The need for flexibility when negotiating professional boundaries in the context of home care, dementia and end of life

Homecare workers needs and experiences in end of life care: rapid review

BACKGROUND

Social homecare workers provide essential care to those living at home at the end of life. In the context of a service experiencing difficulties in attracting and retaining staff, we have limited knowledge about the training, support needs and experiences of this group.

AIM

To gain a timely understanding from the international literature of the experience, training and support needs of homecare workers providing end-of-life care.

METHODS

We conducted a rapid review and narrative synthesis using the recommendations of the Cochrane Rapid Reviews Methods Group. Building on a previous review, social homecare worker and end-of-life search terms were used to identify studies. Quality appraisal was conducted using a multimethods tool.

DATA SOURCES

CINAHL and Medline databases (2011-2023; English language).

RESULTS

19 papers were included representing 2510 participants (91% women) providing new and deeper insights. Four themes were generated: (1) emotional support; homecare workers need to manage complex and distressing situations, navigating their own, their clients' and clients' family, emotions; (2) interaction with other social and healthcare workers; homecare workers are isolated from, and undervalued and poorly understood by the wider healthcare team; (3) training and support; recognising the deteriorating client, symptom management, practicalities around death, communications skills and supervision; (4) recognising good practice; examples of good practice exist but data regarding effectiveness or implementation of interventions are scant.

CONCLUSIONS

Social homecare workers are essential for end-of-life care at home but are inadequately trained, often isolated and underappreciated. Our findings are important for policy-makers addressing this crucial challenge, and service providers in social and healthcare.

Life experience and identity of spousal caregivers of people with dementia: A qualitative systematic review

BACKGROUND

The number of people with dementia is on the rise worldwide, and dementia care has become the focus of global health services. People with dementia are primarily cared for by informal caregivers, with spouses seen as a particularly vulnerable group. Focusing on the spousal caregiving experience and having a good caregiver identity contributes to group bonding and enhanced social support.

OBJECTIVE

To explore the dynamic changes that occur in the caregiving experience of spouse caregivers and explicate the identity of spouses during this process alongside its causes.

DESIGN

A qualitative systematic review.

DATA SOURCE

The following eight electronic databases were searched: PubMed, Web of Science (Core Collection), The Cochrane Library, Embase, CINAHL and CNKI, WanFang and Vip.

REVIEW METHODS

The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) and Joanna Briggs Institute Reviewer's Manual criteria were used to report the results. Study screening and data extraction were conducted independently by two reviewers, and quality was assessed using the Joanna Briggs Institute's Qualitative Research Standard Assessment tool. Data synthesis was performed using thematic analysis.

RESULTS

A total of 15 studies were included and synthesized into three analytical themes: (1) attitudes and emotions toward dementia, (2) emotional ups and downs in dementia care, and (3) who am "I". In binary care, patience and marital responsibilities are identified as facilitators, while care burden and social isolation are identified as hindrances. In addition, gender differences were identified as influencers of identity.

CONCLUSIONS

In this review, spouse identity of people with dementia is complex and affects caregiving experience together with dementia cognition. Disease cognition, caregiving burden and social isolation are identified. Interventions for barriers are suggested to enhance social support.

Home Health Nurses' Perceptions of Caring for Persons With Severe and Persistent Mental Illnesses

BACKGROUND

Severe and persistent mental illnesses (SPMIs) affect a significant portion of the adult population in the United States. Despite their enhanced medical disease burden, individuals with SPMIs often lack access to appropriate medical care. Home health services offer cost-effective options for caring for this population in the comfort of their homes. However, little is known about the perceptions of home health nurses providing care to persons with SPMIs, and how they are adjusting care to persons with SPMIs.

AIMS

This study aimed to explore home health nurses' perspectives on caring for persons with SPMIs.

METHODS

Using a grounded theory approach, individual semi-structured interviews were conducted with home health and home hospice nurses. The research questions focused on the nurses' experiences, barriers and facilitators to care, and the impact of the home environment on caring for persons with SPMIs. Data analysis followed coding procedures outlined in grounded theory, resulting in the development of an axial coding model.

