Experiences of a communication-skills course for care partners of people living with dementia, empowered conversations: A qualitative framework analysis

OBJECTIVES

Our aims were to examine whether an experiential course for care partners of people living with dementia, Empowered Conversations (EC), was acceptable to participants and to explore participants' perceptions of the impact of the course upon their communicative interactions. EC is based on an integrative model derived from psychological and linguistic theory and empirical evidence. EC is based on mentalisation theory, perceptual control theory and linguistic theory (The Communicative Impact Model).

METHODS

Qualitative data were collected via 28 semistructured interviews. Framework analysis was used to analyse data.

RESULTS

Three superordinate themes, 'improved communication', 'improved well-being' and 'support through others' were identified. Twenty-seven out of the 28 participants described feeling that they were able to better connect with the person living with dementia that they were supporting through attending EC.

CONCLUSIONS

The findings indicated that EC was acceptable and beneficial to care partners. Care partners developed a range of strategies and understandings that enabled them to communicate better with the person they were supporting, enhanced well-being and relationships, as well as developing social networks. This is the first qualitative study to examine a psychosocial intervention for care partners of people living with dementia using a non-CBT framework and indicates that perceived control could influence how care partners respond to stress and difficulties.

A brief transdiagnostic group (the take control course) compared to individual low-intensity CBT for depression and anxiety: a randomized non-inferiority trial

Few studies have examined brief transdiagnostic groups. The Take Control Course (TCC) was developed for patients with mild to moderate common mental health problems. We examined whether TCC is non-inferior to individual low-intensity cognitive behaviour therapy (CBT) in a single-blind individually randomised parallel non-inferiority trial. The primary outcomes were depression (PHQ9) and anxiety (GAD7) at 6-month follow-up (primary outcome point) and 12-month follow-up. The non-inferiority margin that we set, based on previous trials, corresponds to approximately 3 points on the PHQ9 and approximately 2.5 points on the GAD7. Intention-to-treat (ITT) and per-protocol (PP) analyses of 6-month data of 156 randomised patients indicated that TCC was non-inferior to individual low-intensity CBT on anxiety (ITT Coefficient = 0.24; 95% CI: -1.45 to 1.92; d = 0.04; p = .79), and depression (ITT Coefficient = 0.82; 95% CI: -1.06 to 2.69; d = 0.14; p = .39) outcomes, and functioning (ITT Coefficient = 0.69; 95% CI: -2.56 to 3.94; d = 0.08; p = .68). The findings at 12 months were inconclusive and require further testing. This randomised trial provides preliminary support that TCC is not less effective than short-term individual CBT within Improving Access to Psychological Therapies (IAPT) services.

A feasibility study of the impact of a communication-skills course, 'Empowered Conversations', for care partners of people living with dementia

Objectives

To examine the feasibility, acceptability and impact of an experiential course for family care partners of people living with dementia, Empowered Conversations (EC). This study aimed to assess the impact of participation in an EC course on care partner stress levels, communication and mentalization (a form of relational-based empathy).

Method

This study uses an uncontrolled pre–post-follow-up design. Follow-up was at 4-months after the initial EC session where baseline data were collected. One hundred and fifty-nine care partners were recruited. EC is a training course that has been designed to improve care partner communication, well-being and relationships. It is based on an integrative framework that targets the specific psychological, relationship and communication needs of carers. This framework informs targeted strategies and interactive exercises that facilitate carers to consider the goals and emotions of those they are caring for, alongside their own goals and emotions, and to use this to maximize good communication.

Results

Stress was significantly reduced across the three time points. Communication significantly improved across time. There were no significant changes in reflective functioning (mentalization).

Discussion

This study provides preliminary evidence that a communication-skills training course for care partners of people living with dementia is an acceptable and feasible intervention and has an impact both post-intervention and at follow-up. These findings require validation in a rigorous, randomized study.

