Introduction

4.3 Practice focus: Adele’s literature review Earlier you learned that in her professional role Adele ‘wondered whether the benefits I had observed in my own attention processes [mindfulness] would also benefit people with cognitive impairment’, including people with dementia. Adele’s role involved helping people to restore their mental wellbeing, and one aspect of her work involved Mindfulness (NHS, 2018). If you want to find out more about mindfulness, Professor Mark Williams, former director of the Oxford Mindfulness Centre, has outlined its theoretical basis in the article ‘Mindfulness and psychological process’ (Williams, 2010) and some of its practical applications in the article ‘Mindfulness, depression and modes of mind’ (Williams, 2008). Adele was interested in applying what she knew about mindfulness in her practice setting for people in later life.

The information sheet above (Figure 1) was created for illustrative purposes in that it was an outcome of Adele’s literature review, just as much as either Jean’s or Julie’s publications. The leaflet promotes the new service/practice that Adele’s literature review supported. While publication can be an outcome of doing a literature review, it doesn’t have to be. Adele wanted to develop a new service/practice within her work environment. Her literature review led to that but she still had the practical task of advertising the service and engaging with service users and carers. Activity 3 Mindfulness and working with people with dementia Listen to the following interview with Adele Pacini. Audio 1 SANDY FRASER Hello. I’m Sandy Fraser. With me today I have a contributor to one of our case studies, Adele Pacini. ADELE PACINI Hello Sandy. SANDY FRASER We’ll be exploring how Adele used her literature review about mindfulness to influence her practice environment. Adele, can you tell us a little bit about your own working environment and about mindfulness for people who have dementia? ADELE PACINI Yes. I work in the NHS in secondary mental health services. I work across two teams, the complexity in later life team and the memory assessment team. And the mindfulness for people with dementia was part of an intervention for the memory assessment service. SANDY FRASER So, you wanted to introduce mindfulness groups for people with dementia. So how did your immediate colleagues react when you put that idea forward? ADELE PACINI I would say that there was certainly some reluctance to consider the idea of mindfulness groups. The team I was working in was very medicalised in its approach. There was a strong preference for using medication over psychological interventions. And indeed, there’d never been any therapy groups in the pathway before. Some people doubted whether people would be willing and/or able to attend and other people wondered whether it would actually work. There was a sense that it was untried and untested and we should, if we were going to start introducing therapy groups, we should start with something that had been used by other teams with similar populations. SANDY FRASER In your own organisation? ADELE PACINI Yes, yes. So, an adjoining team. So a team that works in the geographical area next to ours had already run a compassion focus therapy group. And so that was more established and more accepted within the teams. SANDY FRASER Is that compassion therapy in relation to dementia? ADELE PACINI It was. It was, yes. But my sense was that it didn’t really help people with their cognitive difficulties. So, the compassion approach is really helpful for people with dementia, but the mindfulness seemed to add on an extra bit in terms of helping people with their memory and attention, which is why I wanted to introduce that. SANDY FRASER What do you think was going on there? Why was mindfulness as a thing – why did it impact on the cognitive function in the way that the compassion therapy didn’t? ADELE PACINI I think the mindfulness approach is that it’s quite different in terms of how the group is structured. So, participants attend the six-weekly course and there’s homework after each of the sessions. So, they have a daily amount of homework to complete. And those are all mindfulness practices, and those practices really help people to focus their attention. So they focus very much on the here and now. So, they might be focusing on parts of their body or sounds that they hear, and that continued sort of using focus attention seems to really help people. One, obviously help their attention but also help their memory. Because if we’re not paying attention to things we can’t remember it. SANDY FRASER: And so perhaps part of the problem in your team was they just didn’t know that. That wasn’t part of – ADELE PACINI Yes, yes, absolutely. And I think there’s still very much a stigma around dementia even within mental health teams that it’s something that can’t, you can’t intervene so much. That it’s a progressive disease. And that once somebody has it there’s not much that can be done to help them other than offer medication. SANDY FRASER So, you needed to collect evidence through doing a literature review to convince your colleagues? What kind of evidence did you try to collect? Was it quantitative or qualitative or did it involve mixed methods? ADELE PACINI I’d say it was mainly quantitative. The NHS is very much biased towards quantitative methods. They want to know what the outcomes have been and that tends to be in terms of improvements on questionnaire measures and scores, those kinds of things. There wasn’t a lot of qualitative research anyway. For the quantitative, one of the issues was that the outcome research was mainly relating to mild cognitive impairment rather than dementia. So mild cognitive impairment is something that people are sometimes diagnosed with before they have a diagnosis of dementia. Some people will stay just with mild cognitive impairment and it won’t progress to dementia. So, the fact that mindfulness was helping people with mild cognitive impairment I felt was important, and was suggestive that it would help people with dementia. But the team weren’t as convinced by this. And they also weren’t convinced because we’re not commissioned to provide services for mild cognitive impairment. SANDY FRASER One of the things in what you just said there intrigues me. So, was part of the reason that you chose quantitative over qualitative, was it to do with the audience that you knew you had to convince? ADELE PACINI Yes, absolutely. Yes. SANDY FRASER You also said it so happened that there wasn’t much qualitative evidence. But if there had been more – say that had investigated how carers around people with dementia and how mindfulness worked – do you think that would have convinced your team more or less than the more quantitative evidence? ADELE PACINI No, I don’t think it would have, to be honest. I think the team, and particularly my manager actually was very focused on quantitative outcomes. And within