The evolution and ecology of multiple antipredator defences.

Prey seldom rely on a single type of antipredator defence, often using multiple defences to avoid predation. In many cases, selection in different contexts may favour the evolution of multiple defences in a prey. However, a prey may use multiple defences to protect itself during a single predator encounter. Such "defence portfolios" that defend prey against a single instance of predation are distributed across and within successive stages of the predation sequence (encounter, detection, identification, approach (attack), subjugation and consumption). We contend that at present, our understanding of defence portfolio evolution is incomplete, and seen from the fragmentary perspective of specific sensory systems (e.g., visual) or specific types of defences (especially aposematism). In this review, we aim to build a comprehensive framework for conceptualizing the evolution of multiple prey defences, beginning with hypotheses for the evolution of multiple defences in general, and defence portfolios in particular. We then examine idealized models of resource trade-offs and functional interactions between traits, along with evidence supporting them. We find that defence portfolios are constrained by resource allocation to other aspects of life history, as well as functional incompatibilities between different defences. We also find that selection is likely to favour combinations of defences that have synergistic effects on predator behaviour and prey survival. Next, we examine specific aspects of prey ecology, genetics and development, and predator cognition that modify the predictions of current hypotheses or introduce competing hypotheses. We outline schema for gathering data on the distribution of prey defences across species and geography, determining how multiple defences are produced, and testing the proximate mechanisms by which multiple prey defences impact predator behaviour. Adopting these approaches will strengthen our understanding of multiple defensive strategies.

Patient Identification of Diagnostic Safety Blindspots and Participation in "Good Catches" Through Shared Visit Notes.

Policy Points Patients and families can identify clinically relevant errors, including "blindspots"-safety hazards that are difficult for clinicians or organizations to see. Health information transparency, including patient access to electronic visit notes, now federally mandated in the US and the subject of policy debate worldwide, creates a new opportunity to engage patients in diagnostic safety. However, not all patients access notes. Patient identification of blindspots in their notes underscores the need to systematically and equitably engage willing patients in safety, promote patient "good catches," and establish routine systems for patient feedback to help avoid preventable diagnostic errors and delays. CONTEXT: Policy shifts toward health information transparency provide a new opportunity for patients to contribute to diagnostic safety. We investigated whether sharing clinical notes with patients can support identification of "diagnostic safety blindspots"-potentially consequential breakdowns in the diagnostic process that may be difficult for clinical staff to observe. METHOD: We used mixed methods to analyze patient-reported ambulatory documentation errors among 22,889 patients at three US health care centers who read ≥ 1 visit note(s). We identified blindspots by tailoring a previously established taxonomy. We used multiple regression analysis to identify factors associated with blindspot identification. FINDINGS: 774 patients reported a total of 962 blindspots in 4 categories: (1) diagnostic misalignments (n = 421, 43.8%), including inaccurate symptoms or histories and failures or delay in diagnosis; (2) errors of omission (38.1%) including missed main concerns or next steps, and failure to listen to patients; (3) problems occurring outside visits (14.3%) such as tests, referrals, or appointment access; and (4) multiple low-level problems (3.7%) cascading into diagnostic breakdowns. Many patients acted on the blindspots they identified, resulting in "good catches" that may prevent potential negative consequences. Older, female, sicker, unemployed or disabled patients, or those who work in health care were more likely to identify a blindspot. Individuals reporting less formal education; those self-identifying as Black, Asian, other, or multiple races; and participants who deferred decision-making to providers were less likely to report a blindspot. CONCLUSION: Patients who read notes have unique insight about potential errors in their medical records that could impact diagnostic reasoning but may not be known to clinicians-underscoring a critical role for patients in diagnostic safety and organizational learning. From a policy standpoint, organizations should encourage patient review of visit notes, build systems to track patient-reported blindspots, and promote equity in note access and blindspot reporting.

Distribution models calibrated with independent field data predict two million ancient and veteran trees in England.

