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Introduction

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

Why use literature reviews in health and social care? is a free course which introduces and explains how literature reviews can support evidence-based practice in health and social care. A literature review can offer a systematic way in which to sift through information to produce relevant existing knowledge and discern knowledge gaps. This short course explores different examples of the use of literature reviews that have informed policy and practice; social work with older people, cessation of cigarette smoking in pregnant women and use of mindfulness therapy with respect to older people with dementia and their carers.

This OpenLearn course is an adapted extract from the Open University course K323 Investigating health and social care.

Learning outcomes

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

After studying this course, you should be able to:

recognise how a literature review of current knowledge and research can contribute to investigation of health and social care.

1 Information overload?

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

Long description

What is the point of having countless books and libraries whose titles their owners could scarcely read through in his whole lifetime? The mass of books burdens the student without instructing him, and it is far better to devote yourself to a few authors than to get lost among many.

(Seneca, 2005, p. 45)

Seneca wrote these words 2,000 years ago; as a Stoic philosopher he sought ‘tranquillity of mind’. He felt that one source of stress in life was simply ‘too much information’.

Yet then, as today, we all need information to negotiate our lives. Whether we are health service users or practitioners, we need to get the right kind of information to obtain or deliver the best, most appropriate service. How do we know what the right, most helpful kind of information is?

A lot of ‘good information’ used to be located behind the walls of university libraries. Nowadays a lot of information can be found on the web and social media. However these sources also give many examples of ‘fake news’. (e.g. Sommariva et al., 2018). Balancing this, the internet allows non-professionals to find evidence with which they can challenge health and social care practitioners. Professionals can no longer simply rely on the status of being a ‘professional’. Consumers’ rights and citizens’ rights imply that the services we receive or practise should be evidence-based. For all stakeholders it becomes very important to discern what ‘counts’ as good evidence for adopting a particular policy or practice in health and social care. The internet has also facilitated an explosion in the number of academic journals reporting primary empirical research allowing more people to access leading edge research. However, potentially we are still left with the same problem that Seneca encountered 2,000 years ago – namely potential information overload. Learning about how to conduct a literature review in a systematic way can cut through the mass of research out there in health and social care.

Using a literature review to inform health and social care policy and practice can utilise existing research to answer new questions. At the very least approaching information systematically might identify the need for new research. Significantly, because so much research is now accessible online it means that we might be able to answer new questions. Literature reviews are often considered ‘very academic’ but actually they are a practical way to interrogate research and find answers. Whether you are a service user, carer or health and social care practitioner, learning how to conduct a literature review can put good evidence in your hands. It can give you a powerful tool to introduce and employ evidence-based policy and practice in your immediate environment.

The key starting point of a literature review is your research question.

Activity 1 Why are literature reviews important?

Watch the following video, which introduces the ideas that need to be considered when finding relevant literature.

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Video 1 Let’s talk about questions

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NARRATOR:

Let's talk about questions. This short course will introduce how literature reviews can be relevant to health and social care practice. Very often, literature reviews begin with a research question.

There are three different broad types of question. Questions of quantity, in which the data comes in the form of numbers. Questions of quality, in which the data comes in the form of words or pictures or anything nonnumerical. Questions of assessment or evaluation, in which the data can be both numerical and nonnumerical. If, for example, you asked, how many GPs work at the local GP practice? That would be a question of quantity. In a research interview if you asked, did you feel you were listened to by your GP? That would be a question of quality. If you wanted to know if the treatment or policy was working, that would be an evaluative question and you might need qualitative and quantitative data to answer that.

A quick way to find an answer to any of these questions might be to search for answers using Google. For example, do patients think GPs listen to them? But one simple question can bring up a huge amount of information.

How would you know that Google has provided you with the best information at the top of the list? You might have thousands of entries to look at. How do you know what to look at first, or how much information to look through? Then you have to think about the reliability of the information. Who, which organization provided that.

Did the organization or person have a biased agenda? What sources of information should you trust and why? In health and social care questions can be complicated. There are questions about health and equality. Is health a post code lottery? There are questions around patient and service user rights.

