The experiences of hospital staff who provide care for people living with dementia: A systematic review and synthesis of qualitative studies.

AIMS AND OBJECTIVES: To systematically review and synthesise qualitative data from studies exploring the experiences of hospital staff who care for people living with dementia (Plwd). BACKGROUND: In hospital, the number of Plwd continues to rise; however, their experiences of care remain problematic. Negative experiences of care are likely to contribute to poorer mental and physical health outcomes for Plwd while in hospital and after discharge. Experiences of the hospital staff who care for Plwd can also be poor or unrewarding. It is important to understand the experiences of staff in order to improve staff well-being and ultimately the experience of care for Plwd while in hospital. DESIGN: Systematic review and evidence synthesis of qualitative research. DATA SOURCES: We searched 16 electronic databases in March 2018 and completed forward and backward citation chasing. METHODS: Eligible studies explored the experiences of paid and unpaid staff providing care in hospital for Plwd. Study selection was undertaken independently by two reviewers, and quality appraisal was conducted. We prioritised included studies according to richness of text, methodological rigour and conceptual contribution. We adopted approaches of meta-ethnography to analyse study findings, creating a conceptual model to represent the line of argument. FINDINGS: Forty-five studies reported in 58 papers met the inclusion criteria, and of these, we prioritised 19 studies reported in 24 papers. The line of argument was that Institutions can improve staff experiences of care for Plwd by fostering person-centred care (PCC). PCC aligned with staff perceptions of 'good care'; however, staff often felt prevented from providing PCC because of care cultures that prioritised tasks, routines and physical health. Staff experienced conflict over the care they wanted to give versus the care they were able to give, and this caused moral distress. When staff were able to provide PCC, this increased experiences of job satisfaction and emotional well-being. CONCLUSIONS: Person-centred care not only has the potential to improve the experience of care for Plwd and their carers, but can also improve the experiences of hospital staff caring for Plwd. However, without institutional-level changes, hospital staff are often unable to provide PCC even when they have the experience and knowledge to do so. IMPLICATIONS FOR PRACTICE: Institutional-level areas for change include the following: training; performance indicators and ward cultures that prioritise psychological needs alongside physical needs; adequate staffing levels; inclusive approaches to carers; physical environments that promote familiarisation, social interaction and occupation; systems of documentation about individual needs of Plwd; and cultures of sharing knowledge across hierarchies.

Effectiveness of pharmacist home visits for individuals at risk of medication-related problems: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Medication mismanagement is a major cause of both hospital admission and nursing home placement of frail older adults. Medication reviews by community pharmacists aim to maximise therapeutic benefit but also minimise harm. Pharmacist-led medication reviews have been the focus of several systematic reviews, but none have focussed on the home setting. REVIEW METHODS: To determine the effectiveness of pharmacist home visits for individuals at risk of medication-related problems we undertook a systematic review and meta-analysis of randomised controlled trials (RCTs). Thirteen databases were searched from inception to December 2018. Forward and backward citation of included studies was also performed. Articles were screened for inclusion independently by two reviewers. Randomised controlled studies of home visits by pharmacists for individuals at risk of medication-related problems were eligible for inclusion. Data extraction and quality appraisal were performed by one reviewer and checked by a second. Random-effects meta-analyses were performed where sufficient data allowed and narrative synthesis summarised all remaining data. RESULTS: Twelve RCTs (reported in 15 articles), involving 3410 participants, were included in the review. The frequency, content and purpose of the home visit varied considerably. The data from eight trials were suitable for meta-analysis of the effects on hospital admissions and mortality, and from three trials for the effects on quality of life. Overall there was no evidence of reduction in hospital admissions (risk ratio (RR) of 1.01 (95%CI 0.86 to 1.20, I2 = 69.0%, p = 0.89; 8 studies, 2314 participants)), or mortality (RR of 1.01 (95%CI 0.81 to 1.26, I2 = 0%, p = 0.94; 8 studies, 2314 participants)). There was no consistent evidence of an effect on quality of life, medication adherence or knowledge. CONCLUSION: A systematic review of twelve RCTs assessing the impact of pharmacist home visits for individuals at risk of medication related problems found no evidence of effect on hospital admission or mortality rates, and limited evidence of effect on quality of life. Future studies should focus on using more robust methods to assess relevant outcomes.

Emotional disorder and absence from school: findings from the 2004 British Child and Adolescent Mental Health Survey.

