Evidence and practice: a review of vignettes in qualitative research.

BACKGROUND: Developing and working through a PhD research study requires tenacity, continuous development and application of knowledge. It is paramount when researching sensitive topics to consider carefully the construction of tools for collecting data, to ensure the study is ethically robust and explicitly addresses the research question. AIM: To explore how novice researchers can develop insight into aspects of the research process by developing vignettes as a research tool. DISCUSSION: This article focuses on the use of vignettes to collect data as part of a qualitative PhD study investigating making decisions in the best interests of and on behalf of people with advanced dementia. Developing vignettes is a purposeful, conscious process. It is equally important to ensure that vignettes are derived from literature, have an evidence base, are carefully constructed and peer-reviewed, and are suitable to achieve the research's aims. CONCLUSION: Using and analysing a vignette enables novice researchers to make sense of aspects of the qualitative research process and engage with it to appreciate terminology. IMPLICATIONS FOR PRACTICE: Vignettes can provide an effective platform for discussion when researching topics where participants may be reluctant to share sensitive real-life experiences.

Does talking about end of life with adults with intellectual disability cause emotional discomfort or psychological harm?

BACKGROUND: Caregivers often avoid involving people with intellectual disability in end-of-life discussions and activities. One reason is fear that the person may become upset or psychologically harmed. METHODS: Pre and post a 6-month intervention about end of life, we assessed depression, anxiety, and fear of death among intervention (n = 24) and comparison (n = 20) participants with intellectual disability. End-of-life 'encounters' (conversations/activities about end of life) were monitored, including comfort ratings. RESULTS: Overall, 79% of encounters were rated very comfortable/somewhat comfortable. Participants initiated 69% of encounters. There was no significant pre-post change in depression or fear of death. Anxiety improved significantly. CONCLUSIONS: This is the first controlled, longitudinal study providing robust evidence about whether discussing end of life leads to emotional discomfort or psychological harm. Data showed adults with intellectual disability can safely engage in conversations/activities about end of life. The high percentage of participant-initiated encounters showed participants wanted to talk about end of life.

Facilitating personal development for public involvement in health-care education and research: A co-produced pilot study in one UK higher education institute.

BACKGROUND: Public involvement in the education of students enrolled on higher education programmes has gained impetus. For students enrolled on professional health-care programmes and health-related modules in the UK, there is also a requirement by professional bodies to include "service user" involvement in preparation for entry to a professional health-care register and continuing professional development. Actively involving patients and members of the public in research is also a requirement by many research funders. In this article, the term Patient and Public Involvement (PPI) will be used throughout to include lay members, volunteers, user and carers. OBJECTIVES: A unique pilot study was introduced across a health faculty to integrate PPI in a deliberate way. It aimed to provide an educational, focused programme of events that was meaningful to develop and inform peoples' knowledge, skills and confidence for their involvement in the health faculty. DESIGN: PPI members volunteered to sit on a steering group to determine the educational journey; the outcomes of three focus groups with PPI members (N = 32) and academics informed the programme content which included a range of workshops covering the exploration of public roles and barriers to involvement, introduction to research and interviewing skills. RESULTS: The workshops were well attended, and outcomes indicated the importance of co-production when designing, delivering and evaluating programmes. DISCUSSION: Co-production underpinned this pilot study, resulting in a programme which was meaningfully received by public contributors. RECOMMENDATIONS: Co-production was seen as integral to this research to ensure that outcomes were indeed "fit for purpose".

Last months of life of people with intellectual disabilities: A UK population-based study of death and dying in intellectual disability community services.

BACKGROUND: Population-based data are presented on the nature of dying in intellectual disability services. METHODS: A retrospective survey was conducted over 18 months with a sample of UK-based intellectual disability service providers that supported over 12,000. Core data were obtained for 222 deaths within this population. For 158 (71%) deaths, respondents returned a supplemented and modified version of VOICES-SF. RESULTS: The observed death was 12.2 deaths per 1,000 people supported per year, but just over a third deaths had been deaths anticipated by care staff. Mortality patterns, place of usual care and availability of external support exerted considerable influence over outcomes at the end of life. CONCLUSION: Death is not a common event in intellectual disability services. A major disadvantage experienced by people with intellectual disabilities was that their deaths were relatively unanticipated. People with intellectual disabilities living in supported living settings, even when their dying was anticipated, experienced poorer outcomes.

Supporting people with an intellectual disability and dementia: A constructivist grounded theory study exploring care providers' views and experiences in the UK.

