Cost and economic evidence for asset-based approaches to health improvement and their evaluation methods: a systematic review.

BACKGROUND: Asset-based approaches (ABAs) tackle health inequalities by empowering people in more disadvantaged communities, or targeted populations, to better utilise pre-existing local community-based resources. Using existing resources supports individuals to better manage their own health and its determinants, potentially at low cost. Targeting individuals disengaged with traditional service delivery methods offers further potential for meaningful cost-savings, since these people often require costly care. Thus, improving prevention, and management, of ill-health in these groups may have considerable cost implications. AIM: To systematically review the extent of current cost and economic evidence on ABAs, and methods used to develop it. METHODS: Search strategy terms encompassed: i) costing; ii) intervention detail; and iii) locality. Databases searched: Medline, CENTRAL and Wed of Science. Researchers screened 9,116 articles. Risk of bias was assessed using the Critical Appraisal Skills Programme (CASP) tool. Narrative synthesis summarised findings. RESULTS: Twelve papers met inclusion criteria, representing eleven different ABAs. Within studies, methods varied widely, not only in design and comparators, but also in terms of included costs and outcome measures. Studies suggested economic efficiency, but lack of suitable comparators made more definitive conclusions difficult. CONCLUSION: Economic evidence around ABAs is limited. ABAs may be a promising way to engage underserved or minority groups, that may have lower net costs compared to alternative health and wellbeing improvement approaches. ABAs, an example of embedded services, suffer in the context of economic evaluation, which typically consider services as mutually exclusive alternatives. Economics of the surrounding services, mechanisms of information sharing, and collaboration underpin the success of assets and ABAs. The economic evidence, and evaluations in general, would benefit from increased context and detail to help ensure more nuanced and sophisticated understanding of the economics of ABAs. Further evidence is needed to reach conclusions about cost-effectiveness of ABAs.

Operationalising the Recovery College model with people living with dementia: a realist review.

OBJECTIVES: Post-diagnostic support is a significant factor in facilitating personal recovery following a diagnosis of dementia, but access is often inconsistent and insufficient. Recovery Colleges offer peer-led, co-produced courses that can support people to have meaningful lives and have been adapted for use in the context of dementia. A realist review was conducted to understand the application and sustainability of Recovery College dementia courses. METHOD: An iterative, five-step process combined literature published to 2023 with knowledge from stakeholders with lived and professional experience of dementia involved with Recovery College dementia courses (PROSPERO registration CRD42021293687). RESULTS: Thirty-five documents and discussions with 19 stakeholders were used to build the initial programme theory comprising of 24 context-mechanism-outcome configurations. Reoccurring factors included: attending to aspects of co-production and course delivery to ensure they promoted inclusion and were not compromised by organisational pressures; how stigma impacted access to course opportunities; and embedding personal recovery principles throughout course development to be relevant for people living with dementia and those who support them. CONCLUSION: People struggling to reconcile their future alongside dementia need practical and emotional support to access and benefit from Recovery College dementia courses, ways to achieve this will be explored through a realist evaluation.

Pharmacist-independent prescriber deprescribing in UK care homes: Contextual factors associated with increased activity.

AIMS: The Care Home Independent Pharmacist Prescriber Study (CHIPPS) process evaluation hypothesized that contextual factors influenced the likelihood of deprescribing by pharmacist-independent prescribers. The aim of this paper is to test this hypothesis. METHODS: From CHIPPS study data, medications deprescribed totalled 284 for 370 residents in UK care homes. Regression analysis was used to describe the relationship between the number of medicines stopped and contextual factors (number of residents cared for, pharmacist employment within associated medical practice, previous care home experience, hours active within trial, years' experience as a pharmacist and as a prescriber). RESULTS: Number of residents and pharmacist-independent prescriber employment within a medical practice were positive predictors of deprescribing. CONCLUSION: Previous experiences were not related to deprescribing likelihood. Increasing the number of residents increases the opportunity for deprescribing and therefore this relationship is intuitive. The location within a medical practice is an interesting finding that requires further exploration to understand its exact nature.

Care-home Nurses' responses to the COVID-19 pandemic: Managing ethical conundrums at personal cost: A qualitative study.