RESULTS/CONCLUSIONS

The findings provide valuable insights into the challenges and opportunities faced by home health nurses when providing care for individuals with SPMIs. The outcomes of this study are intended to contribute to the understanding of current care practices and can guide the allocation of resources to improve care for this vulnerable population, such as incorporating training specific to persons with severe psychiatric illnesses.

Nurse assistants' perception of caring for older persons who are dying in their own home : An interview study

BACKGROUND

As the proportion of older persons in society increases, there is a growing trend towards providing end-of-life care in their homes. Palliative care is a complex and knowledge-demanding form of care, and nurse assistants are those who work closest to the older person at the end-of-life in their own homes. However, nurse assistants sometimes have low educational and insufficient levels of knowledge in palliative care, which can affect the quality of care they provide. Moreover, nurse assistants' experiences are relatively unexplored in this context. The purpose of the study was to illuminate nurse assistants' experiences in caring for dying older persons at home.

METHOD

An empirical, qualitative interview study was conducted with 14 nurse assistants with experience of palliative care in homecare. The material was analyzed using thematic content analysis.

RESULTS

From the nurse assistant's experiences, one main theme emerged: doing everything possible for the dying older person despite challenges. Moreover, three sub-themes emerged: making a difference at a crucial time, death awakens emotions, and balancing personal and professional relationships. The nurse assistants' saw their role primarily as relieving symptoms but also focusing on next of kin. The following are described as essential parts of their role: carrying out practical nursing tasks, focusing on the physical environment, working alone and seeking help from colleagues due to a physical distance to the other members of the multidisciplinary team. The nurse assistants experienced a lack of support as there was no structured guidance or debriefing available in difficult emotional situations. Furthermore, they disclosed that they were left alone to deal with their feelings.

CONCLUSION

This study demonstrates that nurse assistants strive to provide comprehensive care for dying older persons despite facing obstacles from their working conditions and work organization. They lack supervision and education in palliative care, but they rely on their experience-based knowledge to a large extent and provide care according to the four cornerstones of palliative care.

Supported: Supporting, enabling, and sustaining homecare workers to deliver end-of-life care: A qualitative study protocol

BACKGROUND

Homecare workers provide essential care at home for people at end-of-life but are often poorly trained and supported.

AIM

To explore the experiences and needs of homecare workers and the views of homecare clients and carers, and other community-based health and social care staff about the homecare worker role, including identification of good practice.

METHODS

In this qualitative exploratory study, we will conduct 150 semi-structured interviews with homecare workers within three geographic English localities chosen for maximum socio-demographic variation. Eligible participants will be consenting adults providing care services (workers [n = 45], managers [n = 15] community practitioners [n = 30]), receiving care (clients thought to be in the last 6 months of life [n = 30], family carers [n = 15], or commissioners of homecare services supporting end-of-life care [n = 15]. Interviews may adopt a Pictor-guided or standard semi-structured approach according to their preference. Managers and commissioners can contribute to an online focus group if preferred. A range of recruitment strategies will be used, including through homecare agencies, local authorities, local NHS services, charities, voluntary sector groups and social media. Interviews and focus groups will be recorded, transcribed, anonymised, and analysed adopting a case-based approach for each geographic area within-case and then comparison across cases using reflexive thematic analysis. The design and analysis will be informed by Bronfenbrenner's Adapted Ecological Systems theory. This study is registered on the Research Registry (No.8613).

CONTRIBUTION

We will provide evidence on ways to improve the experiences and address the needs of homecare workers in relation to caring for people nearing end-of-life. It will offer insight into good practice around supporting homecare workers including responding to their training and development needs. Findings will inform subsequent stages of an evaluation-phase study of a training resource for homecare workers.

Application of the Person-Centered Care to Manage Responsive Behaviors in Clients with Major Neurocognitive Disorders: A Qualitative Single Case Study

OBJECTIVES

Our study aimed to describe "how" and "why" the person-centered care (PCC) approach was applied within a long-term care (LTC) community to manage responsive behaviors (RBs) in individuals with major neurocognitive disorders.

