The development of community paramedicine; a restricted review.

Community paramedic roles are expanding internationally, and no review of the literature could be found to guide services in the formation of community paramedicine programmes. For this reason, the aim of this restricted review was to explore and better understand the successes and learnings of community paramedic programmes across five domains being; education requirements, models of delivery, clinical governance and supervision, scope of roles and outcomes. This restricted review was conducted by searching four databases (CENTRAL, ERIC, EMBASE, MEDLINE and Google Scholar) as well as grey literature search from 2001 until 28/12/2021. After screening, 98 articles were included in the narrative synthesis. Most studies were from the USA (n = 37), followed by Canada (n = 29). Most studies reported on outcomes of community paramedicine programmes (n = 50), followed by models of delivery (n = 28). The findings of this review demonstrate a lack of research and understanding in the areas of education and scope of the role for community paramedics. The findings highlight a need to develop common approaches to education and scope of role while maintaining flexibility in addressing community needs. There was an observable lack of standardisation in the implementation of governance and supervision models, which may prevent community paramedicine from realising its full potential. The outcome measures reported show that there is evidence to support the implementation of community paramedicine into healthcare system design. Community paramedicine programmes result in a net reduction in acute healthcare utilisation, appear to be economically viable and result in positive patient outcomes with high patient satisfaction with care. There is a developing pool of evidence to many aspects of community paramedicine programmes. However, at this time, gaps in the literature prevent a definitive recommendation on the impact of community paramedicine programmes on healthcare system functionality.

Family Dynamics and the Alzheimer's Disease Experience.

Using constructivist grounded theory, this study explored how family groups respond to Alzheimer's disease in its early stages. Seven family units (N = 22) participated in a series of 26 longitudinal interviews and 14 other family caregivers took part in three focus groups at a later stage for refinement and verification of the findings. Data analysis revealed four types of family dynamics: close dynamics at the start that were maintained throughout the experience, close dynamics at the start which became conflicting, conflicting dynamics at the start which remained problematic, and conflicting dynamic at the start which became closer over time. Factors such as prior relationships and family history, motivation to care, family organization, communication, and the family vision for future shaped the development of these dynamics. This theory of family dynamics in Alzheimer's disease has the potential to inform the development of more adequate early interventions for families living with the illness.

Keeping Things in Balance: Family Experiences of Living With Alzheimer's Disease.

Background and Objectives: Historically, research, practice, and policy on Alzheimer's family care has been largely focused on dyadic relationships and the experience of burden and stress, often failing to capture the complex caring dynamics as they unfold over time. This study sought to develop a more nuanced understanding of how people with Alzheimer's disease (AD) and their families are affected by the disease and how they respond to the challenges AD poses. Research Design and Methods: Using constructivist grounded theory, the study explored the experiences of living with AD for native Spanish families residing in Navarra. Data were collected from a series of 26 interviews with seven family units living with early stage AD and further validated with three focus groups with 14 caregivers of people with mid/advanced AD. Data were analyzed to capture the main processes involved and charted how these evolved over time. Results: Keeping things in balance describes the way family works to preserve a balance between caring and their lives before the onset of AD. Three main temporal stages to the experience of early AD, along with their associated processes, were identified: (a) what's going on here and the processes of noticing, suspecting, and confirming; (b) our life is changing underpinned by the processes of watching and redefining; and (c) keeping things together and its associated balancing process. These reinforced the dynamic nature of living with AD over time. Discussion and Implications: This study was novel in its design as it included the person with AD as part of the functioning family unit. The temporal stages and the key social processes identified have the potential to inform the development of "stage-specific" interventions for the support of the whole family at various points in time.

Implementing a psycho-educational intervention for care assistants working with people with dementia in aged-care facilities: facilitators and barriers.

