Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis.

AIM: To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. DESIGN: Systematic review, without meta-analysis, with vote counting based on direction of effect. DATA SOURCES: Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. REVIEW METHODS: Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. RESULTS: Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result. CONCLUSION: This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. IMPACT: The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: Protocol for a systematic review.

AIM: To synthesize the evidence relating to the ability of specialist care home support services to prevent the hospital admission of older care home residents, including hospital admission at the end-of-life. DESIGN: Systematic review and narrative synthesis. METHODS: Ten electronic databases will be searched from 2010 - 31 December 2018 using predetermined search terms. All studies of specialist healthcare services to meet care home residents' physical healthcare needs which provide outcome data on hospital admission or place of death compared with usual care will be included. Two reviewers will independently assess studies' eligibility and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool. Data will be extracted by one reviewer and checked by a second according to predetermined categories. Data will be synthesized in evidence tables and narrative. Funder: National Institute for Health Research School for Social Care Research, November 2016. DISCUSSION: Care of older people in care home settings is a key aspect of nursing nationally and internationally. This review will increase understanding of the extent to which different models of specialist healthcare support for care homes are associated with key resident outcomes. IMPACT: Standard healthcare support for care home residents is often inadequate, resulting in avoidable hospital admissions and lack of resident choice as to place of death. Although a range of specialist healthcare services are emerging, little is known about their relative effectiveness. This paper marshalls evidence of relevance to commissioners investing in healthcare provision to care homes to meet NHS targets.

Community mental health teams for older people in England: Variations in ways of working.

OBJECTIVE: Integrated community mental health teams (CMHTs) are a key component of specialist old age psychiatry services internationally. However, in England, significant shifts in policy, including a focus on dementia and age inclusive services, have influenced provision. This study portrays teams in 2009 against which subsequent service provision may be compared. METHODS: A bespoke national postal survey of CMHT managers collected data on teams' structure, composition, organisation, working practices, case management, and liaison activities. RESULTS: A total of 376 CMHTs (88%) responded. Teams comprised a widespread of disciplines. However, just 28% contained the full complement of professionals recommended by government policy. Over 93% of teams had a single point of access, but some GPs bypassed this, and 40% of teams did not accept direct referrals from care homes. Initial assessments were undertaken by multiple disciplines, and 71% of teams used common assessment documentation. Nevertheless, many social workers maintained both NHS and local authority records. In 92% of teams, nominated care coordinators oversaw the support provided by other team members. However, inter-agency care coordination was less prevalent. Few teams offered the range of outreach/liaison activities anticipated in the national dementia strategy. CONCLUSIONS: Compared with previous studies, teams had grown and changed, with a clear increase in non-medical practitioners, particularly support workers. Measures to facilitate integrated care within CMHTs (eg, common access and documentation) were widespread, but integration across health and social care/primary and secondary services was less developed. Consideration of barriers to further integration, and the impact of current reforms is potentially fruitful.

Provision and perceived quality of mental health services for older care home residents in England: a national survey.

OBJECTIVE: This study examined the nature, extent and perceived quality of the support provided by community mental health teams for older people (CMHTsOP) to care home residents. METHODS: A postal survey was sent to all CMHTsOP in England. Information was collected about teams' staffing and their involvement in case finding, assessment, medication reviews, care planning and training as well as team managers' rating of the perceived quality of the service they provided for care home residents. Data were analysed using chi-squared tests of association and ordinal regression. RESULTS: Responses were received from 225 (54%) CMHTsOP. Only 18 per cent of these teams contained staff with allocated time for care home work. Services for care home residents varied considerably between teams. Two-fifths of teams provided formal training to care home staff. Team managers were more likely to perceive the quality of their service to care homes as good if they had a systematic process in place for reviewing antipsychotic drugs or routine mental health reviews, including contact with a GP. CONCLUSION: The findings suggested that more evidence is needed on the best approach for supporting care home residents with mental health needs. Areas to consider are the potential benefits of training to care home staff and regular mental health reviews, utilising links between GPs and CMHTsOP. Copyright © 2017 John Wiley & Sons, Ltd.

What becomes of people admitted to acute old age psychiatry wards? An exploration of factors affecting length of stay, delayed discharge and discharge destination.

