Behavior In Clinical Settings Research Articles

Motivational interviewing interventions in graduate medical education: a systematic review of the evidence.

Motivational interviewing (MI) is a patient-centered method of behavior change counseling. It has shown promise in enabling patients to identify and improve problem health behaviors. Incorporating MI education into residency training may be beneficial. To review the current evidence regarding the impact of MI education in graduate medical education. Of the 9 studies of MI education in graduate medical education training, most noted favorable outcomes after MI education. Outcomes included improvements in residents' view of MI, MI skill use and competency, and resident satisfaction with MI interventions. Of the 5 studies that looked at residents' views of MI, 3 found improvements in resident assessments of the importance of and confidence in using MI. Of the 4 studies of MI skills, 3 reported improvements in residents' use of and competency in the MI skill. The quality of MI education in the graduate medical education literature is limited by overreliance on preintervention and postintervention analysis as a study design, the variable intensity of educational interventions, and limited use of validated assessment tools and quantitative outcome measures. Review of the literature shows that MI education can be successfully implemented within the residency education environment. The intensity of MI interventions, coupled with experiential learning and feedback, correlated with favorable outcomes in terms of resident use of MI skills and resident satisfaction. Further study is needed to determine which MI skills are most effectively taught to residents, the impact of MI training on resident behavior in clinical settings, and the impact on clinical outcomes.

Inferring Causation from Cross-Sectional Data: Examination of the Causal Relationship between Hyperactivity–Impulsivity and Novelty Seeking

Previous research suggests an association between hyperactivity–impulsivity – one of the two behavioral dimensions that form attention deficit hyperactivity disorder – and the temperament characteristic of novelty seeking. We aimed to examine etiological links underlying the co-occurrence between these behaviors using a general population sample of 668 twin pairs, ages 7–10, for whom we obtained parent ratings in middle childhood; and pilot longitudinal data on 76 children. Structural equation modeling confirmed a shared genetic etiology (genetic correlation, rD = 0.81; 95% confidence intervals = 0.34–1.00) and showed that much (64%) of the covariation can be accounted for by shared genetic effects. In addition, causal paths were modeled between the two behaviors; 12% of the variance in novelty seeking at age 7 was accounted for by hyperactive–impulsive behaviors at the same age. The causal effects model fits with the current characterization of hyperactive–impulsive behaviors reflecting a heightened need for stimulation. This has important implications for the management of hyperactive–impulsive behaviors in clinical settings.

Uncivil Student Behaviors in Clinical Settings: Strategies for Clinical Nurse Educators

Clinical educators may have difficulty determining how best to respond to uncivil behaviors from students in clinical settings. This column describes communication, ground rules, and policy enabling clinical educators to teach effectively and minimize inappropriate student responses.

A “Back to Basics” Approach to Reduce ED Medication Errors

Medication error is the most frequently reported error in the emergency department. Nationally, 36% of medication errors occur in the administration phase. The purpose of this study is to reduce medication administration errors in the emergency department by reinforcing basic medication administration procedures. This study examined a 3-month educational intervention using a nonrandomized, single group comparing pre-post outcome variables. The educational intervention, titled "Preventing Medication and IV Administration Errors," described current medication errors in the emergency department, and recommended practices for reducing medication administration errors. Of 127 nurses, 75% participated. Three measures used pre- and post-intervention were: a) knowledge of medication administration procedures assessed by tests; b) behaviors reflecting recommended medication practices assessed by surveys; and c) medication administration errors, identified via chart review and voluntary error reports. In the post-test, 91% achieved perfect scores vs. 69% on the pre-test (P =. 0001). In the post-survey, the proportion responding that they follow recommended practice "all" or "most" of the time increased in 8 of the 10 survey questions, but the changes did not reach statistical significance (P = .98). Reviews of charts (299 pre-test and 295 post-test) revealed little change in total medication errors: 25% vs. 24% (P = .78). Voluntarily reported medication errors dropped from 1.28 to .99 errors/1000 patients. This educational intervention successfully improved knowledge of recommended medication administration practices. However, improved knowledge did not translate to a significant change in practice. More research is needed to identify interventions that can modify behavior in clinical settings.

