Alzheimer's Disease (AD) is among the most prevalent of the dementias and it is anticipated that much of the care required for the dependent patient will be provided in the home setting by a caregiver. The purpose of this study was to identify the importance of needs related to caregiving and the level of satisfaction of those needs related to the caregivers of Alzheimer's victims. The theoretical framework for this study is Dorthea Orem's "Self-Care Deficit Theory."The sample was 18 caregivers who attended one of three Alzheimer's Support Group meetings held in three central Indiana cities. Human subjects rights were protected. The Home Caregiver Needs Survey (HCNS), Hileman, 1990, was used to identify the information, household, patient psychological needs of the and care needs, personal and caregivers of Alzheimer's patients and to determine if these needs are being adequately met. Findings included: (a) the caregivers perceived the need for information, patient care, personal, spiritual, psychological need to be somewhat important to important; teach, assist and support caregivers throughout the and (b) satisfaction of the needs indicated that the caregivers were somewhat satisfied to satisfied with the needs presented. Implications call for: (a) Nursing intervention to caregiving experience. (b) Home health care agencies and senior citizens action groups to lobby for support and programs to assist caregivers. / School of Nursing

Bakgrund: Inom den palliativa vården har möjligheten att få vårdas i hemmet ökat genom åren. Idag vet man att närstående utför betydande insatser inom vården och omsorgen och att deras insatser bedöms vara tidsmässigt mycket större än från den offentliga vården. Att vara närstående till någon som är sjuk är en upplevelse som är unik för varje enskild individ. Upplevelsen av isolering, att behöva ignorera sina egna känslor och kämpa för sin egen överlevnad kan uppstå hos de närstående som vårdar en sjuk i hemmet. Syfte: Att belysa närståendes upplevelser av palliativ hemsjukvård. Metod: En litteraturöversikt har gjorts baserad på elva vetenskapliga artiklar som granskats och analyserats. De databaser som använts vid artikelsökningen är Cinahl plus with Full Text, PubMed samt Medline with full text med sökorden Family, Palliative home care, Experiences och Sweden. Efter analysen av texterna i artiklarna framkom fyra teman, vilka var önskan att bli sedd av det palliativa vårdteamet, upplevelsen av maktlöshet, vikten av kommunikation och av att få information samt stöd och stödgruppens betydelse för de närstående. Resultat: Resultatet visar att många närstående känner sig förbisedda då en stor del av det palliativa vårdteamets fokus hamnar på den sjuke. Detta leder även till att de närstående upplever maktlöshet. Det palliativa vårdteamet kan genom god kommunikation och information få de närstående att känna sig uppmärksammande som individer samt att få bli inbjudna till delaktighet i vården av den sjuke. Något som också visat sig vara ovärderligt och bidrog till att skapa mening i det vardagliga livet för de närstående var stödet från omgivningen samt stöd i form av stödgruppsträffar tillsammans med andra närstående i liknande situationer. Diskussion: Diskussionen har baserats på de fyra teman som framkommit i resultatet och sedan relaterats till omvårdnadsteorin, Peaceful end-of-life theory samt konsensusbegreppen människa och vårdande. Betydelsen av kommunikation och information från det palliativa vårdteamet diskuteras, samt vikten av att göra de närstående delaktiga och uppmärksammade i vården av den sjuke. / Background: Within palliative care the opportunity to receive care in the home has increased over the years. Today we know that next of kin’s perform considerable efforts in health and social care and that their efforts, based on time, are considered to be larger than the public services efforts. To be next of kin to someone who is ill is an experience that is unique to each individual. The experience of isolation, having to ignore their own feelings and fight for their own survival may occur in the next of kin who care for an ill person at home. Aim: To highlight next of kin’s experiences of palliative home care. Methods: A literature review has been conducted based on eleven scientific articles, which have been reviewed and analyzed. The databases used in the article search are Cinahl Plus with Full Text, PubMed and MEDLINE with full text using the keywords Family, Palliative home care, Experiences and Sweden. The analysis of the articles revealed four themes which were, a desire to be seen by the palliative care team, the experience of powerlessness, the importance of communication and receiving information and also support and the support group significance for the next of kin’s. Results: The results show that many next of kin’s feel neglected as a large part of the palliative care team's focus is on the sick person. This also leads to the next of kin experiencing powerlessness. The palliative care team can through good communication and information make the next of kin feel noticed as individuals and be invited to participate in the care of the sick person. What also proved invaluable and helped to create meaning in the everyday life of the next of kin was support from the surroundings and support in terms of support group meetings together with other next of kin’s in similar situations. Discussions: The discussion was based on the four themes that emerged from the results and has then been related to the middle-range theory, Peaceful end-of-life and also the central concepts of nursing, person and nursing. The importance of communication and information from the palliative care team are discussed, and also the importance of making next of kin’s participate in the care of the sick person and to be noticed.