OBJECTIVES: The study sought to identify the variables associated with increased length of stay on old age psychiatry inpatient wards. It also explored the factors related to delayed discharge and the likelihood of patients admitted from home returning there. METHODS: Data were collected on the sociodemographic, clinical and service receipt characteristics of a 6-month series of admissions to seven wards in England in 2010/2011. The cohort was followed for a 9- to 11-month period. The relationship between patients' status on admission and the specified outcome variables was explored. RESULTS: Information was collected on 216 admissions, of whom 165 were discharged in the study period. Mean length of stay was 64 days. Female gender, higher dependency, greater challenging behaviour and locality predicted extended stay. Forty per cent of cases experienced delayed discharge. Better physical health, more cognitive impairment, receipt of social care and locality were associated with delayed discharge. The vast majority of patients admitted from home returned there. Younger patients and patients with less dependency, cognitive impairment and challenging behaviour had a higher likelihood of returning home. Patients receiving social care or admitted because of carer stress, a risk of self-neglect, accidental self-harm or abuse/exploitation were less likely to return home. CONCLUSIONS: The study provides a useful starting point for identifying cases on which future efforts to improve inpatient outcomes might centre and suggests local rather than national responses may be needed. It also highlights an urgent need for a national focus on the scope, purpose and effectiveness of acute inpatient care. Copyright © 2016 John Wiley & Sons, Ltd.

Support workers in community mental health teams for older people: roles, boundaries, supervision and training.

AIMS: The aim of this study was to explore the support worker functions in community mental health teams for older adults in relation to roles, boundaries, supervision and training. BACKGROUND: Support workers in community mental health teams provide important help to older people with complex mental and physical health needs in their own homes. Their numbers have grown substantially in recent years, but without professional registration there is concern that boundaries with qualified practitioners are insufficiently clear and that they do not receive the support they require. DESIGN: Qualitative research using interview data and thematic framework analysis investigated support workers' and registered practitioners' perspectives on roles, boundaries, supervision and training. METHODS: Semi-structured face-to-face interviews were undertaken in 2011, with 42 members of nine teams spread across England, including support workers and community mental health nurses. Coding of transcribed audio-recordings and subsequent analysis was undertaken by four researchers. RESULTS: Support workers undertook diverse roles and had considerable autonomy over their duties. Participants agreed about what tasks support workers should not undertake, yet there was evidence of 'negotiated' boundaries and examples of these being breached. Lines of authority were complex, yet support workers were supported through open communication with the wider team. Training was problematic, with few courses tailored for support workers and efforts towards formal qualification hindered by low pay and time pressures. CONCLUSION: Local and national attention is needed to prevent 'drift' into activities that both support workers and registered practitioners consider outside their remit. Barriers to training and further qualification need to be addressed.

Is integrated care associated with service costs and admission rates to institutional settings? An observational study of community mental health teams for older people in England.

OBJECTIVES: To evaluate the association between the degree of integration in community mental health teams (CMHTs) and: (i) the costs of service provision; (ii) rates of mental health inpatient and care home admission. METHODS: An observational study of service use and admissions to institutional care was undertaken for a prospectively-sampled cohort of patients from eight CMHTs in England. Teams were chosen to represent 'high' or 'low' levels of integrated working practice and patients were followed-up for seven months. General linear models were used to estimate service costs and the likelihood of institutional admission. RESULTS: Patients supported by high integration teams received services costing an estimated 44% more than comparable patients in low integration teams. However, after controlling for case mix, no significant differences were found in the likelihood of admission to mental health inpatient wards or care homes between team types. CONCLUSIONS: Integrated mental health and social care teams appeared to facilitate greater access to community care services, but no consequent association was found with community tenure. Further research is required to identify the necessary and sufficient components of integrated community mental health care, and its effect on a wider range of outcomes using patient-reported measures. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd.

Community mental health teams for older people: variations in case mix and service receipt (I).