INTRODUCTION: The COVID-19 pandemic had an unprecedented effect on those living and working in care-homes for older people, as residents were particularly vulnerable to contracting the SARS-CoV-2 virus, associated with high morbidity and mortality. Often undervalued, care-home nurses (RNs) are leaders, managing complex care while working in isolation from their professional peers. The pandemic made this more apparent, when care and treatments for COVID-19 were initially unknown, isolation increased due to withdrawal of many professional health services, accompanied by staff shortages. OBJECTIVE: To explore RNs' experiences of working in older people's care-homes during the COVID-19 pandemic. DESIGN: Qualitative interview study. SETTING: Care-homes for older people in England and Scotland, UK. METHODS: Recruitment via direct contact with care-homes, social media, and links provided by national partners, then purposive sampling for age, gender, type of care-home, and location. Data collected through one-to-one online interviews using topic guide developed collaboratively with care-home nurses, focusing on how COVID-19 impacted on nurses' resilience and mental wellbeing. Data analyzed thematically using Tronto's ethics of care framework to guide development of interpretative themes. RESULTS: Eighteen nurses (16 female; 16 adult, and two mental health nurses) were interviewed March-June 2021; majority aged 46-55 years; mean time registered with Nursing and Midwifery Council: 19 years; 17 had nursed residents with COVID-19. RNs' experiences resonated with Tronto's five tenets of ethical care: attentiveness, responsibility, competence, responsiveness, and solidarity. All nurses described being attentive to needs of others, but were less attentive to their own needs, which came at personal cost. RNs were aware of their professional and leadership responsibilities, being as responsive as they could be to resident needs, processing and sharing rapidly changing guidance and implementing appropriate infection control measures, but felt that relatives and regulatory bodies were not always appreciative. RNs developed enhanced clinical skills, increasing their professional standing, but reported having to compromise care, leading to moral distress. Broadly, participants reported a sense of solidarity across care-home staff and working together to cope with the crisis. CONCLUSION: Care-home nurses felt unprepared for managing the COVID-19 pandemic, many experienced moral distress. Supporting care-home nurses to recover from the pandemic is essential to maintain a healthy, stable workforce and needs to be specific to care-home RNs, recognizing their unique pandemic experiences. Support for RNs will likely benefit other care-home workers either directly through wider roll-out, or indirectly through improved wellbeing of nurse leaders. CLINICAL RELEVANCE: The COVID-19 pandemic, an international public health emergency, created many challenges for Registered Nurses (RNs) working in long-term care facilities for older people, as residents were particularly vulnerable to the impact of the SARS-CoV-2 virus. Care-home RNs faced challenges distinct from their hospital-based nursing peers and non-nursing social care colleagues due to their isolation, leadership roles, professional legal obligations, and ethical responsibilities, leading to psychological distress on the one hand, but also a newly found confidence in their existing and newly developed skills, and increased recognition by the wider health community of their specialisms.

Hospital clinicians' perspectives of using compression therapy on venous leg ulcers: a systematic qualitative review.

Venous leg ulcer treatment is frequently discontinued in hospitals in contravention of national guidance, significantly affecting patient outcomes and increasing NHS costs. AIM: To identify, from the published literature, reasons for variable implementation. METHOD: Systematic review with narrative synthesis, including full papers in English with empirical qualitative data. Synonyms for venous leg ulcer, compression therapy and secondary care were searched across a range of health-related databases. The Critical Appraisal Skills Programme (CASP) checklist determined study quality, and meta-ethnography was used for data synthesis. RESULTS: 7040 titles and abstracts and 41 full-text papers were screened with four papers selected. Three key themes were generated: educational needs surrounding implementation of compression therapy, patient factors regarding adherence and organisational resources including availability of appropriate equipment and trained staff. CONCLUSION: Barriers at the ward level were identified. There is a need to better understand why hospitals are not addressing them.

Feasibility and acceptability evaluation of the Promoting Independence in Dementia (PRIDE) intervention for living well with dementia.

