Patients’ narratives of orthognathic treatment for facial asymmetry: a qualitative study

To explore patients’ experiences of orthognathic treatment for facial asymmetry and their adaptation to facial changes after surgery, we did a qualitative, cross-sectional study of patients after treatment for non-cleft asymmetry at two UK sites. A total of 15 patients aged 19-40 years were approached after being identified using patient databases and clinical notes. Individual and photo-elicitation interviews were conducted covering experiences prior to treatment, during treatment, and after surgery. Interviews were transcribed and thematic narrative analysis undertaken. Participants were largely positive about their orthognathic treatment. The following themes were identified: preoperative (becoming aware, negative impacts of asymmetry, committing to treatment, establishing expectations), pre-surgery orthodontics and inpatient experiences (challenges and coping strategies, preparedness, support, and shared experiences); and postoperative (surgery as ‘worth it’, positive impacts of treatment, adapting to facial change). Undergoing orthognathic surgery was portrayed as a journey involving recognisable narratives (treatment unfinished, threat of liminality, treatment as resolution, and treatment as transformation). Patients’ experiences of facial asymmetry are associated with feeling ‘abnormal’, and negative impacts, and orthognathic treatment for facial asymmetry is worthwhile. Having the feeling that something is ‘wrong’ legitimised by clinicians allows patients access to a recognisable treatment narrative (resolution). Orthognathic treatment is also described as transformation from ‘normal abnormality’ to being ‘normal’. Nevertheless, the associated challenges can be frustrating, particularly if resolution is hard to envisage. Further psychological input could help patients cope with these challenges and the complex process of adapting to facial change.     

Rupture Resolution Rating System (3RS): Development and validation

Objective: Our aim was to examine the reliability and validity of the Rupture Resolution Rating System (3RS), an observer-based measure of alliance ruptures and resolution processes. Method: We used the 3RS to rate early sessions from 42 cases of cognitive behavior therapy. We compared the 3RS to a simplified version of the Structural Analysis of Social Behavior (SASB), as well as patient and therapist self-reports of ruptures and the alliance. Results: Coders achieved high rates of interrater reliability on the frequency of confrontation and withdrawal ruptures and resolution strategies (ICCs?=?.85 to .98), as well as ratings of the therapist’s contribution to ruptures and the extent to which ruptures were resolved (ICC?=?.92). Predictive validity analyses found that confrontation markers (d?=?.74), successful resolution (d?=?.67), and ratings of the therapist’s contribution to ruptures (d?=?.61) predicted dropout from therapy. Analyses of convergent validity with the SASB failed to meet predictions; however, we observed theoretically coherent relations between 3RS and SASB variables. Confrontation rupture markers were significantly associated with patient self-report of rupture (d?=?1.54) and therapist self-reported alliance (r?=??.50, p?=?.002). Conclusions: This study provides evidence that the 3RS is a reliable and useful tool for examining psychotherapy process and predicting dropout.

Clinical or methodological significance of this article: This study provides evidence of the reliability and validity of the 3RS, an observer-based measure of alliance ruptures and resolution processes. The 3RS can be used to identify problems in the therapeutic relationship that are associated with premature dropout from therapy.     

医护人员医学叙事能力量表的编制及信效度检验

目的 开发适用于医护人员的医学叙事能力量表（Narrative Competence Scale,NCS）,并检验其信效度。方法 以叙事理论、故事理论、诺丁斯关怀理论为指导,结合文献分析和对17名叙事医学/叙事护理实践型医护人员的访谈结果,构建医护人员医学叙事能力量表的条目池。通过德尔菲法、预调查、项目分析形成初版量表,并对607名医护人员进行问卷调查,检验量表的信效度。结果 NCS包括27个条目,划分为3个维度（累积方差贡献率为65.02%）,总量表的Cronbach's α系数为0.950,折半信度为0.935,1个月后重测信度为0.717（P< 0.001）,内容效度指数为0.89,NCS与杰斐逊共情量表、人文关怀能力量表总分及各维度均呈正相关（P< 0.001）。结论 该研究形成的NCS具有良好的信效度,适用于中国医护人员医学叙事能力水平的测评。     

Implementing group visits for opioid use disorder: A case series

Abstract

Background: Group-based models of Office-Based Opioid Treatment with buprenorphine-naloxone (B/N) are increasingly being implemented in clinical practice to increase access to care and provide additional therapeutic benefits. While previous studies reported these Group-Based Opioid Treatment (GBOT) models are feasible for providers and acceptable to patients, there has been no literature to help providers with the more practical aspects of how to create and maintain GBOT in different outpatient settings. Case series: We present 4 cases of GBOT implementation across a large academic health care system, highlighting various potential approaches for providers who seek to implement GBOT and demonstrate “success” based on feasibility and sustainability of these models. For each case, we describe the pros and cons and detail the personnel and resources involved, patient mix and group format, workflow logistics, monitoring and management, and sustainability components. Discussion: The implementation details illustrate that there is no one-size-fits-all approach, although feasibility is commonly supported by a team-based, patient-centered medical home. This approach includes the capacity for referral to higher levels of mental health and addiction support services and is bolstered by ongoing provider communication and shared resources across the health system. Future research identifying the core and malleable components to implementation, their evidence base, and how they might be influenced by site-specific resources, culture, and other contextual factors can help providers better understand how to implement a GBOT model in their unique clinical environment.     