'It's nice to think somebody's listening to me instead of saying "oh shut up"'. People with dementia reflect on what makes communication good and meaningful

WHAT IS KNOWN ON THE SUBJECT?: People with dementia experience cognitive decline which can affect their ability to communicate with others and consequently getting their needs met. Loneliness and social isolation are associated with depression and anxiety, while difficulties communicating may magnify such difficulties. Enhancing meaningful interactions may support maintenance of valued relationships and positive wellbeing. Although previous research has examined communicative experiences, this has been from the perspectives of professionals or caregivers. Exploring meaningful communication from the perspectives of people with dementia is crucial in supporting relationships and wellbeing. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: People with dementia can be active participants in research. They are aware of their cognitive impairments as well as social interactions and features constituting meaningful communications. People with dementia recognized carers' attempts to understand and empathize with them; allowing them to feel valued and heard, empowering them to maintain interactions. Alternatively, feeling dismissed, inferior or pressured to provide 'correct' responses deterred them from further conversations. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: People with dementia have an awareness of their relationships, communications and preferences. Thus, it is imperative to respect this population and make attempts to understand their communication as they sense this effort even when miscommunications occur. Embrace qualities that facilitate person-centred care within communications is vital as this can preserve valued relationships, support one's needs and enhance wellbeing. Such features include active listening, empathizing, being physically and mentally present, spending time to know the individual and sharing experiences, thoughts and emotions. Abstract Introduction Social isolation can be problematic for people with dementia; understanding what makes communication meaningful may reduce such risk. Scientific rationale Previous research has examined caregivers' or professionals' experiences of meaningful communication. Understanding this from the perspectives of people with dementia could enhance their interactions and wellbeing. Aim Exploring what makes communication meaningful from the perspective of people with dementia. Methods Nine dyadic interactions between a person with dementia and a family carer were filmed. Individuals with dementia watched the footage and reflected on their communications in semi-structured interviews. Results Three superordinate themes emerged. Themes 'sharing moments of emotional connection' and 'empowering one's ability to communicate' related to the experience of feeling connected, understood, valued and heard, allowing further communication. Conversely, 'inhibitors to communication' related feeling disempowered and reduced interactions. Discussion Even when carers could not understand what people with dementia attempted to communicate, their efforts to interact with them were valued and considered meaningful as they reinforce their sense of connectedness. Implications for practice Embracing a person-centred approach by actively attuning to the person and continuously attempting to empathize and understand persons with dementia can help preserve important relationships and allow the person to feel valued and interpersonally connected.

Use of the Method of Levels Therapy as a Low-Intensity Intervention to Work With People Experiencing Sleep Difficulties

Sleep problems are common with nearly one in three people reporting disturbed sleep. In line with guidelines, most people experiencing poor sleep in the United Kingdom are referred for cognitive and behavioral treatment approaches. A large proportion of these clients are seen by Psychological Well-being Practitioners (PWPs) delivering low-intensity therapy within Improving Access to Psychological Therapies (IAPT) services. The training of PWPs in the treatment of sleep problems is limited to sleep hygiene psychoeducation. The role that sleep hygiene psychoeducation plays in improving sleep quality is unclear, especially if used as a stand-alone intervention. The article introduces method of levels (MOL) as an alternative approach explaining sleep problems by transdiagnostic mechanisms. Two clinical cases are presented to demonstrate how MOL was implemented to support clients with the perceived sleep issue. This article adds to growing evidence that a transdiagnostic approach to helping people experiencing psychological distress is needed.

Communication Empowerment Framework: An integrative framework to support effective communication and interaction between carers and people living with dementia

Objectives

To demonstrate the power of integrating three theoretical perspectives (Mentalization Theory, Perceptual Control Theory and the Communicative Impact model), which jointly illuminate the communication challenges and opportunities faced by family carers of people with dementia. To point the way to how this framework informs the design and delivery of carer communication and interaction training.

Method

Conceptual synthesis based on a narrative review of relevant literature, supported by examples of family carers.

Results

We use the conceptual models to show how the capacity to mentalize (“holding mind in mind”) offers a greater sense of control over internal and external conflicts, with the result that they can be deescalated in pursuit of mutual goals.

Conclusions

The integrative conceptual framework presented here highlights specific psychological and relational mechanisms that can be targeted through carer training to enhance communication with a person living with dementia.

Communication training interventions for family and professional carers of people living with dementia: a systematic review of effectiveness, acceptability and conceptual basis

OBJECTIVES

To update previous reviews and provide a more detailed overview of the effectiveness, acceptability and conceptual basis of communication training-interventions for carers of people living with dementia.

METHOD

We searched CINAHL Plus, MEDLINE and PsycINFO using a specific search and extraction protocol, and PRISMA guidelines. Two authors conducted searches and extracted studies that reported effectiveness, efficacy or acceptability data regarding a communication training-intervention for carers of people living with dementia. Risk of bias was assessed using the Cochrane Collaboration guidelines. Quality of qualitative studies was also systematically assessed.

