Facing the issue of dependence: some implications from the literature for the hospice and hospice nurses

Adaptation to care dependency in community care

Purpose

The purpose of this paper is to explore the lived experiences of adapting to care dependency among adults receiving health and social care in ordinary housing.

Design/methodology/approach

This was done by conducting a phenomenological study by interviewing ten adults, receiving home care services in ordinary housing.

Findings

Participants not only adapted by becoming a “good patient” but they had four strategies they used: sociability, distance, competence and compliance, contributing to a sense of dignity and personal safety.

Research limitations/implications

Further research is needed regarding how to preserve quality of care with adults with various ways of adapting to care dependency.

Practical implications

The relationship between professionals and adults in care dependency is a dynamic process where a need for understanding different modes of adaptation is vital. Good treatment and quality care may be different things to different adults, depending on what aspects of the process of adaptation concern them the most, and depending on their individual adaptation strategy.

Originality/value

This paper contributes to the understanding of modes of adaptation to care dependency from the perspective of adults indicating that working person centered may include respecting strategies not traditionally being associated with “the good patient.”

Responsiveness of the Care Dependency Scale for Rehabilitation (CDS-R)

Around 10% of Western Europe's population suffer from a disability which can entail a decrease of independency and quality of life. However, the lives of these people can be improved by rehabilitative treatment and care. Changing the degree of dependency from dependent to independent is essential in rehabilitation, as is the assessment of these changes. To perform such kind of measurements, assessment instruments have to be responsive. In spite of this concern, responsiveness of assessment instruments is studied to a small extent only. This also applies to the Care Dependency Scale for Rehabilitation (CDS-R), a short assessment instrument measuring the care dependency of patients regarding physical and psychosocial aspects. In this longitudinal-study, the responsiveness of the CDS-R, in general and related to different disease-groups, should be determined. Therefore, a convenience sample of 1564 patients was assessed in an Austrian rehabilitation centre with the scale after admission and before discharge. Responsiveness was determined by descriptive analysis, calculation of effect-sizes and significance tests. Differences between admission and discharge occurred on a statistically significant level for patients who changed. Kazis' effect-sizes can be considered as of small/medium effect for patients who changed (0.24/0.49), and as of large effect according to Liang (0.86/1.46). Eta squared was 0.10/0.19 which can be interpreted as of moderate/large effect for patients who changed. Responsiveness-analyses related to different disease-groups showed constantly large effect-sizes for patients with musculoskeletal-disorders. These results indicate that the CDS-R can detect patient-changes over time and discriminate between patients who change under rehabilitation or not. These aspects argue for the responsiveness of the scale, wherefore the CDS-R seems to be appropriate for the assessment of treatment/health-care effectiveness and the evaluation of individual patient-changes. Nevertheless further research is recommended to confirm the level of responsiveness of the scale in general and for different disease-groups.

Health care staff's opinions about existential issues among patients with cancer

Objective:

The objective of this study was to explore health care staff's opinions about what existential issues are important to patients with cancer and staff's responsibility when existential issues are raised by patients.

Method:

Four focus group interviews were conducted with health care staff (N = 23) at an in-patient hospice, on an oncology ward, on a surgical ward, and with a palliative home health care team. The focus group interviews focused on two questions, first, about health care staff's opinions about patients' important existential questions and, second, about health care staff's responsibility when existential issues are raised by the patient. The interviews were taperecorded, transcribed verbatim, and analyzed by qualitative content analysis into subcategories and categories.

Results:

Four categories and 11 subcategories emerged from the first question. The first category, “life and death,” was based on joy of living and thoughts of dying. The second category “meaning,” consisted of acceptance, reevaluation, hope, and faith. The third category, “freedom of choice,” consisted of responsibility and integrity, and the fourth and last category, “relationships and solitude,” consisted of alleviation, dependency, and loss. One category emerged from the second question about the health care staff's responsibility, “to achieve an encounter,” which was based on the subcategories time and space, attitudes, and invitation and confirmation.