OBJECTIVES: Post-diagnostic psychosocial interventions could play an important role in supporting people with mild dementia remain independent. The Promoting Independence in Dementia (PRIDE) intervention was developed to address this. METHOD: The mixed methods non-randomized, pre-post feasibility study occurred across England. Facilitators were recruited from the voluntary sector and memory services. Participants and their supporters took part in the three-session intervention. Outcome measures were collected at baseline and follow-up. To evaluate acceptability, focus groups and interviews were conducted with a subsample of participants and facilitators. RESULTS: Contextual challenges to delivery including national research governance changes, affected recruitment of study sites. Thirty-four dyads consented, with 14 facilitators providing the intervention. Dyads took part in at least two sessions (79%), and 73% in all three. Outcome measures were completed by 79% without difficulty, with minimal missing data. No significant changes were found on pre and post assessments. Post hoc analysis found moderate effect size improvements for self-management (SMAS instrument) in people with dementia (d = 0.41) and quality of life (EQ5D measure) in carers (d = 0.40). Qualitative data indicated that dyads found PRIDE acceptable, as did intervention facilitators. CONCLUSIONS: The three-session intervention was well accepted by participant-dyads and intervention facilitators. A randomized controlled trial of PRIDE would need to carefully consider recruitment potential across geographically varied settings and site stratification according to knowledge of contextual factors, such as the diversity of post-diagnostic services across the country. Letting sites themselves be responsible for identifying suitable intervention facilitators was successful. The self-report measures showed potential to be included in the main trial.

Exploring disconnected discourses about Patient and Public Involvement and Volunteer Involvement in English health and social care.

BACKGROUND: Patient and public involvement (PPI) in health and social care policy, service decision-making and research are presented as good practice in England. Yet the explicit rationale for PPI and how it is positioned within the literature, policy and practice remain confused, in particular, in relation to Volunteer Involvement (VI). In health and social care, PPI and VI are managed and valued as conceptually distinct, yet the discourses in their policy and practice documents treat them as closely related in fundamental ways. OBJECTIVE: Compare and critically evaluate discourses framing PPI and VI within English health and social care. DESIGN: A critical discourse approach was used to explore the accounts of PPI and VI in policy. These accounts were then compared and contrasted with personal accounts of volunteering in health and social care settings. RESULTS: Twenty documents from key national health and social care bodies were discursively examined in terms of their framing PPI and VI. A narrative disconnect between the two was repeatedly confirmed. This finding contrasted with an analysis of personal accounts of VI which displayed VI as a form of PPI. CONCLUSION: There is a disconnect between language, narratives and practice in PPI and in VI which may have direct consequences for policy and practice. Recognising and managing it can offer innovative ways of enabling volunteers to be involved across health and social care settings, ensuring the experiential value added by volunteers' service contributions, to be recognised so that their democratic participation may be seen to shape services.

Process evaluation for the Care Homes Independent Pharmacist Prescriber Study (CHIPPS).

BACKGROUND: Medicines management in care homes requires significant improvement. CHIPPS was a cluster randomised controlled trial to determine the effectiveness of integrating pharmacist independent prescribers into care homes to assume central responsibility for medicines management. This paper reports the parallel mixed-methods process evaluation. METHOD: Intervention arm consisted of 25 triads: Care homes (staff and up to 24 residents), General Practitioner (GP) and Pharmacist Independent Prescriber (PIP). Data sources were pharmaceutical care plans (PCPs), pharmacist activity logs, online questionnaires and semi-structured interviews. Quantitative data were analysed descriptively. Qualitative data were analysed thematically. Results were mapped to the process evaluation objectives following the Medical Research Council framework. RESULTS: PCPs and activity logs were available from 22 PIPs. Questionnaires were returned by 16 PIPs, eight GPs, and two care home managers. Interviews were completed with 14 PIPs, eight GPs, nine care home managers, six care home staff, and one resident. All stakeholders reported some benefits from PIPs having responsibility for medicine management and identified no safety concerns. PIPs reported an increase in their knowledge and identified the value of having time to engage with care home staff and residents during reviews. The research paperwork was identified as least useful by many PIPs. PIPs conducted medication reviews on residents, recording 566 clinical interventions, many involving deprescribing; 93.8% of changes were sustained at 6 months. For 284 (50.2%) residents a medicine was stopped, and for a quarter of residents, changes involved a medicine linked to increased falls risk. Qualitative data indicated participants noted increased medication safety and improved resident quality of life. Contextual barriers to implementation were apparent in the few triads where PIP was not known previously to the GP and care home before the trial. In three triads, PIPs did not deliver the intervention. CONCLUSIONS: The intervention was generally implemented as intended, and well-received by most stakeholders. Whilst there was widespread deprescribing, contextual factors effected opportunity for PIP engagement in care homes. Implementation was most effective when communication pathways between PIP and GP had been previously well-established. TRIAL REGISTRATION: The definitive RCT was registered with the ISRCTN registry (registration number  ISRCTN 17847169 ).

