Comparing and contrasting the role of family carers and nurses in the domestic health care of frail older people

An integrative review on family caregivers' involvement in care of home-dwelling elderly

Often family members provide care-giving, which allows older adults to remain in their homes. With declining health and increasing frailty, care-giving of elderly people becomes a task of family caregivers (FC) in conjunction with home care nurses. It has been shown in both acute care settings and long-term care facilities that family members prefer to be involved in decision-making and care planning for their next of kin. Therefore, an integrative review was conducted to explore the body of knowledge of FCs' involvement in home-care settings from the FCs' perspective. CINAHL, PubMed, and Cochrane databases was searched with the terms family caregiver, involvement, home care, and community dwelling. Studies written in German or English between 1996 and 2017 focusing on FCs' caring for home-dwelling older adults together with home care nurses were included and critically appraised. The extracted findings were analysed with concept analysis method. Twenty-six studies were included and five themes were identified. Four themes formed the basis of assistance towards family caregivers by nurses and included "relationship building with professionals," "negotiating with professional care," "being professionally supported," and "managing role expectations and knowledge sharing". The fifth theme, "working together" described the mutual care for the care recipient. Although the first four themes were consistent with a pre-existing conceptual model by Sims-Gould and Marin-Matthews (2010), the fifth required an expansion of the model with an additional contribution "collaborative practice". The findings illustrate that involvement in care is an interactional process, which provides the basis for collaborative practices with the home care nurses for family caregivers. Family members often want to be part of the healthcare team, and nurses need contextual factors that allow providing their full range of skills and knowledge to involve family caregivers accordingly.

Exploring the collaboration between formal and informal care from the professional perspective-A thematic synthesis

In Dutch policy and at the societal level, informal caregivers are ideally seen as essential team members when creating, together with professionals, co-ordinated support plans for the persons for whom they care. However, collaboration between professionals and informal caregivers is not always effective. This can be explained by the observation that caregivers and professionals have diverse backgrounds and frames of reference regarding providing care. This thematic synthesis sought to examine and understand how professionals experience collaboration with informal caregivers to strengthen the care triad. PubMed, Medline, PsycINFO, Embase, Cochrane/Central and CINAHL were searched systematically until May 2015, using specific key words and inclusion criteria. Twenty-two articles were used for thematic synthesis. Seven themes revealed different reflections by professionals illustrating the complex, multi-faceted and dynamic interface of professionals and informal care. Working in collaboration with informal caregivers requires professionals to adopt a different way of functioning. Specific attention should be paid to the informal caregiver, where the focus now is mainly on the client for whom they care. This is difficult to attain due to different restrictions experienced by professionals on policy and individual levels. Specific guidelines and training for the professionals are necessary in the light of the current policy changes in the Netherlands, where an increased emphasis is placed on informal care structures.

Seeing the collective: family arrangements for care at home for older people with dementia

With the predicted growth in the number of people with dementia living at home across the globe, the need for home-based care is expected to increase. As such, it will be primarily family carers who will provide this crucial support to family members. Designing appropriate support for family carers is thus essential to minimise risks to their health, to prevent premature institutionalisation or poor care for persons with dementia, as well as to sustain the effective functioning of health and social care systems. To date, the high volume of research related to care at home and acknowledged low impact of interventions suggests that a re-examination of the nature of care at home, and how we come to know about it, is necessary if we are to advance strategies that will contribute to better outcomes for families. This paper describes findings from an ethnographic study that was designed to support an analysis of the complexity and materiality of family care arrangements – that is, the significance of the actual physical, technological and institutional elements shaping care-giving situations. In this paper, we describe the arrangements made by one family to show the necessary collectivity of these arrangements, and the consequences of the formal care system's failure to respond to these.

The Importance of Trust in Successful Home Visit Programs for Older People

Outcomes of proactive home visit programs for frail, older people might be influenced by aspects of the caregiver-receiver interaction. We conducted a naturalistic case study to explore the interactional process between a nurse and an older woman during two home visits. Using an ethics of care, we posit that a trusting relationship is pivotal for older people to accept care that is proactively offered to them. Trust can be build when nurses meet the relational needs of older people. Nurses can achieve insight in these needs by exploring older people's value systems and life stories. We argue that a strong focus on older people's relational needs might contribute to success of proactive home visits for frail, older people.

