The Effects of Stress on Formal Caregivers and Care Quality

Jun 23, 2023 | 0 comments

Jun 23, 2023 | Essays | 0 comments

Table of Contents

ABSTRACT

The created problem statement in the DNP I project was to determine the reasons for increased formal caregiver stress among the formal caregivers who are serving dementia patients. It is important to address the problem of increased formal caregiver stress among the nurses and the nursing aides because of the increasing rate of the condition among the formal caregivers. The purpose of the project is to determine if a stress reduction program introduced by the project developer using a caring approach with an emphasis on nursing staff interactions and relationships with patients will reduce stress, attrition, patient-related incidents, and loss of workdays in nursing staff who experience caregiver stress. The paper adopted two conceptual/theoretical frameworks, that is, “the Neuman Systems Model” and “the Science of Unitary and Irreducible Human Beings”. Concerning the Education Practice Question, the stated problem will be overcome by considering intervention which includes the reduction of workload and working hours by increasing the number of caregivers and incentives. The project plan will involve a caring and patient-centered approach. It will incorporate respectful care that takes into account patient values, needs, and preferences and ensure that these elements guide all clinical decisions. In analysis/ evaluation, Findings from the qualitative phenomenological interviews will be analyzed based on the modified van Kaam method by Moustakas. Furthermore, a computer software program known as NVivo10 will be utilized in ensuring proper coding of the large interview transcripts of the 12 participants. Finally, for the analysis of the data collected from the two phases, a triangulation of findings will be employed to compare the similarities and differences of the behavior as well as the work attitude of the participants who were under the control group and those who did not receive the intervention. The significance and implications of the project to nursing are that it helps in illuminating the issue of stress when dealing with dementia patients and then suggest interventions proven to have success or positive effects on both the care providers and the patients. It is also important to patients because they can receive improved quality of care with the proven interventions to cope with stress. Lastly, the mental health care industry will realize cost savings through having reduced sick absences and attrition among nursing personnel and will be better prepared to provide quality care to the baby boomers who will join the dementia population in hospitals.

1.0 INTRODUCTION AND BACKGROUND

The created problem statement in the DNP I project was, to determine the reasons for increased formal caregiver stress in the formal caregivers who are serving dementia patients. The term formal caregivers refer to the hospital staff, nursing staff, untrained are staff and the professional staff that is involved in the nursing homes and residential facilities. However, the paper will use the term formal caregivers to refer to the nurses and the nursing aides of the hospitals and nursing homes. According to Adelman, Tmanova, Delgado, Dion, and Lachs (2014), increased stress levels informal caregivers who are serving dementia patients is associated with low educational attainment, increased number of working hours, social isolation of caregivers, depression, residence with the patient, decrease satisfaction related to caregiver job and financial stress. In addition to this, the formal caregivers have also reported that in turn of providing such a long duration of care services, they receive minimal benefits and incentives (Adelman, Tmanova, Delgado, Dion & Lachs, 2014).

Dementia is a progressive cognitive/mental condition that is facilitated by other medical conditions such as Alzheimer’s disease, and it is characterized by decreased problem-solving skills, forgetfulness, behavioral changes, and difficulties with language (Williams, Arthur, Niedens, Moushey & Hutfles, 2013). According to Shriver (2010), taking care of people with dementia can be stressful for the caregivers, especially when the disease has progressed to the final stages; and the patient becomes verbally and physically violent. The literature also indicates that the aggression and violent behavior that dementia patients exhibit is a result of discomfort of any kind, misunderstanding, and lack of attention. It was reported that sufficient staffing ensures that the patients receive the required attention, and has been proven to reduce aggression and violent behavior (Gordon, et al, 2003). Adequate staffing also creates an environment, which mirrors that of home and has been shown to reduce the associated violent and aggressive behaviors.

Givens, Mezzacappa, Heeren, Yaffe, and Fredman (2014) contended that caregivers also find it difficult to handle the patients’ restlessness, repeated agitation, and inability to remain at the same place. Not only do the patients abuse nurses both physically and verbally, but they also suffer from burnout due to the shortage of nurses in this field (Summers & Hoffman, 2006). This is because handling patients with dementia require nurses who are well equipped, trained, and psychologically prepared to handle the challenges that accompany caring for dementia patients (Mitchell, 2009). Also, sufficient staffing in conjunction with the 12-hour shifts instead of the 8-hour shift has been shown through studies to help with burnout, hence reducing the stress on the nurses and nurse aides (Gordon, Grant, & Stryker, 2003). Mental health problems were regarded as untreatable in the past, and this led to negligent services and facilities (McKhann, et. al, 2011). However, mental healthcare has resurged in recent years although it still experiences challenges, especially when it comes to nursing staff and how to manage the patients.

Because of the increasing formal caregiver stress among the nurses and the nursing aides recently, there is a need for research on interventions to the formal caregiver stress to the formal caregivers working with dementia patients. The topic is very important because it will provide a caring and patient-centered approach that will incorporate respectful care that takes into account patient values, needs, and preferences and ensure that these elements guide all clinical decisions. Moreover, it will address the avoidance of patient injuries from the care provided by nursing personnel

1.1 Purpose of the Project:

This project attempts to determine if a stress reduction program introduced by the project developer using a caring approach with an emphasis on nursing staff interactions and relationships with patients will reduce stress, attrition, patient-related incidents, and loss workdays in nursing staff who experience caregiver stress. Moreover, the project seeks to identify ways on how to provide improved quality of care to patients who are diagnosed with dementia.

1.2 Education Practice Question

Concerning the Education Practice Question, the stated problem will be overcome by considering intervention. According to Bush and Anderson (2014), these interventions will include the reduction of workload and working hours by increasing the number of caregivers and incentives. Case management education should be provided to caregivers to increase their knowledge about dementia. Training sessions should be provided to the caregivers to increase their skills related to problem-solving, managing dementia behaviors, modifying the home environment, and management of stress. The assigning of alternate caregivers is also an effective intervention that will provide an opportunity for the caregivers to go on vacations, take rest, or get involved in other activities (Bush & Anderson, 2014).

