Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)

Background Dementia has an enormous impact on the lives of individuals and families, and on health and social services, and this will increase as the population ages. The needs of people with dementia and their carers for information and support are inadequately addressed at all key points in the illness trajectory. Methods The Unit is working specifically on an evaluation of the impact of the Mental Capacity Act 2005, and will develop practice guidance to enhance concordance with the Act. Phase One of the study has involved baseline interviews with practitioners across a wide range of services to establish knowledge and expectations of the Act, and to consider change processes when new policy and legislation are implemented. Findings Phase 1, involving baseline interviews with 115 practitioners, identified variable knowledge and understanding about the principles of the Act. Phase 2 is exploring everyday decision-making by people with memory problems and their carers

Communications in general practice and the domestication of ICT

The NHS is currently being transformed by the implementation of the National Programme for Information Technology (NPfIT). This thesis examines the use of Information Communications Technology (ICT) and its consequences for communications in general practice. While drawing on a range of social scientific approaches to ICT, this research explores the particular utility of the 'domestication' framework advanced by Silverstone and Sorensen. It considers how users in general practice 'tame' and use technology by incorporating its affordances into their work roles and communication practices.Drawing on previous survey work, this research adopts a comparative, ethnographic approach, analyzing patterns of talk and writing in two general practices in London. Empirical work involved analysis of local and national policy documentation and two ethnographic studies that were designed to identify changes in attitudes and behaviours across a defined set of actors over time. Interviews generated preliminary evidence as to how multiple users in general practice communicated by a variety of means, including the problems/concerns they encountered or created in doing so. Observation was used to gather further direct evidence of those problems as they were negotiated and resolved.Although the two cases were both of practices that had been identified in an earlier survey as 'paper-light' which might therefore have been assumed to make effective use of ICT, usage was uneven and sharp differences were noted in the way in which broadly similar technologies were domesticated by specific user groups. Analysis of these differences produced three key findings. Firstly, domestication of ICT in general practice is difficult. To be successfully domesticated, ICTs have to be locally negotiated both horizontally and vertically in order to connect with working practices of the individual users. Secondly, the struggle to 'tame' ICTs is shaped by the extent to which different groups of users perceive ICT as assisting or compromising their roles and responsibilities. This, in turn, increases the diversity between user groups. Thirdly, the research indicated the importance of local context and workplace cultures which facilitate or inhibit the negotiations or 'communications about communications' required to domesticate ICTs.A concluding discussion reflects on the changing relationship between ICTs and communications in general practice and, in particular, the impact of ICT on faceto-face communications. The key contribution of the study lies in offering a theoretically-sophisticated framework in which to examine and explicate detailed patterns of communications in general practice. By addressing both electronic and paper-based communication as well as face-to-face interaction, it provides a basis for future research in this area as NPfIT develops

Transforming Health in Prince George's County, Maryland: A Public Health Impact Study

Executive Summary and Technical Reports and Supporting Documents Section II of the Public Health Impact Study of Prince George’s County report includes technical reports that document the methods, findings, limitations and a summary for each of the seven study components. We also include copies of the study instruments, where appropriate. While the findings of these study components formed the basis for the integrated answers to the study’s five framing questions, the technical reports include more detailed data than was possible to include in Section I, and also provide insights for the study as a whole.http://sph.umd.edu/princegeorgeshealth/SPH_ImpactStudy_TechnicalReports.pd

Exploring the psychological health of emergency dispatch centre operatives : a systematic review and narrative synthesis

