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5. Guideline methodology

The literature search strategy was developed with the support of an NHS librarian using the following question ‘What evidence is there to assist radiographers and others to give the best care to people with dementia and their carers when attending for imaging or radiotherapy?’

The topic did not conform to the PICO (Patient/Population, Intervention, Comparison, Outcome) framework as there was neither a specific intervention nor a specific comparison. Therefore it was decided to adapt this framework (Table 1 below) and keywords were listed under the domains of patient population, outcome and setting/professional group. An initial search identified a paucity of literature focussed on the imaging or radiotherapy setting in terms of this topic, and therefore the search was broadened to include all settings involving acute hospital services.

Table 1 

Domain: Patient Population Outcome Setting / professional group
Keywords Dementia Patient care Radiographer
  Alzheimer's disease Professional-patient relations Radiotherapist
    Person centred care Hospital
    Dignity Acute hospital
    Communication Allied health professional
    Quality of care Nursing staff
      Ward

Further restrictions included English language, published between 1997 and 2013, humans, adults. The time period to search was decided based on the seminal work published by Kitwood14 , which marked an attitudinal shift in dementia care. However, due to the volume of references identified this was further limited to a ten year period: 2003-2013. Searches were conducted using NHS Evidence and the following databases were searched independently: AMED, MEDLINE, CINAHL and Embase. 

The search terms for each domain were used to identify MeSH headings, these differed between each database, and where no MeSH heading was available, free text was used. The explode function and truncation was used where it was deemed appropriate. The searches for each domain were combined using the Boolean operator ‘OR’ and to combine the different domains the Boolean operator ‘AND’ was used. 

Inclusion was determined by reading the title and abstract to determine if a reference met the inclusion criteria, which was any article where the focus was on care of people with dementia in an acute care setting. Articles were excluded if their focus was on other care settings (e.g. community care, or long term care), if the main focus of the article was on diagnosis or design features rather than on patient care, and if the main focus of the article was on end-of-life care.

References were prioritised for reading by date of publication with the most recent receiving higher priority, and also by likely relevance to the radiography setting determined from the abstract. Data saturation was assessed by two members of the core group and once this was reached it was agreed that further inclusion was not necessary. 

Fig 1 Outcome of literature search

5.2 Literature review

All articles were published in peer review journals, although the standard of the journals did vary from those that published primarily informal discussion articles, to those that mainly published primary research.

Of the included articles, 1 was a systematic review, 13 reported primary research findings, 12 were discussion papers and 2 reported case studies. Of the primary research articles 10 were qualitative studies, and 3 were quantitative, which reflects the nature of this specific topic which lends itself to qualitative enquiry. The research methods are outlined in table 2 below. 

Table 2

Method Number of articles
Survey 2
Pre-test/post-test 1
Focus groups 3
Observations/ethnography 3
Interviews 4

Of those studies that recruited participants these included hospital staff/nursing students (8 studies), family carers of people with dementia (2 studies) and people with dementia (3 studies). The majority of the included studies were single site, or used multiple hospital sites within a single Trust. The majority of the research was conducted in the UK, with a single study emanating from each of the following countries: Australia, USA, Republic of Ireland and Canada. In terms of the discussion articles and case studies, the majority of those included focus on the UK healthcare system, with 1 focussing on care in the USA. 

The quality of the discussion papers varied with some giving a clear justification for the inclusion of references and providing a comprehensive reference list, whilst others appeared to be less formal providing little detail about where references were found and limited bibliographies. However, as all of the discussion articles appeared to corroborate each other in terms of the general ideas on patient care that were being presented it was decided to include all of the discussion articles. Indeed, due to the nature of the topic and the importance of clinical experiences and the practical application of patient care techniques it was felt that these articles, along with the case study articles, could provide valuable supporting information for this guidance document as they often drew upon the authors clinical experiences and had a practical focus. 

5.3 Description of how recommendations were developed 

The core group leader and clinical-academic researcher met to consider the evidence and develop the recommendations for the practice guideline. Each article had been summarised using the data extraction tool (Appendix D in the Process Manual). These were reviewed and a judgement made about their quality and value. This enabled a list of raw recommendations to be compiled together with the associated evidence source. 

The core group leader undertook a thematic analysis of the raw recommendations, selecting themes according to the initial guideline questions in 3 above and allocating recommendations to these, removing any duplication whilst retaining the source reference details. During this process it became apparent that some themes required further expansion; for example, optimising staff behaviours needed to be disaggregated into specific sections about training needs and relationship building. This draft was circulated to remaining core group members for further comment and refinement prior to undertaking the consultation process outlined in 4.3 above.  

The application of GRADE for each individual recommendation within this practice guideline was considered by core group. However, due to the limitations of GRADE, which cannot be applied where a topic area has no clear outcome measures or obvious comparison approaches15, it was rejected.  It is acknowledged by the authors that the body of evidence in this area is not strong, comprising mostly of expert opinion in the form of discussion papers and small single centre observational studies.  

5.4 Limitations of the guideline including consideration of possible bias 

In terms of the strength of the recommendations contained within this guideline, no contradictory evidence was identified with a strong level of agreement between all sources. The sources from which each recommendation was drawn are highlighted throughout the document. One limitation of the evidence that informed these guidelines is that none of it focussed specifically on the radiography setting. However, the guideline development core group universally agreed that the similarities with other settings in the acute hospital are sufficient to allow for the application of this evidence within radiography.

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