Many intervention studies lack an investigation and description of the factors that are relevant to its success or failure, despite its relevance to inform future interventions. This study aimed to explore the facilitators and barriers to the implementation of a psycho-educational intervention for care assistants caring for people with dementia in aged-care facilities. A process evaluation was carried out alongside a pretest/post-test controlled study conducted in aged-care facilities. Seven focus-group interviews involving 21 care assistants (female; mean age 43.37 ± 10.0) and individual semi-structured interviews with two managers (female; mean age 45.5 ± 10.26) were conducted 2 weeks and 6 months after the intervention, in two aged-care facilities. Interviews were recorded, transcribed and submitted to content analysis by two independent researchers. Results were organised into implementer, participant and organisation level hindered and facilitator factors. Findings enable the interpretation of the experimental results and underscore the importance of collecting the perception of different grades of staff to obtain information relevant to plan effective interventions.

Person-centredness in direct care workers caring for residents with dementia: Effects of a psycho-educational intervention.

This study assessed the effects of a psycho-educational intervention on direct care workers' person-centredness during morning care to residents with dementia. A controlled pretest-posttest study was conducted in four aged-care facilities with 56 direct care workers (female, mean age 44.72 ± 9.02). Two experimental facilities received a psycho-educational intervention comprising person-centred care competences and stress management skills; control facilities received an education-only intervention, without stress support. In total, 112 video-recorded morning care sessions were coded using the Global Behaviour Scale. Both groups reported significantly higher scores on eight of 11 items of the Global Behaviour Scale and on the Global Behaviour Scale total score at posttest (F=10.59; p=0.02). Global Behaviour Scale total score improvements were higher for the experimental group, with values close to significance (F=3.90; p=0.054). The findings suggest that a psycho-educational intervention may increase care workers' person-centredness. Further research is needed to explore the long-term sustainability and extent of its benefits on workers and residents.

Gaining consensus on family carer needs when caring for someone dying at home to develop the Carers' Alert Thermometer (CAT): a modified Delphi study.

AIM: To report a multi-phase modified Delphi study conducted with carers and professionals to identify the priority areas for inclusion in an alert screening tool for carers providing support to someone dying at home. BACKGROUND: Internationally, there is a growing emphasis on increasing choice for patients who wish to die at home which relies heavily on care provided by the unpaid family carers. Family carers can have high levels of unmet needs comprising their psychological and physical health and their ability to provide effective care and support. Development of an alert tool to identify carers' needs in everyday practice required identification and consensus of the priority areas of need for inclusion. DESIGN: Multi-phase modified Delphi study and instrument development. METHOD: Qualitative and quantitative data collection took place between 2011-2013 with 111 carers and 93 professionals to identify carers' needs and gain consensus on the priority areas for inclusion in the alert tool. An expert panel stage and final evidence review post-Delphi were used. RESULTS: The Delphi panels had high levels of agreement and consensus. Ten areas of carer need across two themes of 'the current caring situation' and 'the carer's own health and well-being' were prioritized for inclusion in the alert tool. An optional end-of-life planning question was included following the final stages. CONCLUSIONS: The results provide evidence of carers' needs to be assessed, areas for consideration in the education of those who support carers and someone dying at home and targeting of services, while demonstrating the usefulness and adaptability of the Delphi method.

Effects of a Psychoeducational Intervention for Direct Care Workers Caring for People With Dementia: Results From a 6-Month Follow-Up Study.

This study aimed to assess the effects of a psychoeducational intervention, designed to improve direct care workers' stress, burnout and job satisfaction, and person-centered communicative behavior in people with dementia. A pretest-posttest control group design was conducted in 4 aged-care facilities. Two experimental facilities received a psychoeducational intervention, and 2 control facilities received an education only. Data were gathered from 53 care workers at baseline, immediately, and 6 months after the intervention, through self-administrated instruments and video-recorded morning care sessions. The experimental group showed a significant decrease in care workers' burnout and a significant improvement in several communicative behaviors (e.g., involvement). Stress levels deteriorated at 6 months, and no intervention effects were found for job satisfaction. The findings highlight the importance of providing care workers with both technical competences and tools for stress management, as this might be associated with a reduction in their levels of exhaustion and improved communicative behaviors.