Relational experiences of people seeking help and assessment for subjective cognitive concern and memory loss.

Objective: To understand the experience of people who seek help for subjective cognitive concern and memory loss, including people not referred for further assessment. To understand the patients' perspective of the medical process of receiving a cognitive assessment. This work is situated within the context of policy priorities for dementia diagnosis.Methods: Participants with and without dementia were recruited through NHS trusts and community organisations in four regional areas in England. Data were collected using longitudinal qualitative interviews. Transcript data were thematically analysed.Results: Sample of 41 people (mean 75 years, 25 dementia diagnoses). Interpretative thematic analyses focused on the presence or absence of trust in relational experiences. There were three transition points where trust could be specifically developed or undermined: (1) deciding to seek help; (2) healthcare practitioners' response to help-seeking; (3) process and outcome of assessment. Triggers for help-seeking for subjective cognitive concern were being prompted by family and knowing a relative with dementia. When participants perceived healthcare practitioners' behaviour as dismissive, they had less trust in the outcome of the healthcare encounter. Misunderstandings and absence of trust in assessment processes led to participants stating they did not fully agree with the outcomes of the assessment.Conclusions: Healthcare practitioners have an important role in supporting people with subjective cognitive concern ensuring patients have trust in assessment outcomes. Where the validity of the assessment process is seen as ambiguous, people can be left dealing with uncertainty, rather than being clear about ways they can manage their condition, situation or status.

Maintaining Social Connections in Dementia: A Qualitative Synthesis.

The clinical symptoms of dementia include difficulty with speech, poor short-term memory, and changes in behavior. These symptoms can affect how the person with dementia understands and performs in social interactions. This qualitative review investigated how people with mild to moderate dementia managed social connections. A systematic search of social science databases retrieved 13 articles; data were synthesized using thematic analysis. Results established the work undertaken by people with dementia to maintain and present a social persona seen as socially acceptable. Interpretations are contextualized within Goffman and Sabat's theories on "self." People with dementia were agentic in impression management: undertaking work to maintain recognized social roles, while being aware of when their illness led to others discrediting them. Wider recognition of strategies used to maintain a social self could inform interventions designed to increase capability and confidence in co-managing social connections following dementia diagnosis.

Embedding patient and public involvement: Managing tacit and explicit expectations.

BACKGROUND: Evidencing well-planned and implemented patient and public involvement (PPI) in a research project is increasingly required in funding bids and dissemination activities. There is a tacit expectation that involving people with experience of the condition under study will improve the integrity and quality of the research. This expectation remains largely unproblematized and unchallenged. OBJECTIVE: To critically evaluate the implementation of PPI activity, including co-research in a programme of research exploring ways to enhance the independence of people with dementia. DESIGN: Using critical cases, we make visible and explicate theoretical and moral challenges of PPI. RESULTS: Case 1 explores the challenges of undertaking multiple PPI roles in the same study making explicit different responsibilities of being a co-applicant, PPI advisory member and a co-researcher. Case 2 explores tensions which arose when working with carer co-researchers during data collection; here the co-researcher's wish to offer support and advice to research participants, a moral imperative, was in conflict with assumptions about the role of the objective interviewer. Case 3 defines and examines co-research data coding and interpretation activities undertaken with people with dementia, reporting the theoretical outputs of the activity and questioning whether this was co-researcher analysis or PPI validation. CONCLUSION: Patient and public involvement activity can empower individual PPI volunteers and improve relevance and quality of research but it is a complex activity which is socially constructed in flexible ways with variable outcomes. It cannot be assumed to be simple or universal panacea for increasing the relevance and accessibility of research to the public.

Co-research with adults with intellectual disability: A systematic review.