BACKGROUND: There is a need to better understand the experiences and support needs of paid and family carers of people with an intellectual disability and dementia, and the role of Intellectual Disability Dementia Care Pathways (IDDCPs). This study explored the experiences of carers, and IDDCPs and other support structures within those experiences. METHODS: A constructivist grounded theory methodology was implemented. Data were obtained through 23 semi-structured interviews with two family carers, eight paid carers and eight healthcare professionals. FINDINGS: The study's theory produced five interrelated categories: Impact of Dementia, Challenging the Diagnosis Process, Continuum of Support, Continuity and Continuum of Understanding. CONCLUSIONS: Findings have demonstrated the importance of planning and supporting carers' holistic needs; the role of an IDDCP in the post-diagnostic support (or lack of it) for carers; and the importance of a timely diagnosis of dementia. Recommendations for practice are offered.

End-of-life care in intellectual disability: a retrospective cross-sectional study.

BACKGROUND: Adults with intellectual disability (ID) experience inequality in access to healthcare that is considered to extend to end-of-life care. Their experiences of healthcare at the end of life and how these compare with the general population are unknown. AIM: To describe the end-of-life care outcomes for adults with ID living in residential care in the UK using the VOICES-SF questionnaire and compare these with the general population. DESIGN: Nationwide population-based postbereavement survey. PARTICIPANTS: 38 ID care providers took part in the study. The supported over 13 000 people with ID. Over the 18-month period of data collection, 222 deaths were reported. The survey was completed, by care staff, for 157 (70.7%) of those deaths. RESULTS: Decedents had complex health, functional and behavioural needs. Death was unanticipated in a high proportion of cases. Quality of care provided across care settings was generally well rated. However, hospital care and care provided at the time of was less well rated, particularly in comparison with the general population. Respondents reported low levels of involvement in care and awareness of approaching death among adults with ID, and lower than in the general population. CONCLUSIONS: Access to end-of-life care for adults with ID may be constrained by a failure to identify approaching the end of life. The high proportion of unexpected deaths in this population warrants further study. There is a need to increase and support the involvement of adults with ID to be active partners in planning care at the end of their lives.

Encountering offenders in community palliative care settings: challenges for care provision.

BACKGROUND: There is very little research into the way that offender management strategies impinge on the practices and decision-making of palliative care personnel in community settings. AIMS: To improve understanding of the challenges that community palliative care service providers encounter when caring for people who have been sentenced to custody and are under the supervision of the prison or probation services. METHODS: This paper discusses one part of a larger multidisciplinary study on bereavement, loss and grief in the criminal justice system. It reports the findings from a focus group with 10 health professionals working within specialist community palliative care services. Thematic analysis was undertaken to identify and explicate the most significant themes arising from the transcript data. RESULTS: There were situations where the participants were able to identify that patients were under the jurisdiction of the criminal justice system or had relatives in custody. Three themes emerged that highlighted distinctive aspects of providing care to this patient group. These themes were: patients under prison, probation or police supervision altered the dynamics of care provision; prisoners were restricted from supporting or contacting their dying relatives in the community; and participants (professionals) were obstructed from supporting patients at home because of criminal or antisocial behaviour by relatives of the dying. CONCLUSIONS: Health professionals face multiple challenges that curtail them from fully realising the aims of palliative care for patients and relatives under criminal justice supervision, in ways that merit further consideration and research.

How might organisational institutionalism support the challenges of the modern hospice?

The external environment within which UK charitable hospice care operates is changing. More people are dying with conditions other than cancer; however, this disease still dominates modern hospice care. Organisational institutionalism offers a theoretical lens through which to consider the challenges facing the hospice movement. Concepts such as legitimacy, decoupling, deinstitutionalisation, and reinstitutionalisation can help hospice leaders understand the challenges of change and some of the strategies that can be employed at local and national levels. This paper outlines a number of environmental and influencing factors driving and impacting change. A model of institutional change is introduced, explored, and considered from the context of hospice. When it comes to understanding change, legitimacy is a major concept introduced to challenge and pose questions for hospices to address. This paper proposes a model demonstrating a perspective regarding the current structure of services within hospice organisations. The model argues that only hospice care for people with cancer is truly institutionalised and that other areas of care lack comparable legitimacy. It provides 3 directions for hospice in addressing the challenges faced: (i) decoupling, (ii) deinstitutionalisation then reinstitutionalisation, and (iii) a new social movement. The paper concludes with recommendations for future consideration.