Effects of a psycho-educational intervention on direct care workers' communicative behaviors with residents with dementia.

This study assessed the effects of a person-centered care-based psycho-educational intervention on direct care workers' communicative behaviors with people with dementia living in aged-care facilities. An experimental study with a pretest-posttest control-group design was conducted in four aged-care facilities. Two experimental facilities received an 8-week psycho-educational intervention aiming to develop workers' knowledge about dementia, person-centered care competences, and tools for stress management. Control facilities received education only, with no support to deal with stress. In total, 332 morning care sessions, involving 56 direct care workers (female, mean age 44.72 ± 9.02 years), were video-recorded before and 2 weeks after the intervention. The frequency and duration of a list of verbal and nonverbal communicative behaviors were analyzed. Within the experimental group there was a positive change from pre- to posttest on the frequency of all workers' communicative behaviors. Significant treatment effects in favor of the experimental group were obtained for the frequency of inform (p < .01, η(2)partial = 0.09) and laugh (p < .01, η(2)partial = 0.18). Differences between groups emerged mainly in nonverbal communicative behaviors. The findings suggest that a person-centered care-based psycho-educational intervention can positively affect direct care workers' communicative behaviors with residents with dementia. Further research is required to determine the extent of the benefits of this approach.

Development of the Carers' Alert Thermometer (CAT) to identify family carers struggling with caring for someone dying at home: a mixed method consensus study.

BACKGROUND: There is an increasing international policy direction to promote home death for dying patients which will impact on the demands placed on family carers. The early identification of carer needs and appropriate intervention can help avoid crisis situations for the carer and avoidable hospital admissions which are reported to be a global concern. The aim of the study was to explore what professionals and carers of patients with cancer and advanced progressive illness, in their last year of life, find burdensome and to develop an alert system for use by non-specialist staff. METHODS: A mixed-method, multi-phased, consensus study sequentially utilising qualitative and quantitative data to develop and pilot the Carers' Alert Thermometer (CAT). 245 people (117 carers and 128 professionals) participated in the study across a range of health and social care settings in the North West of England (2011-2014). RESULTS: A number of key domains were identified and prioritised by consensus for inclusion in the CAT. The 8 domains fit within two overarching themes of the reported carer experience; the support needed by the carer to provide care and the support needed for the carer's own health and well-being. The resultant CAT is an evidence-based alert thermometer consisting of 10 questions, guidance on the possible actions for each alert and space for an action plan to be jointly agreed by the assessor and carer. Preliminary piloting of the CAT has shown it to be valued, fit for purpose and it can be administered by a range of personnel. CONCLUSIONS: The CAT enables the identification of current and potential future needs so a proactive approach can be taken to supporting the carer as their role develops over time, with a view to enhancing their well-being and preventing avoidable hospital admissions; ultimately supporting patient choice to remain in their own home.

Supporting direct care workers in dementia care: effects of a psychoeducational intervention.

An experimental study using a pre-posttest control group design was conducted to assess the effects of a person-centered care-based psychoeducational intervention on direct care workers' stress, burnout, and job satisfaction. The intervention aimed to develop person-centered care competences and tools for stress management. Four aged care facilities were randomly assigned to a psychoeducational or an education-only intervention (control). Data were collected from 56 direct care workers (female, mean age 44.72 ± 9.02) through measurements of burnout (Maslach Burnout Inventory), job satisfaction (Minnesota Satisfaction Questionnaire-short form), and stress (Perceived Stress Scale) and focus-group interviews. Results showed significant positive effects in emotional exhaustion (P = .029) and positive but no significant effects in stress and job satisfaction. According to qualitative data, the experimental group perceived enhanced group cohesion, emotional management, and self-care awareness. Psychoeducational interventions may contribute to reduce direct care workers' burnout. Further work is needed to determine the extent of its benefits.

Effects of Person-Centered Care Approaches to Dementia Care on Staff: A Systematic Review.

