A phenomenological-hermeneutic study exploring caring responsibility for a chronically ill, older parent with frailty

Frontline nurses' experiences of managing visitor restrictions during the COVID-19 pandemic in a Danish university hospital - Lessons learned

BACKGROUND

Worldwide visitor restrictions forced nurses to separate patients from their relatives. However, the experience of implementing shifting restrictions from the frontline nurses' perspectives in a Danish context has yet to be assessed.

AIM

The aim of this descriptive qualitative study was to explore frontline nurses' experiences of managing shifting visitor restrictions in a Danish somatic university hospital during the COVID-19 pandemic.

METHODS

An online questionnaire, including open-ended questions, was developed. Data were analysed using descriptive statistics and content analysis.

FINDINGS

116 nurses from 29 departments participated; they were informed about restrictions primarily by their charge nurses and hospital intranet. Shifting visitor restrictions compelled the nurses to constantly adjust and negotiate their practices. When deciding to suggest deviating from the restrictions, they shared their decision-making with colleagues. Visitor restrictions left the hospital environment quieter, but they also created a lack of overview and predictability, an emotional burden, and a negative impact on the quality of care.

CONCLUSION

Restricting relatives' access challenged the nurses' professional values, and it seems to have affirmed their appreciation of relatives' role as important partners in contemporary hospital-based health care.

Uncertainty in serious illness: A national interdisciplinary consensus exercise to identify clinical research priorities

BACKGROUND

Serious illness is characterised by uncertainty, particularly in older age groups. Uncertainty may be experienced by patients, family carers, and health professionals about a broad variety of issues. There are many evidence gaps regarding the experience and management of uncertainty.

AIM

We aimed to identify priority research areas concerning uncertainty in serious illness, to ensure that future research better meets the needs of those affected by uncertainty and reduce research inefficiencies.

METHODS

Rapid prioritisation workshop comprising five focus groups to identify research areas, followed by a ranking exercise to prioritise them. Participants were healthcare professionals caring for those with serious illnesses including geriatrics, palliative care, intensive care; researchers; patient/carer representatives, and policymakers. Descriptive analysis of ranking data and qualitative framework analysis of focus group transcripts was undertaken.

RESULTS

Thirty-four participants took part; 67% female, mean age 47 (range 33-67). The highest priority was communication of uncertainty, ranked first by 15 participants (overall ranking score 1.59/3). Subsequent priorities were: 2) How to cope with uncertainty; 3) healthcare professional education/training; 4) Optimising clinical approaches to uncertainty; and 5) exploring in-depth experiences of uncertainty. Research questions regarding optimal management of uncertainty were given higher priority than questions about experiences of uncertainty and its impact.

CONCLUSIONS

These co-produced, clinically-focused research priorities map out key evidence gaps concerning uncertainty in serious illness. Managing uncertainty is the most pressing issue, and researchers should prioritise how to optimally manage uncertainty in order to reduce distress, unlock decision paralysis and improve illness and care experience.

Caregiving for frail home-dwelling older people: A qualitative study of family caregivers' experiences

BACKGROUND

The increasing frailty of home-dwelling older people can lead to rising expectations from their family caregivers due to various demographic developments and political guidelines. European data show that 60% of home-dwelling older people receive informal care. Frailty among older people is a state of vulnerability, increasing the risk of adverse health outcomes, declining daily activities and needing long-term care.

AIM

To explore family caregivers' lived experiences with caring for frail, home-dwelling older people.

METHODS

We conducted a phenomenological study to obtain in-depth descriptions of the phenomenon. We interviewed nine family caregivers, five men and four women between 52 and 90 years old, in-depth in their homes. We used a hermeneutical phenomenological approach described by van Manen and followed the COREQ checklist.

RESULTS

The phenomenon's essential meaning is described as striving to adapt throughout the caring relationship. The interrelated themes describe different caring relationships, caring for a family member and letting go of the primary caring responsibility.

