Social aspects of caregiving for people living with motor neurone disease: Their relationships to carer well-being

Factors to consider for motor neurone disease carer intervention research: A narrative literature review

OBJECTIVE

The experience of caregiving in the context of motor neurone disease (MND) is extremely challenging. Over the past 15 years, quantitative and qualitative studies have delineated the psychosocial aspects of this experience, exploring its impact on caregivers' quality of life, rates of depression, distress, anxiety, and burden. Our paper aimed to provide an overview of the lived experience of MND caregivers, identifying the variables that can influence MND caregiver functioning that are relevant to the development of an intervention.

METHOD

A narrative review was conducted, synthesizing the findings of literature retrieved from 2000 to early 2016.

RESULTS

A total of 37 articles were included in the review. The articles varied considerably in terms of methodology and quality. The main influential aspects reported and identified were factors pertaining to the patient, factors intrinsic to the caregiver, relationship factors, and social support factors.

SIGNIFICANCE OF RESULTS

There is evidence to support the fact that caregivers have poorer outcomes when they care for patients with a more severe clinical profile, poorer emotional health or neurobehavioral concerns, or when the caregivers themselves struggle with adaptive problem-solving and coping skills. The availability and use of social support are also likely to be important for caregiver psychosocial outcomes. Further investigation is required to clarify the influence of changes in the relationship with the patient. Significant factors affecting the caregiver experience are considered in relation to their amenability to psychosocial intervention. Recommendations are made regarding the optimal features of future psychosocial intervention research.

Occupational Disruption: Living with Motor Neurone Disease

Little is known of the day-to-day experience of living with motor neurone disease from the perspective of those who have it, apart from what can be found in personal accounts such as those published on web pages. In this study, which was informed by phenomenology, seven people living in an urban setting in New Zealand were asked to describe their experiences.

This report focuses on the study findings that related specifically to disruption to occupation. It describes how early changes in occupational performance alerted the participants to the fact that something was wrong. The findings also showed the pervasive impact of an awkward and unreliable body on participation in occupations that gave meaning to life, expressed identity and filled time. Issues of how the family's world was changed, the introduction of assistive devices into their homes and the betrayal of trust were also powerfully evident in participants' stories.

Although the findings are broadly consistent with those of previous studies, the disruption to occupation and the consequent role losses are new findings. Further research into the impact of the loss of participation in occupation, the ways in which people are perceived when occupations are disrupted and the experience of having occupations taken away prematurely is recommended.

A 10-year literature review of family caregiving for motor neurone disease: moving from caregiver burden studies to palliative care interventions

BACKGROUND

There is growing awareness that different terminal diseases translate into different family caregiver experiences, and the palliative and supportive care needs of these families are both similar and unique. Family members caring for people with motor neurone disease may experience exceptional strain due to the usually rapid and progressive nature of this terminal illness.

AIM

The purpose of this review is to synthesize contemporary research and provide a comprehensive summary of findings relevant to motor neurone disease family caregivers, as well as highlight some of the suggested interventions to alleviate burden and improve quality of life for this group.

DESIGN

We conducted a comprehensive review of empirical research on family caregiving for people with motor neurone disease in peer-reviewed journals published in English, January 2000-April 2011. Fifty-nine studies met the inclusion criteria.

RESULTS

This comprehensive literature review was consistent with previous research documenting the substantial burden and distress experienced by motor neurone disease family caregivers and revealed important points in the trajectory of care that have the potential for negative effects. The diagnosis experience, assisted ventilation, cognitive changes and end-of-life decision making create challenges within a short time. This review has also implicated the need for improvements in access to palliative care services and highlighted the absence of interventions to improve care.

CONCLUSIONS

Caregiver burden and quality-of-life studies on motor neurone disease family caregivers have so far dominated the research landscape .The focus needs to be on developing interventions that provide direct practical and psychosocial supports for motor neurone disease family caregivers.

What are the roles of carers in decision-making for amyotrophic lateral sclerosis multidisciplinary care?

PURPOSE

Family carers of patients with amyotrophic lateral sclerosis (ALS) are presumed to have frequent involvement in decision-making for symptom management and quality of life. To better understand and improve decision-making, we investigated the range and extent of carer participation in decision-making. By focusing on the perspectives of ALS support carers, the study aimed to explore carer participation in decision-making, to identify carer roles, and determine the facilitators and barriers to carer participation in decision-making for ALS multidisciplinary care.

PARTICIPANTS AND METHODS

An exploratory, in-depth study was conducted with eight carers of ALS patients from two specialized ALS multidisciplinary clinics. Carers participated in semi-structured interviews that were audio recorded and transcribed then coded and analyzed for emergent themes.

