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BackgroundA key part of the patient safety system is how it responds to and learns from safety incidents. To date, there is limited research on understanding system-based approaches to investigating incidents that occur within this complex interacting system.ObjectivesThe aims of this study were to qualitatively explore mental health professionals’ perceptions of patient safety incident investigations; to understand the impact of the transition to systems-based approaches and to explore the influence of different elements of the system on the goals of patient safety.Design, setting and participantsThe qualitative study involved 19 semi-structured interviews with professionals working within the patient safety system across two mental health National Health Service trusts. The data were analysed using thematic analysis.ResultsThose interviewed identified that a change in approach to incident investigation, from root cause analysis to systems-based, would lead to rigorous investigations that are effectively linked to learning. Over time, this was described as a contributory factor to reducing feelings of blame and positively influencing safety culture. There were considerations of potential negative effects from a systems-based approach, such as the shifting rather than elimination of blame, and the possibility of missing individual poor practice. The findings identify the presence of several interdependencies across the system that could have a positive or negative influence on the outcomes of incident responses.ConclusionsThis study demonstrates that the interdependencies within the system and our limited understanding of safety in mental healthcare introduces complexity and uncertainty to incident investigation outcomes. This is likely to impact on safety incident responses and learning, where acknowledging and evaluating this complexity is likely to reduce any potential negative outcomes that exist.

Purpose The purpose of this paper is to review and critically evaluate UK psychiatry national recruitment process for 2021, which was re-structured following the COVID-19 pandemic. Additionally, this paper aims to review the empirical evidence of the selection methodologies in psychiatry recruitment. Design/methodology/approach The UK national psychiatry recruitment process is discussed, with a focus on the changes made to recruitment in 2021. The advantages and disadvantages of different selection methodologies are explored, with an emphasis on evaluating the validity, acceptability and reliability of different recruitment selection methodologies. The potential impact of the changes to psychiatry recruitment are explored. Findings The decision of the National Recruitment Office to remove certain selection methods for recruitment in 2021 may have limited their ability to choose the best candidate for the training place and be fair to the applicant. Overall, there is a lack of research into the validity of the selection methods used in psychiatry recruitment. A framework for outcome criteria relevant to psychiatry recruitment should be developed, which would allow research into selection methods and guide the NRO to examine the evidence base effectively. Originality/value This paper examined the recruitment methods used to choose doctors for psychiatry training in the UK, demonstrating that the empirical evidence base for psychiatry recruitment is limited. This paper can contribute to our understanding of selection methodologies used in psychiatry recruitment and highlights the value of different recruitment approaches for choosing the best psychiatrists of the future.

AimsThe aim of this review is to systematically investigate simulation in psychiatry to enable the evidence based introduction of psychiatry simulation into the undergraduate curriculum at the University of Liverpool.BackgroundTransformations in the structure of psychiatric delivery and reductions in funding to mental health care have limited the availability of direct patient clinical experiences for medical students. Experiential learning through simulation can be utilised as a powerful pedagogical tool and provide exposure to a broad range of psychopathology.Although psychiatric skills and knowledge are gained from the current University of Liverpool undergraduate curriculum, there is no specific well-designed psychiatry simulation.MethodThe author searched MEDLINE, EMBASE and PsycINFO databases for studies that met the inclusion criteria. Search terms included ‘simulation (psychiatry or ‘mental health’). Studies were also searched using snowballing via citation tracking within the databases.Inclusion criteria comprised studies of an educational intervention that involved simulation. The intervention had to be utilised within the field of psychiatric teaching.ResultThe literature review illustrated the dearth of studies analysing role-playing (RP) and/or simulated patients (SP) in psychiatry with it typically encountered as part of the more general communication skills curriculum. Studies analysing SP and RPs demonstrate how they build on the social context of learning alongside drawing on a range of educational theories, including experiential learning. However, studies show that well-designed simulation training should encompass more facets of learning to be transformative, specifically reflecting upon ones experiences alongside understanding and interpreting this new knowledge, allowing it to guide future actions and change practice.Studies analysing virtual-reality in psychiatry are limited but demonstrate significant improvements in students’ acquisition of key psychiatric skills and exposure to psychopathology. More studies are needed to evaluate the efficiency and cost-effectiveness of virtual-reality over more traditional methods.Despite the increase in simulation teaching within psychiatry, and the expansion of innovative simulation approaches in other specialties, there was limited use of novel approaches found within the studies analysing psychiatric simulation. There were studies evaluating novel approaches to psychiatry simulation outside of the undergraduate curriculum.ConclusionWhilst there are barriers to overcome in simulation training, these are primarily logistical and are clearly outweighed by the educational gain demonstrated throughout this review. Simulation training in psychiatry has often remained limited to traditional communication-oriented scenarios using RP or SP. A greater emphasis on furthering the advancement and integration of more innovative approaches into psychiatric undergraduate teaching is needed.

