The professional identity of psychiatry depends on it being regarded as one amongst many medical specialties and sharing ideals of good practice with other specialties, an important marker of which is the achievement of shared decisionmaking and avoiding a reputation for being purely agents of social control. Yet the interactions involved in trying to achieve shared decision-making are relatively unexplored in psychiatry. This study analyses audiotapes of 92 outpatient consultations involving nine consultant psychiatrists focusing on how pressure is applied in shared decisions about antipsychotic medication. Detailed conversation analysis reveals that some shared decisions are considerably more pressured than others. At one end of a spectrum of pressure are pressured shared decisions, characterised by an escalating cycle of pressure and resistance from which it is difficult to exit without someone losing face. In the middle are directed decisions, where the patient cooperates with being diplomatically steered by the psychiatrist. At the other extreme are open decisions where the patient is allowed to decide, with the psychiatrist exerting little or no pressure. Directed and open decisions occurred most frequently; pressured decisions were rarer. Patient risk did not appear to influence the degree of pressure applied in these outpatient consultations.

Background: Acute inpatient care has come under sustained criticism. Services suffer from high occupancy, increased acuity, and patient dissatisfaction with care. The number of beds has been reduced in favour of alternative services. Aim: To articulate clearly the role of acute inpatient care. Method: Drawing on research evidence and the experiences of inpatient and community staff, we present a model to describe the function and tasks of inpatient care. Results: An admission is the result of severity of acute mental disorder, coupled with an acute admission problem. The decision to admit is processed through a filter composed of bed availability, social supports and other services available to the prospective patient. That combined reason provides the primary task of the admission. However patients also bring with them other life and health problems. While not a cause of admission, these problems have to be managed by inpatient staff. Where they can be resolved, they represent an ''admission bonus''. Finally, acute care functions because of the legitimate authority of staff, their 24-hour availability for support and supervision, and the provision of treatment and containment. Conclusion: This model explicates many aspects of acute inpatient care that otherwise create confusion.

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Patients and psychiatrists work together to create a safe conversational environment in which to discuss this potentially difficult issue. Unlike previous studies of patient reports of psychotic symptoms and side effects of drowsiness being ignored, psychiatrists nearly always respond to disclosures of partial/non-adherence. Psychiatrists should apply the same listening skills to patients' disclosures of troubling side effects and psychotic symptoms.

The aim of this audit was to assess the effect of the Quality Mark programme on the quality of acute care received by older patients by comparing the experiences of staff and older adults before and after the programme. Data from 31 wards in 12 acute hospitals were collected over two stages. Patients and staff completed questionnaires on the perceived quality of care on the ward. Patients rated improved experiences of nutrition, staff availability and dignity. Staff received an increase in training and reported better access to support, increased time and skill to deliver care and improved morale, leadership and teamwork. Problems remained with ward comfort and mealtimes. Overall, results indicated an improvement in ratings of care quality in most domains during Quality Mark data collection. Further audits need to explore ways of improving ward comfort and mealtime experience.