'A journey of self-discovery and transformation': A theoretical and comprehensive evaluation of the Queen's nursing institute Scotland community development programme.

AIM: To evaluate adoption, implementation and maintenance of the Queen's Nursing Institute Scotland development programme. DESIGN: A comprehensive, longitudinal, qualitative evaluation. METHOD: Participants from the first two cohorts were interviewed at different stages to explore adoption, implementation and maintenance. Managers of participants engaged in interviews to explore service changes. Facilitators took part in a focus group exploring delivery. A member-checking event was held. Data collection was between March 2017 and October 2019. Data analysis was thematically followed by the application of Normalization Process Theory. RESULT: Ninety-four interviews, two focus groups and a member-checking event were conducted. Prior to the programme most participants were burnt-out and considering leaving. Engaging led to a journey of self-discovery and transformation. The programme was perceived to change their way of thinking, personally and professionally, unlike any training and development previously experienced. Participants were rejuvenated and reinvigorated, sharing their learning with colleagues, service users and family, implementing new working practices and furthering their careers. They developed communities of practice amongst their cohorts with strong bonds; enabling them to build and sustain learnings. CONCLUSION: Participants experienced a journey of self-discovery and transformation unlike anything before due to the personal investment in them. Participants were rejuvenated and reinvigorated with many moving into new roles. The programme equipped them with a range of leadership and resilience skills. IMPACT: The Queen's Nursing Institute Scotland Development Programme had a profound impact on participants, personally and professionally, which was perceived as lifelong. These findings and programmes are transferable beyond Scotland and to different professions.

Abdominal cancer symptoms: Evaluation of the impact of a regional public awareness campaign.

OBJECTIVE: A regional 'Be Clear on Cancer' (BCoC) campaign developed by Public Health England aimed to promote public awareness of key abdominal cancer symptoms in people aged 50 years and over. METHODS: Data were analysed for metrics at different stages in the patient care pathway including public awareness, GP attendance and referrals, to cancer diagnosis. RESULTS: There was significantly higher recognition of the BCoC abdominal campaign in the campaign region compared to the control area (Post Campaign/Control, n = 401/406; 35% vs. 24%, p < 0.05). The campaign significantly improved knowledge of 'bloating' as a symptom (p = 0.03) compared to pre-campaign levels. GP attendances for abdominal symptoms increased significantly by 5.8% (p = 0. 03), although the actual increase per practice was small (average 16.8 visits per week in 2016 to 17.7 in 2017). Urgent GP referrals for suspected abdominal cancer increased by 7.6%, compared to a non-significant change (0.05%) in the control area. For specific abdominal cancers, the number diagnosed were similar to or higher than the median in the campaign area but not in the control area in people aged 50 and over: colorectal (additional n = 61 cancers), pancreatic (additional n = 102) and stomach cancers (additional n = 17). CONCLUSIONS: This campaign had a modest impact on public awareness of abdominal cancer symptoms, GP attendances and cancers diagnosed.

The experiences of older adults with a diagnosed functional mental illness, their carers and healthcare professionals in relation to mental health service delivery: An integrative review.

AIMS AND OBJECTIVES: To analyse the experiences of older people with a diagnosed functional mental illness and their carers in relation to mental health service delivery and analyse the experiences of health and social care professionals who care for and treat older people who have a diagnosed functional mental illness. BACKGROUND: The prevalence of functional mental illness in older adults is notable but to date has received less research attention than dementia. Older adults with functional mental illness have life expectancy of up to 20 years less than the rest of the population. Therefore, the experiences of older adults with functional mental illness, their carers and healthcare professionals, in relation to mental health services, need further exploration. DESIGN: Integrative literature review. METHODS: A five-stage process was informed by Whittemore and Knafl. MeSH was used. Keyword searches of MEDLINE, CINAHL, Cochrane Library, PsycINFO, EMBASE and AMED were conducted between January 2000-October 2017. Titles were screened, and data were extracted manually and analysed using narrative synthesis. The PRISMA checklist was used. RESULTS: A total of 342 articles were deemed potentially relevant to this review. Once inclusion and exclusion criteria were applied, 28 articles were included. The literature presented an overarching theme "determinants influencing older people with functional mental illness use of services." The overarching theme is supported by two main themes: inevitable consequences of ageing and variations of the availability of healthcare services for older people with functional mental illness. CONCLUSION: Several determinants influence use of services by older people with functional mental illness. Older people with functional mental illness often perceived they did not have a mental health need. Within the literature, there was little acknowledgement of the experiences of older people with functional mental illness regarding their support needs. RELEVANCE TO CLINICAL PRACTICE: This integrative review has highlighted that some older people with functional mental illness do not seek mental health support because they believe that functional mental illness is an inevitable consequence of ageing; this is mirrored at times by healthcare professionals and carers. In addition to this finding, different views prevail regarding the impact that ageless and age-defined mental health service delivery models have on the needs of older people with functional mental illness. Further research is required to understand these findings.

