adams dave allen nee ryan patricia baldwin clive ball ... · delamere sandra mooney brona delaney...

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Adams Dave Allen nee Ryan Patricia Arkins Brigid Autar Ricky Baldwin Clive Ball Elaine C. Barnes Susie Barron Carol – concurrent paper Barron Carol – poster presentation Clynes Mary Baxter Rosario Beal Margaret W. Beeman Pamela B. Paulanka Betty J. Begley Cecily M Begley Thelma Boyle Thomasina Brady Vivienne Brady Nevin Caroline Brennan Anne Gordon Evelyn Brennan Damien Brennan Miriam Kelly Marcella Mee Lorraine Bride Ann


Brophy Sarah Jane Büchner Claire Bulfin Susan Burton Aileen Butchko Kerr Rita McBride Nancy Butler Michelle - Nurse's Role Butler Michelle - Care of Older Persons Byrne Anne S. Byrne Evelyn – concurrent paper Byrne Evelyn - poster Byrne Geraldine Byrne Gobnait – concurrent paper Byrne Gobnait – poster McCabe Catherine Fahey-Mc McCarthy Elizabeth Corry Rita Glacken Michele Macgregor Caitriona Adams Audrey Cannon Catherine Cannon Mary Cardwell Pauline Carey Cliona Carey Eileen Carter Bernie Casey Dympna


Casey Dympna Murphy Kathy Cerruti Dellert Jane Gasalberti Denise Chamley Carol Anne Carson Elizabeth Pauline Clarke Jean Clynes Mary Coffey Alice Coleman Claire Coleman Deborah Coleman Laniece Collins Rita Condell Sarah Conteh Magnus Lunn Cora Conway Edel Cooley Clodagh Corbett Andrea Corcoran Philip Corroon Anne-Marie Cowman Seamus Coyne Imelda Conlon Joy Cronin Gerard Cronin Gerard Cronin Camille


Crow Jayne Jones Shirley Culleton-Quinn Elizabeth Culley Lorraine Curtis Elizabeth A Day Mary Rose – concurrent paper Day Mary Rose – poster Deady Rick Delamere Sandra Mooney Brona Delaney Duffy Anita Dempsey Jennifer Dempsey Laura Denny Margaret Devane Declan Devine Maurice Dowling Maura Doyle Carmel Doyle Carmel Murphy Maryanne Drennan Jonathan – concurrent paper Drennan Jonathan - poster Drennan Jonathan Byrne Anne S. Drummond Elaine Duffy Mel


Dunnion Mary Kelly Billy Egan Suzanne Ellis Mairghread JH Ellis Roger Evans William Nicholl Honor Farrell Miriam Feely Malachy Flood Anne – concurrent paper Flood Anne - poster Gale Eve Hegarty John Gallagher Pamela Gallagher Patrick Gibbons-Twomey Colette - concurrent paper Cannon Catherine Flood Anne Gibbons-Twomey Colette – poster Gidman Janice Gillen Ailsa Gilrane-Mc Garry Ursula Glacken Michele Higgins Agnes Gleeson Madeline Glover Donna Godfrey Mary


Gonc Vida Goonan Noreen Gordon Evelyn Gormley Sandra Graham Margaret Cassidy Irene Tuohy Dympna Griffiths Colin McCabe Catherine Hackett Myles Hall Jennifer Hardie Anne M. Hardy Steve Harnett Alison Harrison Nigel Lyons Christina Hartnett Liz Hatamleh Reem Haycock-Stuart Elaine Hayden Deborah Hayes Claire Healy Denise Healy Maria Hegarty Josephine Burton Aileen Higgins Agnes Hindley Carol


Hiney Geraldine Hourican Susan Howe Rachel Howlin Frances Hughes Christine Hutchings Maggie Jansen Pat Jean-Baptiste Giovannie Jones Jean Hardie Anne Robertson Alison Joyce Pauline Cowman Seamus Kane Raphaela Kavanagh McBride Louise Keane Noreen Kearns Alan J Keenan Iain Crow Jayne Keenan Paul Kelly Mary Keogh Johannes Kielty Lucy A. Kiger Alice Kilcullen Nora Kinsella Margaret


Kothari Áine


E-/BLENDED LEARNING IN NURSE/MIDWIFERY EDUCATION

Dr Winifred Eboh PhD, BSc, RM, RGN (Lecturer); Dr Sheelagh Martindale PhD, MSc, RGN (Lecturer); Dave Adams MSc, RGN, RMN (Lecturer); Neil Johnson MSc, RGN (Lecturer); Elaine Mowatt, M Ed, RGN (Lecturer). The Robert Gordon University School of Nursing and Midwifery Faculty of Health and Social Care Garthdee Campus Garthdee Road ABERDEEN AB10 7QG An ever changing and technically advancing society (Mowforth et al., 2005) has placed demands on nurses and midwives to embrace these changes in their practice to meet the needs of a more knowledgeable and expectant public. For these expectations to be realised within clinical settings, nursing and midwifery educators are equally challenged to train professionals who are up to the challenge. As nurse lecturers based at a school of nursing and midwifery which has two student intakes a year with numbers ranging from 200 to 300 per intake. Delivering a modular course can present countless challenges demanding more innovative ways of teaching that goes beyond face to face class room contacts. To that end the principle author has received a Winston Churchill Travel fellowship to visit centres in Europe that use e-/blended learning media to deliver health related subjects to diverse healthcare professionals including nurses and midwives. It is anticipated that the module team will use these two media (as well as traditional methods) to deliver specific courses within our school which will address certain long-term expectations (Hovenga, 2004); these include:

• Teaching modules to large class sizes undertaking different branches of nursing e.g. adult, children, mental health and midwifery;

• Providing the right level of education in accordance with the QAA standards for diploma and degree nurse education to students with entry qualifications ranging from PhD to Standard/O levels; school leavers to mature students returning to education after bringing up their children;

• Generating interest in traditional academic subjects e.g. research, anatomy and physiology and skill-based subjects including cardiac resuscitation and the carrying out of observations like blood pressure, temperature, pulse and respiration amongst many others.

This paper will present the findings from the fact finding European trip and module development programmes. References: Hovenga, E.J.S. (2004) Globalisation of Health and medical informatics education – what are the issues? International Journal of Medical Informatics 73 101-109 Mowforth, G., Harrison, J., Morris, M. (2005) An investigation into adult nursing students’ experience of the relevance and application of behavioural sciences (biology psychology and sociology) across two different curricula Nurse Education Today 25 41-48


Quality Assurance Agency for Higher Education http://www.qaa.ac.uk (accessed 18th April 2005).

