Care-Giver Burden Essay

Care-Giver Burden

Client Concern
Healthcare in America is an issue of finances.  Healthcare is an issue, especially for the financially strapped family. Thus, the concern of the cost of healthcare is not only a concern to the client but it also is a concern to the caregiver since it is their salary which is in question.  The following paper will focus on the care-giver burden of a patient who cannot afford to be taken care of because of lack of insurance or lack of funds in general.

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In the following pages care-giver burden will be addressed using several articles concerning care-giver burden and three theorists;  Martha E. Rogers, Imogene King, and Dorothy E. Johnson.  The articles are in design stressing the issue of guilt and depression when a family decides they don’t have the time or the money to keep a loved one at home and must face putting them in a care facility (Sanders article Shouldering the Burden of Care). Other articles address the issue of keeping a family member at home (child) and the upkeep cost that entails such as home health aid cost, medications, or leaving a job (Wilson, Leslie S.  et al. The Economic Burden of Home Care for Children with HIV and Other Chronic Illnesses).  Also, the review of patient care for nurses and the burden of lack of authority in administration this presents is another form of care-giver burden (Welchman, Jennifer & Glenn G. Griener, Patient Advocacy and Professional Associations:  Individual and Collective Responsibilities).  Each of these issues involves a direct relationship to the patient and their concerns for the burden they may become for their family, or for themselves in regards with money and insurance.  There are many facets to unravel in the primary care system but for this paper, care-giver burden is the primary concept in terms of money.

Problem
Connelly et al’s article entitled, A Qualitative Study of Charge Nurse Competencies is very direct in its understanding of a problem.  The problem that exists in the medical field, as presented in this article is the lack of guidelines that would enable a charge nurse to correctly perform his/her duties.  The facts gathered from the authors were taken primarily from “charge nurses, head nurses, staff nurses and supervisory personnel” (298).  Of the nurses mentioned most were coming from a background in medical surgical and intensive care units and the entire interview was based on the competencies of “clinical/technical, critical thinking, organizational and human relations skills (298).  Thus the problem that evolves in the medical building is that charge nurses are often times unprepared for their responsibility and lack appropriate leadership skills because the majority of charge nurses are being taken from clinical staff nurses and are ill equipped to be a charge nurse.  The main problem that arises from this according to Connelly et al’s article is that these ‘green’ nurses do not have the necessary leadership skills and as Connelly et al. state, “Orienting nurses to the charge nurse role and planning leadership education courses can be difficult because few clearly delineated competencies appear in the literature” (298).  The solution in this scenario is to discontinue taking nurses from the clinical staff and to properly train nurses to be in this charge nurse position of authority.  This could mean a solution based on offering classes in which the charge nurse is responsible for taking and becoming familiar with what is expected of them and how to deal with habitual situations which occur in their vocation.  This is only one solution to the problem, other solutions could include having a more strict hiring policy in which the charge nurse being hired and put in this position already has the necessary skills to be in this position.  Thus, the problem solving solution begins at the root of the problem, the ill equipped nurse hirings.

Although the article presents a concept of a problem (leadership in charge nurses) it does not bring up the point of contention except to say that there is not enough research done on charge nurses and the literature is lacking in information about the skills necessary to be a charge nurse.  Albeit, it is true that to be a charge nurse there is a lot of responsibility involves but the article does not address the hiring process of a charge nurse or what exclusive qualifications they have that bring them to their vocation.  In order for a position to be instated in an institute there have to be hiring guidelines, leastwise, the hiring system would be chaotic.  The authors do not expound on this detail.

     Although the pool of data gathered for this article includes several levels of nurse leadership representation it does not include a wider range that includes pooling from the administrative side of healthcare.  If there is a lack of literature involved in the qualitative study of charge nurse competencies, the problem exists in the administrative field, and thus, their opinion and their frame of reference would be just as valid as the other nursing levels from which data was pooled.
The article mentions that other medical articles have given some guidelines for leadership and what to do during a crises have been written, but there must be a unifying guideline so that legal rules and obligations for the charge nurse may be administered and followed (299).  The article gives a brief summary of the duties for a charge nurse which is stated as follows, “Overall, the charge nurse has been considered to be responsible for maintaining appropriate standards of care and professional/patient interactions” (299).

