Karen Spilsbury

Systematic review of information and support interventions for caregivers of people with dementia.

BackgroundDementia is an important health and social care problem and is one of the main causes of disability in later life. The number of families affected by dementia will dramatically increase over the next five decades. Despite the implications for health and social care services in the future, the overwhelming majority of care for people with dementia takes place away from health care settings. Providing informal care for someone with dementia can be psychologically, physically and financially expensive and a range of health service interventions aimed at supporting and providing information to these carers has developed to help carers meet these demands. This review examines whether information and support interventions improve the quality of life of people caring for someone with dementia.MethodsA systematic review examining evidence from randomised controlled trials in which technology, individualised or group-based interventions built around the provision of support and/or information were evaluated.ResultsForty-four studies were included in the review. Controlling for the quality of the evidence, we found statistically significant evidence that group-based supportive interventions impact positively on psychological morbidity. However, whilst the improvement was unlikely to be due to chance, the clinical significance of this finding should be interpreted tentatively, due to the difficulties in interpreting the standardised mean difference as a measure of effect and the complex aetiology of depression. No evidence was found for the effectiveness of any other form of intervention on a range of physical and psychological health outcomes.ConclusionThere is little evidence that interventions aimed at supporting and/or providing information to carers of people with dementia are uniformly effective. There is a pressing need to ensure that supportive interventions at the development stage are accompanied by good quality randomised evaluations in which outcomes that are important to clinicians and carers are measured.

The Effectiveness and Cost‐Effectiveness of Respite for Caregivers of Frail Older People

The proportion of frail elderly people in the industrialized world is increasing. Respite care is a potentially important way of maintaining the quality of life for these people and their caregivers. The objective of this systematic review was to determine the effectiveness and cost‐effectiveness of different models of community‐based respite care for frail older people and their caregivers. To identify relevant studies, 37 databases were searched, and reference checking and citation searches were undertaken. Well‐controlled effectiveness studies were eligible for inclusion, with uncontrolled studies admissible only in the absence of higher‐quality evidence. Studies assessed the effect of community‐based respite on caregivers of frail elderly people relative to usual care or to another support intervention. Eligible economic evaluations also addressed costs. Where appropriate, data were synthesized using standard meta‐analytic techniques. Ten randomized, controlled trials, seven quasi‐experimental studies and five uncontrolled studies were included in the review. For all types of respite, the effects upon caregivers were generally small, with better‐controlled studies finding modest benefits only for certain subgroups, although many studies reported high levels of caregiver satisfaction. No reliable evidence was found that respite care delays entry to residential care or adversely affects frail older people. The economic evaluations all assessed day care, which tended to be associated with similar or higher costs than usual care. Given the increasing numbers of frail elderly people and the lack of up‐to‐date, good‐quality evidence for all types of respite care, better‐quality evidence is urgently needed to inform current policy and practice.

Systematic review of the perceptions and experiences of accessing health services by adult victims of domestic violence

This systematic review synthesises evidence on the perceptions and experiences of adult victims of domestic violence when accessing healthcare services. The review was concerned with disclosure of domestic violence by adult victims when accessing health services, the responses of healthcare professionals to these victims, victims’ perceived barriers to support, and the appropriateness of support and referrals. These aims required the review to focus on studies using in-depth qualitative methods to explore victims’ perceptions and experiences. A comprehensive systematic search of 12 databases was carried out in June/July 2005. Application of the review protocol and inclusion criteria resulted in 10 studies (conducted in the UK, USA and Australia) being considered eligible for the review. Data were extracted from these studies and a quality assessment completed. Thematic analysis was carried out to enable the identification of recurrent themes within the included studies. Findings indicate that victims of domestic violence experience difficulties when accessing healthcare services. Victims perceive that these difficulties can be attributed to inappropriate responses by healthcare professionals, discomfort with the healthcare environment, perceived barriers to disclosing domestic violence, and a lack of confidence in the outcomes of disclosure to a health professional. The methodological quality of included studies was variable, but no papers were rejected based on quality issues. These results can contribute to and inform a comprehensive assessment of the experiences of adult victims of domestic violence when accessing healthcare services. The health service is in a unique position to contribute towards the assessment and identification of domestic violence and to provide access to appropriate support. The messages of this study are important for policy-makers and practitioners.