Instruments for assessing nurses' palliative care knowledge and skills in specialised care setting: An integrative review.

AIMS AND OBJECTIVES: To examine the content and reported psychometric properties of instruments for assessing nurses' palliative care knowledge and skills in specialised healthcare units. BACKGROUND: Knowledge of palliative care, and competence in the delivery of care, is essential. Assessment of competence is an important means of evaluating the knowledge and skills of practitioners in order to improve the quality of care provided for patients and their families. DESIGN: An integrative review. METHODS: A systematic literature search was conducted in November 2018 in five databases: CINAHL, PubMed (Medline), Cochrane, Scopus and Web of Science. The quality assessment was conducted using the Joanna Briggs Institute's (JBI) Checklist for Analytical Cross-Sectional Studies. The data were analysed using content analysis. PRISMA guidelines were followed to ensure explicit reporting. RESULTS: Overall, 5,413 studies were identified and 23 met the inclusion criteria. Nurses' knowledge and skills, as assessed by the instruments, were as follows: (a) care for the patient, (b) care for the patient's family and (c) professional requirements. Ten instruments were identified assessing nurses' knowledge and skills through knowledge tests and skill evaluation self-tests. The psychometric properties of the instruments were reported to varying degrees, mainly focusing on internal consistency and content validation. CONCLUSIONS: Nurses' knowledge and skills were seen to contribute to the holistic care of the patient and his or her family, and the possession of adequate information and skills is essential when dealing with death and dying. The instruments are commonly available and potentially reliable, although reliability must be determined with caution, so validation studies in other cultures are recommended. RELEVANCE TO CLINICAL PRACTICE: These results could be utilised to improve the quality of palliative care by evaluating the knowledge and skills of nursing staff or when considering the needs of palliative care education.

Systematic and integrative reviews: synthesising evidence for community nursing practice.

Ease of access to vast amounts of information presents significant opportunities and challenges for nurses in the community as they seek to base their practice on the best available evidence. Growing expectations around evidence-based practice have developed alongside developments in evidence synthesis, which adopts robust approaches to identifying, appraising and synthesising key evidence for clinical decision-making. The context in which evidence-based practice occurs is key, and this article discusses the skills and knowledge needed for community nurses to discern how evidence and information should influence their decisions to review and change approaches to clinical practice. Importantly, if nurses understand the status of evidence underpinning areas of practice, they can ensure that the preferences and needs of patients and families are met.

Caring for older people with dementia in the emergency department.

BACKGROUND: Admission to an emergency department (ED) may expose the older person with dementia to a range of negative consequences, including a deterioration in their behavioural symptoms. The authors conducted a review of primary research relating to the experiences of older people with dementia, their carers and ED nurses, to understand how these experiences might inform nursing practice. METHODS: Integrative review with a search of the electronic databases of Medline, CINAHL and PSYCHINFO using specified inclusion and exclusion criteria. RESULTS: Three themes were identified: carers and older people with dementia-waiting and worrying; nurses juggling priorities; and strategies for improvement-taking a partnership approach. CONCLUSION: Older people with dementia may be exposed to disparities in treatment in the ED. A practice partnership between carers and ED nurses may help to prevent this. ED nurses need support to blend technical- and relationship-centred care. Participatory research exploring the experiences of older people with dementia, their carers and ED nurses is needed.

