Year

2020

Degree Name

Master of Philosophy

Department

School of Nursing

Abstract

Healthcare providers are faced with many challenges when trying to meet the complex needs of those with age related diseases, such as dementia. In residential aged care facilities (RACFs), up to 90% of those with dementia exhibit responsive behaviours (RB) and these are associated with increases in mortality, morbidity and decreased quality-of-life for residents. The term ‘responsive behaviours’ refers to words and actions displayed in response to personal, social or physical environments and are an expression of meaning, needs or concerns. There is a need for more focus in policy, practice and research to improve the management of and reduce the negative impacts of RB on residents and care staff within RACFs. Affective RB symptoms in particular have been found to be the most burdensome. In time constrained workplaces, care staff require guidance towards resources that can facilitate better evidence based practice (EBP). This research adopts the Outcome-Focused Knowledge Translation Framework (OFKTF) in its investigation of knowledge translation (KT) with the aim of identifying best ‘sources of evidence’ to inform practices which are useful to care staff to support residents with affective RB. Specifically, the series of studies undertaken investigates the value of different approaches to synthesis and identifying best ‘sources of evidence’ to guide knowledge translation. Study 1 utilises panoramic meta-analysis (a statistical method pooling effect estimates over systematic reviews and meta-analyses, similar to a systematic review of systematic reviews and meta-analyses) to synthesise the available literature on nonpharmacological interventions for affective RB. However this method was unable to generate definitive recommendations for the non-pharmacological intervention of affective symptoms. This is due to heterogeneity and sampling issues within the included RCTs and insufficient number of RCTs to generate power within the calculations. Despite this, the review highlights overall positive outcomes from the use of non-pharmacological interventions for affective symptoms. It is also useful to generate three tentative recommendations regarding the best available interventions for practice: music therapy for anxiety, staff development for depression and personcentred care for aggression. Despite some value, the study concludes that EB management of RBs in RACFs would also benefit from alternative sources of evidence including expert opinion and an assessment of the quality and useability of CPGs.

To address this, Study 2 identifies available clinical guidelines using a systematic search and assesses their quality using the Intervention Centre for Allied Health Evidence (iCAHE) guideline quality checklist. Two of seven identified CPGs reach a high level of quality. Despite being ranked second, The Behaviour Management: A Guide to good Practice (DBMAS) guide is judged to be the clearest, most complete and easiest to navigate CPG. Quality assessment is found to be insufficient in isolation to identify best sources of evidence but has promise when used in conjunction with other methods such as clinical expertise.

Following on from this, Study 3 sought to establish expert opinion regarding best available guidelines for management of RB. This is achieved through surveying a panel of experts on their use and recommendation of different CPGs. Results from this study highlight the Behaviour Management: A Guide to good Practice (DBMAS) as a high quality guideline with expert preference. Expert preference for guidelines was the same for both overall management of RBs and specifically for the management of affective symptoms. The survey method is able to generate clearer recommendations for RB interventions by comparing quality assessment with expert opinion to reveal the Behaviour Management: A Guide to good Practice (DBMAS) as a high-quality CPG with expert recommendation. However, the results should be interpreted with caution, due to the small and potentially biased sample for the study. The additional value of expert opinion (study 3) to identify best sources of evidence is less conclusive due to study bias. However, overall, the value of mixed methods approaches when identifying ‘sources of evidence’ for KT, should be promoted, especially where the quality of evidence is low. The studies undertaken highlight that the different methods (research synthesis (study 1) and analysis of quality and usability of guidelines (study 2)) are useful to assist in identifying best ‘sources of evidence’ for nonpharmacological alleviation of affective responsive behaviours in dementia.

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Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.