The VOICE study – a before and after study of a dementia communication skills training course

Background A quarter of acute hospital beds are occupied by persons living with dementia, many of whom have communication problems. Healthcare professionals lack confidence in dementia communication skills, but there are no evidence-based communication skills training approaches appropriate for professionals working in this context. We aimed to develop and pilot a dementia communication skills training course that was acceptable and useful to healthcare professionals, hospital patients and their relatives. Methods The course was developed using conversation analytic findings from video recordings of healthcare professionals talking to patients living with dementia in the acute hospital, together with systematic review evidence of dementia communication skills training and taking account of expert and service-user opinion. The two-day course was based on experiential learning theory, and included simulation and video workshops, reflective diaries and didactic teaching. Actors were trained to portray patients living with dementia for the simulation exercises. Six courses were run between January and May 2017. 44/45 healthcare professionals attended both days of the course. Evaluation entailed: questionnaires on confidence in dementia communication; a dementia communication knowledge test; and participants’ satisfaction. Video-recorded, simulated assessments were used to measure changes in communication behaviour. Results Healthcare professionals increased their knowledge of dementia communication (mean improvement 1.5/10; 95% confidence interval 1.0–2.0; p<0.001). Confidence in dementia communication also increased (mean improvement 5.5/45; 95% confidence interval 4.1–6.9; p<0.001) and the course was well-received. One month later participants reported using the skills learned in clinical practice. Blind-ratings of simulated patient encounters demonstrated behaviour change in taught communication behaviours to close an encounter, consistent with the training, but not in requesting behaviours. Conclusion We have developed an innovative, evidence-based dementia communication skills training course which healthcare professionals found useful and after which they demonstrated improved dementia communication knowledge, confidence and behaviour

Communication between people living with dementia and healthcare practitioners in hospital: developing and evaluating a staff training intervention: the VOICE study

Background 25% of hospital beds are occupied by a person living with dementia. Dementia affects expressive communication and understanding. Healthcare professionals report lack of communication skills training. Objectives To identify teachable effective strategies for communication between healthcare professionals and people living with dementia, and to develop and evaluate a communication skills training course. Design We undertook a systematic literature review, video-recorded 41 encounters between staff and people with dementia, and used conversation analysis to investigate communication problems and solutions. We designed a communication skills training course using co-production and multiple pedagogic approaches. We ran a pilot, followed by six courses for healthcare professionals. We measured knowledge, confidence and communication behaviours before, immediately-and one month-after the course, and undertook interviews with participants and managers. Behaviours were measured using blind-rated videos of simulations. Setting General hospital acute geriatric medical wards; clinical skills centre. Participants We video-recorded 26 people with dementia and 26 professionals. Ten experts in dementia care, education, simulation and communication contributed to intervention development. Six healthcare professionals took part in a pilot course and 45 took part in the training. Results Literature review identified 27 studies, describing ten communication strategies, with modest evidence of effectiveness. Healthcare professional-initiated encounters followed a predictable phase structure. Problems were apparent in requests (with frequent refusals) and in closings. Success was more likely when requests were made directly, with high entitlement (authority to ask), and with lowered contingencies (made to sound less difficult , by minimising the extent or duration of the task, as king patients ‘to try’, offering help, or proposing collaborative action). Closings were more successful if the healthcare professional announced the end of the task, made a specific arrangement, body language matched talk, and through use of ‘closing idioms’. The training course comprised two days, one month apart, using experiential learning, including lectures, video-workshops, small group discussion, simulation (with specially-trained actors) and reflection. We emphasised incorporation of previous expertise, and commitment to person-centred care. 44 participants returned for the second training day; 43 provided complete evaluation data. Knowledge and confidence both increased. Some behaviours, especially relating to closings, were more commonly used after training. The course was highly-rated in interviews, especially the use of simulation, real-life video clips, and interdisciplinary learning. Participants reported that they found the methods useful in practice and were using them a month after the course finished. Limitations Data were from people with moderate to severe dementia, in an acute hospital, during healthcare professional initiated interactions. Analysis was limited to problems and solutions that were likely to be ‘trainable’. Actors required careful preparation to simulate people with dementia. Communication skills training course participants were volunteers, unlikely to be representative of the general workforce, who displayed high levels of baseline knowledge, confidence and skills. Before-and-after evaluations, and qualitative interviews, are prone to bias. Future work Further research should investigate a wider range of health, social care and family carers. Conversation analysis should be used to investigate other aspects of healthcare communication. Conclusions Requests and closings pose particular difficulties for professionals communicating with people with dementia. We identified solutions to these problems and incorporated them into communication skills training, which improved knowledge, confidence and some communication behaviours. Simulation was an effective training modality