Significance of results:

One strength of this study was that the findings were fairly congruent in different settings and in different geographical areas. Health care staff were aware of the importance of existential issues to patients. The existential issues, mentioned by health care staff, are similar to findings from studies conducted among patients, which is another strength of the present study. Health care staff are also confident about how to act when these issues are raised by the patients. The challenge for the future is to implement the findings from this study among health care staff in different settings.

Care Dependence

The purpose of this study was to describe people's experiences of being dependent on others for care in their final stage of life, as well as what they felt made their experience of being dependent easier or more difficult. The phenomenological-hermeneutical method was chosen, where data collection consisted of open-ended interviews with nine people undergoing palliative care at a hospice unit or at home. The meaning of being care dependent is described via the following themes: changed relationship with oneself and with others, striving to adapt oneself to the situation, obstacles, and opportunities along the way while dependent. The result is described as an effort, a journey from independence to moments where it was possible to rest and recuperate while struggling with care dependency. Nursing staff require knowledge and understanding of experiences with care dependency to make life easier for people during increasing dependency in the final stage of life.

Care dependency of children in Egypt

AIMS

This study aimed to modify the Care Dependency Scale so that it could be used for children, to apply its Arabic version to Egyptian children to test the reliability and validity of the modified scale and to compare the care dependency of disabled and non-disabled Egyptian children.

BACKGROUND

A higher dependence of children in their daily tasks undoubtedly places a greater burden on their caregivers. To estimate the extent of the problem of care dependency, data from different countries and proper standard instruments are required.

METHOD

The Care Dependency Scale was modified for children by Delphi technique. This study assessed the care dependency of non-disabled children compared with children with physical and mental disabilities using the modified version of the Care Dependency Scale for paediatrics. The total sample included 260 Egyptian school-age children (50.8% of whom were disabled and 49.2% were non-disabled).

RESULTS

Reliability was examined in terms of internal consistency using Cronbach's alpha (0.91). Inter-rater reliability revealed moderate to very good Kappa statistics between 0.57-0.89. Content validity and criterion validity were evaluated. Differences regarding care dependency were found between disabled and non-disabled children.

CONCLUSION

The psychometric properties of the Care Dependency Scale for paediatrics support its usefulness in measuring the care dependency of children in Egypt. This study provides an Arabic version of the Care Dependency Scale for paediatrics that is easy to administer and may be useful to measure the care dependency in various Arabic countries.

RELEVANCE TO CLINICAL PRACTICE

The findings raise concerns regarding the extent to which disabled and also non-disabled school-age children are care dependent leading to an increased burden of care on nurses or on caregivers in general. The Care Dependency Scale for Paediatrics can help nurses conduct an appropriate assessment of children's care dependency so that any nursing care can be planned according to the children's needs.

Evaluating the impact of a cancer supportive care project in the community: patient and professional configurations of need

Advances in cancer care and treatment have created a new and somewhat anomalous category of patients with a diagnosis of non-curative disease who still have a considerable period of life remaining. During much of this time they may remain relatively well, without manifest need for clinical care. The responses of patients to this challenging situation are largely unknown. However, it has been assumed that because they confront a difficult experience they will need, or can benefit from, professional intervention. The implementation of pre-emptive support measures is anticipated to improve patients' resilience in coping with their illness and approaching death. This study aimed to investigate the impact of the keyworker role in a 3-year cancer supportive community care project to identify and provide for the needs of patients with a diagnosis of non-curative cancer. It was a qualitative study incorporating face-to-face interviews and focus groups with 19 healthcare professionals and 25 patients and carers from an urban East Midlands locality and a thematic analysis of qualitative interview and focus group transcripts. The project was positively evaluated by patients, carers and professionals. However, the findings raised questions about the different configuration of 'need' within the lay and professional perspectives and how this should most appropriately be addressed. In contrast to widespread professional assumptions about patients' need for counselling, many patients preferred to turn to their friends and families for support, and to adopt a stance of emotional and personal self-reliance as a strategy for coping with their predicament. The study highlights the continuing orientation of services around professional, rather than patient, agendas and the momentum towards increasing specialisation of professional roles and the medicalisation of everyday life that flows from this.