METHODS

A descriptive holistic single case study design was employed in the context of an LTC community in Quebec, using semi-structured interviews and non-participatory observations of experienced care providers working with clients with RBs, photographing the physical environment, and accessing documents available on the LTC community's public website. A thematic content analysis was used for data analysis.

RESULTS

The findings generated insight into the importance of considering multiple components of the LTC community to apply the PCC approach for managing RBs, including a) creating a homelike environment, b) developing a therapeutic relationship with clients, c) engaging clients in meaningful activities, and d) empowering care providers by offering essential resources.

CONCLUSIONS

Applying and implementing the PCC approach within an LTC community to manage clients' RBs is a long-term multi-dimensional process that requires a solid foundation.

CLINICAL IMPLICATIONS

These findings highlight the importance of considering multiple factors relevant to persons, environments, and meaningful activities to apply the PCC approach within LTC communities to manage RBs.

Risks and risk mitigation in homecare for people with dementia-A two-sided matter: A systematic review

Policy guidance promotes supporting people to live in their own homes for as long as possible with support from homecare services. People living with dementia who need such support can experience a range of physical and cognitive difficulties, which can increase the risks associated with homecare for this group. We aimed to examine risk and safety issues for people with dementia and their homecare workers and risk mitigation practices adopted by homecare workers to address identified risks. We searched MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, ASSIA and Cochrane Central Register of Controlled Trials databases 5 March 2021. Included studies focussed on homecare for people with dementia and had a risk or safety feature reported. Risk of bias was assessed with the Joanna Briggs Institute Critical Appraisal tools. Two authors assessed articles for potential eligibility and quality. A narrative synthesis combines the findings. The search identified 2259 records; 27 articles, relating to 21 studies, met the eligibility criteria. The review identified first-order risks that homecare workers in the studies sought to address. Two types of risk mitigation actions were reported: harmful interventions and beneficial interventions. Actions adopted to reduce risks produced intended benefits but also unintended consequences, creating second-order risks to both clients with dementia and homecare workers, placing them at greater risk. Risk mitigation interventions should be person-centred, the responsibility of all relevant professions, and planned to minimise the creation of unintended risks.

Caring for people with dementia in their own homes: homecare workers' experiences of tolerating and mitigating risk

Little is known about risk management in homecare for people with dementia. We aimed to gain an understanding of the ways in which homecare workers assess and manage risk whilst caring for people with dementia in their own homes. We conducted a qualitative interview study with 17 homecare workers assisting people with dementia with their personal care. Interviews were face-to-face, semi-structured, recorded and transcribed verbatim. Analysis was inductive and thematic. A key theme of risk was identified, with three main sources: the client as a source of risk to the homecare worker, the clients' home and behaviours as a risk to the client, and the wider health and social care system as a risk to both clients and homecare workers. Three interrelated aspects of risk were found to influence homecare workers' decision making and actions: homecare workers' perception of the level of risk, their perceived ability to control the risk and their tolerability of risk. The higher the perceived risk, the stronger the action taken by the worker or agency to mitigate it and the greater the impact on the client. To support effective development of this workforce there is a need to devise training that incorporates the use of tacit knowledge and experiential learning. Risk management policies for homecare should acknowledge and utilise the expertise, experiences and values of homecare workers.

Home-care workers' experiences of assisting people with dementia with their personal care: A qualitative interview study