Large, citizen-science species databases are powerful resources for predictive species distribution modeling (SDM), yet they are often subject to sampling bias. Many methods have been proposed to correct for this, but there exists little consensus as to which is most effective, not least because the true value of model predictions is hard to evaluate without extensive independent field sampling. We present here a nationwide, independent field validation of distribution models of ancient and veteran trees, a group of organisms of high conservation importance, built using a large and internationally unique citizen-science database: the Ancient Tree Inventory (ATI). This validation exercise presents an opportunity to test the performance of different methods of correcting for sampling bias, in the search for the best possible prediction of ancient and veteran tree distributions in England. We fitted a variety of distribution models of ancient and veteran tree records in England in relation to environmental predictors and applied different bias correction methods, including spatial filtering, background manipulation, the use of bias files, and, finally, zero-inflated (ZI) regression models, a new method with great potential to investigate and remove sampling bias in species data. We then collected new independent field data through systematic surveys of 52 randomly selected 1-km2 grid squares across England to obtain abundance estimates of ancient and veteran trees. Calibration of the distribution models against the field data suggests that there are around eight to 10 times as many ancient and veteran trees present in England than the records currently suggest, with estimates ranging from 1.7 to 2.1 million trees compared to the 200,000 currently recorded in the ATI. The most successful bias correction method was systematic sampling of occurrence records, although the ZI models also performed well, significantly predicting field observations and highlighting both likely causes of undersampling and areas of the country in which many unrecorded trees are likely to be found. Our findings provide the first robust nationwide estimate of ancient and veteran tree abundance and demonstrate the enormous potential for distribution modeling based on citizen-science data combined with independent field validation to inform conservation planning.

An analysis of complaints about hospital care in the Republic of Ireland.

BACKGROUND: Patients and family members make complaints about their hospital care in order to express their dissatisfaction with the care received and prompt quality improvement. Increasingly, it is being understood that these complaints could serve as important data on how to improve care if analysed using a standardized tool. The use of the Healthcare Complaints Analysis Tool (HCAT) for this purpose has emerged internationally for quality and safety improvement. Previous work has identified hot spots (areas in care where harm occurs frequently) and blind spots (areas in care that are difficult for staff members to observe) from complaints analysis. This study aimed to (i) apply the HCAT to a sample of complaints about hospital care in the Republic of Ireland (RoI) to identify hot spots and blind spots in care and (ii) compare the findings of this analysis to a previously published study on hospital complaints in the UK. METHODS: A sample of complaints was taken from 16 hospitals in the RoI in Quarter 4 of 2019 (n = 641). These complaints were coded using the HCAT to classify complaints by domain, category, severity, stage of care and harm. Chi-squared tests were used to identify hot spots, and logistic regression was used to identify blind spots. The findings of this study were compared to a previously published UK study that used HCAT to identify hot spots and blind spots. RESULTS: Hot spots were identified in Irish hospital complaints while patients were receiving care on the ward, during initial examination and diagnosis, and while they were undergoing operations or procedures. This aligned with hot spots identified in the UK study. Blind spots were found for systemic problems, where patients experience multiple issues across their care. CONCLUSIONS: Hot spots and blind spots for patient harm can be identified in hospital care using the HCAT analysis. These in turn could be used to inform improvement interventions, and direct stakeholders to areas that require urgent attention. This study also highlights the promise of the HCAT for use across different healthcare systems, with similar results emerging from the RoI and the UK.

Online patient feedback as a safety valve: An automated language analysis of unnoticed and unresolved safety incidents.

Safety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organization. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value. Accordingly, we developed an automated language analysis method for measuring the likelihood of patient-reported safety incidents in online patient feedback. Feedback from patients and families (n = 146,685, words = 22,191,427, years = 2013-2019) about acute NHS trusts (hospital conglomerates; n = 134) in England were analyzed. The automated measure had good precision (0.69) and excellent recall (0.98) in identifying incidents; was independent of staff-reported incidents (r = -0.04 to 0.19); and was associated with hospital-level mortality rates (z = 3.87; p < 0.001). The identified safety incidents were often reported as unnoticed (89%) or unresolved (21%), suggesting that patients use online platforms to give visibility to safety concerns they believe have been missed or ignored. Online stakeholder feedback is akin to a safety valve; being independent and unconstrained it provides an outlet for reporting safety issues that may have been unnoticed or unresolved within formal channels.

Pre- and post-copulatory traits working in concert: sexual dichromatism in passerines is associated with sperm morphology.