2.0 LITERATURE REVIEW

Dementia is a disease that is progressive and the patients who suffer from it lose the ability to live independently without other assistance. According to Wright, Basmajian, & NFBC (2010), the majority of the dementia patients are taken cared for by the hospital and formal caregivers, and these people are often placed in situations of increasing personal demands. Scott, Bartholomew & Dotson (2011) stated that caring for a demented elderly person by formal caregivers such as nurses and nurse aides is a major challenge to them since it entails financial, social, physical, and emotional burden. Furthermore, it has been described as one of the situations that are hard and faced by formal caregivers (Khalsa, 2010). According to Chen et al (2015), dementia patients’ formal caregivers can experience various emotional problems. One of the disorders that are often not treated and overlooked is referred to as nurses’ depression. Sarabia-Cobo (2015) document that nurses of dementia patients have more symptoms of depressions compared to the nurses who are caregivers of the aged and gender-matched. These formal caregivers of dementia patients report more depressive symptoms and more emotional strain compared to the caregivers of non-dementia patients. The rates of prevalence of the symptoms of depression among the nurses of demented patients are documented to be ranging from 28% to 55 % (Robb, 2010).

Over the years, there has been an increasing growth in research on formal caregiving that majorly focuses on the negative effects of offering care by the nurses and nursing aides and the interventions on how to prevent or reduce these effects (Ball et al, 2010). The formal caregiver’s stress is a critical issue for the nurses since they play a significant role in the care of the individuals suffering from dementia, and the negative consequences of health that they may be exposed to (Oliveira, Brewster & Rowe, 2015). Its importance is gaining momentum because of the expected rise in the number of persons who are elderly with dementia (Iavarone et al, 2014).

High depression levels are found in nurses and nursing aides providing care to people with dementia or those suffering from Alzheimer’s disease in hospitals. Providing care to a patient who is suffering from Alzheimer’s disease or any other related dementia can be overwhelming and challenging. Such frustration and stress with its impact on the formal caregivers’ mental and physical health can result in potential abuse. This literature review will present a review of relevant literature on the issues of negative health consequences to formal caregivers, with the main focus on the factors responsible for depression, apathy, lost workdays, job attrition, and burnout. Further, it will present ways of enhancing the health of the caregivers, strategies to cope with stress, and the potential for patient abuse.

An online literature search was conducted that covers the period from 2010 to 2015 on CINAHL and Psych INFO databases. The keywords used during the process of literature search singly or in combination including dementia, depression, formal caregivers, Alzheimer’s disease, and caregivers’ burden. Additionally, the study used textbooks and Google search as references.

2.1 The main problem and what it demands

As defined by WHO, dementia is not just a problem of memory. Wang et al (2014) asserted that dementia is the impairment of the functions of the higher cortical, including the capacity to offer solutions to the day to day problems, memory, control of the emotional reactions, correct applications of the social skills, and learning perception-motor skills performance, in the absence of large scale clouding of a person’s consciousness. According to Bekhet (2013), dementia presents a huge burden on the formal health care sector. Alzheimer’s disease prevalence is projected in the next 50 years to triple, and this will generate a significant burden on both formal caregivers and formal healthcare systems who provide most of the health care. Caring for a demented patient appears to be linked with multiple effects on the health of formal caregivers and some researchers have named them as Alzheimer’s disease “hidden victims” (Wright, Basmajian, & NFBC, 2010). Most illnesses associated with dementia are progressive in nature, and the early problems and symptoms markedly differ from the symptoms from the later stages. Moreover, other additional problems and symptoms normally develop later as the disease progress

Scott, Bartholomew & Dotson (2011) pointed out that in dementia’s moderate stages, the patient with dementia often needs some support level from nurses to enable them to continue maintaining their function. Khalsa (2010) stated that it is at this stage often that the nurses often begin to realize the full extent of the different demands required from them. Given that the deteriorating function of the memory is a problem, it is normally not the major problem impacting upon the formal caregivers. It is more often the behavioral and personality changes that are a major concern, which have the greatest effect on the nurses and nursing aides who work with a dementia patient.

2.2 Support systems

These are formal and are offered by the nurses or the nursing aides at the hospital settings or the nursing homes. According to Han et al (2014), professional or formal caregivers include the hospital staff, nursing staff, untrained are staff, and the professional staff that is involved in the nursing homes and residential facilities. Most dementia patients will be placed into the nursing care or residential in their illness moderate to severe stages, despite the efforts of the community support services and formal caregivers. The settlement of dementia patients into the facilities of nursing care or residential facilities is often a process that is stressful for both the nurses and the dementia patient (Sarabia-Cobo, 2015).

Probably most dementing patients are taken to hospitals and nursing homes where they can get proper care and medication. However given that dementia is a condition that progresses slowly compared with other illnesses such as cancer, the period over which caring needs to be given is very long. Therefore, without a proper and supportive care system that is strong, most formal caregivers are constrained in their efforts of looking after the dementia patient (Chen et al, 2015).

2.3 Factors Responsible for Formal Caregiver Depression

Ball et al (2010) indicated that the nurses and nursing aides offer assistance to the dementing patients with the daily living activities that deal with mobility, nourishment, and incontinence. According to the study done by Abdollahpour et al (2015), about 73% of the formal caregivers of Alzheimer’s disease patients who are aged 65 years and above provide high care levels. Moreover, these nurses are two times more likely to report increased levels of emotional strain and physical stress as a straight result of their duties of caregiving. Similarly, other consequences of caring for a dementing patient may also detrimental effects on the health of the nurses (Gitlin et al, 2010).

Because of the many responsibilities and high burden, formal caregivers engage in lesser actions of health promotions compared to the nursing non-caregivers, experience poorer self-health, and also report lower satisfaction with life (Gitlin et al, 2010; Oliveira, Brewster & Rowe, 2015; Neville et al, 2015). Aboulafia-Brakha et al (2014) indicated that formal caregivers who experience a significant depressive mood may be affected adversely by their abilities to perform health maintenance behavior that is desirable or even self-care behaviors about the symptoms. Similarly, formal caregivers according to Bleijlevens et al (2015) experience more mental and physical distress compared to the nursing non-caregivers within the same age group.

