Background: Risk assessment of sexual violence involves evidence based evaluation of the risks posed by sexual offenders. It informs risk management; the provision of treatment that reduces the risk of future sexual violence. Previous research has focused on assessment of the predictive accuracy of different risk assessment tools, as well as the identification of risk factors that are associated with recidivism. In contrast, the clinical practice of risk assessment is a research area that has been neglected. The aim of this thesis was to explore the practice of risk assessment in a specialist sex offender liaison service (SOLS). Particular attention was paid to the structured professional judgement method of risk assessment. Method: A systematic review of the literature identified psychological factors associated with sexual recidivism in adult male offenders. Study 1 employed a cohort quantitative design and aimed to ascertain whether risk judgements made by the SOLS were predicted by factors that were identified by the systematic review (and previously existing meta-analyses) as being evidence based. Ordinal logistic regression and linear regression analyses (N = 96) were used to investigate the hypothesised predictive associations between variables. Study 2 utilised a qualitative framework analysis (N = 31) and aimed to explore the views of users of SOLS risk assessments with respect to their practical utility. Results: The systematic review suggested that psychopathy and sexual deviance were supported as risk factors for sexual recidivism. Inconsistent results were found with respect to denial. Study 1 found that psychopathy, denial, and sexual preoccupation were significantly associated with risk judgement scores made by the SOLS, while sexual deviance, and problems with intimate relationships, were not. The best explanatory model accounted for only 40 per cent of the variance in risk judgement score. Study 2 revealed five major themes: informing risk management; confirming what was known and giving weight; understanding personality; treatment; and the usefulness and limitations of risk assessment.

The study answers the question: 'How can nurses' properly considered decisions relating to patient care be demonstrated?' Nurses in the United Kingdom have a professional requirement to demonstrate': the properly considered clinical decisions relating to patient care' (UKCC, 1994; NMC, 2002). However, their decisionmaking has been reported as complex and poorly understood, and apart from nursing records, little evidence exists to demonstrate their decisions. The development of the nurses' role as a decision-maker is traced from an origin in Nightingale's text (1860) through to the present day. This role is shaped by organisational, nursing and medical profession influences. Having established that nurses have a role as decision-makers, a conceptual framework is used to examine different explanations about the decision process, outcome, context and how decisions are made. Before undertaking fieldwork, a survey of nurses' decision-making in general medical and surgical wards was conducted. The findings were compared with the conceptual framework to generate questions and avenues for enquiry. An ethnographic study was undertaken in 1999 - 2000 in four general medical wards in two English provincial NHS Trusts with registered nurses (general). A model of decision-making was developed as a mid range theoretical explanation of how they made decisions. This involved a narrative based approach in which nurses generated an account (narrative) of knowing a patient and used this to identify needs. The patient was known in a narrative through three categories of information: nursing, management and medical. These categories were constructed through nurses' information seeking and processing using a tripartite conceptual lens. These facets correspond to different aspects of the nurse's role as a carer, care manager and medical assistant. The patient is known in three ways in a narrative, as a person to care for, an object to be managed, and as a medical case. An oral tradition surrounded its use, and nursing records were not central to decision-making. The narrative was used to make decisions and influence medical decisions. Once it was established how nurses made decisions, a method was developed to show how they could demonstrate their properly considered clinical decisions relating to patient care. This involved using the narrative based decision-making model as an analytical framework applied to nurse decision narratives. Narrative based decisionmaking offers a development of existing descriptive theoretical accounts and new explanations of some features of the decision process. This particularly includes the use of personal note sheets, the role of judgements and the cycle of communicating the narrative to nurses and its subsequent development as a process of developing an explanation of how the patient is known. Having addressed how nurses can demonstrate their properly considered clinical decisions relating to patient care, conclusions are drawn and implications explored in relation to practice, professional regulation, education and method. Recommendations include a challenge to the assumption about decision-making underpinning existing NMC guidance on recordkeeping, and the need to recognise diversity of decision-making practice across different nursing sub-groups. The narrative revealed nurses' ways of constructing knowing patients and rendering this visible. Nurses' not only have a duty, but also a need, to demonstrate decisions so that they can render visible what it is they are and do.

