Tony Foley

“We’re certainly not in our comfort zone”: a qualitative study of GPs’ dementia-care educational needs

BackgroundRising dementia prevalence rates rise combined with the policy objective of enabling people with dementia to remain living at home, means that there will be a growing demand for dementia care in the community setting. However, GPs are challenged by dementia care and have identified it as an area in which further training is needed. Previous studies of GPs dementia care educational needs have explored the views of GPs alone, without taking the perspectives of people with dementia and family carers into account. The aim of the study was to explore GPs’ dementia care educational needs, as viewed from multiple perspectives, in order to inform the design and delivery of an educational programme for GPs.MethodsA qualitative study of GPs, people with dementia and family carers in a community setting was undertaken. Face-to-face interviews were performed with GPs, people with dementia and with family carers. Interviews were audio-recorded, transcribed verbatim and thematically analysed.ResultsThirty-one people were interviewed, consisting of fourteen GPs, twelve family carers and five people with dementia. GPs expressed a wish for further education, preferentially through small group workshops. Five distinct educational needs emerged from the interviews, namely, diagnosis, disclosure, signposting of local services, counselling and the management of behavioural and psychological symptoms (BPSD). While GPs focused on diagnosis, disclosure and BPSD in particular, people with dementia and family carers emphasised the need for GPs to engage in counselling and signposting of local services.ConclusionsThe triangulation of data from multiple relevant sources revealed a broader range of GPs’ educational needs, incorporating both medical and social aspects of dementia care. The findings of this study will inform the content and delivery of a dementia educational programme for GPs that is practice-relevant, by ensuring that the curriculum meets the needs of GPs, patients and their families.

The development and evaluation of peer-facilitated dementia workshops in general practice

Abstract Background: Rising dementia prevalence rates, combined with the policy objectives of integrated care in the community, means that general practitioners (GPs) are playing an increasing and pivotal role in dementia care. However, GPs are challenged by dementia care and have identified it as an area of learning need. We describe the development, roll-out and evaluation of peer-facilitated workshops for GPs, as part of a national programme to support GPs in their delivery of dementia care. Method: Informed by a triangulated educational needs analysis, small-group case-based workshops were designed. Five GPs were trained as facilitators and delivered workshops in GP practices within their own locality. A mixed-methods evaluation was undertaken, incorporating participant completion of post-workshop questionnaires along with the collection and analysis of qualitative data obtained from a focus group with workshop facilitators. Results: 104 GPs attended 39 workshops (median attendance number 3, range 2–9). The majority of participants reported an improvement in their knowledge and confidence in dementia care. In particular, participants felt that workshop content was relevant and they liked peer-facilitation within their own practices. Facilitators emphasised the importance of skilful facilitation of sensitive topics and described the tension between being regarded as a facilitator and a subject expert. Conclusions: The findings of this study indicate that practice-based, peer-facilitated, small-group workshops improve self-reported knowledge and confidence in dementia care and are well-received by GPs. Findings further suggest that similar educational approaches may be effective in supporting GPs in other areas of complex chronic care in general practice.

‘Working away in that Grey Area…’ A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia

Abstract Background general practitioners (GPs) have identified the management of behavioural and psychological symptoms of dementia (BPSD) as a particularly challenging aspect of dementia care. However, there is a paucity of research on why GPs find BPSD challenging and how this influences the care they offer to their patients with dementia. Objectives to establish the challenges GPs experience when managing BPSD; to explore how these challenges influence GPs’ management decisions; and to identify strategies for overcoming these challenges. Design qualitative study of GPs experiences of managing BPSD. Methods semi-structured interviews were conducted with 16 GPs in the Republic of Ireland. GPs were purposively recruited to include participants with differing levels of experience caring for people with BPSD in nursing homes and in community settings to provide maximum diversity of views. Interviews were analysed thematically. Results three main challenges of managing BPSD were identified; lack of clinical guidance, stretched resources and difficulties managing expectations. The lack of relevant clinical guidance available affected GPs’ confidence when managing BPSD. In the absence of appropriate resources GPs felt reliant upon sedative medications. GPs believed their advocacy role was further compromised by the difficulties they experienced managing expectations of family caregivers and nursing home staff. Conclusions this study helps to explain the apparent discrepancy between best practice recommendations in BPSD and real-life practice. It will be used to inform the design of an intervention to support the management of BPSD in general practice.