Purpose Self-harm, including death from suicide, remains a significant public health challenge. The prison population is known to be a high-risk group for self-harm and suicide. The purpose of this study is to explore the trends in the frequency of self-harm over the course of the COVID-19 pandemic within a high-secure hospital. The authors hypothesised that the pandemic could adversely affect the mental health of patients, which could increase the rates of self-harm. Reasons for changes in the frequency of self-harm and the strategies used in response to the pandemic were also investigated. Design/methodology/approach This paper encompasses findings from a quality improvement project that investigated self-harming behaviours from February 2020 to February 2021 in a high-secure psychiatric hospital. Incidents of self-harm were recorded based on the hospital’s ward structure. Data was collected on the incidence of self-harm rates over the COVID-19 pandemic, with a focus on how the pandemic may have had an effect on self-harm. Findings This paper found an increase in the incidents of self-harm during the initial stages of the pandemic. The first national lockdown period yielded a rise in self-harm incidents from pre-COVID levels. The frequency of self-harm reduced following the first lockdown and returned to pre-COVID levels. The authors explored the psychological effects of COVID, isolation, interpersonal dynamics and changes in the delivery of care as reasons for these trends. Practical implications This study demonstrates the substantial challenges of the COVID-19 pandemic to secure psychiatric services. Having an awareness of how the pandemic can impact on self-harm is important, as it allows the correct balance of restriction of our patients’ liberty to a degree deemed necessary to control the pandemic and the delivery of effective patient care. The key clinical implications include the importance of direct face-to-face patient contact, effective communication, therapeutic interventions and activities, the psychological impact of quarantine and the influence the pandemic can have on an individual’s function of self-harm. Originality/value This paper is the first, to the authors’ knowledge, to explore the impact of COVID-19 in a high-security psychiatric hospital. The authors also explore possible explanations for the changes in the trends of self-harm and include the consideration of strategies for improving the prevention and management of self-harm in high-secure settings during a pandemic.

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.

AimsThe Dynamic Appraisal of Situational Aggression (DASA) is one of a few instruments designed for the prediction of violence specifically for inpatient populations. It is important that risk assessment tools demonstrate clinical utility, and that barriers to successful implementation are addressed. If successful, the tool should not only predict risk, but lead to the utilisation of interventions intended to manage and reduce risk. The aim of this study is to learn more about the acceptability of the tool (adherence), it's outputs (nursing interventions), and the outcomes (inpatient aggression and violence). Understanding more about the relationship and processes between an intervention and its outcomes is a key step in intervention evaluation.MethodsData were collected over a three-month period within a medium secure forensic hospital. A total of 43 patients were included for analysis.Categories of nursing intervention were coded and content analysis of electronic health records analysed. Incidents of aggression/violence to others was recorded as aggression to patient and aggression to staff. Data were gathered on the completion of the DASA score for all patients for each 24-hour period. A DASA score of 2–3 for moderate risk and ≥4 for high risk was used. The change in DASA score (before and after intervention) and frequency of incidents was calculated for each intervention implemented.ResultsThe average adherence of the DASA tool was 58.82% (Range 1.09% - 90.02%). The most frequent intervention following a moderate and high DASA score was that no interventions were provided. The second most frequent outcome following a high score was a focussed discussion with the patient, the use of increased monitoring and the use of seclusion. For those patients that recorded a high score on the DASA tool, eight of those scores were followed by an incident of aggression (n = 8 / 50%). There was no statistically significant difference between the change in DASA scores between interventions implemented, for both high and moderate scores.ConclusionThe ultimate goal of risk assessment is the management and prevention of risk. Thus, if a high score does not result in strategies for intervention, it renders the assessment process worthless. A recommendation for future clinical practice would be the systematic recording of interventions and risk management strategies when in receipt of a high score on the DASA. Greater operationalisation of risk management strategies and their ability to reduce aggression is needed to enhance risk assessment research and clinical practice.

Purpose People with intellectual disability face extensive health inequality and premature mortality. Medical students have reported that they lack the skills, knowledge and confidence to work with those with intellectual disability and autism. This emphasises the need for tomorrow’s doctors to be adequately trained. This study aims to investigate students’ knowledge, skills and attitudes towards people with intellectual disability and autism, examining whether these outcomes change following curricula re-design and with implementation of an e-learning module. Design/methodology/approach The university curricula in intellectual disability and autism were re-designed and an e-learning module developed using co-production. This was delivered to fourth-year medical students with a subgroup receiving the additional e-learning. A controlled trial evaluated students’ knowledge, skills and attitudes using pre- and post-questionnaires. Statistical tests of difference were used to the scores obtained. Findings This study showed an improvement in knowledge, skills and attitudes with intellectual disability and autism after curricula engagement, with an incremental benefit observed for students also completing the e-learning module. There was significant difference in pre-and-post placement scores assessing student attitudes towards intellectual disability and autism teaching. Originality/value This study highlights the importance of a multi-faceted, co-produced curricula re-design in intellectual disability and autism. The benefit of the e-learning module holds hope that the newly introduced mandatory Oliver McGowan training will be beneficial in the development of tomorrow’s doctors. Effective training in intellectual disability and autism is vital to improve the care and support delivered and reduce unnecessary deaths.