Adverse Childhood Experience Scores, more commonly known as ACE scores, have provided new insight into the effects of adverse events on longstanding health and chronic illnesses in adults. Evidence shows that individuals with history of ACEs have increased risk of developing multiple chronic illnesses with or without increased exposure to activities that are detrimental to health, i.e. tobacco, alcohol, or other drug use. Additionally, a history of ACEs significantly increases an individual’s likelihood of participating in behaviors that are detrimental to long-term health, including risky behaviors and resulting addiction issues. However, in most individuals with ACEs, their childhood experiences, or the extent of the experience, is not likely to be mentioned in casual conversation. By increasing knowledge on ACE scores and implementing scoring of all individuals possible, it would improve a physician’s ability to assess risk and health screening needs for a patient on a more individualized basis. The purpose of this study is to educate Bristol Family Medicine residents on the daily uses and clinical correlations provided by ACE scoring in an attempt to increase score documentation of future patients.We will begin by providing a short knowledge assessment about ACE scores to residents in the Bristol Family Medicine residency program. We will then give a detailed presentation on the usefulness and effectiveness of using ACE scores in clinical judgement and screening. Following the presentation, we will provide a similar knowledge assessment as well as a questionnaire to assess likelihood of residents to implement ACE scores in their current practice.

People are seeking health information from a wide variety of sources. The comprehensive information in clinical practice guidelines (CPGs) represents an excellent source of evidence based information which should be communicated to this audience. Currently, there is little research about how to write a version of a CPG that would be easily accessible to people and more information is needed to identify barriers and supports, and potential solutions to disseminate CPGs to this audience (i.e. patients and the public). This thesis represents a body of research consisting of four scientific papers with an overarching objective to understand and explore how CPGs and recommendations primarily developed and written for health care professionals can be disseminated to patients and the public. A CPG was developed using the rigorous methods of the GRADE approach; a randomised controlled trial was conducted to evaluate a format to disseminate synthesised evidence to patients and the public; a systematic review of the literature with a thematic and narrative synthesis of patient and public attitudes towards and awareness of CPGs was performed; and a qualitative description and content analysis of a sample of patients versions of CPGs was conducted. The studies found that people are interested in patient versions of CPGs for a variety of purposes, such as for decision making, as a tool to prepare for consultations with health care providers, and as advice for self-care management. However, barriers to their use may include lack of personalisation of information, negative attitudes towards guidelines as ways to restrict and control access to care, and lack of understanding of the recommendations and the evidence. A format to disseminate the evidence from a guideline is proposed, but future research should focus on strategies to personalise the information, to overcome the negative attitudes towards guidelines, and to communicate the recommendations and the evidence informing the recommendations. / Thesis / Doctor of Philosophy (PhD)

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No description available.

The 2008 World Health Report emphasises that we need “primary health care (PHC) now more than ever”. Competent primary health care providers who “put people first” are required in the front line in order to make a difference. The need for widely accessible, competent and caring professional nurses thus places expectations on training programmes and health services. In South Africa, a number of studies have been conducted on primary health care and methods of teaching clinical competence to nursing students (Truscott 2010; Magobe et al. 2010; Naledi et al. 2010) but not on the experiences of nursing students during PHC practice. The researcher observed that the emphasis on the positive, supportive and helpful experiences of nursing students in coping with challenges during their clinical practice was distinctly lacking. The objective of the study was to explore and describe the experiences of nursing students during the clinical practice in PHC settings. It was expected that this information will enable the researcher to formulate recommendations to support nursing students to cope with challenges during clinical practice in a PHC setting. A qualitative descriptive inquiry, with an appreciative approach was used. Five semi-structured focus group interviews were conducted to obtain data. The population comprised of 4th year nursing students who were selected using purposive sampling with the assistance of a mediator, namely the Head of the Department for PHC at a Nursing College. The sample size was determined by data saturation. Data analysis was carried out simultaneously with the collection of data. Fifteen main themes were identified during a consensus discussion between the researcher and the co-coder. The main findings related to the meaning students attached to being placed in a PHC clinic; positive, supportive and helpful experiences; how they can be supported and what help them cope irrespective of challenges they experienced. Conclusions were drawn which pertained to: placement in a PHC setting for clinical practice; positive, supportive and helpful experiences; support when placed at a PHC setting for clinical practice and coping measures when placed at a PHC setting for clinical practice; and recommendations were formulated for nursing education, nursing research and nursing practice that focused on supporting and empowering nursing students to cope with challenges experienced at a PHC setting. / MCur, North-West University, Potchefstroom Campus, 2015