Person-centered care (PCC) has been the subject of several intervention studies reporting positive effects on people with dementia. However, its impact on staff remains unclear. The purpose of this systematic review was to assess the impact of PCC approaches on stress, burnout, and job satisfaction of staff caring for people with dementia in residential aged care facilities. Research articles published up to 2013 were searched on PubMed, Web of Knowledge, Scopus, and EBSCO and reference lists from relevant publications. The review was limited to experimental and quasi-experimental studies, published in English and involving direct care workers (DCWs). In all, 7 studies were included, addressing different PCC approaches: dementia care mapping (n=1), stimulation-oriented approaches (n=2), emotion-oriented approaches (n=2), and behavioral-oriented approaches (n=2). Methodological weaknesses and heterogeneity among studies make it difficult to draw firm conclusions. However, 5 studies reported benefits on DCWs, suggesting a tendency toward the effectiveness of PCC on staff.

Caring about caring: developing a model to implement compassionate relationship centred care in an older people care setting.

AIM: This study actively involved older people, staff and relatives in agreeing a definition of compassionate relationship-centred care and identifying strategies to promote such care in acute hospital settings for older people. It was a major component of a three year programme (the Leadership in Compassionate Care Programme, LCCP) seeking to integrate compassionate care across practice and educational environments. BACKGROUND: Compassionate caring and promoting dignity are key priorities for policy, practice and research worldwide, being central to the quality of care for patients and families, and job satisfaction for staff. Therapeutic relationships are essential to achieving excellence in care but little is known about how to develop and sustain such relationships in a culture that increasingly focuses on throughput and rapid turnover. APPROACH AND METHODS: The study used appreciative inquiry and a range of methods including participant observation, interviews, story telling and group discussions to actively engage older people, relatives and staff. A process of immersion crystallization was used to analyze data with staff as co-analysts. FINDINGS: The study adds considerably to the conceptualization of compassionate, relationship-centred care and provides a model to aid staff deliver such care in practice, based on 'appreciative caring conversations' that enable all parties to gain two forms of 'person and relational knowledge' about 'who people are and what matters to them' and 'how people feel about their experience'. Such knowledge enables staff, patients and carers to 'work together to shape the way things are done'. The study generated a model called the 7 'C's that captures in detail the factors necessary to promote 'appreciative caring conversations'. CONCLUSIONS AND IMPLICATIONS: The study demonstrates that engaging in 'appreciative caring conversations' promotes compassionate, relationship-centred care but that these conversations involve practitioners taking risks. Such 'relational practices' must therefore be valued and accorded status. Staff require appropriate support, facilitation and strong leadership if these practices are to flourish.

Factors influencing advanced practice nurses' ability to promote evidence-based practice among frontline nurses.

BACKGROUND: Advanced practice nurses (APNs) have an important role in promoting evidence-based practice (EBP) among frontline nurses (FLNs). Factors influencing FLNs' engagement with EBP are well documented but little is known about factors that affect APNs' ability to facilitate evidence in practice. AIMS: To identify factors that influence APNs' ability to promote EBP among FLNs. METHODS: A multiple case study of 23 APNs from hospital and primary care settings across seven English health authorities was undertaken. Data collection comprised interviews and observation of APNs and interviews with FLNs and other healthcare professionals. Data were analysed using the Framework approach. FINDINGS: Four groups of influencing factors were identified: (1) Personal attributes of APNs included knowledge and skills in EBP, clinical credibility with frontline staff and leadership style. (2) Relationships with stakeholders included APNs' interactions with FLNs and the level of support from managers and medical colleagues. (3) Aspects of the APN role included their sphere of responsibility and workload. (4) Organisational context included the organisational culture, FLNs' workload, professional networks and available resources. IMPLICATIONS: Educational preparation for APNs should enable them to develop expertise in EBP plus interpersonal and leadership skills to manage relational dynamics in clinical settings. APN role specifications should provide the opportunity to promote EBP. The organisational culture should be conducive to enabling EBP with managers supportive of this aspect of the APNs' role. CONCLUSIONS: APNs need to be supported to address the individual, interpersonal and organisational factors, which influence their ability to promote EBP. Organisational commitment at the highest level is key to APNs' ability to fulfil this aspect of their role.

