A qualitative study of the theoretical models used by UK mental health nurses to guide their assessments with family caregivers of people with dementia

Abstract

Some researchers suggest that nurse training does not provide adequate theoretical knowledge to guide mental health nurses’ work with carers of people with dementia. In recent years theoretical guidance for working with carers has emerged in the nursing literature. However, little attention has been given to theory practice links. This study used interpretative phenomenological analysis to investigate the theoretical model used by nurses to guide carer assessments. During the analysis the data evolved into a description of the model underlying the nurses’ work. In the discussion this model was compared with the stress process model (SPM). This comparison highlighted striking similarities between the themes in the nurses’ model of carer stress and the theoretical constructs of the SPM. However, the SPM describes influential links between different constructs which were absent in the nurses’ model. The research illustrates developmental training needs for mental health nursing to improve the efficacy of assessments and therefore, interventions.

Introduction

Due to social and political changes in the UK more family caregivers for people with dementia are being referred to mental health nurses for assessment and treatment. Caregiving for a member of the family who is suffering from dementia can be stressful (Schulz et al., 1990). Accepting the view that theory should guide practice (Holdsworth, 1995), it is recommended that assessments of carers should be based on a theoretical understanding of the stress process of caring. However, nurse training does not provide the required theoretical knowledge to guide the nurses’ work (Sheppard, 1991). Sheppard (1991) explained that the gap between what nurses know and the demands of their role exists because nursing theory is inadequate. This means that nurses’ work is developed by trial and error experience, rather than theoretical training. One concern is that if the theoretical models adopted by the nurses are limited and fragmentary as suggested by Sheppard (1991), then the practice may mirror this. Without comprehensive assessment based on some understanding of the caregiving process, it is unlikely that treatments will be adequately targeted and this may be reflected in poor treatment outcomes (Nolan et al., 1994).

Adams (1999) highlighted that the theoretical underpinnings of mental health nursing treatment of carers are unclear. He studied the practice of four nurses and their work with 13 of their cases. Adams (1999) observed one visit to each carer, interviewed the nurse and the carer and analysed the data using grounded theory. The findings illustrated the orientation of nurses’ work with carers. For example, the nurses described that during their assessment they used a variation of Roper's nursing model (see Walsh, 1998). However, Adams’ (1999) analysis suggested that their practice was based on the transactional model of stress from psychological theory, rather than nursing models from their training. He called for further research directed towards gaining more understanding of the theoretical ideas that underpin the work of mental health nurses with carers.

Until recently a lack of appropriate theoretical approaches has inhibited the possibility of comprehensive assessment of carers by mental health nurses (Nolan et al., 1995). Nurses need a comprehensive theoretical framework to guide their assessment and help identify the appropriate type of treatment when working with carers of people with dementia (Challenger and Hardy, 1998). Webb and Morris (1994) emphasised that nurses need to understand the carer stress process, to help guide assessment and guidance is available (Nolan et al., 1994). The question is whether these theoretical developments have been absorbed and now underpin practice.

The need for research exploring the use of theoretical models in practice has been identified (Walsh, 1998; Adams, 1999). This study describes the theoretical model of the caregiving experience which guided nurses’ assessment with family carers of people with dementia. A qualitative methodology was necessary to allow the researcher to consider the ‘insider's perspective’ (Conrad, 1990) that is essential when studying theoretical models in this context. As thinking processes guiding assessment cannot easily be articulated (see Benner et al., 1996), interpretative phenomenological analysis (IPA) was the chosen methodology. One of the philosophical roots of IPA is symbolic interactionism (see Denzin, 1995) which proposes that the meanings individuals ascribe to events are only obtained through a process of interpretation from the narrative which may be a description of behaviour, for example (Smith et al., 1997). IPA therefore offers an appropriate methodology for researching theoretical models underlying practice by providing a procedure that can be used to develop a thematic description of the nurses’ model.