Induced Transducer Orientation During Ultrasound Imaging: Effects on Abdominal Muscle Thickness and Bladder Position

The use of ultrasound imaging (USI) by physiotherapists to assess muscle behavior in clinical settings is increasing. However, there is relatively little evidence of whether the clinical environment is conducive to valid and reliable measurements. Accurate USI measurements depend on maintaining a relatively stationary transducer position, because motion may distort the image and lead to erroneous conclusions. This would seem particularly important during dynamic studies typical of a physiotherapy assessment. What is not known is how much transducer motion can occur before error is introduced. The aim of this study is to shed some light on this question. Eight healthy volunteers (19 to 52 y) participated. USI images were taken of the lateral abdominal wall (LAW) and bladder base (midline suprapubic) at various manually induced transducer orientations (approximately –10 to 10° about 3 axes of rotation), which were quantified by a digital optical motion capture system. Measurements of transversus abdominis (TrA) thickness and bladder base position (cranial /caudal and anterior/posterior) were calculated. Repeated measures analysis of variance was performed to determine if the measurements obtained at the induced transducer orientations were statistically different ( p < 0.05) from an image corresponding to a reference or starting transducer orientation. Motion analysis data corresponding to measurements that did not differ from reference image measurements were summarized to provide a range of acceptable transducer motion (relative to the pelvis) for clockwise (CW)/counter-clockwise (CCW) rotation, cranial/caudal tilting, medial/lateral tilting and inward/outward displacement. There were no significant changes in TrA thickness measurements if CW/CCW transducer motion was <9° and cranial/caudal or medial/lateral transducer tilting was <5°. Further, there were no significant changes in measurements of bladder base position if CW/CCW transducer motion was <10°, cranial/caudal or medial/lateral transducer tilting was <10° and 8°, respectively and inward/outward motion was <8 mm. These findings provide guidance on acceptable amounts of transducer motion relative to the pelvis when generating measurements of TrA thickness and bladder base position. Future sonographic studies and clinical assessment investigating these parameters could take these findings into account to improve imaging technique reliability. (E-mail: j.l.whittaker@soton.ac.uk)

Patterns of communication between gastroenterologists and patients suffering from ulcerative colitis

This paper will examine how gastroenterologists and patients suffering from ulcerative colitis manage interactions in clinical settings, looking specifically at the management of talk across two primary discourse phases of clinical encounters (discovery and decision) and the co-construction of conceptual narratives and metaphors related to treatment. Grounded in recent literature on the practice of narrative medicine, this paper draws on discourse and metaphor analysis to deconstruct and interpret linguistic patterns of communication in 50 clinical interactions between gastroenterologists and patients. The goal of this paper is to provide medical research and healthcare practitioners with fresh insights into physician and patient behaviour in clinical settings.

Commentary: Integrating Lessons from Evidence-based Assessment of Adherence into Clinical Practice