Passerine birds produce costly traits under intense sexual selection, including elaborate sexually dichromatic plumage and sperm morphologies, to compete for fertilizations. Plumage and sperm traits vary markedly among species, but it is unknown if this reflects a trade-off between pre- and post-copulatory investment under strong sexual selection producing negative trait covariance, or variation in the strength of sexual selection among species producing positive covariance. Using phylogenetic regression, we analysed datasets describing plumage and sperm morphological traits for 278 passerine species. We found a significant positive relationship between sperm midpiece length and male plumage elaboration and sexual dichromatism. We did not find a relationship between plumage elaboration and testes mass. Our results do not support a trade-off between plumage and sperm traits, but may be indicative of variance among species in the strength of sexual selection to produce both brightly coloured plumage and costly sperm traits.

Discrete or indiscrete? Redefining the colour polymorphism of the land snail Cepaea nemoralis.

Biologists have long tried to describe and name the different phenotypes that make up the shell polymorphism of the land snail Cepaea nemoralis. Traditionally, the view is that the ground colour of the shell is one of a few major colour classes, either yellow, pink or brown, but in practise it is frequently difficult to distinguish the colours, and define different shades of the same colour. To understand whether colour variation is in reality continuous, and to investigate how the variation may be perceived by an avian predator, we applied psychophysical models of colour vision to shell reflectance measures. We found that both achromatic and chromatic variation are indiscrete in Cepaea nemoralis, being continuously distributed over many perceptual units. Nonetheless, clustering analysis based on the density of the distribution did reveal three groups, roughly corresponding to human-perceived yellow, pink and brown shells. We also found large-scale geographic variation in the frequency of these groups across Europe, and some covariance between shell colour and banding patterns. Although further studies are necessary, the observation of continuous variation in colour is intriguing because the traditional theory is that the underlying supergene that determines colour has evolved to prevent phenotypes from "dissolving" into continuous trait distributions. The findings thus have significance for understanding the Cepaea polymorphism, and the nature of the selection that acts upon it, as well as more generally highlighting the need to measure colour objectively in other systems.

Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind Spots in Quality and Safety.

Policy Points: Health care complaints contain valuable data on quality and safety; however, there is no reliable method of analysis to unlock their potential. We demonstrate a method to analyze health care complaints that provides reliable insights on hot spots (where harm and near misses occur) and blind spots (before admissions, after discharge, systemic and low-level problems, and errors of omission). Systematic analysis of health care complaints can improve quality and safety by providing patient-centered insights that localize issues and shed light on difficult-to-monitor problems. CONTEXT: The use of health care complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, which we developed, was used to analyze a benchmark national data set, conceptualize a systematic analysis, and identify the added value of complaint data. METHODS: We analyzed 1,110 health care complaints from across England. "Hot spots" were identified by mapping reported harm and near misses onto stages of care and underlying problems. "Blind spots" concerning difficult-to-monitor aspects of care were analyzed by examining access and discharge problems, systemic problems, and errors of omission. FINDINGS: The tool showed moderate to excellent reliability. There were 1.87 problems per complaint (32% clinical, 32% relationships, and 34% management). Twenty-three percent of problems entailed major or catastrophic harm, with significant regional variation (17%-31%). Hot spots of serious harm were safety problems during examination, quality problems on the ward, and institutional problems during admission and discharge. Near misses occurred at all stages of care, with patients and family members often being involved in error detection and recovery. Complaints shed light on 3 blind spots: (1) problems arising when entering and exiting the health care system; (2) systemic failures pertaining to multiple distributed and often low-level problems; and (3) errors of omission, especially failure to acknowledge and listen to patients raising concerns. CONCLUSIONS: The analysis of health care complaints reveals valuable and uniquely patient-centered insights on quality and safety. Hot spots of harm and near misses provide an alternative data source on adverse events and critical incidents. Analysis of entry-exit, systemic, and omission problems provides insight on blind spots that may otherwise be difficult to monitor. Benchmark data and analysis scripts are downloadable as supplementary files.

Near Misses in Financial Trading: Skills for Capturing and Averting Error.

OBJECTIVE: The aims of this study were (a) to determine whether near-miss incidents in financial trading contain information on the operator skills and systems that detect and prevent near misses and the patterns and trends revealed by these data and (b) to explore if particular operator skills and systems are found as important for avoiding particular types of error on the trading floor. BACKGROUND: In this study, we examine a cohort of near-miss incidents collected from a financial trading organization using the Financial Incident Analysis System and report on the nontechnical skills and systems that are used to detect and prevent error in this domain. METHOD: One thousand near-miss incidents are analyzed using distribution, mean, chi-square, and associative analysis to describe the data; reliability is provided. RESULTS: Slips/lapses (52%) and human-computer interface problems (21%) often occur alone and are the main contributors to error causation, whereas the prevention of error is largely a result of teamwork (65%) and situation awareness (46%) skills. No matter the cause of error, situation awareness and teamwork skills are used most often to detect and prevent the error. CONCLUSION: Situation awareness and teamwork skills appear universally important as a "last line" of defense for capturing error, and data from incident-monitoring systems can be analyzed in a fashion more consistent with a "Safety-II" approach. APPLICATION: This research provides data for ameliorating risk within financial trading organizations, with implications for future risk management programs and regulation.