The relatives' voice: how do relatives experience participation in reablement? A qualitative study

BACKGROUND

Reablement is an early and time-limited home-based model of rehabilitation intervention with an emphasis on intensive, goal-oriented, and multidisciplinary assistance for persons experiencing functional decline. When rehabilitation in general takes place in the person's own home, in contrast to an institution, relatives may have larger responsibilities in helping and supporting the family member. Although there is evidence, showing that family caregivers, such as spouses and children, experience burdens and demanding situations related to their caregiving role, there are currently few publications exploring relatives' experiences of participating in reablement. The aim of our study was to explore and describe how relatives in a community setting in Norway experienced participation in the reablement process.

METHODS

Six relatives participated in semi-structured interviews. Qualitative systematic text condensation was used as the analysis strategy.

RESULTS

Five themes emerged that summarized the relatives' experiences with reablement: 1) a wish to give and receive information, wish to be involved; 2) wish to be a resource in reablement process; 3) conflicting expectations; 4) have more free time to themselves; and 5) a lack of follow-up programs.

CONCLUSION

Our findings highlight the involvement and collaborative process between health professionals, older adults, and relatives and have practical significance for health care services. To advance collaborative practices, the municipal health and social care services should consider establishing a system or a routine to foster this collaboration in reablement. Follow-up programs should be included.

Tenerlos En La Casa: The Material World and Craft of Family Caregiving for Relatives With Dementia

The environment has been found to be critical to the well-being of patients with dementia. The purpose of this study was to describe strategies Colombian caregivers used in the home to manage the care of relatives with dementia. Grounded theory techniques were used. Interviews were conducted in Medellín, Colombia, with 18 primary caregivers and 2 health care professionals. Participant observations were conducted in caregivers’ support groups and homes. Family caregivers rebuilt the environment as the disease progressed to accommodate caregiving and preserve family life. Caring for a relative with dementia is a craft that transforms the material world in which patient and caregiver live. The findings show the value of place-sensitive approaches to the study and practice of caregiving.

Impact of home care management on the involvement of informal caregivers by formal caregivers

This study explores the link between management characteristics of home care agencies and the involvement of informal caregivers in caregiving. Based on a study of policy documents of two agencies and semi-structured interviews with five team managers and 31 formal caregivers, we conclude that, although the importance of involving informal caregivers is emphasized in official documentation, actual contact with informal caregivers is often lacking. Comparison of the work processes of the two agencies shows that contact with informal caregivers and their potential involvement are enhanced by smaller teams, less task division, and clarity about the responsibilities of formal caregivers.

Relationships between nurses and older people within the home: exploring the boundaries of care

AIM

To explore the nature of relationships between nurses and older people within the home and to illuminate the nature and quality of caring boundaries within this setting.

BACKGROUND

Older people are increasingly receiving nursing care in the home. There has been little exploration of the nature of the nurse-older patient relationship within this setting.

METHODS

An ethnographic approach using semi-structured interviews with 16 community nurses and 13 older patients (aged 65 years and over), were undertaken to explore the nature of care relationships within the home setting.

FINDINGS

The study has highlighted the centrality of the location of care and the concept of 'the home' in terms of geographical and metaphorical meanings. Moreover, the study has clearly illuminated the complex nature of relationships and boundary construction from a number of perspectives.

CONCLUSION

As the location of care for older people continues to move closer to home it is crucial that the implicit qualities that are valued within nurse-patient relationships within this context of care, and which contribute to the quality of care, are recognized and made more explicit at the organizational and policy level.

PRACTICE IMPLICATIONS

For nurses working within the home there is a clear impetus to clearly define and articulate the full breadth of their role, the nature of relationships and issues surrounding professional boundary construction within this environment. There is also a need for the core qualities that underpin the receipt of care within the home and the facets of the nurse-patient relationship valued by older people to be fully recognized and accounted for.

