Functionally impaired elderly: their need for home nursing care

An understanding of care requirements of functionally impaired elderly living in the community is especially important to community health nurses (CHNs), if they are to maximize services to elderly care recipients and their lay caregivers. This study is a report of the functional status of 53 elderly care recipients who were receiving care by informal and formal caregivers. Findings on the functional abilities of elderly in this study are compared with findings from studies of nursing home and community residing elderly. Implications for nursing practice relative to assessments and interventions for functionally impaired elderly are given. Results of the research point to the need for additional investigations to determine home-care needs of growing numbers of of frail elderly.     

Feasibility of Tele-Prompt: A tablet-based prompted voiding intervention to support informal caregivers of older adults with urinary incontinence

Urinary incontinence (UI) is a highly prevalent condition, burdening older adults and their informal caregivers. This study explored the development and feasibility of a 6-week evidence-based, educational/skill building program delivered via tablet-personal computer aimed at developing informal caregiver UI knowledge; and enhancing informal caregiver skill set in prompted voiding and toileting strategies. Caregivers also received individualized weekly coaching sessions from a nurse expert. Feasibility and preliminary efficacy were tested in three caregiver/care-recipient dyads. Recruitment of eligible participants through community-based resources was a challenge to feasibility. Most caregivers found the technology acceptable, but adherence to prompted voiding was inconsistent. All caregivers rated the intervention highly, reported improvements in their care-recipient's urine leakage, found access to a UI expert beneficial, and would recommend it to a friend. The results suggest that the tablet-facilitated intervention was feasible and acceptable to informal caregivers and showed promise for improving both caregiver and care recipient outcomes.     

Urinary incontinence and newly invented pad technique: patients', close relatives' and nursing staff's experiences and beliefs

Urinary incontinence (UI) is a major public health issue and considered to be undertreated, costly and often lead to suffering for patients. Close relatives involved in caring for sufferers describe UI as a complicated problem. For older patients, close relatives and staff, it is important with high absorption UI pads in order to have an undisturbed nightly rest and to prevent bedsores. The aim was twofold: to understand older persons', close relatives' and nursing staff's views and experiences of UI, and their experience of using a particular UI pad system with an alarm. A qualitative design with individual and focus‐group interviews was used to describe 6 patients', 14 close relatives' and 22 staff's experience of UI. These were analysed by using qualitative manifest analysis. The findings were divided into four categories. The patients expressed that they, due to UI, regarded themselves as burdens to others. The patients, the relatives and some staff experienced UI as a natural consequence of ageing. The UI pad system appeared to be a functional incontinence aid during the night, but more research is needed to develop the product and to find new fields of applications. From all perspectives, it appears that nursing cannot be replaced by technology, though the UI pad system can be a very useful complement in UI nursing care. Complementary use of the UI pad system might lead to a more economically effective and safe use of the existing nursing resources.     

Sleep and Sleep-Wake Disturbances in Care Recipient-Caregiver Dyads in the Context of a Chronic Illness: A Critical Review of the Literature

ContextAlterations in sleep-wake patterns of care recipients and their informal caregivers are common in the context of a chronic illness. Given the current notion that sleep may be regulated within and affected by close human relationships, concurrent and interrelated sleep problems may be present in care recipient-caregiver dyads.ObjectivesTo critically analyze evidence regarding concurrent sleep patterns or changes in care recipient-caregiver dyads in the context of a chronic illness and address methodological and research gaps.MethodsUsing a wide range of key terms and synonyms, three electronic databases (Medline, CINAHL, and Embase) were systematically searched for the period between January 1990 and July 2011.ResultsTen studies met prespecified selection criteria and were included for analysis. Study quality was fair to good on average. Seven studies were conducted in the context of dementia or Parkinson's disease, two in the context of cancer, and one study included a group of community elders with mixed related comorbidities and their informal caregivers. Bidirectional associations in the sleep of care recipient-caregiver dyads seem to exist. Concurrent and comparable nocturnal sleep disruptions also may be evident. Yet, inconsistencies in the methods implemented, and the samples included, as well as uncertainty regarding factors coaffecting sleep, still preclude safe conclusions to be drawn on.ConclusionThe dyadic investigation of sleep is a promising approach to the development of truly effective interventions to improve sleep quality of care recipients and their caregivers. Nevertheless, more systematic, longitudinal dyadic research is warranted to augment our understanding of co-occurrence and over time changes of sleep problems in care recipient-caregiver dyads, as well as to clarify covariates/factors that appear to contribute to these problems within the dyad and across time and context of illness.     

