Copyright © eContent Management Pty Ltd. Contemporary Nurse (2013) 45(2): 255–263.
The provision of health and social care services for older people by respite providers DAVID EVANS School of Nursing and Midwifery, University of South Australia, Adelaide, SA, Australia
Abstract: Respite services have been established to support family carers by providing a break from the responsibilities of caregiving. However the literature and anecdotal evidence suggests that respite services offer carers much more than just providing a period of rest. This study was initiated to identify and describe the health and social care services that are offered to family carers and care-recipients by respite services in South Australia. The findings show that respite providers offer a service to both the family carer and care-recipient. Both groups are offered socialisation and engagement opportunities, and care-recipients have access to a diverse range of health care services. The description of respite that emerges from this study is that of a complex service offering much more than just a period of rest from caregiving duties.
Keywords: respite, carer, care-recipient, nursing, health, social
O
lder people account for significant proportion of the world population and this proportion is expected to increase over the next few decades. Accompanying this transition to an older population, age-related conditions are becoming a greater challenge for society. Approximately half of the people aged 80–84 years old have two or more chronic health conditions simultaneously (WHO, 2008). A consequence of these population changes is that there are more older people with complex care needs who are only able to continue living at home because a family member or friend acts as their carer. To help support these family carers, respite services have been established. Respite provides a short period of relief from the duties of care. Nurses play an important role in respite services, coordinating programmes, providing programme support and delivering nursing services to the clients. However, the role that nurses and other health and social care disciplines play in respite services is not well understood. Respite is sometimes portrayed as a relatively simple service offering of a period of relief for informal carers in the community. Yet despite this image, it is evident in the literature and in anecdotal evidence that respite providers also offer broader health and social care support. These additional services do much more than provide a break from caregiving responsibilities. While there are references to these services in the literature, they remain a
poorly understood component of respite. This paper reports the findings of an investigation into the health and social care support activities offered as part of the respite service for older people. FAMILY CARERS Becoming a carer is an unexpected responsibility for most people, one that brings many additional demands. There are both positive and negative experiences associated with being a carer. The positive aspects include companionship and the fulfilling, rewarding and meaningful nature of the role (Cohen, Colantonio, & Vernich, 2002). However, some carers describe a significant burden as a result of the caregiving role (Shim, Barroso, & Davis, 2011). Carers experience higher rates of depression and stress than noncaregivers (Pinquart & Sorenson, 2003). The constant demands of the caregiving role limit the opportunities to attend to personal needs. Living in the same house as the care-recipient is associated with negative psychosocial consequences (Covinsky et al., 2001) and the risk of social isolation (Robinson, Fortinsky, Kleppinger, Shugrue, & Porter, 2009). Studies suggest that 10–20%, or greater of older people may be socially isolated (Gardner, Brooke, Ozanne, & Kendig, 1999; Hawton et al., 2011; Victor, Scambler, Bond, & Bowling, 2000). This social isolation has a negative impact on health and wellbeing (Hawton et al., 2011; Victor et al., 2000) and may impact
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on a wide range of health outcomes (Tomaka, Thompson, & Palacios, 2006). Social isolation adds to the challenges faced by the carer because it is linked to an increased mortality (Wu & Rudkin, 2000) a greater risk of dementia (Fratiglioni, 2000), elevated blood pressure (Bower, 1997) and suicide (Centre for Disease Control and Prevention, 1996). Changes in society and in families, combined with the greater geographic mobility of society, suggests that social isolation will continue to increase (Tomaka et al., 2006). Many family carers are themselves older people and so have their own health issues. Older adults report a range of different barriers to accessing services and this can have a negative impact on their health and level of functioning (Taylor & Hoernig, 2006). Mobility limitations may increase an individual’s need for medical care while also hindering their access to services and fulfilling their health needs (Iezzoni, McCarty, Davis, & Siebens, 2000; Taylor & Hoernig, 2006). Caregivers and care-recipients are also reported to be reluctant to utilise community based services (Cox, 1997; Gaugler, Kane, Kane, & Newcomer, 2005) or commonly delay accessing them (Cox, 1997; Zarit, Stephens, Townsend, & Greene, 1998). It is therefore not surprising that being a carer is linked to increased mortality (Schultz et al., 1999) and poorer life satisfaction (Broe et al., 1999). With the ageing of the population there will be increased demands placed on community based health and social care resources. Carers and carerecipients will likely have greater difficulty accessing support services. Limited access to services and barriers to meaningful engagement with the community will increase the burden of the caregiving role as more carers are forced to negotiate the system on their own. RESPITE To help minimise the negative aspects of the caregiving role, a range of different communitybased services offer support to family carers and care-recipients. One of these services is respite, which provides a short break from the duties of care and time for the carer to rest and attend to their own needs. Periods of respite can improve