Formal caregivers to the persons suffering from Alzheimer’s disease are one of the greatest resources in the healthcare system, and their task is very difficult since it is compounded with physical exhaustion and psychological stress (Chiu et al, 2014; Iavarone et al, 2014; Boots et al, 2014). The carriers of psychological stress according to Martín-Carrasco et al (2014), have been theorized as daily hassles (Aboulafia-Brakha et al, 2014), modifications to change (Han et al, 2014), and strains in roles (Robb, 2010). Wang et al (2014) defined stress as a specific relationship between the environment and the person that is appraised by the individual as exceeding or taxing their resources and endangering their wellbeing. The symptoms of depression and burden got by Alzheimer’s disease patients’ formal caregivers have been the most extensively researched results of caregiving. The relationship between burden feelings and the overall role of the formal caregivers is well documented (Martín-Carrasco et al 2014; Aboulafia-Brakha et al, 2014; Han et al, 2014; Robb, 2010). Many studies suggest that dementia patients’ formal caregivers have a higher likelihood to be depressed compared to the non-caregiver controls (Martín-Carrasco et al 2014; Aboulafia-Brakha et al, 2014; Han et al, 2014; Robb, 2010). Reports also indicated that the symptoms of depressions are twice more common among the nursing caregivers compared to the nursing non-caregivers (Chiu et al, 2014; Iavarone et al, 2014; Boots et al (2014).

Several studies point out that many formal caregivers are at a higher risk of experiencing clinical depressions (Bekhet (2013; Wright, Basmajian, & NFBC (2010; Scott, Bartholomew & Dotson (2011). Almost half of the formal caregivers in several studies reported that they met diagnostic criteria for diagnosing depression when they applied a structured clinical interview (Khalsa, 2010; Chien et al, 2011). Besides, there is some available evidence pointing out that depression diagnosis can be related causally to the situation of caregiving. Chen et al (2015) found out that about a quarter of nurses met the diagnostic criteria for depression while in their role of caregiving, even though they have never been diagnosed or treated for depression before assuming their role of caregiving in hospitals and nursing homes. The implications of this are well understood by the findings that indicate that a nurse who is stressed has a higher likelihood of institutionalizing the care recipient (Cipriani et al, 2011; Sarabia-Cobo, 2015). Ball et al (2010) suggest that the efforts of identifying and treating formal caregivers’ depression should be multidisciplinary, focus on the many risk factors, and finally make considerations of the patient’s and caregivers’ cultural contexts simultaneously.

2.4 The risk factors for caregivers’ depression

The depression prevalence among the formal caregivers of persons suffering from dementia has been approximated to be between 40%-60% which is sharply in contrast to 8% reported among the nursing non-caregivers within a similar age (Abdollahpour et al, 2015). Therefore, it is significant to recognize the characteristics or risk factors that may be associated or may facilitate the disease.

2.4.1 Characteristics of the patient

Several studies overwhelmingly support the fact that a higher frequency of patients’ behavioral problems is associated with an increased level of formal caregivers’ burden and depression (Gitlin et al, 2010; Oliveira, Brewster & Rowe, 2015). The behavioral disturbances frequency that is manifested by the patient is the strongest formal caregiver distress strongest predictor and plays a crucial role in the decisions of the nurse to institutional a patient (Abdollahpour et al, 2015). Several pieces of literature continue to demonstrate consistently that behavioral problem frequency is a more reliable and dependable predictor of caregivers’ depression and burden compared to the cognitive and functional impairments of the individual (Abdollahpour et al, 2015; Gitlin et al, 2010; Bleijlevens et al, 2015). Nurses and nursing aides face unpredictable and unaccustomed circumstances, which escalates anxiety and stress. According to Gitlin et al (2010), anxiety can be increased by demented patients’ behavioral problems who cannot be managed successfully consistently. It is important to note that anxiety is associated with physical ill health, stress, and depression. Aboulafia-Brakha et al (2014) suggested that Behavioral and Psychological Symptoms of Depression (BPSD) are associated with the distress of the patient and nurses perceive it as the most difficult symptoms to control or manage (Gitlin et al, 2010). BPSD affect adversely the caregiver-patient relationship (Neville et al, 2015). The distress of the formal caregiver is specifically related to the behavioral disturbances that are aggressive (Cipriani et al, 2011). Therefore, BPSD leads to increased formal caregiver burden, and this leads to depression. However, Gitlin et al (2010) indicated that not all behavior changes are a problem. In most instances, the explanation that a behavior change is part of the dementia disease makes the nurse tolerant of the behavior. Sometimes, the behavior is not abnormal and merely occurring at the wrong time or the wrong place.

Formal caregivers of the dementing patients assist them with the activities of dialing living for a very extensive duration. Functional and physical deficiencies in dementia patients may escalate the hardness of offering physical care besides being more stressful, especially to nurses and nursing aides (Braun et al, 2010). Multiple studies indicate a weak relationship of objective measures of a functional status of patients and formal caregivers’ depression/burden (Bleijlevens et al, 2015; Chiu et al, 2014), whereas other studies document a stronger relationship (Iavarone et al, 2014). Boots et al (2014) identified three-point factors that had a strong relationship with Alzheimer’s disease formal caregiver depression, and they include the presence of hallucination, functional scores of ADL of 12 and above, and finally depression in dementia patients.

2.4.2 Characteristics of the formal caregiver

(a) Health

The health of the formal caregivers is a significant caregiver depressions predictor (Abdollahpour et al, 2015). This relationship with depression indicates that nurses having lower physical health levels are more vulnerable to caregiving psychological consequences. Studies have pointed out formal caregivers’ poor physical health than age when compared to their peers of the same age, and these health problems are associated with increased depression risk. The formal caregivers have reported having perceived poorer health, a large number of physical symptoms, have poor immune responses to the various viral attacks, show slower rates of healing of wounds, and have significantly higher plasma insulin levels than the control subjects age-matched (Scott, Bartholomew & Dotson, 2011). Similarly, longitudinal studies also indicate that formal caregivers are at an increased risk for developing mild hypertension compared to their nursing non-caregiving age-matched controls. Moreover, they have an increased tendency of developing very serious illnesses, also, to increase for all mortality causes.

Individuals suffering from depression have a higher risk of cardiovascular diseases. Many formal caregivers do not pay attention to that is sufficient for their healthy diet needs, regular exercise, and sufficient sleep. These practices according to Chiu et al (2014) also essential for successful management of stress. They possess a protective role in the reduction of depression risk and other problems of health. Nurses and nursing aides who do not pay special attention to their needs of health have higher chances of developing problems of health, and this leads to increased depression risk. Other researchers also found out that the formal caregivers who do not take good care of their personal health reported increased formal caregiving stress levels and more behaviors that are problematic with the recipients of care (Khalsa, 2010).

