Managing loneliness: a qualitative study of older people's views.

Engaging with older people who self-identify as lonely may help professionals in mental health and other services understand how they deal with loneliness. The evidence-base for effective interventions to address loneliness is inconclusive. This study aimed to explore how community-dwelling lonely older people in England manage their experiences of loneliness. Twenty eight community-dwelling older people identifying as lonely, based on responses to two loneliness measures (self-report and a standardised instrument), participated in in-depth interviews between 2013 and 2014. Fifteen lived alone. Thematic analysis of transcribed interviews was conducted by a multidisciplinary team including older people.Participants drew on a range of strategies to ameliorate their distress which had been developed over their lives and shaped according to individual coping styles and contexts. Strategies included physical engagement with the world beyond their home, using technologies, planning, and engagement with purpose in an 'outside world', and acceptance, endurance, revealing and hiding, positive attitude and motivation, and distraction within an 'inside world'. Strategies of interests and hobbies, comparative thinking, religion and spirituality and use of alcohol straddled both the inside and outside worlds. Participants conveyed a personal responsibility for managing feelings of loneliness rather than relying on others. This study includes the experiences of those living with loneliness whilst also living with other people. When developing policy and practice responses to loneliness it is important to listen attentively to the views of those who may not be engaging with services designed for 'the lonely' and to consider their own strategies for managing it.

Exploring the support for UK migrants experiencing gambling-related harm: insights from two focus groups.

OBJECTIVES: To obtain insights about the accessibility of UK gambling support services from the perspectives of individuals and organisations supporting migrants experiencing gambling-related harm. STUDY DESIGN: Two focus groups were conducted in Leeds and London, United Kingdom, in 2018. METHODS: Thirty-two participants shared their views and experiences from their support work with migrant communities or support services and personal experiences. Thematic analysis identified four themes: (1) the relationship between gambling-related harm and migration, (2) the 'harm paradox' and migrant gambling, (3) barriers to help seeking and (4) ways to improve current support. RESULTS: Participants considered that individuals' migration history may impact on their gambling participation. They considered that recent migrants experience similar gambling-related harms to the UK general population; however, their experience of harms may be exacerbated or accelerated by socio-economic circumstances. Concerns surrounding trust, confidentiality, social interaction, integration and language proficiency were interwoven with barriers that migrants may encounter when engaging in help-seeking behaviour. Participants called for better evidence and understanding of the culturally specific and contextual harms that migrants may experience from their gambling. They advocated a stronger emphasis on prevention and the development of culturally competent gambling support services. CONCLUSIONS: Migrants are vulnerable to gambling-related harm; however, existing gambling support services may not meet their needs. Efforts should be made to ensure gambling support services are accessible to migrants and culturally sensitive. More research is needed to investigate gambling-related harm from the perspectives of migrants and to improve the promotion, design, delivery and accessibility of gambling support services for this population.

Perceived needs for support among care home staff providing end of life care for people with dementia: a qualitative study.

OBJECTIVE: The aim of the current exploratory study was to investigate the impact on care home staff when working with people with dementia at the end of life and to explore how they cope with this aspect of their work. With UK policy encouraging death in the place of residence, rather than hospital, more people with dementia are dying in care homes. METHOD: A qualitative approach was employed; 20 care home staff working in five English care homes were interviewed. Thematic Analysis was used to analyse the data. RESULTS: Care home staff found the external demands on them and difficulties associated with interacting with people with dementia sometimes challenging, stressful and anxiety-provoking, particularly as residents approached end of life. Emotional aspects of caring for dying residents were sometimes heightened by close attachments with residents and their families. Staff were able to recognise these unmet needs and identified a need for further training and emotional support to manage these stressors. CONCLUSIONS: This study revealed rich and complex understandings of the practice dimensions of caring for people with dementia at the end of life and the impact these have on staff. There is a need to develop effective psychosocial interventions that focus on emotional support for care home staff. There will be challenges in providing this in employment settings that are generally low paid, low status, have high turnover and are reliant on temporary or migrant staff, where training is not rewarded, mandatory or culturally valued. Copyright © 2016 John Wiley & Sons, Ltd.