Background. The study objective was to investigate and synthesize available evidence relating to the psychological health of Emergency Dispatch Centre (EDC) operatives, and to identify key stressors experienced by EDC operatives. Methods. Eight electronic databases (Embase, PubMed, Medline, CINAHL, PsycInfo, PsycArticles, The Psychology and Behavioural Sciences Collection, and Google Scholar) were searched. All study designs were included, and no date limits were set. Studies were included if they were published in English, and explored the psychological health of any EDC operatives, across fire, police, and emergency medical services. Studies were excluded if they related solely to other emergency workers, such as police officers or paramedics. Methodological quality of included studies was assessed using checklists adapted from the Critical Appraisal Skills Programme. A narrative synthesis was conducted, using thematic analysis. Results. A total of 16 articles were included in the review. Two overarching themes were identified during the narrative synthesis: `Organisational and Operational Factors' and `Interactions with Others'. Stressors identified included being exposed to traumatic calls, lacking control over high workload, and working in under-resourced and pres- sured environments. Lack of support from management and providing an emotionally demanding service were additional sources of stress. Peer support and social support from friends and family were helpful in managing work-related stress. Discussion. EDC operatives experience stress as a result of their work, which appears to be related to negative psychological health outcomes. Future research should explore the long-term effects of this stress, and the potential for workplace interventions to alleviate the negative impacts on psychological health.</p

The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study

Background: There is international interest in the potential role of different forms of communicationtechnology to provide an alternative to face-to-face consultations in health care. There has beenconsiderable rhetoric about the need for general practices to offer consultations by telephone, e-mail orinternet video. However, little is understood about how, under what conditions, for which patients and inwhat ways these approaches may offer benefits to patients and practitioners in general practice.Objectives: Our objectives were to review existing evidence about alternatives to face-to-face consultation;conduct a scoping exercise to identify the ways in which general practices currently provide these alternatives;recruit eight general practices as case studies for focused ethnographic research, exploring how practicecontext, patient characteristics, type of technology and the purpose of the consultation interact to determinethe impact of these alternatives; and synthesise the findings in order to develop a website resource about theimplementation of alternatives to face-to-face consultations and a framework for subsequent evaluation.Design: Mixed-methods case study.Setting: General practices in England and Scotland with varied experience of implementing alternatives toface-to-face consultations.Participants: Patients and practice staff.Interventions: Alternatives to face-to-face consultations include telephone consultations, e-mail,e-consultations and internet video.Main outcome measures: How context influenced the implementation and impact of alternatives to theface-to-face consultation; the rationale for practices to introduce alternatives; the use of different forms ofconsultation by different patient groups; and the intended benefits/outcomes.Review methods: The conceptual review used an approach informed by realist review, a method forsynthesising research evidence regarding complex interventions.Results: Alternatives to the face-to-face consultation are not in mainstream use in general practice, withlow uptake in our case study practices. We identified the underlying rationales for the use of thesealternatives and have shown that different stakeholders have different perspectives on what they hope toachieve through the use of alternatives to the face-to-face consultation. Through the observation of real-lifeuse of different forms of alternative, we have a clearer understanding of how, under what circumstancesand for which patients alternatives might have a range of intended benefits and potential unintendedadverse consequences. We have also developed a framework for future evaluation.Limitations: The low uptake of alternatives to the face-to-face consultation means that our researchparticipants might be deemed to be early adopters. The case study approach provides an in-depthexamination of a small number of sites, each using alternatives in different ways. The findings aretherefore hypothesis-generating, rather than hypothesis-testing.Conclusions: The current low uptake of alternatives, lack of clarity about purpose and limited evidence ofbenefit may be at odds with current policy, which encourages the use of alternatives. We have highlightedkey issues for practices and policy-makers to consider and have made recommendations about priorities forfurther research to be conducted, before or alongside the future roll-out of alternatives to the face-to-faceconsultation, such as telephone consulting, e-consultation, e-mail and video consulting.Future work: We have synthesised our findings to develop a framework and recommendations aboutfuture evaluation of the use of alternatives to face-to-face consultations.Funding details: The National Institute for Health Research Health Services and DeliveryResearch programme.ABSTRACTNIH

Perceptions of wellness recovery action plan (WRAP) training: a systematic review and metasynthesis