http://www.qaa.ac.uk/


Transactional Analysis and the Assessment of Clinical Practice. Ms Patricia Allen nee Ryan RMN, DipN, MSc (Inter-professional Health and Welfare Studies), PGCE (A), Ed.D. (in progress) Senior Lecturer 27 Manor Avenue Caterham Surrey CR3 6AP England [email protected] Since the Fitness for Practice report (UKCC 1999) and Making a Difference directives (Dept of Health 1999) the assessment of clinical practice in nursing is purported to be as important as the assessment of the theoretical aspects of nursing programmes with a professed 50% theory, 50% practice split. However, despite the message of the philosophical value of practice there are in reality, major differences between how clinical practice and theoretical work is assessed. In most Higher Education Institutions that provide nurse education programmes there can be up to five stages where theoretical assignments are scrutinised and verified. This will can include first marking by a qualified teacher, sometimes second marking, moderation, an internal department or school panel and the external examiners as well. In the practice assessment process the attention to detail, fairness and parity are sadly lacking and whilst it is acknowledged that this may not be deliberate, it is nevertheless true. In my experience as a practitioner and a lecturer, busy clinicians, who have to juggle competing priorities in a less than ideal situation, often undertake practice assessment. I recently heard of a student who had to complete their own summative practice assessment as her mentor, the manager of a busy acute admission ward, had become unexpectedly unavailable due to several unforeseen admissions to the unit. I wonder how unusual this is…. Students report relationships with mentors are unpredictable, as is the mentor’s interest, their level of clinical skills and experience. Mentors report that students can be equally diverse and also have variable levels of motivation, intelligence and skills. In addition to these unsurprising differences there are also other factor to consider including race, culture, gender, age, and religion to name a few. What then is the answer to the problem of providing an equally stringent approach to the assessment of clinical practice and theoretical work? My research will offer some insights into this dilemma by seeking the views of both the students and their mentors alike using an action research methodology. It will seek to discover a way forward to ensure an equal relationship between the assessment of theory and practice and consider some of the methods used by other health professional groups to assess practice will be examined to establish if there are lessons to be learned from them.

mailto:[email protected]


Banning M (2004) The use of structured assessments, practical skills and performance indicators to assess the ability of pre-registration nursing students' to apply the principles of pharmacology and therapeutics to the medication management needs of patients. Nurse Education in Practice Jun 4(2): 100-6 Department of Health (1999) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. HMSO: London United Kingdom Central Council (1999) Fitness for Practice: Report of the UKCC Commission for Nursing and Midwifery Education (Peach Report). London: United Kingdom Central Council for Nursing, Midwifery and Health Visiting.

http://web11.epnet.com/searchpost.asp?tb=1&_ua=bo+R%5F+lst+Patient++Assessment+db+cinmesh+fst+Outcome++Assessment+shn+1+dt+assessment+bt+assessment+do+R%5F+nr+239+263A&_ug=sid+6D534431%2D630F%2D4468%2D9260%2D4683A01886CE%40sessionmgr5+dbs+cin20http://web11.epnet.com/searchpost.asp?tb=1&_ua=bo+R%5F+lst+Patient++Assessment+db+cinmesh+fst+Outcome++Assessment+shn+1+dt+assessment+bt+assessment+do+R%5F+nr+239+263A&_ug=sid+6D534431%2D630F%2D4468%2D9260%2D4683A01886CE%40sessionmgr5+dbs+cin20


The Therapeutic Value of Mixed Sex and Female Acute Admission Wards in Psychiatry Brigid Arkins RPN, MSc Lecturer School of Nursing and Midwifery, Brookfield Site,University College Cork, Cork Main Study Aim The main aim of the study is to ascertain if the female acute admission ward is more therapeutic than mixed sex acute admission wards Introduction There has been very little research into the therapeutic value of mixed and female acute admission wards. The research conducted is preliminary to this area. Since the 1990’s there has been many concerns raised about the safety of women on mixed sex wards. Some studies conducted during this period stated that women prefer mixed sex wards as they are more therapeutic. Whilst other studies highlighted that women suffered from sexual harassment and assaults on acute admission wards. The research took place in a London mental health hospital that had 4 mixed sex acute admission wards and 1 female acute admission ward. Methodology Non experimental research Ex Post Facto (correlation) Qualitative descriptive Data collection Ward Atmosphere Scale (Moo’s (1996) was given to 42 staff from different discipline 31 female patients were interviewed 10 staff from different disciplines partook in the semi structured interviews Data analysis Statistical analysis through SPSS Thematic analysis Results • The ability develop therapeutic relationships was enhanced on the female ward. • Women felt safer on the female ward • Women felt frightened on both mixed sex and female wards • Women’s ward preference is context related • More women on the female ward felt that the admission was helping their recovery References Clearly M & Warren R. (1998) An exploratory investigation into women’s experience in a mixed sex psychiatric admission unit Australian and New Zealand Journal of Mental Health Nursing 7, pg. 33-40 Kettles A. (1997) Survey of patient’s preferences for mixed or single sex wards. Journal of Psychiatric and Mental Health Nursing 4 pg. 56 - 57 Mind (2000) Environmentally Friendly? Patients Views of Conditions on Psychiatric Wards, London Mind Publications


Moo’s RH (1996) Ward atmosphere Scale Sampler set Annual Test Booklets and Scoring Key. Development, Application and Research. A Social Climate scale. 3rd ED. California, Mind Garden


ADVANCING NURSING PRACTICE IN THE MANAGEMENT OF DEEP VEIN THROMBOSIS (DVT). DEVELOPMENT, APPLICATION AND EVALUATION OF THE AUTAR DVT RISK ASSESSMENT SCALE

SUBMITTED BY RICKY AUTAR, PhD, MSc, BA (HONS) DIP N, RGN, RMN, CERT ED, RNT PRINCIPAL LECTURER DE MONTFORT UNIVERSITY CHARLES FREARS CAMPUS 266 LONDON ROAD LEICESTER LE2 1RQ ENGLAND EMAIL: [email protected] PHONE; +44 116 201 3945



Advancing nursing practice in the management of Deep vein Thrombosis (DVT). Development application and evaluation of the Autar DVT Risk Assessment Scale.

ABSTRACT Deep Vein Thrombosis (DVT) is a disease of hospitalised patients and poses a serious threat to their recovery. DVT is most preventable and venous thromboprophylaxis consensus groups recommend that patients be risk assessed so that prophylaxis can be tailored to individuals.In the spirit of such recommendation, the Autar DVT risk assessment scale was developed (Autar 1994;1996a;1996b). Founded on Virchow’s triad in the genesis of DVT and comprising seven subscales of thrombogenic risk factors, the DVT risk calculator was validated on a small orthopaedic population. Although positive outcomes were reported, the small yet well formed study did not permit generalisability of findings and wider application across the boundaries of practice. Further to revalidate the DVT scale for its universal application and finding and generalisability , 150 patients were randomly recruited from Orthopaedic, Surgical and Medical specialities. DVT is a continuing problem and therefore all patients were followed up for a minimum of three months after discharge from hospital. Interestingly, 39 per cent of the patients with DVT (11/28) developed DVT at home. Five reproducibility studies on the orthopaedic, medical and surgical directorates achieved kappa values ranging 0.88 to 0.95, confirming the consistency of the instrument. A Receiver Operating Characteristic (ROC) curve was constructed to determine the optimal predictive accuracy of the DVT scale and a cutoff score of 11 yielded approximately 70 per cent sensitivity. Data from two patients, who could not be followed up, were excluded for evaluation of the predictive accuracy of the DVT scale. Overall, 115 patients out of the 148 (78%) were correctly classified and predicted. This predictive accuracy of the DVT risk calculator was an underestimation of its efficacy as it was masked by the administration of prophylaxis to a large number of high risk patients. As a result of the findings and the availability of new and compelling research evidence , the Autar DVT scale was revisited and revised for maximisation of its predictive validity (Autar 2002; Autar 2003).

