Implementation processes in a cognitive rehabilitation intervention for people with dementia: a complexity-informed qualitative analysis

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ. https://creativecommons.org/licenses/by/4.0/Objectives: Healthcare is often delivered through complex interventions. Understanding how to implement these successfully is important for optimising services. This article demonstrates how the complexity theory concept of ‘self-organisation’ can inform implementation, drawing on a process evaluation within a randomised controlled trial of the GREAT (Goal-oriented cognitive Rehabilitation in Early-stage Alzheimer’s and related dementias: a multi-centre single-blind randomised controlled Trial) intervention which compared a cognitive rehabilitation intervention for people with dementia with usual treatment. Design: A process evaluation examined experiences of GREAT therapists and participants receiving the intervention, through thematic analysis of a focus group with therapists and interviews with participants and their carers. Therapy records of participants receiving the intervention were also analysed using adapted framework analysis. Analysis adopted a critical realist perspective and a deductive-inductive approach to identify patterns in how the intervention operated. Setting: The GREAT intervention was delivered through home visits by therapists, in eight regions in the UK. Participants: Six therapists took part in a focus group, interviews were conducted with 25 participants and 26 carers, and therapy logs for 50 participants were analysed. Intervention: A 16-week cognitive rehabilitation programme for people with mild-to-moderate dementia. Results: ‘Self-organisation’ of the intervention occurred through adaptations made by therapists. Adaptations included simplifying the intervention for people with greater cognitive impairment, and extending it to meet additional needs. Relational work by therapists produced an emergent outcome of ‘social support’. Self-organised aspects of the intervention were less visible than formal components, but were important aspects of how it operated during the trial. This understanding can help to inform future implementation. Conclusions: Researchers are increasingly adopting complexity theory to understand interventions. This study extends the application of complexity theory by demonstrating how ‘self-organisation’ was a useful concept for understanding aspects of the intervention that would have been missed by focusing on formal intervention components. Analysis of self-organisation could enhance future process evaluations and implementation studies. Trial registration number: ISRCTN21027481.Peer reviewedFinal Published versio

What is current practice in offering debriefing services to post partum women and what are the perceptions of women in accessing these services: A critical review of the literature

Objective: The main research question is to describe current practice in offering debriefing services to postpartum women and learn about the perceptions of women accessing these services Design: Critical review of the literature using a meta ethnography approach. Findings: Twenty papers were identified. These included four surveys, three qualitative studies, one mixed methods study and three literature reviews. Nine randomised controlled trials (RCTs) provided additional information from alongside surveys and description of interventions. Two types of debriefing were identified: structured and unstructured. The more formal psychoanalytic forms took place within the RCTs whilst the unstructured discussion sessions commonly with midwives were identified in other research papers. In addition there is confusion amongst service providers about the nature of debriefing and what is delivered. Various aspects of providing a postnatal debriefing service were identified including the optimal timing, specific groups offered debriefing and the number of sessions offered. Postnatal debriefing enabled women to have their birth experiences validated by talking and being listened to and being provided with information. Finally from the limited literature identified relating to midwives’ perceptions of postnatal debriefing there was an overall feeling from midwives that they considered it to be beneficial to women. Key conclusions: The findings of this literature review imply that women’s responses to receiving postnatal debriefing are generally positive. This review has found that women appear to value talking and being listened to by a midwife following birth. They seem to have a strong need to have their story heard. This discussion also allows the women to have questions answered and information given where necessary. The whole process places a seal on a woman’s birth experience which is validated. Implications for practice: Although there is no evidence to suggest that postnatal debriefing reduces morbidity, women find the service of value. Maternity providers should consider offering a postnatal debriefing service to meet those needs in advance of further research in this area

Patient safety content and delivery in pre-registration nursing curricula: A national cross-sectional survey study

Background: Patient safety is a core principle of health professional practice and as such requires significant attention within undergraduate curricula. However, patient safety practice is complex requiring a broad range of skills and behaviours including the application of sound clinical knowledge within a range of health care contexts and cultures. There is very little research that explores how this is taught within Australian nursing curricula. Objectives: To examine how Australia nursing curricula address patient safety; identify where and how patient safety learning occurs; and describe who is responsible for facilitating this learning. Design and Setting: A cross-sectional descriptive study of nursing undergraduate curricula using a nine-item survey tool. Participants were key informants from 18 universities across seven Australian States and Territories. Conclusion: Although there is consensus in relation to the importance of patient safety across universities, and similarity in views about what knowledge, skills and attitudes should be taught, there were differences in: the amount of time allocated, who was responsible for the teaching and learning, and in which setting the learning occurred and was assessed. There was little indication of the existence of a systematic approach to learning patient safety, with most participants reporting emphasis on learning applied to infection control and medication safety. Wide variation across universities, was reported, particularly in terms of how teaching occured, in what setting and by whom. There was evidence of both integrated and explicit concentration on patient safety learning but also fragmentation. Little evidence of the systematic development of critical reasoning and patient safety knowledge and skills across the years of the nursing program and across the classroom/ laboratory and clinical environments was apparent

Strength in numbers : collaborative science for new experimental model systems

The work is made available under the Creative Commons CCO public domain dedication.. The definitive version was published in PLoS Biology 16 (2018): e2006333, doi:10.1371/journal.pbio.2006333.Our current understanding of biology is heavily based on a small number of genetically tractable model organisms. Most eukaryotic phyla lack such experimental models, and this limits our ability to explore the molecular mechanisms that ultimately define their biology, ecology, and diversity. In particular, marine protists suffer from a paucity of model organisms despite playing critical roles in global nutrient cycles, food webs, and climate. To address this deficit, an initiative was launched in 2015 to foster the development of ecologically and taxonomically diverse marine protist genetic models. The development of new models faces many barriers, some technical and others institutional, and this often discourages the risky, long-term effort that may be required. To lower these barriers and tackle the complexity of this effort, a highly collaborative community-based approach was taken. Herein, we describe this approach, the advances achieved, and the lessons learned by participants in this novel community-based model for research.The research efforts, connections, and collaborations described in this paper and protocols.io (https://www.protocols.io/) were supported by the Gordon and Betty Moore Foundation’s Marine Microbiology Initiative

