Family carer experiences of hospice care at home: Qualitative findings from a mixed methods realist evaluation.

BACKGROUND: Hospice-at-home aims to enable patients approaching end-of-life to die at home and support their carers. A wide range of different service models exists but synthesised evidence on how best to support family carers to provide sustainable end-of-life care at home is limited. AIM: To explore what works best to promote family carers' experiences of hospice-at-home. DESIGN: Realist evaluation with mixed methods. This paper focuses on qualitative interviews with carers (to gain their perspective and as proxy for patients) and service providers from 12 case study sites in England. Interviews were coded and programme theories were refined by the research team including two public members. SETTING/PARTICIPANTS: Interviews with carers (involved daily) of patients admitted to hospice-at-home services (n = 58) and hospice-at-home staff (n = 78). RESULTS: Post bereavement, 76.4% of carers thought that they had received as much help and support as they needed and most carers (75.8%) rated the help and support as excellent or outstanding. Of six final programme theories capturing key factors relevant to providing optimum services, those directly relevant to carer experiences were: integration and co-ordination of services; knowledge, skills and ethos of hospice staff; volunteer roles; support directed at the patient-carer dyad. CONCLUSIONS: Carers in hospice-at-home services identified care to be of a higher quality than generic community services. Hospice staff were perceived as having 'time to care', communicated well and were comfortable with dying and death. Hands-on care was particularly valued in the period close to death.

A Qualitative Exploration of UK Leisure Horse Owners' Perceptions of Equine Wellbeing.

Human assessment of equine wellbeing is fundamental to ensuring the optimal care of domestic horses. However, terminology associated with wellbeing is still not fully defined and there are currently no validated quality of life (QoL) assessment tools. Furthermore, little is known about what equine wellbeing or QoL means to horse owners, or how their beliefs impact on the management decisions they make for their horse. This study sought to establish how UK leisure horse owners use wellbeing-related terminology by exploring their accounts within a focus group setting. Four online focus group discussions (FGD) were held and qualitative data were collected. FGDs involved a semi-structured discussion, followed by a group activity to compare seven equine wellbeing-related terms of interest introduced by the facilitator. The collected data were analysed using a constructivist grounded theory approach, and also by content analysis, to examine the frequency and subjective meaning of the terms of interest. The results showed that horse owners did not clearly delineate between different terms, rather, they used the terms in the context of their own assessments of their horse. The meanings assigned to what owners experienced with their horse were individual and subjective, shaped by past experiences, relationships with their animal, and peers or social groups. This individualised construction of equine wellbeing impacted on the meaning conveyed when using wellbeing-related terminology. In this study, we extend the literature on equine wellbeing terminology usage, and highlight differences between the academic literature and the real-world experiences of horse owners.

Hospice at Home services in England: a national survey.

OBJECTIVE: Hospice at Home (HAH) services aim to enable patients to be cared for and die at home, if that is their choice and achieve a 'good death'. A national survey, in 2017, aimed to describe and compare the features of HAH services and understand key enablers to service provision. METHODS: Service managers of adult HAH services in the 'Hospice UK' and National Association for Hospice at Home directories within England were invited to participate. Information on service configuration, referral, staffing, finance, care provision and enablers to service provision were collected by telephone interview. RESULTS: Of 128 services invited, 70 (54.7%) provided data. Great diversity was found. Most services operated in mixed urban/rural (74.3%) and mixed deprivation (77.1%) areas and provided hands-on care (97.1%), symptom assessment and management (91.4%), psychosocial support (94.3%) and respite care (74.3%). Rapid response (within 4 hours) was available in 65.7%; hands-on care 24 hours a day in 52.2%. Charity donations were the main source of funding for 71.2%. Key enablers for service provision included working with local services (eg, district nursing, general practitioner services), integrated health records, funding and anticipatory care planning. Access to timely medication and equipment was critical. CONCLUSION: There is considerable variation in HAH services in England. Due to this variation it was not possible to categorise services into delivery types. Services work to supplement local care using a flexible approach benefitting from integration and funding. Further work defining service features related to patient and/or carer outcomes would support future service development.

Understanding what works, why and in what circumstances in hospice at home services for end-of-life care: Applying a realist logic of analysis to a systematically searched literature review.