These questions can involve multiple perspectives and the answers can vary depending on who you ask and the form the question takes. The web gives you plenty of information, but unless you approach that knowledge in a systematic way, your answers may end up being superficial or incomplete. Sum up then-- ask a good question.

You should know what kind of data you require. If you have a good question, it will limit the amount of information you need. An overambitious question may never be truly answerable. To answer a good question, literature reviews need to synthesize the data and information found in relevant research evidence.

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Discussion

Many people work in or receive health and social care services in the UK. It is a significant part of our economy. Efficient and effective use of resources is only one rationale for why professional practice and policy should be grounded in reliable evidence. Perhaps more important than that, our policy and practice should be ethical. Either rationale needs evidence to support proposed and existing practice. And so it becomes very important as to what ‘counts’ as good evidence.

Literature reviews help summarise current evidence, to suggest both ‘what works’ and what needs to change. There is a huge amount of information ‘out there’, and cutting through that on a systematic basis begins with understanding the major types of questions we can ask. Questions of:

quantity, from which we expect answers in terms of numbers
experience or quality, in which we can expect answers in terms of how people express how they feel about an experience
assessment or evaluation, in which answers could be provided either in the form of number or an expression of experience but which indicate if a policy or practice has worked or not.

2 Using evidence in practice

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

Once you’ve completed your literature review you will need to think through how you are going to use it. You will have marshalled the evidence you need based on precise research question. Your aim will be to convince your readers – your manager, your colleagues, your campaigning associates or whoever – that you’ve drawn from a relevant reservoir of evidence to support recommendations which will change practice or policy.

You might think that a literature review is a highly ‘academic’ exercise. Well, it is; but it should also be seen as very practical. It should be seen as something that can be incorporated into everyday professional practice, by harvesting and harnessing the host of research into health and social care that exists to inform the development of new policy and practice. To help steer your thinking the next section explores three case studies which illustrate what this might mean. Use these case studies to stimulate your thinking about literature you might want to look into further.

The three case studies that have been chosen concern mental health, public health and social work. Each have a different policy and practice focus. Will your eventual investigation have a policy or practice focus?

3 How literature reviews can shape policy and practice

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

Case study: Jean Gordon (Effective social work with older people)

I qualified as a social worker in my mid-twenties and since then have had a varied career as a practitioner, practice educator, social work tutor and, more recently, as a self-employed researcher. I’ve worked in residential childcare, schools, hospitals and community mental health, in the third sector as well as Scottish local authorities. Throughout my career I’ve been curious about the basis on which social workers make decisions about whether, how and why to intervene in people’s lives. I’ve also become increasingly aware of the often-slim evidence base that we draw on, and the importance of being able to locate and make sense of accessible, relevant research to inform policy and practice.

In 2005 I had the opportunity to contribute to the development of a new direction for social work services in Scotland. The 21st Century Social Work Review was undertaken in the wake of a major inquiry into the abuse of adults with learning disabilities in the Scottish Borders. The Review Group was asked to take a fundamental look at all aspects of social work and make recommendations about how services should be developed to respond to twenty-first-century challenges for the profession. It commissioned a wide range of research including a review of the evidence base for effective social work with older people, conducted by [the] Social Work Research Centre at the University of Stirling.

(Source: Kerr et al., 2005)

Case study: Julie Hirst (Smoking cessation and pregnant women)

I worked for the NHS for 24 years before transferring to Derbyshire County Council in 2013. My work focused on addressing the social factors that impact on people’s health.

When I conducted my literature review, I was working for the NHS as a public health specialist. I had just inherited the task of reducing the prevalence of smoking in pregnant women in Derbyshire. I knew very little about what worked to help pregnant women quit smoking, so I approached my literature review with an open mind. My initial search terms included ‘smoking’ and ‘pregnancy’. I searched a range of databases including the Cochrane Library, CINAHL, PubMed and NICE. This gave me a huge amount of evidence about the impacts of smoking on the baby and the mother, including the shocking statistic of 40% of infant deaths being attributable to maternal smoking. The results also highlighted some key risk factors for maternal smoking, including relative deprivation, young maternal age and low educational attainment.