The 2008 World Health Report emphasises that we need “primary health care (PHC) now more than ever”. Competent primary health care providers who “put people first” are required in the front line in order to make a difference. The need for widely accessible, competent and caring professional nurses thus places expectations on training programmes and health services. In South Africa, a number of studies have been conducted on primary health care and methods of teaching clinical competence to nursing students (Truscott 2010; Magobe et al. 2010; Naledi et al. 2010) but not on the experiences of nursing students during PHC practice. The researcher observed that the emphasis on the positive, supportive and helpful experiences of nursing students in coping with challenges during their clinical practice was distinctly lacking. The objective of the study was to explore and describe the experiences of nursing students during the clinical practice in PHC settings. It was expected that this information will enable the researcher to formulate recommendations to support nursing students to cope with challenges during clinical practice in a PHC setting. A qualitative descriptive inquiry, with an appreciative approach was used. Five semi-structured focus group interviews were conducted to obtain data. The population comprised of 4th year nursing students who were selected using purposive sampling with the assistance of a mediator, namely the Head of the Department for PHC at a Nursing College. The sample size was determined by data saturation. Data analysis was carried out simultaneously with the collection of data. Fifteen main themes were identified during a consensus discussion between the researcher and the co-coder. The main findings related to the meaning students attached to being placed in a PHC clinic; positive, supportive and helpful experiences; how they can be supported and what help them cope irrespective of challenges they experienced. Conclusions were drawn which pertained to: placement in a PHC setting for clinical practice; positive, supportive and helpful experiences; support when placed at a PHC setting for clinical practice and coping measures when placed at a PHC setting for clinical practice; and recommendations were formulated for nursing education, nursing research and nursing practice that focused on supporting and empowering nursing students to cope with challenges experienced at a PHC setting. / MCur, North-West University, Potchefstroom Campus, 2015