(b) Social support

Han et al (2014) pointed out that social support has significant effects on the outcomes of the formal caregiver. Reports indicate invariably that most social support relates to fewer symptoms of depression and lower perceived burden (Han et al, 2014; Sarabia-Cobo, 2015). Formal caregiver burden and social support have been identified to mediate depression among formal caregivers (Han et al, 2014).

According to Han et al (2014), social support has additional significant functions in that the nurses may get to know other services from people who have applied or used them before, and even create a network of other formal caregivers who are in similar situations (Han et al, 2014).

(c) Other characteristics of the caregivers

Self-identity loss is linked with depressions of the formal caregivers. Nurses encounter three processes leading to this problem: role engulfment, chronic stress, and loss of the dementia patient. Role engulfment is very common since nurses no longer have the energy and time of engaging in other activities. Before engaging in caregiving, these activities have been a significant support source.

Another risk predictor’s category for formal caregiver expression involves formal caregiving context characteristics, which include the relationship of the nurse to the recipient of care and the arrangement of living.

2.5 Stress assessment

Stress according to Quick (2013) is a necessary part of human lives and can be bother beneficial or detrimental. The stress response is basically determined by the people’s perception of an event, a problem, or a transition. Finding the equilibrium in people’s lives and managing stress can be quite a challenge. The first significant step is to recognize the extent to which a person is affected by the stress in their lives and then move forward towards the strategies that will make it better. Various tools can be used to measure the level of stress in a person.

According to Quick (2013), stress comes to people differently and differ from one person to the other. Besides, individuals respond to respond differently and chronic and acute stress have different effects and the distinction between them is very much unclear. AIS (2015) pointed out that hundreds of different stress questionnaires range from the social Readjustment rating scale that was proposed by Holmes and Rahe four decades ago and asses major change events in life, to the current one called Daily Hassles Scale which encompasses minor daily annoyances such as being stuck in traffic, fights with family or customer. Furthermore, other assessment tools like the profile of Mood states, Perceived Stress Scale assesses the stress effects. AIS (2015) further noted that some researchers have designed stress quizzes that can be used by people for self-assessment and have not been validated and therefore their validity and reliability are questionable.

However, the paper will briefly discuss only three tools of which two will be used in the study that is perceived Stress Scale and questionnaires.

2.5.1 Perceived stress scale (PSS)

This classic stress assessment tool is a more precise tool for measuring personal stress. Developed originally in 1983, this tool is the most popular instrument for helping in understanding how different circumstances affect people’s feelings and their perceived stress (Quick, 2013). The designed questions for this scale asks about a person’s feeblish and their thoughts for the past one month. In every question, a person will be asked to indicate how often they thought or felt in a certain way. Even though some of the questions used in this scale are similar, there exist some differences and therefore the individual being assessed should treat every question separately.

For the establishment of eligible participants, the Perceived Stress Scale (PSS) a stress assessment instrument helps in understanding ones feeling and perceived stress under different settings. By using this instrument, one can determine his/her Personal Stress Score (PSS). The frequency of feelings and thoughts in the most recent months are solicited by the questions (Quick, 2013).

2.5.2 Questionnaires

The questionnaire is used as an instrument in the assessment of stress levels because it is useful in measuring the opinions, attitudes, and motives of people with different behaviors and to measure the behaviors of the past to be used in future action predictions (Morrow 2011). Furthermore, the questionnaire is the most suitable stress assessment tool because it is less likely to alter the participant’s behavior, is adaptable to the surrounding, is simple to complete by the respondents with complete anonymity, and lastly reliable and valid (Jackson & Furnham 2010). However, Morrow (2011) adds that a questionnaire designed for a specific intervention must examine certain factors of duration, complexity, respondent’s intellectual capacity, age groups, the activity being surveyed, and the participant’s financial constraints.

One of the importance of closed questionnaires as observed by Jackson & Furnham (2010) is that the respondents are kept to the topic in addition to easy analysis of the responses. However, the respondents are subjected to giving simple answers. This is contrary to open questionnaires where the respondents have the freedom to express themselves in detail but greater efforts, thinking, and time are required (Morrow 2011).

The questionnaires used in the assessment sometimes also have certain limitations. Some of the questions in the questionnaires have pre-coded nature that deters the respondents or makes respondents’ misinterpret the question asked (Jackson & Furnham, 2010). Moreover, it can create bias in the analysis of the results by imposing answer structures that portray the reflection of the researcher’s reasoning and not the respondent. Morrow (2011) points out that truth in the answers cannot also be tested evasiveness and reluctance of the respondents cannot be reflected.

2.5.3 The Ardell Wellness Stress Test

This tool is unique and is used in the assessment of stress holistically. This tool incorporates mental, physical, spiritual, emotional, and social health aspects for a balanced assessment (Quick, 2013).

2.6 Impact of caregiver stress on formal caregivers

Caregiving for dementia patients tremendously burdens the financial, social, psychological, and physical world of the formal caregivers who provide caregiving services to dementing patients in hospitals and nursing homes. Some of the impacts of caregiver stress affect the health of the nurses and also leads to a high rate of job attrition. Compared to other patients without dementia, the dementing persons have a higher likelihood of taking medications, be older, and require services such as mobile meals, transportation, medication management, and adult day care (Ball et al, 2010).

According to Bekhet (2013), formal caregivers who try dealing with a dementing elderly person’s disruptive behavior may be at risk of being harmed physically. Moreover, inadequate support to the nurse or the nursing aide may lead to increased caregiver stress and depression, incomplete treatment of the symptoms of the patient, and in some cases abuse or neglect of the patient.

Another impact of caregivers’ stress on formal caregivers is the absence and high rate of job attrition amongst the nurses. Bleijlevens et al (2015) indicated that these could be a result of depression compounded by family problems, caregiver burden, patents behavioral disturbances, violence, and inadequate support to the nurses and the nursing aides.