CONCLUSIONS

Family caregivers describe care as meaningful yet demanding. In our study, the varying condition of frailty was an additional challenge in care. By addressing these challenges, healthcare providers can better support and help family caregivers to withstand their caring relationships. The Norwegian Centre for Research Data approved the study (Ref.61202).

A Heideggerian analysis of good care in an acute hospital setting: Insights from healthcare workers, patients and families

This study articulates the relational constituents of good care beyond techno-rational competence. Neoliberal healthcare means that notions of care are readily commodified and reduced to quantifiable assessments and checklists. This novel research investigated accounts of good care provided by nursing, medical, allied and auxiliary staff. The Heideggerian phenomenological study was undertaken in acute medical-surgical wards, investigating the contextual, communicative nature of care. The study involved interviews with 17 participants: 3 previous patients, 3 family members and 11 staff. Data were analysed iteratively, dwelling with stories and writing and rewriting to surface the phenomenality of good care. The data set highlighted the following essential constituents: authentic care: caring encompassing solicitude (fürsorge); impromptu care: caring beyond role category; sustained care: caring beyond specialist parameters; attuned care: caring encompassing family and culture; and insightful care: caring beyond assessment and diagnosis. The findings are clinically significant because they indicate the importance of nurse leaders and educators harnessing the potential capacity of all healthcare workers to participate in good care. Healthcare workers reported that participating in or witnessing good care was uplifting and added meaning to their work, contributing to a sense of shared humanity.

Uncertainty in multimorbidity: a shared experience we should recognise, acknowledge and communicate

Multimorbidity is increasingly common and inevitably results in uncertainties about health, care and the future. Such uncertainties may be experienced by patients, carers and health professionals. Given the ubiquitous presence of uncertainty, all professionals should be prepared to approach and address it in clinical practice. Uncertainty in multimorbidity can rarely be eliminated, and so, must be carefully addressed and communicated; however, there is little evidence on how to approach it. Key areas are: recognising the existence of uncertainty, acknowledging it, and communicating to achieve a shared understanding. Evaluation of what has been discussed, and preparedness to repeat such conversations are also important. Future research should explore optimal communication of uncertainty in multimorbidity.

Total uncertainty: a systematic review and thematic synthesis of experiences of uncertainty in older people with advanced multimorbidity, their informal carers and health professionals

OBJECTIVES

uncertainty pervades the complex illness trajectories experienced by older adults with multimorbidity. Uncertainty is experienced by older people, their informal carers and professionals providing care, yet is incompletely understood. We aimed to identify and synthesise systematically the experience of uncertainty in advanced multimorbidity from patient, carer and professional perspectives.

DESIGN

systematic literature review of published and grey qualitative literature from 9 databases (Prospero CRD 42021227480).

PARTICIPANTS

older people with advanced multimorbidity, and informal carers/professionals providing care to this group. Exclusion criteria: early multimorbidity, insufficient focus on uncertainty.

ANALYSIS

weight-of-evidence assessment was used to appraise included articles. We undertook thematic synthesis of multi-perspective experiences and response to uncertainty.

RESULTS

from 4,738 unique search results, we included 44 articles relating to 40 studies. 22 focused on patient experiences of uncertainty (n = 460), 15 on carer experiences (n = 197), and 19 on health professional experiences (n = 490), with 10 exploring multiple perspectives. We identified a shared experience of 'Total Uncertainty' across five domains: 'appraising and managing multiple illnesses'; 'fragmented care and communication'; 'feeling overwhelmed'; 'uncertainty of others' and 'continual change'. Participants responded to uncertainty by either active (addressing, avoiding) or passive (accepting) means.

CONCLUSIONS

the novel concept of 'Total Uncertainty' represents a step change in our understanding of illness experience in advanced multimorbidity. Patients, carers and health professionals experienced uncertainty in similar domains, suggesting a shared understanding is feasible. The domains of total uncertainty form a useful organising framework for health professionals caring for older adults with multimorbidity.