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review

To synthesise the existing published literature on general practitioners (GP)s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions.

General practitioners’ knowledge, attitudes and experiences of managing behavioural and psychological symptoms of dementia: protocol of a mixed methods systematic review and meta-ethnography

BackgroundIn the context of rising dementia prevalence, the workload of general practitioners (GPs) in dementia care is set to increase. However, there are many aspects of dementia care that GPs find challenging. Behavioural and psychological symptoms of dementia (BPSD) affect the majority of people with dementia and is an aspect of dementia care that GPs find particularly difficult to manage. The aim of this mixed methods systematic review is to undertake a synthesis of qualitative and quantitative studies on GPs’ knowledge, attitudes and experiences of managing BPSD.MethodsSeven electronic bibliographic databases will be searched from inception to present. All qualitative or quantitative studies that explore the knowledge, attitude or experiences of GPs towards the management of BPSD in community and/or residential settings will be eligible for inclusion. A meta-ethnography will be conducted to synthesise included studies. Primary outcome measures will include GPs’ experiences of managing BPSD, GPs’ knowledge of BPSD and their attitude to different approaches to the management of BPSD, in particular their attitude to non-pharmacological approaches. All included papers will be independently assessed for methodological validity by two reviewers using the following tools: the Joanna Briggs Institute checklist for qualitative research, the Effective Public Health Practice Project (EPHPP) tool for intervention studies and the National Institute of Health (NIH) quality assessment tool for observational and analytical cross-sectional studies. As there is no agreed quality assessment tool for descriptive cross-sectional studies, an original tool will be developed. Two independent reviewers will apply the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) tool to the review findings. The results will be reported in line with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement.DiscussionThis study will be the first systematic review that synthesises the existing literature of GPs’ knowledge, attitudes and experiences of managing BPSD in community and residential care. This review will improve our understanding of GPs’ perspectives on the management of BPSD, and the results will be used to inform the development of an intervention to improve the management of BPSD in general practice.Systematic review registrationPROSPERO CRD42017054916.

Cognitive assessment of older adults in general practice: the collateral history

BackgroundThe collateral (or informant) history is a key component in the assessment of older adults presenting with a memory problem or concern over cognition. Despite this, it rarely features in medical literature and academic curricula. Its role in general practice has never been assessed.AimsThe aim of this study is to assess the role of the collateral history in the investigation of cognitive impairment in general practice.MethodsAn online survey distributed to three nationally representative cohorts of GPs in Ireland (n = 692).ResultsNinety-five (14%; 52.2% male) responded. Nearly all (87%; 83/95) indicate that it is most often a family member who brings possible cognitive impairment to the attention of their GP. The vast majority obtain a collateral history in > 90% of cases (72.6%; 69/95) and rate it very useful in their clinical assessment of cognition. GPs report the collateral history as readily available and rarely refused, with the general practice environment well-suited to obtaining collateral histories. A small minority routinely use the GPCOG informant section (3.2%; 3/95). Nearly all (92.6%; 88/95) report having received no training in obtaining collateral histories with most (79%; 75/95) welcoming of further training in this area.ConclusionsDespite recognition of the utility and importance of the collateral history, the vast majority of GPs report having never received training in obtaining one and do not use structured tools to guide their interview. Further emphasis on the informant history as a distinct clinical entity on medical curricula and increasing emphasis on the availability of structured informant tools are warranted.

The MRCGP Clinical Skills Assessment: an integrative review of evidence

Abstract Background Successful completion of all three components of the Membership of the Royal College of General Practitioners UK (MRCGP) is required for a doctor to practise independently as a general practitioner (GP). One component, the Clinical Skills Assessment (CSA), is a high fidelity, high stakes examination designed to provide an objective external assessment of clinical skills. Aim The aim of this integrative review was to identify, critically appraise and synthesise published empirical evidence on the CSA to identify areas for further inquiry or future collaboration. Design and setting An integrative review of empirical literature focused on the MRCGP CSA. Method A search strategy was developed to conduct an integrative review of empirical published literature. The quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT). Results 11 of the 31 records reviewed were included. Studies were heterogeneous looking at the use of simulated patients, child actors and mock CSAs. Variables contributing to performance on the CSA, with a particular emphasis on the International Medical Graduate, were identified. Conclusion A small pool of published evidence regarding the CSA exists, focused on factors influencing CSA performance. Future research could explore the effectiveness of interventions to improve performance on the CSA and use robust measures to consider candidates’ experience of the CSA.