RESULTS

Searches identified 450 studies (after de-duplication). Thirty-eight studies were identified for inclusion in the review. Twenty-two studies focused on professional carers; 16 studies focused mainly on family carers. Training-interventions were found to improve communication and knowledge. Overall training-interventions were not found to significantly improve behaviour that challenges and caregiver burden. Acceptability levels were high overall, but satisfaction ratings were found to be higher for family carers than professional carers. Although many interventions were not supported by a clear conceptual framework, person-centred care was the most common framework described.

CONCLUSION

This review indicated that training-interventions were effective in improving carer knowledge and communication skills. Effective interventions involved active participation by carers and were generally skills based (including practicing skills and discussion). However, improvements to quality of life and psychological wellbeing of carers and people living with dementia may require more targeted interventions.

Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis

BACKGROUND

A 2010 meta-analysis of internet-delivered CBT (iCBT) RCTs argued 'computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care' without data on effectiveness or practicality in routine practice.

METHODS

Databases, reviews and meta-analyses were searched for randomised controlled trials of cCBT or iCBT versus a control group (care as usual, waitlist, information control, psychological placebo, pill placebo, etc.) in people who met diagnostic criteria for major depression, panic disorder, social anxiety disorder or generalised anxiety disorder. Number randomised, superiority of treatment versus control (Hedges'g) on primary outcome measure, length of follow-up, follow up outcome, patient adherence and satisfaction/harm were extracted; risk of bias was assessed. A search for studies on effectiveness of iCBT in clinical practice was conducted.

RESULTS

64 trials were identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-with good acceptability. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials.

LIMITATIONS

Studies variably measured changes in quality of life and disability, and the lack of comparisons with medications weakens the field.

CONCLUSIONS

The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical health care.

Gatekeeping access to community mental health teams

Aims and Method

A retrospective survey to explore how consultant psychiatrists, senior house officers and community psychiatric nurses prioritised referrals to four sectorised community mental health teams.

Results

Referral outcomes appeared to be comparable for patients with psychoses, sub-threshold mental health problems and personality disorders. However, differences in the outcomes were apparent for patients with a primary diagnosis of drug/alcohol misuse, as well as for patients with affective disorders and neuroses.

Clinical Implications

It may be necessary to establish clearer, consistent boundaries in order to consolidate services for patients with severe mental health problems.

A systematic scoping review and synthesis of dementia and communication theory

Aim

This review considers the theoretical literature concerning communication between a person with dementia and a person without dementia.

Methods

Theoretical accounts of communication between a person with dementia and a person without dementia were identified through database searches, hand searching of reference lists and contacting experts in the topic area.

Results

Twenty-one articles were included in the final review, yielding 18 different theoretical accounts of communication in the context of dementia. Thematic synthesis showed that four categories could account for the majority of the material described in these theories, even though they were derived from very different perspectives. These categories were mutuality, personhood, anxiety reduction and environmental considerations.

Discussion

The four categories identified in the thematic synthesis were reminiscent of Kitwood’s theory of person-centred dementia care. Different interpretations of this finding are considered. Most theoretical accounts focused on the relational aspects of communication. This meant that societal and individual accounts of communication in the context of dementia were relatively impoverished in terms of theory.

Conclusions

There is widespread agreement regarding the important components of good quality communication in the context of dementia. This suggests exciting opportunities for collaboration between apparently disparate bodies of literature. Individual and societal accounts of communication in the context of dementia are relatively neglected and would benefit from more research.

Improving access to mental health care in an Orthodox Jewish community: a critical reflection upon the accommodation of otherness

Background

The English National Health Service (NHS) has significantly extended the supply of evidence based psychological interventions in primary care for people experiencing common mental health problems. Yet despite the extra resources, the accessibility of services for ‘under-served’ ethnic and religious minority groups, is considerably short of the levels of access that may be necessary to offset the health inequalities created by their different exposure to services, resulting in negative health outcomes. This paper offers a critical reflection upon an initiative that sought to improve access to an NHS funded primary care mental health service to one ‘under-served’ population, an Orthodox Jewish community in the North West of England.

Methods

A combination of qualitative and quantitative data were drawn upon including naturally occurring data, observational notes, e-mail correspondence, routinely collected demographic data and clinical outcomes measures, as well as written feedback and recorded discussions with 12 key informants.

Results

Improvements in access to mental health care for some people from the Orthodox Jewish community were achieved through the collaborative efforts of a distributed leadership team. The members of this leadership team were a self-selecting group of stakeholders which had a combination of local knowledge, cultural understanding, power to negotiate on behalf of their respective constituencies and expertise in mental health care. Through a process of dialogic engagement the team was able to work with the community to develop a bespoke service that accommodated its wish to maintain a distinct sense of cultural otherness.