Interventions for preventing falls in people with multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is one of the most prevalent diseases of the central nervous system with recent prevalence estimates indicating that MS directly affects 2.3 million people worldwide. Fall rates of 56% have been reported among people with MS in a recent meta-analysis. Clinical guidelines do not outline an evidence-based approach to falls interventions in MS. There is a need for synthesised information regarding the effectiveness of falls prevention interventions in MS. OBJECTIVES: The aim of this review was to evaluate the effectiveness of interventions designed to reduce falls in people with MS. Specific objectives included comparing: (1) falls prevention interventions to controls and; (2) different types of falls prevention interventions. SEARCH METHODS: We searched the Trials Register of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group, Cochrane Central Register of Controlled Trials (2018 Issue 9); MEDLINE (PubMed) (1966 to 12 September 2018); Embase (EMBASE.com) (1974 to 12 September 2018); Cumulative Index to Nursing and Allied Health Literature (EBSCOhost) (1981 to 12 September 2018); Latin American and Caribbean Health Science Information Database (Bireme) (1982 to 12 September 2018); ClinicalTrials.gov; and World Health Organization International Clinical Trials Registry Platform; PsycINFO (1806 to 12 September 2018; and Physiotherapy Evidence Database (1999 to 12 September 2018). SELECTION CRITERIA: We selected randomised controlled trials or quasi-randomised trials of interventions to reduce falls in people with MS. We included trials that examined falls prevention interventions compared to controls or different types of falls prevention interventions. Primary outcomes included: falls rate, risk of falling, number of falls per person and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors screened studies for selection, assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval to compare falls rate between groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of fallers in each group. MAIN RESULTS: A total of 839 people with MS (12 to 177 individuals) were randomised in the 13 included trials. The mean age of the participants was 52 years (36 to 62 years). The percentage of women participants ranged from 59% to 85%. Studies included people with all types of MS. Most trials compared an exercise intervention with no intervention or different types of falls prevention interventions. We included two comparisons: (1) Falls prevention intervention versus control and (2) Falls prevention intervention versus another falls prevention intervention. The most common interventions tested were exercise as a single intervention, education as a single intervention, functional electrical stimulation and exercise plus education. The risk of bias of the included studies mixed, with nine studies demonstrating high risk of bias related to one or more aspects of their methodology. The evidence was uncertain regarding the effects of exercise versus control on falls rate (RaR of 0.68; 95% CI 0.43 to 1.06; very low-quality evidence), number of fallers (RR of 0.85; 95% CI 0.51 to 1.43; low-quality evidence) and adverse events (RR of 1.25; 95% CI 0.26 to 6.03; low-quality evidence). Data were not available on quality of life outcomes comparing exercise to control. The majority of other comparisons between falls interventions and controls demonstrated no evidence of effect in favour of either group for all primary outcomes. For the comparison of different falls prevention interventions, the heterogeneity of intervention types across studies prohibited the pooling of data. In relation to secondary outcomes, there was evidence of an effect in favour of exercise interventions compared to controls for balance function with a SMD of 0.50 (95% CI 0.09 to 0.92), self-reported mobility with a SMD of 16.30 (95% CI 9.34 to 23.26) and objective mobility with a SMD of 0.28 (95% CI 0.07 to 0.50). Secondary outcomes were not assessed under the GRADE criteria and results must be interpreted with caution. AUTHORS' CONCLUSIONS: The evidence regarding the effects of interventions for preventing falls in MS is sparse and uncertain. The evidence base demonstrates mixed risk of bias, with very low to low certainty of the evidence. There is some evidence in favour of exercise interventions for the improvement of balance function and mobility. However, this must be interpreted with caution as these secondary outcomes were not assessed under the GRADE criteria and as the results represent data from a small number of studies. Robust RCTs examining the effectiveness of multifactorial falls interventions on falls outcomes are needed.

Integrative review; identifying the evidence base for policymaking and analysis in health care.