In the past two decades, our appreciation of the complexity of disease management behavior has increased, and the methods now available to assess adherence behavior have advanced accordingly. Multiple methods are now implemented in research settings, including electronic monitoring devices, well-validated interviews, and procedures that allow real-time data collection of adherence behavior. Quittner and colleagues (Quittner, in press; Modi, Lemanek, Ieverse-Landis, & Rapoff, 2007) provide a comprehensive overview of the most current methods available to measure adherence behavior, and offer a compelling list of recommendations for future instrument development and research on adherence assessment. Reviewing the available methods not only provides us with a useful framework for approaching scientific inquiry in this area, but also naturally raises some larger issues in how health care professionals understand and use information regarding patients’ adherence to medical regimens. One practical limitation of measuring adherence behavior with state of the art methods is that the strategies that yield the most comprehensive picture of disease management behavior are generally also the most expensive and time-consuming, and may additionally require sophisticated data management procedures. This introduces substantial barriers for implementing these approaches into routine clinical care, where adherence assessment may be needed the most. Our colleagues in their busy primary care practice settings and emergency departments could benefit from a simpler, more targeted approach. What they want may not be possible—we know that you cannot capture the complexity of adherence behavior, particularly to complicated regimens, by asking a few quick questions or by ordering a simple blood test. There is no easy solution for nonadherence, and there is no simple measurement method to capture adherence behavior. Our increasing knowledge of findings from the growing body of adherence research does enable us to share perspectives that may have direct benefit for those on the front line in health care settings. First, expect that many patients will not adhere to treatment recommendations (Matsui, 2000), and that their report of how well they are following your instructions is likely to be “enhanced.” Research has consistently demonstrated that self-reports of adherence are inflated when compared to objective methods of monitoring (Riekert & Rand, 2002). As a result, reports of nonadherence are more likely to be accurate than reports of adherence. Second, be clear in your recommendations for disease management. Research on provider communication suggests that information provided to families is often inadequate, and as a result comprehension may be compromised (see DiMatteo, 2000, for a review). If families have difficulty understanding your directions, can they be following through on your treatment plan? As Quittner and colleagues point out, the increasing use of electronic medical records may provide an opportunity to systematize treatment plans, and in doing so provide clear written recommendations for families. Third, if you only have time for a few questions, consider reviewing issues and circumstances that are likely to arise and impede adherence. A further frontier in the measurement of adherence may be the development of practical methods and brief strategies to assess disease management behavior in clinical settings. With our increased understanding of the best practices to measure the complexity of adherence, we are beginning to develop “gold-standard” approaches against which briefer screening tools may be compared. Utilizing these sophisticated paradigms, in combination with briefer self-report instruments, may allow us to develop screening instruments to be used in clinical practice when more intensive, time-consuming approaches are not feasible. For example, it would be useful to determine a brief set of questions that could be used to identify families having significant adherence problems, or those at risk for deterioration of disease management. Implementation of well-validated screening tools for broad use in clinical practice will serve two useful functions, (a) it will raise the issues of adherence to the health care team in a more systematic manner, and (b) it will help identify families in most need of more intensive assessment and intervention. Through enhancing the health care team's awareness of typical barriers to adherence, the extent of nonadherence, and the need to address poor adherence as a multi-faceted clinical problem, we are likely to improve the overall care provided to all children and families. Conflict of interest: None declared.

Decreased Left Ventricular Torsion and Untwisting in Children with Dilated Cardiomyopathy

The purpose of this study was to analyze left ventricular (LV) torsion and untwisting, and to evaluate the correlation between torsion and other components of LV contraction in children with dilated cardiomyopathy (DCM). Segmental and global rotation, rotational rate (Vrot) were measured at three levels of LV using the two-dimensional (2D) speckle tracking imaging (STI) method in 10 DCM patients (range 0.6-15 yr, median 6.5 yr, 3 females) and 17 age- and sex-matched normal controls. Global torsion was decreased in DCM (peak global torsion; 10.9±4.6° vs. 0.3±2.1°, p<0.001). Loss of LV torsion occurred mainly by the diminution of counterclockwise apical rotation and was augmented by somewhat less reduction in clockwise basal rotation. In DCM, the normal counterclockwise apical rotation was not observed, and the apical rotation about the central axis was clockwise or slightly counterclockwise (peak apical rotation; 5.9±4.1° vs. -0.9±3.1°, p<0.001). Systolic counterclockwise Vrot and early diastolic clockwise Vrot at the apical level were decreased or abolished. In DCM, decreased systolic torsion and loss of early diastolic recoil contribute to LV systolic and diastolic dysfunction. The STI method may facilitate the serial evaluation of the LV torsional behavior in clinical settings and give new biomechanical concepts for better management of patients with DCM.