Conclusions

This critical reflection illustrates how dialogic engagement can further the mechanisms of candidacy, concordance and recursivity that are associated with improvements in access to care in under-served sections of the population, whilst simultaneously recognising the limits of constructive dialogue. Dialogue can change the dynamic of community engagement. However, the full alignment of the goals of differing constituencies may not always be possible, due the complex interaction between the multiple positions and understandings of stakeholders that are involved and the need to respect the other’-s’ autonomy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2509-4) contains supplementary material, which is available to authorized users.

Using drawings as a reflective tool to enhance communication in dementia care

Communication skills training can be a valuable means of supporting professional and family carers of people with dementia. Most communication skills training programmes for those caring for people with dementia focus on dementia awareness and the technical aspects of communication, such as the pace and volume of the carer's speech. However, it is also important to examine what is conveyed about a carer's internal experience in their non-verbal interactions with people living with dementia. This article explores how drawings can be used to help carers to reflect on what is communicated and question any hidden assumptions. It discusses three case studies to demonstrate the complex dynamics that may be involved in interactions with people with dementia: the loss of shared memories, facing towards someone with dementia rather than away from them, and talking about issues that may be upsetting. Drawings provide a means for carers to access their unspoken thoughts and emotions, and can help them to improve their understanding of non-verbal interactions with people who have dementia.

A critical realist rationale for using a combination of quantitative and qualitative methods

Although using a combination of quantitative and qualitative approaches is widely advocated, there is considerable scope for confusion due to the complex ontological and epistemological issues that need to be resolved. This paper examines some of the issues that may arise when the methods are combined. Three distinct standpoints with regard to using mixed method approaches are highlighted: a methodological purist position, a pragmatic standpoint and an anti-conflationist position. It is suggest that an anti-conflationist approach that is underpinned by the philosophy of critical realism is compatible with all three of the purposes of methodological triangulation identified by Risjord and his co-authors (Risjord et al., 2001, 2002) and that adopting a critical realist perspective may circumvent many of the problems that are associated with paradigm ‘switching’. The case for adopting a critical realist framework is illustrated by a case study, in which a combination of quantitative and qualitative methods was used to explore how and why gatekeeping decisions emerge at the interface between primary care and community mental health teams.

Prospective cohort feasibility study of a transdiagnostic group intervention for common mental health problems: The Take Control Course

OBJECTIVES

While transdiagnostic psychological treatments appear to be promising, they require greater empirical support. Further, a number of available transdiagnostic treatments are targeted at clients with a specific category of disorder, such as clients with anxiety disorders. This study is a preliminary examination of the effectiveness, feasibility, and acceptability of a new transdiagnostic six-session group-based intervention (Take Control Course; TCC) predominantly aimed at clients within primary care. The group is aimed at a broad range of clients; it is derived from an integrative transdiagnostic theory, which specifies mechanisms of psychopathology across disorders. Briefer interventions are gaining an increasing evidence base, and this study seeks to compare the TCC to an established brief intervention within primary care.

DESIGN

Prospective cohort study comparing two active psychological treatments.

METHODS

Take Control Course group (n = 66) was compared to a non-randomized control group of clients accessing individual low-intensity interventions (n = 43) using random-effect regression models. Primary outcomes were depression and anxiety scores; additional outcomes included social and other functioning.

RESULTS

For the TCC group, changes on all pre-post outcomes were significant with moderate effect sizes. The between-group differences were not significant.

CONCLUSIONS

Results show potential for TCC to be an effective intervention, but further work is required to validate these findings in a more rigorous, randomized study.

PRACTITIONER POINTS

Transdiagnostic understandings of psychological distress may inform pragmatic and effective treatments that can be offered to a broad range of clients. This study describes a transdiagnostic intervention (TCC) that targets maintenance processes common across disorders, and presents initial outcome data. The TCC was found to reduce pre-post scores on measures of anxiety and depression.

The Take Control Course: Conceptual Rationale for the Development of a Transdiagnostic Group for Common Mental Health Problems

BACKGROUND

Increasingly, research supports the utility of a transdiagnostic understanding of psychopathology. However, there is no consensus regarding the theoretical approach that best explains this. Transdiagnostic interventions can offer service delivery advantages; this is explored in the current review, focusing on group modalities and primary care settings.