I refined my search by adding: ‘effective interventions’ and excluded literature over five years old. This gave me a more useful range of evidence, including a number of systematic reviews and meta-analyses. All the evidence I found emphasised the relatively low success rates for any intervention aiming to help pregnant women to quit smoking. Interventions described included the NHS Stop Smoking Service, counselling, health education, social support and financial incentives. Interestingly, financial incentives emerged as four times as effective as any other intervention (25% versus 6%). One limitation was that all the evidence on financial incentives came from studies in the USA.

(Source: Ierfino et al., 2015)

Case study: Adele Pacini (Mindfulness for later life)

I am a chartered clinical psychologist in the NHS, specialising in later life mental health care, including dementia assessments. I became interested in Mindfulness (NHS, 2018) on a personal level after completing my clinical psychology training, when I found that I was still pretty stressed despite not having the excuse of exams!

I started a daily practice from there, and it has been interesting to think about the practice of mindfulness on a personal level, and also from a theoretical perspective in terms of how it impacts on the mind. I wondered whether the benefits I had observed in my own attention processes would also benefit people with cognitive impairment. I keep up to date with the research literature via email alerts from journals, and I noticed that a good deal of research interest was developing in this area.

4 Policy or practice focus, or a mixture?

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

The case studies in the previous section offer contrasting professional disciplines and subject matter: social work with older people, promoting public health through smoking cessation and mental health in later life. Each of the literature reviews we featured have been published or presented at different times for different purposes. A fundamental distinction in purpose is whether a review is concerned with policy or practice. In this section, you’ll look at reviews that focus on policy or practice or a mixture of both, using Jean’s, Julie’s and Adele’s cases.

Activity 2 Bottom-up policy?

Watch this interview with Jean and Julie about their literature reviews.

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SANDY FRASER:

Hello and welcome. I’m Sandy Fraser, one of the authors on this module. Today, we want to talk through how literature reviews can be used to support evidence-based changes to policy and practice. I have with me, two experienced social work and public health practitioners who’ve used literature reviews in their work, Jean Gordon and Julie Hirst.

JEAN GORDON:

Hello.

JULIE HIRST:

Hello.

SANDY FRASER:

Jean, one of the things I wanted to talk through was how did you get involved in the literature review you did concerned with the 21st Century Review?

JEAN GORDON:

The 21st Century Review brought together a whole range of literature review and other sources of evidence. And the particular literature review that I was asked to be involved in is about effective social work with older people. And I got involved, I suppose partly because of my – well, certainly my interest in research and some experience, but not a great deal at that time of literature review. But also my experience working as a practitioner in social work. So I was able to bring that practice-based knowledge to the task.

SANDY FRASER:

Julie, your literature review was about smoking cessation with pregnant women.

JULIE HIRST:

That’s right.

SANDY FRASER:

Was that always an interest, or were you – did you have to do it?

JULIE HIRST:

I had to do it. It is an interest to me because it’s a very important public health issue, obviously, maternal smoking. But it was actually handed to me as a piece of work. I was given the task in Derbyshire of reducing the prevalence of pregnant women who smoke. And therefore, I decided to do a literature review to help me to understand how best I could do that.

SANDY FRASER:

Turning back to Jean, it’s been quite a long time since the 21st Century Review of Social Work in Scotland took place and also therefore, your literature review within it about older people. Do you think that the 21st Century Review had an impact in policy terms about the way in which local authorities worked with older people?

JEAN GORDON

I think in broad terms, what it did was to raise the profile of social work, including social work with older people, and to pay more attention to the voices of practitioners, service users, and carers. And in relation to practitioners, one of the things that happened was that practitioner forums were set up, which gave social workers with experience in lots of fields, including working with older people, to actually get together and influence policy and practice in their local authorities and in other organisations, too. One of the messages that I suppose came from 21st Century Review was about distinctive role of social work and how that fits into multidisciplinary working and integrated teams, which is particularly relevant in Scotland today with the integration of health and social care. So some of the themes, although 2006 is a long time ago, some of those themes are still running on and still important for social workers to be thinking about.