Regulatory Components of the Alternative Complement Pathway in Endothelial Cell Cytoplasm, Factor H and Factor I, Are Not Packaged in Weibel-Palade Bodies

<div><p>It was recently reported that factor H, a regulatory component of the alternative complement pathway, is stored with von Willebrand factor (VWF) in the Weibel-Palade bodies of endothelial cells. If this were to be the case, it would have therapeutic importance for patients with the atypical hemolytic-uremic syndrome that can be caused either by a heterozygous defect in the factor H gene or by the presence of an autoantibody against factor H. The in vivo Weibel-Palade body secretagogue, des-amino-D-arginine vasopressin (DDAVP), would be expected to increase transiently the circulating factor H levels, in addition to increasing the circulating levels of VWF. We describe experiments demonstrating that factor H is released from endothelial cell cytoplasm without a secondary storage site. These experiments showed that factor H is not stored with VWF in endothelial cell Weibel-Palade bodies, and is not secreted in response in vitro in response to the Weibel-Palade body secretagogue, histamine. Furthermore, the in vivo Weibel-Palade body secretagogue, DDAVP does not increase the circulating factor H levels concomitantly with DDAVP-induced increased VWF. Factor I, a regulatory component of the alternative complement pathway that is functionally related to factor H, is also located in endothelial cell cytoplasm, and is also not present in endothelial cell Weibel-Palade bodies. Our data demonstrate that the factor H and factor I regulatory proteins of the alternative complement pathway are not stored in Weibel-Palade bodies. DDAVP induces the secretion into human plasma of VWF —- but not factor H.</p></div

Intensity scatter plots comparing FH with VWF do not show colocalization or a single correlation.

<p>HUVECs were treated and stained for FH (red) and VWF (green) as detailed in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0121994#pone.0121994.g001" target="_blank">Fig. 1AB</a>. Images are shown without the DAPI-stained nuclei. (A) FH detection with mouse anti-FH + goat anti-mouse AF-647 (red); (B) VWF detection with rabbit anti-VWF + chicken anti-rabbit AF-488 (green); and (C) Merged image of (A) and (B) detecting FH and VWF. The correlation coefficients, Pearson’s (PCC) and Manders’ (M1 and M2), for these 2 images are on the left bottom of the image. (D) The intensity scatter plot of the merged image in (C) showing 2 linear independent relationships of the data. The scattering of points along each of the axes indicates a low degree of signal overlap. The intensity delta is the distance from either outer color line to the plot’s center of density line and defines the area considered for colocalization. An intensity delta of 30 pixels was used for all of the colocalization measurements. The inset in (C) shows an enlargement of the plot’s origin.</p

Changes in FH levels measured in plasma stored at 4°C for 26 days.

<p>Six individual units of plasma anticoagulated with citrate-phosphate-dextrose were stored at 4°C for 26 days. The FH levels were measured by fluorescent immunoassay on day 1 and after 14 and 26 days of storage at 4°C.</p><p>Changes in FH levels measured in plasma stored at 4°C for 26 days.</p

Colocalization coefficients of internal FH in HUVECs concurrently stained with VWF, β-actin and FI.

<p>Colocalization coefficients, Pearson’s (PCC) and Manders’ (M1 and M2), were measured in HUVEC images stained concurrently for FH and with VWF, β-actin, or FI, using the antibody pairs 2, 3 and 4 described under Internal HUVEC FH, VWF, β-actin and FI Detection in the Methods section. Data were analyzed in 2–4 images per experiment from 4–7 experiments with each antibody pair.</p><p>^aIndicates signal correlation in the two channels.</p><p>Colocalization coefficients of internal FH in HUVECs concurrently stained with VWF, β-actin and FI.</p

Intensity scatter plots of FH with FI indicate a high degree of colocalization in the HUVEC cytoplasm.

<p>HUVECs were formaldehyde-fixed, treated with Triton-X and stained concurrently for FH and FI. (A) FH was detected using 2 mouse monoclonal antibodies to human FH plus chicken anti-mouse AF IgG-647 (red). (B) FI was detected using polyclonal goat anti-human FI plus donkey anti-goat AF IgG-488 (green). (C) Shows the merged image detecting both FH (red) and FI (green) and the calculated values for the Pearson’s (PCC) and Manders’ (M1 and M2) correlation coefficients. (D) The intensity scatter plot of the merged image in (C) shows a single linear correlation indicative of a signal overlap. The population is skewed towards the y-axis on account of the higher green intensity values of FI detection.</p