our practice as a team there was a focus on collecting quantitative outcome measures for improvements after interventions. That model of practice was quite well established. Qualitative evidence either from our own patients or from the research just wasn’t valued as highly. SANDY FRASER So, you’ve done your literature review – which you found out what you found out and it comes time to present your evidence to your colleagues. How easily were your colleagues convinced by the evidence that mindfulness groups might be helpful? ADELE PACINI They weren’t very convinced to be honest. There was some scepticism in that they didn’t quite seem to believe what the research was saying. There seemed to be a disconnect really between their experience with patients and what the research was saying. There were some comments around ‘Well, that’s because they selected a particular population’. Obviously, research trials are often more filtered than the people we see in clinical practice. So, there was some scepticism certainly about whether this would actually apply for the people that we see. SANDY FRASER Ultimately, they were convinced. It did work. ADELE PACINI It did work, yes, yes. And even after there was evidence that it worked with our patients and carers there was still some scepticism. And I think it wasn’t simply within the multidisciplinary team. So other psychologists that I work with were equally surprised. And in fact, I was surprised that some of the outcome measures were as good as they were. SANDY FRASER So, you managed to change practice in your workplace. So have the mindfulness groups got off the ground and how have they progressed so far? ADELE PACINI Yes. The mindfulness groups did get off the ground. We ran one group as a pilot group. Following the outcomes from that we ran a second group. And we’re currently running a third group in the NHS. We’ve also been successful in working with a local charity to gain some funding directly from the Clinical Commissioning Groups to run some mindfulness groups for people that aren’t served under the NHS commissioning contract. So that’s specifically for people with mild cognitive impairment and also for carers who may or may not be caring for someone with dementia. SANDY FRASER Could you just explain some of that lingo around commissioning groups and things like that? ADELE PACINI Yes. So, the Clinical Commissioning Group now holds a budget really for healthcare in our region. They decide where the funding goes. So, part of that funding goes to the NHS in a block contract, so we’re commissioned to provide specific services and some of that funding goes to charities and similar organisations who tend to offer services that aren’t specifically covered by the NHS or don’t naturally fall under a healthcare provision. SANDY FRASER But the bottom line that you’re describing is that the groups have been implemented not just in your immediate situation but outside of your immediate situation. And it’s led to practice innovations outside of your immediate environment. ADELE PACINI Yes, absolutely. That’s been one of the really positive things from the groups is that it’s snowballed in a sense and we’ve been able to broaden the groups and offer them to people who wouldn’t otherwise be able to access them under the NHS. SANDY FRASER So, how successful was your success? What I really mean is the implementation was successful, but did it start to change the minds of those who had been originally reluctant about getting into mindfulness both within your team and also in your wider organisation? Did it change their attitudes? ADELE PACINI I think to some extent it did. I would say there were some practitioners who were initially very reluctant who if not now are a proponent of mindfulness do accept it as a viable intervention. There were other practitioners who were already quite psychologically minded who have gone further with it. I’d say some practitioners are quite strong advocates for it now really and use it in their day-to-day practice and use it on a personal level as well. So, in that sense, yes, there has been wider implications for the groups. SANDY FRASER Did you have to do any additional networking to make the mindfulness groups successful? ADELE PACINI Yes, I did. I linked in with our local university. And part of that linking in was really to gain some credibility for the mindfulness groups in terms of their support and their expertise really helped me to justify why the groups would be of benefit. I also did some networking with a local charity to gain some funding via the CCG. And that again helped to raise the profile of the groups and increase the credibility again really in terms of they were willing to fund us to run them. SANDY FRASER Students in this module may have been stimulated by their own practice environments in forming their investigation. They might be aiming to change their own or their team’s practice. Based on your own experience, what advice would you give to students about using literature reviews to do this? ADELE PACINI Well, I certainly think that you need to translate literature into both format and content that’s going to be most acceptable to your team. I think if I had attempted to present my colleagues with a series of papers it would not have been received well. I would say that in the end I adapted the depth of the material. I used PowerPoints. I talked about the clinical issues that we have with our clinical population. And how the literature and the findings from the literature might help to address that. SANDY FRASER Well, thank you very much for helping us today Adele. I’m sure your comments will help our students. ADELE PACINI Thank you for having me. Answer these questions: Would you describe Adele’s approach as ‘bottom-up’ or ‘top-down’? Ultimately, Adele was successful in changing practice. What steps did she take to enable her success? Adele’s approach was definitely ‘bottom-up’. It didn’t depend on any particular overall policy. Neither a government department nor her employer wished to implement a policy on mindfulness practice. Adele’s concern was that existing forms of therapy and practice to help people with cognitive impairment and dementia were not sufficient. She thought a change of practice was required. However, she couldn’t simply introduce a practice on her own. She had to win over others, not least because the Clinical Commissioning Group (CCG) had to ‘buy’ services from her employer. Adele was successful for a number of reasons because she was aware of what her immediate audience needed to know. However, her success also involved understanding that she needed to network with potential allies outside her immediate work environment, for example, the local university and a local charity. Success in using secondary research to begin a change process requires that you understand which stakeholders in your audience will challenge your evidence, and which stakeholders will be your potential allies.