OBJECTIVES: The study sought to identify the characteristics of community-dwelling older people supported by community mental health teams (CMHTs) in England and, in particular, to determine whether there is a common threshold for CMHT entry and/or a core client group. METHODS: Data were collected about a random sample of 15 CMHTs' caseloads, including information about their sociodemographic characteristics, physical health, dependence, mental health, risks and service receipt. The sample was divided into 16 subgroups of people with similar needs for care (case types), and differences between teams were explored. RESULTS: Information was obtained for 1396 patients. Just under half had a functional mental health problem, slightly over a third an organic disorder, seven per cent both, and nine per cent no diagnosis. Considerable variation was found in teams' caseloads, and there was no evidence of a common caseload threshold. Two of the commonest case types represented people with functional diagnoses who were independent in activities of daily living (ADL) and had no/low levels of challenging behaviour. Another representing people with organic/mixed diagnoses, ADL dependence, challenging behaviour and at least one medium risk was also fairly common. The two case types that represented patients with the most complex needs accounted for more than a quarter of some teams' caseloads but less than a tenth of others. CONCLUSIONS: It is wrong to assume that CMHTs all have similar caseloads. Commissioners must ensure that the network of services provided can meet the needs of all eligible patients, whilst more research is required on who such teams should target.

Community mental health teams for older people: variations in case mix and service receipt (II).

OBJECTIVES: To determine the extent to which services provided to older people via community mental health teams (CMHTs) vary in duration, composition and intensity. In particular, to identify the degree to which differences between teams are due to casemix. METHODS: Data were collected about the services provided to a random sample of patients from 15 CMHT caseloads, including contact with CMHT staff, other specialist mental health and social care services. The relationship between patients' needs and service receipt was explored. RESULTS: Information was obtained for 1396 patients. Average time on CMHT caseloads was 11.6 months, but there were marked between-team differences. The proportion of re-referrals also varied from under a tenth to over half. People with functional mental health problems and complex needs were most likely to be long-term CMHT clients. The proportion of patients seen by a consultant in the previous 6 months ranged from approximately a fifth to almost all. Differences with respect to contact with other qualified practitioners were less marked. Older people with functional disorders, challenging behaviour and at least one medium risk had the most regular contact with CMHT staff. Risk of self-harm, delusions and paranoia increased the likelihood of consultant involvement. Support workers were more likely to see people at risk of self-neglect. The receipt of other services, including day hospitals and inpatient care varied greatly. CONCLUSIONS: Considerable diversity was found in the length, nature and frequency of services provided to patients with different needs. Differences between teams were not wholly explained by case mix.

Identifying alternatives to old age psychiatry inpatient admission: an application of the balance of care approach to health and social care planning.

BACKGROUND: Mental health problems in older people are common and costly, posing multiple challenges for commissioners. Against this backdrop, a series of initiatives have sought to shift resources from institutional to community care in the belief that this will save money and concurs with user preferences. However, most of this work has focused on the use of care home beds and general hospital admissions, and relatively little attention has been given to reducing the use of mental health inpatient beds, despite their very high cost. METHODS: The study employed a 'Balance of Care approach' in three areas of North-West England. This long-standing strategic planning framework identifies people whose needs can be met in more than one setting, and compares the costs and consequences of the possible alternatives in a simulation modelling exercise. Information was collected about a six-month cohort of admissions in 2010/11 (n = 216). The sample was divided into groups of people with similar needs for care, and vignettes were formulated to represent the most prevalent groups. A range of key staff judged the appropriateness of these admissions and suggested alternative care for those considered least appropriate for hospital. A public sector costing approach was used to compare the estimated costs of the recommended care with that people currently receive. RESULTS: The findings suggest that more than a sixth of old age psychiatry inpatient admissions could be more appropriately supported in other settings if enhanced community services were available. Such restructuring could involve the provision of intensive support from Care Home Outreach and Community Mental Health Teams, rather than the development of crisis intervention and home treatment teams as currently advocated. Estimated savings were considerable, suggesting local agencies might release up to £1,300,000 per annum. No obvious trade-off between health and social care costs was predicted. CONCLUSIONS: There is considerable potential to change the mix of institutional and community services provided for older people with mental health problems. The conclusions would be strengthened by further studies and the incorporation of evidence about relative outcomes. However, the utility of the approach in challenging established patterns of resource allocation and building local ownership for change is apparent.

Most appropriate placement for people with dementia: individual experts' vs. expert groups' decisions in eight European countries.

