The empirical evidence base for the use of the HCR-20: A narrative review of study designs and transferability of results to clinical practice.

The HCR-20, a widely used method of assessing and managing risk, relies on the structured professional judgement approach. This paper reports a narrative literature review of the HCR-20 studies to explore the applicability of the study results to the use of the HCR-20 in clinical practice. From a literature search using terms "HCR-20" and "HCR 20", 206 papers were included. Of studies using the HCR-20 version 2 (n = 191), 92% (n = 176) relied on variables based on scores derived by adding item scores, and 50% (n = 95) tested the HCR-20 using predictive validity methodology. Of the HCR-20 version 3 studies (n = 21), the "presence of risk factors" step was the most commonly examined (n = 18, 86%), but 2 of the 7 steps ("scenario planning" and "management") were not examined at all. Amongst those studies whose primary focus was on the HCR-20, 67% (n = 64/95) did so by assessing the predictive validity of the tool. Only one employed a design to test whether the use of the HCR-20 affected violence rates. The predominant study design provides support for the use of the HCR-20 as an actuarial tool, and there is limited empirical evidence in support of its effectiveness as a structured professional judgement approach to the assessment and management of the risk of violence.

Patients embodied and as-a-body within bedside teaching encounters: a video ethnographic study.

Bedside teaching encounters (BTEs) involve doctor-patient-student interactions, providing opportunities for students to learn with, from and about patients. How the differing concerns of patient care and student education are balanced in situ remains largely unknown and undefined. This video ethnographic study explores patient involvement during a largely student-centric activity: 'feedback sequences' where students learn clinical and practical skills. Drawing on a data subset from a multi-site study, we used Conversation Analysis to investigate verbal and non-verbal interactional practices to examine patients' inclusion and exclusion from teaching activities across 25 BTEs in General Practice and General Surgery and Medicine with 50 participants. Through analysis, we identified two representations of the patient: the patient embodied (where patients are actively involved) and the patient as-a-body (when they are used primarily as a prop for learning). Overall, patients were excluded more during physical examination than talk-based activities. Exclusion occurred through physical positioning of doctor-patient-student, and through doctors and students talking about, rather than to, patients using medical jargon and online commentaries. Patients' exclusion was visibly noticeable through eye gaze: patients' middle-distance gaze coincided with medical terminology or complex wording. Inclusory activities maintained the patient embodied during teaching activities through doctors' skilful embedding of teaching within their care: including vocalising clinical reasoning processes through students, providing patients with a 'warrant to listen', allocating turns-at-talk for them and eye-contact. This study uniquely demonstrates the visible nature patient exclusion, providing firm evidence of how this affects patient empowerment and engagement within educational activities for tomorrow's doctors.