Mapping the introduction of Assistant Practitioner roles in Acute NHS (Hospital) Trusts in England

AIMS This mapping study describes current or planned introduction of assistant practitioner roles in English National Health Service Acute Hospital Trusts. BACKGROUND In the last decade there has been a growth in nursing support workforce numbers and their scope of practice. An important United Kingdom support worker development is the Assistant Practitioner role. METHOD A national census was carried out (April 2007) via an emailed questionnaire to Directors of Nursing. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using thematic analysis. RESULTS Eighty-five per cent (143/168) of Directors of Nursing, from all 10 English Strategic Health Authorities, responded. Forty-six per cent (n = 66) of Trusts had introduced assistant practitioners and 22% (n = 31) were planning to implement the role before 2009. There is wide variation in assistant practitioner numbers across and between Strategic Health Authorities, Trusts and clinical areas. Resistance to the role existed in 32% (n = 46) of Trusts. Reasons for resistance included no perceived need for the role, lack of evidence of effectiveness, financial constraints and professional and patient safety concerns. IMPLICATIONS FOR NURSING MANAGEMENT These findings, which contribute to the international evidence-base on health care support workers roles, provide nurse managers with numbers of assistant practitioners and their deployment. This is useful for Nurse Managers making workforce decisions.

Nurse led care

Whats the difference between medical and nursing care? The answer is not straightforward, but shortages in the medical workforce mean that nurses are increasingly called on to undertake work that was previously done by doctors (such as undertaking surgery,1 prescribing drugs, performing triage in emergency departments), whereas shortages in the nursing workforce mean that healthcare assistants now do many tasks that nurses are trained to do. This fluidity in professional roles and competencies enables the health workforce to respond to need, but are outcomes for patients being improved? Do these benefits come at an additional cost, and if so, are they worth paying for?

A randomised evaluation of CollAborative care and active surveillance for Screen-Positive EldeRs with sub-threshold depression (CASPER): study protocol for a randomized controlled trial

BackgroundDepression accounts for the greatest burden of disease among all mental health problems, and is expected to become the second-highest amongst all general health problems by 2020. By the age of 75, 1 in 7 older people meet formal diagnostic criteria for depression. Efforts to ameliorate the burden of illness and personal suffering associated with depression in older people have focussed on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/sub-threshold depressive syndromes but these patients also suffer impairments in their quality of life and level of functioning.Methods/DesignThe CASPER study has been designed to assemble an epidemiological cohort of people over 75 years of age (the CASPER cohort), from which we will identify those eligible to participate in a trial of collaborative care for sub-threshold depression (the CASPER trial).We aim to undertake a pragmatic randomised controlled multi-centre trial evaluating the effectiveness and cost-effectiveness of collaborative care; a low intensity psychological intervention in addition to usual general practitioner care versus usual general practitioner care alone. General practitioners from practices based in the North of England will be asked to identify potentially eligible patients over the age of 75 years. Patients will be sent a letter inviting them to participate in the study.We aim to recruit approximately 540 participants for the CASPER trial. A diagnostic interview will be carried out to ascertain trial eligibility with the major depressive episode module of the Mini International Neuropsychiatric Interview (M.I.N.I.), eligible participants randomised to either the intervention or usual care. The primary outcome will be measured with the Patient Health Questionnaire-9 (PHQ-9) and additional quality of life measures will be collected. Data will be collected at baseline, 4 and 12 months for both trial and cohort participants.Trial RegistrationISRCTN: ISRCTN02202951

Challenges and opportunities associated with the introduction of assistant practitioners supporting the work of registered nurses in NHS acute hospital trusts in England

Objectives To understand the challenges and opportunities associated with the introduction of assistant practitioner (AP) roles supporting the work of ward-based registered nurses (RNs) in National Health Service (NHS) acute hospital trusts in England. Methods Three case studies of NHS acute hospital trusts. This paper presents qualitative findings, drawing on documentary data sources and data generated through interviews and focus group discussions. Results Introduction of APs into ward-based nursing teams has been variable, and often driven by external pressures rather than perceived organizational need. This, along with little national guidance, has created some confusion about the role, but at the same time has permitted flexible role development through ‘negotiated compromise’ at local level. While there are various areas of potential improvement in policy and practice, APs are generally perceived to have the potential to make a valuable contribution to patient care. Conclusions Findings from this study will help policy-makers, organizations and practitioners understand factors that enable and/or inhibit the integration of new assistant roles within existing occupational structures to develop innovative services and enhance patient care. These factors are important when considering how care will be delivered to maximize the skills of the entire nursing workforce.