AIM: The aim of this was to identify and synthesize the evidence underpinning the health policymaking process to inform the development of a health-related policy analysis framework. DESIGN: A mixed methods review using "Best Fit" Framework synthesis. DATA SOURCES: PUBMED and CINAHL+ databases for English language papers published between March 2013 - March 2017. REVIEW METHODS: Titles were screened, data abstracted and analysed by two authors at each stage. Findings from included studies were coded against six a priori categories which had been constructed through a preliminary literature review, consultation and consensus. RESULTS: Sixty-eight papers were included. There exists empirical support for six key domains which require to be addressed in the policymaking and analysis process: (1) Context; (2) Process; (3) Content; (4) Stakeholder Consultation; (5) Implementation; and (6) Evaluation. Failure to contextualize and integrate these six domains in problem identification, policy analysis, strategy and policy development, policy enactment and policy implementation is problematic. CONCLUSION: There is a need to test and refine the constructs linked to the policymaking cycle taking cognizance of the context where these are developed, implemented and evaluated. IMPACT: This review makes a novel contribution to the synthesis of evidence to inform the policymaking and analysis process. Findings illuminate the complexity of policymaking, the competing pressures involved and the importance of the local, national and international context. These findings have international relevance and provide empirical support for key criteria to guide those involved in context specific policymaking and/or the analysis of existing policy.

Caring for an older person with dementia in the Emergency Department (ED): An Appreciative Inquiry exploring family member and ED nurse experiences.

AIMS AND OBJECTIVES: To generate insights about what matters and is valued by family members of older people with dementia in the emergency department. To explore the experiences of emergency nurses looking after older people with dementia in an episode of care. BACKGROUND: In the emergency department, older people with dementia are at risk of suboptimal care. Little is known of the experiences of family members of being with an older person with dementia in the emergency department or the experiences of emergency nurses looking after older people with dementia in this environment. DESIGN AND METHODS: Phase 1 Data Analysis of the Discovery Phase of an Appreciative Inquiry study. Study participants were family members of older people with dementia and emergency nurses. Data collection methods included interviews with family members of older people with dementia and 30 hr of participant observation working alongside emergency nurses. This study was guided by the Standards for Reporting Qualitative Research. RESULTS: Two themes emerged from the analysis: What matters to family members with four subthemes and challenges for family members and nurses in the emergency department with two subthemes. CONCLUSION: This study demonstrates that some emergency nurses are connecting with family members even in the briefest of clinical encounters. It is feasible for more emergency nurses to do the same more of the time. RELEVANCE TO CLINICAL PRACTICE: The older person with dementia must be given a triage category of no less than 3 (to be seen by the doctor within the hour) on arrival in the department. Further education is needed to assist emergency nurses to establish rapport and incorporate family member insights as part of care planning and assessment of the needs of the older person with dementia.

Developing a new health-related policy analysis tool: An action research cooperative inquiry approach.

AIM: To develop a tool for the analysis of nursing, midwifery and health-related policy and professional guidance documents. BACKGROUND: Analysis tools can aid both policy evaluation and policy development. However, no framework for analysing the content of professional regulation and guidance documents among health care professionals currently exists. METHOD: This study used an action research, cooperative inquiry design. Data were generated from two integrative literature reviews and discussions held during the cooperative inquiry meetings. RESULTS: A set of key themes to be considered in the development or evaluation of health policy or professional regulation and guidance documents were identified. These themes formed the basis of the six domains considered by the Health-related Policy Analysis Tool (HrPAT): Context, Process, Content, Stakeholder Consultation, Implementation and Evaluation. CONCLUSION: Use of the HrPAT can assist in policy development, evaluation and implementation, as well as providing some retrospective analytical insights into existing health policies. IMPLICATION FOR NURSING MANAGEMENT: Professional regulation documents, guidelines and policy reports should be capable of being scrutinized for their content, quality and developmental process. The HrPAT can assist relevant stakeholders in the development, analysis and evaluation of such documents, including local, service-level policies and guidelines.

Enacting evidence-based practice: pathways for community nurses.