OBJECTIVE

This review seeks to explore whether a Perceptual Control Theory (PCT) explanation of psychopathology across disorders is a valid one. Further, this review illustrates the process of developing a novel transdiagnostic intervention (Take Control Course; TCC) from a PCT theory of functioning.

METHOD

Narrative review.

RESULTS AND CONCLUSIONS

Considerable evidence supports key tenets of PCT. Further, PCT offers a novel perspective regarding the mechanisms by which a number of familiar techniques, such as exposure and awareness, are effective. However, additional research is required to directly test the relative contribution of some PCT mechanisms predicted to underlie psychopathology. Directions for future research are considered.

Dementia care: using empathic curiosity to establish the common ground that is necessary for meaningful communication

Over the past two decades the advocates of person-centred approaches to dementia care have consistently argued that some of the negative impacts of dementia can be ameliorated in supportive social environments and they have given lie to the common but unfounded, nihilistic belief that meaningful engagement with people with dementia is impossible. This discussion paper contributes to this welcome trend by exploring how carers can use empathic curiosity to establish the common ground that is necessary to sustain meaningful engagement with people who have mild to moderate dementia. The first section of the paper gives a brief theoretical introduction to the concept of empathic curiosity, which is informed by perceptual control theory and applied linguistics. Three case examples taken from the literature on dementia care are then used to illustrate what empathic curiosity may look like in practice and to explore the potential impact that adopting an empathic and curious approach may have.

Dementia communication using empathic curiosity

Communication skills training materials in dementia care usually focus on reminiscence. This is important because talking about past events can help people with dementia to retain their sense of self. This article examines the use of an alternative set of communication skills known as empathic curiosity, which may help to promote meaningful communication in the here and now with people who are living with dementia.

Using behavioural activation in the treatment of depression: a control theory perspective

Behavioural activation is an intervention that can be used to counteract the typical patterns of withdrawal, avoidance and inactivity that characterize depression. This paper examines the processes of change that may occur during behavioural activation from the perspective of control theory. Some of the key concepts that are associated with control theory are introduced and the process of change that may occur during behavioural activation is illustrated using two case studies. The case studies provide anecdotal evidence which supports the hypothesis that the effective implementation of behavioural activation may depend upon clients being able to retain or regain the sense of control that they value. The differences between a control-theory-based approach and more orthodox behavioural and cognitive approaches are highlighted and the implications of these differences are discussed. Flexible approaches that are informed by control theory, may offer a useful alternative to the more established behavioural and cognitive approaches towards behavioural activation.

Empathic curiosity: resolving goal conflicts that generate emotional distress

The quality of the therapeutic alliance between therapist and client is consistently identified as a key component of cognitive behavioural interventions. However, relatively little is known about the causal mechanisms that generate the effects that are ascribed to the therapeutic alliance. This paper outlines how one such causal mechanism, empathic curiosity, may operate. The explanation is rooted in control theory, a theory that explains the link between our experiences and our goal-directed behaviour. Empathic curiosity is underpinned by the core skills of empathic listening and maintaining a curious attitude. From a control theory perspective, the value of this type of listening may be reinforced when speak to people about their salient concerns, as they perceive them in the current flow of their conscious thoughts. This can be facilitated by linking curious questions to the non-verbal disruptions in their body posture and conversational flow. The approach is illustrated using three case examples. In all three examples, the clients involved were able to reflect upon and re-organize conflicting goals that had been a source of significant emotional distress.

The experience of recovery from the perspective of people with common mental health problems: findings from a telephone survey

BACKGROUND

For people with common mental health problems such as depression and anxiety related disorders the understanding of what recovery means and what it may entail is less fully developed than for people with less common mental health problems such as schizophrenia.

AIM

The aim of this telephone survey was to obtain a clearer conception and better understanding of the value of recovery from the perspective of service users who have experienced common mental health problems.

METHODS

Data was collected from telephone interviews with 98 service users using a mixture of quantitative and qualitative methods.

RESULTS

The service users' quantitative ratings of their subjective improvement indicated that recovery was a state of being that was manifestly different from the experience of being unwell. The data from the qualitative interviews corroborated these findings. A central theme that also emerged from the analysis of the data was that recovery was associated with having a greater sense of balance and control. Service users indicated that this sense of balance and control operated on many levels, however it was most significant in the context of dealing with their most salient concerns and pursuing their personal goals.

CONCLUSION

More emphasis may need to be placed on enabling service users to identify their salient concerns and pursue their personal goals in order to give them the sense of balance and control they are looking for.