Stakeholders' perception of the desired Master's program for Kenya in community health nursing: Areas of competency*

Introduction: After the World Health Assembly approved the WHA 45.5 in 1992, which addressed the nursing shortage by refocusing nurses and midwives to meet community health needs, community demands for educated nurses and the needs of higher nursing education in developing countries increased. However, in developing countries that suffering from multiple resource deficiencies, such as Kenya, the strategic direction of higher education in nursing was unclear. Therefore, in Kenya, a major university school of nursing initiated a collaborative study with a well‐established Japanese nursing college to determine the service‐providers' perspective about upgrading the Master's community nursing curriculum. Purpose: The aim of the study was to describe the Kenyan stakeholders' perspective and the expected roles and abilities of Master's graduates in community nursing. Methods: This qualitative, cross‐sectional study used convenience sampling to obtain 21 participants. The content analysis of the data was based on 19 semistructured interviews. Results: Sixteen categories and 42 subcategories were derived from the five key questions that related to the expectations of the Master's program. The Master's graduates were expected to acquire knowledge and skills relating to administration, management, epidemiology, research, and education. The participants recognized that epidemiology, important for preventive care, was minimal among the current community health nurses. Also, Master's graduates must be prepared to manage health programs. Conclusion: The stakeholders expected that Master's graduates would become leaders in community health nursing, with a broad range of knowledge and skills, most notably in the areas of management and administration, epidemiology, and research. Those abilities should be reflected in the curriculum content.     

Spousal interactions in alzheimer's disease and stroke caregiving: Relationship to care recipients' functional abilities and physical and emotional health

Background: Previous research suggests that the quantity and quality of interactions between caregivers and care recipients have an impact on health outcomes of ill persons. Building on the work of Bowlby (1988) and Wright, Hickey, Buckwalter, and Clipp (1995), spousal interactions are conceptualized as adult attachment; it is argued that this attachment provides protective functions for ill spouses.Objectives: Our objectives in this study were to examine spousal interactions along two divergent illness trajectories, Alzheimer's disease (AD) and stroke, and to relate time 1 spousal interactions to care recipients' time 2 functional abilities and physical and emotional health.Study Design: This longitudinal pilot study compared 42 couples (84 spouses) equally divided between early phase AD, 12 weeks after stroke, and healthy controls. Baseline (time 1) data and 6-month follow-up data (time 2) were collected in home interviews. Measures included spousal interactions and illness characteristics of persons with AD and recipients of care after a stroke.Results: AD couples reported lower quantity and quality of interactions compared with stroke couples. Spousal interactions were positively correlated to physical and emotional health in AD care recipients and to functional abilities in stroke care recipients. Only AD care recipients' interactions were related to depression.Conclusions: Spousal interactions along the AD trajectory represented the protective function of attachment; along the stroke trajectory, reciprocal adult exchanges continued.     

The meaning of women's experience of living with long-term urinary incontinence is powerlessness