BACKGROUND: Co-research with people with intellectual disability is a distinct form of patient and public involvement (PPI). This systematic review summarize published studies and protocols to report on the process of co-research in social and healthcare research. METHOD: Relevant studies were identified using electronic searches on ASSIA, PsycInfo and MedLine. Study quality was assessed, and information relevant to the process of working with co-researchers was extracted and thematically analysed. RESULTS: Thirteen studies were retrieved. Data are reported under three themes: (i) challenges of co-research; (ii) facilitators of co-research; (iii) benefits of co-research. Best practice is presented as a model of co-research. Content analysis on 12 research protocols identified four themes related to PPI. CONCLUSIONS: All stakeholders involved in co-research with people with intellectual disability can benefit, providing there is adequate infrastructure to accommodate and empower the co-researchers. Many current intellectual disability research projects still lack systematic involvement of PPI members.

A synthesis of the evidence on peer research with potentially vulnerable adults: how this relates to dementia.

BACKGROUND: There is limited literature around peer research in dementia. This study aims to identify the benefits, the risks and the practical challenges and to develop a model of good practice in peer research with people with dementia. METHODS: We searched on PsycInfo, PubMed and Google Scholar for empirical investigations or discussion papers on peer research. Given the limited literature in the field of dementia, we included studies with groups who share similar demographics (older people), experience of stigma (mental health service users) and exclusion from research (people with learning disabilities). We applied no restrictions on language and publication date. ANALYSIS: We identified three themes: the potential benefits, the potential risks and the practical challenges of peer research. We developed a model of good practice. The European Working Group of People with Dementia reviewed our paper and added to our findings. RESULTS: We included seven papers. Potential benefits of peer research included enriched data and empowering people with dementia. Potential risks included power differentials between researchers and issues of representativeness. The practical issues for good practice included the training of peer researchers, defining involvement and roles, working with cognitive impairment and considering resource implications. The European Working Group of People with Dementia emphasised the importance of equality issues. CONCLUSION: Involving people with dementia in peer research can generate several benefits, including empowerment and opportunities for inclusion for the peer researchers and the research participants living with dementia, challenging academics' traditional views on research processes and gathering enhanced research data. There remains a need for further research on the impact of peer research in dementia studies. Copyright © 2016 John Wiley & Sons, Ltd.

Shifting dementia discourses from deficit to active citizenship.

Within western cultures, portrayals of dementia as 'a living death' are being challenged by people living with the diagnosis. Yet dementia remains one of the most feared conditions. The sociological lens of citizenship provides a conceptual framework for reviewing the role of society and culture in repositioning dementia away from deficit to a discourse of agency and interdependence. Awareness of cognitive change, and engaging with the diagnostic process, moves people into a transitional, or 'liminal' state of uncertainty. They are no longer able to return to their previous status, but may resist the unwanted status of 'person with dementia'. Drawing on qualitative studies on social participation by people with dementia, we suggest that whether people are able to move beyond the liminal phase depends on acceptance of the diagnosis, social capital, personal and cultural beliefs, the responses of others and comorbidities. Some people publicly embrace a new identity whereas others withdraw, or are withdrawn, from society to live in the shadow of the fourth age. We suggest narratives of deficit fail to reflect the agency people with dementia can enact to shape their social worlds in ways which enable them to establish post-liminal citizen roles. (A Virtual Abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

Member Checking: A Tool to Enhance Trustworthiness or Merely a Nod to Validation?

The trustworthiness of results is the bedrock of high quality qualitative research. Member checking, also known as participant or respondent validation, is a technique for exploring the credibility of results. Data or results are returned to participants to check for accuracy and resonance with their experiences. Member checking is often mentioned as one in a list of validation techniques. This simplistic reporting might not acknowledge the value of using the method, nor its juxtaposition with the interpretative stance of qualitative research. In this commentary, we critique how member checking has been used in published research, before describing and evaluating an innovative in-depth member checking technique, Synthesized Member Checking. The method was used in a study with patients diagnosed with melanoma. Synthesized Member Checking addresses the co-constructed nature of knowledge by providing participants with the opportunity to engage with, and add to, interview and interpreted data, several months after their semi-structured interview.

Psychological impact of family history risk assessment in primary care: a mixed methods study.