INTRODUCTION

Venous Thromboembolism (VTE) is a spectrum of disease ranging from Deep Vein Thrombosis (DVT) to Pulmonary Embolism (PE), a potentially fatal condition. Fifty percent of patients with initial DVT go on to develop Post- Thrombotic Syndrome (PTS) a chronic disabling condition (Strandness et al, 1983; Prandoni et al, 1996). VTE seriously damages health and is a silent killer (Autar 1996a).The scale of this problem is highlighted in table1 by the risk level according to patient group.


Table1: Incidence of DVT by patient group Speciality DVT% ( Weighted mean) General surgery 25 Orthopaedic surgery 45-51 Urology 9-32 Gynaecological surgery 14-22 Neurosurgery including strokes 22-56 Multiple trauma 50 General medicine 17 Data: International Consensus Statements (1997; 2002).

BACKGROUND VTE is most preventable (Kakkar & Stringer 1990) and routine prophylaxis saves between 4000-8000 lives annually (Hull et al, 1990). Essentially, primary and secondary prophylaxes are the two approaches to VTE management. Primary prophylaxis is the proactive prevention of DVT. This is achieved by risk assessment and the stratification of such risk followed by the implementation of the most effective prophylaxis. On the other hand, secondary prophylaxis is reactive to the treatment of DVT, directed at preventing PE and PTS (Clagett et al, 1992). Notably, primary prophylaxis is superior to secondary prophylaxis, both in terms of cost and quality of life perspectives (Anderson and Wheeler, 1995). In the light of abundancy of evidence overwhelmingly supportive of the efficacy of prophylaxis, VTE consensus groups vigorously recommend risk stratification of patients followed by a tailor made prophylaxis for individual based on the category of risk(Table 2). Table2: VTE consensus groups.

• National Institutes of Health (NIH) 1986 • European Consensus statement 1991 • Scottish Intercollegiate Guidelines Network (SIGN) 1995 • American College of Chest Physicians (ACCP) 1995 • THRiFT 1992/1998 • International Consensus Statements 1997/2001

VTE risk assessment, stratification and management A framework for a systematic and comprehensive DVT risk stratification and venous thromboprophylaxis management is outlined in flow chart below:


VTE risk management Aim:to prevent DVT, PE, PTS ↓ Identify patient related risk factor (s) ↓ Identify patient condition related risk factor(s) ↓ Stratify patient onto one of the three related risk groups ↓ ↓ ↓ Low Moderate High ↓ Is pharmacological prophylaxis contra-indicated? ↓ ↓ Yes No ↓ ↓ Mechanical prophylaxis Pharmacological prophylaxis GCS LDUH IPC LMWH ↓ Outcome:to prevent DVT, PE, PTS Clinical risk assessment and stratification identify patients into one of the three risk categories which ultimately facilitate the implementation of the appropriate interventions (THRiFT, 1998). Risk stratification involves the cumulative consideration of the patient’s related risk factors with their condition related risk factor(s), which calculate the overall category of risk (Anderson and wheeler 1995; Autar, 1998). A plethora of prognostic indexes have been formulated to identify patients at risk of DVT (Table 3). Table 3: Prognostic indices

*Nicolaides & Irving 1975 *Clayton et al 1976 *Rakoczi et al 1978 *Crandon et al 1980 *Lowe et al 1982 *Melbring & Dahlgren 1983 *Sue-Ling et al 1986 *Janssen et al 1987 *Rocha et al 1988


All of the indexes combined clinical risk factors and fiddly laboratory procedures to arrive at some equations for identifying DVT risk. However, the equations are forbiddingly complex to work out and reliance on non standardised laboratory results delayed prompt risk assessment and explained why the prognostic indexes were not widely and favourably implemented (Gallus, 1989). A risk assessment tool is one that is easy to use and modelled on simple proven clinical risk factors are more likely to be widely applied (Ruckley 1985). It is within this guided philosophy that the Autar DVT scale (1994; 1996b was developed.(Figure 1).


Figure 1: AUTAR DVT RISK ASSESSMENT SCALE (1994; 1996) Name: Unit No: Ward:

Age: Type of admission: Diagnosis

AGE SPECIFIC GROUP (years) score 10-30 0 31-40 1 41-50 2 51-60 3 61+ 4

BUILD / BODY MASS INDEX (BMI) Wt(kg/ Ht (m)2 Build BMI score Underweight 16-18 0 Average/ Desirable 20-25 1 Overweight 26-30 2 Obese 31-40 3 Very obese (morbid) 41+ 4

MOBILITY score Ambulant 0 Limited (uses aids, self) 1 Very limited (needs helps) 2 Chair bound 3 Complete bed rest 4

SPECIAL RISK CATEGORY score Oral Contraceptives: 20-35 years 1 35+ years 2 Pregnancy/ Puerperium 3

TRAUMA RISK CATEGORY Score item(s) only preoperatively. score Head injury 1 Chest injury 1 Spinal injury 2 Pelvic injury 3 Lower limb injury 4

SURGICAL INTERVENTION: Score only one appropriate surgical intervention. score Minor surgery < 30 mins 1 Planned major surgery 2 Emergency major surgery 3 Thoracic 3 Abdominal 3 Urological 3 Neurosurgical 3 Orthopaedic (below waist) 4

HIGH RISK DISEASES: Score the appropriate item(s) score Ulcerative colitis 1 Anaemia: Sickle Cell 2 Haemolytic 2 Polycythaemia 2 Chronic heart disease 3 Myocardial infarction 4 Malignancy 5 Varicose veins 6 Cerebrovascular accident 6 Previous DVT 7

ASSESSMENT PROTOCOL Score range Risk Categories ≤ 6 No risk 7-10 Low risk 11-14 Moderate risk ≥ 15 High risk SCORING: Identify appropriate items, add and record daily

Assessor Date Score


Founded on Virchow’s triad and the fibrinolytic body system, in the genesis of VTE, the Autar DVT scale comprised the following seven subscales:

1. Age Specific group 2. Build/ Body Mass Index (BMI) 3. Mobility 4. Special Risk Category 5. Trauma 6. Surgery 7. High risk diseases

After an initial pilot study, the DVT risk assessment tool was evaluated on 21 patients on a Trauma/ Orthopaedic unit. Seven days data collected on each of the 21 patients to validate the sensitivity, specificity and consistency of the DVT scale, yielded as much data for analysis as what would have been collected on 147 patients being singly risk assessed within 24 hours of admission. Analysis of data gathered achieved 100% sensitivity, 81% specificity and a value of r at 0.98 for consistency (Autar 1996b). However, the external validity in terms of generalisability of the findings is questionable; on account of sample size and limited representation of the populations in the study. Since its development and application, the Autar DVT scale has been the subject of ongoing scrutiny and evaluation (Autar 1994; Autar 1996; Autar 1998).Due to the evolving nature of medicine, systematic reviews, new evidence derived from robust research findings and consensus statements published from 1991-2001, it is imperative for any new tool to be modified in order to reflect the new findings to guide best practice. As a result, the Autar DVT scale was revisited and revalidated as a doctoral initiative.

