Synthesizing contemporary integrative interpersonal theory and the narrative identity approach to examine personality dynamics and regulatory processes.

OBJECTIVE: The goal of this paper is to promote the integration of two approaches to personality and assessment: Contemporary Integrative Interpersonal Theory (CIIT) and the Narrative Identity Approach (NI). METHODS: We review CIIT and NI, describe their similarities and differences, and articulate opportunities to integrate the approaches to more fully account for personality dynamics and self-regulation. RESULTS: We identify several areas within which concepts from CIIT and NI could be synthesized and offer four concrete suggestions for integrating the assessment methods within each approach: (1) using narratives to explicate interpersonal perception, (2) using stories to clarify interpersonal context, (3), using the Interpersonal Situation as a framework for unpacking narrative elements, and (4) coding interpersonal sequences in narrative data. CONCLUSIONS: CIIT and NI have potential to augment one another both theoretically and methodologically in ways that would be fruitful for conceptualizing and studying personality dynamics and self-regulation.

'A human face and voice': transgender patient-educator and medical student perspectives on gender-diversity teaching.

BACKGROUND: Transgender and gender diverse (TGD) people face many obstacles in accessing health care, including discrimination, institutional bias, and clinician knowledge deficits. We developed a clinical skills and education module on gender-affirming care for pre-clinical medical students, in collaboration with a TGD-led civil society organisation. The module consisted of an educational session followed by preceptor-facilitated small group tutorials, led by TGD patient-educators (n = 22) who used their lived experience to explore medical history-taking and broader issues related to TGD healthcare with students (n = 199). This study aimed to explore the views of students and TGD patient-educators on the structure, delivery and impact of the module. METHODS: Analysis of responses of TGD patient-educators and students to the module (2020 and 2021), in post-intervention surveys using open-ended questions for TGD patient-educators (18 responses from 22 educators) and free text comments as part of a quantitative survey for medical students (89 responses). RESULTS: Responses from students and patient-educators to the session were highly positive. Students and patient-educators emphasised that the teaching session succeeded through elevating the centrality of shared experience and creating a safe space for learning and teaching. Safety was experienced by patient-educators through the recognition of their own expertise in a medical environment, while students reported a non-judgemental teaching space which allowed them to explore and redress recognised limitations in knowledge and skill. Patient-educators described their motivation to teach as being driven by a sense of responsibility to their community. Preceptor attitudes may function as a barrier to the effectiveness of this teaching, and further attention should be paid to supporting the education of clinical facilitators in TGD health. CONCLUSION: The experiences of TGD patient-educators and medical students in this study suggest that this model of teaching could serve as a transferable template for TGD health and the inclusion of other historically marginalised groups in medical education.

Characteristics and outcomes of Aboriginal and Torres Strait Islander patients with dialysis-dependent kidney disease in Australian intensive care units.

BACKGROUND: In Australia, 531 people per million population have dialysis-dependent chronic kidney disease (CKD5D). The incidence is four times higher for Aboriginal and Torres Strait Islander (indigenous) people compared with non-Indigenous Australians. CKD5D increases the risk of hospitalisation, admission to the intensive care unit (ICU) and mortality compared with patients without CKD5D. There is limited literature describing short-term outcomes of patients with CKD5D who are admitted to the ICU, comparing indigenous and non-indigenous patients. AIMS: This registry-based retrospective cohort analysis compared demographic and clinical data between indigenous and non-indigenous patients with CKD5D and tested whether indigenous status predicted short-term outcomes independently of other contributing factors. Adjusted hospital mortality was the primary outcome measure. METHODS: Data were from the Australian and New Zealand Intensive Care Society's Centre for Outcome and Resource Evaluation Adult Patient Database. Australian ICU admissions between 2010 and 2017 were included. Data from 173 ICU (2136 beds) include 1 051 697 ICU admissions, of which 23 793 had a pre-existing diagnosis of CKD5D. RESULTS: Indigenous patients comprised 11.9% of CKD5D patients in ICU. CKD5D was prevalent among 4.9% of indigenous and 2.9% of non-indigenous ICU admissions. Indigenous patients were 13.5 years younger, had fewer comorbidities and lower crude mortality despite equivalent calculated mortality risk. After adjusting for age, remoteness and severity of illness, indigenous status did not predict mortality. CONCLUSIONS: Socioeconomic disadvantage contributes to earlier development of CKD5D and the overrepresentation in ICU of indigenous people. Mortality is equivalent once correcting for confounders, but addressing inequality requires strengthening preventative care.

