"I don't want to take any risks even if it's gonna mean this service-user is gonna be happier": A thematic analysis of community support staff perspectives on delivering Transforming Care.

BACKGROUND: Transforming Care is making mixed progress in supporting people with intellectual and developmental disabilities, and complex needs, move to more appropriate specialist accommodations closer to home. Community support staff often spend greatest amounts of time with service-users, yet are some of the least heard voices about why placements succeed and fail to varying extents. METHOD: Managers and support staff (n = 13), working in ostensibly "specialist" community placements, were interviewed about perceived barriers and facilitators to implementing Transforming Care. Transcripts were subjected to thematic analysis. RESULTS: Participants identified difficulties balancing people's rights, safety and quality of life needs, and felt the system's expectations of them are hard to deliver within the resources, legislation, values and support models provided them. Multidisciplinary expertise was highly valued for both emotional and practical support, but was least valued when perceived as overly blaming or inspectorial. Specialist health input was seen to withdraw prematurely for this particular client group. CONCLUSION: Recommendations are provided for how staff perspectives should inform Transforming Care in interests of service-users.

A low cost virtual reality system for home based rehabilitation of the arm following stroke: a randomised controlled feasibility trial.

OBJECTIVE: To assess the feasibility of conducting a randomised controlled trial of a home-based virtual reality system for rehabilitation of the arm following stroke. DESIGN: Two group feasibility randomised controlled trial of intervention versus usual care. SETTING: Patients' homes. PARTICIPANTS: Patients aged 18 or over, with residual arm dysfunction following stroke and no longer receiving any other intensive rehabilitation. INTERVENTIONS: Eight weeks' use of a low cost home-based virtual reality system employing infra-red capture to translate the position of the hand into game play or usual care. MAIN MEASURES: The primary objective was to collect information on the feasibility of a trial, including recruitment, collection of outcome measures and staff support required. Patients were assessed at three time points using the Wolf Motor Function Test, Nine-Hole Peg Test, Motor Activity Log and Nottingham Extended Activities of Daily Living. RESULTS: Over 15 months only 47 people were referred to the team. Twenty seven were randomised and 18 (67%) of those completed final outcome measures. Sample size calculation based on data from the Wolf Motor Function Test indicated a requirement for 38 per group. There was a significantly greater change from baseline in the intervention group on midpoint Wolf Grip strength and two subscales of the final Motor Activity Log. Training in the use of the equipment took a median of 230 minutes per patient. CONCLUSIONS: To achieve the required sample size, a definitive home-based trial would require additional strategies to boost recruitment rates and adequate resources for patient support.

Level and pattern of neuropsychological functioning in early-onset psychoses.

The present study aimed to compare the level and pattern of cognitive deficits in patients with early-onset psychoses with an age, gender and IQ matched control group. In order to ensure a representative sample of patients with psychoses, participants with an IQ of less than 70 were included. Forty-eight patients with an onset of psychoses before the age of 16, and 47 age, gender and IQ matched controls without psychoses were recruited. Psychotic symptomatology was assessed using the Schedules for Clinical Assessment to obtain DSM-IV and ICD-10 diagnoses. Positive and negative symptoms were assessed using the Positive and Negative Symptoms Scale. Levels of cognitive function were measured using a comprehensive neuropsychological battery. A pattern of specific impairments was not found, with few significant differences between the two cohorts. However both cohort groups performed lower than age derived norms. Therefore it appears that there are global cognitive deficits rather than specific deficits in early-onset psychoses when compared to normative data, in-line with conclusions of early-onset schizophrenia research, but patients did not have greater deficit than controls when matched on IQ, gender and age, even after excluding participants with IQ less than 70.

Attitudes towards suicide among nurses and doctors working with children and young people who self-harm.

This paper presents a study investigating the attitudes towards suicide in nurses and doctors who work with children and young people who self-harm. The effect of basic demographic factors on attitudes towards suicide in the staff group is explored. The Suicide Opinion Questionnaire was implemented to collect data on attitudes towards suicide. A 5-point Likert Scale was used to score responses and attitudes were measured on eight clinical scales. Participants were 179 nurses and doctors working in three clinical areas: accident and emergency; paediatric medicine and adolescent inpatient mental health services. Nurses and doctors indicated agreement on the Mental Illness, Cry for Help, Right to Die, Impulsivity, Normality and Aggression scales, and less agreement on the Religion and Moral Evil scale. Only the scores for Mental Illness were statistically different in relation to professional group. There were no other significant differences on the other clinical scales in relation to gender, age clinical speciality and length of experience in current post. It is argued that complex attitudes need to be taken into account in training for healthcare professionals and in the development of contemporary suicide prevention policy.