The potential of case management for people with dementia: a commentary.

BACKGROUND: A recent review of studies of case management in dementia argues that lack of evidence of cost-effectiveness should discourage the use of this approach to care. We argue that that this is too conservative a stance, given the urgent need throughout the world to improve the quality of care for people with dementia and their caregivers. We propose a research agenda on case management for people with dementia. METHOD: A critical comparison was made of the studies identified in two systematic reviews of trials of case management for dementia, with selective inclusion of non-trial studies and economic evaluations. RESULTS: Our interpretation of the literature leads us to four provisional conclusions. First, studies with long follow-up periods tend to show delayed relocation of people with dementia to care homes. Second, the quality of life of people with dementia and their caregivers may also influence the likelihood of relocation. Third, different understandings of what constitutes case management make interpretation of studies difficult. Fourth, we agree that the population most likely to benefit from case management needs to be characterised. Earlier intervention may be more beneficial than intervening when the condition has progressed and the individual's situation is highly complex. However, this runs counter to some definitions of case management as an administrative, professional, and systemic focus on people with high needs and where expensive support is accessed or in prospect. CONCLUSIONS: More work needs to be carried out in a more focused way in order to establish the value of case management for people with dementia. Since care home residence is such a sizeable contributor to the costs of dementia care, studies need to be long enough to capture possible postponed relocation. However, case management studies with shorter follow-up periods can still contribute to our understanding, since they can demonstrate improved quality of life. Future research should be built around a common, agreed definition of types of case management.

Making decisions at the end of life when caring for a person with dementia: a literature review to explore the potential use of heuristics in difficult decision-making.

OBJECTIVE: Decision-making, when providing care and treatment for a person with dementia at the end of life, can be complex and challenging. There is a lack of guidance available to support practitioners and family carers, and even those experienced in end of life dementia care report a lack of confidence in decision-making. It is thought that the use of heuristics (rules of thumb) may aid decision-making. The aim of this study is to identify whether heuristics are used in end of life dementia care, and if so, to identify the context in which they are being used. DESIGN: A narrative literature review was conducted taking a systematic approach to the search strategy, using the Centre for Reviews and Dissemination guidelines. Rapid appraisal methodology was used in order to source specific and relevant literature regarding the use of heuristics in end of life dementia care. DATA SOURCES: A search using terms related to dementia, palliative care and decision-making was conducted across 4 English language electronic databases (MEDLINE, EMBASE, PsycINFO and CINAHL) in 2015. RESULTS: The search identified 12 papers that contained an algorithm, guideline, decision tool or set of principles that we considered compatible with heuristic decision-making. The papers addressed swallowing and feeding difficulties, the treatment of pneumonia, management of pain and agitation, rationalising medication, ending life-sustaining treatment, and ensuring a good death. CONCLUSIONS: The use of heuristics in palliative or end of life dementia care is not described in the research literature. However, this review identified important decision-making principles, which are largely a reflection of expert opinion. These principles may have the potential to be developed into simple heuristics that could be used in practice.

After the Liverpool Care Pathway--development of heuristics to guide end of life care for people with dementia: protocol of the ALCP study.