2.7 Ways of Enhancing Health of Caregivers and the strategies to cope with Stress

There has been a growing interest in researching factors that assist the formal caregivers to manage their role successfully while minimizing the effects on their general wellbeing and their mood. Chen et al (2015) pointed out that much of these studies have been done on the general stress framework and coping theory, examining the styles of coping of caregivers and the association between types of styles of coping reported depression symptoms.

Different interventions have been developed that support formal caregivers. These interventions include; programs of training and education, support that is based on information and technology, and planning care formal approaches, which take into account particular needs of caregivers, sometimes using nurses specially designed or other healthcare team members (Martín-Carrasco et al, 2014).

2.7.1 Programs of Training and Education

Martín-Carrasco et al (2014) demonstrated that the higher education level of the caregiver about dementia increases the feelings of the formal caregiver that he or she is competent. This realization was more likely to have decreased their patients’ abilities to third expectations. Other studies have examined the feeling of competence and coping strategies and have indicated that a dementing patients’ unrealistic expectations increase the nurses’ depression risk, and in converse, a decrease of the expectation of the nurse is linked with lower depression rates (Chen et al, 2015). According to Robb (2010), nurses who continuously maintain positive feelings for their dementing patients have a higher commitment level to formal caregiving and a lower level of strain. Besides, formal caregivers experiencing powerlessness feelings, unpreparedness, and lack of control have higher depression levels. Martín-Carrasco et al (2014) asserted that the most effective depression treatment by formal caregivers appears to be a combination of emotional support and education.

2.7.2 Spirituality

Puchalski (2012) indicated that spiritual support can also be regarded as a resource for coping and this has been researched among the older Mexican Americans, African Americans. Studies that examined the spiritual support role observed that formal caregivers who are African Americans report more rewards spiritually for providing care (Puchalski, 2012), and reliance on church support and prayer (Winteret al, 2015). Similarly, religious coping also plays a significant role and is present often at Hispanics and African American higher levels. For the formal caregivers of REACH, Winter et al (2015) found out that religious coping is higher for African Americans and Hispanics compared to the white formal caregivers. The involvement of religion is frequently associated with also more access to social support (Puchalski, 2012).

2.7.3 Problem solving

Literature suggests that nurses using coping strategies that are more active like problem-solving, experience lesser depression symptoms compared to those relying on more passive methods. In support of this argument, Aboulafia-Brakha et al (2014) indicated a significant relationship between positive strategies for the management of disturbed behavior and the action strategies for the management of the illness meaning and the decreased levels of depression in nurses. Gitlin et al, 2010) suggested that a critical role of the healthcare professionals is in assisting the nurses to enhance their skills for coping, supporting the skills existing, and in flirtation the development of the new skills.

The roles positive aspects: Giving of care has some positive relationship for nurses including the pride in fulfilling their duties as a spouse, satisfaction with their own competence, and enhanced closeness with the receiver of the care (Braun et al, 2010). These formal caregiving uplifts perceived were linked with lower formal caregiver depression and burden levels in a meta-analysis (Chien et al, 2011). The perceived uplifts according to Chien et al (2011) are more common among the color caregivers compared to the whites.

2.7.4 Professional and social support

Formal support presence of high quality is associated with lower depression of the nurses and nursing aides, and less decline in the emotional health of the formal caregivers who are African Americans, but not the emotional health for the whites (Oliveira, Brewster & Rowe, 2015). Support to the nurses by other nursing colleagues assists in alleviating stress if the supporter is empathic and understanding. Han et al (2014) stated that persons who are highly stressed may not gain from others attempted social support compared to the persons who are moderately stressed.

Formal caregivers need to get the chance of learning ways of coping with stress effectively, to reduce their reliance on treatment and anxiety. Aboulafia-Brakha et al (2014) pointed out that the behavioral skills of the nurses and effective training program for self-management results in a lower frequency of behavioral problems of the patient and assists in improving the mood of the caregiver. Aboulafia-Brakha et al (2014) designed an intervention of a formal caregiver that instructs the formal caregivers’ skills on behavioral management to address the behavioral problems exhibited by the persons with Alzheimer’s disease, in addition to strategies for problem-solving to increase nurses pleasant activities. Neville et al, (2015) also suggested that psychotherapy may be beneficial for patients diagnosed with early dementia, but given that there is a cognitive loss, some form of technology adaptation is necessary and the involvement of the formal caregivers is paramount. The cognitive-behavioral intervention of the nurses can have great benefits to the caregiver of the dementing patient, besides having a positive impact on the behavior of the patient (Aboulafia-Brakha et al, 2014).

Passive coping styles have been linked to a greater burden. People who use the coping style of escape-avoidance are known to be having more interpersonal conflicts and more depression.

2.8 Respite role

Many formal caregivers perceive respite care as a very important service when taking care of dementing patients. The information on different respite options, and the availability of flexible, reliable, and affordable programs that can manage problems of behavior, appear to be prioritized in enhancing the wellbeing of the nurses (Neville et al, 2015). Neville et al, (2015) examined the respite care effects and described it as a temporary institutionalization of the dementing patient in a hospital and a nursing home (for a period of two weeks in both cases). In a study conducted by Neville et al, (2015), respite care was proven to be having a positive effect on the experienced burden by the nurses, in addition to the physical and cognitive functioning of the dementing patient. Neville et al (2015) conducted a study on individual support to formal caregivers (emotional and information support in conjunction with the relaxation exercises). The group that receives emotional support significantly improved on mood, while the control group significantly deteriorated. Bleijlevens et al, 2015) documented evaluation findings of the psychological benefits of usage of adult care by the nurses who are helping a patient with dementia. The study concluded that usage of daycare leads to better psychological well-being and lower levels of stress-related to the formal caregiver.

2.9 Potential for Patient Abuse

According to Chiu et al (2014), abuse may include financial, sexual, psychological, and physical maltreatment and maybe as a result of others’ actions, or maybe from neglect by self or by others. While offering care to a dementia patient, caregiver depression may lead to both physical and verbal abuse. Different studies have pointed out the risk factors for abuse of elderly persons by their nurses (Chiu et al, 2014; Iavarone et al, 2014). Some of the identified factors include excessive psychological and physical demands related to formal caregiving, poor health, advanced age, impaired daily living activities, and physical frailty on the part of the recipient of care. Furthermore, substance and alcohol abuse by formal caregivers; care recipient; formal caregiver psychopathology is some of the risk factors. Besides, many researchers have found out that mental health factors like the depression of the formal caregiver while caregiving a dementing patient increases the abuse risk within a relationship of caregiving (Boots et al, 2014; Aboulafia-Brakha et al, 2014). Similarly, the nurses also can face physical and verbal abuse from the dementia patients they are taking care of. Cipriani et al (2011) indicated that in some scenarios, Alzheimer’s disease or other dementia forms may make the patient aggressive uncharacteristically. In other circumstances, physical violence and verbal abuse may have been a typical interaction of the patient before the onset of the illness, and the illness may exacerbate it.