Systematic evaluation of current control devices used by people with intellectual disabilities in non-immersive virtual environments.

Virtual environments have a role to play in facilitating the acquisition of living skills in people with intellectual disabilities, improving their cognitive skills and providing them with entertainment. However, the currently recommended devices to allow navigation in and interaction with the environments are difficult to use. Using a methodology established in an earlier study, the study aims to systematically document the performance of users with the currently recommended devices in order to (i) inform the design of a usable control device or devices and (ii) act as a baseline against which they can be evaluated. 40 people with severe intellectual disabilities aged 21-67 years used four environments with an equal number of sessions with the different devices being evaluated. Results indicate that when forward movement is provided by the software using the mouse for both navigation and interaction allows better performance both initially and after exposure than using the fire button on the joystick. When the user had to initiate forward movement with the navigation device, the joystick allowed better performance than the arrows on the keyboard. Preventing slippage of the joystick base would make its use much easier and it is suggested that separate devices are retained for navigation and interaction.

A social semiotic interpretation of suicidal behaviour in young people.

This article presents a study of nurses' and doctors' perceptions of young people who engage in suicidal behaviour. A contemporary view of grounded theory is used to guide the collection and analysis of qualitative data from nurses and doctors working with young people in an accident and emergency department, paediatric medicine and child and adolescent mental health services (adolescent inpatient unit). The analysis of 45 semi-structured interviews generated the category: Processes of communication and associated meanings: Another voice, Complex messages and Seeing and using the social environment. A social semiotic framework is used to explore the way in which nurses and doctors perceive young people who engage in suicidal behaviour. The article concludes by considering the implications for policy and practice.

A comparison of some psychological and physiological effects exerted by zetidoline (DL308) and by oxazepam.

In a double-blind, balanced crossover study, eight healthy male volunteers ingested either DL-308 (10 mg), DL-308 (20 mg), oxazepam (30 mg) or placebo. Subjective estimates of coordination and anxiety, objective performance measurements and cardiovascular measurements were taken at 1, 3, 5 and 8 h after ingestion. DL-308 (20 mg) exerted a strong sedative effect as judged by self-reported coordination scores and performance on logical reasoning and reaction time tests. The effect was evident almost immediately and, on the coordination and reasoning tests, lasted up to 8 h following ingestion. Attention is drawn to the need to extend performance testing in order to maximise test sensitivity. No drug had any consistent or strong influence on cardiovascular measures.

Personality, smoking and inflammatory bowel disease.

OBJECTIVE: To assess whether psychological factors distinguished patients with Crohn's disease (CD) from those with ulcerative colitis (UC). DESIGN: Survey of prevalent inflammatory bowel disease patients (n = 82) attending a gastroenterology clinic. METHODS: Administration of three self-report rating scales, the Eysenck Personality Questionnaire, the General Health Questionnaire and the Hospital Anxiety and Depression scale. RESULTS: CD patients were significantly more extroverted (P = 0.04) than UC patients, tended to have higher psychoticism scores (P = 0.06) but similar neuroticism scores. Extroversion and psychoticism scores were weakly associated with smoking status. In logistic regression models that adjusted for age, sex and smoking the associations with extroversion and psychoticism scores persisted but were no longer significant at the 5% level. In the final model the psychoticism score was more important than the extroversion score. CONCLUSION: These results suggest that there are substantial personality differences between patients with CD and UC. Although some of the differences in this study were associated with smoking, adjusting for smoking reduced, but did not abolish, the associations with personality scores.

Carers' attributions for challenging behaviour.

OBJECTIVES: The purpose of this study was to apply Weiner's (1986) attributional model of helping to the care of clients presenting with challenging behaviour. A number of predictions were tested: (a) that aggressive, destructive, and self-injurious behaviours would differentially affect carers' ratings of attributional dimensions; (b) that carers' propensity to help would be mediated by positive affect rather than optimism; (c) that optimism would be reduced by a perceived stable cause, such as client's level of dependency. DESIGN AND METHOD: The participants were 50 care staff working in challenging behaviour day services, who were presented with six case studies to rate. A two-factor repeated measures design was employed to examine the effects of challenging behaviour and dependency on carers' ratings of attributional dimensions, affects, optimism and helping. Correlational analysis was employed to examine the relative effects of positive affect, negative affect and optimism on carers' propensity to help. RESULTS: All three predictions were confirmed. The more independent and outer directed the challenging behaviour, the greater the carers' attributions of control and negative affect, and the less the propensity to help. The more self-directed and dependent the client's challenging behaviour, the greater the carers' attribution of stability, positive affect and propensity to help. CONCLUSIONS: The results are discussed in relation to the concept of helping and the experience of carers coping with challenging behaviours.