Impossible decision? An investigation of risk trade-offs in the intensive care unit.

In the intensive care unit (ICU), clinicians must often make risk trade-offs on patient care. For example, on deciding whether to discharge a patient before they have fully recovered in order to create a bed for another, sicker, patient. When misjudged, these decisions can negatively influence patient outcomes: yet it can be difficult, if not impossible, for clinicians to evaluate with certainty the safest course of action. Using a vignette-based interview methodology, a naturalistic decision-making approach was utilised to study this phenomena. The decision preferences of ICU clinicians (n = 24) for two common risk trade-off scenarios were investigated. Qualitative analysis revealed the sample of clinicians to reach different, and sometimes oppositional, decision preferences. These practice variations emerged from differing analyses of risk, how decisions were 'framed' (e.g. philosophies on care), past experiences, and perceptions of group and organisational norms. Implications for patient safety and clinical decision-making are discussed. Practitioner Summary: Physicians managing ICUs have to make rapid decisions with incomplete information and suboptimal resources. A qualitative vignette-based interview study examined how such decisions are made. We found physicians used a heterogeneous mixture of risk assessments, factual knowledge and prior experience to make judgements, which leads to potential for inconsistent decision-making.

Why many Batesian mimics are inaccurate: evidence from hoverfly colour patterns.

Mimicry is considered a classic example of the elaborate adaptations that natural selection can produce, yet often similarity between Batesian (harmless) mimics and their unpalatable models is far from perfect. Variation in mimetic accuracy is a puzzle, as natural selection should favour mimics that are hardest to distinguish from their models. Numerous hypotheses exist to explain the persistence of inaccurate mimics, but most have rarely or never been tested against empirical observations from wild populations. One reason for this is the difficulty in measuring pattern similarity, a key aspect of mimicry. Here, we use a recently developed method, based on the distance transform of binary images, to quantify pattern similarity both within and among species for a group of hoverflies and their hymenopteran models. This allowed us to test three key hypotheses regarding inaccurate mimicry. Firstly, we tested the prediction that selection should be more relaxed in less accurate mimics, but found that levels of phenotypic variation are similar across most hoverfly species. Secondly, we found no evidence that mimics have to compromise between accuracy to multiple model species. However, we did find that darker-coloured hoverflies are less accurate mimics, which could lead to a trade-off between mimicry and thermoregulation in temperate regions. Our results shed light on a classic problem concerning the limitations of natural selection.

Microwave fields have little effect on α-synuclein aggregation in a Caenorhabditis elegans model of Parkinson's disease.

Potential health effects of radiofrequency (RF) radiation from mobile phones arouse widespread public concern. RF fields from handheld devices near the brain might trigger or aggravate brain tumors or neurodegenerative diseases such as Parkinson's disease (PD). Aggregation of neural α-synuclein (S) is central to PD pathophysiology, and invertebrate models expressing human S have helped elucidate factors affecting the aggregation process. We have recently developed a transgenic strain of Caenorhabditis elegans carrying two S constructs: SC tagged with cyan (C) blue fluorescent protein (CFP), and SV with the Venus (V) variant of yellow fluorescent protein (YFP). During S aggregation in these SC+SV worms, CFP, and YFP tags are brought close enough to allow Foerster Resonance Energy Transfer (FRET). As a positive control, S aggregation was promoted at low Hg(2+) concentrations, whereas higher concentrations activated stress-response genes. Using two different exposure systems described previously, we tested whether RF fields (1.0 GHz CW, 0.002-0.02 W kg(-1); 1.8 GHz CW or GSM, 1.8 W kg(-1)) could influence S aggregation in SC+SV worms. YFP fluorescence in similar SV-only worms provided internal controls, which should show opposite changes due to FRET quenching during S aggregation. No statistically significant changes were observed over several independent runs at 2.5, 24, or 96 h. Although our worm model is sensitive to chemical promoters of aggregation, no similar effects were attributable to RF exposures.