OBJECTIVE OF STUDY The objective of the study was to revalidate the Autar DVT scale for its predictive validity, reliability and practical application. Available data were utilised to determine the current protocol, in relation to venous prophylaxis.

METHOD It was essentially a quantitative and longitudinal study. An apriori power analysis was undertaken to determine a medium effect sample size. Statistical sampling package G* Power (Erdfelder et al 1996) was applied and Cramer’s V statistic selected to calculate the power of x2. Choosing the conventional alpha input of 0.05, a minimum considered acceptable power (1- ß) of 0.80 as default, G* Power calculated a sample of 149 patients required for the study. As a result, 50 in-patients were randomly recruited from each of the three clinical specialities: orthopaedic/trauma, general surgery and the medical directorates. The choice of the three specialities enables the examination of the problem of VTE in the high risk patient groups as in surgery and on the medical unit where a weighted mean of 17 % of DVT were reported (International Consensus statement, 1977). Table 4 illustrates the variability of the risk categories within the sample


Table 4: Sample representation of the risk categories.

Risk categories Number of patients % High 19 13 Moderate 37 25 Low 51 34 No risk 43 28 Total 150 100

All adult patients over the age of 18 were randomly recruited; irrespective of gender as sex difference is no respecter of DVT, unless additional risk factors such as HRT and oral contraceptives are present. Patients admitted with current DVT and receiving active treatment for the condition were excluded in order to obviate any bias outcome, in relation to the effectiveness and predictive validity of the DVT scale.

DATA COLLECTION

The 150 patients were risk assessed for DVT within 24 hours of admission. The choice of risk assessment within 24 hours was considered timely for optimal predictive accuracy of the DVT scale, when the patients are deemed to be most vulnerable due to the acute nature of their condition or surgical intervention, with accompanying fibrinolytic shutdown (Merli & Martinez, 1987: Kakkar & Stringer, 1990). Elective patients undergoing surgery were also risk assessed within the 24 hours defined time frame, but immediately after their surgical intervention, when both hypercoagulable state and venous stasis, favouring thrombi formation are at their peak (Nicolaides 1990).However, elective surgical patients who could not be risk assessment within the 24 hours defined time frame from admission, due to postponed or delayed surgery, were excluded from the study. Further to evaluate the DVT scale for its practical utility and application, a Likert type postal questionnaire was applied to the users of the DVT scale. The questionnaire comprised 29 items formulated at evaluating the appropriateness and clarity of each the variables of the seven subscales. A response rate of 88% (22/25) was recorded.

DATA ANALYSIS AND RESULTS

Reliability of the DVT scale

To establish the consistency of the DVT scale, data rated independently and

simultaneously by instructed paired registered nurses on the 150 patients were

computed. Estimates of reliability computed by different procedures for the same

instrument are not identical (Polit, 1996) and total percentage agreement (T %), kappa

statistic (k) and Intra-class Correlation Coefficients (ICC) were applied.

Data on the 150 patients that estimated the T% agreement, were converted into the

four nominal categories of no risk, low moderate and high risk


As the number of observation recorded for each subject was the same, Intra-class

Correlation Coefficients (ICCs) were also computed for all the five clinical areas. ICC

estimates the average among all possible pairs of observation (Bland & Altman,

1996). Paired observation data used to estimate the T% agreement and k values were

also computed to estimate the ICCs on the five wards, using SPSS (version 11) via

statistic pull down and selection of intra-class correlation coefficient.

The T (%) agreement ranging between 85-98%, kappa values within 0.88- 0.95 and

ICCs values of .94-.99 confirmed the reliability of the DVT scale.

Predictive accuracy of the Autar DVT scale

Patients were closely monitored for DVT throughout inpatient stay and for three

months beyond. Unavoidably, data from 2 of the 150 patients were excluded from the

analysis as it was not possible to make contact with them during the follow up period.

The gold standard for DVT was defined as patients with confirmed diagnosis of DVT,

treated by secondary anticoagulant therapy. Twenty-eight such subjects (19%) met the

gold standard (Table 5) and patients admitted primarily for anticoagulant therapy for

DVT were not included in the study.

Table 5: Prevalence of DVT on the three clinical specialities

Speciality No of patients No of DVT %

Orthopaedic Trauma 50 8 16 Medical 50 12 24 Surgical 48 8 17 Total 148 28 19

The distribution of patients with and without DVT as predicted by the absolute cutoff

score of 15≥ is illustrated in the contingency table 6.

Table 6: Distribution of patients with without DVT by absolute scores.

DVT present DVT absent Total

Score 15 ≥ A 7 TP B 12 FP 19 Score ≤ 14 C 21FN D 108 TN 129 Total 28 (19%) 120 148

True positives (TP) are those who are predicted positive and have DVT.7 patients

were correctly predicted as true positive. False positives (FP) are those incorrectly

predicted to have DVT but did not: 12 FP were recorded. 108 patients were correctly


predicted negative for the disease are true negatives (TN). False negatives are

incorrectly those predicted negative for DVT (TN): 21 FN were recorded.

Test accuracy is defined as the number of true positive and true negative divided by

the number of patients studied (Wheeler et al, 1994). 78 % of patients (7TP+108 TN/

148) were accurately recorded. 78 % of those predicted negative that do not have

DVT. However, the administration of venous thromboprophylaxis masked the

predictive accuracy of the DVT scale, as 50% of patients in the study were recipient

of some known form of primary venous thromboprophylaxis.

DISCUSSION & CONCLUSION

As new evidence becomes available, it is mandatory to make the appropriate changes

to guide and inform clinical practice (Sackett et al, 1996). In the light of the results

and the new evidence, the following changes to the DVT subscales were made (figure

2) and rationales for such recommendations highlighted. The recommendations relate

specifically to some of the subscales, notably the age specific group, special risk

category, the surgical intervention category and some of the variables in the high risk

disease subscale.


AUTAR DVT RISK ASSESSMENT SCALE revisited: Figure2 Name: Unit No: Ward:

Age: Type of admission: Diagnosis

AGE SPECIFIC GROUP (years) score

10-30 0 31-40 1 41-50 2 51-60 3 61-70 4 71+ 5

BUILD / BODY MASS INDEX (BMI) Wt(kg/ Ht (m)2 Build BMI score Underweight 16-18 0 Average/ Desirable 20-25 1 Overweight 26-30 2 Obese 31-40 3 Very obese (morbid) 41+ 4

MOBILITY score

Ambulant 0 Limited (uses aids, self) 1 Very limited (needs helps) 2 Chair bound 3 Complete bed rest 4

SPECIAL RISK CATEGORY score Oral Contraceptives: 20-35 years 1 35+ years 2 Hormone replacement therapy 2 Pregnancy/ puerperium 3 Thrombophilia 4

TRAUMA RISK CATEGORY

Score item(s) only preoperatively. score Head injury 1 Chest injury 1 Spinal injury 2 Pelvic injury 3 Lower limb injury 4

SURGICAL INTERVENTION: Score only one appropriate surgical intervention. score Minor surgery < 30 mins 1 Planned major surgery 2 Emergency major surgery 3 Thoracic 3 Gynaecological 3 Abdominal 3 Urological 3 Neurosurgical 3 Orthopaedic (below waist) 4

CURRENT HIGH RISK DISEASES: Score the appropriate item(s) score Ulcerative colitis 1 Polycythaemia 2 Varicose veins 3 Chronic heart disease 3 Acute myocardial infarction 4 Malignancy (active cancer) 5 Cerebrovascular accident 6 Previous DVT 7

ASSESSMENT INSTRUCTION Complete within 24 hours of admission Scoring: Ring out the appropriate item(s) from each box, add score and record total below; Total score: Assessor: Date:

ASSESSMENT PROTOCOL

Score range Risk categories ≤ 10 Low risk 11-14 Moderate risk 15 ≥ High risk Please record any other clinical observations that may supplement this DVT risk assessment.