The idea of developing automated tools able to deal with the complexity of clinical information processing dates back to the late 60s: since then, there has been scope for improving medical care due to the rapid growth of medical knowledge, and the need to explore new ways of delivering this due to the shortage of physicians. Clinical decision support systems (CDSS) are able to aid in the acquisition of patient data and to suggest appropriate decisions on the basis of the data thus acquired. Many improvements are envisaged due to the adoption of such systems including: reduction of costs by faster diagnosis, reduction of unnecessary examinations, reduction of risk of adverse events and medication errors, increase in the available time for direct patient care, improved medications and examination prescriptions, improved patient satisfaction, and better compliance to gold-standard up-to-date clinical pathways and guidelines. Logistic regression is a widely used algorithm which frequently appears in medical literature for building clinical decision support systems: however, published studies frequently have not followed commonly recommended procedures for using logistic regression and substantial shortcomings in the reporting of logistic regression results have been noted. Published literature has often accepted conclusions from studies which have not addressed the appropriateness and accuracy of the statistical analyses and other methodological issues, leading to design flaws in those models and to possible inconsistencies in the novel clinical knowledge based on such results. The main objective of this interdisciplinary work is to design a sound framework for the development of clinical decision support systems. We propose a framework that supports the proper development of such systems, and in particular the underlying predictive models, identifying best practices for each stage of the model’s development. This framework is composed of a number of subsequent stages: 1) dataset preparation insures that appropriate variables are presented to the model in a consistent format, 2) the model construction stage builds the actual regression (or logistic regression) model determining its coefficients and selecting statistically significant variables; this phase is generally preceded by a pre-modelling stage during which model functional forms are hypothesized based on a priori knowledge 3) the further model validation stage investigates whether the model could suffer from overfitting, i.e., the model has a good accuracy on training data but significantly lower accuracy on unseen data, 4) the evaluation stage gives a measure of the predictive power of the model (making use of the ROC curve, which allows to evaluate the predictive power of the model without any assumptions on error costs, and possibly R2 from regressions), 5) misclassification analysis could suggest useful insights into determining where the model could be unreliable, 6) implementation stage. The proposed framework has been applied to three applications on different domains, with a view to improve previous research studies. The first developed model predicts mortality within 28 days of patients suffering from acute alcoholic hepatitis. The aim of this application is to build a new predictive model that can be used in clinical practice to identify patients at greatest risk of mortality in 28 days as they may benefit from aggressive intervention, and to monitor their progress while in hospital. A comparison generated by state of the art tools shows an improved predictive power, demonstrating how an appropriate variables inclusion may result in an overall better accuracy of the model, which increased by 25% following an appropriate variables selection process. The second proposed predictive model is designed to aid the diagnosis of dementia, as clinicians often experience difficulties in the diagnosis of dementia due to the intrinsic complexity of the process and lack of comprehensive diagnostic tools. The aim of this application is to improve on the performance of a recent application of Bayesian belief networks using an alternative approach based on logistic regression. The approach based on statistical variables selection outperformed the model which used variables selected by domain experts in previous studies. Obtained results outperform considered benchmarks by 15%. The third built model predicts the probability of experiencing a certain symptom among common side-effects in patients receiving chemotherapy. The newly developed model includes a pre-modelling stage (which was based on previous research studies) and a subsequent regression. The computed accuracy of results (computed on a daily basis for each cycle of therapy) shows that the newly proposed approach has increased its predictive power by 19% when compared to the previously developed model: this has been obtained by an appropriate usage of available a priori knowledge to pre-model the functional forms. As shown by the proposed applications, different aspects of CDSS development are subject to substantial improvements: the application of the proposed framework to different domains leads to more accurate models than the existing state-of-the-art proposals. The developed framework is capable of helping researchers to identify and overcome possible pitfalls in their ongoing research works, by providing them with best practices for each step of the development process. An impact on the development of future clinical decision support systems is envisaged: the usage of an appropriate procedure in model development will produce more reliable and accurate systems, and will have a positive impact on the newly produced medical knowledge which may eventually be included in standard clinical practice.

Objectives. To examine the clinical effectiveness of guided self-help (GSH) for anxiety and depression in routine clinical practice, and the role of self-efficacy, therapeutic alliance and socio-economic status in influencing that effectiveness. Design. A within-subjects repeated measures design in which participants served as their own controls by completing questionnaires across a control period prior to GSH intervention, then again at post-intervention and 3- and 6-month follow-up. Methods. GSH participants completed outcome measures for mental health (HADS) and work/social functioning (WSAS). Factors explored by regression as possible predictors of effectiveness were self-efficacy, therapeutic alliance and socioeconomic status. Results. Sixty people completed GSH, with analyses indicating effectiveness of GSH in significantly improving mental health and social functioning at post-treatment and 3-month follow-up, but not at 6-month follow-up. Effectiveness was also indicated under intent-to-treat conditions (n = 97) with medium effect sizes (≈ 0.6) for each outcome measure at post-treatment. Improvement in mental health was predicted by lower self-efficacy and greater therapeutic alliance. Completers of the intervention had significantly higher socio-economic status than non-completers. Conclusions. The current study has suggested effectiveness of GSH in routine clinical practice across different primary care services at post-treatment, but with less evidence of this at follow-up. Effectiveness has been highlighted to be influenced by self-efficacy and therapeutic alliance, suggesting the importance of considering non-specific factors when patients access GSH in primary care. This study underlines the need for further research exploring longer-term clinical effectiveness and examining for whom GSH works in order to constructively inform future evidence-based practice.