BACKGROUND: We have undertaken a systematically searched literature review using a realist logic of analysis to help synthesise the diverse range of literature available on hospice at home services. AIM: To find out in the existing literature what features of hospice at home models work best, for whom and under what circumstances. DESIGN: A realist logic of analysis was applied to synthesise the evidence focusing on mechanisms by which an intervention worked (or did not work). An initial programme theory was developed using the National Association for Hospice at Home standards, Normalisation Process Theory and through refinement using stakeholder engagement. DATA SOURCES: PubMed, Science Direct, AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, Medline, PsychINFO, SCOPUS, Web of Science, DARE, Google Scholar, NHS Evidence, NIHR CRN portfolio database, NIHR journal library of funded studies, including searches on websites of relevant professional bodies (August 2014, June 2017, June 2019). RESULTS: Forty-nine papers were reviewed, of which 34 contributed evidence to at least one of the eight theory areas: marketing and referral, sustainable funding model, service responsiveness and availability, criteria for service admission, knowledge and skills of care providers, integration and coordination, anticipatory care, support directed at carers. CONCLUSIONS: Our literature review showed how it was possible to develop a coherent framework and test it against 34 published papers and abstracts. Central to this review was theory building, and as further evidence emerges, our programme theories can be refined and tested against any new empirical evidence.

Optimum hospice at home services for end-of-life care: protocol of a mixed-methods study employing realist evaluation.

INTRODUCTION: Hospice at home (HAH) services aim to enable patients to be cared for and die in their place of choice, if that is at home, and to achieve a 'good death'. There is a considerable range of HAH services operating in England. The published evidence focuses on evaluations of individual services which vary considerably, and there is a lack of consistency in terms of the outcome measures reported. The evidence, therefore, does not provide generalisable information, so the question 'What are the features of hospice at home service models that work, for whom, and under what circumstances?' remains unanswered. The study aims to answer this question. METHODS AND ANALYSIS: This is a mixed-methods study in three phases informed by realist evaluation methodology. All HAH services in England will be invited to participate in a telephone survey to enable the development of a typology of services. In the second phase, case study sites representing the different service types will collect patient data and recruit carers, service managers and commissioners to gather quantitative and qualitative data about service provision and outcomes. A third phase will synthesise and refine the results through consensus workshops. ETHICS AND DISSEMINATION: The first survey phase has university ethics approval and the second phase, Integrated Research Application System (IRAS) and Health Research Authority (HRA) approval (IRAS ID:205986, REC:17/LO/0880); the third phase does not require ethics approval. Dissemination will be facilitated by project coapplicants with established connections to national policy-making forums, in addition to publications, conference presentations and reports targeted to service providers and commissioners.

Evaluation of a pilot service to facilitate discharge of patients with stable long-term mental health needs from secondary to primary care: the role of Primary Care Mental Health Specialists.

Aim We aimed to evaluate a pilot service to facilitate discharge of patients with stable long-term mental health needs from secondary to primary care. BACKGROUND: Patients with stable long-term mental health conditions are often not discharged from secondary mental health services when no longer needed due to insufficient systems and processes to enable safe, effective, recovery-focussed treatment and support. The Primary Care Mental Health Specialist (PCMHS) Service was developed to address this gap; new PCMHS posts were introduced to act as a conduit for patients being discharged from secondary care and a single point of referral back into secondary care, should it be required. The two-year pilot, across six Clinical Commissioning Groups in South East England, began in March 2013. METHODS: Interviews were conducted with all PCMHS employed in the pilot service (n=13) and a sample of service users (n=12). The views of professionals working alongside the service, including GPs, Psychiatrists and Mental Health Nurses, were captured using a brief online questionnaire (n=50). Time and Activity Recording Sheets were used to capture data required for economic analysis. Findings Our findings indicate that the service is working well from the perspective of patients; staff employed within the service and professionals working alongside the service. Patients described the service as a 'safety net' they could fall back on in case of difficulties, whereas staff used the analogy of a 'bridge' to describe the way the service improved communication and collaboration between the various professionals and organisations involved in the patient's care. Improvements in well-being were seen to result from increased support for those transitioning from secondary to primary care, a more pro-active approach to relapse prevention and increased engagement in daily activities. Each PCMHS covered 36 patients in a one-month period, with a unit cost of £73.01 per patient.

Postural characteristics of female dressage riders using 3D motion analysis and the effects of an athletic taping technique: A randomised control trial.