Community nurses are expected to deliver evidence-based practice, which is challenging given the diversity and breadth of the evidence base from which they can draw. This study aimed to explore community nurses' experiences of implementing change in their practice. Qualitative semi-structured interviews (n=9) and focus groups (n=2) with community nurses (n=17) were conducted. Three pathways to introduce change in practice were identified by participants: bottom-up, top-down and collaborative pathways. These are based on the nature of the proposed change, the available evidence, 'buy in' from colleagues and issues around implementation. The findings identify approaches to implementing change in community nursing practice. Practitioners would benefit from support to navigate the complex process of change through managerial support, ongoing education, accessible online resources and support through a practice development role.

Discursive constructions of professional identity in policy and regulatory discourse.

AIM: To examine and describe disciplinary discourses conducted through professional policy and regulatory documents in nursing and midwifery in Ireland. BACKGROUND: A key tenet of discourse theory is that group identities are constructed in public discourses and these discursively constructed identities become social realities. Professional identities can be extracted from both the explicit and latent content of discourse. Studies of nursing's disciplinary discourse have drawn attention to a dominant discourse that confers nursing with particular identities, which privilege the relational and affective aspects of nursing and, in the process, marginalize scientific knowledge and the technical and body work of nursing. DESIGN: We used critical discourse analysis to analyse a purposive sample of nursing and midwifery regulatory and policy documents. METHOD: We applied a four-part, sequential approach to analyse the selected texts. This involved identifying key words, phrases and statements that indicated dominant discourses that, in turn, revealed latent beliefs and assumptions. The focus of our analysis was on how the discourses construct professional identities. FINDINGS: Our analysis indicated recurring narratives that appeared to confer nurses and midwives with three dominant identities: "the knowledgeable practitioner," the "interpersonal practitioner" and the "accountable practitioner." The discourse also carried assumptions about the form and content of disciplinary knowledge. CONCLUSIONS: Academic study of identity construction in discourse is important to disciplinary development by raising nurses' and midwives' consciousness, alerting them to the ways that their own discourse can shape their identities, influence public and political opinion and, in the process, shape public policy on their professions.

The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review.

OBJECTIVES: To explore the experiences of caregivers of terminally ill patients with delirium, to determine the potential role of caregivers in the management of delirium at the end of life, to identify the support required to improve caregiver experience and to help the caregiver support the patient. METHODS: Four electronic databases were searched-PsychInfo, Medline, Cinahl and Scopus from January 2000 to July 2015 using the terms 'delirium', 'terminal restlessness' or 'agitated restlessness' combined with 'carer' or 'caregiver' or 'family' or 'families'. Thirty-three papers met the inclusion criteria and remained in the final review. RESULTS: Papers focused on (i) caregiver experience-distress, deteriorating relationships, balancing the need to relieve suffering with desire to communicate and helplessness versus control; (ii) the caregiver role-detection and prevention of delirium, symptom monitoring and acting as a patient advocate; and (iii) caregiver support-information needs, advice on how to respond to the patient, interventions to improve caregiver outcomes and interventions delivered by caregivers to improve patient outcomes. CONCLUSION: High levels of distress are experienced by caregivers of patients with delirium. Distress is heightened because of the potential irreversibility of delirium in palliative care settings and uncertainty around whether the caregiver-patient relationship can be re-established before death. Caregivers can contribute to the management of patient delirium. Additional intervention studies with informational, emotional and behavioural components are required to improve support for caregivers and to help the caregiver support the patient. Reducing caregiver distress should be a goal of any future intervention.© 2016 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.

Nurses', midwives' and key stakeholders' experiences and perceptions on requirements to demonstrate the maintenance of professional competence.

