Week 10 Flashcards
Aggression
Behaviour that is intended to injure a person or to destroy property
Can be physical or verbal
Different types of aggression
Psychoanalytic theory Freud 1920
Many of actions determined by instincts particularly sexual instinct
When expression of these instincts is frustrated an aggressive drive is induced
Aggression is a basic drive like hunger
Catharsis
Frustration- aggression hypothesis Dollard et al 1939
Aggression is always a consequence of frustration
The existence of frustration always leads to some form of aggression
Revised frustration- aggression hypothesis Berkowitz 1989
Inability to attain a goal- frustration- negative affect- aggressive drive- overt aggressive behaviour
Aggressive cues. ^
Aggressive cue theory Berkowitz 1966
Frustration produces anger rather than aggression
Frustration is psychologically painful and anything that is psychologically or physically painful can lead to aggression
For anger/psychological pain to be converted into aggression cues are needed: environmental stimuli associated with either with aggressive behaviour or with the frustrating object or person
Ethological perspective Lorenz 1963
Aggression is fighting instinct in beast and man which is directed against members of the same species
Important in the evolutionary development of species as it allows individuals to adapt to their environments survive in them and successfully reproduce
Social learning theory Bandura 1963
Past learning
Current punishments and rewards
Social and environmental factors
Aggressive behaviours are learned through reinforcement and the limitation of aggressive models
Observational learning
Deindividuation
Certain groups situations can minimise the salience of peoples personal identities reduce their sense of public accountability and in doing so produce aggressive or unusual behaviour
-group size
-anonymity
Stanford prison experiment Zimbardo et al 1971
Prisoners and guards stepped far beyond boundaries
Dangerous and psychologically damaging situations arose
One third guards judged to have exhibited “genuine” sadistic tendencies
Obedience- milgram 1963
Many people indicated their desire to stop the experiment and check on the learner
Some test subjects paused at 135 volts and began to question the purpose of the experiment
Most continued after being assured that they wouldn’t be held responsible
Up to 3x 450 volt shocks
Neurobiological factors
Neuroanatomical differences: prefrontal areas, amygdala, hippocampus, hypothalamus
Lower levels of serotonin
Higher levels of testosterone before birth and in early childhood
Lower levels cortisol
Ways in which brain functioning can lead to aggression:
-increased arousal interfering with the ability to think
-decreased ability to inhibit impulses
-impairment of attention, concentration, memory, and higher mental processes
-misinterpretation of external stimuli and events
Phineas gage 1848
Most front part of left side of brain destroyed
Became impatient, irritable, erratic and uncaring
Warning signs of aggressive behaviour
Irritability: rising tension
Fast speech
Restless pacing
Loud voice
Glaring eyes
Verbal threats
Intrusion into others personal space
Gut instinct
Dealing with angry patients
Avoid being defensive
Calm, speak firmly
Body language
Demonstrate you’re taking concerns seriously
Nature or nurture aggression
Nature: believe aggression is an innate drive- psychoanalytic theory, ethology, neurobiology
Nurture: believe aggression is a learned response- social learning theory, neurobiology
Psychoanalytic theory personality composed three elements
Id: impulsive and unconscious, responds immediately to basic desires, aggression is part of Id
Ego: our rational self, represses aggressive impulse
Superego: ideal image of ourselves, repress aggressive impulse
Catharsis
Process of providing release from strong or repressed emotions. Acting aggressive is an effective way to reduce aggressive impulse
General aggression model GAM
Suggests aggression is a result of both the personality and interaction of the person in the situation
GAM can be broken down into : proximal processes and distal processes
Proximal processes: immediately related to aggressive behaviours begins with 2 inputs- situational input and personal input these influence the internal state which then influences appraisal and decision process which then determines whether a thoughtful or impulsive action takes place. The social encounter then influences situational and personal input for next cycle
Distal process: influence short term processes through long term aggressive behavioural tendencies show how continued exposure to aggression develops long term aggressive personalities
2 factors that influence development of aggressive personality: biological modifiers, environmental modifiers
Personality developed effect personal and situational inputs
Confidentiality
‘Patients have a right to expect that their personal information will be held in confidence by their doctors’ GMC 2017