Incorporating narrative repair in the treatment of avoidant personality disorders: A case in point.

Avoidant personality disorder (AvPD) is characterized by multiple struggles, including shyness, feelings of inadequacy, and hypersensitivity to interpersonal judgments. Research indicates that people with AvPD also show disturbances in narrative identity, which is an internal and evolving story created about the personal past, present, and presumed future. Here, the novel Guide for Narrative Repair (GNaR) recently developed by (Thomsen et al., 2020) is introduced as a potentially useful tool to help people with AvPD in crafting more adaptive narrative identities. The guide is brought to life via a case study analysis of Adam, a male outpatient suffering from AvPD. Consistent with the GNaR, disturbances in Adam's storied self are brought to light and ways to facilitate his narrative repair are proposed. We conclude with implications related to the case as well as the potential narrative turn in AvPD treatment.

The redemption and contamination research form: exploring relations with narrative identity, personality traits, response styles, and life satisfaction.

Narrative identity is typically assessed by collecting participants' autobiographical scenes and then coding these stories for themes including redemption (negative beginning, positive ending) and contamination (positive beginning, negative ending). Complimenting this approach, we introduce a self-report measure capturing the degree to which individuals explicitly view their lives and social worlds in redemptive and contaminated ways - the Redemption and Contamination Research Form (RCRF). In Studies 1 and 2, participants completed the RCRF and a measure of life satisfaction. In Study 2, participants also provided three autobiographical scenes, later coded for redemption and contamination. Across studies, our novel self-rated redemptive mindset variable corresponded positively with life satisfaction and, in Study 2, the redemption present in scenes. Relations remained significant after considering several covariates (e.g., traits, response styles). These results, which illustrate the utility of self-rated redemptive mindsets, carry implications for the multi-method assessment of constructs indigenous to narrative identity.

Contextualizing personality: Personality within and across social roles and conceptual levels.

OBJECTIVE: Personality psychologists have begun to consider the predictive ability of comparable personality characteristics at the levels of traits, goals, and narrative identity. Here, we build upon and extend this work by adopting a contextualized personality approach. Doing so entailed exploring the implications of personality characteristics within three social roles and at each level of personality in relation to role-specific and generalized measures of psychological adjustment. METHODS: Undergraduates (N = 155) rated traits and specified goals and narratives pertaining to their roles as friends, students, and sons/daughters. Measures of trait-based, goal-based, and narrative-based approach orientation were subsequently derived. RESULTS: Within personality levels, mean-levels of approach orientation differed significantly across social roles. Goal-based and narrative-based approach orientation showed inconsistent associations with role-specific psychological adjustment. When approach orientation was aggregated across roles, however, it demonstrated positive relations with adjustment at each personality level. CONCLUSIONS: There exists contextual variability among and between personality characteristics and adjustment. In addition, in certain cases, aggregating across contextualized personality measures (within conceptual levels) may provide a more reliable indicator of the underlying psychological construct. These results contribute to an evolving understanding of personality coherence and the relation between personality characteristics and context.

Medical perspectives regarding goals-of-care consultations in Emergency Departments.

Goals-of-care discussions aim to establish patient values for shared medical decision-making. These discussions are relevant towards end-of-life as patients may receive non-beneficial treatments if they have never discussed preferences for care. End-of-life care is provided in Emergency Departments (EDs) but little is known regarding ED-led goals-of-care discussions. We aimed to explore practitioner perspectives on goals-of-care discussions for adult ED patients nearing end-of-life. We report the qualitative component of a mixed methods study regarding a 'Goals-of-Care' form in an Australian ED. Eighteen out of 34 doctors who completed the form were interviewed. We characterised ED-led goals-of-care consultations for the first time. Emergency doctors perceive goals-of-care discussions to be relevant to their practice and occurring frequently. They aim to ensure appropriate care is provided prior to review by the admitting team, focusing on limitations of treatment and clarity in the care process. ED doctors felt they could recognise end-of-life and that ED visits often prompt consideration of end-of-life care planning. They wanted long-term practitioners to initiate discussions prior to patient deterioration. There were numerous interpretations of palliative care concepts. Standardisation of language, education, collaboration and further research is required to ensure Emergency practitioners are equipped to facilitate these challenging conversations.