AIMS: To investigate the extent of variability in individuals' and multidisciplinary groups' decisions about the most appropriate setting in which to support people with dementia in different European countries. BACKGROUND: Professionals' views of appropriate care depend on care systems, cultural background and professional discipline. It is not known to what extent decisions made by individual experts and multidisciplinary groups coincide. DESIGN: A modified nominal group approach was employed in eight countries (Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden and the UK) as part of the RightTimePlaceCare Project. METHODS: Detailed vignettes about 14 typical case types of people with dementia were presented to experts in dementia care (n = 161) during November and December 2012. First, experts recorded their personal judgements about the most appropriate settings (home care, assisted living, care home, nursing home) in which to support each of the depicted individuals. Second, participants worked in small groups to reach joint decisions for the same vignettes. RESULTS: Considerable variation was seen in individuals' recommendations for more than half the case types. Cognitive impairment, functional dependency, living situation and caregiver burden did not differentiate between case types generating high and low degrees of consensus. Group-based decisions were more consistent, but country-specific patterns remained. CONCLUSIONS: A multidisciplinary approach would standardize the decisions made about the care needed by people with dementia on the cusp of care home admission. The results suggest that certain individuals could be appropriately diverted from care home entry if suitable community services were available.

All things to all people? The provision of outreach by community mental health teams for older people in England: findings from a national survey.

OBJECTIVE: The objective of this study is to identify the extent of outreach activity community mental health teams (CMHTs) for older people provide to mainstream services in light of the recommendations of the National Dementia Strategy. In particular, to determine the range of settings in receipt of support; to specify the form of this activity; to identify the professionals involved; and to explore the factors associated with the provision of such support. METHODS: A self-administered postal questionnaire was sent to all CMHTs in England. The reported arrangements were categorised and reviewed according to a taxonomy of outreach developed from the literature. RESULTS: Three hundred and seventy six (88%) of the CMHTs responded. Although nearly all teams undertook some outreach work, much of this was informal in nature. Nevertheless, the vast majority of teams had some formal outreach arrangements in at least one mainstream setting. Just less than three-quarters provided support (most typically education) to care homes, approaching half centres to day centres, and over a third to primary care practices, social services teams, home care providers and general hospitals, respectively. Link workers were the favoured means of supporting general hospital staff. Community mental health nurses were most commonly involved in providing outreach, and larger teams were more likely than smaller teams to have formalised arrangements. A significant minority of teams expressed concerns about their capacity to provide effective services. CONCLUSIONS: The findings suggest that both more resources and more evidence will be needed to meet the National Dementia Strategy's aim of improving care for older people with mental health problems in mainstream settings.

Membership and management: structures of inter-professional working in community mental health teams for older people in England.

BACKGROUND: Community mental health services are regarded as the preferred first tier of specialist psychogeriatric support, with integrated multidisciplinary teams believed to offer improved decision-making and greater continuity of care than separate single-profession services. In England over 400 community mental health teams (CMHTs) form the cornerstone of such support, yet research has neither assessed progress toward integrating key professional disciplines nor the nature of their membership and management arrangements. METHODS: A self-administered questionnaire was sent to all CMHTs for older people in England, seeking a combination of objective and subjective information on team structure and management. RESULTS: Responses from 376 (88%) teams highlighted broader multidisciplinary membership than found in a 2004 survey, with particular growth in the number of support workers and other unqualified practitioners. Only modest progress was found in the integration of psychologists and social workers within CMHTs. The data also revealed a trend toward "core" team membership, and away from "sessional" membership in which staff may have divided loyalties between services. Multidisciplinary working was reported as beneficial by many respondents, but examples of "silo working" were also found, which may have hampered service delivery in a minority of teams. CONCLUSIONS: The reported growth in the number of practitioners without professional registration raises issues about the appropriate skill mix and substitution within CMHTs, while local agencies should review barriers to the integration of psychologists and social workers. Further research is required to explore the quality of multidisciplinary team working.

Cost effectiveness of pilot self-assessment sites in community care services in England.