AIM: To present the qualitative findings from a study on the development of scheme(s) to give evidence of maintenance of professional competence for nurses and midwives. BACKGROUND: Key issues in maintenance of professional competence include notions of self- assessment, verification of engagement and practice hours, provision of an evidential record, the role of the employer and articulation of possible consequences for non-adherence with the requirements. Schemes to demonstrate the maintenance of professional competence have application to nurses, midwives and regulatory bodies and healthcare employers worldwide. DESIGN: A mixed methods approach was used. This included an online survey of nurses and midwives and focus groups with nurses and midwives and other key stakeholders. The qualitative data are reported in this study. METHODS: Focus groups were conducted among a purposive sample of nurses, midwives and key stakeholders from January-May 2015. A total of 13 focus groups with 91 participants contributed to the study. FINDINGS: Four major themes were identified: Definitions and Characteristics of Competence; Continuing Professional Development and Demonstrating Competence; Assessment of Competence; The Nursing and Midwifery Board of Ireland and employers as regulators and enablers of maintaining professional competence. CONCLUSION: Competence incorporates knowledge, skills, attitudes, professionalism, application of evidence and translating learning into practice. It is specific to the nurse's/midwife's role, organizational needs, patient's needs and the individual nurse's/midwife's learning needs. Competencies develop over time and change as nurses and midwives work in different practice areas. Thus, role-specific competence is linked to recent engagement in practice.

The liminal self in people with multiple sclerosis: an interpretative phenomenological exploration of being diagnosed.

AIMS AND OBJECTIVES: To explore the lived experience of the meaning of being diagnosed with multiple sclerosis on the individual's sense of self. BACKGROUND: The time leading up to and immediately following the diagnosis of multiple sclerosis has been identified as a time period shrouded by uncertainty and one where individuals have a heightened desire to seek accurate information and support. The diagnosis brings changes to the way one views the self which has consequences for biographical construction. DESIGN: A hermeneutic phenomenological study. METHODS: In-depth qualitative interviews were conducted with 10 people recently diagnosed with multiple sclerosis. The data were analysed using interpretative phenomenological analysis. FINDINGS: This study presents the three master themes: the 'road to diagnosis', 'the liminal self' and 'learning to live with multiple sclerosis'. The diagnosis of multiple sclerosis may be conceptualised as a 'threshold moment' where the individual's sense of self is disrupted from the former taken-for-granted way of being and propose a framework which articulates the transition. CONCLUSION: The findings highlight the need for healthcare professionals to develop interventions to better support people affected by a new diagnosis of multiple sclerosis. The conceptual framework which has been developed from the data and presented in this study provides a new way of understanding the impact of the diagnosis on the individual's sense of self when affected by a new diagnosis of multiple sclerosis. This framework can guide healthcare professionals in the provision of supportive care around the time of diagnosis. RELEVANCE FOR CLINICAL PRACTICE: The findings provide practitioners with a new way of understanding the impact of the diagnosis on the individual's sense of self and a framework which can guide them in the provision of supportive care around the time of diagnosis.

Challenges in accessing and interviewing participants with severe mental illness.

Background Interviews are widely used in qualitative research to collect data. However, little has been written about interviewing people with severe mental illness (SMI). Aim To report and analyse an experience of addressing the ethical and practical challenges of interviewing people with SMI. Discussion Semi-structured interviews were conducted as part of a doctoral study to explore how service users and healthcare professionals built relationships with each other. Conclusion Although interviewing participants with SMI was challenging, rich data illustrating their experiences were gathered. Careful planning around ethical considerations, such as obtaining informed consent, was required to maximise the opportunities to gather in-depth information during the interviews. The relationship established between researcher and the participants assisted with sensitive disclosures and allowed participants to tell their stories. Implications for research This paper provides strategies to help guide researchers planning interviews with vulnerable populations, including those with SMI. These strategies include how to discuss sensitive issues and promote engagement. Listening to participants' life stories is an intense experience, requiring support for the interviewer to stay neutral during interviews. It is also important to be aware of the differences between the roles of nurse and nurse researcher before undertaking in-depth qualitative interviews, particularly with vulnerable participants.

Development of a cross-cultural HPV community engagement model within Scotland.