The Happy Antics programme: Holistic exercise for people with dementia

Background: Holistic exercise for people with dementia could have psychological and physical benefits, but there is a lack of research on the experience of this type of exercise. Therefore, the objective of this study was to determine the feasibility and acceptance of holistic exercise among people with dementia. Method: A holistic exercise programme for people with dementia was designed and implemented. Semi-structured interviews were undertaken to explore participants' experience of holistic exercise, transcribed verbatim and analyzed. Results: Seven themes were generated from the data. They were enjoyment, relaxation, keeping active, social interaction, pain relief, learning something new and intention to continue, respectively. Conclusion: The results of the current small-scale study provide evidence for the feasibility and acceptance of holistic exercise for people with dementia. In addition, participants appeared to benefit in terms of psychological and physical wellbeing

Current use was established and Cochrane guidance on selection of social theories for systematic reviews of complex interventions was developed

Objective: To identify examples of how social theories are used in systematic reviews of complex interventions to inform production of Cochrane guidance. Study Design and Setting: Secondary analysis of published/unpublished examples of theories of social phenomena for use in reviews of complex interventions identified through scoping searches, engagement with key authors and methodologists supplemented by snowball- ing and reference searching. Theories were classified (low-level, mid-range, grand). Results: Over 100 theories were identified with evidence of proliferation over the last 5 years. New low-level theories (tools, taxon- omies, etc) have been developed for classifying and reporting complex interventions. Numerous mid-range theories are used; one example demonstrated how control theory had changed the review’s findings. Review-specific logic models are increasingly used, but these can be challenging to develop. New low-level and mid-range psychological theories of behavior change are evolving. No reviews using grand the- ory (e.g., feminist theory) were identified. We produced a searchable Wiki, Mendeley Inventory, and Cochrane guidance. Conclusions: Use of low-level theory is common and evolving; incorporation of mid-range theory is still the exception rather than the norm. Methodological work is needed to evaluate the contribution of theory. Choice of theory reflects personal preference; application of theory is a skilled endeavor

Accrual and drop out in a primary prevention randomised controlled trial: qualitative study

<p>Abstract</p> <p>Background</p> <p>Recruitment and retention of participants are critical to the success of a randomised controlled trial. Gaining the views of potential trial participants who decline to enter a trial and of trial participants who stop the trial treatment is important and can help to improve study processes. Limited research on these issues has been conducted on healthy individuals recruited for prevention trials in the community.</p> <p>Methods</p> <p>Semi-structured interviews with people who were eligible but had declined to participate in the Aspirin for Asymptomatic Atherosclerosis (AAA) trial (N = 11), and AAA trial participants who had stopped taking the trial medication (N = 11). A focus group with further participants who had stopped taking the trial medication (N = 6). (Total participants N = 28).</p> <p>Results</p> <p>Explanations for declining to participate could be divided into two groups: the first group were characterised by a lack of necessity to participate and a tendency to prioritise other largely mundane problems. The second group's concern was with a high level of perceived risk from participating.</p> <p>Explanations for stopping trial medication fell into four categories: side effects attributed to the trial medication; starting on aspirin or medication contraindicating to aspirin; experiencing an outcome event, and changing one's mind.</p> <p>Conclusions</p> <p>These results indicate that when planning trials (especially in preventive medicine) particular attention should be given to designing appropriate recruitment materials and processes that fully inform potential recruits of the risks and benefits of participation.</p> <p>Trial registration</p> <p>ISRCTN66587262</p

The emotional labour of quality improvement work in end of life care : a qualitative study of Patient and Family Centred Care in England

Abstract: Background: There is a growing emphasis on understanding patient experience in order to inform efforts to support improvement. This paper reports findings from an implementation study of an evidence-based intervention called Patient and Family Centred Care (PFCC) designed to tap into patient experiences as a basis for improvement. In this study the PFCC intervention was spread to a new service area (end of life care) and delivered at scale in England. The findings presented here focus specifically on one key aspect of the intervention: staff shadowing of patients, and the experiences of staff carrying out shadowing for the purposes of service improvements. Methods: The study methods were ethnographic observations of key events, semi-structured interviews with members of participating teams and the programme implementation support team and managers, and a review of the documents used in the set up and running of the programme. Results: One of the key strengths of the PFCC approach is to encourage staff through shadowing to engage with patient experience of services. Many staff described the process of shadowing as a transformative experience that alerted them to immediate areas where their services could be improved. However, engaging with patient experience of end of life care services also had unintended consequences for some staff in the form of emotional labour. Furthermore, we observed difficulties encountered by staff that are not accounted for in the existing PFCC literature relating to how care service structures may unevenly distribute the amount of ‘emotional labour’ that staff members need to invest in implementing the programme. Conclusions: Connecting with patient experience is a crucial aspect of a number of quality improvement interventions that aim to help staff to engage with the lived experience of their services and reconnect their motivations for working in the health care system. However, there may be unintended consequences for health care service staff, particularly in sensitive areas of service delivery such as end of life care. The ‘emotional labour’ for staff of engaging in quality improvement work informed by patient experience should be considered in planning and supporting patient experience led quality improvement