Home-care workers are increasingly caring for clients living with dementia. Workers usually have limited dementia training and are low paid and often lone working. Little is known about how home-care workers assist people with dementia with their personal care. We aimed to explore the experiences of home-care workers and the knowledge and skills they rely on when providing personal care to people with dementia. In 2020, we conducted 17 semi-structured, face-to-face interviews with home-care workers in the East of England. Analysis was inductive and thematic. Two key themes were present in the data: 'structural conditions' and 'clients' dementia-related characteristics'. For each of these, we examined the challenges faced by home-care workers and the strategies they used to manage these challenges. Challenges included time allocation for visits, completing care plan tasks, lone working, communication and understanding, refusals of care, and client behaviours. To mitigate these challenges, home-care workers utilised system support, time management, training and experience and enacted a caring relationship, thought about their approach, and used distraction and communication skills. Workers relied on skills such as, relationship building, team working, observation, communication, decision making and interpersonal sensitivity. They drew on knowledge about the person, the person's needs, their own abilities, company policies and procedures and their role and responsibilities as a home-care worker. Home-care workers had more scope to mitigate client-based challenges by adapting care within client interactions, than to manage structural challenges where there was a limit to what workers could do. Despite a commissioning focus on time- and task-based care, when caring for people with dementia, home-care workers used interaction as a way to bring the person along and complete care activities. Home-care services should acknowledge the importance of interactions with people with dementia within home care and support their workers to develop interpersonal sensitivity.

Right at Home: Living with Dementia and Multimorbidities

Dementia is recognised as the biggest health crisis of our time in terms of high personal and social costs and wider impact on health and social care systems. Increases in people living with dementia and multimorbidities presents critical challenges for homecare worldwide. Healthcare systems struggle to provide adequate home-care services, delivering limited care restricted to a single-condition focus. This study explored the experiences and expectations of homecare from the multiple perspectives of people living with dementia and multimorbidities and homecare workers providing support. Findings draw from qualititative semi-structured interviews with people with dementia (n=2), their partners (n=2), other partners or family carers (n=6) and homecare workers (n=26). Three themes are idenfiifed: (a) the preference for and value of home; (b) inadequate homecare provision and enhanced care-burden; (c) limited training and education. Despite continued calls for homecare investment, the focus on reduction in costs hides key questions and further dialogue required exploring how people with dementia can be supported to live independendently and flourish at-home. This study considers these complex experiences and care requirements through the prism of disability and human rights frameworks. This paper concludes with consideration of more recent human social rights debate. We critically dicuss what this may mean for people living with dementia and consider the implications for corequisite policy development to optimise available homecare support.

Accessing community dementia care services in Ireland: Emotional barriers for caregivers

Despite the benefits of utilising community-based care services (CBS) for people with dementia and their caregiver being well established, people with dementia and caregivers use fewer services in comparison to other people in need of care. While societal, cultural and logistical factors effecting caregiver use of CBS are frequently studied, research of internal emotional barriers, mental limitations created by one's own self that prevents open communication of thoughts and feelings, and their effect on CBS use is limited. This paper explores internal emotional barriers on caregivers' use of CBS within the Irish Healthcare System. Professional Healthcare Providers were also interviewed as a preliminary indicator of their awareness of these internal emotional barriers and their impact on caregivers' use of CBS. Using interpretive description methodology, interviews with 20 caregivers and fourteen dementia professional healthcare providers were transcribed and a thematic analysis methodology applied to illuminate themes/patterns within participants' subjective perceptions of caregivers emotional barriers to using CBS. Four themes emerge: reluctance to question general practitioner (GP) authority; embarrassment during level of care requirement reviews; sense of obligation to provide all care; and fear of stigma. Caregivers interviewed were reluctant to communicate concerns with professional healthcare providers (PHPs), thereby reducing the PHP's awareness of these barriers and delaying/preventing use of CBS. As key gatekeepers within the care pathway, GPs should address the uneven power dynamic with the caregiver through user-centred models of care, which actively encourage open dialogue, and receive training to identify the indicative behaviours of internal emotional barriers and empower the caregiver to communicate their feelings/concerns directly.

Confronting power in low places: historical analysis of medical dominance and role-boundary negotiation between health professions in Nigeria

Introduction

Interprofessional interaction is intrinsic to health service delivery and forms the basis of task-shifting and task-sharing policies to address human resources for health challenges. But while interprofessional interaction can be collaborative, professional hierarchies and discipline-specific patterns of socialisation can result in unhealthy rivalry and conflicts which disrupt health system functioning. A better understanding of interprofessional dynamics is necessary to avoid such negative consequences. We, therefore, conducted a historical analysis of interprofessional interactions and role-boundary negotiations between health professions in Nigeria.

