Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial

Background: Sleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety. Methods and design: This will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 × 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing. Discussion: Previous studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation

Prolonged exposure and psychodynamic treatment for posttraumatic stress disorder

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Patients’ and clinicians’ experiences of consultations in primary care for sleep problems and insomnia: a focus group study

Background Insomnia affects around one-third of adults in the UK. Many sufferers seek help from primary care. Aim To explore patients’ and primary care practitioners’ expectations, experiences, and outcomes of consultations for sleep difficulties, as a basis for improving the treatment of insomnia in primary care. Design of study A qualitative phenomenological approach. Method Separate focus groups for GPs and nurse prescribers and patients recruited from eight general practices that were in a quality improvement collaborative. Constant comparative analysis was used. Results Emergent themes from 14 focus groups comparing participating patients (n = 30) and practitioners (n = 15), provided insights on presentation, beliefs, expectations, and management of sleep problems. Patients initially tried to resolve insomnia themselves; consulting was often a last resort. Patients felt they needed to convince practitioners that their sleep difficulties were serious. They described insomnia in terms of the impact it was having on their life, whereas clinicians tended to focus on underlying causes. By the time patients consulted, many expected a prescription. Clinicians often assumed this was what patients wanted, and felt this would hamper patients’ ability to take non-drug treatments seriously. Clinicians expected patients who were already on sleeping tablets to be resistant to stopping them, whereas patients were often open to alternatives. Conclusion Better management of insomnia should take into account the perceptions and interactions of patients and practitioners. Practitioners need to empathise, listen, elicit patients’ beliefs and expectations, assess sleep better, and offer a range of treatments, including cognitive and behavioural therapies, tailored to individual needs. Practitioner education should incorporate understanding of patients’ decision-making processes, the clinicians’ role during the consultation, and how to negotiate and deliver strategies for resolving sleep problems

Perceptions and experiences of community first responders on their role and relationships: qualitative interview study

Background Community First Responder (CFR) schemes work with ambulance services to support lay volunteers in responding to medical emergencies. In 1999, UK government encouraged ambulance services to use CFRs, especially in rural locations. Their role is primarily to stabilise patients’ conditions and perform basic clinical procedures before handing over to statutory ambulance service crew. By early 2014, there were 2,431 CFR schemes, using over 12,000 volunteers in the UK. We aimed to explore the perceptions and experiences of CFRs about their role. Methods We interviewed four female and 12 male adult CFRs across Lincolnshire from June-July 2016. Interviews were transcribed verbatim and coded thematically in NVivo 10. Results The interviews revealed five overarching themes: ‘getting started and keeping going’; ‘the reality of being a CFR’; ‘recognition and relationships’; ‘learning to be a CFR’ (training and feedback); and ‘the way forward’. CFRs were keen to enhance their skills and progress, but less enthusiastic about fundraising for schemes. CFRs preferred scenario-based training to prepare for incidents and sought formal feedback from their work. They valued informal emotional support to cope with stressful incidents. The public often confused CFRs with ambulance staff, while the relationship between CFRs and ambulance staff was sometimes ambivalent. To address the lack of awareness among the public and the ambulance service, this scheme is actively raising its profile. Conclusion The desire to help and learn, as well as the emotional support and identity were important drivers to becoming and remaining a CFR. Barriers included: fundraising duties and lack of recognition from the public and statutory services. In response, CFR schemes are actively raising their profile. Our findings provide insight into how CFRs might be better supported. Further research is required on the benefits of CFRs, as well as the public and ambulance service perceptions of what they do