Care dependency among school-aged children: Literature review

Many disabilities and chronic illnesses of children result in those children being dependent on their caregivers. The higher dependence of children in their daily tasks undoubtedly places a greater burden on their caregivers and on care-providers in the health-care system, especially nurses. The objectives were to gain an overview of the literature dealing with care dependency among children and the factors possibly influencing their dependency on care, and to obtain instruments for measuring children's care dependency. MEDLINE, CINAHL, and PsychINFO were searched for different publications from 1995 to 2005. The literature reveals four categories of factors associated with care dependency of the child. With respect to instruments, a variety of instruments were identified but most of them were restricted to children with specific health conditions. For this reason, the paper suggests the development of a new instrument for assessing children's care dependency that is applicable to healthy children.

Nurses' and patients' perceptions of expert palliative nursing care

AIM

This paper reports a study of the perceptions of patients and nurses of palliative care and, in particular, the concept of the expert palliative nurse.

BACKGROUND

Palliative care is a growing specialty and is practised globally. There is, however, limited information on patients' views about palliative care. While the idea of expertise in nursing is not new, few studies have explored the concept of the expert nurse in palliative care. Some evidence exists on palliative nurses' perceptions of their care, that it is supportive and involves maintaining therapeutic relationships with patients. Facing a terminal illness has been identified as a stressful and fearful experience that affects all aspects of life. It has also been revealed that dying patients may have unmet care needs, mainly in the areas of pain and symptom control, emotional support, and spending time alone.

METHODS

A phenomenological study was carried out, using in-depth interviews and thematic content analysis. A convenience sample of 22 Registered Nurses and 22 dying patients was interviewed in 1996-1997.

FINDINGS

Dying patients had a desire to maintain independence and remain in control. Palliative care nurses experienced both effective and ineffective interpersonal communication, the building of therapeutic relationships with dying patients and attempting to control patients' pain and distressing symptoms. Patients and nurses agreed that the two most important characteristics of an expert palliative nurse were interpersonal skills and qualities such as kindness, warmth, compassion and genuineness.

CONCLUSION

Although the study was conducted in the United Kingdom, the findings have relevance for palliative care practice globally in terms of dependence, issues of patient choice, nurses being interpersonally skilled and building therapeutic relationships with patients.

Quality of life in older people with cancer - a gender perspective

The aim of this study was to investigate quality of life (QoL) and its association with sense of coherence (SOC), complaints, comorbidity, social resources, perceived economic situation and receiving help for daily living, investigating differences between women and men aged 75 and above with cancer and comparing women and men aged 75 and above without cancer. A further aim was to identify which of these factors were associated with low QoL in older people with cancer. The sample consisted of women (n = 74) and men (n = 76) with the inclusion criteria aged 75 and above and a cancer disease, and a matched comparison group of women (n = 64) and men (n = 74) without cancer. EORTC QLQ C-30, SF-12 and SOC-13 were used. Women with cancer were more vulnerable than their male counterparts in QoL, SOC, perceived economic situation and social resources. Factors associated with low QoL in older people with cancer were receiving help for daily living, comorbidity, degree of complaints and pain. From a caring perspective the findings suggest a focus on symptoms and treatment, to acquire an understanding of how a cancer disease, comorbidity and various complaints affect QoL and independence in older women and men and to intervene accordingly. It also suggests that socio-economic and social problems and needs influence their treatment and care and therefore should be in focus.

Meaning of dependency on care as narrated by 10 patients

This article is part of an ongoing study that aims to illuminate the meaning of dependency on care. The aim of this particular study is to disclose the meaning of dependency on care as narrated by patients. We conducted interviews with patients (six men and four women) who had been in medical or surgical wards for at least 14 days. Seven of the patients were also interviewed one week after discharge. The participants ranged in age from 41 to 84 years old. The interviews were tape-recorded and transcribed verbatim. A phenomenological-hermeneutic approach was used to interpret the resulting text. The results show that to be dependent on care is to face the inevitability of not being able to manage by oneself--it is being attached to the nurses and bound to the care they offer. Being dependent on care involves a struggle to get care without treading on the nurses' toes. The nurses are one's lifelines and getting care is essential, no matter what. It is better to receive any form of care, good or bad, than to receive nothing. Being dependent on care is to be exposed and subjected to a nurse's ability and benevolence. One comprehensive understanding of the meaning of dependency on care is simply that "one does not saw off the branch one is sitting on." Furthermore, dependency on care involves a struggle to move forward in a life that hurts. Patients lose much of their freedom of choice in daily life and grieve their loss of ability and value. Patients may be able, however, to see things they would have never noticed earlier in life. Dependency on care is understood as one kind of "limit situation." Patients who are dependent on care may reevaluate their potential in life and gain another perspective on life.