INTRODUCTION: End of life care guidance for people with dementia is lacking and this has been made more problematic in England with the removal of one of the main end of life care guidelines which offered some structure, the Liverpool Care Pathway. This guidance gap may be eased with the development of heuristics (rules of thumb) which offer a fast and frugal form of decision-making. OBJECTIVE: To develop a toolkit of heuristics (rules of thumb) for practitioners to use when caring for people with dementia at the end of life. METHOD AND ANALYSIS: A mixed-method study using a co-design approach to develop heuristics in three phases. In phase 1, we will conduct at least six focus groups with family carers, health and social care practitioners from both hospital and community care services, using the 'think-aloud' method to understand decision-making processes and to develop a set of heuristics. The focus group topic guide will be developed from the findings of a previous study of 46 interviews of family carers about quality end-of-life care for people with dementia and a review of the literature. A multidisciplinary development team of health and social care practitioners will synthesise the findings from the focus groups to devise and refine a toolkit of heuristics. Phase 2 will test the use of heuristics in practice in five sites: one general practice, one community nursing team, one hospital ward and two palliative care teams working in the community. Phase 3 will evaluate and further refine the toolkit of heuristics through group interviews, online questionnaires and semistructured interviews. ETHICS AND DISSEMINATION: This study has received ethical approval from a local NHS research ethics committee (Rec ref: 15/LO/0156). The findings of this study will be presented in peer-reviewed publications and national and international conferences.

Managing risk in the city: the role of welfare professionals in managing risks arising from vulnerable individuals in cities.

Modern cities depend on individualism and the process of contracting. Contracts between individuals contribute to stability and order in cities. However, this is challenged by risks and uncertainties especially those relating to vulnerable individuals who are unable or unwilling to enter into contractual relations. This paper focuses on the role of caring professions and the impact of new strategies for managing risks related to vulnerable adults and children, especially the shift from managing risk in institutions to managing risk in the community. This paper is based on research funded through the ESRC Risk and Human Behaviour Programme.

Student approaches: supporting students in A&E settings.

Nurses working in accident and emergency (A&E) departments near to Higher Education Institutions will be familiar with students attending as the result of sports injuries, and as the consequence of a range of accidents stemming from over-enthusiastic socializing. However, a number of students arrive at A&E departments in distress as the result of mental health problems. This article reports the findings of a small research project exploring mechanisms and support systems for assisting students with mental health needs. It briefly outlines the research and its findings and then considers three relevant issues for those working in A&E: student profiles, student support and the position of students who are considering or engaged in professional education. The article ends with a brief discussion of the position of students undertaking placements within A&E departments.

Social Marxism, class conflict and health care.

In the first of a six-part series the sociological theories of Karl Marx are examined and related to the purported neutrality of medicine. The role of nursing within a Marxist analysis of the world is considered, and the value of such analysis is described.

Durkheim, social integration and suicide rates.

This second paper of six on the application of sociology in health care considers the work of Emile Durkheim. He was concerned with the production of social order through relationships and shared values. Durkheim conceived social phenomena as 'social facts' which could be studied, and his treatment of suicide as a case study of social fact is discussed here. His work on the processes of social cohesion has influenced the work of sociologists up to the present day.

Weber, authority and the organisation of health care.

The third paper in the series on sociology discusses the work of Max Weber. It traces the origins and main themes of his work. The parallels between his work and contemporary issues in the organisation of health care are outlined, in particular, the insights provided into bureaucracy and authority.

Parsons, professions and the sociology of health care.

The fourth paper in the sociology series examines the work of the American Talcott Parsons. His work has particular relevance to the sociology of health and illness. The concept of the sick role as a means of understanding the effects of ill health, which he proposed, is critically examined here.

Goffman, the individual, institutions and stigmatisation.

In the fifth part of our series about sociology, the sociology of Erving Goffman is discussed, particularly in relation to his work on institutions. In contrast with earlier prominent sociological figures, Goffman's emphasis was on the individual rather than on grand-scale theories about social systems.

Giddens and late modernity: analysing 20th century life.

The final paper of our series on principal figures in sociology examines the work of Anthony Giddens, a British sociologist who is still working. Major components of his analysis of late 20th century life are discussed.

Risk: the sociological view of perception and management.

In this final article on sociology we focus on one issue which is central to health and health care--risk--and consider the contribution of sociology to an understanding of the ways in which risk is perceived and managed.

User involvement in the development of a health promotion technology for older people: findings from the SWISH project.