Human Factors in Financial Trading: An Analysis of Trading Incidents.

OBJECTIVE: This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. BACKGROUND: Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors-related issues in operational trading incidents. METHOD: In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. RESULTS: Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors-related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. CONCLUSION: We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. APPLICATION: This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy.

The relationship between national culture and safety culture: Implications for international safety culture assessments.

In this article, we examine the relationship between safety culture and national culture, and the implications of this relationship for international safety culture assessments. Focussing on Hofstede's uncertainty avoidance (UA) index, a survey study of 13,616 Air Traffic Management employees in 21 European countries found a negative association between safety culture and national norm data for UA. This is theorized to reflect the influence of national tendencies for UA upon attitudes and practices for managing safety (e.g., anxiety on risk; reliance on protocols; concerns over reporting incidents; openness to different perspectives). The relationship between UA and safety culture is likely to have implications for international safety culture assessments. Specifically, benchmarking exercises will consistently indicate safety management within organizations in high UA countries to be poorer than low UA countries due to the influence of national culture upon safety practices, which may limit opportunities for identifying and sharing best practice. We propose the use of safety culture against international group norms (SIGN) scores to statistically adjust for the influence of UA upon safety culture data, and to support the identification of safety practices effective and particular to low or high UA cultures. PRACTITIONER POINTS: National cultural tendencies for uncertainty avoidance (UA) are negatively associated with safety culture.This indicates that employee safety-related attitudes and practices may be influenced by national culture, and thus factors outside the direct control of organizational management.International safety culture assessments should attempt to determine the influence of national culture upon safety culture in order that benchmarking exercises compare aspects of safety management and not national culture.Safety culture against international group norms (SIGN) scores provide a potential way to do this, and can facilitate the identification of best practice within countries operating in a low or high UA cultural cluster.

What can acute medicine learn from qualitative methods?

PURPOSE OF REVIEW: The contribution of qualitative methods to evidence-based medicine is growing, with qualitative studies increasingly used to examine patient experience and unsafe organizational cultures. The present review considers qualitative research recently conducted on teamwork and organizational culture in the ICU and also other acute domains. RECENT FINDINGS: Qualitative studies have highlighted the importance of interpersonal and social aspects of healthcare on managing and responding to patient care needs. Clear/consistent communication, compassion, and trust underpin successful patient-physician interactions, with improved patient experiences linked to patient safety and clinical effectiveness across a wide range of measures and outcomes. Across multidisciplinary teams, good communication facilitates shared understanding, decision-making and coordinated action, reducing patient risk in the process. SUMMARY: Qualitative methods highlight the complex nature of risk management in hospital wards, which is highly contextualized to the demands and resources available, and influenced by multilayered social contexts. In addition to augmenting quantitative research, qualitative investigations enable the investigation of questions on social behaviour that are beyond the scope of quantitative assessment alone. To develop improved patient-centred care, health professionals should therefore consider integrating qualitative procedures into their existing assessments of patient/staff satisfaction.

Safety sans Frontières: An International Safety Culture Model.

The management of safety culture in international and culturally diverse organizations is a concern for many high-risk industries. Yet, research has primarily developed models of safety culture within Western countries, and there is a need to extend investigations of safety culture to global environments. We examined (i) whether safety culture can be reliably measured within a single industry operating across different cultural environments, and (ii) if there is an association between safety culture and national culture. The psychometric properties of a safety culture model developed for the air traffic management (ATM) industry were examined in 17 European countries from four culturally distinct regions of Europe (North, East, South, West). Participants were ATM operational staff (n = 5,176) and management staff (n = 1,230). Through employing multigroup confirmatory factor analysis, good psychometric properties of the model were established. This demonstrates, for the first time, that when safety culture models are tailored to a specific industry, they can operate consistently across national boundaries and occupational groups. Additionally, safety culture scores at both regional and national levels were associated with country-level data on Hofstede's five national culture dimensions (collectivism, power distance, uncertainty avoidance, masculinity, and long-term orientation). MANOVAs indicated safety culture to be most positive in Northern Europe, less so in Western and Eastern Europe, and least positive in Southern Europe. This indicates that national cultural traits may influence the development of organizational safety culture, with significant implications for safety culture theory and practice.

Phenotypic heterogeneity is a selected trait in natural yeast populations subject to environmental stress.