SANDY FRASER:

And were definitely part of the evidence from your literature review.

JEAN GORDON:

The evidence from our literature review, but also all this evidence that came together from a number of different literature reviews and other sources.

SANDY FRASER:

How about you, Julie? I mean, where did we get with impact of the work that you did?

JULIE HIRST:

Well, in terms of impact, we helped 48 women to quit smoking through pregnancy. It was a small pilot, so the numbers were small. And 25 of those women were still quit six months later. We went back, and we validated the tests, so we know that that happened. So 48 women managed to stop smoking throughout their pregnancies, helping to improve the lives of the babies and also for the mums, of course. And yes, 25 were quit six months later, so hopefully, they would remain smoke-free for the rest of their lives.

SANDY FRASER:

So that was true of the pilot, but did the policy outlast the pilot? What happened with the policy? Did it carry on?

JULIE HIRST:

It did. I mean, the original literature review showed that financial incentives, which is what we piloted were four times more effective than any other intervention that we know about to help pregnant women quit smoking. We piloted it at a small scale, and because of the literature review itself, the findings and the outcomes of our pilot, then yes, a decision was made to fund because obviously, it cost more money than the usual treatments that we were giving. But a decision was made. It was important enough to be able to fund that, to roll it out across the whole county of Derbyshire.

SANDY FRASER:

And is it still running today, or is it –?

JULIE HIRST:

It’s not still running today. It ran for about three years, and then things changed at different levels in the – I mean, we started out in the NHS, actually, and we kind of straddled the changes in terms of the Health and Social Care Act 2012, when that got implemented. And like a lot of policies and practice actually, organisations change. And we’ve got to flex with it.

So it started in the NHS. It got sustained for some time in the local authority. And then things changed at the local authority, and a decision was made to stop it and do different things.

SANDY FRASER:

One of the things that strikes me about both of your literature reviews and the policies that you were involved in is they’re quite big policies. One covers the whole of Scotland for quite a long time, long lasting. Another one covers the whole of Derbyshire. Again, the impact of what you were about lasted for quite a long time. But they were, if you like, big policies, but our students are in a slightly different situation. They either are on the Open Programme, or they’re embedded in their social work degree or their health and social care degree. So they are not going to be in a situation to influence big policy. Should that daunt them in any way? Is there a way that they can deal with small, more localised policy?

JULIE HIRST:

Well, yes, I would say so because all frontline practitioners see and observe things and notice things that could be done better. And if they feel that something could be done better at the frontline, they’ve got a fantastic opportunity to help to develop bottom-up policy, as it were. And in that way, change practice as well. So it’s kind of a cycle, isn’t it? It’s a loop, and just as an example, if people see things that they think could be done better, the first thing that I would suggest they do is look for the evidence, as students are learning to do on this module. If you are convinced, then as a student, as a practitioner, then maybe you want to convince your peers and certainly your line manager that a change is important and could make a big difference. And in that way, a bottom-up policy could be developed.

SANDY FRASER:

But even if it’s a bottom-up policy, with policy, there’s usually some kind of key decision maker who can say yes or no who, for example, if I’m wanting to tackle practice, that might be my own practice. So I have to find it, and I am the decision maker. I’m going to do a literature review. I’m going to search for the evidence. I’m going to change what I do next. But policy is a bit different, isn’t it?

JULIE HIRST:

It is, and it requires more of an organisational buy-in, if you like, and therefore, the people you’ve got to persuade are wider than say just changing your own practice. But I think that’s why it’s important to be convinced yourself. If you’re convinced enough that things should change, then you should be able to convince others. And if you can’t, then probably you don’t have the evidence to do so.

SANDY FRASER:

And Jean, how does that work in social work?