Symptom experience in non-dialysis-dependent chronic kidney disease: A qualitative descriptive study.

BACKGROUND: Studies indicate that symptoms attributable to impaired kidney function are important determinants of quality of life and functional status in patients with chronic kidney disease (CKD). Accordingly, symptom assessment and subsequent control are prerequisites of high-quality care in this patient population. Whilst symptom burden in patients with advanced CKD managed without dialysis has been likened to that of palliative care cancer populations, there is little information about the nature and range of symptoms in earlier stages of the CKD trajectory. This paper reports the findings of the preliminary phase of a study aimed at exploring the symptom experience in patients with CKD stages 4 and 5. METHODS: Eighteen semi-structured patient interviews were conducted, using an interview schedule developed specifically to guide discussion. Data were analysed using thematic analysis to identify symptom categories and thematic patterns across the patient experiences. RESULTS: Patients reported a wide range of symptoms, with over 50 different categories and sub-categories emerging from the interview data. Symptom categories could be broadly classified into physical symptoms, such as 'Altered taste perception', 'Sleep disturbance' and 'Fatigue', and psychological symptoms, such as 'Forgetfulness', 'Poor concentration' and 'A sensation of gradually slowing down'. Of note, when questioned further, patients indicated that they would not usually report their symptoms to clinicians. CONCLUSIONS: This study suggests that patients with CKD stages 4 and 5 may have a high symptom burden. The finding that patients did not routinely report their symptoms emphasises a need for clinicians to incorporate symptom assessment into routine clinical consultations.

Defining consensus norms for palliative care of people with intellectual disabilities in Europe, using Delphi methods: A White Paper from the European Association of Palliative Care.

BACKGROUND: People with intellectual disabilities often present with unique challenges that make it more difficult to meet their palliative care needs. AIM: To define consensus norms for palliative care of people with intellectual disabilities in Europe. DESIGN: Delphi study in four rounds: (1) a taskforce of 12 experts from seven European countries drafted the norms, based on available empirical knowledge and regional/national guidelines; (2) using an online survey, 34 experts from 18 European countries evaluated the draft norms, provided feedback and distributed the survey within their professional networks. Criteria for consensus were clearly defined; (3) modifications and recommendations were made by the taskforce; and (4) the European Association for Palliative Care reviewed and approved the final version. SETTING AND PARTICIPANTS: Taskforce members: identified through international networking strategies. Expert panel: a purposive sample identified through taskforce members' networks. RESULTS: A total of 80 experts from 15 European countries evaluated 52 items within the following 13 norms: equity of access, communication, recognising the need for palliative care, assessment of total needs, symptom management, end-of-life decision making, involving those who matter, collaboration, support for family/carers, preparing for death, bereavement support, education/training and developing/managing services. None of the items scored less than 86% agreement, making a further round unnecessary. In light of respondents' comments, several items were modified and one item was deleted. CONCLUSION: This White Paper presents the first guidance for clinical practice, policy and research related to palliative care for people with intellectual disabilities based on evidence and European consensus, setting a benchmark for changes in policy and practice.

Knowing, planning for and fearing death: Do adults with intellectual disability and disability staff differ?

BACKGROUND: Adults with intellectual disability (ID) are thought to understand less about death than the general population but there is no available research demonstrating this. Further, the detail of any possible differences in understanding is unknown. METHODS: We compared the responses of 39 adults with mild or moderate ID and 40 disability staff (representing the general population) on (a) understanding the concept of death, (b) knowledge of and self-determination about end-of-life planning, and (c) fear-of-death. RESULTS: We found that adults with ID had a significantly poorer understanding of the concept of death, knew much less about and were less self-determined about end-of-life planning, but reported greater fear-of-death. CONCLUSIONS: We demonstrated, for the first time, the feasibility of assessing end-of-life planning and fear-of-death among adults with ID. The poorer understanding and lower levels of self-determination we found suggest that future research should develop and evaluate interventions to increase understanding and self-determination.

Musculoskeletal pain in older adults at the end-of-life: a systematic search and critical review of the literature with priorities for future research.

