What is it to be a daughter? Identities under pressure in dementia care

Meaning-making of dementia caregiving: A systematic review of qualitative studies

BACKGROUND

Being the backbone of informal care for people living with dementia, caregivers suffer overwhelming physical and psychological challenges in their daily caregiving experience. Proactive coping strategies to alleviate the caregiving burden are of utmost importance. Meaning-making emerges as an effective coping approach to benefit caregivers and mitigate their care burden. However, the conceptualisation of meaning-making on its dimensions and process has been ambiguously identified.

OBJECTIVES

To synthesise the qualitative research evidence on meaning-making in a dementia context to identify: (1) the situational dimension in making sense of caregiving scenarios, and (2) how the meaning-making process evolves during dementia caregiving.

METHODS

This systematic review identified 62 qualitative studies published between 1969 and 2022 from the major databases. Eligible studies met the following inclusion criteria: (1) having informal caregivers of people living with dementia; (2) involving meaning-making of care experience; (3) adopting qualitative design; and (4) full-text of research articles. The risk of bias was evaluated using the Clinical Appraisal Skills Programme checklist. By using Qualitative Evidence Synthesis, themes relevant to critical dimensions and phases of meaning-making were generated from the extracted data.

RESULTS

Sixty-two studies involving 2487 subjects were synthesised investigating the critical dimensions and process of meaning-making of dementia care experience. Results indicated that the dementia care experience can be made sense of in several folds: (1) it involved complicated demands from people living with dementia and requires customised care; (2) the dynamics of dyadic interactions with dilemma and ambivalence; and (3) adaptive coping encapsulating perceptions of loss and growth, complied and integrated values, balanced expectations of care and self, and improvement in self-efficacy. The meaning-making process underwent phases of meaning creation (meaning created in initial encounter with dementia symptoms), meaning appraisal (assimilation and accommodation pathways for appraisal), and meaning adherence (integration of the appraised meanings).

CONCLUSION

Findings suggest meaning-making of dementia caregiving is a multi-faceted and multi-phased recursive process. Future implications give directions on the facilitation of meaning-oriented interventions to enhance the awareness of caregiving role and the knowledge of dementia care, learn techniques of reframing and restructuring, and seek meaningful perspectives; and to adopt strategies to overcome the barriers for meaning-making by empowering self-identity, roles and expectations, and the dyadic relationship. In addition, our findings inform future advancement in the conceptualisation and measurement of meaning-making in the context of family caregiving. Optimisation of the meaning-making process inspires professional assistance to enhance caregivers' coping for dementia care experience.

Moral learning through caring stories of nursing staff

BACKGROUND

Implementing person-centred care (PCC) in nursing homes is challenging due to a gap between theory and practice. Bridging this gap requires suitable education, which focuses on learning how to attune care to the values and preferences of residents and take moral, relational, and situational aspects into account. Staff's stories about the care they provide (i.e. caring stories) may deliver valuable insights for learning about these aspects. However, there is limited research on using staff's narratives for moral learning.

OBJECTIVE

This study aims to provide insight into the perspectives of nursing staff on using their caring stories to learn about PCC.

RESEARCH DESIGN

In this qualitative research, we conducted two rounds of interviews with 17 participants working in nursing homes. We wanted to obtain nursing staff's perceptions of working with their caring stories and the impact on PCC.

ETHICAL CONSIDERATIONS

Participation was voluntary, and participants provided written consent. The study protocol is approved by The Institutional Review Board of the Medical Ethical Committee Leiden-Den Haag-Delft.

FINDINGS

Working with caring stories enables nursing staff to provide PCC and improves job satisfaction. It increases awareness of what matters to residents, fosters information rich in context and meaning, and enhances voice and vocabulary. Through in-depth team reflections, nursing staff discussed the significant moments for residents, which centralizes the discussions on the moral quality of care.

DISCUSSION

Working with caring stories fosters dialogue on PCC and enhances reflection on ethical situations in daily encounters, contributing to the moral development of nursing staff. Putting nursing staff's narratives at the centre of learning suits their daily practice and intrinsic motivation. Therefore, the outcomes of this study are an addition to the existing literature about using narratives in long-term care.