Training the assessors: A Mini-CEX workshop for GPs who assess undergraduate medical students

Dear Editor, Assessment in the clinical setting has become a core component of undergraduate medical student education. Medical educators strive to embrace clinical assessments that sit at the top of Miller’s Pyramid, assessing what a student does in practice, as opposed to what they know.[1,2] The Mini-CEX (mini clinical evaluation exercise) is one of these assessment approaches and has been designed to provide formative, structured assessment and constructive feedback to the learner in order to drive learning.[3,4] Studies demonstrate that the Mini-CEX has a high construct validity, enabling differentiation between levels of performance,[5] while it also has a high convergent validity, correlating well with other measures of clinical performance.[6,7] However, other studies highlight issues that limit Mini-CEX benefit, including limited feasibility with impractical assessments [6] and significant interassessor variability.[8–10] Regarding inter-assessor variability, evaluations of the use of the Mini-CEX advise that assessors need formal training in assessment and feedback.[11,12] As part of the third-year MB BCh BAO curriculum in University College, Cork, students undertake a fiveweek clinical attachment in general practice, undertaking a Mini-CEX assessment with their GP tutor at the end of their attachment. We held a workshop for these GP tutors, the aims of which were to:

Consultations on driving in people with cognitive impairment in primary care: A scoping review of the evidence

Objectives To review the empirical evidence on approaches used by Primary Care Physicians (PCPs) in fitness to drive (FtD) consultations with people living with cognitive impairment. Design Scoping review of empirical literature focused on primary studies of any design. Setting Primary care practice. Participants PCPs or their equivalent and/ or individuals with cognitive impairment across the spectrum of mild cognitive impairment to dementia. Measurements Systematic search of Medline, Cinahl, PsychINFO, Academic Search Complete, Psychological and Behavioural Sciences Collection, SocIndex and Social Sciences FT were conducted. Records screened by two reviewers against agreed inclusion criteria. Mixed studies (qualitative and quantitative) were synthesized within overarching themes. Results Eighteen studies met our inclusion criteria. Synthesized data showed PCPs have mixed feelings on the appropriateness of their role in FtD assessments, with many feeling particularly uncomfortable and lacking confidence in the context of possible cognitive impairment. Reasons include lack of familiarity with legal requirements and local resources; fear of damaging the doctor-patient relationship; and impact on the patient’s quality of life. Patients voiced their desire to maintain agency in planning their driving cessation. Studies evaluating pragmatic educational programmes suggest these can improve physician confidence in FtD consultations. Conclusion The increasing number of older people affected by cognitive impairment, for whom driving may be a concern, has implications for primary care practice. Addressing the reasons for PCPs lack of comfort in dealing with this issue is essential in order for them to better engage in, collaborative discussion with patients on plans and preferences for driving cessation.

The development and evaluation of an online dementia resource for primary care based health professionals

Background Primary care based health professionals struggle with many aspects of dementia care. General practitioners (GPs) find providing post-diagnosis information on services and supports particularly challenging. Likewise, people with dementia and their family caregivers feel they need more support from their GPs in this post-diagnosis period. Objective This study aimed to develop and evaluate an online educational resource for primary care health professionals that included a dementia specific services and supports directory. Method A previously conducted educational needs analysis informed the content of the resource. This content was further developed by a review of the literature and through consultation with an expert reference group and a stakeholder group. A mixed method approach was taken to the evaluation of the online resource which included analysis of the website traffic, qualitative feedback from stakeholders and evaluation by general practitioners. Results The online resource www.dementiapathways.ie was developed. Initial qualitative feedback obtained from potential end-users was positive. Data analysis was performed on over 4000 people who accessed the site. Finally, the online resource was demonstrated to 190 general practitioners in 36 workshops. All of the general practitioners surveyed felt that dementipathways.ie would be a useful resource for them. Several potential barriers to the successful development and implementation of a services and supports directory were identified. Conclusion This study provides a prototype for the development of an online dementia educational resource and demonstrates the value of a dementia-specific services and supports directory for primary care based health professionals.