Emotional disorder may be associated with absence from school, but the existing evidence is methodologically weak. We studied the relationships between anxiety, depression and emotional difficulties, and school absence (total, authorised and unauthorised) using data from the 2004 British Child and Adolescent Mental Health Survey (BCAMHS). The BCAMHS was a cross-sectional, community survey of 7977 5- to 16-year-olds. Emotional disorder was assessed using the Development and Wellbeing Assessment (DAWBA), and emotional difficulties using the Strengths and Difficulties Questionnaire (SDQ) completed by teachers and parents. Teachers reported days absent in the previous school term. Multivariable negative binomial regression was used to examine the impact of emotional disorder and difficulties on absence. Age, gender and general health were explored as moderators. Anxiety, depression and emotional difficulties were associated with higher rates of all types of absence [rate ratios for total absence: anxiety 1.69 (1.39-2.06) p < 0.001; depression 3.40 (2.46-4.69) p < 0.001; parent-reported emotional difficulties 1.07 (1.05-1.10) p < 0.001; teacher-reported emotional difficulties 1.10 (1.08-1.13) p < 0.001]. The strongest association was observed for depression and unauthorised absence. Relationships were stronger for secondary compared to primary school children. Health and educational professionals should be aware that children with poor attendance may be experiencing emotional ill health, regardless of absence type. The absence may provide a useful tool to identify those who require additional mental health support. Findings highlight the widespread burden of emotional disorder and the need to support those with emotional ill health in continuing to access education.

Interventions to improve the mental health of children and young people with long-term physical conditions: linked evidence syntheses.

BACKGROUND: Although mental health difficulties can severely complicate the lives of children and young people (CYP) with long-term physical conditions (LTCs), there is a lack of evidence about the effectiveness of interventions to treat them. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of interventions aiming to improve the mental health of CYP with LTCs (review 1) and explore the factors that may enhance or limit their delivery (review 2). DATA SOURCES: For review 1, 13 electronic databases were searched, including MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Science Citation Index. For review 2, MEDLINE, PsycINFO and CINAHL were searched. Supplementary searches, author contact and grey literature searches were also conducted. REVIEW METHODS: The first systematic review sought randomised controlled trials (RCTs) and economic evaluations of interventions to improve elevated symptoms of mental ill health in CYP with LTCs. Effect sizes for each outcome were calculated post intervention (Cohen's d). When appropriate, random-effects meta-analyses produced pooled effect sizes (d). Review 2 located primary qualitative studies exploring experiences of CYP with LTCs, their families and/or practitioners, regarding interventions aiming to improve the mental health and well-being of CYP with LTCs. Synthesis followed the principles of metaethnography. An overarching synthesis integrated the findings from review 1 and review 2 using a deductive approach. End-user involvement, including topic experts and CYP with LTCs and their parents, was a feature throughout the project. RESULTS: Review 1 synthesised 25 RCTs evaluating 11 types of intervention, sampling 12 different LTCs. Tentative evidence from seven studies suggests that cognitive-behavioural therapy interventions could improve the mental health of CYP with certain LTCs. Intervention-LTC dyads were diverse, with few opportunities to meta-analyse. No economic evaluations were located. Review 2 synthesised 57 studies evaluating 21 types of intervention. Most studies were of individuals with cancer, a human immunodeficiency virus (HIV) infection or mixed LTCs. Interventions often aimed to improve broader mental health and well-being, rather than symptoms of mental health disorder. The metaethnography identified five main constructs, described in an explanatory line of argument model of the experience of interventions. Nine overarching synthesis categories emerged from the integrated evidence, raising implications for future research. LIMITATIONS: Review 1 conclusions were limited by the lack of evidence about intervention effectiveness. No relevant economic evaluations were located. There were no UK studies included in review 1, limiting the applicability of findings. The mental health status of participants in review 2 was usually unknown, limiting comparability with review 1. The different evidence identified by the two systematic reviews challenged the overarching synthesis. CONCLUSIONS: There is a relatively small amount of comparable evidence for the effectiveness of interventions for the mental health of CYP with LTCs. Qualitative evidence provided insight into the experiences that intervention deliverers and recipients valued. Future research should evaluate potentially effective intervention components in high-quality RCTs integrating process evaluations. End-user involvement enriched the project. STUDY REGISTRATION: This study is registered as PROSPERO CRD42011001716. FUNDING: The National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Many children and young people with a long-term physical health condition also experience feelings of depression, anxiety and other mental health issues that affect their day-to-day life, their family and others around them. This review investigates whether or not interventions (treatments, strategies and resources) can help children and young people with their mental health. The study also reviewed studies that explored the attitudes and experiences of those involved in receiving or delivering similar interventions. The study found 25 publications that evaluated 11 different types of interventions, including cognitive­behavioural therapy (seven studies) and music therapy (one study). There were some positive effects for the strategies tested on both mental health and other outcomes, but, because the studies were often small, exact effects were uncertain. Many of the studies were not very well designed or carried out and differences between research designs meant that it was hard to compare different studies. The study found 57 publications that explored experiences of interventions. Analysis suggested that it is important that strategies involve building good relationships and are delivered in what feels like a safe space. Participants in studies tended to like interventions that provided social support and helped them feel better about living with a long-term physical condition. Successful interventions were viewed as accessible and engaging. These studies were often conducted well, but they focused on the range of interventions rather than the review evaluating how well interventions work. There are many gaps in the research carried out so far. Some long-term conditions affecting children and young people have not been the subject of studies of mental health interventions, and some important outcomes, such as school attendance and self-care, have not been assessed. More carefully designed UK research consulting children and young people, parents and practitioners is needed before it can be clear what works for children with particular physical conditions to help their mental health, and why.