Caring for Frail Older People Living Alone in Italy: Future Housing Solutions and Responsibilities of Family and Public Services, a Qualitative Study

When frail older people age alone in place, with increasing functional limitations, they require support in performing daily living activities. In this respect, it is important to assess their preferences in terms of future housing solutions, and their opinions/orientations on the care responsibilities of both family and public services. The present study aimed to explore these aspects in Italy. Qualitative interviews were carried out in 2019 within the “Inclusive ageing in place” (IN-AGE) research project, involving 120 frail older people who lived at home in three Italian regions (Lombardy, Marche, and Calabria). A content analysis was conducted, and some quantifications of interviewees’ statements were provided. The results revealed that the majority of seniors prefer ageing at home, at least with a personal care assistant (PCA), whereas moving to a nursing home is typically deemed as a last option. Moreover, they considered the family to be primarily responsible for taking care of them, even with the support of public services. In addition, some territorial differences emerged. Strengthening an integrated model of long-term care (LTC) for older people, where both formal and informal supports allow frail older people to age at home, seems thus a good overall policy solution to pursue, with interventions based also on the needs and preferences of both seniors and their respective families.

Next of kin's experiences of registered nurses' leadership close to older adults in municipal home care in Sweden: an interview study

Background

Next of kin to older adults over 65 years in municipal home care are concerned whether their older adults’ needs are being met. In municipal home care, the registered nurses’ leadership is important and complex, entailing multi-artist skills involving the older adults and their next of kin. Yet, little is known about next of kin’s experiences of registered nurses’ leadership. Thus, the aim of this study was to explore next of kin’s experiences of registered nurses’ leadership close to older adults in municipal home care.

Methods

Individual telephone interviews were conducted with next of kin (n = 11) of older adults from April to September 2020 in two municipalities in western Sweden. Data were analysed using qualitative content analysis.

Results

The results are presented with the theme, registered nurses do what they can, including two categories, interaction and competence, and the subcategories, relationship, communication, availability, responsibility, team leadership and cooperation. Registered nurses’ leadership was experienced as a balancing act between their commitments and what they were able to achieve.

Conclusions

Next of kin’s experiences of registered nurses’ leadership can contribute knowledge that will strengthen and prepare registered nurses for their leadership roles. This knowledge can support the development of policies for organisational preconditions that ensure quality and safe care to older adults in municipal home care.

The tension between carrying a burden and feeling like a burden: a qualitative study of informal caregivers' and care recipients' experiences after patient discharge from hospital

Purpose: The number of people aged 80 and above is projected to triple over the next 30 years. Expanding public expenditure on long-term care servicesHas made policies encouraged informal caregiving. Burden of care describes challenges connected to informal caregiving. Dependent patients report feelings of being a burden. Few studies have focused on both the experience of caregiver burden and recipients' feelings of burden. This study explore the experiences of old patients and informal caregivers in the first 30 days after the patient's discharge. Method: Aphenomenological approach was used to explore the subjective experiences of the participants . Semi-structured individual interviews were analysed thematically. Results: The reults reflect imbalance regarding care needs relative to time, social roles, physical and emotional states, and formal care resources. Four themes emerged from the interviews: 1) Bridging the gap, 2) Family is family, 3) Never enough, and 4) Stress and distress. Conclusions: The participants face strains within their roles. The care situation has potential to be burdensome. To secure healthcare quality for old patients, the informal carer's role needs to be recognized. Informal care based on altruism and reciprocity seems to be positive, whereas informal care based on family norms might have a negative impact.

The position of home-care nursing in primary health care: A critical analysis of contemporary policy documents

Internationally, primary health care has in recent years gained a more central position in political priorities to ensure sustainable health care for the population. Thus, more people receive health care locally and in their own homes, where home-care nursing plays a large role. In this article, we investigate how home-care nursing is articulated and made visible in contemporary Norwegian policy documents. The study is a Fairclough-inspired critical discourse analysis seeking to uncover the position of nursing in the prevailing political ideologies on current primary health care. In the documents, we identified several complementary and conflicting understandings about home-care nursing. Home-care nursing is presented as a basic part of a municipality's health services, but at the same time, its content and contribution are unclear and almost invisible. We argue that the absence of nursing leads to significant perspectives being left out and tie this to the fact that some patient groups and tasks seem to be disadvantaged. The political placement of home-care nursing in the health-care landscape is thus not just about nursing as a professional practice but also concerns fundamental care values in our society in relation to disadvantaged groups and work tasks.