Successive English government policies about older people's health and well-being aim to improve health and quality of life by promoting independence. Improving access to information and services that can improve health and well-being and reduce health risks is central to the modernisation of health and social care. Most recently, tailored and person-centred approaches with a strong emphasis on promoting health and well-being are central to policy, including the proposals for 'Life Checks' and the recent emphasis on commissioning 'community well-being'. We carried out a qualitative study to identify the key aspects of social situations that affect health and well-being, from the perspectives of older people and professionals, to enrich and expand an existing health risk appraisal tool so that it could be used for self-assessment of health and social well-being. This tool, Health Risk Appraisal in Older people (HRAO), has been evaluated in different European settings, including English general practice. Focus groups were recruited from general practice, older people's forums, social care and voluntary organisations in two London boroughs where the HRAO tool had previously been tested. The social factors determining health that were prioritised by older people and service providers and recommended for inclusion in the health risk appraisal tool were recent life events, housing and garden maintenance, transport, both public and private, financial management, career status & needs, the local environment and social networks and social isolation. This study has identified key social determinants of health that could usefully be added to 'Life Checks' for older people and that could also inform the commissioning of community well-being. Modified with the addition of social domains, the HRAO technology could be a suitable tool to achieve current policy objectives.

The Mental Capacity Act 2005: implications for dietetic practice.

The Mental Capacity Act (MCA) 2005 will be implemented in England and Wales in 2007 and have consequences for dietitians who work with people who may lack capacity to make specific decisions. This paper will explore issues arising from the introduction of the Act and considers the implications for dietitians involved in the delivery of clinical care, using enteral feeding as an illustrative example. If patients lack capacity to make specific decisions, dietitians will be required to record if, how and why they reached a decision, how they are involved in the decision making process and need to be able to justify their actions in relation to those decisions. This paper discusses the importance of dietitians' involvement in best interests decision making and considers the implications of decision making where people have drawn up a Lasting Power of Attorney. The role of such advance decisions is discussed and consideration is given to the potential compatibility of perspectives between the patient and family that may give rise to disputes. Dietitians may be well placed within multidisciplinary team working to ensure patients and their carers are part of the decision making process through effective communication and support for patients. Dietitians in England and Wales must consider the implications of the MCA upon their clinical practice and others outside these jurisdictions may like to reflect on the relevance of such developments in their own contexts.

Grandparents' guidance.

This article looks at the less well known casualties of some family breakdowns; grandparents who have lost contact with grandchildren on the divorce, death or separation of the parents or on the placing of their grandchildren in the care of the local authority. Although health visitors may feel their immediate concern is with the children and parents in such circumstances, their increasing work with older people will make it necessary that they appreciate the feelings of grandparents and are also able to offer practical advice.

The debate on ethnicity and dementia: from category fallacy to person-centred care?

The concept of ethnicity remains attractive and meaningful to service developers and professionals, although research suggests that this disguises other facets of identity and difference. An epidemiological perspective on the relationship between ethnicity and dementia supports the idea that ethnicity (defined as particular shared cultural characteristics) is not likely to influence unduly the emergence of dementia in individuals. Cultural factors may protect against dementia, impeding its recognition and influencing its course and these deserve further investigation. Ethnicity is a general concept that subsumes and conceals the impact of migration, education, health beliefs and socio-economic status on health, and therefore is problematic. Empirical research on dementia and ethnicity reveals that intra-ethnic group variation is greater than inter-ethnic group variation; supporting the view that ethnicity as a category may not have great explanatory power and may foster a category fallacy. However, the experiences of people with dementia and their carers show that the important issues for service providers to consider are language, religious belief and observance, cultural practices (including food and personal care practices) and social support and coping mechanisms. In this position paper we argue that these issues are applicable to all individuals with dementia, independent of apparent ethnicity, and that promotion of cultural competence in service provision should not be relegated to an ethnic minority agenda. The task for health and social care providers is therefore to recognise the diversity of users and to increase access to appropriate quality mainstream person-centred services, rather than to develop segregated or specialized services.