OBJECTIVE: Self-assessment has been advocated in community care but little is known of its cost effectiveness in practice. We evaluated cost effectiveness of pilot self-assessment approaches. METHODS: Data were collected from 13 pilot projects in England, selected by central government, between October 2006 and November 2007. These were located within preventative services for people with low-level needs, occupational therapy, or assessment and care management. Cost effectiveness, over usual care, was assessed by incremental cost-effectiveness ratios (ICERs), in British pounds per unit gain in assessment satisfaction. A public-sector perspective was adopted; the provider costs of the agencies taking part. RESULTS: At 2006-07 prices, including start-up and on-going costs, only three pilots demonstrated cost effectiveness. Two pilots in assessment and care management had ICERs of £3810 and £755 per satisfaction gained, well below a benchmark from a trial of usual assessment of £18296 per satisfaction gained. When extrapolating uptake to numbers accessing assessments over 1 year, one occupational therapy pilot, of £123/satisfaction gained, also fell below this benchmark in sensitivity analysis. There was less evidence for preventative services. CONCLUSIONS AND IMPLICATIONS: Most pilot projects were not cost effective. However, self assessment is potentially cost effective in assessment and care management and occupational therapy services. Better quality cost data from pilot sites would have permitted more detailed analysis. Measuring downstream effects in terms of users' well being from receipt of self-assessment would also be beneficial.

Healthcare support services for care home residents.

Managing the physical healthcare needs of care home residents presents a considerable challenge to national healthcare systems. A range of local, specialist support initiatives are emerging to address this. A study is being conducted to identify what services are being provided, how they are organised and delivered, and the relative worth of each care model. Preliminary findings indicate that forms of specialist healthcare support for care homes range from enhanced primary care services to multidisciplinary support teams. These initiatives present challenges and opportunities for staff. The roles of nurses in care homes and specialist services will change as they establish new ways of working, extend their responsibilities and enhance their skills. These services can help nurses provide high quality care to residents. Gaps in the evidence base for dedicated healthcare support services can be addressed through this study and further research planned.

Enabling older people with mental health needs to engage with community social care: A scoping review to inform a theory of change.

Despite apparent need, many older people with cognitive impairment and/or mental health needs do not fully engage with social care. This can manifest in different ways, including passive or aggressive attempts to avoid or repel care workers. However, little is known about how to support such individuals in their own homes and deliver effective care. Against this background, we undertook a scoping review with a view to developing a preliminary theory of change suggesting how care might be modified to engage this client group. The most recent search was conducted on 21/04/21. Papers were included if they (i) focused on older people (65+) living at home with social care needs and (ii) described difficulties/problems with the provision/receipt of social care associated with individuals' mental health needs. Twenty-six citations were identified through electronic database searches and reference screening, and the results were charted according to key theory of change concepts (long-term outcomes, preconditions, interventions, rationale and assumptions). All the included papers were related to people with dementia. Four subgroups of papers were identified. The first highlights those external conditions that make it more likely an intervention will be successful; the second describes specific interventions to engage older people who by virtue of their mental health needs have not engaged with social care; the third explores what services can be done to increase service uptake by older people with mental health needs and their caregivers more generally; and the fourth details theoretical approaches to explaining the behaviour of people with dementia. Each provides information that could be used to inform care delivery and the development of interventions to improve engagement with health and social care for these individuals. The study concludes that different framing of engagement difficulties, such as that offered through positioning theory, may assist in future service design.

Maximising the engagement of older people with mental health needs and dementia with social care.

Older people with mental health needs and dementia often face difficulties with daily living and community participation, requiring the intervention of social care services. However, cognitive and emotional needs often mean that mainstream support is not appropriate. In England, mental health support workers may attempt to address these concerns, to prevent mounting care needs and the potential for institutional care. Yet, their work has not been researched to identify good practices and to understand the mechanisms through which they engage older people. A new qualitative study used semi-structured interviews and focus groups with specialist support workers (n = 22), managers (n = 7), homecare staff (n = 4) and service users and carers (n = 6). The latter group were interviewed by co-authors with lived experiences of dementia and care. Participants were recruited from mental health services, home care organisations and third-sector agencies across the North of England in 2020-2021. The study identified three themes that described support worker activities. First, 'building trusting relationships' identified steps to establish the foundations of later interventions. Paradoxically, these may involve misleading clients if this was necessary to overcome initial reluctance, such as by feigning a previous meeting. Second, 're-framing care' referred to how the provision of care was positioned within a narrative that made support easier to engage with. Care framed as reciprocal, as led by clients, and having a positive, non-threatening description would more likely be accepted. Third, 'building supportive networks' described how older people were enabled to draw upon other community resources and services. This required careful staging of support, joint visits alongside workers in other services, and recognition of social stigma. The study was limited by constrained samples and covid context requiring online data collection. The study recommends that support workers have more opportunity for sharing good practice across team boundaries, and improved access to specialist training.