RESULTS

Carers made a significant contribution to ALS decision-making. Their roles were: promoting the patient voice, promoting patient health literacy, and providing emotional support and logistical assistance. Facilitators of carer participation in decision-making were perceived to be: health professional endorsement of patients' decision-making style; access to credible information sources; evidence-based information from the ALS clinic, ALS support association, and health practitioners; supportive relationships with family and friends; spiritual faith; ease of contact with ALS services; and availability of physical and practical support for carers. Barriers to carer participation included: changes to patient communication and cognition; conflict between respect for patients' independence and patients' best interest; communication breakdown between patient, carer, and service providers; the confronting nature of disease information; credibility of Internet sites; carer coping strategies; lack of support for the carer; and the burden of care.

CONCLUSION

Carers enhance ALS patient-centered care through their participation in decision-making. They collaborate with patients and health professionals to form a decision-making triad within specialized multidisciplinary ALS clinical care. Nevertheless, health professional engagement with carers as collaborative partners is acknowledged to be a significant challenge.

The personal experience of partners of individuals with motor neuron disease

Most research on partners' experiences of living with a person with MND is questionnaire-based with no qualitative study focusing on the period between diagnosis and end-of-life care. This study aimed to provide an in-depth qualitative exploration of the experience of living with, and caring for, a partner with MND. Semi-structured interviews were conducted with eight individuals, and transcripts analysed from an interpretative phenomenological perspective. Two main themes were derived. 'Impact on life' included having concern for partner's safety, having social restrictions, being continually tired, struggling with anger and frustration, loss of intimacy and uncertainty around the future; while 'Adjusting to the situation' included trying to be strong, retaining a sense of normality, appreciation of specialist services, adopting a problem-solving approach, living day to day and ability to remain positive. In conclusion, experiences of stress and loss are illustrated in this sample of partners of those with MND, and it is suggested both these aspects should be integrated into understanding of carers' experiences. Carers appear to inhibit their grief in order to appear strong. Greater understanding of the consequences of this would help in providing appropriate emotional support.

The need for support services for family carers of people with motor neurone disease (MND): views of current and former family caregivers a qualitative study

PURPOSE

Family carers provide the majority of home-based care for people with motor neurone disease (MND). Carers' need for, and use of, support services are not fully understood; this study aimed to explore, from a qualitative perspective, the views of current and former family carers of people with MND.

METHODS

A qualitative study was undertaken in Northwest England, using narrative interviews with current (18) and former (10) carers of a family member with MND. An optional longitudinal element involving diary completion was offered to the current carers. Data were analyzed using a thematic framework approach.

RESULTS

Carer's needs vary, but encompass the provision of information and training, availability of respite care, counselling, and access to trained paid-for carers.

CONCLUSIONS

There is need for a range of support services to be made available from which carers can select those most appropriate for them. Some support services are not always available for carers of this client group. There is a need for carers to access greater manual handling and training for physical care. Without sufficient support, carer burden can be overwhelming which may impact on the place of care of the patient and ultimately has implications for health and social care services.

The reliability, validity and feasibility of tools used to screen for caregiver burden: a systematic review

OBJECTIVE

The overall objective of this review is to quantitatively measure the psychometric properties and the feasibility of caregiver burden screening tools. The more specific objectives were to determine the reliability, validity as well as feasibility of tools that are used to screen for caregiver burden and strain.

INCLUSION CRITERIA

This review considered international quantitative research papers that addressed the psychometric properties and feasibility of caregiver burden screening tools.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies from 1980-2007 published only in the English language. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract and the index terms used to describe the article. A second search identified keywords and index terms across major databases. Third, the reference list of identified reports and articles was searched for additional studies.

METHODOLOGICAL QUALITY

Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appropriate critical appraisal instrument from the Joanna Briggs Institutes' System for the Unified Management, Assessment and Review (SUMARI) package.

LIMITATIONS

Because burden is a multidimensional construct defined internationally with a multitude of other terms, only those studies whose title, abstract or keywords contained the search terminology developed for this review were identified for retrieval.

RESULTS

The construct of caregiver burden is not standardized, and many terms are used to describe burden. A caregiver is also identified as a carer. Instruments exist in multiple languages and have been tested in multiple populations. A total of 112 papers, experimental and non-experimental in nature, were included in the review. The majority of papers were non-experimental studies that tested or used a caregiver burden screening tool. Because of the nature of these papers, a meta-analysis of the results was not possible. Instead a table is used to depict the 74 caregiver burden screening tools that meet the psychometric and feasibility standards of this review. The Zarit Burden Interview (ZBI), in particular the 22-item version, has been examined the most throughout the literature. In addition to its sound psychometric properties, the ZBI has been widely used across languages and cultures.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The significant amount of research that has already been done on psychometric testing of caregiver burden tools has provided a solid foundation for additional research. Although some tools have been well tested, many tools have published limited psychometric properties and feasibility data. The clinician needs to be aware of this and may need to team up with a researcher to obtain additional research data on their specific population before using a minimally tested caregiver burden screening tool. Because caregiver burden is multidimensional and many different terms are used to describe burden, both the clinician and researcher need to be precise in their selection of the appropriate tool for their work.