Structure and Measurement Invariance of Adult Romantic Attachment.

Romantic attachment is a popular theory for explaining affect, cognition, and behavior in romantic contexts. This popularity has led to a surge of self-report measures assessing dimensions of attachment. In this study, we considered the ability of 2 common attachment measures, the Adult Attachment Questionnaire (AAQ) and the Experience in Close Relationships-Revised (ECR-R), to replicate the avoidant and anxious attachment factors. We also determined the degree of measurement invariance across, and mean differences between, genders and single and nonsingle individuals. Both the AAQ (N = 650) and the ECR-R (N = 1,271) successfully distinguished avoidant and attachment factors. The AAQ showed evidence for partial strong measurement invariance, whereas the ECR-R showed strict factorial invariance for both gender and relationship status. Gender differences were detected on both measures in a direction consistent with previous research, with males exhibiting higher levels of avoidant attachment (relative to females) and females exhibiting higher levels of anxious attachment (relative to males). Furthermore, when compared to individuals who were currently single, those in romantic relationships exhibited lower levels of avoidant tendencies. This research aligns with the notion that the AAQ and ECR-R reliably assess similar constructs, across genders and single and nonsingle individuals.

Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes.

BACKGROUND: Inhaled drug delivery is the cornerstone treatment for asthma and chronic obstructive pulmonary disease (COPD). However, use of inhaler devices can be challenging, potentially leading to critical errors in handling that can significantly reduce drug delivery to the lungs and effectiveness of treatment. METHODS: A systematic review was conducted to define 'critical' errors and their impact on health outcomes and resource use between 2004 and 2016, using key search terms for inhaler errors in asthma and COPD (Search-1) and associated health-economic and patient burden (Search-2). RESULTS: Search-1 identified 62 manuscripts, 47 abstracts, and 5 conference proceedings (n = 114 total). Search-2 identified 9 studies. We observed 299 descriptions of critical error. Age, education status, previous inhaler instruction, comorbidities and socioeconomic status were associated with worse handling error frequency. A significant association was found between inhaler errors and poor disease outcomes (exacerbations), and greater health-economic burden. CONCLUSIONS: We have shown wide variations in how critical errors are defined, and the evidence shows an important association between inhaler errors and worsened health outcomes. Given the negative impact diminished disease outcomes impose on resource use, our findings highlight the importance of achieving optimal inhaler technique, and a need for a consensus on defining critical and non-critical errors.

Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among Heroin Users in the United Kingdom.

BACKGROUND: Heroin overdose is a major cause of premature death. Naloxone is an opioid antagonist that is effective for the reversal of heroin overdose in emergency situations and can be used by nonmedical responders. OBJECTIVE: Our aim was to assess the cost-effectiveness of distributing naloxone to adults at risk of heroin overdose for use by nonmedical responders compared with no naloxone distribution in a European healthcare setting (United Kingdom). METHODS: A Markov model with an integrated decision tree was developed based on an existing model, using UK data where available. We evaluated an intramuscular naloxone distribution reaching 30% of heroin users. Costs and effects were evaluated over a lifetime and discounted at 3.5%. The results were assessed using deterministic and probabilistic sensitivity analyses. RESULTS: The model estimated that distribution of intramuscular naloxone, would decrease overdose deaths by around 6.6%. In a population of 200,000 heroin users this equates to the prevention of 2,500 premature deaths at an incremental cost per quality-adjusted life year (QALY) gained of £899. The sensitivity analyses confirmed the robustness of the results. CONCLUSIONS: Our evaluation suggests that the distribution of take-home naloxone decreased overdose deaths by around 6.6% and was cost-effective with an incremental cost per QALY gained well below a £20,000 willingness-to-pay threshold set by UK decision-makers. The model code has been made available to aid future research. Further study is warranted on the impact of different formulations of naloxone on cost-effectiveness and the impact take-home naloxone has on the wider society.