     The highlighting factor of the article is in the attention given to the charge nurse and patient relationship, for this is where the ultimate responsibility of the charge nurse is placed.  Another factor which the article gives is the definition to what ‘competencies’ are, “Competencies were conceptualized as the expectations that professionals have for a particular role” (299).  From an analytical perspective, the definition given presents a broach spectrum of definition and does not pinpoint a true sense of what competencies are, and even in the definition the article does not give adherence to what the patient expects from the charge nurse, what colleagues and nurses under the charge nurses’ supervision come to define as competencies.  Thus, even the definition given in the article has room for debate in the measurement of other’s perceptive of the word competencies.

Three Approaches to the Concern
Approach of Martha E. Rogers. Roger’s theory involves four postulates: energy fields, openness, pattern, and pandimensionality.  (Barrett et. Al 2000).  Each of these postulates involves the client’s concern over their health and the relationships they form with not only the nurses but with their own families.  Rogers goes on to explain that power is at the core of each of these relationships, “(power)…is the capacity to participate knowingly in the nature of change characterizing the continuous patterning of the human and environmental fields.  The observable, measurable pattern manifestations of power are awareness, choices, freedom to act intentionally, and involvement in creating change” (Barrett et al.)  Most care-giving authority is given to nurses; both in a hospital setting and during stay at home cases.  The preceding concept or the patient is its important to have a strong trusting relationship with the care-giver in order for them to feel more comfortable and also feel their issues and concerns are being heard.  If the patient does not feel comfortable then the care-giver burden becomes apparent in scowling-unreceptive-to-therapy patients.  However, in Welchman and Griener’s article, Patient Advocacy and Professional Associations, a rising concern over nurses’ burden when taking care of patients begins to be seen,

“…nurses are being taught to be patient advocates and both nurses and patients are the worse for it.  The nursing profession’s redefinition of the nurse’s role from loyal handmaid to patient advocate in the 1980s was supposed to protect patients by empowering nurses to think and act autonomously in their dealings with other health professionals.  …individual nurses have been burdened with a responsibility that most professions assign…to their professional associations.  It is not a responsibility that individuals can readily fulfill.  Unless or until the duty of advocacy is taken off the shoulders of individual nurses and returned to the professional bodies that represent them, nurses and patients will continue to suffer unnecessarily”(2005).

The nurses’ role in patient care involves everything a patient needs or may potentially need (feeding, bathing, bathroom visits, company) and according to Rogers’ theory making the patient part of the active choice of their own health.  Therefore, in the context of this theory there is no control, because control is not held one over the other (nurse over patient) but power is shared, as Rogers’ theory states, “…people can knowingly participate in creating their reality by actualizing some of their potentials rather than others.  In this theory there is no control; control is an illusion since other persons or groups and their environments are likewise simultaneously also participating in what is being created”.  Each of these duties cannot be accomplished without proper support from family/administration, and without this support and the lack of performance in a nurse’s duty a patient will lapse in trust.  This is the contention in the make-up of care-giver burden; nurses cannot fulfill their role to maximum potential without the backing of the hospital rules.

The burden is twofold for the nurse and the patient.  As Welchman and Griener state in a final cul-de-sac, “Advocacy for improvements in access to and deliver of health care is best viewed as a collective responsibility of health professions owed to society as a whole, not as the sole province of individual practitioners”(2005).

Approach Imogene King.  King’s theory lies in the clients’ perception of self.  This perception ranges from their body image to their own growth and development before and after surgery or during care-giver visits.  As such, the crux of King’s theory is that of communication.  Her theory subsists of human beings as, “…open systems interacting with the environment” (Williams, Imogene King’s Interacting Systems Theory, 2001).  Throughout the relationship of nurses and clients communication is the key to better health.  This occurs through the patient forming several relationships with different people around them; these include personal systems, interpersonal systems, and social systems.  Thus, King’s ultimate goal stated in the theory is goal attainment.  However, there are outside factors that stand in the way of working and healthy relationships.  In Wilson et al.’s study of patient care for ill and HIV children the stats for financing reflects a tremendous burden, “..in-home care for ill children (ranging from approximately $19,000 to $36000) is higher than that of hiring caregivers for healthy children (approximately $10,000)” (2005).  This burden is further emphasized for the family if they are not equipped to pay a professional care-giver and are dependent upon themselves for such care; this issue raises the other issues of job attendance (some families pass up promotions, decline extra working hours, or quit their jobs entirely in order to care for the ill which makes the financial burden that much more potent).