Characteristics of Dieting and Nondieting Adolescents in a Psychiatric Inpatient Setting

The clinical and psychosocial characteristics of 239 dieting and nondieting adolescents (61% female; mean age=15.3) recruited from an inpatient psychiatric setting were examined. Dieting adolescents were compared to nondieting adolescents on exercise frequency, weight control behaviors, risky behaviors, psychiatric comorbidity and distress, eating disorder symptomatology, smoking, coping, and family factors. While dieters did not statistically differ from nondieters on scores of body mass index, dieting youth reported greater levels of self-reported distress, poorer coping, greater eating disorder symptomatology, and were more likely to engage in extreme weight control behaviors. In addition, dieting was associated with higher rates of major depression (58% vs 34%) and eating disorders (14% vs 1%). Among adolescent smokers, dieters endorsed smoking as a weight control behavior. Engaging in risky behaviors or familial factors did not differentiate dieters from nondieters. Given the number of negative correlates associated with dieting in adolescents, identifying dieting and weight control behaviors in clinical settings may prove to be an effective strategy in the development of prevention and intervention efforts for youth.

Side effects of extinction: prevalence of bursting and aggression during the treatment of self-injurious behavior.

Findings from basic and applied research suggest that treatment with operant extinction may produce adverse side effects; two of these commonly noted are an increase in the frequency of the target response (extinction burst) and an increase in aggression (extinction-induced aggression). Although extinction is often used to treat problem behavior in clinical settings, few applied studies have examined the prevalence of these side effects or their possible attenuation with other operant procedures. An analysis of 41 data sets for individuals who received treatment for self-injurious behavior indicated that extinction bursts or increases in aggression occurred in nearly one half of the cases. The prevalence of bursting and aggression was substantially lower when extinction was implemented as part of a treatment package rather than as the sole intervention.

Dieting Status and its Relationship to Eating and Physical Activity Behaviors in a Representative Sample of US Adolescents

Objective To determine whether adolescents engaging in extreme weight loss methods (ie, vomiting and diet pills) and those using more moderate methods differ from each other in dietary intake (fruits, vegetables, and higher-fat foods) and physical activity, and to compare these variables in dieting and nondieting adolescents. Design Data were obtained from the 1993 Youth Risk Behavior Survey. Subjects/settings The survey was administered to a nationally representative sample of 16,296 adolescents in grades 9 through 12 in a school setting. Statistical analyses Data were analyzed for 16,125 adolescents. Associations between weight control behaviors and dietary intake and physical activity were examined using mixed-model logistic regressions, controlling for grade in school, race, parental education, region of the country, and urban vs nonurban residence. Results Differences in dietary and physical activity were found among adolescents who use extreme weight loss methods and moderate methods, and between dieters and nondieters. Adolescents using moderate methods of weight control engaged in more health-promoting eating and exercise behaviors than did extreme dieters or nondieters. Girls categorized as extreme dieters were less likely to eat fruits and vegetables than were moderate dieters (odds ratio [OR]=.56) or nondieters (OR=.75), and were more likely than more moderate dieters (OR=.76) to have consumed 2 or more servings of high-fat foods during the previous day. Applications/conclusions Our findings suggest the importance of distinguishing between different types of dieting behaviors in clinical settings and research studies. Adolescents engaging in extreme weight control behaviors may be at particular risk for inadequate nutritional intake. In contrast, adolescents using more moderate methods may be consuming a more healthful diet than are nondieters. For all adolescents, nutrition guidance on healthful and safe weight control strategies is needed. J Am Diet Assoc. 1998;98:1127–1132,1135.

Dieting and Binge Eating among Adolescents: What Do They Really Mean?

