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Psychological research has emphasized the importance of narrative for a person's sense of self. Building a coherent narrative of past events is one objective of psychotherapy. However, in guided self-help therapy the patient has to develop this narrative autonomously. Identifying patients' narrative skills in relation to psychological distress could provide useful information about their suitability for self-help. The aim of this study was to explore whether the syntactic integration of clauses into narrative in texts written by prospective psychotherapy patients was related to mild to moderate psychological distress. Cross-clausal syntax of texts by 97 people who had contacted a primary care mental health service was analyzed. Severity of symptoms associated with mental health difficulties was assessed by a standardized scale (Clinical Outcomes in Routine Evaluation outcome measure). Cross-clausal syntactic integration was negatively correlated with the severity of symptoms. A multiple regression analysis confirmed that the use of simple sentences, finite complement clauses, and coordinated clauses was associated with symptoms (R 2 =.26). The results suggest that the analysis of cross-clausal syntax can provide information on patients' narrative skills in relation to distressing events and can therefore provide additional information to support treatment decisions.

Aim. This paper is a report of a study to identify the content of, and participation in, medicine discussion between nurse prescribers and people with diabetes in England. Background. Diabetes affects 246 million people worldwide and effective management of medicines is an essential component of successful disease control. There are now over 20,000 nurse independent prescribers in the UK, many of whom frequently prescribe for people with diabetes. With this responsibility comes a challenge to effectively communicate with patients about medicines. National guidelines on medicines communication have recently been issued, but the extent to which nurse prescribers are facilitating effective medicine-taking in diabetes remains unknown. Methods. A purposive sample of 20 nurse prescribers working with diabetes patients audio-recorded 59 of their routine consultations and a descriptive analysis was conducted using a validated coding tool: MEDICODE. Recordings were collected between January and July 2008. The unit of analysis was the medicine. Results. A total of 260 instances of medicine discussion identified in the audio-recordings were analysed. The most frequently raised themes were 'medication named' (raised in 88·8% of medicines), 'usage of medication' (65·4%) and 'instructions for taking medication' (48·5%). 'Reasons for medication' (8·5%) and 'concerns about medication' were infrequently discussed (2·7%). Measures of consultation participation suggest largely dyadic medicine discussion initiated by nurse prescribers. Conclusion. MEDICODE discussion themes linked to principles of recent guidelines for effective medicine-taking were infrequently raised. Medicine discussion was characterized by a one statement-one response style of communication led by nurses. Professional development is required to support theoretically informed approaches to effective medicines management.

Background: Nurse prescribers are in a key position to promote medicine-taking in diabetes. Although patients' beliefs about medicines are important predictors of medicine-taking, evidence suggests nurses do not routinely explore these. Objectives: To evaluate a theory-based intervention designed to increase nurse prescribers' exploration of medicines' beliefs with people with diabetes. Design: Mixed methods concurrent triangulation design. Settings: Nurse prescribers were recruited from 7 Trusts in England. Participants: A purposive sample of 14 nurse prescribers attended four 1 day workshops. Methods: Audio-recordings of each nurse prescribers' consultations with diabetes patients were collected at baseline, 1 week, 3 months and 6 months after the intervention. Nurse prescribers were interviewed at 1 month and 6 months post-intervention. Changes in medicines' discussion and participation in consultations were analysed using MEDICODE. Interview data were analysed using Framework Analysis. Results: MEDICODE themes of 'attitudes towards medication' showed a significant rise at 1 week (p<0.01) and 3 months (p<0.05). 'Asks patient opinion about medication' significantly increased at 1 week (p<0.01). Discussion on 'concerns about medication' rose significantly at 1 week (p<0.001) and 6 months (p<0.01). Discussion on 'expected effects of medication', 'action of medication' and 'reasons for medication' showed no change. There were no significant changes in Dialogue Ratio. However, the Preponderance of Initiative moved towards more patient initiative at 1 week (p<0.0001), 3 months (p<0.0001), and 6 months (p<0.0001). In interviews, nurses reported increased attention to patients' medication beliefs and adoption of patient-centred skills. Contextual factors that positively influenced ability to explore medicines beliefs in practice settings were: support of colleagues and practicing new skills. Inhibiting factors included: patients' perceived lack

The research reported in this thesis investigates the self-efficacy construct in the context of (real world) diabetes self-management programmes. Self-efficacy interventions, although widely implemented in diabetes care, lack basic information on what exactly was delivered. More importantly, there has been no assessment tool which would enable researchers to externally evaluate the use of self-efficacy-based techniques in interventions and provide accurate report information about the process of intervention delivery. To address this gap, the present PhD aimed to develop a reliable and valid coding tool to assess the use of self-efficacy-based techniques among nurses delivering education for people with diabetes and test its clinical utility by delivering a self-efficacy-based intervention to diabetes nurses. The four sources of self-efficacy: mastery experience, role modelling, verbal persuasion and physiological and affective states formed the conceptual basis of the coding tool. The findings of the literature review and observation of three educational programmes provided an operationalisation of the four sources of self-efficacy and resulted in 11 verbal behavioural techniques. Four coders rated diabetes programmes to establish reliability of the coding tool. Cross-sectional and longitudinal data from 52 patients, based on self-report and objective measures, as well as demographic information about five nurses were related to nurse-led self-efficacy based techniques to establish the validity of ASSET. In a single pre-post design, the feasibility and effectiveness of ASSET-based interventions delivered to five nurses were evaluated. The key findings were that ASSET could be a useful tool to identify the use of self-efficacy in interventions. The use of self-efficacy-based techniques reflected nurses’ work-related experience gained prior to the study, and to some extent predicted patientrelated outcomes including intention and behaviour regarding diabe

Objective: The paper presents the development of a coding tool for self-efficacy orientated interventions in diabetes self-management programmes (Analysis System for Self-Efficacy Training, ASSET) and explores its construct validity and clinical utility. Methods: Based on four sources of self-efficacy (i.e., mastery experience, role modelling, verbal persuasion and physiological and affective states), published self-efficacy based interventions for diabetes care were analysed in order to identify specific verbal behavioural techniques. Video-recorded facilitating behaviours were evaluated using ASSET. Results: The reliability between four coders was high (K = 0.71). ASSET enabled assessment of both self-efficacy based techniques and participants' response to those techniques. Individual patterns of delivery and shifts over time across facilitators were found. In the presented intervention we observed that self-efficacy utterances were followed by longer patient verbal responses than non-self-efficacy utterances. Conclusion: These detailed analyses with ASSET provide rich data and give the researcher an insight into the underlying mechanism of the intervention process. Practice implications: By providing a detailed description of self-efficacy strategies ASSET can be used by health care professionals to guide reflective practice and support training programmes.