Case management for high-intensity service users: towards a relational approach to care co-ordination

This study is based on a formative evaluation of a case management service for high-intensity service users in Northern England. The evaluation had three main purposes: (i) to assess the quality of the organisational infrastructure; (ii) to obtain a better understanding of the key influences that played a role in shaping the development of the service; and (iii) to identify potential changes in practice that may help to improve the quality of service provision. The evaluation was informed by Gittell's relational co-ordination theory, which focuses upon cross-boundary working practices that facilitate task integration. The Assessment of Chronic Illness Care Survey was used to assess the organisational infrastructure and qualitative interviews with front line staff were conducted to explore the key influences that shaped the development of the service. A high level of strategic commitment and political support for integrated working was identified. However, the quality of care co-ordination was variable. The most prominent operational factor that appeared to influence the scope and quality of care co-ordination was the pattern of interaction between the case managers and their co-workers. The co-ordination of patient care was much more effective in integrated co-ordination networks. Key features included clearly defined, task focussed, relational workspaces with interactive forums where case managers could engage with co-workers in discussions about the management of interdependent care activities. In dispersed co-ordination networks with fewer relational workspaces, the case managers struggled to work as effectively. The evaluation concluded that the creation of flexible and efficient task focused relational workspaces that are systemically managed and adequately resourced could help to improve the quality of care co-ordination, particularly in dispersed networks.

Inventory management

A critical aspect of blood transfusion is the timely provision of high quality blood products. This task remains a significant challenge for many blood services and blood systems reflecting the difficulty of balancing the recruitment of sufficient donors, the optimal utilization of the donor's gift, the increasing safety related restrictions on blood donation, a growing menu of specialized blood products and an ever-growing imperative to increase the efficiency of blood product provision from a cost perspective. As our industry now faces questions about our standard practices including whether or not the age of blood has a negative impact on recipients, it is timely to take a look at our collective inventory management practices. This International Forum represents an effort to get a snap shot of inventory management practices around the world, and to understand the range of different products provided for patients. In addition to sharing current inventory management practices, this Forum is intended to foster an exchange of ideas around where we see our field moving with respect to various issues including specialty products, new technologies, and reducing recipient risk from blood transfusion products.

Patient registries: a central component of the chronic care model

Patient registries are a central component of the Chronic Care Model and research suggests that their use is associated with improved outcomes for patients with a range of chronic diseases. This article begins by outlining the case for using patient registries and it identifies some of the issues that need to be considered when setting up a registry. The second part of the article describes how a patient registry was used to support a newly established active case management service. The case study teases out some of the practical constraints and contextual factors that affected the development and implementation of patient registry. However it also highlights that the patient registry was highly valued by front line clinicians who used it, as it was an effective caseload and performance management tool.

Using the chronic care model to tackle depression among older adults who have long-term physical conditions

Effective psychological and pharmacological treatments are available, but for depressed older adults with long-term physical conditions, the outcome of routine care is generally poor. This paper introduces the chronic care model, a systemic approach to quality improvement and service redesign, which was developed by Ed Wagner and colleagues. The model highlights six key areas that need to be addressed, if depression is to be tackled more effectively in this neglected patient group: delivery system design, patient-provider relationships, decision support, clinical information systems, community resources and healthcare organization. Three influential programmes, the Improving Mood Promoting Access to Collaborative Treatment programme, the Prevention of Suicide in Primary Care Elderly Collaborative Trial, and the Program to Encourage Active, and Rewarding Lives for Seniors, have shown that when the model is adopted, significant improvements in outcomes can be achieved. The paper concludes with a case study, which illustrates the difference that adopting the chronic care model can make. Radical changes in working practices may be required, to implement the model in practice. However, Greg Simon, a leading researcher in the field of depression care, has suggested that there is already sufficient evidence to justify a shift in emphasis from research towards dissemination and implementation.

Gatekeeping access to community mental health teams: a qualitative study

BACKGROUND

Gatekeeping access to services at the interface with primary care has been identified as one of the key issues that community mental health teams (CMHTs) have to confront.

OBJECTIVES

The aim of this study was to develop a better understanding of the contextual influences that impact upon the outcome of gatekeeping decisions.

DESIGN

An interview-based qualitative study, informed by the philosophy of critical realism.

SETTING

An urban catchment area in Northern England.

PARTICIPANTS

Twenty-nine interviews were conducted with gatekeeping clinicians and service managers.