JEAN GORDON:

I’m just thinking of an example of going back to that, I was talking earlier about multidisciplinary working and integrated teams and so on. And a lot of social workers work in integrated teams these days. So, from for a practitioner’s point of view, there are lots of questions to be asked really about how members of an integrated team work together and what the particular role of social work is within that and how social workers can best work with their colleagues. And that’s something that a practitioner could be.

SANDY FRASER:

You mean policies to support integrated care in that particular workplace?

JEAN GORDON:

Yes. Yeah, so how integrated working is part of a big policy move, how does that actually work on the ground? And that’s something that a practitioner could really get involved in in terms of looking at the evidence base for effective integrated working and in relation to social work specifically. How can social work best contribute to that whole effort?

SANDY FRASER:

One of the things we’ve just been talking about, though, is how that works, policy change with respect to health and social care practitioners, but the way that this module sort of sees that is it also can include service users and carers as part of a way that they could gather evidence. How would gathering evidence for policy change work for them?

JEAN GORDON:

I think for service users and carers, having that evidence base, being able to gather the evidence they need to present a case for change, for example, in relation to health and social care being offered in a more individualised kind of way, more person-centred kind of way than it is at the moment, or can be, then actually be able to draw on the evidence out there is one way really to make your case and to challenge I suppose established thinking about how services may be offered at the moment and look at alternatives.

SANDY FRASER:

And Julie, how does that work in a public health context?

JULIE HIRST:

Well, I think it’s a really important principle of public health actually. It’s empowerment and seeing everybody as equals. Now, we all know, don’t we in health and social care that quite often people feel a massive power differential because professionals have a lot of knowledge that they’ve trained over the years to acquire. They’ve got all the resources, and they can determine where those resources go to some extent. So I think if service users and their carers understand and can conduct literature reviews, find out what the evidence is, find out what they should be receiving, find out how to get it. Look at the choices as well. Then I think it’s a very, very empowering thing for them to do in and of itself as well as potentially leading to better care.

SANDY FRASER:

Jean, Julie, you’ve provided a lot of food for thought today. Thank you very much.

JEAN GORDON:

Thank you.

JULIE HIRST:

Thank you.

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In the video, there was a discussion of ‘bottom-up’ policy. What do you think ‘bottom-up’ policy might mean?

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Discussion

Hopefully you agree that this interview raised various issues and not just the answer to the activity question.

We can contrast two approaches to evidence-based policy inherent in the discussion with Jean and Julie. You should consider both in framing any investigation. Both Jean’s and Julie’s literature reviews were ‘top-down’ in the sense that they were commissioned by other people to take part in literature reviews. In Jean’s case, it was because the people leading the 21st Century Review were part of her network of shared professional contacts. The 21st Century Review Group needed the evidence about social work with older people. In Julie’s case, her managers asked her to review the evidence for ‘what works’ relating to smoking cessation in pregnancy. A matter of public health. Her employers, first the NHS and then, following the 2012 Care Act, local authorities, (Northern Ireland, Scotland and Wales arrange public health services differently) wanted an effective policy to help pregnant women stop smoking.

This can be contrasted with ‘bottom-up’ evidence-based policy, in which a practitioner might take note of a broad policy that affects their workplace and ask questions about it. For example, Jean noted that integrated health and social care is favoured in different jurisdictions, although she knew more about it in Scotland. Jean suggested that a practitioner might be interested in the evidence of effectiveness of integration, and what factors made it successful, to inform the local implementation of integrated care. Can you identify a broad policy of interest that fits your investigations?

You will now look at what our contributors said about each of their literature reviews.

4.1 Policy focus: Jean’s literature review

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

Jean’s literature review was published in 2005 and was for a Scottish project. When it was produced, it fed into the most substantial review of the social work profession since the late 1960s: Changing Lives, the report of the 21st Century Social Work Review (Scottish Executive, 2006). If you are interested in social work with older people, you can use the hyperlinks embedded in the case study text to learn more about Jean’s literature review and the project it was part of, to get ‘the big picture’. Even though it was produced in 2006, its effects are still present in Scotland. Jean’s literature review was one part of the process that allowed policy makers to frame new policies about working with older people at that time.