Emergency consultants value medical scribes and most prefer to work with them, a few would rather not: a qualitative Australian study.

OBJECTIVE: The utilisation of medical scribes in the USA has enabled productivity gains for emergency consultants, though their personal experiences have not been widely documented. We aimed to evaluate the consultant experience of working with scribes in an Australian ED. METHODS: Emergency consultants working with scribes and those who declined to work with scribes were invited to participate in individual interviews (structured and semistructured questions) about scribes, scribe work and the scribe program in October 2016. RESULTS: Of 16 consultants, 13 participated in interviews, that is, 11 worked with scribes and 2 did not and 3 left Cabrini prior to the interviews. Consultants working with scribes found them most useful for capturing initial patient encounters, for finding information and completing discharge tasks. Scribes captured more details than consultants usually did. Editing was required for omissions, misunderstandings and rearranging information order, but this improved with increasing scribe experience. Consultants described changing their style to give more information to the patient in the room. Consultants felt more productive and able to meet demands. They also described enjoyment, less stress, less cognitive loading, improved ability to multitask, see complex patients and less fatigue.In interviews with the two consultants declining scribes, theme saturation was not achieved. Consultants declining scribes preferred to work independently. They did not like templated notes and felt that consultation nuances were lost. They valued their notes write-up time as time for cognitive processing of the presentation. They thought the scribe and computer impacted negatively on communication with the patient. CONCLUSION: Medical scribes were seen to improve physician productivity, enjoyment at work, ability to multitask and to lower stress levels. Those who declined scribes were concerned about losing important nuances and cognitive processing time for the case.

Feasibility evaluation of a pilot scribe-training program in an Australian emergency department.

Objective Medical scribes have an emerging and expanding role in health, particularly in Emergency Medicine in the US. Scribes assist physicians with documentation and clerical tasks at the bedside while the physician consults with his or her patient. Scribes increase medical productivity. The aim of the present study was to examine the feasibility of a pilot hospital-administered scribe-training program in Australia and to evaluate the ability of an American training course (Medical Scribe Training Systems) to prepare trainee scribes for clinical training in an emergency department in Australia. Methods The present study was a pilot, prospective, observational cohort study from September 2015 to February 2016 at Cabrini Emergency Department, Melbourne. Scribe trainees were enrolled in the pre-work course and then trained clinically. Feasibility of training scribes and limited efficacy testing of the course was undertaken. Results The course was acceptable to users and demand for training exists. There were many implementation tasks and issues experienced and resources were required to prepare the site for scribe implementation. Ten trainees were enrolled for preclinical training. Six candidates undertook clinical training, five achieved competency (required seven to 16 clinical shifts after the preclinical course). The training course was helpful and provided a good introduction to the scribe role. The course required adaptation to a non-US setting and the specific hospital setting. In addition, it needed more detail in some common emergency department topics. Conclusion Training scribes at a hospital in Australia is feasible. The US training course used can assist with preclinical training. Course modification is required. What is known about the topic? Scribes increase emergency physician productivity in Australia. There is no previous work on how to train scribes in Australia. What does this paper add? We show that implementing a scribe-training program is feasible and that a training package can be purchased from the US to train scribes in Australia and that it is useful. We also show the adaptation that the course may require to meet Australian emergency department needs. What are the implications for practitioners? Scribes could become an additional member of the emergency department team in Australia and can be trained locally.

Malleability of implicit associations across development.

The prevalence of implicit intergroup bias in adults underscores the importance of knowing when during development such biases are most amenable to change. Although research suggests that implicit intergroup bias undergoes little change across development, no studies have directly examined whether developmental differences exist in the capacity for novel implicit associations to form or change. The present study examined this issue among children ages 5-12. Results from over 800 children provided evidence that novel implicit associations formed quickly, regardless of child age, association type (evaluative or non-evaluative) or the target of the association (social or non-social). Moreover, the magnitude of these changes was comparable across conditions. Coupled with similar findings among adults, these data underscore the importance of first impressions in shaping implicit intergroup bias and provide further evidence that the acquisition of implicit associations is governed by a domain-general mechanism that may be fully in place by age 5.