The association between child and adolescent depression and poor attendance at school: A systematic review and meta-analysis.

BACKGROUND: Depression in young people may lead to reduced school attendance through social withdrawal, loss of motivation, sleep disturbance and low energy. We systematically reviewed the evidence for an association between depression and poor school attendance. METHODS: Seven electronic databases were searched for quantitative studies with school-aged children and/or adolescents, reporting a measure of association between depression and school attendance. Articles were independently screened by two reviewers. Synthesis incorporated random-effects meta-analysis and narrative synthesis. RESULTS: Searches identified 4930 articles. Nineteen studies from eight countries across North America, Europe, and Asia, were included. School attendance was grouped into: 1) absenteeism (i.e. total absences), 2) excused/medical absences, 3) unexcused absences/truancy, and 4) school refusal. Meta-analyses demonstrated small-to-moderate positive cross-sectional associations between depression and absenteeism (correlation coefficient r = 0.11, 95% confidence interval 0.07 to 0.15, p = 0.005, I2 = 63%); and depression and unexcused absences/truancy (r = 0.15, 95% confidence interval 0.13 to 0.17, p < 0.001, I2 = 4%; odds ratio = 3.74, 95% confidence interval 2.11 to 6.60, p < 0.001, I2 = 65%). Few studies reported associations with school refusal or excused/medical absences, and few utilised longitudinal data, although results from two studies suggested an association between depression and subsequent absenteeism. LIMITATIONS: Study quality was poor overall, and methodological heterogeneity, despite creating a broad evidence-base, restricted meta-analysis to only small subsamples of studies. CONCLUSIONS: Findings suggest associations between depression and poor school attendance, particularly absenteeism and unexcused absences/truancy. Clinicians and school staff should be alert to the possibility of depression in children and adolescents with poor attendance. Future research should utilise longitudinal data to confirm the direction of the association, investigate associations with excused absences, and test potential moderators of the relationship.

Review: The association between anxiety and poor attendance at school - a systematic review.

BACKGROUND: Anxiety may be associated with poor attendance at school, which can lead to a range of adverse outcomes. We systematically reviewed the evidence for an association between anxiety and poor school attendance. METHODS: Seven electronic databases were searched for quantitative studies that reported an estimate of association between anxiety and school attendance. Anxiety had to be assessed via standardised diagnostic measure or validated scale. Articles were screened independently by two reviewers. Meta-analyses were performed where possible, otherwise results were synthesised narratively. RESULTS: A total of 4930 articles were screened. Eleven studies from six countries across North America, Europe and Asia, were included. School attendance was categorised into: (a) absenteeism (i.e. total absences), (b) excused/medical absences, (c) unexcused absences/truancy and (d) school refusal. Findings from eight studies suggested associations between truancy and any anxiety disorder, as well as social and generalised anxiety. Results also suggested cross-sectional associations between school refusal and separation, generalised and social anxiety disorders, as well as simple phobia. Few studies investigated associations with absenteeism or excused/medical absences. CONCLUSIONS: Findings suggest associations between anxiety and unexcused absences/truancy, and school refusal. Clinicians should consider the possibility of anxiety in children and adolescents with poor attendance. However, there is a lack of high quality evidence, little longitudinal research and limited evidence relating to overall absenteeism or excused/medical absences, despite the latter being the most common type of absence. These gaps should be a key priority for future research.

Non-Pharmacological Interventions for ADHD in School Settings: An Overarching Synthesis of Systematic Reviews.