Thus, it is important within King’s theory that each relationship remain free from outside stress factors in order for the recovery of the patient to be successful.  The dyad of the nurse and the patient must remain free from concerns of money, otherwise the nurse is seen as merely a worker and not a concerned care-giver and the patient is stressed because they may not have coverage for certain operations or insurance to properly cover the care-giver’s assistance.  In King’s theory, communication led to recover, “King believed that interactions between the nurse and the client lead to transactions that relate in goal attainment.  Furthermore, King proposed that through mutual goal setting and goal attainment, transactions result in enhanced growth and development for the client” (Williams).  Therefore, the issue of money cannot come between the dyad.

     Approach of Dorothy E. Johnson.  Johnson’s theory states that nurses should approach their profession and their client based on behavioral systems.  Within the behavioral systems there are several subsystems, “Attachment, achievement, aggressive, dependence, sexual, ingestive, and eliminative” (Johnson Behavioral System, 2002).  In each subsystem Johnson stated that the goal is unanimous among each individual.  Thus, a nurse is required, in accordance to Johnson’s theory, to have a strong relationship with the client so that each subsystem is fulfilled, “The interrelationships of the structural elements of the subsystem to maintain a balance that is adaptive to that individual’s needs”.  The nurse then is required to cater to each individual’s need.

The client then becomes dependent on the nurse, which furthers a trusting relationship.  The nurse is supposed to exhibit a helping behavior that promotes nurturing to the client.  Thus, the client gets a sense from the nurse of ‘approval, attention or recognition, and physical assistance’.  There must not be an imbalance in the Johnson theory or else the client’s health is jeopardized.  One issue of imbalance that definitely does exist is that of concerns about money; either the client not having it, or the nurse’s pay; each scenario resulting in disequilibrium.

The potential cost of in home health care is a care-giver burden as well as a patient burden.  The weight stressed here is not one that is easily remedied.  When put into perspective the cost is much more than money but also wavers on emotional stress to the care-giver and patient when the care-giver’s stresses are known to the patient.  Such stresses as highlighted above are job attendance, quitting a job, and the issue of time spent with a patient as opposed to time spent with other members of a family.  As Sanders states in Shouldering the Burden of Care, in which one family is analyzed, “Faced with her mother’s inevitable decline, she wonders whether she should continue to care for her in her home.  But the more important question is, can she?” (2005).  Thus, the issues of money are not only a concern for the patient but for the patient’s family as well; and through this, the patient is further stressed because not only can they not afford healthcare but they are putting their loved ones in a position where they are financially liable.  When the family is unable to support the patient, more stress is piled on the patient, and this becomes detrimental to the patient’s health.

Timeline

     The timeline of this scenario is presented in this fashion:

Hiring ill           Patient doesn’t receive         State of healthcare

equipped nurse       enough treatment                becomes national problem

__\_____________/_______________________/_________________

       /                     

       Cost of healthcare rises        Nurse loses job

Ways that Approaches are Congruent

This is the main point of care-giver burden: when faced with a choice of sending the patient to a nursing home, or institute where they can possibly be better attended to, should the family send the patient/family member away, or should they endure?  The potential for this question to raise a respite for patient care or to give into the burden of home-health care is pertinent in its prospective view of burden.  This is the common link proposed and evaluated in each theorists review.  The focus of the care-giver burden is the relationship between the patient and the nurse.

     Along this congruency found in each theorist’s findings, there is also the relationship between care-giver burden and money which is another facet that links each theorist and theory together.  The high-cost measurement presented in the Wilson study harkens to the reality of facts and numbers involving patients and their estimated cost of care per year in this country, and when a job is lost or sacrificed for the benefit of the patient the new stress becomes ‘where will the money come from for the upkeep of home health care?’