The study objectives were to gain insight into how the terms “dieting” and “binge eating” are understood and used by adolescents and to assess whether interpretations of these terms are consistent across age and gender. Twenty-five focus groups were conducted with 203 adolescents (138 girls and 65 boys) in urban public junior and senior high schools. Respondents were asked questions about dieting and binge eating behaviors. In the majority of groups (n=19), healthful eating behaviors, such as eating less fat or more fruits and vegetables, were mentioned in reference to dieting. However, in many of the groups (n=13) unhealthful eating behaviors, such as skipping meals or “starvation,” were also described. Dieting was frequently described as an umbrella term for different behaviors aimed at weight control (ie, physical activity) or in nonbehavioral terms (ie, as a desire or plan for weight loss). Although binge eating was described as overeating by many participants, often it was not clear if youth were referring to uncontrolled overeating. In nearly half of the groups, participants indicated unfamiliarity with the term “binge eating.” There was some confusion between binge eating and other forms of disordered eating. The findings suggest that prevalence rates of self-reported dieting and binge eating behaviors should be interpreted with caution and it should not be assumed that the majority of adolescents who self-report dieting are engaging in unhealthful behaviors. In providing nutrition counseling to youth, and in assessing dieting and binge eating behaviors in clinical settings and in research studies, specific behaviors should be defined. J Am Diet Assoc. 1998;98:446-450.

A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors

Objectives: To examine the overall effectiveness of patient education and counseling on preventive health behaviors and to examine the effects of various approaches for modifying specific types of behaviors. Data sources: Computerized databases (Medline, Healthline, Dissertation Abstracts, and Psychological Abstracts), bibliographies 1971–1994. Search terms (patient education, patient compliance, and self care) with modifiers (evaluation and specific preventive behaviors). Study selection: Randomized and non-randomized controlled trials measuring behavior in clinical settings with patients without diagnosed disease. Abstracts and retrieved studies screened by multiple reviewers; 13% of retrieved studies met screening criteria. Data extraction: Replicated coding by multiple observers. Data synthesis: Behaviors were grouped based on whether the behavior is addictive and whether the desired change required subtraction of existing behaviors or adding new behaviors. The weighted average effect size from a random effects model for smoking/alcohol studies was 0.61 (CI=0.45, 0.77), for nutrition/weight, 0.51 (CI=0.20, 0.82) and for other behaviors, 0.56 (CI =0.34, 0.77) indicating that the behavioral outcomes for these subgroups were significantly different from zero. Multiple regression models for the three groups indicated that using behavioral techniques, particularly self-monitoring, and using several communication channels, e.g., media plus personal communication, produces larger effects for the smoking/alcohol and nutrition/weight groups. Conclusions: Patient education and counseling contribute to behavior change for primary prevention of disease. Some techniques are more effective than others in changing specific behaviors.

Use of Standardized Patients to Assess Between-Physician Variations in Resource Utilization

As medical costs are increasingly being scrutinized, there is heightened interest in defining variations in physician behavior in clinical settings. To evaluate if standardized patient (SP) technology is a reliable and feasible method of studying interphysician variations in test ordering, referral requests, prescribing behavior, and visit costs. The study was conducted with blinded SP visits to family medicine and internal medicine residents, university-affiliated family physicians, and community-based family physicians. Resource utilization and visit costs were assessed using test requisitions, consult requests, and prescriptions that were collected by the SPs. Physicians' offices in ambulatory care, hospital-based clinics and in the community. Four persons (aged 57-77 years) trained to simulate having osteoarthritis of the hip. In one simulation, the patient had gastropathy due to nonsteroidal anti-inflammatory drug use, and in the other, the patient sought therapy for hip discomfort. Reliability of cost estimates of physician services, tests, consultations, prescriptions, and total visits and test-ordering behavior for nonsteroidal anti-inflammatory gastropathy. Overall, 112 (63%) of the physicians who were sent invitations to the study agreed to participate. Of 312 total SP visits conducted over a 1-year period, unblinding due to SP detection occurred on 36 occasions (11.5%). Reliable cost estimates of physician services, tests, and consultations, and moderately reliable estimates of total visit costs, were obtained with 4 visits per practicing physician and with 2 visits per resident. There were extreme variations in total visit costs generated by the study physicians. A small number of physicians had a major impact on this variability. Standardized patient technology provides a reliable, feasible method to assess variations in resource utilization between physicians.