VENOUS THROMBOPROPHYLAXIS

Low risk: Ambulation+ Graduated Compression Stockings. Moderate risk: Graduated Compression stockings+ Heparin + Intermittent Pneumatic Compression Stockings. High risk: Graduated Compression Stockings+ Heparin+ Intermittent Pneumatic Compression. International Consensus Group recommendation, 2001 © R Autar, 2002.


Age Specific group

There is a linear and strong correlation between advancing age and the development

of DVT (Nordstrum et al, 1992). Post mortem and clinical studies have demonstrated

that the frequency of DVT increases exponentially with age (Gibbs, 1957; Rosendall,

1997).

A DVT rise of 20 per cent is reported in the 40-60 year old patients. This doubles

between the age of 60 and 70 years and in patients over 70 the figure trebles (Borrow

& Goldson, 1981; Caprini & Natonson, 1989). Older people in the 70s and 80s now

comprise two thirds of all the patients in acute setting (DOH, 2001) and 328 recorded

cases of DVT were reported for the 70s and 80s, compared to only 100 per 1000 for

65-69 age group(OPCS 1990).

In the age specific subscale, the 51-60 and 61+ age groups were assigned risk scores

of 3 and 4 respectively. Relative to the incidence of DVT that rises sharply in the

different age groups, the elderly patients in the 70-80 age groups are recognised as the

highest risk group (Anderson & Wheeler, 1995) and accordingly assigned a relative

risk score of 5.

Special risk category

(HRT)

At the time of the development, application and evaluation of the Autar DVT scale

(1994) there were insufficient and inconclusive data available supporting the causal

relationship between DVT and HRT (RCOG, 1995). It was noted that most women

receiving HRT had other risk factors, particularly age or undergoing gynaecological

surgery ( Notelovitz & Ware). 1982. Carter (1992) also found no association between

DVT and HRT. It was held that the lower dose of oestrogen in HRT than oral

contraception and their smaller effect on haemostasis in comparison carries little or no

risk. Since, three studies published in 1996 (Jick et al, 1996, Daly et al, 1996 and

Grodstein et al, 1996) have all confirmed that there is a 2-4 fold increase in DVT both

in oestrogen only and combined oestrogen / progestogen preparations.

Most recently, a randomised controlled trial (Lowe et al, 2000) confirmed a two to

fourfold increase of DVT in women taking HRT.


There is now compelling evidence that a causal relationship between HRT and DVT

exists. HRT is now a new addition to the special risk hypercoagulability subscale and

is assigned a risk score of 2.

Thrombophilia

Hereditary hypercoaguable states are associated with an increased risk of thrombosis

(Shafer, 1985).The number of hypercoaguable states is still growing but the nine that

have been confirmed and classified as

Thrombophilia or Hereditary Thrombotic Diseases (HTD) are listed below:

• Protein C deficiency

• Protein S deficiency

• Antithrombin III deficiency

• Plasminogen deficiency

• Dysfibrinogenia

• Tissue Plasminogen Activator deficiency (t-PA).

• Plasminogen Activator Inhibitor excess (PAI).

• Heparin cofactor II

• Factor V Leiden

Of these hypercoaguable states listed above, Protein C (10%), Protein S (12%) and

Antithrombin III deficiencies (3%) are most common (Cooper, 1994). Factor V

Leiden is an inherited mutation in the gene coding for Factor V and accounts for

about 5 % of the white population. It causes activated protein C resistance (APCR)

resulting in an increased susceptibility to develop DVT (Vandenbroucke et al, 1996).

90-95 per cent of patients with thrombophilia present with DVT (Marlar &

Mastovich, 1990). Proportional to the magnitude of the problem, thrombophilia is

assigned a risk score of 4 in the special risk subscale.

Surgical intervention category

The questionnaire survey reveals that clarification of several variables would enhance

the practical application and predictive accuracy of the DVT scale.


Emergency major surgery carries a DVT risk of 2.7% compared to 0.2 to2.0% for

elective major surgery (Coon, 1976). In order to highlight the difference in risk, major

surgery has been renamed “Elective major surgery”.

Similarly, the variable orthopaedic surgery has been redefined as below “waist

orthopaedic surgery”, to explicitly reflect the high risk with orthopaedic procedures

such as total hip and knee arthroplasties and repair of fractured femur, tibia and fibula.

High risk diseases subscale

New findings of the high risk diseases in the causation of DVT, directly and

indirectly, have also necessitated their critical review.

Sickle cell anaemia and haemolytic anaemia have been implicated in earlier literature

for the reason of restricted blood flow and the release of cell breakdown products. In

sickle cell anaemia thrombi occur frequently in the microcirculation, but there is no

recorded data that it causes DVT (Bell & Simon, 1982).

Similarly, there is no current classified data to support haemolytic anaemia with

causal association with DVT (Belcher, 1993). Sergeant (1992) claims that early

publications linking sickle cell anaemia and haemolytic anaemia to DVT, due to

increased blood viscosity may have been exaggerated and speculative. As both sickle

cell anaemia and haemolytic anaemia do not appear to have any DVT predictive

currency, they have been duly deleted in the revalidated DVT scale (Autar, 2002).

Varicose veins

Consistent with its high ranking by the European Consensus Group (1991) and

THRiFT (1992), varicose veins as a DVT risk factor was assigned a high risk score of

6 (Autar, 1994).

In previous studies derived from regressive analysis of covariates, varicose veins were

found to be an independent risk factor (Nicolaides & Irving, 1975; Clayton et al 1976;

Crandon et al, 1980; Lowe et al 1982).


However, literature on varicose veins is controversial. The studies showing a

relationship between DVT and varicose veins were undertaken in patients who had

major abdominal surgery and invited criticism for the population sample also

contained older and obese patients. Varicose veins may have coexisted incidentally

with major abdominal surgery, advancing age and obesity as additive factors to cause

DVT. In a study of 1231 patients, Anderson and Wheeler (1995) reported a DVT

incidence of only 5.8 per cent due to varicose veins.

The retention of the high risk score of 6 for varicose veins over predicts risk, is

unjustified and its original risk score regraded to 3 based on odds ratio and relative

risk calculation.