‘Patients entrust us with or allow us to gather, sensitive information relating to their health and other matters as part of their seeking treatment. They do so in confidence and they have the legitimate expectation that staff will respect their privacy and act appropriately’ NHS code of Practice 2003
Principlism
Arguments for confidentiality if we look at 4 principles model
Non-maleficence: disclosure- potential harm
Autonomy: requires security, self determination
Beneficence: it’s rare that breaching a patient’s confidentiality would be in their interests
Justice: fairness
Deontological
A duty of confidence arises when one person discloses information to another in circumstances where it is reasonable to expect that the information will be held in confidence
- a legal obligation that is derived from case law
- is a requirement established within professional codes of conduct
-must be included within NHS employment contracts as a specific requirement linked to disciplinary procedures
Utilitarian
There would be multiple and potentially severe ramifications for individual patients and for society as a whole if doctors breached confidentiality
Therefore rule utilitarians would support maintaining confidentiality generally act utilitarians would assess on a case by case basis
Virtue ethicists
Would a good doctor breach confidentiality
What constitutes a legal breach
An individual can sue in the civil courts for breach of confidentiality
It’s also possible to pursue a criminal case
To establish a legal branch:
- the information disclosed must have the quality of confidentiality
-the information must have been gained in confidential circumstances
-the plaintiff must show that there was unauthorised use of the information
Successful suits also show that harm resulted from the breach
The breach does not have to be deliberate
What constitutes a professional breach
Information that can identify individual patients must not be used or disclosed for purposes other than healthcare without the individuals explicit consent, some other legal bases or where there is a robust pubic interest or legal justification to do so. In contrast, anonymised information is not confidential and may be used with relatively few constraints
NHS code of practice of confidentiality 2003
-where and when you saw the patient
-patients with rare diseases
Assume confidentiality
GMC guidance:
In general you can only share personal information about a patient within the healthcare team or for the purposes of audit
Even then you should make every effort to ensure patients are aware that their information might be shared in this way
And patients can refuse to let you do so
If this will affect their care (not being able to refer to another team) you must make sure your patient is aware of that
Situations where confidentiality can be breached
Situations where confidentiality can be set aside but only with patients consent:
- research
-publication
-teaching
-third party requests
Situations where confidentiality can be set aside without consent:
-disclosure required by law
-disclosure is in public interest- serious crime, communicable disease
You should still notify the patient of your intention to breach their confidence unless this would be prejudicial to the reason you are breaching it - to prevent a crime
The data protection act 2018
Covers all healthcare records of living patients- paper and electronic
Harm suffered due to contravening the act is subject to compensation
Enacted with the GDPR applies post-brexit
Organisations are accountable for following the act and must be able to demonstrate that they do so
Data protection act 2018 personal data
Must be:
-processed fairly and lawfully
-obtained only for one or more specified and lawful processes
-adequate, relevant and not excessive in relation to the purposes
-accurate and up to date
-not kept for longer than is necessary
-processes in accordance with the rights of data subjects within the act
-protected against unauthorised processing, accidental loss, damage or destruction
-not transferred overseas unless that country ensures adequate protection for the data
Sensitive information
Some types of data must be handled extra carefully under GDPR rules known as ‘special category’ data
Uk GDPR defines special category data as:
-personal data revealing racial or ethnic origin
-personal data revealing political opinions
-personal data revealing religious or philosophical beliefs
- personal data revealing trade union membership
-genetic data
-biometric data (when used for identification purpose)
-data concerning health
-data concerning persons sex life
-data concerning persons sexual orientations
Data protection act SARs
The NHS is the owner of the medical records
Patients do have the right to access their records via a process called a Subject Access Request. but this can be refused if:
-unsure of the identity of the person seeking the info
-disclosure of the info relating to third party would result
-compliance would cause serious harm
-disclosure is not in best interests of the data subject
SARs can only be made for living persons, however relatives may be able to view health records of deceased patients under the Access to Health Records Act 1990