Studying the Motivated Agent Through Time: Personal Goal Development During the Adult Life Span.

This research examined the rank-order and mean-level consistency of personal goals at two periods in the adult life span. Personal goal continuity was considered among a group of young adults (N = 145) who reported their goals three times over a 3-year period and among a group of midlife adults (N = 163) who specified their goals annually over a 4-year period. Goals were coded for a series of motive-based (viz., achievement, affiliation, intimacy, power) and domain-based (viz., finance, generativity, health, travel) categories. In both samples, we noted a moderate degree of rank-order consistency across assessment periods. In addition, the majority of goal categories exhibited a high degree of mean-level consistency. The results of this research suggest that (a) the content of goals exhibits a modest degree of rank-order consistency and a substantial degree of mean-level consistency over time, and (b) considering personality continuity and development as manifest via goals represents a viable strategy for personality psychologists.

Lay Conceptions of Volitional Personality Change: From Strategies Pursued to Stories Told.

Recent research suggests that individuals play an active role in their own personality development. Here, we investigated lay conceptions of this volitional personality change process. In Study 1, participants (N = 602) provided open-ended descriptions of their desired personality changes as well as the strategies they were using to achieve these changes. In Study 2, participants (N = 578) completed these same measures and provided narrative descriptions of the emergence of their desires for (and previous) personality changes. Desired changes were quantified in a manner consistent with the Five-Factor Model (though desires pertinent to Openness to Experience were rare), whereas reported strategies were distinguished on the basis of cognitive and behavioral content. Desires to increase in Extraversion corresponded negatively with the use of cognitive strategies and positively with the use of behavioral strategies, whereas desires to increase in Agreeableness exhibited the opposite pattern. Finally, desires for change were typically construed as stimulated by specific events, whereas previous personality changes were attributed to shifts in social roles. Laypersons hold a diverse range of desired changes and strategies. In addition, different categories of events are recognized as catalysts of desires for (and previous) changes.

Down on the upside: redemption, contamination, and agency in the lives of adult children of alcoholics.

We investigated differences in the nature and implications of Adult Children of Alcoholics (ACOAs; n = 53) and non-ACOAs' (n = 80) narrative identities. Participants described six autobiographical narratives and completed measures of emotional functioning. Narratives were coded for redemptive (bad things turning good), contaminated (good things turning bad), and agentic (perceived control) imagery. ACOAs exhibited similar levels of redemptive and contaminated imagery, and lower levels of agency in their narratives, relative to non-ACOAs. In addition, themes of redemption, contamination, and agency corresponded divergently with emotional functioning. Among ACOAs, narrative redemption and agency were related to poorer emotional functioning whereas, among non-ACOAs, narrative contamination predicted poorer emotional functioning. These findings provide indication of the manner in which ACOAs story their lives. They also align with the emerging area of research noting that, among certain vulnerable populations, redemptive and agentic imagery serve as predictors of maladaptive functioning.

Sticking to the (romantic) script: an examination of love life scripts, stories, and self-reports of normality.

Life scripts represent cultural expectations regarding the events in the prototypical life whereas life stories represent narrative constructions of the events occurring in individuals' own lives. In Study 1, we generated an outline of the love life script and a list of the self-definitional events individuals tend to associate with their own love lives. Participants were prompted to produce and rate seven important events in the prototypical love life and several significant moments from their own love lives. Building upon these descriptive efforts, in Study 2, we developed self-report measures of perceived and desired love life normality. These characteristics positively predicted the conventionality of autobiographical narratives drawn from participants' love life stories. Furthermore, perceived normality and desired normality were positively and negatively related to functioning within the romantic domain, respectively. These results underscore the role love life scripts and love life stories play in functioning within the romantic domain.

The Suitability of End Point Designs for Health Technology Assessment in Chronic Pain Studies.