CONCLUSION

Using nursing staff's narratives contributes to PCC and positively impacts nursing staff. We recommend using staff's caring stories as a vehicle for moral learning in the transition to PCC.

The narrative self in rural dementia: a case study from eastern Nova Scotia

This analysis examines how the narrative self of a person with dementia is maintained by family members in a small rural Nova Scotian community. In the literature, the expectation is often that rurality is a condition of isolation, distance from family and limited health resources. However, drawing on three years of ethnographic and interviewing research with a large extended family whose patriarch, Alexander, is a person with dementia, we demonstrate how a community's rurality influences interpretations of dementia. In Alexander's rurality, of particular import are local definitions of belonging, which privilege intimate knowledge of local history, working as a farmer to shape the land, and being of Scottish descent and male. As family members find Alexander's belonging to come into question in their community, we show them to employ narratives in which he is valorised for continuing to uphold local values – of ‘usefulness’ and of ‘being the land’. We show how the family members must also revisit and revise these narratives when Alexander's belonging is further called into question outside the family setting and, specifically, at the local farmer's market, where Alexander is often no longer greeted by other marketgoers. The men and women of the family arrive at different interpretations of this development, with the women considering marketgoers to demean and dehumanise Alexander, while the men feel that the marketgoers are avoiding interactions that would embarrass him. Such disagreements reveal the ongoing emotional labour of creating narratives that lack closure, certainty and consensus, as well as ways in which gender and rurality operate intersectionally in the process of meaning-making.

Living with end-stage renal disease: Moral responsibilities of patients

BACKGROUND:

Living with a renal disease often reduces quality of life because of the stress it entails. No attention has been paid to the moral challenges of living with renal disease.

OBJECTIVES:

To explore the moral challenges of living with a renal disease.

RESEARCH DESIGN:

A case study based on qualitative research. We used Walker's ethical framework combined with narrative ethics to analyse how negotiating care responsibilities lead to a new perspective on moral issues.

PARTICIPANTS AND RESEARCH CONTEXT:

One case was chosen from 20 qualitative interviews with renal patients in the Netherlands.

ETHICAL CONSIDERATIONS:

Several actions have been taken to ensure the informed consent, privacy, anonymity and confidentiality of the patient in this article. More details are offered in this article. The study has been conducted in line with the recommendations of the Medical Ethical Committee of the VU Medical Center.

FINDINGS:

A renal disease can force people to change their identity, relationships, values and responsibilities. The case study illustrates the moral challenges confronting renal patients.

DISCUSSION AND CONCLUSION::

Moral issues can be raised by the changes to identities, relationships, values and responsibilities caused by renal disease. Support services for renal patients and their relatives should pay more attention to these issues in order to promote self-management.

Science of the Particular: An Advocacy of Naturalistic Case Study in Health Research

Case studies can provide us with in-depth understanding of a single demarcated entity. Cases can be corporations and clinics, but are usually people. There are several approaches to case study. Naturalistic case study constitutes the science of the particular. The aim of naturalistic case study is to understand with minimum intervention the particularity of a case in its ordinary situation from multiple perspectives. Naturalistic case study relies on a humanistic commitment to study the world from the human perspective. The purpose here is to illuminate how five key features of naturalistic case study can be used in health research. Case studies are of use in various disciplines. In this article we show that the naturalistic case study can have extraordinary value in health research, and is useful from a variety of perspectives. We do so by presenting a case report of a 92-year-old resident moving to a care center.

The experience of self and threats to sense of self among relatives caring for people with Alzheimer's disease

This study explored how the relatives of people with Alzheimer's disease expressed Self 2 and Self 3 according to Harré's social constructionist theory of selfhood. Having a relative with Alzheimer's disease affects one's life. In this study, we concentrated on how close relatives of people with Alzheimer's disease experienced their sense of self. This study was descriptive and qualitative. Interviews were conducted with 20 relatives of 10 people with Alzheimer's disease from 2009 to 2011. The data were analysed according to Harré's social constructionist theory of selfhood including Selves 2 and 3. Participants reported that Alzheimer's disease challenged their personal attributes, relations and positioning. Understanding how Alzheimer's disease affects the sense of self among close relatives is important, as this knowledge is pivotal for supporting these relatives who are often informal caregivers in ways that enable a fulfilling and meaningful life.

Shifting patterns of everyday activity in early dementia: experiences of men and their families

In this article we draw from a larger study to examine experiences of two men and their families as they negotiate changing patterns of everyday activity in the months after receiving a diagnosis of dementia. We conducted in-depth interpretive phenomenological analysis of interview and observational data that were gathered from the men and various members of their families (n = 7) over a period several months. Findings are presented as three themes: The best kind of man (highlighting participants' historical positioning); It's a little different now (recognizing challenges posed by the dementia); and You have to do something (showing how the men and their families responded to and accommodated these challenges). We discuss these findings in terms of how everyday activity is not only important for supporting personhood in dementia, but it also contributes to sustaining family identity, and does so in a way that is deeply influenced by gender and masculinity.

Using meta-ethnography to understand the emotional impact of caring for people with increasing cognitive impairment

The majority of people with degenerative neurological conditions are cared for within their own families. Cognitive impairment can be a significant and increasing symptom of these conditions. In this article we report how a team of experienced researchers carried out a meta-ethnography of qualitative research articles focusing on the impact of caring for a loved one with cognitive impairment. We followed the seven-step process outlined by Noblit and Hare. Synthesized findings from 31 papers suggest emotional impact is complex and uncertain and varies from day to day. The benefit of using meta-ethnography is that the results represent a larger sample size and a reinterpretation of multiple studies can hold greater application for practice. The results of this study offer an opportunity for nurses to be aware of both the positive and negative sides of caring and being cared for. This knowledge can be used to discuss with patients and carers how best to prepare for decreasing cognition and still maintain a worthwhile quality of life.

Dialogue for air, air for dialogue: towards shared responsibilities in COPD practice

For the past several years patients have been expected to play a key role in their recovery. Self management and disease management have reached a hype status. Considering these recent trends what does this mean for the division of responsibilities between doctors and patients? What kind of role should healthcare providers play? With findings based on a qualitative research project of an innovative practice for people with Chronic Obstructive Pulmonary Disease (COPD) we reflect on these questions. In-depth interviews conducted with people with COPD, physiotherapists and a pulmonologist show that shifting responsibilities require a supportive attitude from healthcare providers and a dialogical communication between patients and professionals. Our findings show more is needed in order to motivate people with COPD to take responsibility and become co-owners in a process of recovery. The case example illustrates that people with COPD need support from fellow patients to learn to accept their disabilities. Awareness that COPD is more than just a lack of air, that mind and body interact, is a first step to investigate other potential problems and to enhance one's quality of life.

Huntington disease: families' experiences of healthcare services

AIM

This paper is a report of a study of the perceptions of family caregivers regarding the availability and adequacy of health and social care services for their family member with Huntington disease, and to compare findings from these reports in United Kingdom and United States of America samples.

BACKGROUND

Huntington disease is an inherited neurodegenerative condition. Family members often take responsibility for care of relatives with long-term conditions. Studies have demonstrated there are both positive and negative outcomes for carers.

METHODS

During 2006 and 2007, respondents from the United Kingdom (n = 108) and the United States (n = 119) who were caring for a relative affected with Huntington disease completed the Community Health Care Services Scale to identify areas of concern and the extent to which specific issues bothered carers. Data were analysed using statistical tests including chi-square, t-tests and factor analysis. Results were compared between carers in the two cohorts.

RESULTS

Three main factors were derived: 'community resources', 'individualized care' and 'knowledge of Huntington disease'. Carers had concerns about the knowledge of healthcare professionals providing care and thought that there were insufficient services to support them and the affected person. There were different challenges for carers when the affected person had a long-term neurodegenerative condition because these carers were also likely to have responsibilities for earning and caring for children.

CONCLUSION

Comprehensive facilities and resources are needed to support families affected by long-term complex conditions. Healthcare professionals need to be aware of the health needs of carers as well as those of the affected person.