BACKGROUND: Routine family history risk assessment for chronic diseases could enable primary care practitioners to efficiently identify at-risk patients and promote preventive management strategies. OBJECTIVES: To investigate patients' understanding and responses to family history risk assessment in primary care. METHOD: A mixed methods study set in 10 Eastern England general practices. Participants in a family history questionnaire validation study were triaged into population or increased risk for four chronic diseases (type 2 diabetes, cardiovascular disease, breast cancer, colorectal cancer). Questionnaires completed immediately prior to the family history consultation (baseline) and 4 weeks later (follow-up) assessed the psychological impact, including State-Trait Anxiety Inventory scores. Semi-structured interviews explored the meaning participants gave to their personal familial disease risk. RESULTS: Four hundred and fifty-three participants completed both baseline and follow-up questionnaires and 30 were interviewed. At follow-up, there was no increase in anxiety among either group, or differences between the groups [difference in mean change 0.02, 95% confidence interval -2.04, 2.08, P = 0.98]. There were no significant changes over time in self-rated health in either group. At follow-up, participants at increased risk (n = 153) were more likely to have recent changes to behaviour and they had stronger intentions to make changes to diet (P = 0.001), physical activity (P = 0.006) and to seek further information in the future than those at population risk (n = 300; P < 0.001). Using qualitative analysis, five themes were developed representing ways in which participants gave meaning to familial disease risk ('Being reassured', 'Controlling risk', 'Dealing with it later', 'Beyond my control', 'Disbelieving the risk'). The meanings they attributed to increased risk appeared to shape their intention to undertake behaviour change. CONCLUSION: Routine assessment for familial risk of chronic diseases may be undertaken in primary care without causing anxiety or reducing self-rated health. Patient responses to family history risk assessment may inform promotion of preventive management strategies.

A qualitative exploration of the use of calendar landmarking instruments in cancer symptom research.

BACKGROUND: Late diagnosis is considered to be a major factor contributing to poorer cancer survival rates in the UK. Interventions have focussed on the promotion of earlier diagnosis in patients with potential cancer symptoms. However, to assess the effectiveness of these interventions, the time from symptom onset to presentation needs to be reliably and accurately measured. This qualitative study explored the use of calendar landmarking instruments in cancer symptom research. METHODS: We performed a secondary analysis of transcripts of interviews using the calendar landmarking instrument, undertaken with patients who had either been diagnosed with cancer (n = 40, IRCO study, Western Australia), or who had symptoms suggestive of cancer (n = 38, SYMPTOM study, North East and Eastern England). We used constant comparison methods to identify use of the calendar landmarking instruments and the impact of their application. RESULTS: The calendar landmarking instrument appeared to help many patients, either by acting as a prompt or helping to refine recall of events. A combination of personal (e.g. birthday) and national (e.g. Christmas) landmarks seemed to be the most effective. Calendar landmarking instruments appeared more useful where the time period between onset of symptoms and date of first consultation was less than three months. The interviewee's age, gender and cancer type did not appear to influence whether or not the instrument facilitated recall, and there were no instances where the use of the instrument resulted in the disclosure of a new first symptom. Symptoms of similar chronic conditions could create difficulties when applying the instrument; it was difficult for these participants to characterise and disentangle their symptoms which prompted their decisions to seek help. Some participants tended to prefer to use their own, already personalised, diaries to assist in their recall of events. CONCLUSIONS: This study is the first to describe the potential role of calendar landmarking instruments to support research interviews which explore symptoms and events along the cancer diagnostic pathway. The major challenge remains as to whether they actually improve accuracy of recall.

Barriers and enablers to deprescribing for older people in care homes: The theory-based perspectives of pharmacist independent prescribers.