OBJECTIVES: To identify the pain instruments and study end points most commonly used in clinical trial settings and to provide insight into the extent to which outcome measures in clinical studies are meeting payer needs. METHODS: A literature review was conducted to identify published clinical studies and ongoing/recently completed registered trials in chronic pain. Inclusion criteria were interventional study, chronic pain in adults, and pain measured within the primary end point. RESULTS: Of 1256 PubMed citations and 3006 clinical trial registry entries, 356 reported large clinical studies in pain populations (e.g., malignant, neuropathic, functional, and musculoskeletal). Studies were designed for superiority in 28% of PubMed citations and 8% of registry entries. The primary end points of most studies were single-dimension pain instruments, such as the numerical rating scale (n = 131) and the visual analogue scale (n = 69). In cases in which multidimensional pain end points were used, this was most commonly the Brief Pain Inventory (n = 37). Payer-relevant end points were typically limited to secondary end points, and were limited and/or reported inconsistently in published studies and ongoing/recently completed studies: preference-weighted quality of life (36% and 42%), resource use (2% and 8%), physical function (28% and 39%), and psychological function (25% and 24%). CONCLUSIONS: Most pain trials were not designed to show superiority to an active comparator, and they used single-dimension pain scales as their primary end point in combination with a broader selection of secondary end points. The inclusion of payer-relevant end points among clinical trials was inconsistent.

GrOup based physical Activity for oLder adults (GOAL) randomized controlled trial: study protocol.

BACKGROUND: Physical activity has health benefits across the lifespan, yet only 13 % of Canadian older adults are sufficiently active. Results from a number of observational studies indicate that adults display positive preferences for exercising with others of a similar age and same gender, and that intra-group age- and gender-similarity are associated with elevated exercise adherence. However, research has yet to experimentally examine the extent to which intra-group age- and gender-related similarity affect exercise adherence behaviors. METHODS/DESIGN: The GrOup-based physical Activity for oLder adults (GOAL) trial is a three-arm randomized control trial that will examine the efficacy of two different group-based exercise programs for older adults (informed by the tenets of self-categorization theory) in relation to a standard group-based exercise program. Within this manuscript we outline the design and proposed evaluation of the GOAL trial. The first arm is comprised of exercise groups made up of participants of a similar-age and of the same gender; the second arm consists of groups with similar-aged mixed gender participants; the control arm is comprised of mixed-aged mixed gender participants. We aim to compare the adherence rates of participants across conditions, as well as potential moderation effects and mediating mechanisms. DISCUSSION: Results from this trial will inform intervention designs to improve the exercise adherence behaviors of older adult. At a systems-level, should support be derived for the efficacy of the interventions tested in this trial, changing group composition (i.e., age, gender) represents a feasible program adaptation for physical activity centers. TRIAL REGISTRATION: ClinicalTrials.gov # NCT02023632 . Registered December 13, 2013.

For the overweight, is proximity to in-shape, normal-weight exercisers a deterrent or an attractor? An examination of contextual preferences.

BACKGROUND: For the overweight, is the thought of exercising in close proximity to physically fit, normal-weight individuals a deterrent or an attractor? Efforts to address this question stand to inform future intervention-based research. PURPOSE: The purpose of the study was to examine whether overweight individuals possess a preference for exercising alongside similarly overweight (relative to in-shape, normalweight) persons. METHODS: Relying upon an experimental paradigm, American participants evaluated one of four exercise contexts and completed a measure of social physique anxiety. RESULTS: Overweight participants high in social physique anxiety exhibited a preference for exercise contexts comprised of other overweight individuals whereas overweight participants low in physique anxiety exhibited a preference for contexts comprised of in-shape, normal-weight individuals. A relative preference for social contexts among normal-weight participants was not observed. CONCLUSIONS: These findings suggest that the provision of group-based programs designed exclusively for the overweight may be appropriate for overweight individuals anxious about the evaluation of their physique. These results also suggest that such programs may conflict with the preferences of overweight persons with a low degree of social physique anxiety. Thus, for the overweight (but not the normal-weight), exercising in close proximity to in-shape, normal-weight individuals can be both a deterrent and an attractor.