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the quality of life for the carer and care-recipient (Gitlin, Reever, Dennis, Mathieu, & Hauck, 2006) and bring some normality back into their life (Ashworth & Baker, 2000). Respite is a diverse service with poorly defined boundaries. It has been described as a soft service because of the difficulties in classifying and quantifying it (Bamford et al., 2009). Traditionally it has been viewed as relief from the duties of caregiving. However, it is also a blanket term that is used to describe a very diverse set of services (Lee, Morgan, & Lindesay, 2007). It is offered in range of settings, including community (Gottlieb & Johnson, 2000), institutions (Gottlieb & Johnson, 2000), specialist facilities (Arksey & Bamford, 2007; Bamford et al., 2009) and in the home (Chumbler, Dobbs-Kepper, Beverly, & Beck, 2000; Grant et al., 2003). There is no consensus on the overall aim of respite (Arksey et al., 2004), and there is some confusion about who the clients of the service are, family carer or carerecipient. Despite the call for a common language for respite (Noyes, 1996), it remains a conceptually broad and ambiguous service. While the primary purpose of respite is to provide a temporary relief from the responsibilities of care, it is evident in the literature and in anecdotal evidence that respite services also offer a range of health, education and socialisation support activities. The health services that are offered as part of respite include physiotherapy, speech therapy, nursing services, occupational therapy, psychological therapy and functional and physical rehabilitation (Baumgarten, Lebel, Laprise, Leclerc, & Quinn, 2002; Pomeroy et al., 1999; Silverstein, Wong, & Brueck, 2010). Exercise programmes are offered by some respite services (Baumgarten et al., 2002; Fitzsimmons & Buettner, 2002; Noyes, Daley, & French, 2000; Silverstein et al., 2010), as are complementary therapies such as massage (Fitzsimmons & Buettner, 2002; MacDonald, 1998), aromatherapy, sensory stimulation (Fitzsimmons & Buettner, 2002), guided imagery and humour (Noyes et al., 2000). Education (Silverstein et al., 2010), health promotion (Noyes et al., 2000), counselling and support groups (Baumgarten et al., 2002; Noyes et al., 2000; Silverstein et al., 2010) are also offered by
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some respite services. Socialisation activities as a component of the respite service have included social rehabilitation (Baumgarten et al., 2002), socialisation opportunities (Baumgarten et al., 2002; Noyes et al., 2000), crafts and games (Fitzsimmons & Buettner, 2002). Despite the references in the literature to these broader health and social care services as a component of respite, they have not been well described. Most commonly respite is presented as providing a period of relief from caregiving. In this context, respite is the ‘outcome’ of the service. However, respite as a ‘service’ to support the health and social needs of carers and care-recipients has not been well articulated. There are suggestions in the literature that respite offers a broad base of support, but its framework and structure remains ambiguous. This study was initiated to explore the health and social care support services offered by respite providers to family carers and care-recipients.
Participants Participants consisted of a convenience sample of coordinators of respite services in South Australia. Respite services were included in the study if they supported older people and their informal carers. Respite services that provided support to younger people or children and their family carers were excluded. Respite services were identified through key informants, internet searches, snowball sampling and by contact with residential care facilities. Services were identified in the metropolitan area and in rural and remote regions. The specific respite providers that were identified included: hospitals; residential aged care facilities; volunteer groups; town councils; community health centres; and home support services. In rural and remote regions it was more often a combined health service that was the provider of the respite service. Coordinators of these services were recruited by email or post and invited to participate in the study.
METHOD Aim The aim of this study was to identify and describe the health and social care services offered to family carers and care-recipients by respite providers. Health and social care were broadly defined as follows: (1) Health care was considered to any form of access to a health-related service (such as dental, podiatry or optical services) or access to a health care practitioner (such as nurse, physiotherapist or general practitioner). (2) Social care was broadly defined as interventions that support individuals by meeting needs or enabling them to meet needs that arise as a result of physical, mental or emotional impairment (Burge, