Policy and advocacy for informal caregivers: How state policy influenced a community initiative

The Impact of Caregiving on Informal Caregivers of People with Dementia: Family Functioning, Burden, and Burnout

Caregiving is a complex occupation, with a significant impact for informal caregivers (IC). Stress-process models propose a framework that considers that this impact depends on primary and secondary stressors, but also on the IC situation appraisal. This work aimed to verify: whether being, or not, an IC of an individual with dementia influenced the relationship between family functioning and burnout; the association between neuropsychiatric symptoms of the individual with dementia and IC burnout and whether the IC burden and perceived family functioning had a mediating role in such relationship. This cross-sectional study investigated differences in family functioning and its association with burnout between IC and non-IC. For IC specifically, the study examined a mediation model to explore the possibility of neuropsychiatric symptoms indirectly affecting IC burnout through the impact on family functioning and burden. Measures included the Copenhagen Burnout Inventory, the McMaster Family Assessment Device, the Neuropsychiatric Inventory, and the Zarit Burden Interview. Results showed an association between poorer family function and high burnout, specifically in IC. They also showed that burden mediated the relationship between neuropsychiatric symptoms and burnout. The findings offer a significant contribution to the growing knowledge about the relationship between stressors associated with informal caregiving in dementia context, such as neuropsychiatric symptoms and its outcomes, like burnout.

"He is changing, but I'm changing too": An interpretative phenomenological analysis of spouse caregivers' identity in the context of dementia

OBJECTIVE

This study explores the process through which informal caregivers, particularly spouses, construct their identity within the context of caregiving for individuals with dementia. Despite extensive research in psychology aimed at defining caregiving (e.g. tasks, consequences), few informal caregivers identify themselves as such. For instance, the affective bond shared between caregivers and care-recipients often imbues caregiving responsibilities with a sense of "naturalness," especially if the care-recipient is a spouse.

METHODS

To investigate the nature of caregiver identity construction, eight semi-structured interviews were conducted with spouse caregivers of dementia patients. The collected data underwent interpretative phenomenological analysis (IPA).

RESULTS

Three interconnected themes emerged from the analysis: (1) Perceiving changes in my partner, which involves recognising alterations in the care-receiver's characteristics due to dementia; (2) Processing changes, encompassing the experience of grieving losses and reminiscing about the past; and (3) Perceiving changes in myself, referring to the acknowledgement of personal changes due to caregiving.

CONCLUSION

The study emphasises the dynamic and ongoing nature of caregiver identity construction, which begins with the early recognition of changes in the care-receiver. Interestingly, spouse caregivers oscillate between their identity as a spouse and caregiver, influenced by how they process changes undergone by their partner. Contrasting with previous theories on caregivers' identity, our results focus of caregivers' perceptions rather than their relationship with the care-recipient or caregiving tasks.

A Harmful Care: The Association of Informal Caregiver Burnout With Depression, Subjective Health, and Violence

Providing informal care to a relative can lead to informal caregiver burnout, which is expected to lead to deleterious consequences. Among these consequences lie the risk of perpetrating violent behaviors against the care-recipient, the caregivers' risk of depression, and their low subjective health. To investigate these associations, a sample of 499 informal caregivers completed a questionnaire addressing informal caregiver burnout, depression, subjective health, and violence. Hierarchical regression models were used to investigate the potential association of burnout with these potential consequences, while controlling for sociodemographic variables and received violence. The results show that burnout, and especially emotional exhaustion, is significantly associated with depression, low subjective health, and perpetrated physical violence, but not with perpetrated psychological violence. For both psychological and physical violence, it appears that receiving violence is one of the best predictors of perpetrating violence. With these results, this cross-sectional study confirms the association of informal caregiver burnout with deleterious consequences-even if this observation must be pondered-and the central role of received violence in predicting perpetrated violence, suggesting the risk of violence escalation. The implications of these results suggest that the emotional state of informal caregivers is one of the indicators of potential deleterious consequences and should, as such, be considered as a warning signal by field workers.

Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation

BACKGROUND

Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis.

OBJECTIVES

To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events.

MAIN RESULTS

We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies.

AUTHORS' CONCLUSIONS

The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.

Caregivers of People With Disabilities: A Program to Enhance Wellness Self-Care

Caregivers are a source of support for family members with disabilities. However, caregivers are at risk for caregiver burden, which can erode self-care skills and lead to poor physical and mental health outcomes. Caregiver Wellness Self-Care, developed to address that risk, is a 5-week group program in which participants learn about strategies that cultivate their inner resources, while connecting with others for support. Wellness, self-care, mindfulness, and yoga-based information and practices are taught in the sessions and included in participant handouts. Self-reflection and planning activities with facilitated discussions further support awareness and personal transformation. Designed by and for people providing care to an adult family member with a mental health disorder and a developmental/intellectual disability, the program was piloted three times. The current article describes the development of the program through caregiver involvement, participant and facilitator feedback, and implications for future efforts to build caregiver wellness self-care skills. Implications for nurses are highlighted. [Journal of Psychosocial Nursing and Mental Health Services, 59(5), 25-32.].

Needs, Aggravation, and Degree of Burnout in Informal Caregivers of Patients with Chronic Cardiovascular Disease

This study aimed to answer three main questions with respect to home caregivers for people with cardiovascular disease: (1) Are the needs of home caregivers being met (and at what level)?; (2) what is the level of emotional exhaustion, depersonalization, and personal accomplishment of home caregivers?; (3) what sociodemographic variables of home caregivers are related to unmet needs and level of emotional exhaustion, depersonalization, and personal accomplishment? The study used the Camberwell Modified Needs Assessment questionnaire and the Maslach Burnout Inventory questionnaire. This study reports on 161 informal home caregivers of patients with cardiovascular disease. We found that younger caregivers were less likely to report unmet needs (p = 0.011), and showed lower rates of burnout on depersonalization and emotional exhaustion. In addition, caregivers who worked more often reported higher levels of met needs (p = 0.022), and showed lower rates of burnout on depersonalization (p = 0.005) and emotional exhaustion (p = 0.018). Subjects residing in urban areas were more likely to report unmet needs (p = 0.007), and showed higher rates of burnout on emotional exhaustion (p = 0.006). Older caregivers who are unemployed and reside in cities should be offered programs to determine their unmet needs and to receive support.

Informal Caregiver Burnout? Development of a Theoretical Framework to Understand the Impact of Caregiving

Informal caregiving is a rewarding but demanding role. The present theoretical framework proposes to adapt the tridimensional concept of burnout to informal caregiving as a way to address the potential consequences of caregiving. This adaptation reflects caregivers' reported difficulties, as well as empirical findings on emotional exhaustion, depersonalization, and personal accomplishment as caregiving outcomes. But to understand burnout in informal caregiving contexts, it is also necessary to find ways to model it. The Informal Caregiving Integrative Model (ICIM) is thus proposed. This model is based on the integration of elements from literature on both informal caregiving stress and professional burnout. The goal of the ICIM is to emphasize the importance of every category of determinants of informal caregiver burnout (i.e., relating to the caregiver, the caregiving setting, and the sociocultural context), with a key mediating role for the caregivers' appraisal of their situation and their relationship with the care-recipient. This article is a first integrative step in the consideration of a form of burnout specific to informal caregivers and supports the design of empirical and interventional studies based on the theoretical foundation that the ICIM proposes.