Myocardial Infarction

In this high risk disease category, the variable “myocardial infarction”, was deemed to

be ambiguous and opened to interpretation as either an acute episode or a past medical

history. A previous myocardial infarction does not necessarily carry risk (Carter et al,

1987) and aptly redefining the variable as “acute myocardial infarction”, emphasises

an acute event, capable of causing DVT.

CVA and previous DVT

CVA and a previous DVT are very well recognised high risk diseases in the causation

of DVT, each associated with a risk score of 7 (Autar, 1994). The incidence of DVT

ranges between 42-60 per cent for CVA (Kamal 1987; Brunner & Suddarth, 1992).

Reportedly, in patients with a previous history of DVT, the recurrence of an episode is

between 48-68 per cent (Dalen et al, 1986). An even higher risk than CVA was

reported by Samama et al (1993) who recorded an odds ratio of 7.9 for patients with

previous DVT. There is now a strong consensus that previous DVT predisposes to the

recurrence of the condition and is acknowledged as the highest risk factor in the

causation of DVT (Nordstrom et al, 1992; Samama et al, 1993; Anderson et al, 1995).

Previous DVT is riskier than CVA and is capped at the risk score of 7. CVA is

assigned a revised score of 6 and in this way; the small difference in the risk

associated with these conditions is maintained.


The DVT risk assessment protocol

The DVT risk assessment strategy (Autar, 1994) places patients into one of the four

risk categories: no risk, low, moderate and high risk. The justification of a no risk

category assessment protocol arose out of the need to differentiate between those who

are not, in order to facilitate allocation of limited resources effectively. A latest study

(Anderson & wheeler, 1995) reported a DVT incidence of 11% in patients with no

single risk factor. The association between DVT and the number of risk factors

present is illustrated in Table 7.

Table 7: Association between risk factors and DVT (Anderson & Wheeler, 1995).

No of risk factors DVT (%)

0 11

1 24

2 36

3 50

≥ 4 100

Data extrapolation on the medical wards studied, identified two patients in the no risk

category who developed DVT. Resultantly, the four risk categories of the DVT scale

have been reviewed to three risk categories (figure 2). The removal of the no risk

category from the assessment protocol places the low risk category into a wider risk

score range of less than 10 and resolves any problem of spurious precision between

the no and low risk categories. The other risk score ranges of 11-14 and 15≥ are

maintained to identify the moderate and high risk categories respectively. This

modified risk assessment protocol is also consistent with the recommended

antithrombotic assessment strategy. (International Consensus Group, 1997 & 2001).

The Autar DVT scale relies on routine data gathered on admission, allowing for a

prompt DVT risk assessment and timely intervention. Like the universally recognised

Glasgow coma scale, the Autar DVT scale can be applied by nurses and doctors alike

and other health care professionals


The use of computer programmed with logistic regression formulas, as devised by

Janssen et al (1987) is technology for the future. Until artificial intelligence is readily

available for carrying bedside assessment, paper and pencil assessment tools as the

DVT scale, remain the most effective method of predicting risk and guiding decision

making.

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THRiFT (1998) Risk of and Prophylaxis for Venous Thromboembolism in Hospital Patients. Phlebology. 13: 87-97. Vandenbroucke JP, Van der Meer FJM, Helmerhorst FM et al (1996) Factor V Leiden: Should we screen oral contraceptive users and pregnant women? British Medical Journal. Vol 312: 1226 Wheeler HB, Hirsh J,Wells P et al (1994) Diagnostic Tests for Deep Vein Thrombosis. Arch Intern Med.Vol 154: 1921-1928. ADVANCING NURSING PRACTICE IN THE MANAGEMENT OF DEEP VEIN THROMBOSIS (DVT). DEVELOPMENT, APPLICATION AND EVALUATION OF THE AUTAR DVT RISK ASSESSMENT SCALE

SUBMITTED BY RICKY AUTAR, PhD, MSc, BA (HONS) DIP N, RGN, RMN, CERT ED, RNT PRINCIPAL LECTURER DE MONTFORT UNIVERSITY CHARLES FREARS CAMPUS 266 LONDON ROAD LEICESTER LE2 1RQ ENGLAND EMAIL: [email protected] PHONE; +44 116 201 3945



WORK IN PROGRESS. Not to be cited or quoted without written permission of the author

© Clive Baldwin 2005 Perspectives on Munchausen syndrome by proxy: Lessons from narrative analysis Clive Baldwin, Senior Lecturer School of Health Studies University of Bradford p.c.baldwin@bradford .ac.uk Abstract In recent years the diagnosis of Munchausen syndrome by proxy (MSbP) – an alleged form of child abuse in which the perpetrator (usually a mother) fabricates or induces illness in another (usually a child) - and its proponents have come under increasing criticism from lay people, health professionals, the courts and politicians. The debate tends to be polarised between those who think that MSbP (and its successor Factitious or Induced Illness – FII) is so fundamentally flawed that it should be abandoned and those who believe in its validity and efficacy in protecting children. Both sides make claim and counter-claim against the actions of the other, each seeking to negate the challenge posed by the other. This does little, however, to move the debate forwards. In this paper I intend to draw on narrative analysis in order to shed light on the conceptualisation and operationalisation of the diagnosis of MSbP. Such sociological research can raise new questions, pose new challenges and contribute to the current debate. Based on case study materials (interviews, court documents, medical records, social work reports and so on) I will illustrate the narrative features involved in cases of alleged MSbP; in particular, characterisation and agency, trajectory, smoothing, coherence, fundamentalism and the narrative mobilisation of bias. These features interact in ways that influence the investigation of alleged cases of MSbP and their presentation in court. The paper will conclude with recommendations for professional practice in cases of alleged MSbP, in particular the restoration of authorship and accountability, the need for reflexivity, clarity of central action, symmetrical approaches to evidence and professional agnosticism. Introduction Munchausen syndrome by proxy (MSbP is an alleged form of child abuse in which the perpetrator (usually the mother) induces or fabricates illness in another (usually a child) in order to seek medical attention. There are basically two polarised and incommensurable narratives around MSbP. A The first, told by many in the medical, health care and social work communities, is that MSbP is a theory with a respectable history; the second, told among some in the above communities but also some lawyers, politicians, academics and lay people, is that MSbP is a theory without scientific merit.


If one looks closely at the literature and current debate around MSbP, it is a concept that is undergoing a great deal of critique. A highly contested and controversial diagnosis MSbP:

a) Incorporates a number of conceptual and empirical problems:

a. Contradictory indicators; b. Catch-all indicators; c. No research baseline for its major tenets; d. No rigorous research to support its use;

b) Does not meet criteria for clinical validity (Kendall); c) Is not recognised by either the WHO or the APA;

d) Has been rejected by courts in the UK, US and Australia as failing to meet the

necessary evidentiary standard and/or as an unproven and unhelpful concept

e) Even among its proponents there is disagreement about what it is, the underlying motivation and whether it is a paediatric or psychiatric diagnosis.