Purpose The purpose of this systematic review was to address two questions: what is the qualitative evidence for the effects of the Wellness Recovery Action Plan (WRAP) training, as perceived by adults with mental health difficulties using it? What is the quality of qualitative literature evaluating WRAP? Design/methodology/approach Five electronic reference databases and the EThOS database for unpublished research were systematically searched, as well as two pertinent journals. Study quality was assessed using Critical Appraisal Skills Programme criteria and results analysed using thematic synthesis. Findings Of 73 studies, 12 qualitative papers met inclusion criteria and were generally good quality. Analyses demonstrated expected findings, such as increased understanding and active management of mental health in the context of group processes. Results also highlighted that WRAP training promoted acceptance and improved communication with professionals. Peer delivery of WRAP was highly valued, with contrasting perceptions of peers and professionals evident. Some cultural considerations were raised by participants from ethnic minorities. Research limitations/implications WRAP training participation has positive self-perceived effects beyond those captured by measures of recovery. Broader implications are suggested regarding earlier access to WRAP, professional support and communication between professionals and service users. Recommendations for further research include the relationship between social support and illness self-management and peer-delivered acceptance-based approaches. Multiple time-point qualitative studies could offer insights into WRAP training processes and whether changes are sustained

Learning about sex: Results from Natsal 2000.

11-13 September 2002

Assessment of quality of care provided to patients who died in the care of Tshwane District Hospital

Objective: To assess the quality of care rendered to admitted patients in need of end-of- life care at Tshwane District Hospital in Pretoria Central, Gauteng, South Africa. Method: A combined retrospective review of the patient’s folder and a descriptive qualitative study through interviewing the deceased patient’s relatives was used. An after-death audit (ADA) tool, developed by the researcher and supervisor using the Gold Standard Framework ADA Tool, which is used in the UK was used as a reference as was agreed to be appropriate for this study. This explored the ability of healthcare workers at district hospital level to identify patients who were at end-of-life through noting and recording the end-of-life symptoms and signs and the interventions taken within the last 72 hours of the patients’ life. An interview guide for the bereaved family members was developed using the family medicine principle of patient-centred care and management in order to investigate their perception of the quality of care rendered to their relatives whilst admitted at Tshwane District Hospital during their last days. Results: 96 files were audited, revealing that patients between the ages of 21 years to 101 years were admitted. This confirmed the increase in number of older people with incurable chronic disease and multi-morbidity such as malignancy and HIV/AIDS, as compared to younger patients. Of those admitted, 55.2% were admitted from home and 15.6% were referred from a tertiary institution. 83% of these patients were admitted due to non-cancer diagnosis, of which about 36% of those admissions were HIV- related, followed by renal causes (10%), cardiac (10%) and COPD (3%). Cancer accounted for approximately 16.6% of the admissions. The duration of stay was between 4.3 to 4.7 days, with younger and white patients admitted for shorter periods compared to their older and black counterparts. The audited patient records recorded signs in their files (gasping - 51.04%, low BP, low pulse - 18.75%) and symptoms of end-of-life (confused, ill, weak - 18.75%) but patients were not identified or recognised as being close to end-of-life and were not referred for palliative care. The only recorded intervention that patients received was oxygen by mask (54.1%). Record reviews and family interviews revealed poor patient involvement in decision-making as only about 9.3% were involved in their own care management. There was also a lack of family involvement in patient management (4.4%), poor multi-disciplinary /team involvement as only 29.2% were referred to the other members of the multi-disciplinary team, and a low referral to hospice (8.3%). According to the 18 consented family members’ interviews conducted, there was lack of information with poor updates on patients’ problems or prognosis. Only 58,8% felt that enough information was given and the members interviewed were not offered any additional services (76.5%). They indicated that they thought referral to hospice would have improved the quality of life and care of their loved ones at end-of-life. The majority of family members (88.24%) also reported little care for patients during the dying phase as their relatives (patients) had symptoms (23.53%) but nothing had been done to relieve these symptoms. Conclusion: There is an increased need for palliative care and end-of-life care education and skills at district hospitals as most patients are admitted or down-referred for care to district hospitals at the end-of-life. When looking at interventions rendered, the study revealed poor quality of care rendered to patients at their end-of-life, poor patient and family involvement in management decisions, and a lack of multi-disciplinary approach of care. Helping or training of the healthcare workers at District Care level Hospitals to be able to recognise a patient in need of palliative care or have an ability in recognising those patients who require end-of-life care or are in their last 72hrs of life (which refers to the patients in the final hours or days of their lives, or those with a terminal illness that has become progressively advanced) is still a challenge in the District level hospital. The integration of palliative care at district hospitals would improve the quality of care for both patients and their families