Defining roles, relationships, boundaries and participation between elderly people and nurses within the home: an ethnographic study

Recently there has been a marked shift in the location of nursing care in the UK from the hospital setting to the community and more particularly the home, with elderly people identified as key recipients of care in this setting. A number of commentators have highlighted the particular situation of elderly people with regard to care provision, illuminating the often disempowering nature of care interactions between nurses and elderly people. However, although there is clear evidence from a number of settings that care for elderly people has been less than optimal, to date there is little comparable evidence available regarding elderly people's experiences of nursing care within the home environment. Utilising an ethnographic approach, incorporating participant observation and semistructured interviews with nurses and elderly people (aged 65 years and over), the aim of this study was to explore the nature of the care relationship within the home setting. Thirteen elderly people who were receiving nursing care within the home and 16 community nurses within one Primary Care Trust in the UK took part in the study and data were collected over a period of 1 year. Three themes emerged from the data: the location of care; the nature of nurse-patient relationships; and the meaning of health and illness. These offer an account of the ways in which roles and relationships are constructed, negotiated and experienced by nurses and elderly people in the home, illuminating the centrality of relationships between nurses and elderly people in defining the experiences and perceptions of both groups of the quality of care overall. As the location of care continues to move closer to home, it is crucial that the implicit qualities that are valued within nurse-patient relationships in this context are recognised and made more explicit at both the organisational and policy level.

Nurses' and carers' appraisals of workload in care of frail elderly awaiting nursing home placement

AIM

The aim of this study is to describe carers' and nurses' appraisals of workload in care of frail elderly awaiting nursing home (NH) placement.

BACKGROUND

Carers' workload of care for frail elderly awaiting NH placement has been studied separately from that of nurses' workload. The literature neither addressed a comparison of carers' and nurses' appraisals of psychological and physical workloads nor the most strenuous factors common to the workloads of both nurses and carers in care of the same elderly person. The terms 'carers' and 'nurses' in this paper refer to informal caregivers and to both enrolled nurses and Registered Nurses respectively, when no particular one is stated.

METHOD

The sample comprised 11 nurses and 11 carers paired based on care provided to the same elderly person awaiting NH placement in Norway. Data collected by a workload-scale was analyzed by descriptive statistics. Data collected by individual interviews were analyzed by qualitative content analysis. Carers' and nurses' appraisals of workload were compared and contrasted and most strenuous factors described.

FINDINGS

The findings show that both carers and nurses rated workload levels maximum. Carers' highest ratings concerned psychological workload, while nurses' highest ratings concerned physical workload. The workload ratings concerning elderly with advanced dementia disease were most similarly aligned. Qualitative content analysis showed three categories that describe the most strenuous factors common to the workloads of both carers and nurses. These were feeling responsible, burdened and ambivalent.

CONCLUSION

This study reports carers' and nurses' appraisals of workload in care of frail elderly awaiting NH placement. The results show many similarities and some differences. These results may help guide policy development to address resource allocations to elderly care. Further research is needed to address workloads of care for elderly awaiting NH placement.

A critical examination of home care: end of life care as an illustrative case

Drawing on end of life care as an illustrative case, this paper critically examines the provision of care in the home, identifying a number of inherent tensions. For 60 years the hospital has been the preferred site of care. However, the UK caring division of labour is currently undergoing a process of (re)domestication and the provision of home care is increasingly regarded as a 'gold standard' for the organisation of care, in institutional and domestic contexts. In this paper we argue that while 'home care' policies serve a range of professional and political agendas, they contain unacknowledged contradictions and strains, creating challenges for both family and professional carers. The realities of home care are examined through reconceptualising qualitative data generated from three research projects concerned with dying in the community. We argue that, whilst previous work has highlighted the burdens the redomestication of care places upon carers, home care philosophies and policies have led to over-romanticised notions of care which privilege the value of caring relationships without acknowledging the dynamic interaction of such social relationships with the actual work of caring. Moreover, such policy trends have created a nexus of social expectations and obligations for which modern society is unprepared. With reference to both end of life care, and home care more widely, we argue that health care planners and professionals need to think more critically about the way care is delivered. Home is not merely about a physical space, but the social and emotional relationships therein. Good 'home care,' characterised by attention to patient-centred needs and flexible in design and scope, does not have to be located within the private sphere; relationships may actually be maintained and nurtured by enabling people to have a realistic choice of care in an institution.

What do informal carers need from district nursing services?