The study aim was to describe the lived experience of patients with an ostomy due to cancer following hospital discharge, using a Heideggerian phenomenological lens. Colaizzi’s (1978) process guided a thematic analysis of nine unstructured interviews. The overall essence of patients’ transition experience was Adjusting to a New Way of Living. Four major themes emerged, Some Things are Different, Always on my Mind, Moving Towards Independence, and I’m Not Alone. Results suggest that the transition involves: adjusting to the ostomy and cancer; financial implications; changes in self, physical being, lifestyle, and social aspects of life; and psychological acceptance and preparation for the unexpected. Home care nurses and patients’ support network facilitated meeting their comprehensive care needs; while cancer treatments, the role of the significant other in the loss of privacy, funding inconsistencies, and temporary ostomy status were barriers. Patients need a comprehensive care approach to better facilitate the transition process.

The restructuring of Canadian health care for more than twenty years has ushered in opportunities for growth in private home care services. Within this socio-economic reality, some seniors and families feeling the impacts of the cutbacks to health and social services have turned to other alternatives of care to fill care gaps. A new type of caregiver, the paid companion, has surfaced in this respect. Operating either independently or through private health care agencies, paid companions resemble surrogate family members or friends who perform a variety of services for the elderly who can afford to pay for private home care and support. My research objective has been to explore and develop an understanding of the experiences and relationships of paid companions and their clients within the context of the political-economic climate of neoliberalism that has supported the development of paid companions. This thesis presents research conducted between 2009 and 2010 in the Greater Victoria area with 30 participants: 15 companions, 8 clients, and 7 key informants. The two qualitative methods of qualitative (semi-structured open-ended) in-person interviews and autodriven photo elicitation were utilized in order to examine the subjective experiences of paid companions and their clients. The research revealed the ambiguity and divergence of opinion around the terms ‘companion’ and ‘paid companion,’ which are inherent in the nature of the work itself. The majority of participants emphasized that friendship and fictive kinship often form the core of a relationship that has been built on caregiving and trust. While paid companions derive fulfillment by providing care for clients, the relationships they develop with them are intrinsically linked to the companionship and care they give. Although clients’ care needs most often stem from general health and mobility issues, the relationships that are gradually formed with their companions often become as important as the task-based assistance their companions provide to them. / Graduate

Access arrangements for birth parents of crown wards are a concern for child protection workers. Data on 84 crown wards were collected from 11 in care workers at a Children's Aid Society in Ontario, to determine whether best practice guidelines were being observed. Best practice derived from literature was operationalized as: (1) inclusion of birth parents and others in decisions affecting the child, and (2) connectivity ---maintaining family ties. Regression analyses were performed to identify predictors of inclusion and connectivity scores. Results showed three significant predictors of inclusion---worker knowledge, years in child welfare, and birth parents' source of income---and two predictors of connectivity---worker knowledge and parents' source of income. Findings suggest that agency training and support of workers can have a positive effect on implementation of best practice. The effect of income source is a puzzle, as income from employment was associated with lower inclusion scores, but higher connectivity scores.

This research evaluates Quebec's health care policy by analyzing how the partnership metaphor is implemented in policy and practice. The partnership construction is identified in 4 interpretive communities within long-term community services to the elderly population. This analysis focuses on the placement decision for cognitively impaired clients in home care. Interpretive policy analysis is employed to examine 3 policy documents and 3 client files, while grounded theory serves to analyze 13 semi-structured interviews with 2 administrators and 3 open triads of client, caregiver, and case manager. The findings show partnership to be an egalitarian, collaborative ideal widely adopted but with little consensus on the pertinent objects and actors. Important differences emerge in how partnership is applied to the placement decision, indicating a too flexible application. Specific restrictions are recommended on the application of the partnership metaphor in order to improve community services and organizational structures in health care.