Aim. The aim was to illuminate the meaning of women's experiences of living with urinary incontinence (UI). Background. Living with long‐term UI means a variety of consequences for everyday life. Women's narratives about their lived experiences are important in enabling nurses to better understand and to help women achieve symptom control. No previous study could be found that has focused on the meaning of women's experience of living with UI from a symptom management perspective. Method. Fourteen women with UI (range: 34–52 years) who had sought professional help were interviewed. A phenomenological hermeneutic method was used to analyse and interpret the interview texts. Findings. The women's experiences of living with UI are presented in terms of two interlaced themes of being in a vulnerable situation and striving for adjustment. Being in a vulnerable situation means that the women had no control over UI and experienced powerlessness. The sub‐themes in this case were living with an uncontrolled body, living with incontinence as taboo and experiencing a less satisfying encounter. Striving for adjustment means that the women tried to handle their incontinence in different ways to regain power and continue to live as normal. The sub‐themes here were living in readiness, making urine leakage comprehensible, accepting living with UI and being familiar with the situation. Conclusion. The meaning of women's experience of living with UI is powerlessness. Relevance to clinical practice. Nurses should supervise women in pelvic floor muscle training to achieve control over incontinence, thereby helping them regain power. Additionally, Integrated Approach to Symptom Management can help nurses enhance women's self‐care abilities.     

The meaning of work for nursing assistants who stay in long‐term care

Aims and objectives. The purpose of this study was to investigate the meaning of work for nursing assistants who stay in long‐term care. Background. Nursing assistants are important caregivers in long‐term agencies. While studies have examined why nursing assistants leave, their motivation to stay has not been well studied. Design. An existential‐phenomenological study was conducted using Pollio's approach. Methods. In‐depth interviews were conducted with 11 nursing assistants in four nursing homes. Interviews were analysed within the context of an interpretive research group. Findings were represented in a diagram of interrelated figural/ground themes. Conclusions. The meaning of work emerged as an experience of family, pride and control, in spite of an environment fraught with hostility, disrespect and lack of control. Relevance to clinical practice. Nursing assistants provide most of the care to residents of long‐term facilities. Understanding their perspective offers insight into nursing administrators in creating environments in which safe, compassionate and cost‐effective care co‐exist. Implications for clinical practice are framed within King's theory of goal attainment.     

Diagnostic reasoning in the care of a vocally disruptive severely demented patient. A case report.

In order to investigate the effect of nursing investigations based on diagnostic reasoning and research findings on vocally disruptive behaviour in a severely demented patient a single subject study was set up. The nursing diagnoses described problems that seemed connected with sensory deprivation and care that had not been adapted to the patient's abilities. The vocally disruptive behaviour decreased when the nursing treatment plan was followed. When the caregivers stopped following the care plan the disruptive behaviour increased. Another intervention was made and once again the disruptive behaviour decreased. In conclusion the study showed that nursing diagnoses and orders were not enough. The caregivers must also understand the importance of following the care plan and cope with the emotional reactions evoked by the care. Effective leadership, regular supervision of and support to the caregivers seem necessary.     

The costs of urinary incontinence in nursing homes

A simple model was used to calculate the contribution of urinary incontinence (UI) to the costs of nursing home care. First-order costs are defined as the costs of managing UI: supplies, laundry, and labor. Second-order costs are defined as the costs of managing the complications of UI. Data were gathered from nursing homes, medical supply companies, and a large laundry company. First-order costs of four common methods of managing UI range between $ 3.00 and $ 11.00 per incontinent patient per day. Based on these estimates, UI accounts for between $ 0.5 and $ 1.5 billion (3-8%) of the costs of nursing home care. Management of UI with indwelling catheters results in the lowest first-order costs, but the second-order costs (as well as the potential increased morbidity and mortality risks) probably outweigh any cost savings. More active evaluation and treatment of UI in nursing homes could result in considerable cost savings and improved well-being for both patients and caregivers.     

Institutionalized elders with dementia: collaboration between family caregivers and nursing home staff in Taiwan