Caldicott guardians
Since 1977 all NHS trusts have had a caldicott guardian responsible for safeguarding patient data
Caldicott principles:
-justify the purpose for using confidential info
-only use it when absolutely necessary
-use the minimum that’s required
-access should be on a strict need to know basis
-everyone must understand his or her responsibilities
-understand and comply with the law
What is bullying
Although no legal definition ACAS describes it as “unwanted behaviour from a person or group that is either: offensive, intimidating, malicious or insulting, an abuse or misuse of power that undermines, humiliates, or causes physical or emotional harm to someone”
Bullying might
Be a regular pattern of behaviour or a one off incident
Happen face to face, social media, in emails , or calls
Happen at work or in other work related situations
Not always be obvious or noticed by others
Not have any witness but its still bullying
When bullying might be classed as harassment
Harassment is when bullying or unwanted behaviour is about any of the following ‘protected characteristics’ under discrimination law (equality act 2010)
-age
-disability
-gender reassignment
-race
-religion or belief
-sex
-sexual orientation
Harassment
The equality act 2010 defines harassment as unwanted conduct that is related to a protected characteristic or unwanted conduct of a sexual nature
It has the purpose or the effect of violating someone’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for them
Harassment is unlawful
Explain impacts of bullying and harassment
Someone who is bullied or harassed at work is likely to experience one or more of the following
-anxiety
-difficulty sleeping
-loss of appetite
-inability to switch off from work
-self doubt, loss of confidence
-feeling isolated
-hyper-vigilance or a need to constantly double- check your work
What does the BMA say
“Bullying increases the risk of psychological distress and mental health problems among doctors”
“Women doctors who have experienced sexual harassment report that it has undermined their confidence in themselves as professionals and negatively affected their careers”
The high cost of bullying for organisations according to BMA
Apart from harm to individuals (staff, patients, compromising patient safety) tolerating bullying and harassment can lead to:
-higher turnover and increased sickness absence
-lower productivity
-potential costs of litigation and compensation
-loss of public goodwill
-reputational damage
How to approach bullying and harassment
BMA says: formal anti-bullying policies and procedures may not work
Barriers to this succeeding include:
-placing the onus on the bullied individual to formally report the problem when surveys and research show an unwillingness to
-a reliance on formal complaints mechanisms prevents early resolution
- a reluctance to impose formal sanctions on ‘high value’ individuals
-a desire to avoid litigation or protracted formal proceedings which can result in pressure to find against the complainant or force them out
Calls for a more comprehensive approach
Good practice recommendations include:
Developing behavioural standards in collaboration with employees and role-modelling good behaviours by senior managers and staff
Early identification of bullying behaviours and acting on risk factors like poor management practices and excessive workloads
Empowering people to talk more openly about what is acceptable and unacceptable behaviour
Strong support structures for employees and managers representatives bullying or fair treatment officers, occupational health
Encouraging informal resolution where appropriate backed up by clear and accessible formal procedures for when early resolution does not work
What you can do as individuals
Be a good role-model
Educate yourself and others continually
Educate support and empower others
Be open with others including being open to criticism
Bystander apathy is common with workplace bullying and harassment
Bystander apathy is often caused by a diffusion of responsibility
Psychological research shows that individual are less likely to offer help to a victim in presence of other people
Number of bystanders often leads to diffusion of responsibility that reinforces mutual denial
If you were the only witness you’d be more likely to step up and intervene
Options for intervening
Distraction: delicate and creativity way to intervene, distract either the harasser or the target with conversation unrelated to the harassment to derail and de-escalate the situation
Getting help: offer help, tell someone offer to report it to provide letter or witness statement
Checking in later: call in later and see if the victim is ok offer if they need help again
Directly intervening
Errors more likely in
Elderly
Polypharmacy
Multiple co-morbidities
What sort of mistakes
Medication- related
Diagnostic
Clinical management
Invasive procedures
Hospital-acquired infections
Surgical procedures
System related
Root cause analysis
Can be used to investigate almost any adverse incident
Looks at all the influences on the outcome not just negative ones