In Canada and internationally, increases in Home Care (HC) services for the elderly have been a policy priority in recent decades. HC services include Home Health Care (HHC) and Homemaking/Personal Support (HM). The primary objectives of this study were to explore the interrelationship among publicly funded, privately funded, and informal HC services in terms of potential for substitution, and between publicly funded HHC and HM services; and the determinants of the receipt of each type of HC services. Stabile, Laporte, and Coyte’s family home care decision model (2006) was extended, to develop an understanding of the demand for HHC and HM services separately and to include different household arrangements. The consequential hypotheses were tested in two empirical studies. Individual panel data for those aged 65 and over were derived from 8 biannual waves of the Canadian National Population Health Survey (1994-95 to 2008-09). A Panel Two-Stage Residual Inclusion method was used to estimate the likelihood of the receipt of HC services, adjusting for socio-demographic, health status, disability, dependence on help with Activities of Daily Living (ADLs), and regional characteristics. The results showed that receipt of publicly funded HM is complementary with receipt of publicly funded HHC services after adjusting for functional and health status. Receipt of publicly funded and privately funded HM services did not show an effect on each other. Receipt of publicly funded HM did not affect the receipt of informal HM services. The availability of informal care from a partner or other adult sharing the household reduced the likelihood of publicly funded HM receipt. Age, dependence on help with ADLs, health status and income are determinants of the propensity to receive publicly funded HHC and HM services as well as privately funded and informal HM. Findings in this study suggest that changes in the availability of publicly funded HC services may not greatly affect the provision of informal care in Canada. The complementary effect between publicly funded HHC and HM services and the income effect in the receipt of publicly and privately funded HC services may raise concerns about equitable access to HC services in Canadian jurisdictions.

Proponents of Canadian health reform in the 1990s argued for regional structures, which enables budget silos to be broken down and integrated budgets to be formed. Although regionalization has been justified on the basis of its potential to increase home care resources, political science draws upon the scope of conflict theory, which instead suggests marginalized actors, such as home care, may be at risk of being cannibalized in order to safeguard the interests of more powerful actors, such as hospitals. Prince Edward Island, Nova Scotia, and New Brunswick, constitute a natural policy experiment. Each has made different decisions about the regionalization model implemented to restructure health care delivery. The policy question underpinning this research is: What are the implications of the different regional models chosen on the allocation of resources to home care? Provincial governments are at liberty to fund home care within the limits of their fiscal capacity and there are no federal terms and conditions which must be complied with. This policy analysis used a case comparison research design with mixed methods to collect quantitative and qualitative data. Two financial outcomes were measured: 1) per capita provincial government home care expenditures and 2) the home care share of provincial government health expenditures. Hospital data was used as a comparator. Qualitative data collected from face-to-face, semi-structured interviews with regional elite key informants supplemented the expenditure data. The findings align with the scope of conflict theory. The trade-off between central control and local autonomy has implications for these findings: 1) home care in Prince Edward Island increased it share from 1.6% to 2.2% of provincial government health spending; 2) maintaining central control over home care in Nova Scotia resulted in an increase in its share from 1.4% to 5.4%, and 3) in New Brunswick, home care share grew from 4.1% to 7.6%. Inertia and entrenchment of spending patterns was strong. Health regions did not appear to undertake resource reallocation to any great extent in either Prince Edward Island or New Brunswick. Resource reallocation did occur in Nova Scotia where the hospital share of government spending went down and was reallocated to home care and nursing homes. But, Nova Scotia is the only province of the three in which home care was not regionalized. Regional interests in maintaining existing levels of in-patient hospital beds was clearly a source of tension between the overarching policy goals formulated for health reform by the provincial governments and the local health regions.