BACKGROUND: Over 70% of care home residents are prescribed potentially inappropriate medications (PIMs) associated with morbidity and mortality. Deprescribing is a common recommendation by pharmacists performing medication reviews in care homes, however requiring prescriber authorisation is a barrier. Care home Independent Pharmacist Prescribing Study (CHIPPS), a cluster randomised control trial integrated pharmacist independent prescriber (PIPs) into care homes to improve medication management, providing a unique opportunity to identify their barriers and enablers to deprescribing. OBJECTIVES: To identify barriers and enablers to PIPs deprescribing medications in care homes. METHODS: Secondary qualitative framework analysis was performed on interviews with CHIPPS' PIPs. A maximum variation sampling approach was used to select from the 14 PIPs included in the process evaluation to achieve diversity of PIPs' contextual factors e.g., previous experience in care homes. Transcripts were coded inductively for barriers and enablers to deprescribing and then mapped to Theoretical Domains Framework (TDF). RESULTS: Eleven PIP's interviews were sampled. Factors acted as enablers and barriers were PIP relationship with General Practitioner (GP), care home staff and residents/families, awareness of the PIP role and family trust in PIPs' deprescribing activities (social influences); PIPs' independent prescribing confidence, previous experience and ability dealing with residents' medications (beliefs about capabilities); understanding of PIP role and PIP confidence in their role as an independent prescriber (Social/professional role and identity); access to residents' records, deprescribing decision support, regular follow-up from care home staff, resident difficulties with medications, teamwork, and time restraints (Environmental context and resources). One factor acted as a barrier: believing negatives of deprescribing outweigh benefits regarding certain medications (Beliefs about consequences). CONCLUSION: PIPs' involvement in deprescribing within care homes is influenced by multiple barriers and enablers. Data mapped to TDF domains represent barriers that need addressing and enablers that should be highlighted to enhance PIPs' effectiveness in future interventions.

What happens when pharmacist independent prescribers lead on medicine management in older people's care homes: a qualitative study.

OBJECTIVE: Older people in care homes frequently experience polypharmacy, increasing the likelihood of medicine-related burden. Pharmacists working within multidisciplinary primary care teams are ideally placed to lead on medication reviews. A randomised controlled trial placed pharmacists, with independent prescribing rights (PIPs), into older people care homes. In the intervention service, PIPs worked with general practitioners (GPs) and care home staff for 6 months, to optimise medicine management at individual resident and care home level. PIP activity included stopping medicines that were no longer needed or where potential harms outweighed benefits. This analysis of qualitative data examines health and social care stakeholders' perceptions of how the service impacted on care home medicine procedures and resident well-being. DESIGN: Pragmatic research design with secondary analysis of interviews. SETTING: Primary care pharmacist intervention in older people care homes in England, Scotland and Northern Ireland. PARTICIPANTS: Recruited from intervention arm of the trial: PIPs (n=14), GPs (n=8), care home managers (n=9) and care home staff (n=6). RESULTS: There were resonances between different participant groups about potential benefits to care home residents of a medicine service provided by PIPs. There were small differences in perceptions about changes related to communication between professionals. Results are reported through three themes (1) 'It's a natural fit'-pharmacists undertaking medication review in care homes fitted within multidisciplinary care; (2) 'The resident is cared for'-there were subjective improvements in residents' well-being; (3) 'Moving from "firefighting" to effective systems'-there was evidence of changes to care home medicine procedures. CONCLUSION: This study suggests that pharmacist independent prescribers in primary care working within the multidisciplinary team can manage care home residents' medicines leading to subjective improvements in residents' well-being and medicine management procedures. Care home staff appreciated contact with a dedicated person in the GP practice. TRIAL REGISTRATION: ISRCTN 17847169.

"The Dynamic Nature of Being a Person": An Ethnographic Study of People Living With Dementia in Their Communities.

BACKGROUND AND OBJECTIVES: A dementia diagnosis can affect social interactions. This study aims to understand how people living with dementia act as social beings within everyday interactions in their local communities. RESEARCH DESIGN AND METHODS: Focused ethnography informed by Spradley's approach to data collection and analysis. Observations in community spaces. RESULTS: Twenty-nine observations were undertaken in everyday social settings with 11 people with dementia who were part of a longitudinal interview study. Data consisted of 40 hr of observation, and researcher field notes. The overarching theme "the dynamic nature of being a person" encapsulates participants' exhibited experiences in negotiating to attain and sustain an acknowledged place in their communities. Two subthemes characterized contexts and actions: (1) "Being me-not dementia": Participants constructed narratives to assert their ontological presence in social settings. They and others used strategies to mediate cognitive changes evidencing dementia. (2) "Resisting or acquiescing to 'being absent in place'": Participants were often able to resist being absent to the gaze from others, but some social structures and behaviors led to a person being "in place," yet not having their presence confirmed. DISCUSSION AND IMPLICATIONS: People living with dementia can actively draw on personal attributes, familiar rituals, objects, and social roles to continue to present themselves as social beings. Identifying how postdiagnosis people may self-manage cognitive changes to retain their presence as a person can help health and social care practitioners and families collaborate with the person living with dementia enabling them to have a continued social presence.