Martín-Carrasco et al (2014) pointed out a report published on British Broadcasting Corporation (BBC) from the House of Commons that indicated that in 2004, about 67% of abuses to the aged persons takes place in their homes, 12 % occur in the nursing homes and finally 10% takes place while in residential care. This shows an association between patient abuse, depression, and a formal caregiver burden. Nurses who are reported to have directed abuse to a patient are in most cases burdened by responsibilities of caregiving, more stressed, and depressed compared to the individuals who do not engage in any abuse. Han et al (2014) stated that interventions aimed at reducing the burden and treating depression should help in limiting the abuse.

Abuse before the dementia onset is likely to be related to a higher likelihood of the abusive nature of the care recipients, and this will be exacerbated once there will be an occurrence of dementia. Even though it is difficult to break such an abusive nature, interventions like formal or individual psychotherapy for nurses, supportive counseling, in a hospital setting, or respite services for the patients for the concerned parties may be helpful.

3.0 Conclusion

The effect of taking care of a patient suffering from dementia brings the risks of getting mental illness to the formal caregivers in the form of depressive symptoms, emotional stress, or even clinical depression. The impacts of these may include negative effects on the nurses and the nursing aides’ quality of life and the care recipient and the delivered standard of care to support the care recipient. Similarly, caregivers’ depression is a very serious problem of healthcare that leads to substantial costs, regarding society, such as entering early to long-term care.

The challenge to the formal caregivers is to recognize properly this symbiotic unification and effectively support it. There is a need for the deliverance of quality care to both units in the unification, the formal caregivers, and the care recipients if a package of care that is meaningful is to be allocated. There is a need for vigilance from the professionals involved in the care of dementia patients to reduce the formal caregiver’s burden and to detect the early symptoms of health compromise in the mental health of the formal caregivers.

Formal caregiver’s personal education in the form of advice concerning dementia condition and the early warning signs of caregivers stress such as sleeplessness, exhaustion, depression, anxiety, social withdrawal, anger, and denial among others if beneficial (Martín-Carrasco et al, 2014).

The needs of the nurses and the nursing aides are increasingly being recognized by different agencies. The specialist services needed for the dementing people need to include formal caregiver’s interventions such as training, structured advice, short breaks, counseling services. Taking care of formal caregivers is equally important as taking care of the patients suffering from dementia for a positive outcome in difficult situations.

3.0 CONCEPTUAL AND THEORETICAL FRAMEWORK

The two selected conceptual and theoretical frameworks are “the Neuman Systems Model” and “the Science of Unitary and Irreducible Human Beings”.

Neuman Systems Model

This theoretical and conceptual framework views the person as an open system that is capable of responding to the stressors present in the environment. The stressors are intrapersonal, interpersonal, and extra personal and these stressors arise due to created, internal, and external environments. When these stressors exceed the normal line of defense then the resistance lines are activated and the system of the person is directed towards the illness. The normal line of defense is the state of equilibrium of the patient. The line of resistance indicates the factors through which the patient is protecting the body system against the stressors. The normal line of defense is protected by the flexible line of defense which rapidly alters in a short period of time. According to this model, it is the responsibility of the nurses to retain the stability of the system through three stages of prevention. These stages include primary, secondary and tertiary prevention. In primary prevention, the nurses strengthen the flexible line and protect the normal line of defense. In secondary prevention, the nurses increase the resistance factors, reduce the reaction, and strengthen the resistance’s internal lines. In tertiary prevention, the nurses tried to return the patient towards wellness (Hayden, 2012).

3.1 Purpose of the Neuman Systems Model

The purpose of the Neuman Systems Model is to reduce the stress levels among the individuals by following three levels of prevention. In primary prevention, the individual should address those factors that cause increased levels of stress. After identifying the stressor, the individual can protect health status by avoiding those factors. If the individual fails to protect the health status from the stressors then the stressors lead the individual towards the illness. At that time, the secondary prevention level is adopted in which the individual internal resistance or will fight with the stressors to maintain a healthy status. If the individual fails to fight back then the stressors cause illness and at that time the tertiary level of prevention is adopted. In the tertiary level of prevention, the individual makes efforts to return towards health and wellness (Hayden, 2012).

3.1.1 Neuman Systems Model Supporting DNP Project

This theoretical and conceptual model will support the DNP project, because when the patients of dementia will be treated appropriately from the primary levels then it will not cause the worsening of the symptoms. The patients suffering from advanced stages of dementia require more intense care services than the patients of dementia suffering from initial stages. If primary or secondary interventions are provided to the dementia patients then it will not lead to the advanced stages and hence the provision of intense care services will not be required. This will ultimately provide relaxation hours to the caregivers, reduced working hours, and reduced treatment efforts in bringing the patient towards wellness. In addition to this, the Neuman Systems Model will also help the caregivers to address the reasons or factors that are causing increased levels of stress. After identification of the factors, the caregivers should seek ways or strategies to reduce the stress levels before leading to the secondary prevention stage.

3.2 The Science of Unitary and Irreducible Human Beings

This theoretical and conceptual framework has defined nursing as the science and art in which the nurses are concern about the people and their lifestyles. According to this model the multidimensionality, indivisible and irreducible energy fields are the manifesting characteristics and are identified by the pattern that is considered as the whole system and cannot be predicted from the parts’ knowledge. Therefore, this model describes the individual as a unique system composed of different factors and characteristics. The individual is characterized by the capacity of imagery, obstruction, thought, language, emotion, and sensation. This model serves as a platform for the nurses to derive hypotheses and theories because this model provides a world view (Baumann, Wright & Settecase-Wu, 2014).

