The CSNAT (the tool itself) is protected by copyright, therefore a licence is required for it use. Licences and the tool itself are made available, free of charge, to researchers from non-commercial organisations.
(1) As a standalone research tool to identify unmet support needs (R1 use)
As the CSNAT is an evidence-based, comprehensive tool comprising 15 domains (broad areas of support need), it can be used solely to collect research data on domains of unmet support need. However, it is important to note that the response categories for each domain are there to help carers express that there is a need for support, they are not a scale to measure the level of need.
(2) In investigations of carers’ support needs that INCLUDE PROVIDING SUPPORT TO CARERS based on CSNAT responses (R2 use)
If within your study, support will be delivered, either by your team or practitioners you are working with, based on using the CSNAT, you are using the CSNAT as part of a practice intervention (CSNAT-I) even though this is within a research study. Therefore, this type of research use requires CSNAT-I Training by your team or practitioners you are working with.
The CSNAT is a communication tool designed to be used as part of a person-centred intervention, the CSNAT intervention (CSNAT-I). Correspondingly, it is suitable for qualitative investigation and analysis of carers’ support needs. Conversely, as it is not a questionnaire or measurement tool, it is not suitable for the quantitative analyses often used with such tools.
The CSNAT questions are not ‘items’ but broad domains for exploration. Therefore, the CSNAT does not directly ‘measure’ need. If the carer indicates they need more support within a domain (question), it requires further exploration to establish what individual needs they have within that domain, as carers will have very different needs within each domain.
Areas of support need are qualitatively distinct. CSNAT domains capture very different areas of need and cannot just be grouped together. They do not represent a single, underlying concept of need.
The purpose of CSNAT response categories is to facilitate communication, not indicate level of need. We have learnt that response gradations may have little meaning to carers (one carer’s “a little more” often equals another carer’s “quite a bit more”). The gradations are there to facilitate communication, as it is often easier for carers to admit they need just ‘a little more’ support than categorically stating they need more help. What matters is whether the carer feels he/she needs more support or not.
- CSNAT responses should not be summarised into a single, total score for the tool.
- Reliability testing in terms of internal consistency is not appropriate for CSNAT because the domains do not contribute to a single construct.
- It is not meaningful to use means and SDs for responses to individual domains.
- We do not recommend using CSNAT responses for correlational analysis. It is better to collapse responses into those who did or did not report they needed more support within each domain. If correlational analysis is undertaken, this should be non-parametric, as response categories are at most on an ordinal scale, and results interpreted with caution.
- CSNAT domains are not suitable for testing change (see below).
- CSNAT should not be used as an outcome measure (see below). A standard outcome measure should be used instead, for instance to measure outcomes between carers who indicate a need/ no need for support or who have had the CSNAT Intervention.
- We are aware that the CSNAT domains have been examined for test-retest reliability but we would not recommend this type of analysis. Any such testing should be interpreted with great caution: we refer to our discussion in a recent paper (Alvariza et al, 2018; https://doi.org/10.1016/j.ejon.2018.04.005).
- Frequency counts of those who reported they needed more support is fine.
It therefore, for instance, makes sense to use descriptive statistics to look at frequencies of carers who say they need more support with a domain or not, to identify the domains where carers most often indicate they have a need for more support. However, using CSNAT domains for other quantitative analysis is not recommended.
The problem with using 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 with the domain of managing symptoms, but this time the 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 need for more support with symptom control, it looks like nothing has changed over time, whereas a lot has happened and the first support need was actually addressed.
The fact that the CSNAT domains do not directly identify what the specific 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 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 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 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.
For services auditing their carer support, what is meaningful to consider are individual needs that were uncovered by CSNAT-I assessment conversations, the action(s) taken to meet individual needs, and how effective these were. For instance, for the CSNAT domain on ‘managing symptoms’, the individual need for one carer may be information about the causes of a symptom, for another how to administer 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, only considering the carer’s indication of a need for support with ‘managing symptoms’ on the CSNAT over time, would make it look like the service had made no effective response to the needs of the carer at all. Only by looking at how well they address identified individual needs, can services really see how effectively they support carers.
If you decide to use analyses for the CSNAT that are not recommended here and publish the results, we would ask that you note in the publication that the analysis undertaken was not recommended by the CSNAT-I team.