Aim: To investigate the delays in the transfer of care of patients from psychiatric intensive care units (PICU) to acute care inpatient wards. Background: Few studies have focused on the characteristics of patients requiring transfer from PICU or delays in transfer of care from PICU to inpatient beds. The efficient transfer of patients from a PICU is essential to provide a dynamic service, promote patient recovery, enable safe, timely discharges and reduce stay in unnecessarily restrictive settings. Method: A 3-month prospective study was performed on two PICUs (Brooklands and Willow), investigating delays to transfer from PICUs to open wards. Days and percentage of discharges was also examined. Following collection of the initial data cycle, Brooklands implemented a 'traffic light' tool to identify delays. Following implementation, the project was repeated one year later. Results: A total of 122 patients were analysed for delays in the transfer of care from PICU to acute open wards. Brooklands PICU demonstrated a prolonged delay to transfer of patients, prompting implementation of a delayed discharge tool, the 'traffic-light' system. Brooklands PICU subsequently demonstrated a statistically significant improvement in the days to transfer. Conclusions: This quality improvement project adds to the limited research base for delays in the transfer of PICU patients and is the first study to implement a delayed discharge tool within a PICU. Further research is required on the transfer of patients from PICUs, examining barriers for these delays and the impact of this on patients within PICU.

AimsThere is a developing body of research that suggests that there may be distinct categories of patients that can explain the relationship between psychosis and antisocial behaviours. Specifically, three pathways of offending, antisocial behaviour and psychosis have been described and there is an evolving empirical evidence base to suggest that these pathways are aetiologically distinct. Firstly, there is a pathway for early-start offenders, which have been identified as those with psychosis preceded by Conduct Disorder (SZ + CD). Secondly, a group that start to display antisocial behaviours in parallel to the onset of psychosis (SZ-AS). The third group involves those with a long history of a psychotic disorder and no history of antisocial behaviours, who will present to services following a first conviction for non-violent or violent crime (SZ). The authors hypothesise that each typology will utilise services differently throughout the clinical trajectory. This pilot study aimed to (i) examine the concurrent validity of the antisocial behaviour and psychosis typologies, and (ii) examine differences in the service utilisation patterns of patients between these groups.MethodsThe sample consisted of adult male patients admitted to low and medium secure forensic hospitals within the Northwest of England. A total of 90 patients were used.A categorisation checklist was developed, and the typology of patients determined from data collected from electronic health records. Data were collected on patient demographics, psychiatric diagnosis, aetiological factors, and service utilisation. Two researchers reviewed the data and determined the typology. Statistical analysis aimed to assess the difference in aetiological variables between the typologies and examine the relationship with how each typology utilised services.ResultsThis study provided further evidence of distinguishing characteristics emphasising typology heterogeneity.The CD-SZ group were more likely to have utilised mental health services <18 years (70%, p = 0.062), and to have used services preceding a diagnosis of psychosis (60%, p = 0.011). Following the onset of a psychotic disorder, the AS-SZ and SZ groups had a higher proportion that used general adult psychiatry services (p = 0.031), with CD-SZ coming in to contact with forensic psychiatry services and criminal justice services earlier and more frequently.ConclusionThis study demonstrates that each typology has a different clinical trajectory through mental health services. This provides further empirical evidence towards different clinical typologies and trajectories of individuals with psychosis and anti-social behaviour. Understanding more about how these typologies utilise services will enable clinicians to introduce interventions help develop effective management plans that address the distinct characteristics of each typology of offender with psychosis.

Our view of the last-scattering surface in the cosmic microwave background (CMB) is obscured by secondary anisotropies, sourced by scattering, extragalactic emission and gravitational processes between recombination and observation. Whilst it is established that non-Gaussianity from the correlation between the integrated-Sachs-Wolfe (ISW) effect and gravitational lensing can significantly bias primordial non-Gaussianity (PNG) searches, recent work by Hill (2018) has suggested that other combinations of secondary anisotropies can also produce significant biases. Building on that work, we use the WebSky and Sehgal et al.(2010) simulations to perform an extensive examination of possible biases to PNG measurements for the local, equilateral and orthogonal shapes. For a Planck-like CMB experiment, without foreground cleaning, we find significant biases from cosmic infrared background (CIB)-lensing and thermal Sunyaev-Zel'dovich (tSZ)-lensing bispectra for the local and orthogonal templates, and from CIB and tSZ bispectra for the equilateral template. For future experiments, such as the Simons Observatory, biases from correlations between the ISW effect and the tSZ and CIB will also become important. Finally we investigate whether foreground-cleaning techniques are able to suppress these biases sufficiently. We find that the majority of these biases are effectively suppressed by the internal-linear-combination method and the total bias to Planck-like and SO-like experiments is less than the \\(1\\,\\sigma\\) statistical error. However, the small total bias arises from the cancellation of several \\(1\\,\\sigma\\) biases for Planck-like experiments and \\(2\\,\\sigma\\) biases for SO-like. As this cancellation is likely sensitive to the precise modelling, to ensure robustness against these biases explicit removal methods should be used, likely at the cost of decreased constraining power.