OBJECTIVE: This overarching synthesis brings together the findings of four systematic reviews including 138 studies focused on non-pharmacological interventions for ADHD used in school settings. These reviews considered the effectiveness of school-based interventions for ADHD, attitudes toward and experience of school-based interventions for ADHD, and the experience of ADHD in school settings. METHOD: We developed novel methods to compare the findings across these reviews inductively and deductively. RESULTS: Key contextual issues that may influence the effectiveness and implementation of interventions include the relationships that pupils with ADHD have with their teachers and peers, the attributions individuals make about the etiology of ADHD, and stigma related to ADHD or intervention attendance. CONCLUSION: Although we found some positive effects for some outcomes and intervention categories, heterogeneity in effect size estimates and research evidence suggests a range of diverse contextual factors potentially moderate the implementation and effectiveness of school-based interventions for ADHD.

Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by age-inappropriate levels of inattention, impulsivity and hyperactivity. School can be particularly challenging for children with ADHD. Few reviews have considered non-pharmacological interventions in school settings. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions delivered in school settings for pupils with, or at risk of, ADHD and to explore the factors that may enhance, or limit, their delivery. DATA SOURCES: Twenty electronic databases (including PsycINFO, MEDLINE, EMBASE, Education Resources Information Centre, The Cochrane Library and Education Research Complete) were searched from 1980 to February-August 2013. Three separate searches were conducted for four systematic reviews; they were supplemented with forward and backwards citation chasing, website searching, author recommendations and hand-searches of key journals. REVIEW METHODS: The systematic reviews focused on (1) the effectiveness of school-based interventions for children with or at risk of ADHD; (2) quantitative research that explores attitudes towards school-based non-pharmacological interventions for pupils with ADHD; (3) qualitative research investigating the attitudes and experiences of children, teachers, parents and others using ADHD interventions in school settings; and (4) qualitative research exploring the experience of ADHD in school among pupils, their parents and teachers more generally. Methods of synthesis included a random-effects meta-analysis, meta-regression and narrative synthesis for review 1, narrative synthesis for review 2 and meta-ethnography and thematic analysis for reviews 3 and 4. RESULTS: For review 1, 54 controlled trials met the inclusion criteria. For the 36 meta-analysed randomised controlled trials, beneficial effects (p < 0.05) were observed for several symptom and scholastic outcomes. Mean weighted effect sizes ranged from very small (d + < 0.20) to large (d + ≥ 0.80), but substantial heterogeneity in effect size estimates across studies was reported. Moderator analyses were not able to clarify which intervention features were linked with effectiveness. For review 2, 28 included studies revealed that educators' attitudes towards interventions ranged in positivity. Most interventions were rated positively or neutrally across different studies. The only intervention that consistently recorded positive attitudes from educators was daily report cards. For review 3, 33 studies met the inclusion criteria. Key findings included tensions regarding the preferred format of interventions, particularly how structured interventions were and the extent to which they are tailored to the child with ADHD. There were mixed views about the impact of interventions, although it was clear that interventions both influence and are influenced by the relationships held by children with ADHD and participants' attitudes towards school and ADHD. For review 4, 34 studies met the inclusion criteria. Key findings included the importance of causal attributions that teachers, parents and pupils made about ADHD symptoms, the decisions teachers made about treatment, the self-perceptions pupils developed about themselves, the role of the classroom environment and stigma in aggravating ADHD symptoms, and the significant barrier to treatment posed by the common presence of conflict in relationships between pupils-teachers, parents-teachers and pupils-peers in relation to ADHD. An overarching synthesis of the four reviews highlighted the importance of the context affecting interventions. It suggested that ADHD psychoeducation and relationship-building skills are potential implications for interventions. LIMITATIONS: The breadth of both interventions and outcomes in the reviewed studies presented a challenge for categorisation, analysis and interpretation in reviews 1-3. Across reviews, relatively few studies were conducted in the UK, limiting the applicability of findings to UK education. In reviews 1 and 2, the poor methodological quality of some included studies was identified as a barrier to establishing effectiveness or comparing attitudes. In review 3 the descriptive analysis used by the majority of studies constrained theorising during synthesis. Studies in review 4 lacked detail regarding important issues like gender, pupil maturity and school level. CONCLUSION: Findings suggest some beneficial effects of non-pharmacological interventions for ADHD used in school settings, but substantial heterogeneity in effect sizes was seen across studies. The qualitative reviews demonstrate the importance of the context in which interventions are used. Future work should consider more rigorous evaluation of interventions, as well as focus on what works, for whom and in which contexts. Gaps in current research present opportunities for the development and testing of standardised tools to describe interventions, agreement on gold-standard outcome measures assessing ADHD behaviour and testing a range of potential moderators alongside intervention trials. STUDY REGISTRATION: This study is registered as PROSPERO CRD42011001716. FUNDING: The National Institute for Health Research Health Technology Assessment programme.