BACKGROUND: Pain is an important issue in end of life care. Although musculoskeletal pain is common in older adults, it is rarely associated with the cause of death and may be overlooked as death approaches. Hence a major target for improving quality of life may be being missed. METHODS: The aim of this study was to systematically search and critically review the literature on musculoskeletal pain at the end of life. Amed, Cinahl, Internurse, Medline, Psych Info, Web of Knowledge and Cochrane review databases were searched for relevant research up to September 2012. The search strategy combined key words expanding the terms 'palliative' for population, 'musculoskeletal' for exposure, and 'pain' for outcome. Predefined inclusion and exclusion criteria were applied. RESULTS: Five relevant papers and one letter to the editor were found, including case studies and epidemiological research. Current evidence suggests musculoskeletal pain is common in older adults at the end of life and that it can have a substantial impact on individual experience. No information about community based treatment of musculoskeletal pain at the end of life was found. CONCLUSION: Priorities for future research include high quality epidemiological studies to establish the prevalence, natural history, impact, assessment, patient priorities and outcomes associated with musculoskeletal pain in the end of life period, and intervention research that provides an evidence base for treatment.

Using action research to design bereavement software: engaging people with intellectual disabilities for effective development.

BACKGROUND: Loss is a universal experience and death is perceived as the ultimate loss. The overarching aim of this research is to produce a qualitative, flexible, interactive, computerised tool to support the facilitation of emotional expressions around loss for people with intellectual disabilities. This paper explores the process of using Participatory Action Research (PAR) to develop this tool. MATERIALS AND METHODS: Participator Action Research provided the indicative framework for the process of developing a software tool that is likely to be used in practice. RESULTS: People with intellectual disability worked alongside researchers to produce an accessible, flexible piece of software that can facilitate storytelling around loss and bereavement and promote spontaneous expression that can be shared with others. CONCLUSION: This tool has the capacity to enable individuals to capture experiences in a storyboard format; that can be stored; is easily retrievable; can be printed out; and could feasibly be personalised by the insertion of photographs.

Cultivating understanding of health issues for adults with intellectual disability.

UNLABELLED: Going into hospital may be a frightening experience. Fears and anxieties may be particularly compounded when the patient has an existing health diagnosis such as a mental health condition or intellectual disabilities (ID). While people with ID often have worse health than other people, they can experience more difficulty accessing healthcare. OBJECTIVES: The aim of this paper is to describe the self-evaluation process and outcome of a series of workshops designed to cultivate understanding of the health needs of adults with ID. DESIGN: The research was designed to explore the impact of the workshops for generic healthcare professionals, using a mixed methods inquiry. SETTINGS: The workshops were interactive, and facilitated by health care clinicians, three people with an ID, advocates and academics. SAMPLE: Participants were mainly qualified and unqualified nurses and other allied health professionals (N=157). METHODS: Quantitative questionnaires comprised of 16 questions with multiple choice answers were distributed to all participants (pre and post workshop). A qualitative feedback sheet to promote shared dialogues was circulated on completion of each workshop. RESULTS: Triangulated research methods of data collection demonstrate a positive impact of the workshops and the learning experienced from a participant perspective. CONCLUSIONS: While resources alone will never replace nurse education and training, they can reinforce best practice, and the resource developed in this paper was maximized by workshops to explore its potential. The remaining challenge is measuring the impact of this work on clinical practice in the longer term.

Hospice nurses' perceptions of caring for patients with a non-malignant diagnosis: a single-site case study.

In the early stages of its development in the UK, palliative care focused almost exclusively on the care of patients with cancer, with efforts concentrated on relieving distressing physical symptoms in the last few weeks of life-often referred to as terminal care. It is increasingly expanding to include non-malignant conditions, but is still predominantly accessed by cancer patients. This paper presents findings from a small-scale qualitative study into nurses' experiences of providing hospice care for patients with a non-malignant diagnosis. Two focus groups were conducted with nurses in one established UK hospice. The results highlight the importance of timely educational preparation, the need for proactive thinking regarding the shifting medical profiles of health care in the UK, and the need for hospice managers to critically consider existing infrastructures (including supervision and support) in anticipation of diverse patient populations. The paper also reiterates that collaboration remains the key to effective support.

Critical reflections on end-of-life care for people with intellectual disabilities: a single case study approach.

People with intellectual disabilities (ID) are enjoying increasing longevity, but are simultaneously having to cope with the additional health problems associated with ageing. Even though people with ID are reported to have worse health than the rest of the population, resulting in greater health-care needs, they also have poorer health care than the average person, including including-end-of-life care. The aim of this paper is to explore the challenges to providing effective end-of-life care for a person with an ID by using critical reflection from a nursing care perspective on an illustrative case study. Death never occurs in a vacuum but rather occurs in a social context, and the social context here was crucial to providing appropriate end-of-life care. It is hoped that the paper will promote discussion both around end-of-life care generally and in relation to this marginalized population.