METHOD

A convenience sample of clinicians was initially approached to take part in a series of semi-structured interviews. This was followed up by a purposive sample of clinicians and service managers, as specific contextual influences were identified and explored in detail. The emerging analysis was then subjected to critical scrutiny by a further sample of gatekeeping clinicians.

FINDINGS

A clear hierarchy of appropriateness was identified with four dimensions: severity, risk, beneficence and a moral dimension. It was suggested that the salient contextual influences that shaped the hierarchy were: (a) the need to fit in with strategic planning directives, (b) the burden of responsibility that clinicians carried, (c) the high number of referrals and the relatively slow turnover of patients on clinical caseloads, (d) the position of CMHTs in the economy of care and (e) the character of the relationship between clinicians and service managers.

CONCLUSION

The findings from the study support a multi-level view of the gatekeeping process within CMHTs, which takes account of the role that key contextual influences play in shaping the range of options that are available to gatekeeping clinicians.

Using process mapping to improve nursing practice and patient care

Process mapping is a technique that models the relationship between activities, people and resources. It is used to develop a better understanding of the patient's experience and to drive forward service modernization. This paper offers a brief guide to process mapping and examines the potential impact it may have on nursing services and patient care.

Critical realism: a way forward for evaluation research in nursing?

BACKGROUND

Critical realism is a relatively new philosophical perspective that combines a realist ontology with a relativist epistemology in subscribing to a form of "robust" relativism. The potential benefits of adopting a critical realist approach are considered in two areas of evaluation research: theory-driven programme evaluation and policy evaluation.

AIM

The aim of the paper is to identify the main features of critical realism and explore its potential as a philosophical framework in the field of evaluation research.

CONCLUSION

We argue that critical realism provides a coherent framework for evaluation research that is based on the understanding of causal mechanisms. This is particularly important for frontline services seeking to use evidence-based interventions, as interventions need to be properly understood if they are to be used effectively in the context of clinical practice. Critical realism can also add depth to policy analysis. However, there is a potential for critical realists to drift beyond the boundary that separates scientific knowledge from speculative theory when making recommendations about the best course of action to follow.

Access and effectiveness in psychological therapies: self-help as a routine health technology

The ability of psychological treatment services to deliver effective and accessible mental healthcare, as demanded by the National Service Framework for mental health, is compromised by the traditional configuration of psychological therapy services, powerful gatekeeping by these services and the difficulties which exist in engaging primary care in mental healthcare. Although a number of service models have been suggested, most address access from the perspective of secondary care service providers. In particular, self-help, a powerful ideology and a clinically effective health technology, is given insufficient prominence in psychological therapy services. Self-help is often only considered for mild problems or as an adjunct to therapy, and it is assumed that mental health professionals with traditional therapeutic skills are needed to support self-help. Following a review of access and self-help in psychological therapies, the present authors propose criteria against which services could be designed in order to fully utilise self-help as a powerful health technology in psychological therapies. Accompanying these criteria is a research framework drawn from recent work on access and illness self-management that can be used to evaluate the performance of services attempting to improve access to psychological therapies.

Interviewing colleagues

Qualitative research methods are popular among nurses and an increasing number of them are undertaking small-scale qualitative studies in conjunction with practice related post -graduate degrees ( Jarvis 2000 ). Phil McEvoy discusses some of the issues that may arise when practitioner - researchers conduct conversational interviews with colleagues as part of a practice based research project.

Using log-linear models to analyse categorical data

This paper provides a brief introduction to log-linear modelling that is designed to be accessible to readers with a cursory knowledge of elementary statistics. Log-linear models belong to the family of general linear models and they are generally regarded as the method of choice for analysing the associations between variables in large sets of categorical data. The primary objective of using log-linear modelling procedures is usually to identify the simplest model that fits the data adequately, although in some instances more than one model may be acceptable. The main drawback of using log-linear models is that the procedures require very large data sets. A case study illustrates that, even with a relatively large sample, problems may arise if the data are unevenly distributed.

Gatekeeping access to services at the primary/secondary care interface

This paper examines the role that mental health clinicians play in gatekeeping access to services at the primary/secondary care interface. Layder's research map is used to explore the factors that influence gatekeeping decisions at four interrelated levels of social organization; self, situated activity, setting and context, plus a historical dimension that permeates each level. The main theme that emerges from the analysis is that the dilemmas that arise from attempting to control the demand for care are difficult to resolve for policy makers, managers or clinicians alike. A combination of factors make it difficult to establish consistent priorities including: the uneven distribution of specialist services, the lack of a consensus definition of severe mental illness and the difficulty of weighing the potential benefits of care for the individual against the need to ensure that resources are distributed fairly. It is suggested that there are no easy answers to these dilemmas because gatekeeping is a socially contested process, in which there will be winners and losers.

