A qualitative study of the theoretical models used by UK mental health nurses to guide their assessments with family caregivers of people with dementia
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.
Section snippets
Participants
Eight of the nine female G Grade mental health nurses working in the Community Mental Health Teams for Older People within one city in England agreed to participate in the study. Because this sample has been derived from a small population and ethically the researcher intends that their anonymity be maintained, only summary demographics will be presented. The age range of the nurses was between 37 and 59 years. The number of years since qualification ranged between 12 and 28. Seven of the eight
Results
This research aimed to describe the theoretical model used by a group of nurses to guide their assessment of carers. The model that evolved from the analysis has eight individual themes related to the carer stress process. Within the model the overriding principle is that individual carers are different in ways that influence their experience of stress. The nurses also described background influences that are unrelated to the caregiving role. The model has four main elements involved in the
Discussion and conclusions
The importance of a comprehensive theoretical model to help guide assesement with carers has been emphasised (Keady and Nolan, 1996). Failure to conceptualise carer stress in detail is likely to impact on the assessment process (Nolan and Grant, 1989). Because assessment is crucial to choosing the most appropriate treatment, if the assessment is unsophisticated in some areas, then the treatment decisions may be flawed (Nolan et al., 1994). Research on outcomes of nursing interventions has
Acknowledgements
The authors would like to thank the nurses that participated in this study.
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