Meaning of dependency on care as narrated by nurses

This article is part of an ongoing study aimed at illuminating the meaning of dependency on care. The aim of this particular study is to illuminate the meaning of the phenomenon 'dependency on care' as narrated by nurses. Interviews with 20 nurses were conducted, tape-recorded and transcribed verbatim. A phenomenological-hermeneutic approach was used to interpret the data. The meaning of dependency on care is revealed as laborious for both patients and nurses. The nurses' text discloses that for patients, dependency on care is a miserable loss of self-determination and self-worth. Nurses appear to be moved by dependents' difficult life and want to do whatever they can for the dependent. Dependency on care is a burdensome responsibility for nurses. For nurses dependency on care is revealed as evoking feelings of guilt and insufficiency and of being constantly concerned and worried. It is to struggle to be patient and understanding, having the arduous task of putting oneself into the dependent patients' shoes in order to cope with the demanding task of balancing between helping and not helping too much. The interpretation discloses, however, that nurses distinguish between easy and trying dependency on care. The understanding indicates that when they meet 'good' patients, nurses reappraise the situation, transform it into something new and meaningful, that is dependency on care is disclosed as 'easy to take'. When coming across'difficult' patients dependency on care is disclosed as trying. It seems that within the unique nurse-patient relationship patients may participate in such a way as to facilitate or inhibit nurses in finding meaning in the immediate caregiving situation. Nurses' evaluations of what constitutes a 'good' or a 'difficult' patient, respectively, seem to play an important role in distinguishing between dependency on care that is easy and that which is trying. The result is viewed through an existential paradigm and there is also reflection about what nurses perceive as valuable qualities in patients which might influence the quality of care.

Care dependency: testing the German version of the Care Dependency Scale in nursing homes and on geriatric wards

The purpose of this study was the psychometric evaluation of the German version of the dependency scale in nursing homes and on geriatric wards. The 15-item scale was originally developed in the Netherlands for assessing the care dependency of demented and mentally handicapped patients. Data of 81 nursing home residents and of 115 geriatric patients were collected. Residents and patients were assessed several time by professionals and nonprofessionals. Reliability was determined by Cronbach's alpha, showing very good results with values of 0.94 and 0.98. Inter-rater and intrarater reliability show moderate to substantial Kappa values. Criterion validity was examined by comparing the data of the scale with the German nursing personal regulation and the German statutory insurance. The results show that the scores of the Care Dependency Scale correlate to the scores of the two classifications. In general, the German version of the scale can be recommended for use in nursing homes and on geriatric wards.

The Care Dependency Scale: an assessment instrument for elderly patients in German hospitals

The purpose of the study was to examine aspects of reliability and validity of the German version of the Care Dependency Scale (CDS), a Dutch assessment instrument originally developed for demented and mentally handicapped patients. Data of 1806 patients, 60 years or older from a larger sample, collected in 11 hospitals in Germany, were analyzed. Reliability was determined by Cronbach's alpha, showing a very good result with a value of.98. Criterion related validity was examined by comparing the data of the CDS with the German nursing personal regulation. The scores of the CDS correlate to the scores of the personal regulation. The study shows further that most elders are fairly independent and care dependency increases with age.

Health promotion in palliative care: the patients' perception of therapeutic interaction with the palliative nurse in the primary care setting

AIMS

To identify and describe palliative patients' perception of factors within the interaction with the community palliative care nurse that enhance feelings of health and well-being, and to begin to define health promotion in relation to palliative nursing in the primary care setting.