Purpose of the Science of Unitary and Irreducible Human Beings Model

The purpose of this model is to provide an understanding that each person should be considered as a whole individual possessing different beliefs, values, and ethical and moral principles. The major focus of this model is to maintain the self-integrity of the individual and to recommend the nurses or other health care providers that the patients should be treated as a person with moral values, respect, and integrity and not as a case study or victim of disease (Baumann, Wright & Settecase-Wu, 2014).

The Science of Unitary and Irreducible Human Beings Model Supporting the DNP Project

This model supported the DNP project because this model has emphasized the integrity and self-esteem of the patients. According to this model, the nurses should consider the patient as a whole. When the nurses will be able to recognize the beliefs and moral values of the patient then it will cause the strengthening of the relationship between the patient and nurses. Through this model, the nurses will be able to understand the sufferings of dementia patients and the difficulties that are faced by dementia patients to carry out their daily routine activities. When the nurses will be able to identify those difficulties then they can more effectively manage their work which will not reduce the workload and stress levels but will also strengthen the relationship between the nurses and dementia patients (Baumann, Wright & Settecase-Wu, 2014).

4.0 PROJECT PLAN

The project will be a quality improvement project that is intended to translate evidence into practice. It will involve a caring and patient-centered approach. It will incorporate respectful care that takes into account patient values, needs, and preferences and ensure that these elements guide all clinical decisions. The project will also address the avoidance of patient injuries from the care provided by nursing personnel. The project will be based on Betty Neuman’s System Model and the Science of Unitary and Irreducible Human Beings. Neuman’s Model suggests that a client is an open system, susceptible to stressors in the environment with the ability to respond to those stressors (Alligood, 2013). It will also be based on the Science of Unitary and Irreducible Human Beings which is a grand nursing theory, which posits that nursing is an art and a science that seeks to promote health for all persons, irrespective of where they are (Baumann, Wright, Settecase-Wu, 2014). Betty Neuman’s System Model will be used to understand how to use the interventions to counter the stressors, while the Science of Unitary and Irreducible Human Beings model will help the nurses understand the need for change in providing better care.

4.1 Population of interest

The participants should be within the age range of 21 to 60 years old with 2 or more years of experience working and taking care of dementia diagnosed patients. Participants can be either male or female. Specifically, the aim of the project will be to include12 participants, composed of six nurses and six nurse aides from the Bronx Lebanon Hospital Special Care Division. A sample size of 12 is enough for a phenomenological study as typically, qualitative studies have the size of 10 to 20 participants as long as the responses are coded and analyzed correctly. Participants will be recruited from the Bronx Lebanon Hospital Special Care Division. Electronic mails will be sent upon obtaining the contact information of the nurses and nurse aides while flyers will be distributed within the unit as well. Electronic mails and flyers will contain the description and purpose of the project; the contact information of the project developer will be included for those who will be interested to join. Nurse and nurse aides who will meet the initial standards of the project will have a pre-interview where the developer will thoroughly explain the overview of the project and see if the individuals will commit to joining the next stages. Individuals who will then agree to join the project formally will be given an informed consent where both parties will sign, validating their approval of being participants in the project as well as ensuring the confidentiality of their identities throughout.

The participants will furnish valuable data since they work directly and firsthand with dementia patients and are, therefore, more exposed to the phenomenon that will be addressed. The project developer will use non-probability purposive sampling. Concerning participant selections, the project developer will seek the help of the Bronx Lebanon Hospital Special Care Division to provide a list and contact information of the current nurse and nurse aides from the Dementia Unit. Upon the approval of the hospital, the developer will contact the nurse and nurse aides if they are interested in joining the project. The project developer will then explain the purpose of the project and once the potential participants agree to formally engage in the project. Informed consent will be presented and signed to ensure that the identities and confidentiality of the nurses as well as their shared information will be protected in the whole duration of the project.

4.2 Setting

The data will be collected most preferably from the Bronx Lebanon Hospital Special Care Division, a department that manages and cares for more than 40 dementia-diagnosed patients. The patient population consisting primarily of Hispanic –Americans and Afro-Americans. The average age range of the patients is 18-90 years. Currently, 70 nursing personnel work at this site, they all experience some level of caregiver stress. The Bronx Lebanon Hospital Special Care Division will be solicited to provide a setting where the project developer can conduct the interventions planned for the study. The interviews after the intervention of the groups (one provided stress reduction training and one that did not) will be held in a private room where both the project developer and participants will be at ease to interact and converse about their experiences working with dementia diagnosed patients. Another factor would be a peaceful and quiet room that would ensure that the two parties could communicate well to avoid any issues with the shared responses of the participants.

4.3 Tools

The Perceived Stress Scale (PSS) a stress assessment instrument will be used as it helps in understanding ones feeling and perceived stress under different settings. By using this instrument one can determine his/her Personal Stress Score (PSS). The frequency of feelings and thoughts in the most recent months are solicited by the questions.

Other tools for the proposed study will be an audio- recorder, a well-structured questionnaire/ interviews, and a pre-test and post-test instrument. To validate the testing instruments four nursing staff will be requested to take the tests. They will identify questions that are unclear and discuss their answers to the questions, to determine that their understanding of the questions was the same as what was expected. This step will be taken to clarify questions and responses before giving the tests to the project participants. Adjustments will be made to the questions depending on the results of this validation process.

The questionnaire that will be used in the interviews will be pilot-tested and evaluated by nursing personnel experienced in working with dementia diagnosed patients so that any missing or additional information can be addressed before the final questionnaires/interviews will be conducted with the actual participants. After the tests for the interventions and interviews, the project developer will create a spreadsheet. Each row of the spreadsheet will represent a single participant who will be identified by a number and one column will show whether the participant answered the question correctly on the pre-test and one if the participant answered the question on the post-test correctly. To achieve success in the project, the developer shall analyze the tests and interviews to identify if the interventions were sufficient to see positive changes in the practice as a whole.

5.0 INTERVENTION/PROJECT TIMELINE

5.1 Interventions

The project developer will implement an educational training program to address the level of stress of the nurses and nursing aides. Participants will be recruited from six clinical units of the Bronx Hospital Special Care Division. Electronic mails and telephone number s and telephone extensions will be sent to all nursing staff with interest in the project. They will be administered a stress level instrument/questionnaire to establish continued eligibility (stress score of 4.0 or more). Candidates meeting the 4.0 stress score threshold will be given full details about the project, the purpose, the potential risks, and the project developer’s name and contact to address any concerns. The acceptable response rate for the questionnaires used will be 80%. To improve response rate Electronic mail reminders will be sent and personal appeal conducted by the management staff of the Bronx Hospital Special Care Division. Their response will be tracked by the project developer with the Microsoft Excel Program datasheet.