OBJECTIVE: To examine cultural barriers and participant solutions regarding acceptance and uptake of the human papillomavirus (HPV) vaccine from the perspective of Black African, White-Caribbean, Arab, Indian, Bangladeshi and Pakistani young people. METHODS: In total, 40 young people from minority ethnic communities in Scotland took part in a qualitative study, involving seven focus groups and four paired interviews, to explore their views and experiences of the HPV vaccine. Using critical discursive psychology, the analysis focused on young people's accounts of barriers and enablers to information, access and uptake of the HPV vaccination programme. RESULTS: Participants suggested innovative strategies to tackle intergenerational concerns, information design and accessibility, and public health communications across diverse contexts. A cross-cultural community engagement model was developed, embracing diversity and contradiction across different ethnic groups. This included four inter-related strategies: providing targeted and flexible information for young people, vaccine provision across the life-course, intergenerational information and specific cross-cultural communications. CONCLUSION: This is the first HPV cross-cultural model inductively derived from accounts of young people from different ethnic communities. We recommend public health practitioners and policymakers consider using the processes and strategies within this model to increase dialogue around public engagement, awareness and receptivity towards HPV vaccination.

Therapeutic exercises for affecting post-treatment swallowing in people treated for advanced-stage head and neck cancers.

BACKGROUND: Head and neck cancer treatment has developed over the last decade, with improved mortality and survival rates, but the treatments often result in dysphagia (a difficulty in swallowing) as a side effect. This may be acute, resolving after treatment, or remain as a long-term negative sequela of head and neck cancer (HNC) treatment. Interventions to counteract the problems associated with dysphagia include swallowing exercises or modification of diet (bolus texture, size), or both. OBJECTIVES: To determine the effects of therapeutic exercises, undertaken before, during and/or immediately after HNC treatment, on swallowing, aspiration and adverse events such as chest infections, aspiration pneumonia and profound weight loss, in people treated curatively for advanced-stage (stage III, stage IV) squamous cell carcinoma of the head and neck. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 6); MEDLINE; PubMed; Embase; CINAHL; LILACS; KoreaMed; IndMed; PakMediNet; Web of Science; ClinicalTrials.gov; ICTRP; speechBITE; Google Scholar; Google and additional sources for published and unpublished trials. The date of the search was 1 July 2016. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) of adults with head and neck cancer (stage III, stage IV) who underwent therapeutic exercises for swallowing before, during and/or immediately after HNC treatment to help produce safe and efficient swallowing. The main comparison was therapeutic exercises versus treatment as usual (TAU). Other possible comparison pairs included: therapeutic exercises versus sham exercises and therapeutic exercises plus TAU versus TAU. TAU consisted of reactive management of a patient's dysphagia, when this occurred. When severe, this included insertion of either a percutaneous endoscopic gastroscopy or nasogastric tube for non-oral feeding. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: safety and efficiency of oral swallowing, as measured by reduced/no aspiration; oropharyngeal swallowing efficiency (OPSE) measures, taken from videofluoroscopy swallowing studies; and adverse events, such as chest infections, aspiration pneumonia and profound weight loss. Secondary outcomes were time to return to function (swallowing); self-reported changes to quality of life; changes to psychological well-being - depression, anxiety and stress; patient satisfaction with the intervention; patient compliance with the intervention; and cost-effectiveness of the intervention. MAIN RESULTS: We included six studies (reported as seven papers) involving 326 participants whose ages ranged from 39 to 83 years, with a gender bias towards men (73% to 95% across studies), reflecting the characteristics of patients with HNC. The risk of bias in the studies was generally high.We did not pool data from studies because of significant differences in the interventions and outcomes evaluated. We found a lack of standardisation and consistency in the outcomes measured and the endpoints at which they were evaluated.We found no evidence that therapeutic exercises were better than TAU, or any other treatment, in improving the safety and efficiency of oral swallowing (our primary outcome) or in improving any of the secondary outcomes.Using the GRADE system, we classified the overall quality of the evidence for each outcome as very low, due to the limited number of trials and their low quality. There were no adverse events reported that were directly attributable to the intervention (swallowing exercises). AUTHORS' CONCLUSIONS: We found no evidence that undertaking therapeutic exercises before, during and/or immediately after HNC treatment leads to improvement in oral swallowing. This absence of evidence may be due to the small participant numbers in trials, resulting in insufficient power to detect any difference. Data from the identified trials could not be combined due to differences in the choice of primary outcomes and in the measurement tools used to assess them, and the differing baseline and endpoints across studies.Designing and implementing studies with stronger methodological rigour is essential. There needs to be agreement about the key primary outcomes, the choice of validated assessment tools to measure them and the time points at which those measurements are made.