The pathology of diphtheria

Diphtheria is an acute, communicable disease caused by Corynebacterium diphtheriae. The disease is generally characterized by local growth of the bacterium in the pharynx with pseudomembrane formation or, less commonly, in the stomach or lungs; systemic dissemination of toxin then invokes lesions in distant organs. Acute disease of the upper respiratory tract usually involves one or more of the following: tonsillar zones, larynx, soft palate, uvula, and nasal cavities. A recent epidemic in Russia emphasized the role of vaccination in reducing disease in children and adults.

Mycobacterial spindle cell pseudotumor of the brain: a case report and review of the literature

Spindle cell pseudotumors found in the skin, lymph nodes, bone marrow, spleen, lungs, and retroperitoneum have been reported recently in immunosuppressed patients, including those with acquired immunodeficiency syndrome. The authors report a similar lesion limited to the brain in a 38-year-old human immunodeficiency virus-negative man receiving steroid therapy for treatment of sarcoidosis. Histopathologically the lesions were composed of spindle and epithelioid histiocytes, small foci of necrosis, and numerous acid-fast bacilli. The acid-fast bacilli were determined by culture and polymerase chain reaction to be Mycobacterium avium intracellulare. Because of the uncommon histologic appearance of this lesion and the potential for treatment if recognized, mycobacterial spindle cell pseudotumors should be included in the differential diagnosis of spindle cell lesions in the brain in immunosuppressed patients.

Mental health. Drawing the line

Employing community psychiatric nurses to assess clients referred to community psychiatric teams can help target resources. The assessment nurses deal both with routine and emergency referrals. Some GPs were initially concerned about nurses undertaking assessments previously carried out by psychiatrists.

Using patients' records as a source of data

This article discusses the use of patients' records as a data source. It examines the ethical issues involved in using patients' records, as well as their potential advantages and limitations.

Leishmaniasis in the United States military

Leishmaniasis is a recurrent health problem for the U.S. and other militaries. Health care workers may be unfamiliar with the risk factors, transmission, clinical features, diagnosis, and treatment of this disease. A team of highly trained specialists is required to properly manage service members with leishmaniasis. Such care is available only in a few medical centers. Although there are no prophylactic drugs to prevent this disease, control of insect populations and use of personal protection measures can minimize arthropod-related casualties. The impact of leishmaniasis on military operations and research initiatives to better prevent, diagnose, and treat infection are discussed.

Psychiatry at the front line: CPNs working outside regular hours in an inner-city A&E department

This paper reports on a study that examines the characteristics of patients with mental health problems, seen outside regular working hours, by CPNs working within an in an inner-city A&E department. The study examined the range of presenting problems for each individual attendance rather than the primary diagnosis or main presenting problem. There were significant differences in the pattern of presentations between patients with and without a mental health professional (MHP) involved in their care. Patients with a MHP involved in their care were much more likely to present with psychosis and suicidal ideation in the absence of deliberate self-harm. Those without a MHP were much more likely to have deliberately harmed themselves, to have interpersonal problems, to have misused alcohol or drugs or to have work/financial problems. The CPNs worked in an autonomous manner and appeared to reduce the intensity of the duty psychiatrists' workload by filtering out patients judged not to be in need of their specialist input.

Treatment of Nocardia asteroides keratitis with polyhexamethylene biguanide

PURPOSE

Polyhexamethylene biguanide (PHMB) is a polymeric biguanide disinfectant that has been used previously in the treatment of Acanthamoeba keratitis. The authors report the first case of Nocardia asteroides keratitis treated successfully with PHMB. Further studies documenting the efficacy of PHMB against N. asteroides in vitro also are presented.

METHODS

A soft contact lens wearer presented with an infectious keratitis. Cultures from the cornea grew N. asteroides. The infection resolved with the treatment with PHMB 0.02%. Serial dilutions of PHMB were performed against N. asteroides in culture.

RESULTS

In vitro dilution studies determined that the minimal inhibitory concentration for PHMB against the tested isolate of N. asteroides was 0.01%. This is a concentration that has been shown to be well tolerated by the cornea in vivo.

CONCLUSIONS

Polyhexamethylene biguanide is effective against both Acanthamoeba and Nocardia and may have a wider range of usefulness than that currently recognized. Further testing, both in vitro and in vivo, is required.