Caregiver bodywork: family members' experiences of caring for a person with motor neurone disease

AIM

This paper reports a study of how family members caring for people living with motor neurone disease managed the deteriorating body, their own bodywork and the associated emotional labour.

BACKGROUND

People living with the neurodegenerative condition of motor neurone disease face the prospect of dying in 3-5 years from progressive loss of voluntary muscle mass and function, culminating in respiratory failure. Theories concerning the body in illness have been used to illustrate patient perspectives; however, family caregivers' experiences of the body have been neglected.

METHOD

An ethnographic case study was undertaken with 18 primary family caregivers and six peripheral caregivers. Primary caregivers participated over 10 months in three face-to-face, semi-structured interviews which included mapping their support networks using ecomaps. Observational data were also recorded as field notes. Peripheral caregivers were interviewed once during the same time period. The data were generated between 2003 and 2004.

FINDINGS

Informal caregiving requires engagement in various aspects of bodywork. Three body concepts were identified: the visible body--how the disease affected the patient and caregivers; the dependent body--the resulting care requirements; and the social body--how living with motor neurone disease affected their social support networks. The visible body is a continual reminder of the ravages of the disease, while the dependent body demands physical and emotional care. Social interactions decline over time, depriving family caregivers of the much needed support for sustaining their commitment to the bodywork required in caregiving.

CONCLUSION

The demands of bodywork for family caregivers are increased by the continual presence of emotional labour as they seek to implement the best way to support their relative with motor neurone disease. Nurses and allied healthcare workers need to assess each family situation, asking appropriate questions to establish the most appropriate interventions to facilitate supportive care.

Non-finite loss and emotional labour: family caregivers? experiences of living with motor neurone disease

AIM AND OBJECTIVES

This paper aims to add to nurses' knowledge concerning the losses and emotional labour family caregivers face caring for people living with neurodegenerative, life-limiting illnesses such as motor neurone disease.

BACKGROUND

Motor neurone disease is a relentless, progressive illness resulting in progressive loss of voluntary muscle mass and function. Previous caregiver research presents the salient losses such as social, financial and relationship loss. However, the non-finite, unpredictable losses faced every day by caregivers and the emotional labour experienced are not effectively represented and have not been explored for caregivers of adult patients with life-limiting, degenerative, illness.

DESIGN/METHODS

Semi-structured interviews, ecomaps of social support networks and field notes were used to collect data for this ethnographic case study. Data were attained at three time points over a 10-month period from 18 primary caregivers and once from six peripheral caregivers.

RESULTS

Data revealed new information about the psychosocial and emotional losses experienced daily, when living with motor neurone disease. The impact of the constancy of voluntary muscle degeneration and the uncertainty of the illness progression in terms of available time and functional loss, threatened people's understanding and expectations of life, their relationships, their personal identity and their future. Managing their relationship with the patient and their reactions to the devastation of motor neurone disease is consistent with the concept of emotional labour.

CONCLUSIONS

Family caregivers living with relentless, life-limiting illness experience non-finite losses and emotional labour on a daily basis. While each individual's experience of loss is unique, nurses need to include caregivers as well as patients, in their spectrum of supportive care.

RELEVANCE TO CLINICAL PRACTICE

Nurses can be independent confidants who share the emotional labour and work with caregivers to develop interventions to assist them to manage their losses and their changing needs for psychological and emotional support.

Who's there and who cares: age as an indicator of social support networks for caregivers among people living with motor neurone disease

This paper explores the social support networks available to the informal carers of people living with motor neurone disease (MND). An ethnographic case study was undertaken using eco mapping, observation and conversational interviews to collect data from 18 primary carers of people living with MND. Interviews took place in participants' homes in metropolitan, regional and rural locations. Participants discussed the content of their support network and drew lines between individuals to indicate the type and strength of relationship. Changes to the network were depicted on eco maps during subsequent interviews. While health policy-makers assume that healthy social capital exists in Australian communities and that social cohesion will ensure active and available support networks in times of illness or disability, data from this exploratory study indicated that this was not consistently the case. Support networks varied in size and composition; however, age was identified as a discriminator of the availability and consistency of support. People in older age groups identified more diverse but consistent support systems while people in younger age groups reported more fluctuations in the strength of relationships and declines in support as caregiving became more demanding. Individual assessment of support networks at regular intervals in the caregiving trajectory is vital for all carers. However carers in younger age groups may need specific support to manage the psychological crises that occur and more access to paid care. Older carers may need consistent support to handle more of the instrumental aspects of care and assistance to mobilise their support networks. Community workers should be alert to the possible need for crisis intervention when tensions in relationships threaten carers' ability to provide effective care.