OBJECTIVES: To observe postural characteristics of female dressage riders, through application of three-dimensional motion analysis and to assess the effects of athletic taping on postural asymmetry during sitting trot. DESIGN: Randomised cross-over. SETTING: Data collection took place at Myerscough Agricultural College in an indoor riding area. PARTICIPANTS: Ten healthy female experienced dressage riders participated. MAIN OUTCOME MEASUREMENTS: Movement kinematics of the trunk and pelvis, pre and post taping intervention. RESULTS: Riders presented pre-intervention with asymmetric movement characteristics through dynamic observation of trunk and pelvic postures during sitting trot. There was a significant increase (p ≤ 0.05) in the range (°) of trunk lateral-flexion following tape intervention applied over the thoracic spine. CONCLUSION: This study supports the quantification of dynamic postural characteristics of dressage athletes by three-dimensional motion analysis. Asymmetrical postures occur within dressage riders when performing sitting trot. The application of tape to 'align' asymmetry altered riders' postures. Taping over the thoracic region resulted in a compensatory increase in motion through the lumbar region. Clinicians should approach the application of postural taping with an awareness of the restrictive mechanisms of tape. Findings may help clinicians determine whether technique/type of tape applied is suitable for achieving marginal gains in the alignment of posture in competitive dressage athletes.

The effect of two preparation procedures on an equine arena surface in relation to motion of the hoof and metacarpophalangeal joint.

A link between surface characteristics and injury has been identified in equine disciplines. Maintenance procedures are reported to affect surface characteristics and could influence horse movement. The study investigated limb and hoof movement on a synthetic surface following two different preparations (harrowing and rolling). Nine horses were recorded using infrared cameras and retro-reflective markers at walk, trot and canter on two surface preparations in a cross-over design. Hoof rotation and displacement, metacarpophalangeal joint (MCPJ) extension and third metacarpal (McIII) inclination (roll, pitch and yaw) were analysed using a general linear model. Surface hardness and traction were also measured. No differences in hoof rotations or hoof displacements were found between preparations. However, following harrowing, greater (P<0.05) MCPJ extension at mid-stance and greater (P<0.05) McIII adduction at impact was found when gait was grouped. Hardness and traction were statistically similar for both preparations. Alteration to the surface cushion appears to be sufficient to produce subtle changes in stride characteristics.

Effects of a stretching regime on stride length and range of motion in equine trot.

The aim of this study was to quantify the effects of two different 8-week stretching regimes on stride length (SL) and range of motion (ROM) in the equine trot. Eighteen horses were divided into three matched groups: a 6 days/week stretching regime (6DSR), a 3 days/week stretching regime (3DSR) and a control no-stretching regime (NSR). SL and ROM data were collected at weeks 0, 2, 4, 6 and 8 for trot in-hand. Stretching had no significant effect on SL. A number of significant differences were found in joint ROM between treatments in the shoulder, stifle and hock, suggesting some negative biomechanical effects of the 6DSR. Stretching daily may be too intensive and cause delayed onset of muscle soreness. Further examination of stretch frequency may establish its potential to enhance performance and welfare.

Development and evaluation of a noninvasive marker cluster technique to assess three-dimensional kinematics of the distal portion of the forelimb in horses.

OBJECTIVE: To develop and evaluate a marker cluster set for measuring sagittal and extrasagittal movement of joints in the distal portion of the forelimb in ponies. ANIMALS: 4 ponies. PROCEDURES: 5 infrared cameras were positioned on a concrete walkway in a frontal-sagittal arc and calibrated. Four segments were defined: hoof, middle phalanx, proximal phalanx, and metacarpus. Rigid clusters with 4 retroreflective markers were placed on each segment. A static trial was recorded with additional anatomic markers on the medial and lateral joint lines. Those anatomic markers were removed, and kinematic data were recorded at 240 Hz during walking. An ensemble mean was computed from the 4 ponies from 5 replicates of the walks. Joint kinematic variables were calculated by use of the calibrated anatomical system technique. The design and error dispersion of each marker were evaluated. RESULTS: Marker clusters were quasiplanar, but variation in orientation error was reduced because the mean radii were > 10 times the largest error dispersion values. Measurements of sagittal rotations of the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints were similar to measurements obtained with bone-fixed triads, but larger discrepancies between the 2 methods were found for extrasagittal rotations. CONCLUSIONS AND CLINICAL RELEVANCE: Development of noninvasive methods for quantifying data pertaining to 3-dimensional motion in horses is important for advancement of clinical analysis. The technique used in the study enabled identification of flexion-extension motions with an acceptable degree of accuracy. Appropriate correction algorithms and improvements to the technique may enable future quantification of extrasagittal motions.