Early career registered nurses: How they stay

BackgroundEarly career registered nurses (ECRNs) are those in the first five years of practice and are at increased risk of leaving the profession. There is limited research investigating the experiences and approaches of ECRNs who have chosen to stay, which can, in turn, shed light on strategies to assist future ECRNs.AimThis article reports on the findings of a study that explored the disorienting dilemmas of ECRNs and asked the question, how do ECRNs stay working in the profession of nursing.MethodsA qualitative methodology, employing a staged narrative approach was used to collect, develop and analyse the stories of 13 ECRNs. Transformative learning theory provided the theoretical framework for the study.FindingsThe disorienting dilemmas experienced upon commencing work as RNs, required ECRNs to question the premise for their disorientation. Through this questioning, they discovered a misalignment between what they imagined it would be like to work as an RN and what they experienced once registered and in the workforce. Supportive but ad hoc relationships facilitated participants’ abilities to transform their frames of reference and begin to develop effective and authentic ways of being in the world, leading to their decision to stay.ConclusionLearning for ECRNs must be a shared responsibility and the findings highlight the importance of relational and ontological learning for ECRNs. Workplaces must be safe, conducive to learning where uncivil and unprofessional behaviours are rejected.     

Understanding and helping children who have experienced maltreatment

Children who experience maltreatment from within their families can suffer trauma that is devastating to their physical and psychological development. The label developmental trauma has developed to describe this trauma and to guide diagnosis. This has been expanded to describe seven domains of impairment. Together these help the clinician to provide a formulation of a child's difficulties which avoids multiple diagnoses and can guide treatment planning. Dyadic Developmental Psychotherapy and Practice (DDP) is an intervention model that can meet the therapeutic needs of the children alongside the support needs of parents and practitioners caring for them. The attitude of PACE (playfulness, acceptance, curiosity and empathy) is central within DDP interventions, used by therapists, parents and practitioners who together make up the network around the child. Tailoring DDP interventions can be guided by a pyramid of need developed by the author. This helps clinicians develop flexible intervention packages tailored to the needs of the child, family and practitioner. Within the paper these ideas are explored illustrated by the fictional example of Janice. She was maltreated in early childhood and now lives in foster care with Mary and Simeon.     

Le travail de l’exil à l’adolescence. Dispositif d’étayage groupal et de médiation par la bande dessinée

ObjectiveThe exile is particularly traumatic for adolescents who, in the host country, live the post-migration experience in uncertainty. In order to enhance the continuous sense of being and the imaginary of a group of young unaccompanied minors, and to promote the narrative of their exile, we have set up a group mediated by comics. We strive to understand how and by which processes a comic mediation group could enable the support of the continuous sense of being as well as the imagination in a group of unaccompanied minors.MethodSix (n = 6) adolescents aged 15 to 17 were invited to design a group comic strip. Participants were invited to create a comic in group. The study was divided in three specific times: (1) the first was to invent a story, (2) the second was to do a storyboard and (3) the third and last one consisted in the creation of a comic. The group proceeded in X session and each session ended with a speaking time. We chose to create a comic as a medium because of its formal qualities: the specificity and complexity of its codes seemed appropriate to work on the time and space. Therefore, the breaks and discontinuities as essential parts of the comic structure allowed the participants to work out their temporal and special experiences of exile. As working in group enables to enhance the creative processes, we have designed and set up a comic mediation group.ResultsWe observed that the creation of the comic facilitates the updating of break and loss experiences, because of its formal structure. This sometimes made the group envelope porous and fragile, and damaged the group associative chain. The mediation group allowed participants to express and transform their primary affects through images and words, which led them to go from a fixed time to a historicized time. The comic became an object that represents the individual psychic reality work, the group work but also refers to the common societal reality that concerns those adolescents. Through the comic, they question the adults, the institutions and the environments that are supposed to protect them. The structure of the comic and the group setting helped participants to restore a sense of security. Moreover, the secure and containing space created by the setting allowed the group to enhance its imagination.DiscussionThe setting permitted participants to be in an active position, which supported them in the process of identity reconstruction. They used comics to transform and make sense of a painful part of their story in order to appropriate it. It is necessary to keep doing research on this subject to improve the support given for this young people. Moreover, it is essential to offer them places where they can be accompanied in the crossing of their exile experience.