These problems work themselves out through individual cases – for example, in one case four different definitions of MSbP were used. In this presentation I want to take a rather different stance to the exploration of the issues raised by the diagnosis of MSbP – that of narrative analysis. Narrative analysis can mean all sorts of things, but here I am using it, not as a shorthand for thematic analysis of cases (a way it is often used) but as introducing narrative theory into the analysis of MSbP. In particular I want to look at two areas: the features of narrative - character and agency, emplotment, fundamentalism and coherency; and, second, narrative techniques used to enhance the persuasiveness of any given narrative. I should, at this point, make clear the limits of this presentation. While what I have to say may be applicable, to a greater or lesser extent, to both narratives of abuse and narratives of innocence I will only be dealing here with how narratives of abuse are constructed and the techniques utilised by the narrators of such narratives in order to enhance the narrative’s persuasiveness. Second, I will only incidentally be dealing with the meta-narrative of the theory of MSbP, focusing more closely here on the narratives of individual cases. The sources for this analysis come from cases of alleged abuse where the allegations were unfounded or the narrative of abuse has been undermined by further hearings. Data comes from case records, interviews with mothers, personal documents and official documents. Narrative features a) Character and agency


In cases of MSbP there is a distinct a-symmetry in how characters are portrayed and the allocation of responsibility for action. Although ‘character work’ is deployed by the narrators of both the narratives of guilt and innocence, the opportunities for and the reception of such character work are unevenly distributed in favour of the narrators of guilt. For example, allegations made about the mother (say, lying about a house fire in the case of P,C&S) can be made with impunity (and even though untrue did not bring any censure of the social worker who made such allegations); while attempts by the mother to characterise professionals as, say, inept, are recuperated into the narrative of guilt as indicators of evasion, hostility or personality disorder. In the narrative of guilt, the mother is portrayed as deceitful, duplicitous, manipulative, hostile etc, etc, etc. Her general morality is questioned (e.g. in one case via suspicions of benefit fraud and living off immoral earnings – neither of which were substantiated) and her actions are to be scrutinised – both those regarding the alleged harm to the child, and those during the investigation and court case (for example, the social services requesting that the ‘expert’ psychiatrist be allowed to sit in the court to assess the mother while the mother was giving testimony. On the other hand, if one reads official records, one would be forgiven for thinking that the narrative of guilt was natural and inevitable. Decisions are made by meetings, not individuals; the motives behind actions of professionals go unnoticed or certainly un-commented upon (while those of the mother are constantly under scrutiny), the progress of a case – its narrative trajectory – is taken as a given, rather than the result of the actions of individuals. Thus, it seems, that professionals are ‘character-less’ and the process ‘agent-less’. This implies that the emergent narrative of guilt is unaffected by human action and is the inevitable outcome of a dispassionate review of the ‘evidence’. b) Emplotment Emplotment is the process whereby events, people, items etc are introduced into the narrative in order to further the story-line. The choice of what to include is thus vitally important because a persuasive story is one that limits ambiguity (i.e. one that limits the possibility of alternative narratives) and one that appeals to stories that are already familiar and accepted. One way of limiting ambiguity is to only introduce into the narrative things that will be used later on. As Chekhov said, if there is a rifle on the wall in Act One, it will be used in Act Three. Extraneous material should be avoided if at all possible. In the case of P,C&S this process can be seen at work in the Local Authority hiding the first expert report (my interpretation is that the report was hidden because it was too ambiguous for the purposes of moving forward the narrative of an extremely dangerous mother) and forcing the parents into a further ‘expert’ evaluation which produced a far more negative report, which could then be introduced in order to further the required story-line. Similarly, allegations made about a father that he impersonated a therapist in order to help a mother evade the authorities, was introduced in order to move on the plot of a family not to be relied upon to protect the child – even though no evidence could be brought to substantiate this allegation – and was re-introduced at several points in the proceedings.


The second part of emplotment is to link the story you are telling to stories that are already familiar to and accepted by your audience and to tell them in such a way that they are as close to those ‘canonical’ stories (stories that typify this sort of story) as possible – a process of narrative smoothing. Thus we see the introduction of material that, while unsubstantiated, serves the purpose of bringing the story into line with canonical stories – eg, in the case of P,C&S allegations were made that the mother had lied about a house fire (such behaviour being common in cases of MSbP), the mother endangering the child by ignoring medical advice and having to be rushed to hospital by ambulance (drama and child endangerment being features of MSbP), the mother being resistant to therapy, hostile and unco-operative (again, features of other MSbP cases) – all of which were unsubstantiated but fitted with the canonical story of MSbP. c) Fundamentalism A persuasive narrative is often one that is relatively simple, clear and unambiguous. Furthermore, the conviction of the narrator may also play a part in promoting the narrative’s persuasiveness. Stories that are hedged about with ‘may be’, ‘possibly’, ‘alternatively’, ‘I think it might be’ are likely to be less persuasive than those presented forcefully, clearly and definitely. Consequently, there is a tendency in adversarial proceedings – and let us be clear that despite the official claims that family court hearings in the UK are inquisitorial not adversarial this is simply not the case – towards a fundamentalist story-telling. This fundamentalism can be quite clearly seen in P,C&S where the local authority argued on a number of occasions for estoppel – that the conviction of the mother for a misdemeanour in the US was proof that she had harmed her child by administering laxatives in a case of MSbP abuse even though there was no ruling of MSbP (according to the juvenile court) and no such findings of fact in the US courts – prior to the full care proceedings in the UK. Furthermore, even Justice Wall criticised the Guardian ad Litem for pre-judging the case. This Guardian ad Litem is also reported as saying that she would not accept the court’s ruling if it went against her. A similar fundamentalism can be detected in the narratives of other professionals. For example, David Southall, a pre-eminent advocate of MSbP, is on record saying that he has never wrongly diagnosed child abuse when it was not there – i.e. false positives. This despite mothers whom he has accused being cleared by the courts. Fundamentalism might also explain Prof Southall’s recent censure by the GMC – preventing him from child protection work for three years and having to report to the GMC every 6 months – as the GMC criticised Prof Southall for holding onto his theory despite lacking the evidence to support it. d) Coherency According to Bennett and Feldman, a coherent narrative is more persuasive than a less coherent narrative – even if the coherent one is not true. Thus, if a narrative can be presented as coherent, it will appear more persuasive. In order to enhance the perceived coherency of a narrative three tactics can be identified:


i. Ignoring contradictory evidence – such as evidence that shows the mother in a good light or the hiding of a report that did not fit with the required narrative.

ii. Recuperating evidence so that it adds to the coherency of the story being

told – for example, the mother in P,C&S challenged the expert’s interpretation of the medical records in great detail – identifying test results that indicated genuine illness, noting errors in the expert’s arithmetic, indicating alternative explanations and so on. Rather than deal with this challenge, the whole report was dismissed as ‘typical of a Munchausen mother’ thus re-establishing the coherency of the narrative of guilt.

iii. A third tactic was to protect the narrators from challenge. For example, in

P,C&S the two US doctors on whose evidence the Local Authority were relying were not even present in court to be cross-examined and the mother was prevented from cross-examining the UK experts in a way that questioned their expertise.