Population aging in Canada is associated with a rising burden of heart failure (HF), a condition associated with substantial morbidity, mortality and health service use. HF management involves pharmacotherapy, exercise, dietary restrictions and symptom monitoring. First-line combination pharmacotherapy for HF consists of an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) in conjunction with a β-adrenergic receptor blocker (β-blocker). This combination therapy can reduce mortality, improve symptoms and reduce health service use. However, evidence about the benefits of these therapies has been derived from randomized controlled trials in younger patients from acute care and specialty clinic settings. Little work has explored outcomes among older individuals and those in the community setting. In purposely studying an older cohort of individuals with HF, the goals of this research were three-fold: to comprehensively describe their sociodemographic, clinical and service use characteristics; to describe rates of usage of first-line HF pharmacotherapy and correlates of non-use; and to examine the outcomes of mortality, long-term care (LTC) admission, long-stay hospitalization, admission, new cognitive decline and new functional decline as well as predictors of these outcomes. To achieve these aims, this work made use of the extensive data available through the Resident Assessment Instrument – Home Care (RAI-HC) database in Ontario. The RAI-HC is mandated for use in Ontario to assess all long-stay home care clients (those expected to receive home care service for at least 60 days). This assessment contains over 300 items about sociodemographic and clinical characteristics, diagnoses, service use and geriatric conditions, such as functional abilities and cognition. The study samples included long-stay home care clients older than 65 years of age. The descriptive analyses (N=264,030) demonstrated that older home care clients with HF are a more complex group than home care clients without HF, with more comorbidity and higher use of medications and health care services. From the analyses examining pharmacotherapy use (N=176,860), rates of use of first-line pharmacotherapy were low, with only 30% of clients with HF receiving recommended combination first-line therapies, a similar proportion receiving no therapies and the remainder receiving at least one therapy. The multivariate analyses revealed that hypertension and diabetes mellitus diagnoses affect first-line therapy use. Regardless of clinical subgroup, use of these therapies was less likely among older clients and those with functional impairment, airway disease or behavioural symptoms. Longitudinal analyses were done using Cox proportional hazards regression modeling (N=9,283) in which individuals were followed for nine months after each RAI-HC assessment. Results from these analyses showed that female gender and living alone reduced the risk of all outcomes except LTC admission, while age over 85 years generally increased the risk of all examined outcomes. Comprehensive clinical indicators, the Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale and Method for Assigning Priority Level (MAPLe) algorithm, increased the risk of all outcomes except new cognitive decline. ACE inhibitor use was protective of LTC admission and functional decline, but not mortality, long-stay hospitalizations or cognitive decline. The complexity of older individuals with HF could impair self-care abilities and points to the need for initiatives to help such individuals manage their care at home with appropriate support and services. The low rates of use of first-line pharmacotherapy among older home care clients with HF highlights the need for better understanding of which factors affect prescribing practices. Better evidence, that is more applicable to older individuals with HF, is needed about the therapeutic benefits of first-line therapies to help enhance the evidence base and improve patient care.

The purpose of this theoretical study was to examine factors associated with the development of attachment relationships for children in long term foster care who Overt demonstrating problematic sexual behaviour. Due to the dearth in available research on this topic, it was necessary to draw from studies in three distinct areas (1) Attachment, (2) Childhood Sexuality, and (3) Placement Stability. In total, the present study examines 13 studies drawn from these three areas, and includes 11 quantitative and 2 mixed method studies. / These studies were chosen for their attention to the middle age child in foster care who was demonstrating problematic sexual behaviour. Due to the lack of attachment studies on fostered middle age children, two infant studies were included with the rationale that middle age children and foster parents engage in a similar attachment process and infant studies would provide direction and context for future studies with older children. In the area of childhood sexuality, clinical samples were also included as they contained large numbers of children who had experienced sexual abuse or who had contact with child protection agencies even if they did not reside in foster care. / Studies were examined along dimensions of sample, methods and findings. The results of this inquiry are then discussed, weaving together the three areas of study to answer two research questions: Is there a relationship between problematic childhood sexual behaviour and the development of a successful attachment relationship with a foster parent? And secondly, is there a particular foster parent attachment profile that promotes attachment security with children who are in care? / Studies reviewed support the hypothesis that problematic childhood sexual behaviour presents challenges to foster parents significant enough to seriously impair the development of a secure attachment and that the foster parent's attachment state of mind will be an important factor in success. Results of the analysis of these questions contribute to an emerging hypothesis that the human sexual system may be intricately woven together with the attachment system, making an attachment analysis of problematic sexual behaviour in children particular relevant. A concluding discussion examines clinical issues which may be targets of intervention and the necessity of future research in this area is proposed.