Aims and objectives. To explore the process of development of collaborative relationship between family caregivers of institutionalized elders with dementia and nursing home staff in Taiwan. Background. Evidence suggests that family members are continuously involved in the lives of loved ones and have not given up their roles as caregivers after the institutionalization of a family member. Little is known, however, about how family caregivers develop a collaborative relationship with nursing home staff, particularly in Asian countries. Design and methods. Grounded theory methodology was used. Data were collected via interviews and observations from 11 family caregivers of patients who were suffering from dementia and living in an institution for persons with dementia in northern Taiwan. Data were analysed by constant comparative analysis. Results. Findings revealed that ‘institutional social penetration’ was the process most used by family caregivers to achieve an harmonious collaborative relationship with the nursing home staff. Institutional social penetration is a dynamic process, which includes three components: self‐disclosure, evaluation of care and penetration strategies. Family caregivers, who had developed a ‘socially penetrating’ relationship with the nursing home staff, were more likely to disclose information in more breadth and depth, to receive positive care evaluations and to adopt multiple effective penetration strategies. Conclusions. Institutional social penetration between family caregivers and nursing home staff can sensitize healthcare providers to meet the family's needs during the placement of their loved one and provide a basis for developing intervention strategies. Relevance to clinical practice. Findings of this study may help healthcare providers to understand the ways in which collaborative relationships develop between the families of elders with dementia and nursing home staff. Interventions can be developed to facilitate self‐disclosure of both the family members and nursing home staff through timely feedback and familiarising family caregivers with different penetration strategies.     

Psychometric properties of the Caregiving Burden Scale for Family Caregivers with Relatives in Nursing Homes: Scale development

Aim: Most family caregivers continue their caregiving for frail relatives after admitting them to long‐term care facilities. The characteristics of this caregiving differ from those related to caregiving in home‐care settings. Thus, a new tool to evaluate the burden of family caregivers in institutional settings is needed. The aim of this study was to develop a new scale, the Caregiving Burden Scale for Family Caregivers with Relatives in Nursing Homes, and to confirm its validity and reliability. Methods: We conducted two cross‐sectional questionnaire surveys. The participants were a convenience sample of family members of residents in seven nursing homes for the validation study and in three nursing homes for the test‐retest study in Japan. Statistical analyses examined exploratory/confirmatory factor analyses, internal consistency, concurrent/discriminate validity, and test‐retest reliability. Results: A four‐factor solution with 16 items was selected as the most interpretable questionnaire. In the confirmatory factor analysis, the indices of fitness highly supported these results. The Cronbach's alpha coefficient for the total score was 0.86 and varied between 0.77 and 0.87 in the four domains. The scale showed moderate correlation with the Nursing Home Hassles Scale, suggesting its concurrent validity. The four domains had only a medium correlation with each other, indicating discriminate validity. Conclusions: The developed scale has acceptable validity and reliability for measuring the caregiving burden of family members with relatives in Japanese nursing homes. Future studies using the scale might lead to the improvement of care for family members with relatives in a long‐term care setting.     

Pain in community-dwelling persons with dementia: frequency, intensity, and congruence between patient and caregiver report

To better understand the pain experience of persons with dementia and to describe what factors are related to congruence of pain reports within patient–caregiver dyads, a cohort study enrolled patient–caregiver dyads at a primary care geriatrics clinic. Thirty–two percent of persons with dementia self-report pain “right now.” Of these, 65% report slight/mild pain, 27% moderate pain, and 8% severe pain or greater. Fifty-two percent of caregivers report their care recipients with dementia are in some pain “right now.” Of these, 52% report slight/mild pain, 30% moderate, and 18% severe pain or greater. Fifty-nine percent of dyads agree on the presence or absence of patient pain. In multivariate analysis of dyadic congruence of pain reports by patient and caregiver factors, only patient factors predicted congruence. The odds of congruence of pain reports increase 3.7 (1.2–12.3) if the patient is male and decrease 0.938 (0.93–0.99) as the patient becomes more agitated. These findings suggest that community-dwelling persons with dementia report less pain than those in the nursing home and caregivers do a fair job of predicting patient pain.     

心脏移植受者主要照顾者心理体验的质性研究

目的了解心脏移植受者主要照顾者在移植受者手术期前后及术后居家照顾期间的情感体验,为医护人员进行护理支持提供借鉴。方法采用质性研究中的现象学研究方法,对10名心脏移植受者家属进行非结构访谈,将获得的资料进行整理、分析、归纳。结果采用类属分析法,总结出关于受者主要照顾者的心理体验的4个主题：手术前后的情感变化;压力的承受;对未来的期望;寻求知识和帮助。结论移植受者主要照顾者在移植不同时期存在不同的情感体验及压力来源。护理人员应根据不同时期需要,提供针对性的、全方位的护理服务。     

How do patients with exacerbated chronic obstructive pulmonary disease experience care in the intensive care unit?