Older people in A&E: Literature review and implications for British policy and practice

As the proportion of older people in the population rises, health services must continue to develop to meet their special needs. This includes accident and emergency (A&E) services which work at the interface between primary and secondary health care for individuals of all ages. This literature review aimed to answer the following questions: 1) What are the characteristics and special needs of older people in A&E? 2) Which of the current literature describes, evaluates or advocates service initiatives aimed at meeting the needs of older people in A&E? 3) What are the policy implications of the literature reviewed for British A&E services?

Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial

Importance There is little evidence to guide management of depressive symptoms in older people. Objective To evaluate whether a collaborative care intervention can reduce depressive symptoms and prevent more severe depression in older people. Design, Setting, and Participants Randomized clinical trial conducted from May 24, 2011, to November 14, 2014, in 32 primary care centers in the United Kingdom among 705 participants aged 65 years or older with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) subthreshold depression; participants were followed up for 12 months. Interventions Collaborative care (n=344) was coordinated by a case manager who assessed functional impairments relating to mood symptoms. Participants were offered behavioral activation and completed an average of 6 weekly sessions. The control group received usual primary care (n=361). Main Outcomes and Measures The primary outcome was self-reported depression severity at 4-month follow-up on the 9-item Patient Health Questionnaire (PHQ-9; score range, 0-27). Included among 10 prespecified secondary outcomes were the PHQ-9 score at 12-month follow-up and the proportion meeting criteria for depressive disorder (PHQ-9 score ≥10) at 4- and 12-month follow-up. Results The 705 participants were 58% female with a mean age of 77 (SD, 7.1) years. Four-month retention was 83%, with higher loss to follow-up in collaborative care (82/344 [24%]) vs usual care (37/361 [10%]). Collaborative care resulted in lower PHQ-9 scores vs usual care at 4-month follow-up (mean score with collaborative care, 5.36 vs with usual care, 6.67; mean difference, −1.31; 95% CI, −1.95 to −0.67; P < .001). Treatment differences remained at 12 months (mean PHQ-9 score with collaborative care, 5.93 vs with usual care, 7.25; mean difference, −1.33; 95% CI, −2.10 to −0.55). The proportions of participants meeting criteria for depression at 4-month follow-up were 17.2% (45/262) vs 23.5% (76/324), respectively (difference, −6.3% [95% CI, −12.8% to 0.2%]; relative risk, 0.83 [95% CI, 0.61-1.27]; P = .25) and at 12-month follow-up were 15.7% (37/235) vs 27.8% (79/284) (difference, −12.1% [95% CI, −19.1% to −5.1%]; relative risk, 0.65 [95% CI, 0.46-0.91]; P = .01). Conclusions and Relevance Among older adults with subthreshold depression, collaborative care compared with usual care resulted in a statistically significant difference in depressive symptoms at 4-month follow-up, of uncertain clinical importance. Although differences persisted through 12 months, findings are limited by attrition, and further research is needed to assess longer-term efficacy. Trial Registration isrctn.org Identifier: ISRCTN02202951

Cardiac misconceptions: comparisons among nurses, nursing students and people with heart disease in Taiwan

AIM This paper is a report of a study to examine the misconceived and potentially maladaptive beliefs (cardiac misconceptions) about heart disease held by nurses, nursing students and people with heart disease in Taiwan. BACKGROUND Research suggests that misconceived and maladaptive beliefs about heart disease influence outcomes in people with heart disease, and that eliciting and dispelling incorrect beliefs can reduce disability in this population. However, nurses do not routinely elicit maladaptive beliefs or attempt to dispel them. METHOD Between October 2005 and March 2006, a survey was conducted using version 1 of the York Cardiac Beliefs Questionnaire to measure cardiac misconceptions in 64 hospital-based nurses (13 of whom were cardiac nurses), 134 nursing students and 238 people with heart disease. RESULTS Nursing students held fewer cardiac misconceptions than nurses (P = 0.042). There were no statistically significant differences in the numbers of misconceptions between cardiac and general nurses, and no statistically significant associations between level of qualification, years of nursing experience and number of misconceptions. Nurses with higher levels of education were more likely to hold fewer misconceptions (P = 0.24). Patients held statistically significantly more misconceptions about heart problems than nurses (P < 0.001). CONCLUSION Nurses who are involved in the care for people with heart disease have a responsibility to assess and dispel peoples misconceptions about their condition, and therefore continuing professional education is required to develop this clinical expertise. Future research should focus on methods of dispelling cardiac misconceptions in both nursing and patient education.