The role of advanced practice nurses in knowledge brokering as a means of promoting evidence-based practice among clinical nurses.

AIM: To identify approaches used by advanced practice nurses to promote evidence-based practice among clinical nurses. BACKGROUND: Barriers encountered at individual and organizational levels hinder clinical nurses in their ability to deliver evidence-based practice. Advanced practice nurses are well placed to promote evidence-based practice through interactions with clinical nurses. However, little is understood about how advanced practice nurses might realize this potential. METHOD: A multiple instrumental case study of 23 advanced practice nurses from hospital and primary care settings across seven Strategic Health Authorities in England was undertaken in 2006. Data collection comprised interviews and observation of advanced practice nurses and interviews with clinical nurses and other healthcare professionals. Data were analysed using the Framework approach. FINDINGS: Advanced practice nurses acted as knowledge brokers in promoting evidence-based practice among clinical nurses. Knowledge management and promoting the uptake of knowledge were key components of knowledge brokering. Knowledge management involved generating different types of evidence, accumulating evidence to act as a repository for clinical nurses, synthesizing different forms of evidence, translating evidence by evaluating, interpreting and distilling it for different audiences and disseminating evidence by formal and informal means. Advanced practice nurses promoted the uptake of evidence by developing the knowledge and skills of clinical nurses through role modelling, teaching, clinical problem-solving and facilitating change. CONCLUSION: The role of advanced practice nurses in knowledge brokering is complex and multi-faceted. It extends beyond the knowledge management, linkage and capacity building identified in the literature to include active processes of problem-solving and facilitating change.

Factors influencing the contribution of advanced practice nurses to promoting evidence-based practice among front-line nurses: findings from a cross-sectional survey.

AIM: This paper is a report of a study to identify factors influencing advanced practice nurses' contribution to promoting evidence-based practice among front-line nurses. BACKGROUND: Despite widespread recognition that care should be evidence-based, nurses experience challenges implementing evidence-based practice. As opinion leaders, advanced practice nurses can influence the practice of front-line nurses by promoting research use. Little is known about how advanced practice nurses use evidence and their influence on care given by front-line nurses. METHOD: A cross-sectional survey of 855 advanced practice nurses working in 87 hospital/primary care settings in England. The questionnaire examined understandings of evidence-based practice, sources of evidence used, ways of working with front-line nurses, perceived impact on front-line nurses, skills in evidence-based practice and barriers to promoting evidence-based practice. Data were collected in 2005 and analysed using descriptive statistics. Comparisons were made between advanced practice nurses with Masters qualifications and those with lower qualifications. FINDINGS: Advanced practice nurses used different sources of evidence. They engaged in various activities to promote evidence-based practice and had a positive influence on front-line nurses' practice. Advanced practice nurses' skills in evidence-based practice varied with few considering themselves expert. Advanced practice nurses with Masters qualifications perceived themselves to be more skilled in all aspects of evidence-based practice than those with lower qualifications. CONCLUSION: Advanced practice nurses are well placed as clinical leaders to promote evidence-based practice by frontline nurses but require further development of their skills in evidence-based practice. In order to maximize their potential, advanced practice nurses require Master's preparation.

[A useful test for evaluating the needs for support of family members--help for an aged parent at home: a tool with potential application in French-speaking Europe]. / Mise à l'essai d'un outil d'évaluation des besoins de soutien des proches--aidants d'un parent âgé à domicile: un outil ayant un potentiel d'application en Europe francophone.