Relatives' negotiation power in relation to older people's acute hospital admission: A qualitative interview study

BACKGROUND

Acutely admitted older people are potentially vulnerable and dependent on relatives to negotiate and navigate on their behalf.

AIM

This study aimed to explore relatives' experiences of their interactions with healthcare professionals during acute hospital admission of older people to derive themes of importance for relatives' negotiations with these professionals.

METHOD

A qualitative design was applied. Relatives of acutely admitted older people at two emergency departments in Denmark were interviewed (n = 17). The qualitative content analysis was guided by Graneheim and Lundman's concepts.

RESULTS

The analysis derived four themes: (a) Mandate, (b) Incentive, (c) Capability and (d) Attitude to taking action. These four sources of relatives' negotiation power can be illustrated in the MICA model.

CONCLUSION

Four themes were identified as important sources of relatives' negotiation power. Since the four sources of power potentially change according to the situation, relatives' negotiation power seems to be context dependent.

Subjective life experiences of family caregivers of dependent older adults

This study aimed to understand the subjective meanings attributed to home care by family caregivers of dependent older adults through a multicenter qualitative investigation that gathered 84 in-depth interviews with family caregivers from eight Brazilian locations. The hermeneutic-dialectic, theoretical, methodological framework was employed. The following categories emerged from the analysis: 1. Movements inhibiting emotions and feelings; 2. Presence of processes of symbiosis and emotional dependence in the older adult-relative relationship; 3. Contentment in caring for the dependent older adult; and 4. Giving up current and future life projects. The results reveal life experiences marked by symbiotic processes, emotional dependence, and psychic stress. Dependence causes suffering and feelings of despair, powerlessness, impatience, but also solidarity and empathy. Withdrawal from the job market, social depreciation of family caregiver's activity, social isolation, neglected self-care, and family conflicts impact caregivers' subjectivity. The elaboration of public policies must consider the social-affective life experiences of family caregivers of dependent older adults in order to include the care of those providing care.

Caring responsibility from the perspectives of older persons whose adult children are their caregivers

AIM

To describe lifeworld insights into the phenomenon of caring responsibility from the perspectives of persons aged 80+ years living alone with chronic illness, physical frailty and dependency on adult children.

DESIGN

A phenomenological inquiry inspired by Reflective Lifeworld Research.

METHOD

Semi-structured lifeworld interviews with 11 persons aged 80+ years were conducted following their discharge. The interviews lasted 35-83 min, were audio-recorded and transcribed verbatim. Both interviews and the analysis followed the epistemological and methodological principles of Reflective Lifeworld Research.

FINDINGS

We identified the essential meaning 'It means everything' and four constituents illuminating different aspects inherent in the complex phenomenon of caring responsibility; 'A life-constraining transition,' 'Trusting the children to fill the gaps and be the glue,' 'Tacit responsibility, agreement and acceptance' and 'Depending on the children and knowing they are burdened by you.'

CONCLUSIONS

Caring responsibility is based on a trusting relationship and tacit agreements indicating an understanding of interdependence and acceptance of dependence on adult children. However, a paradox appears when older persons express a deep-rooted perception of autonomy and independence as they have difficulties with their growing dependency and feelings of being burdensome. Older persons try to balance the continuum of autonomy, their existential self-image and actual capability. The practical part of caring responsibility seems to dominate and strongly affect the parent-child relationship because the child needs to take care of practical issues related to healthcare management and instrumental activities of daily living, leaving less time for meaningful togetherness.

IMPLICATIONS FOR PRACTICE

Older persons want their adult children to be involved and acknowledged when planning care and treatment because they often seem to serve as the 'glue' that makes it possible for the parent to remain in his/her own home.