Jean reflects on the purpose of her literature review.

Re-reading this report 14 years later, it is inevitably beginning to show its age. Nevertheless, some of our review’s conclusions still seem to me to have resonance today, including its stress on the views and wishes of older people, on ethical social work practice, on the importance of multidisciplinary working and the distinctive mix of skills and expertise that social workers bring to situations of uncertainty, risk and conflict.
This literature review was conceived and planned for a very specific purpose: to inform a nationwide review of policy and practice. In writing it, we were mindful that it sat besides, and had to be cross-referenced against, other commissioned work, as well as the work of service user and carer groups and discussions with social workers and their employers to come to its conclusions. As authors we were therefore very aware that our literature review was to be used to bring about change, and that we were charged from the start to identify the implications of our findings for the future development of the profession. The strength of the 21st Century Review’s conclusions came from the mass of evidence, discussions and debates it generated, rather than any single evidence source.

(Kerr et al., 2015)

Jean’s last point is no doubt important; if a substantial policy shift is implied, then the evidence to support it has to be substantial and come in different forms. In the context of a national shift in policy, no single literature review, even though it collates many sources of information and evidence, is likely to be enough. However, most policy change is not national, it is likely to be focused in geographical boundaries or in terms of particular service terms.

4.2 Policy and practice focus: Julie’s literature review

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

Julie’s literature review, conducted in conjunction with a range of public health academics, focused on the use of financial incentives to stop pregnant women from smoking, thus promoting their health and the future health of their children.

Having reviewed the evidence, I admit that I was surprised to discover that financial incentives appeared to be four times more effective than any other approach. Being concerned about the ethics of this approach and anticipating local (professional) resistance to it, I contacted Professor Theresa Marteau, an expert in financial incentives for behaviour change, for advice.
Theresa Marteau replied to my enquiry (some academics don’t, but it’s always worth a try) and sent me her draft research protocol to pilot financial incentives to help pregnant women quit in a UK setting. I secured the support of Derbyshire’s Director of Public Health, including the funding, to pilot this protocol in Derbyshire. The pilot ran for a 12-month period at Chesterfield Hospital. My literature review and its findings were instrumental in making this happen. Without the evidence from my literature review, I would not have been able to secure the managerial or financial support to develop the pilot.
In previous years the quit rate for smoking among pregnant women using Chesterfield Hospital maternity services was 1% of the total cohort of smokers. The quit rate rose to 8% during our pilot. In summary, a total of 239 (39%) of the 615 women (pregnant smokers) in the pilot enrolled on the scheme, of whom 143 made at least one quit attempt and received an incentive payment, and 97 out of 143 women were still quit six weeks later. Of these, 48 women were biochemically validated as still quit at delivery, 25 of whom remained biochemically quit six months later. These results resulted in a further significant policy change, which involved expansion of the intervention to the remaining areas of Derbyshire.

(Ierfino et al., 2015)

Here, Julie reports two things, first that the literature review directly fed into a change of policy and practice, in how public health was promoted. Yet, giving smokers money to quit smoking might, for some people, seem morally wrong or bad practice in principle, despite evidence of effectiveness. Another point here is that Julie’s research led to a pilot to test the policy. In other words, both from a scientific and a political point of view, piloting of potentially controversial policies through new primary empirical research is likely to be necessary. In this case, the pilot led to a generalised change in practice in Derbyshire.

4.3 Practice focus: Adele’s literature review

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

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.

Figure 1

Long description

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.

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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.

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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?

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Discussion

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.

5 End-of-course quiz

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Conclusion

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In this short OpenLearn course you have learned about why and how literature reviews can inform and change policy and practice in health and social care.

You’ve considered how approaching a literature review in a systematic way can cut through an almost overwhelming amount of information that exists.
A systematic approach can also address issues of potential bias and ‘fake news’.
One of the fundamental elements of doing a good literature review is knowing what kind of evidence you need to help you form a good research question.