Will generally identify multiple causes- some will involved human error others problems with system
Should involved speaking directly to the people involved where possible
Serious incidents
May include:
-unexpected or avoidable death
-unexpected or avoidable injury resulting in serious harm
-abuse
Never events
Incidents that prevent delivery of an acceptable quality of healthcare services
Incidents that cause widespread public concern/loss of confidence
Never event
A serious incident that is wholly preventable
National guidance/safety recommendations should have been employed
-wrong site surgery
-certain prescribing errors
-ABO incompatible transfusion
Patient safety strategy
Identifies 2 core elements
-culture of safety
-system of safety
A culture of safety
Avoiding individual blame
Psychological safety for staff
The role of trust
Inclusivity
Kindness and civility
A candid process
The duty of candour applies throughout the process
GMC- “every healthcare professional must be open and honest with patients when something that goes wrong”
This involves: tell the patient, apologise, offer appropriate support, explain fully the short/long term effects
The duty of candour obliges doctor to inform their organisation of any near misses in patients care
However the organisation must then decide if its appropriate to tell patient
Medical negligence
An act or omission that causes harm to an individuals property, reputation or interests
As a civil wrong it’s considered a wrong against the individual rather than a criminal wrong which is considered a wrong against society as a whole
Civil wrongs are usually dealt with by awarding compensation
Clinical negligence
Did you have a duty to the patient
Did you breach that duty
Did you breach cause the patient harm
Breach of duty
Practice has failed to meet an appropriate standard
Tort law usually defines the standard of ‘the reasonable man’
However for medicine this is reinterpreted as the standard of comparable medical practice
Standard for rotating trainees
There is an expectation of safety regardless of experience
Standard is held in relation to the grade without reference to how long they have held the post
An inexperienced doctor is expected to know their limits and ask for more support
Criminal negligence
Harm is the result of ‘gross’ carelessness
Requirement is to establish beyond reasonable doubt as opposed to balance of probabilities
Can carry a custodial sentence and generally would be accompanied by fitness to practice investigation by GMC
Social resistance
When you deviate from the norms of a system you can expect the people around you who follow the rules of the system to resist this
Most people normally follow path of least resistance- system rules norms
Systems model
Behaviour flows along predetermined channel which are set by the norms/rules of that system
Social resistance keeps the behaviour within the norms /rules of this system
Therefore if the norms/rules are followed we have predefined outcomes
If we want our outcomes to be patient safety then we need to make sure it is the path of least resistance
Neurobiological factors aggression
Neuroanatomical differences: (pre)frontal areas, amygdala, hippocampus, hypothalamus
Lower levels of serotonin
Higher levels of testosterone before birth and in early childhood
Lower levels of cortisol
Ways in which brain functioning can lead to aggression:
- increased arousal interfering with the ability to think
-decreased ability to inhibit impulses
-impairment of attention, concentration, memory and higher mental processes
-misinterpretation of external stimuli and events
Sex differences in aggression
Girls have more indirect and verbal aggression
Boys have more physical and verbal aggression
Testosterone is associated with physical aggression
What is a material risk
The test of materiality:
Whether a reasonable person in the patients position would attach significance to the risk
Or if the doctor knows that this particular patient would attach significance to risk
An effective manager
Will:
-clearly communicate what is expected in advance
- apply performance standards in a fair and consistent way
-discuss any performance issues in private with the relevant members of staff
- give constructive feedback and set out the necessary steps for improvement
- be willing to listen and understand what may lie behind any performance problems
- provide appropriate support and opportunities to improve before taking further action
Should not:
- constantly change the goalposts
- be inconsistent in how they deal with performance issues or show favouritism
-criticise, humiliate, or undermine staff in public
-jump to conclusions and seek to blame others for failures
- immediately threaten or take disciplinary action without first offering appropriate support and a chance to improve
When witnessing bullying the process a bystander may go though which would result in their intervention is
Notice that something going on
Interpret the situation as being an emergency
Degree of responsibility felt
Form of assistance
Implement action choice