Populations of genetically uniform microorganisms exhibit phenotypic heterogeneity, where individual cells have varying phenotypes. Such phenotypes include fitness-determining traits. Phenotypic heterogeneity has been linked to increased population-level fitness in laboratory studies, but its adaptive significance for wild microorganisms in the natural environment is unknown. Here, we addressed this by testing heterogeneity in yeast isolates from diverse environmental sites, each polluted with a different principal contaminant, as well as from corresponding control locations. We found that cell-to-cell heterogeneity (in resistance to the appropriate principal pollutant) was prevalent in the wild yeast isolates. Moreover, isolates with the highest heterogeneity were consistently observed in the polluted environments, indicating that heterogeneity is positively related to survival in adverse conditions in the wild. This relationship with survival was stronger than for the property of mean resistance (IC(50)) of an isolate. Therefore, heterogeneity could be the major determinant of microbial survival in adverse conditions. Indeed, growth assays indicated that isolates with high heterogeneities had a significant competitive advantage during stress. Analysis of yeasts after cultivation for ≥ 500 generations additionally showed that high heterogeneity evolved as a heritable trait during stress. The results showed that environmental stress selects for wild microorganisms with high levels of phenotypic heterogeneity.

Patient neglect in healthcare institutions: a systematic review and conceptual model.

BACKGROUND: Patient neglect is an issue of increasing public concern in Europe and North America, yet remains poorly understood. This is the first systematic review on the nature, frequency and causes of patient neglect as distinct from patient safety topics such as medical error. METHOD: The Pubmed, Science Direct, and Medline databases were searched in order to identify research studies investigating patient neglect. Ten articles and four government reports met the inclusion criteria of reporting primary data on the occurrence or causes of patient neglect. Qualitative and quantitative data extraction investigated (1) the definition of patient neglect, (2) the forms of behaviour associated with neglect, (3) the reported frequency of neglect, and (4) the causes of neglect. RESULTS: Patient neglect is found to have two aspects. First, procedure neglect, which refers to failures of healthcare staff to achieve objective standards of care. Second, caring neglect, which refers to behaviours that lead patients and observers to believe that staff have uncaring attitudes. The perceived frequency of neglectful behaviour varies by observer. Patients and their family members are more likely to report neglect than healthcare staff, and nurses are more likely to report on the neglectful behaviours of other nurses than on their own behaviour. The causes of patient neglect frequently relate to organisational factors (e.g. high workloads that constrain the behaviours of healthcare staff, burnout), and the relationship between carers and patients. CONCLUSION: A social psychology-based conceptual model is developed to explain the occurrence and nature of patient neglect. This model will facilitate investigations of i) differences between patients and healthcare staff in how they perceive neglect, ii) the association with patient neglect and health outcomes, iii) the relative importance of system and organisational factors in causing neglect, and iv) the design of interventions and health policy to reduce patient neglect.

The self-construal of nurses and doctors: beliefs on interdependence and independence in the care of older people.

AIM: To compare the self-construal of nurses and doctors and establish whether their roles affect perceptions of independence and interdependence. BACKGROUND: Previous research has identified that errors in patient care occur when health professionals do not work cohesively as a team and have divergent beliefs about collaboration. Thus, it is important to understand factors shaping these beliefs. Although these are usually explained by aspects of group norms, the concept of self-construal may serve as an underlying explanation. DESIGN: A quasi-experimental design was used. PARTICIPANTS: One hundred and two nurses and doctors working in three nursing homes in Belgium took part in this study in 2009. METHODS: Nurses' and doctors' self-construal was measured at their workplace, using Singelis' self-construal scale. Statistical differences between nurses and doctors were investigated using analysis of covariance. RESULTS: Results showed statistically significant differences between doctors' and nurses' self-construal. Doctors reported higher and dominant levels of 'independent self-construal' compared with nurses. There were no differences between nurses and doctors for interdependence. However, gender differences emerged with male doctors reporting lower levels of interdependent self-construal than male nurses. Conversely, female doctors reported higher levels of interdependent self-construal than female nurses. CONCLUSIONS: Differences in the roles and training of nurses and doctors and in knowledge of their interdependencies may explain differences in self-construal. This might be useful for understanding why nurses and doctors develop divergent attitudes towards teamwork. Training that focuses on sharing knowledge on team interdependencies may positively influence teamwork attitudes and behaviour.