More than 5 million informal carers provide support to individuals who wish to remain within their own homes. The role of informal carers in maintaining people within their own homes has been identified as crucial. This article considers the assessment of need of informal carers in the primary care setting, placing particular emphasis on the role of the district nurse as an advocate for informal carers when working with other health and social care service providers. Central to working with informal carers and acting as an advocate is communication, and unless informal carers feel that they are involved in the decision-making process, and listened to, they are unlikely to access appropriate support.

Working in partnership with adult informal carers: policy and practice

In England and Wales alone, more than 5 million informal carers provide support to individuals who wish to remain within their own homes. However, research has identified that there is a limited understanding of the informal carer role among health professionals, and deficits in information sharing and the involvement of informal carers in decision making in relation to care packages. This article considers recent policy relating to this area, placing particular emphasis on the role of the district nurse in working in partnership with informal carers.

Exploring the significance of place in community nursing

There has been a dramatic shift in emphasis in health care in the UK in recent years towards the community setting. Care for someone in his or her own home takes place in a different context from caring for them in hospital, and requires a different approach. This article highlights a number of issues raised by this change, and suggests that there needs to be a focused effort to understand the impact of these issues on practice.

Early recognition of dementia by nurses

BACKGROUND

Early recognition of dementia is a key policy objective designed to maximize the efficacy of treatment and to provide timely and appropriate support before crisis occurs. The impact of early recognition of dementia is under-researched in primary care nursing.

AIM

To explore whether community mental health nurses (CMHNs), community nurses (CNs) and practice nurses (PNs) have different perspectives on early diagnosis of dementia and to consider the possible effects of any variation.

METHOD

Data are drawn from questionnaires completed by CMHNs (79), CNs (153) and PNs (36) who attended workshops offered on 24 occasions in 21 settings across the United Kingdom. The workshops attracted a range of primary care practitioners and were part of a training programme on early diagnosis of dementia.

RESULTS

Analysis of the data shows some differences in knowledge, experience and confidence between the three nurse groups. CMHNs were more confident in their abilities to recognize dementia and found providing support less difficult than CNs and PNs. CMHNs considered that they were best placed to co-ordinate services for people with newly recognized dementia. CNs and PNs, however, reported experience of working with people with dementia and many appeared able to respond to early signs and to identify potential sources of support.

CONCLUSIONS

While CMHNs may have a key role in responding effectively to the newly identified needs of people with early dementia, other nurses working in the community are likely to encounter people with early dementia. In the context of a policy objective to identify people with dementia earlier, all community-based nurses should be able to recognize the possibility of dementia and support those undergoing referral or assessment. Their confidence in doing so should be enhanced by continued professional development. Training in dementia recognition, involvement in and membership of primary care teams supporting people with dementia should not be confined to CMHNs. Nurses who regularly encounter the general population of older people may be well placed to provide continuity of support for those who may, or may not, have cause to suspect that they or their relatives have early dementia.

The essence of 'community' within community nursing: a district nursing perspective

Over the past decade or so, there has been a marked shift in the location and nature of nursing care from the hospital setting to primary and community care. The past decade has also witnessed the development of a number of policy initiatives which indicate that the drive towards the community as a key location of nursing care is set to continue. Although notions of community have been explored extensively within the literature from a number of perspectives, there is an absence of a clear definition, and more particularly for the purposes of the present study, one from a nursing perspective. This lack of conceptual clarity is further compounded when notions of community and the place of nursing within the community are considered contemporaneously. The present pilot study, which was based on semi-structured interviews with district nurses, seeks to address this deficit and explore how district nurses define the nature of their role, both in terms of providing nursing care within the community and also in terms of defining community within the context of their work. The study illuminates the principal position of the home in defining the essence of community within community nursing and notions surrounding the nature of relationships which exist within this setting. This is highlighted through the identification of emerging themes: the maintenance of personal-professional boundaries, notions of holistic care and professional definitions of community. These observations raise important questions regarding the extent to which the location of care and the taken-for-granted assumptions surrounding community-based nursing care have been translated into practice to date. This also raises key issues regarding the tensions which exist for nurses trying to balance notions of community and community-based care within the parameters of organisational and professional boundaries.