The Family Caregivers Support Agreement (FCSA) tool, based on a caregiver-service provider partnership approach to assess the support needs of family caregivers of a home-living aging relative, was field-tested to document its relevance for use in Quebec (Canada) practice settings. The FCSA tool is a modified version of the Carers Outcome Assessment Tool, initially developed as the result of an Anglo-Swedish Study. The field test was conducted with 17 French- and English-speaking caregivers and revealed numerous unmet caregiver needs, especially of a psycho-educational nature. The use of the FCSA tool lead to an identification of homecare support services which corresponded to caregiver needs and expectations. According to the homecare services providers interviewed, the FCSA tool offers a structured and flexible approach that facilitates the identification of services sensitive to caregiver needs. The instrument allows concretizing the partnership process, in particular, by bringing to light the unique needs of individual caregivers, empowering caregivers by considering them active participants in decision making, and fostering a proper fit between services and needs. Results are in line with those of other studies, suggesting that the caregiver role entails common core needs and that the impact of the FCSA tool is comparable regardless of practice setting. All told, the FCSA tool could potentially be applied in the French-speaking Europe.

A partnership approach to service needs assessment with family caregivers of an aging relative living at home: a qualitative analysis of the experiences of caregivers and practitioners.

BACKGROUND: As the global population ages, support for family caregivers who provide the bulk of care to community-dwelling older people is becoming ever more important. However, in many countries, homecare-service practitioners currently do not follow a systematic approach to assessing and responding to caregiver needs. OBJECTIVES: The aim of this study was to explore the experiences of caregivers and practitioners who took part in a field test of the Family Caregivers Support Agreement (FCSA) tool, a modified version of the Carers Outcome Agreement Tool (COAT) initially developed as the result of an Anglo-Swedish study. Both the COAT and the FCSA are designed to facilitate partnerships between caregivers and practitioners so that needs assessment and subsequent support services are negotiated and agreed so as to meet caregiver expectations. DESIGN AND PARTICIPANTS: A qualitative design was adopted and data were collected through focus groups with six practitioners (nurses and social workers) working in two Local Community Service Centres in the province of Quebec (Canada). These practitioners had previously completed the FCSA tool with 17 primary caregivers of frail elderly relatives who were clients of homecare services. Individual interviews were conducted with the caregivers to explore their experiences. Data were analyzed to identify significant themes, from the perspectives of caregivers and practitioners, which provided insights into their experiences and the strategies used by practitioners to facilitate partnership working. FINDINGS: To facilitate meaningful exchanges, practitioners adopted strategies such as sensitive listening and the use of enabling questions to identify and contextualize caregiver needs and to highlight the ability of caregivers to find their own creative solutions to the challenges they face. The caregivers described experiencing a climate of trust that allowed them to express their concerns, to reflect upon their situation and to participate in the development of an action plan for their support. CONCLUSIONS: The study reaffirms findings from Sweden and UK that the use of a tool such as the FCSA enhances partnership working and creates a caregiver-practitioner relationship based on a genuine alliance. As a result, both parties gain new insights into the caring situation. The approach underpinning the FCSA tool has potential for a more widespread application in different contexts.

[Validation of a tool for family caregivers]. / Validation d'un outil pour les proches-aidants.

The purpose of this transcultural study was to translate and adapt for the province of Quebec (Canada) a tool for assessing the support needs of family caregivers of aging persons, as well as to validate the relevance and feasibility of its utilization in Quebec homecare services. Developed jointly in the United Kingdom and Sweden and based on a caregiver-service provider partnership process, the Carers Outcome Agreement Tool (COAT) is presently the focus of a large-scale implementation study in Sweden. Following parallel back-translation and adaptation, the tool, entitled Entente sur le Soutien aux Proches-Aidants (ESPA) in French, was validated in terms of relevance and feasibility via focus groups with service providers and interviews with family caregivers. Results show the ESPA to be a culturally sensitive tool that systematically identifies the support needs of caregivers and indicates the type of help best suited to meet these needs. As with other European studies, the results suggest that the caregiver role comprises a common core of needs and highlights the tool's potential for transfer to the cultural context of French-speaking Europe.

Supporting people who have dementia to die with dignity.

This article highlights some of the key themes and challenges in the empirical, policy and clinical literature on end-of-life care for people with dementia. It is intended to promote critical discussion in this increasingly important area of policy and practice. The authors argue that end-of-life care for people with dementia should recognise the needs of the person and those of their family carers and staff involved.