Striking the balance: a grounded theory analysis of staff perspectives.

Staff from four units for adults with profound learning disabilities described their relationship with a particular client during individual discussions. Issues arising from discussion were elaborated in subsequent individual and group meetings, evolving into an account of interactional aspects of professional care based on a core typology of relationships (Provider, Meaning-maker, Mutual and Companion). The process of this grounded theory analysis is exemplified. The analysis concludes with four propositions about staff-client relationships, and discussion of their implications for clinical services.

Friendship among adults who have developmental disabilities.

The difference between people with developmental disabilities who did and did not have peer-group friends was investigated by interviewing 36 adults attending day centers. Those with a friend were significantly more likely to describe themselves positively on all dimensions. Results showed that people without a peer-group friend were similar to lonely people without disabilities on two of the three factors explored. Qualitative analysis of subjects' descriptions of their friends suggested that most of the people interviewed had relatively shallow relationships.

How tutors assist adults with learning disabilities to use virtual environments.

PURPOSE: To describe strategies used by tutors teaching adults with learning disabilities to use desktop virtual environments and to investigate their effectiveness by examining changes over time in tutor and learner behaviour. METHOD: Twenty adults with learning disabilities spent 12 sessions with one of four non-disabled tutors learning to use desktop virtual environments designed to teach independent living skills. Sessions were recorded on videotape, categories of behaviour were described and tapes analysed for frequency of tutor behaviours and goals achieved by learners. RESULTS: Tutor strategies were described in terms of whether they aimed to help the learner master the interaction devices or to navigate and achieve goals in the virtual environments and how directive they were. There were some differences between tutors but this did not relate to whether tutors were experienced users themselves of the environments or were initially unfamiliar with them. Goal achievement was maintained at a constant level while help with the interaction devices and specific information about the environment decreased over repeated sessions. Rates of non-specific information did not change. CONCLUSIONS: Pretraining with the interaction devices would free both tutor and learner to concentrate on achieving goals in the environments. Much of the specific help given by the tutor could be incorporated into the software.

The tutoring role of mentors working with adults and elderly people with learning disabilities using virtual environments.

This article outlines the potential of virtual training environments in the rehabilitation of adults and elderly people with learning disabilities. Before such virtual training environments are developed, tutoring roles for mentors working with adults and elderly people must be investigated. This is because this group of people has far less expectation of and experience with computers than younger people with learning disabilities, for whom virtual training environments have already proved effective. Effective tutoring strategies employed, together with appropriate and well-designed virtual training environments, will be the outcomes of two methods suggested in this article.

The effect of student nurses' experiences over the Common Foundation Programme on their inferences of suffering.

Poor pain assessment contributes to inadequate postoperative pain relief. Studies in the U.S.A. suggest that nurse education might make students less sensitive to patients' experience of pain. This research examined this process and the factors that influence it in the U.K. Two-hundred and seventeen students completed the Standard Measure of Inferences of Suffering Questionnaire (SMIS) before and after their Common Foundation Programme (CFP). Their inferences of psychological distress increased as studies in the U.S.A. had found but, unlike these studies, no change was found in their inferences of pain. These findings have important implications for both nurse education and the mechanisms to support student nurses in clinical practice.

Virtual environments special needs and evaluative methods.

This paper presents an overview of the development of the Learning in Virtual Environments programme (LIVE), carried out in special education over the last four years. It is more precisely a project chronology, so that the reader can sense the historical development of the programme rather than giving emphasis to any one particular feature or breakthrough, which are covered in other papers and available through the authors. The project conception in a special school in Nottingham is followed by a description of the development of experiential and communicational virtual learning environments. These are followed, in turn, by the results of our testing programmes which show that experience gained in a virtual environment can transfer to the real world and that their use can encourage self-directed activity in students with severe learning difficulties. Also included is a discussion of the role of virtual learning environments (VLEs) in special education and of its attributes in the context of contemporary educational theory.

