health care in primary care, issues relating to roles are likely to be crucial in the effective implementation of the new PCMHWs.

Case Management↗
PubMed2004

Framing the doctor-patient relationship in chronic illness: a comparative study of general practitioners' accounts.

How family doctors conceptualise chronic illness in the consultation has important implications for both the delivery of medical care, and its experience by patients. In this paper, we present the results of a re-analysis of qualitative data collected in a series of studies of British family doctors between 1995 and 2001, to explore the ways in which the legitimacy and authority of medical knowledge and practice are organised and worked out in relation to three kinds of chronic illness (menorrhagia; depression; and chronic low back pain/medically unexplained symptoms). We present a comparative analysis of (a). the moral evaluation of the patient (and judgements about the legitimacy of symptom presentation); (b). the possibilities of disposal; and (c). doctors' empathic responses to the patient, in each of these clinical cases. Our analysis defines some of the fundamental conditions through which general practitioners frame their relationships with patients presenting complex but sometimes diffuse combinations of 'social', 'psychological' and 'medical' symptoms. These are fundamental to, yet barely touched by, the increasingly voluminous literature on how doctors should interact with patients. Moving beyond the individual studies from which our data are drawn, we have outlined some of the highly complex and demanding features of what is often seen as routine and unrewarding medical work, and some of the key requirements for the local negotiation of patients' problems and their meanings (for both patients and doctors) in everyday general practice.

Attitude of Health Personnel↗
PubMed2004

Soft governance and attitudes to clinical quality in English general practice.

OBJECTIVES: English primary care organisations (primary care groups and trusts - PCGs, PCTs) were, and are, responsible for the quality of general practice but lack hierarchical structures and, frequently, contractual relationships through which to influence it. The theory of soft governance describes how managers can influence professional practice by other means. This study examines the hypothesis that PCG/Ts have used 'soft' clinical governance. METHODS: Survey in 2000/01 of general practitioners' (GPs') attitudes, opinions and self-reported activity in six PCGs and six PCTs using a semi-structured mailed questionnaire. To assess how representative respondents were of English GPs generally, four questions from a national sample survey of English GPs were included and the results compared. RESULTS: Responses were obtained from 437 (52%) GPs. They most often mentioned the technical aspects of clinical governance. Managerial, policy and resourcing implications were next most frequently mentioned, usually in unfavourable terms. Most GPs reported that their clinical practice had changed because of clinical governance activities, although nearly 40% also reported little difference in the quality of care provided. The National Service Framework for coronary heart disease influenced practice independently of PCG/T activities. CONCLUSION: English primary care organisations are exercising soft governance (although not by that name) over some but not all aspects of GPs' clinical practice. However, this soft governance is complex, not easy to sustain and appears hard to extend beyond essentially clinical domains.

Attitude of Health Personnel↗
PubMed2003

Integrating service development with evaluation in telehealthcare: an ethnographic study.

OBJECTIVES: To identify issues that facilitate the successful integration of evaluation and development of telehealthcare services. DESIGN: Ethnographic study using various qualitative research techniques to obtain data from several sources, including in-depth semistructured interviews, project steering group meetings, and public telehealthcare meetings. SETTING: Seven telehealthcare evaluation projects (four randomised controlled trials and three pragmatic service evaluations) in the United Kingdom, studied over two years. Projects spanned a range of specialties-dermatology, psychiatry, respiratory medicine, cardiology, and oncology. PARTICIPANTS: Clinicians, managers, technical experts, and researchers involved in the projects. RESULTS AND DISCUSSION: Key problems in successfully integrating evaluation and service development in telehealthcare are, firstly, defining existing clinical practices (and anticipating changes) in ways that permit measurement; secondly, managing additional workload and conflicting responsibilities brought about by combining clinical and research responsibilities (including managing risk); and, thirdly, understanding various perspectives on effectiveness and the limitations of evaluation results beyond the context of the research study. CONCLUSIONS: Combined implementation and evaluation of telehealthcare systems is complex, and is often underestimated. The distinction between quantitative outcomes and the workability of the system is important for producing evaluative knowledge that is of practical value. More pragmatic approaches to evaluation, that permit both quantitative and qualitative methods, are required to improve the quality of such research and its relevance for service provision in the NHS.

Delivery of Health Care↗
PubMed2003

Normative models of health technology assessment and the social production of evidence about telehealth care.

Telehealthcare is a rapidly growing field of clinical activity and technical development. These new technologies have caught the attention of clinicians and policy makers because they seem to offer more rapid access to specialist care, and the potential to solve structural problems around inequalities of service provision and distribution. However, as a field of clinical practice, telehealthcare has consistently been criticised because of the poor quality of the clinical and technical evidence that its proponents have marshalled. The problem of "evidence" is not a local one. In this paper, we undertake two tasks: first, we critically contrast the normative expectations of the wider field of Health Technology Assessment (HTA) with those configured within debates about Telehealthcare Evaluation; and second, we critically review models that provide structures within which the production of evidence about telehealthcare can take place. Our analysis focuses on the political projects configured within a literature aimed at stabilising evaluative knowledge production about telehealthcare in the face of substantial political and methodological problems.

Evidence-Based Medicine↗
PubMed2003

Health technology assessment in its local contexts: studies of telehealthcare.

Health technology assessment (HTA) is one of the major research enterprises of late modernity, reaching into fields of previously autonomous professional practice, and critically interrogating the organisation and delivery of health care. The 'evaluation' of new health technologies within the field of HTA is increasingly a normative political expectation, as discourses of 'evidence-based' practice run through health policy in the UK and elsewhere. Despite its importance in governing the direction of innovation in health care delivery, there are hardly any empirical studies of HTA in practice. In this paper, we draw on two ethnographic studies of telehealthcare implementation and evaluation in the UK to explore the practical conduct of HTA, and we focus specifically on the social organisation and conduct of randomised controlled trials of these new technologies. The paper examines how evaluation forms a mediating set of practices that make the embedding or normalisation of a new technology possible; and present a simple model of the social and technical contingencies within the evaluation process.

Anthropology, Cultural↗
PubMed2003

Improving psychiatric interview skills of established GPs: evaluation of a group training course in Italy.

BACKGROUND: A number of studies have shown that the communication style of GPs has a significant impact on their ability to recognize and manage psychiatric disorders. Italian training programmes do exist, but none have been evaluated for effectiveness. METHODS: Nine established GPs participated in a training programme consisting of twelve 3-h education sessions. Each session consisted of group discussion of videotaped patient interviews selected by GPs. Case discussion followed Lesser's "problem-based approach" criteria. Efficacy of training was assessed by measuring the pre-post change in accuracy in detecting psychiatric illness and changes in the interview skills of the GPs. RESULTS: Accuracy in detection of psychiatric illness increased significantly after training. Changes were seen in the interview style after training, such as use of open-ended questions and appropriate counselling in relation to problems presented by the patient. Physicians also improved their management skills by using a more negotiatory style and providing patients with supportive feedback. The way in which physicians gave advice and information to the patients improved significantly despite the fact that GPs were not instructed about how to give information to their patients. CONCLUSIONS: Group training in problem-based interviewing utilizing video feedback is a robust, culturally transferrable model for improving the skills of established physicians. Our results suggest that training produces indirect effects that are the result of the teaching method rather than of explicit instructions. Further research is required to assess how to optimize the effect of educational interventions to ensure sustainability and maximal impact on measurable outcomes of care.

Clinical Competence↗