The aim was to gain insight into how patients with advanced chronic obstructive pulmonary disease (COPD) experience care in the acute phase. The study has a qualitative design with a phenomenological approach. The empirics consist of qualitative in‐depth interviews with ten patients admitted to the intensive care units in two Norwegian hospitals. The interviews were carried out from November 2009 to June 2011. The data have been analysed through meaning condensation, in accordance with Amadeo Giorgi's four‐step method. Kari Martinsen's phenomenological philosophy of nursing has inspired the study. An essential structure of the patients' experiences of care in the intensive care unit by acute COPD‐exacerbation may be described as: Feelings of being trapped in a life‐threatening situation in which the care system assumes control over their lives. This experience is conditioned not only by the medical treatment, but also by the entire interaction with the caregivers. The essence of the phenomenon is presented through three themes which describe the patient's lived experience: preserving the breath of life, vulnerable interactions and opportunities for better health. Acute COPD‐exacerbation is a traumatic experience and the patients become particularly vulnerable when they depend on others for breathing support. The phenomenological analysis shows that the patients experience good care during breath of life preservation when the care is performed in a way that gives patients more insight into their illness and gives new opportunities for the future.     

Culture-derived strategies of a paediatric home-care nursing specialty team

This is an ethnographic study of one paediatric home‐care nursing specialty team that cares for children and their families affected by perinatal human immunodeficiency virus (HIV) disease. Observations made by the investigator as part of a larger study suggested that the intricacy and breadth of nursing knowledge and actions that were actually used far exceeded what the standard documentation recorded. Spradley's Developmental Research Sequence, combining methods of participant observation and interviewing, was used to answer the question: What nursing strategies are used in managing the health needs of HIV‐exposed infants in a home‐care programme? Thematic analyses revealed that the visit process had four essential elements, as perceived and lived by the nurses: the pursuit; the connection; the work; and the disengagement. This full scope of nursing strategies for assisting and empowering these families remains largely invisible, limited to verbal transmission to family caregivers and among nurses. It needs to be documented, claimed and further studied by nursing.     

A randomized, controlled trial of a patient/caregiver symptom control intervention: effects on depressive symptomatology of caregivers of cancer patients

In this study, we investigated whether a clinical nursing intervention focusing on teaching family caregivers and their cancer patients skills to better manage the patients' symptoms would reduce caregiver depressive symptomatology. Two hundred thirty-seven patient/caregiver dyads were recruited for the study. These dyads were randomized into either the 10-contact, 20-week experimental intervention group (n=118), which focused on assisting the patient and caregiver in managing patient symptoms and reducing emotional distress, or to a conventional care control group (n=119). A longitudinal random effects regression analysis did not indicate that the clinical nursing intervention was effective in decreasing caregiver depression over the 20-week course of the study. The relationship of the intervention to caregiver depressive symptomatology seems to be a complex one. We recommend further research to explore whether a lengthened intervention and/or delayed follow-up might reveal delayed positive effects of such interventions.     

Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward

Aims and objectives. The main aim of this study was to improve the quality of nursing care for older acutely ill hospitalized medical patients through developing, implementing and evaluating a new model of care using a participatory action research process. Background. One of the challenges of nursing today is to meet the health‐care needs of the growing older population. It is important to consider what quality of nursing care means to older patients if nurses are to address gaps between their own perceptions and those of older patients themselves and to consider conceptual models of care appropriate for older patients care in order to improve the quality of care provided. Design. This study is a mixed method triangulated study, involving the use of both quantitative and qualitative methods through participatory action research methodology to establish an evidence‐base for an evolving model of care. Methods. The model was tested on 60 acutely ill patients aged at least 65 years. The medical ward nurses selected a key reference group including the researcher to facilitate the participatory action research process to develop, implement and evaluate a new model of care based on Orem's self‐care model incorporating the Nurses Improving Care to Health System Elders Faculty (Am J Nurs 1994; 94:21) medication protocol to improve the nursing care provided for acutely ill older patients. Results. The participatory action research process resulted in improved heath‐care outcomes for the patients, such as significant improvements in activities of daily living capabilities between admission to discharge, significant improvements in knowledge levels regarding their medication regimes, as well as increased satisfaction with nursing care activities as perceived by older patients and nursing staff. The implementation of educational sessions during the model of care improved the older patient's functional activities and knowledge levels of their medication regime prior to discharge. In addition, by repeatedly explaining procedures, nurses became more involved with their individual patient's care, developing a patient‐centred care relationship based on Orem's self‐care model. Conclusions. This study demonstrates the efficacy of a new model of nursing care in improving the quality of nursing care for older patients in the acute medical ward setting. Relevance to clinical practice. This study is significant because of its evidence‐base and demonstrates how the participatory action research process empowered nurses to make sustainable changes to their practice. The nurses in the study wanted to affect change. The planned change was not dictated by management, but was driven by the clinical nursing staff at the ‘grass roots’ level. Therefore, being involved in the decision‐making process provided an incentive to actively implement change.     

Caregivers' experiences of interaction with families expecting a fetally impaired child

Background. On the basis of earlier research, caregivers’ actions when interacting with clients should be developed. However, nursing research has focused little attention on the interaction between caregivers and families expecting a fetally impaired child. Aim. The study aimed at generating a practical family nursing theory of caregivers’ interaction with families expecting a malformed child. Methods. A grounded theory study was undertaken at Tampere University Hospital in Finland in 1999–2000. Data consisted of semi‐structured interviews with 22 (n = 22) nurses and doctors. The data were analysed using the constant comparative method. Results. The interaction process starts when a caregiver informs the parents of the fetal impairment. The process is influenced by caregivers’ attitude towards issues related to the family's life situation. Caregivers’ views of their job, and of human coping and cultural attitudes towards these issues are also of importance. These factors account for their goals in the interaction, which, in turn, underlie their actions. When the caregiver's interpretation is that the family accepted the help provided, the outcome of the interaction is satisfaction with having been able to help. Correspondingly, in the case of an opposite interpretation, the caregiver experiences strain caused by inadequacy of the help he/she is providing. The core of interaction consists of two dimensions: gaining strength and losing strength in relation to impairment issues. Conclusions. Caregivers’ views of helpful interaction were consistent with earlier research on the subject, but the findings of this study showed that more attention should be focused on the family as a whole. Furthermore, caregivers rarely criticized their own actions, thus their interaction skills should be upgraded by focusing on systematic self‐assessment through training. Nursing research deepening our understanding of why interaction fails is warranted. Relevance to clinical practice. The study results can be used in the family nursing practice as tools in reinforcing the caregivers’ ability to helpful interaction with families expecting a fetally impaired child. The results may enhance caregivers’ systematic self‐evaluation and conscious use of the self.     

Cuidado humanizado en pacientes con cáncer avanzado. Una perspectiva desde la diada paciente-familia

ObjectiveTo explore the meaning of palliative care as perceived by the family caregiver and the patient with advanced cancer.MethodInformation was collected through in-depth interviews and field diaries to conduct this qualitative research study, with an interpretative phenomenological approach. We adopted Heidegger's perspective for the development of hermeneutic interpretation, and therefore followed the stages of intentionality, reduction, and constitution. We used Bardin's constructs of pre-analysis, coding, categorisation, and interpretation for the discourse analysis.ResultsSeventeen patient-family caregiver dyads were considered. The perceptions of palliative nursing care focused on transpersonal relationships and the discourses referred to a lack of closeness between nursing staff and the patient. This was mainly expressed as a lack of emotional understanding and unmet needs. Themes were drawn from these findings based on developing a transpersonal relationship as a priority, including meeting needs and providing the empathic accompaniment that is fundamental for emotional well-being.ConclusionFrom the perspective of the dyads, palliative care covers intangible aspects of care. This requires nursing staff to work collaboratively with colleagues, with other health professionals and interprofessionally, including the institutions involved in care. Further work is required to implement these actions.