BACKGROUND

Health promotion may seem to be of little relevance in palliative care and for patients within its remit, and there is no definition of health promotion in relation to palliative care, yet therapeutic 'new' nursing, and its core elements of holism, egalitarianism and a humanistic approach accord with the philosophy of palliative care and are recognised as health promoting nursing practice.

DESIGN/METHODS

A qualitative methodology was used. Information was obtained from 12 patients by a qualitative semi-structured interview. Data were organised and analysed using recognised guidelines for phenomenological analysis.

FINDINGS

The patients identified two types of therapeutic interaction with the nurse, which enhanced feelings of health and well-being in different ways. Psychological well-being was enhanced by the humanistic and egalitarian personal interaction with the nurse, and the professional interaction focused on the disease and addressed physical problems. Although recognizing the nurses' role in the relief of physical symptoms, the patients' perception of 'feeling better' generally focussed on enhancement of psychological health and well-being.

CONCLUSION

For the patients, a combination of 'new' (therapeutic) nursing and a more traditional expert-led approach resulted in the promotion of an enhanced sense of physical and psychological health and well-being, and was an integral part of community palliative care nursing. Based on the study findings, the researcher offers a definition of health promotion relevant to palliative nursing in the primary care setting, which identifies that for the patients (but with caveats related to generalizability), the practice of holistically therapeutic palliative nursing is the ideal.

Struggling to be/show oneself valuable and worthy to get care. One aspect of the meaning of being dependent on care--a study of one patient, his wife and two of his professional nurses

Dependency on care has commonly been described negatively and as a problem that needs to be addressed. From a larger data material, interviews with an old, hospitalized man with a chronic disease, his wife and two of his professional nurses was selected to study. The aim was to illuminate the meaning of being dependent on care, when it appears "negative". A phenomenological-hermeneutic approach was used to interpret the material. The interpretation shows that dependency on care is reluctantly shown although it is expected to be expressed and/or respected as it is shown. This makes dependency on care camouflaged and the space to be dependent is limited. The meaning of being dependent on care is understood as a two-dimensional struggle for existence. One dimension of the struggle is about to be/show oneself worthy to get care, as dependency on care holds a fear to be abandoned. The other dimension of the struggle is about to be/show oneself valuable as a human being, as identity is built upon being able to manage oneself and be strong. The interpretation if reflected on can open up possibilities to improve the quality of life for patients who are dependent on care.

Being overwhelmed by the feeling of having a home and family. One aspect of the meaning of being dependent on care: a study of one patient and two of his nurses

RATIONALE

This article is part of an ongoing study which aims at disclosing the meaning of being dependent on care. From a larger body of data, interviews with one patient and two of his nurses were selected to study.

AIM

The aim was to deepen understanding of the meaning of being dependent on care when this appears desirable for the patient.

METHODS

A phenomenological-hermeneutic approach was used to interpret the material. Interviews were recorded and transcribed verbatim.

FINDINGS/DISCUSSION

The interpretation discloses the meaning of being dependent on care as an overwhelming, unfamiliar feeling of having a home and family. The patient is beguiled into believing he is the ruler in an established relationship and his dependency on care gives him an opportunity to be surrounded by loving, altruistic, helpful people. Being dependent on care is overwhelming and irresistible, i.e. coveted, but simultaneously it is like walking on thin ice, i.e. treacherous. The irresistible desire concerns being unconditionally cared about. The danger is that this 'family membership' will not last. It is brought to the patient because of his dependency on care and it is based on his terms. There is reflection about the patient being unprepared for dealing with his own world of loneliness.

Rehabilitation and specialist palliative care

Enabling individuals to achieve their maximum potential and quality of life following a diagnosis of advanced cancer, has long been a stated aim of palliative care. Increased life expectancy and the introduction of specialist palliative care to patients at an earlier stage of their illness presents professionals in the specialty with new challenges in meeting the need for rehabilitative care. This article examines some of the recent developments affecting the provision of rehabilitative care and describes one specialist palliative care unit's response to the challenge, highlighting the role of a nurse-led clinic within the service framework.