Impact of the COVID-19 Pandemic on Psychosocial Health of Persons With Spinal Cord Injury: Investigation of Experiences and Needed Resources.

Background: Emerging evidence suggests that the COVID-19 pandemic has been accompanied by increased rates of depression and social isolation. However, we do not yet understand how the COVID-19 pandemic has affected the psychosocial health of people with spinal cord injury (PwSCI), a population that is already at risk of experiencing mental health conditions. Objectives: The aims of the study were to (1) examine the impact of the pandemic on the psychosocial health of PwSCI and (2) investigate the experiences of PwSCI and resources they reported needing during the peak of the pandemic. Methods: A cross-sectional survey with closed- and open-ended questions was administered to 51 PwSCI. Participants were included if they had an SCI, were 18 years or older, lived in St. Louis, Missouri, and surrounding areas, and understood English. Results: Canonical correlation showed a significant association between financial security, food insecurity, and personal assistance service use and adverse psychosocial health outcomes (p < .001). Participants reported interest in resources related to COVID-19 precautions for wheelchair users as well as home exercise programming and financial assistance with utilities. Finally, qualitative analysis revealed four major themes: (1) mental health during the pandemic, (2) financial concerns and reduced access to personal assistance services, (3) feelings of social isolation prior to the pandemic, and (4) local and national authorities' handling of the pandemic. Conclusion: PwSCI are impacted by the COVID-19 pandemic and reported a variety of resource needs. These findings may inform service providers, support systems, and organizations to better support PwSCI during times of crisis.

Towards integrated community mental health teams for older people in England: progress and new insights.

OBJECTIVE: To investigate progress in joint working within community mental health teams for older people (CMHTsOP) against a range of national standards, and to consider team characteristics that may hinder or facilitate integrated practice. METHODS: A postal questionnaire was sent to the managers of all CMHTsOP in England. A total of 376 teams responded representing a response rate of 87.7%. Hypothesis testing and regression analysis, using a composite score based on nine indicators of integration, were conducted to address the study's aims. RESULTS: Whilst the study suggests that progress was being made against a number of key standards of joint working, the study finds that most teams could not access local authority service user records, nor were health staff within most teams able to commission social care services. After controlling for other characteristics, teams with the lowest levels of integration tended to work across multiple local authorities; were managed by a nurse; had high referral rates and were located in formally integrated Care Trusts. CONCLUSIONS: Improved integration could develop by NHS Trusts and local authorities encouraging more information sharing, and further delegating powers to arrange social care services to CMHTOP members. The paper highlights team and locality features that appear to cause obstacles to joint working, but there is a clear gap in the evidence relating team structures and characteristics to the quality of patient care.

Learning end-of-life care in ICU: strategies for nurses new to ICU.

The experience of critical care nurses caring for patients and families during the withdrawal of life support has recently been explored (Vanderspank-Wright, Fothergill Bourbonnais, Brajtman, & Gagnon, 2011). In that study, the nurses were able to find, using their developing knowledge and experience, their own way, over time, through the process of withdrawing life support. Challenges in caring for patients and families were described by the participants in themes such as "the runaway train of technology," which explored nurses' experience of caring in a technologically complex environment. In this current article, the authors will explore the importance of providing "good care" in relation to withdrawal of life-sustaining treatment. The principles of providing "good care" such as patient comfort, open and frequent communication with families, support by fellow co-workers and time to reflect on the care given are fundamental to the overall experience of providing quality end-of-life care in the critical care environment. Practical solutions will be offered to help both new graduates and nurses who are new to ICU, find their way to care for patients and families within this context.