In the area of money, and of authority it is to nurses who are the advocates of the patient in the hospital that studies should be turning.  The role of the change agent in this case is to get the patient to buy into the need of a charge nurse, despite their failings as mentioned above, in order to feel more secure in a home setting, instead of a hospital.  Thus, the change agent successfully convinces the patient to spend more money on home health care which promotes the economy of the healthcare business. If a charge nurse is allowed to be a sufficient leader then the trust between the patient and them is strong (thus making the change agent’s job go smoothly).  In an at home environment the dangers of lack of funds arise and the emotional stress on family members and spending time with each other (either children, wife, or husband) and the noncompliance from other family members in putting the patient/loved-one in a home can be daunting.  The care-giver burden here is clear.  When a family member who isn’t equipped physically or professionally to take care of the ill, then an alternative way must be found and is found with nurses, and the high cost of in-home care.

Ways of Using These Approaches in Practice

     The approach of each theorist is congruent in the way in which emphasis is place solely on the dyad.  The nurse and the client relationship is what promotes better health in each theory presented.  Both the nurse and the client have the same goal; recovery.  This fact is more than highlighted in each theory, as in Rogers’ theory, “Health Patterning modalities are specific ways to help clients participate in creating change”.  This statement is true for each theory.  The purpose of nursing is entirely client focused.

Implications for Using these Approaches in Practice
The implications of using these approaches in practice would be the un-cooperation of either nurse or client.  The key for each theory is interaction, and willing interaction,  The dyad must be strong in order for goals to be successful, and since the nurse and the client have the same goals their failure or their success is interdependent, as Williams states in reference to a client coming back to the hospital for treatment of a leg wound that was not properly taken care of, “This lack of communication between the nurse and the client resulted in goals not being attained”.  Communication then becomes the ultimate key in attaining client-nurse goals.  The approach thus hinges on proper communication, if this is not done, client well-being may suffer as will the nurse’s reputation as a health care professional.

Three Benefits Gained from Using Nursing Models
Three benefits from using nursing models include the congruence of theories.  If the practice of theories remains constant to each nursing situation, then ultimate client care will be achieved due to a full spectrum of client concerns and practices being included in the corresponding theories.

     Another benefit to nursing models is that of framework.  Since the theories used are highlighted in real life situations, nurses have a frame of reference by which to base their empirical decisions.

     The final gain of nursing models being used can be demonstrated through the sharing of theories and ideas.  With this sharing and further implementation of nursing models and theories, practicing nurses have a broad range of finding for themselves what does and does not work for each individual client.

References

Barrett, Elizabeth Ann Manhart.  (August 30, 2000).  The     Theoretical Matrix for a Rogerian Nursing Practice. Journal of Nursing Theory.  Vol. 9, Issue 4.

Cutler, David M. (May 1995).  The Cost and Financing of Health Care. The American Economic Review. Vol. 85,    No. 2. p. 32-37.

Dallet, B.  (1994).  Economic Credentialing; Your Money or  Your Life.  Health Matrix. Vol. 4, Issue 2. pp325 363.

Johnson Behavioral System.  (September 1, 2002).  (Online).     Available:

     http://healthsci.clayton.edu/eichelberger/theory/john    on_behavioral_system.htm

Sager, Alan; Deborah Socolar. (July 23, 2003).  Lower U.S.     Prescription Drug  Prices are Vital to Both Patients

and Drug Makers. Boston University School of Public Health.

Sanders, Stacy, J.  (October 2005).  Shouldering the Burden Of Care.  Hastings Center Report. Vol. 35, Issue 5, p14.

Seiloff, Christina.  (2005).  Imogene King: A Conceptual    Framework for Nursing.  Sage Publications.  New York.

Welchman, Jennifer & Glenn G. Griener.  (December 2005).    Patient Advocacy and Professional   Associations: Individual And Collective Responsibilities.  Nursing  Ethics.  Vol.12, Issue 13, pp296-304.

Williams, Leigh Ann.  (2001).  Imogene King’s Interacting   Systems Theory.  Rural Nursing And Health Care.  Vol. 2, Issue 1.

Wilson, Leslie S.  et al.  (August 2005).  The Economic Burden Of Home Care for Children with  HIV and Other Chronic Illnesses.  American Journal of Public Health.   Vol. 95, Issue 8, p1445-52.

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