e) Narrative trajectory A narrative trajectory is the path that any particular narrative takes after being launched. I choose the word ‘trajectory’ carefully in order to indicate that the course taken is very much a function of the aim of the initial narrative and that without intervention, the narrative will continue on its predetermined path. Attempts to deflect the trajectory may be made, as also can counter-measures to maintain it. For example, the trajectory set in P,C&S was one of guilt from the outset – indicated by the refusal of the social services to even contemplate the offer of the parents for long-term residential assessment and their insistence on admission of guilt from the beginning of the investigations even prior to the court hearings. The trajectory of guilt was then protected in a number of ways – for example, the parents complained about the way the investigation was being handled but were told that such complaints would only be dealt with after the proceedings. Ironically, the European Court of Human Rights ruled that the Local Authority had removed the child at birth unnecessarily and without relevant or sufficient reason. f) Silencing All narratives require an audience and one way of controlling unacceptable narratives is to silence them. This both prevents the development of alternative narratives and limits the potential challenge to the acceptable narrative. So, for example, the silencing of mothers accused of MSbP – through injunctions or coerced undertakings to the court – can be seen as a means of silencing the narrative of innocence. A less obvious means of silencing the narrative of innocence is to refuse to allow elements of the story to be told or developed within the court proceedings themselves. So, for example, a judge’s refusal to hear a witness for the mother on an area of expertise can be interpreted as silencing the development of that particular argument; preventing a mother form cross-examining witnesses can also be viewed in this vein; the social services not soliciting information from professionals previously involved


with the mother but supportive of her also effectively silenced that element of the narrative of innocence. g) Mobilisation of bias Mobilisation of bias is a concept taken from political science and refers to:

" a set of predominant values, beliefs, rituals, and institutional procedures ("rules of the game") that operate systematically and consistently to the benefit of certain persons and groups at the expense of others.

In UK child protection investigations and legal proceedings such bias can be identified in:

Policies, procedures and guidelines that favour the development of the narrative of guilt; for example, in cases of MSbP the mother’s testimony is to be treated with suspicion; assessment should be undertaken by someone with expertise in MSbP (and of course these are pro-MSbP experts not those who question it);

The uncritical acceptance of other discourses e.g. professionals as benevolent

and benign;

Previously circulated narratives (see above re canonical narratives). Re-establishing narrativity In conclusion I want to suggest that if my argument about the narrative construction of cases of MSbP is persuasive then we need to find ways of determining better from worse narratives. I think that this can be done in a number of ways.

Firstly. By restoring authorship and accountability, professionals once again become characters and agents with their own motives, influences, involvements and fallibilities. They once again become decision-makers – and are thus responsible for those decisions and actions they choose. This increases the transparency of the narrative - why this narrative is being constructed and how has it been constructed. We can thus ask questions about the process – for example, why did the social worker in P,C&S choose to fabricate evidence? Why did the Guardian ad Litem fail to mention this fabrication in her report? What was the motivation behind hiding an expert report? In a more recent developing story-line involving Roy Meadow, the creator of MSbP – we may want to ask questions why he thought it acceptable to speak outside of his expertise in the Sally Clarke case; or what motivated David Southall to provide court reports when he had not seen the evidence. Despite claims that Meadow is being scapegoated, a narrative analysis at least gives Meadow the respect of being the author of his own narrative – that he, as an expert witness, chose to step outside his expertise in giving evidence on statistics. A second advantage of restoring narrativity is that reflexivity is thus restored – we can see how professionals, as characters and actors, affect the situation they are


involved in. In the current way of looking at things, one would be forgiven for thinking that professionals are simply observers and reporters of situations. However, professionals are not simply observers but characters and actors within the developing narrative ad as such contribute to the course of that narrative. For example, it was claimed that one mother had an abnormal degree of medical knowledge about her son’s condition – interpreted as an indicator of MSbP – even she had been encouraged to find out about and lent books on the subject by medical personnel. Similarly, the alleged ‘hostility’ of one mother towards the social services might have been as result of the social workers deliberately deceiving her about their plans to remove the child. Focusing on reflexivity goes some way to redressing the balance between competing narratives and ameliorating the worst effects of the bias that appears to be built into the process of investigating and prosecuting cases of MSbP. A third element that might aid us in discerning between good and less good narratives is the degree of conceptual clarity that is being utilised in any given narrative. If MSbP is to be taken seriously as what Bennett and Feldman call the ‘central action’ then it is important that this central action is clear and coherent. Currently, MSbP lacks this conceptual clarity and standard operationalisation. In a review of approx 20 cases, Pankratx (personal communication) identified non-standard usage of the concept of MSbP. As stated above, in one case at least four different definitions of MSbP were in play (sometimes at the same time). While a lack of conceptual clarity and non-standard operationalisation facilitated the development of a persuasive narrative of guilt it cannot be said to have helped the cause of justice. In terms of MSbP this lack of conceptual clarification currently includes:

Confusing and contradictory indicators; No agreement on motivation; Disagreement as to whether it is a paediatric of psychiatric diagnosis The limits of MSbP - cf Schreier vs Jones debate as to whether MSbP

involves attention-seeking behaviour towards a range of professionals (eg lawyers, teachers, sheriffs etc) or just towards health professionals.

Conceptual clarification, agreement and standard operationalisation would facilitate the process of deciding between competing narratives because then at least both narratives are dealing with the same central action (although from opposite sides). Fourth, I would argue that there should be a symmetrical approach to competing narratives, without privilege being given to any source or narrative from the outset. Thus, if we are to treat the mother’s story with suspicion we should also treat those of professionals with suspicion. The case of P,C&S illustrates that professionals are not above lying, fabricating evidence, hiding evidence, bad-mouthing, covering-up and so on. In conclusion


In conclusion I want simply to emphasise the need for professional agnosticism when faced with allegations of MSbP. If facts depend on the persuasiveness of the narrative not the other way around, then it is of paramount importance that we do not favour one narrative over another until both have been constructed and subjected to examination (including the narrative features outlined above). It might be claimed that this is what happens under the current process – that the social services investigate allegations and the process is inquisitorial rather than adversarial. Such a view cannot be upheld in the light of cases such as P,C&S where it is apparent that the development of the narrative of guilt was favoured in the investigation and court proceedings, not only by the actions of individuals but by policies and procedures. By restoring narrativity and using its lessons to help us discern between good and less good narrative processes and products I believe that we have a firmer basis on which to evaluate competing narratives in difficult areas of practice such as child protection.

WORK IN PROGRESS. Not to be cited or quoted without written permission of the author

© Clive Baldwin 2005


The function of the first author in Evidence Based Practice Dr Elaine C. Ball RGN, BA, MA, Cert Ed, Ph.D Senior Lecturer in Nursing School of Nursing University of Salford Peel House Eccles Manchester M20 0NN England ABSTRACT In the teaching of Evidence Based Practice (EBP) there is a given synchrony through which the student is advised to work: the student formulates a question from a problem they have identified in their practice arena. They then undertake a complex reading of multiple texts in which to reason through their ideas, and appraise their argument. However, having taught on the EBP course, it is not uncommon for students to ‘lose’ their own highly important practice issues in a miasma of published (authoritative) texts. Moreover, as nursing is now becoming a credible research profession, the need to be skilled in the art of extracting information embedded in healthcare literature has never been more important. Th

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