Methods

We conducted a review of both published and grey literature to provide historical accounts and enable policy tracing of reforms related to interprofessional interactions. We used Nancarrow and Borthwick’s typology for thematic analysis and used medical dominance and negotiated order theories to offer explanations of the conditions that facilitated or constrained interprofessional collaboration.

Results

Despite an overall context of medical dominance, we found evidence of professional power changes (dynamics) and role-boundary shifts between health professions. These shifts occurred in different directions, but shifts between professions that are at different power gradients were more likely to be non-negotiable or conflictual. Conditions that facilitated consensual role-boundary shifts included the feasibility of simultaneous upward expansion of roles for all professions and the extent to which the delegating profession was in charge of role delegation. While the introduction of new medical diagnostic technology opened up occupational vacancies which facilitated consensual role-boundary change in some cases, it constrained professional collaboration in others.

Conclusions

Health workforce governance can contribute to better functioning of health systems and voiding dysfunctional interprofessional relations if the human resource for health interventions are informed by contextual understanding (informed by comparative institutional and health systems research) of conditions that facilitate or constrain effective interprofessional collaboration.

Facilitating inter-professional integration in palliative care: A service ecosystem perspective

A paradigm shift toward healthcare inter-professional collaboration is leading to searches for ways to better facilitate integration. However, policy rhetoric often fails to acknowledge the complexity of healthcare service systems, and the difficulties involved in achieving successful collaborations. Consequently, more research is called for. We utilize the concept of a service ecosystem, a perspective currently prominent in service science, which is transforming the ways service systems are studied. This research aims to examine palliative care provision through a service ecosystem lens in order to uncover previously unidentified insights and opportunities for improvement. The palliative care ecosystem under study encompasses a defined geographical area of the UK. Data comprises pathographies (i.e., narratives of illness) with patients and their families (n = 31) and in-depth interviews with a variety of palliative care providers (n = 21), collected between 2017 and 2018. Capability issues comprising collaboration, coordination, and resource integration, together with communicating value all emerged as common themes impacting palliative care services. Taking a service ecosystem perspective, we also found shared intentionality for better integration and collaboration, with a desire among palliative care providers for the ecosystem's hospice organization to take the role of leader and facilitator. Acting on these findings, we demonstrate the ways new institutional arrangements provide a foundation for value cocreation. We make a contribution to the burgeoning service ecosystem literature which currently lacks empirical insights, particularly in health. We argue that in complex service systems such as healthcare, the focus must be on service design rather than organizational design, approached from the perspective of aggregation of service providers. We demonstrate empirically how reconfiguring resources and developing new institutional arrangements at the meso level can change micro-macro level interaction, enabling the emergence of new and enhanced value cocreation in palliative care.

Constituents of effective support for homecare workers providing care to people with dementia at end of life

OBJECTIVE

The aim of this study was to enhance understanding about homecare workers providing care to people with dementia at end of life by exploring homecare workers' perceptions of challenges and the support they needed and sometimes received.

METHODS

Qualitative semi-structured interviews were conducted with 29 homecare workers and 13 homecare managers in England. Framework analysis was used to analyse the data.

FINDINGS

Four overarching challenges were identified: working with clients with dementia, including clients' sometimes unpredictable responses, communication difficulties, and mood changes; caring for the dying; conflict with family members; and working alone, which often left homecare workers at risk of exhaustion, fatigue, and a sense of isolation. When their work entailed high levels of emotion, such as a client's death or getting embroiled in a client's family conflict, they felt emotionally drained, under-prepared, and overwhelmed. Supportive elements include receiving encouragement and learning from experienced peers and their feelings being acknowledged by managers at their employing homecare agency. Some workers were offered time off or encouraged to attend the client's funeral as a means of supporting the process of bereavement.

CONCLUSIONS

Peer and manager support are essential and effective in coping with work pressures. There is a need to develop models of effective support to alleviate staff's practical, emotional, and interpersonal pressures. However, due to the isolating nature of homecare work, managers may not recognise early signs of their staff finding stress unmanageable and miss the opportunity to mitigate these negative effects.