Frequently Asked Questions

There are many different carer tools used for different purposes. It is helpful to distinguish between tools that identify that carer support is needed and those that directly identify the support needs carers have.

Tools such as the Zarit Burden Interview, the Caregiver Strain Index or the Distress Thermometer are useful as ‘indicator’ tools. They indicate that carers are experiencing difficulties and support may be needed, but they do not identify what carers’ actual needs are. Those specific support needs need to be identified in another way.

In contrast, the CSNAT comprises a comprehensive set of 15 domains (broad areas) of support need that carers complete to identify the areas in which they need more support. Used as part of the CSNAT Intervention (CSNAT-I) carers’ individual needs are identified and addressed to provide support tailored to their specific needs.

It is well-recognised that carers are reluctant to ask for more support for themselves.When the CSNAT was developed, we decided not to use a Yes/No option for carers to indicate whether they needed more support with any of the CSNAT domains, as it is often difficult for carers to come straight out and say, ‘Yes, I need help’. Instead, the CSNAT asks if they need ‘a little more’ or ‘quite a bit more’ support, as it can be easier to say, ‘OK, perhaps I need a little more support’. The option to indicate need for a ‘little more’ help may overcome barriers to admitting they need support in the first place and open the conversation.

The CSNAT should not be used as an outcome measure. The reasons for this are similar to those that make it unsuitable for measuring change, so please refer to this section for further details.

The CSNAT does not measure the level of need but is a communication tool. Its questions refer to broad domains within which carers may have support needs. Each question or domain is designed to trigger thoughts about different types of needs for further exploration (as happens when used as part of the CSNAT Intervention (CSNAT-I)), and the graded response categories are mainly there to make it easier for carers to express a need. Domains, therefore, do not measure a simple, one-dimensional ‘need’ that can be assigned a meaningful score. A standard outcome measure should therefore rather be used to look at differences in outcome, for instance, between carers who have had the CSNAT Intervention compared with controls, or between carers who report a need for support compared with those who report no need. Such outcome measures may measure e.g. carer distress, strain or quality of life, depending on the focus of the particular investigation.

The problem with using the CSNAT domains as indicators of change, particularly for individual carers, is that domains only indicate the broad area where a carer has need for more support (e.g. managing symptoms). Further investigation is then needed to identify the actual support need and supportive input required (e.g. information about medication dosage for pain), and that support need may then be resolved.

However, carers’ support needs typically change over time. Next week the carer may again require more support in the domain of managing symptoms, but this time the individual support need may be about managing breathlessness, difficulty in getting the right drugs delivered from the pharmacy, or something else. If you only look at whether the carer has indicated a need for more support at the level of domains, it looks like nothing has changed over time, the domain appears unmet. Whereas a lot has happened, at the level of individual needs and the first individual support need was actually addressed.

The fact that the CSNAT domains do not directly identify what the specific or individual support need is (this requires further investigation) and that carers’ support needs change over time due to changes in their own or the patient’s situation, means that the CSNAT domains become a blunt and sometimes misleading indicator of change. If you want to look at the impact of an intervention or at the change in general, it therefore would be better to use other standardised outcome measures that enable you to compare scores.

At most, it may be possible to use the CSNAT frequency counts to consider change within a group of carers. Some papers and presentations have shown the frequency of carers that indicate a need for more support with each CSNAT domain before and after an intervention. However, this would not be the main analysis of the impact of the intervention, but rather help provide context. Any change in frequencies would need to be interpreted with caution, and it may not be appropriate to apply statistical tests to the frequency changes. If used, these should be accompanied by a cautionary statement about the limitations of the CSNAT domains as a measure of change in any reporting of the results.

The CSNAT (the tool itself) is not suitable as an auditing tool, as it is designed as a communication tool within CSNAT-I to open up conversations about carers’ individual needs. The response categories do not represent a numerical scale to score how much support a carer needs. The CSNAT therefore, does not measure the level of need, and it does not identify individual needs directly, it only indicates domains within which carers require more support, for further exploration.

For auditing your carer support, what is meaningful to consider are the individual carer needs that were uncovered through the CSNAT-I assessment conversations, the action(s) taken to meet individual needs, and how effective these actions were. For instance, for the CSNAT domain on ‘managing symptoms’ the individual need for one carer may be understanding the causes of a symptom, for another knowing how to administer a medicine. The outcomes would be whether the carer subsequently felt well informed about causes or confident about medicine administration, respectively. However, each carer may then develop new support needs regarding symptom management, e.g. ways of dealing with cough. Here, if you only consider the carers’ indication of the need for support with the domain of ‘managing symptoms’ on the CSNAT over time, it would look like the service had made no effective response to carers' needs at all.

Only by looking at how well they address identified individual needs, can services really see how effectively they support carers.

The guidance document below addresses different issues relating to CSNAT-I and E-Systems to ensure that both the principles that underpin CSNAT-I and the terms and conditions of the CSNAT licences are followed.

It covers six topics/FAQs:

* Overview of the CSNAT and CSNAT Intervention (CSNAT-I)

* How are CSNAT-I contacts generally recorded?

* Why can I not simply record what the carer ‘ticks’ on the CSNAT (the tool itself)?

* Using CSNAT-I in practice if my organisation has gone paperless wih illlustration of what can be recorded

* A summary of the key CSNAT-I principles to be retained on E-record systems