Questions of:

quantity, from which we expect answers in terms of numbers
experience or quality, in which we can expect answers in terms of how people express how they feel about an experience
assessment or evaluation, in which answers could be provided either in the form of number or an expression of experience but which indicate if a policy or practice has worked or not.

You also read about and listened to examples of how literature reviews can be used in health and social care.

You heard about how Jean’s literature review helped to inform the development of the social work with older people in Scotland.
You heard about how Julie’s literature review helped to introduce an effective new public health intervention, smoking cessation with women who smoked during pregnancy.
You heard about Adele’s introduction of a new practice with people with dementia and their carers which focused on mindfulness.

Hopefully you found the activities in this OpenLearn course supportive of your interests. If you want to develop more insights into the process of constructing a literature review in health and social care then you might think about registering on K323 Investigating health and social care as part of an Open Degree, our BA (Hons) Health and Social Care (R26) or one of our social work degrees.

Glossary

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

Citizens’ rights: Citizens’ rights derive from legislation and regulation support by the state in any given jurisdiction. They may also refer to supposed or proposed rights that could be enacted and supported by a state. Such rights tend to be generic in nature, for example, related to human rights, that is rights to be free from discrimination, persecution, or freedom of movement, speech, or similar.
Consumers’ rights: Consumers’ rights can be seen as a subset of citizens’ rights, in that they are, or proposed to be, rights supported by a state in the particular field of consumer legislation and regulation, and concern the goods and services that are exchanged in any marketplace.
Seneca: Seneca the Younger (4 BCE–65 CE), fully Lucius Annaeus Seneca, known as Seneca; philosopher, playwright and adviser to the Roman Emperor Nero (between 54 and 62 CE) compelled to commit suicide by Nero in 65 CE.
Stakeholders: A person, group or organisation with an interest in a project, so citizens, service users, as well as health and social care practitioners (and their managers) are all ‘stakeholders’ in health and social care.

References

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

Aveyard, H. (2019) Doing a literature review in health and social care, 4th edn. London: Open University Press/McGraw-Hill.

Ierfino, D., Mantzari, E., Hirst, J., Jones, T., Aveyard, P. and Marteau, T.M. (2015) ‘Financial incentives for smoking cessation in pregnancy: a single-arm intervention study assessing cessation and gaming’, Addiction, 110(4), pp. 680–88.

Kerr, B., Gordon, J., MacDonald, C. and Stalker, K. (2005) Effective social work with older people. Available at: https://www.gov.scot/ publications/ effective-social-work-older-people/ (Accessed: 17 January 2021).

NHS (2018) Mindfulness. Available at: https://www.nhs.uk/ conditions/ stress-anxiety-depression/ mindfulness/ (Accessed: 17 January 2021).

Scottish Executive (2006) Changing lives. Available at: https://www.gov.scot/ binaries/ content/ documents/ govscot/ publications/ independent-report/ 2006/ 02/ changing-lives-report-21st-century-social-work-review/ documents/ 0021949-pdf/ 0021949-pdf/ govscot%3Adocument/ 0021949.pdf (Accessed: 17 January 2021).

Seneca, L.A. (2005) Dialogues and letters. Edited and translated by C.D. Costa. St Ives: Penguin.

Sommariva, S., Vamos, C., Mantzarlis, A., Uyen-Loan Dao, L. and Martinez Tyson, D. (2018) ‘Spreading the (fake) news: exploring health messages on social media and the implications for health professionals using a case study’, American Journal of Health Education, 49(4), pp. 246–55.

Williams, J.M.G. (2008) ‘Mindfulness, depression and modes of mind’, Cognitive Therapy and Research, 32(6), pp. 721–33.

Williams, J.M.G. (2010) ‘Mindfulness and psychological process’, Emotion, 10(1), pp. 1–7.

Acknowledgements

The Open University — Tue, 02 Feb 2021 00:00:00 GMT

This free course was written by Sandy Fraser.

Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 Licence.

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