The candidates who volunteer to participate will be required to sign consent forms. Candidates will be scheduled for 30-60 minutes of stress management strategies program training and a return/teach-back demonstration to verify understanding. Every week over 3 months the participants will reach the project developer/ designee by telephone, by electronic mail, or in-person to ensure that any issue and concerns to implementation of the program are corrected. The project developer will reach participants who do not maintain contact as prescribed by telephone or in-person. After the established 3 months interval the participants and those in the control group will meet for a final administration of the stress management questionnaire. The project developer at least once for a makeup session will reach those who do not report as scheduled. The participants of both groups’ time records and the project developer will also consider job performance records. The focus will be to reduce lost workdays, reduce staff attrition, reduce patient incidents, and improve self-perception of overall health. The project developer hopes to have proposed work-environment interventions implemented, which include sufficient staffing, comprehensive stress management training for the nurses, and environmental changes in the facility that involves creating a homelike environment for the patients.

Betty Neuman’s System Model and the Science of Unitary and Irreducible Human Beings will guide the project. Neuman’s Model suggests that a client is an open system, susceptible to stressors in the environment with the ability to respond to those stressors (Alligood, 2013). It will also be based on the Science of Unitary and Irreducible Human Beings which is a grand nursing theory, which posits that nursing is an art and a science that seeks to promote health for all persons, irrespective of where they are (Baumann, Wright, Settecase-Wu, 2014). Betty Neuman’s System Model will be used to understand how to use the interventions to counter the stressors, while the Science of Unitary and Irreducible Human Beings model will help the nurses understand the need for change in providing better care.

5.2 Methods and Timeline

The interventions will run consecutively with one group being assigned the interventions, while the other will not receive the interventions. The pre-test will be implemented and will run for a period of 2 months, while the post-test will run for 3 months after the implementation of the project. Meanwhile, the interviews with the nurse and nurse aides will be conducted at the most convenient time for the participants before and after the interventions have been implemented. Interviews are expected to last from 30 minutes to 1 hour per participant. All interviews will be done within two weeks and any follow-up questions will be performed immediately after the interviews have been reviewed and a determination made that additional information is needed.

5.3 Ethics and Human Subjects Protections

5.3.1 IRB Considerations:

The project developer will seek approval from the Institutional Review Board before engaging the nurses in the project to reduce the risk of ethical and legal issues during the project. The board approves of projects that involve human participants to ensure that the involvement of the participants is not unethical or against any of the rules and regulations of the organization (Cook, Hoas & Joyner, 2013).

5.3.2 Administrative Approval Considerations:

Approval will be sought from the management and administration of the Bronx Lebanon Hospital Special Care Division, as stated above. The approval of the target hospital setting will ensure that the project runs smoothly since with their endorsement, the administration will provide release time for the staff to engage in the project while providing the required support and resources as required.

6.0 ANALYSIS/EVALUATION

Findings from the qualitative phenomenological interviews will be analyzed based on the modified van Kaam method by Moustakas (1994). Meanwhile, a computer software program known as NVivo10 will be utilized as well to ensure the proper coding of the large interview transcripts of the 12 participants. The seven steps of the van Kaam method (1994) as cited in Cross’ (2008) study are as follows:

(a) List data and develop groupings for data for every expression relevant to the experience;

(b) Reduce and eliminate data to develop invariant themes and constituents of the phenomenon and for the sufficient and horizon of experience;

(d) Check and validate the invariant constituents and their accompanying themes against participant’s transcripts;

(e) Create an Individual Textural Description of the phenomenon for each participant with verbatim examples from the transcribed interviews;

(f) Create Individual Structural Descriptions based upon the Individual Textural Description for each participant; and

(g) Create an individual Textural-Structural Description of the meanings and essences of the experience, incorporating the invariant constituents and themes. (p. 120-121)

*The steps above are the words of Moustakas and were adapted and collected from the study of (Cross, 2008, p.54).

From the steps, themes will be developed which will be used to address the clinical research questions of the study as well as shed the light on the purpose of the project. Finally, for the analysis of the data collected from the two phases, the project developer will then employ a triangulation of findings to compare the similarities and differences of the behavior as well as work attitude of the participants who were under the control group and those who did not receive the intervention. Watson, McKenna, and Keady (2008) explained that the triangulation approach involves the “collection of data from multiple sources focused on the phenomenon of interest” (p. 276) which in this study is the stress of caregivers in managing patients diagnosed with dementia. Jick (1979), the proponent of the triangulation method illustrated the advantages of the triangulation method as the following:

Allows the researchers to have more confidence in the results.
It can stimulate new ways and creative methods of capturing a problem;
It can assist in uncovering the off quadrant or deviant dimension of a phenomenon
it can result in “enriched explanations” of research problems;
it can lead to an “integration or synthesis of theories”; and
Can serve as a competing test for theories (since it is comprehensive)

(pp. 608-609).

Therefore, upon the employment of the triangulation method, the results of the pre-tests and post-tests together with the themes formed from the interviews can be compared and contrasted. From here, the findings can be supported by multiple sources, and interventions that were most effective based on the experiences shared can be expanded and promoted to improve the overall management of dementia care.

7.0 SIGNIFICANCE AND/OR IMPLICATIONS TO NURSING

The project will be of great significance to the caregivers, patients, and healthcare providers of dementia. It will help illuminate the issue of stress when dealing with dementia patients and then suggest interventions proven to have success or positive effects on both the care providers and the patients. The stress interventions can be utilized by hospitals, nurses, and nursing aides to reduce or successfully cope with job stress while working with dementia diagnosed patients. The project is of importance to the patients as after careful study and analysis they can then receive improved quality of care with the proven interventions to cope with stress. The mental healthcare industry shall also redeem its integrity with the provision of quality care to the patients, and nursing personnel job satisfaction. The industry will realize cost savings through having reduced sick absences and attrition among nursing personnel and will be better prepared to provide quality care to the baby boomers who will join the dementia population in hospitals.

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