Levels of anxiety and sources of stress in adults with autism.

Clinical reports suggest that anxiety is a pertinent issue for adults with autism. We compared 34 adults with autism with 20 adults with intellectual disabilities, utilizing informant-based measures of anxiety and stress. Groups were matched by age, gender and intellectual ability. Adults with autism were almost three times more anxious than the comparison group and gained significantly higher scores on the anxiety subscales of panic and agoraphobia, separation anxiety, obsessive-compulsive disorder and generalized anxiety disorder. In terms of sources of stress, significant differences between the two groups were also found, and stress was found to correlate with high anxiety levels for the autism group, particularly the ability to cope with change, anticipation, sensory stimuli and unpleasant events. That is, the more anxious the individual with autism, the less likely they were able to cope with these demands. This has important implications for clinicians in terms of both assessment and treatment.

The long-term psychological adjustment of children treated for congenital dislocation of the hip.

Eighty-one children previously treated for congenital dislocation of the hip (CDH) before the age of 5 were followed up several years after their treatment, and their psychological adjustment was compared with that of 3 other groups; (i) 44 children who had experienced a single hospital admission of less than a week before the age of 5; (ii) 26 children who had experienced 2 or more hospital admissions, the first being before the age of 5; and (iii) 51 children who had no experience of hospital admission. All 4 groups were similar in composition in terms of sex ratio, age at follow-up, family size, birth order, parental age and social situation. Psychological adjustment was measured by means of Rutter's questionnaires for parents and teachers. In addition, the children completed a Schonell reading test. Both the parental and the teacher's questionnaires selected more disordered children in the CDH group. The CDH group also had a higher total score and more health and behaviour problems than did the single admission group on the parental questionnaire. On the teacher's questionnaire they were more antisocial than the single and no admission groups combined. No significant differences were found on the reading test. While the overall impression is that the CDH group are poorly adjusted, there is some suggestion that it is the younger children who are contributing to this effect.

Effect of unexpected outcomes and causal attributions on key workers' expectancies of goal attainment.

Goal planning is an integral part of the role of the key worker in services for people with intellectual disability. The present study investigated the effect of the Weiner stability-expectancy principle on unexpected outcomes in goal planning. Four hundred and twenty-two actual goal attainment scales were constructed, with each scale describing the key workers' expected levels of outcome. Two hundred and twenty-six (54%) unexpected outcomes, both successful and unsuccessful, were then rated by key workers to provide a causal explanation for each outcome. These explanations were then grouped according to whether the attributions represented stable or variable causes. Finally, key workers were asked to provide a new expectancy rating to forecast future goal attainment. Two predictions from Weiner's model were confirmed by statistical analysis: (1) that success attributed to stable factors would lead to higher revised forecasts of goal attainment than success attributed to variable factors; and (2) that failure attributed to stable factors would lead to lower revised forecasts of goal attainment than failure attributed to variable factors. The results of the present study confirm that stability attributions do alter key workers' revised forecasts of goal attainment. The results are discussed in terms of the possible consequences for key worker behaviour, such as goal abandonment, differential treatment of service users and the need for a knowledgeable approach to performance appraisal by managers.

Differences in performance impairment due to brompheniramine maleate as a function of the sustained-release system.

1 study examined whether different sustained release systems would cause variation in the effect of an antihistamine, brompheniramine maleate 10 mg, upon mood and psychomotor performance. Two commercial preparations were examined, one giving linear release (LR) of the drug over time, the other releasing the drug in a non-linear fashion (NLR). 2 Thirty-six males were allocated to four separate groups receiving either the drug with LR, drug with NLR, placebo or drug-free control. Single dosage of the drug occurred at 08.30 h and subjects completed mood inventories and performed serial choice reaction time and visual search tasks at 1 h, 2.75 h, 5.5 h and 7.25 h post dosage. 3 The NLR system significantly increased feelings of unco-ordination at 2.75 h and significantly slowed reaction time at both 2.75 and 5.5 h post dosage. The LR system significantly slowed reaction time only at 5.5 h but increased pausing in serial choice performance at that time. Neither system impaired visual search. 4 Results suggest that two preparations having identical active constituents may vary in their effects on psychomotor performance and mood as a function of their sustained release systems. A system giving linear release of the drug can reduce the early post-dosage performance decrement associated with a non-linear release system.