A Two-Factor Model of Aggression

This article synthesizes theoretical material from psychology research into a practical model for conceptualizing violence in psychiatric settings. Relevant research and theory are reviewed, focusing on two important behavioral models of aggressive behavior, hostile aggression and instrumental aggression. The concepts of reinforcement, anticipated rewards, specific and nonspecific stimulus-driven aggression, intermediary emotional states in aroused persons, and the aggression stimulus threshold are developed into a bimodal model applicable to the clinical management of violence. The model provides a broad framework for categorizing, understanding, and addressing aggressive behavior in clinical settings.

Developing a technology for the use of operant extinction in clinical settings: an examination of basic and applied research.

Extinction of operant behavior, which involves terminating the reinforcement contingency that maintains a response, is important to the development, generalization, and reduction of behavior in clinical settings. We review basic and applied research findings on variables that influence the direct and indirect effects of extinction and discuss the potential value of a general technology for the use of extinction. We suggest that current research findings are not sufficient for the development of a comprehensive, applied technology of extinction and provide extensive guidelines for further studies on factors that may affect the course of extinction in clinical settings.

Responding maintained by intermittent reinforcement: implications for the use of extinction with problem behavior in clinical settings.

Results of basic research have demonstrated that behavior maintained on an intermittent schedule of reinforcement (INT) will be extinguished more slowly than behavior maintained on a continuous schedule (CRF). Although these findings suggest that problem behaviors may be difficult to treat with extinction if they have been maintained on INT rather than on CRF schedules, few applied studies have examined this phenomenon with human behavior in clinical settings. The purpose of this study was to determine whether problem behavior maintained on CRF schedules would be extinguished more rapidly than behavior maintained on INT schedules. Three individuals diagnosed with profound mental retardation participated after results of pretreatment functional analyses had identified the sources of reinforcement that were maintaining their self-injury, aggression, or disruption. Subjects were exposed to extinction following baseline conditions with CRF or INT schedules alternated within reversal or multielement designs. Results suggested that problem behavior may not be more difficult to treat with extinction if they have been maintained on INT rather than CRF schedules. However, switching from an INT to a CRF schedule prior to extinction may lower the baseline response rate as well as the total number of responses exhibited during extinction.

Predictors of Registered Nurses' Lifting Behavior

1. Nurses continue to experience back pain and injury as a result of occupational stressors, with most attributed to lifting clients. 2. Research found that only 2% of nurses lifted clients as prescribed by current nursing textbooks. 3. Nurses' lifting behavior was related to the age of the nurse and the type of client movement. 4. Ongoing education regarding prescribed lifting behavior in clinical settings and continued research regarding strategies to increase the prevalence of safe behavior in the workplace are recommended.

Compliance/adherence in health-related exercise.

The well documented association between habitual exercise and health outcomes makes clear that adherence to therapeutic exercise programs is a fundamental issue for health psychology. Recidivism appears, however, to preclude much of the health potential which exercise can offer. High participant dropout rates are typically observed in clinical exercise settings; these generally approach or exceed 50% within six months of initial involvement. Despite the importance of this issue, investigations of the factors which influence long-term adherence to exercise programs have been essentially atheoretical and have not been pursued systematically. The present review attempts to organize available evidence around models of exercise behavior in the hope this will encourage new research. These models consider the exerciser, the exercise setting, and the person-setting interaction. Also illustrated are the predictive limitations of studies which have focused solely on screening and diagnosis or on intervention and control rather than on a strategy combining both approaches. The intended purpose of this review is to facilitate future study of behavioral prescriptions designed to promote exercise adherence. The timeliness of controlled research on exercise adherence is reinforced by the growing use of various interventions for the enhancement of exercise behavior in clinical settings and by similarities between adherence to health-related exercise and compliance with other types of medical prescriptions.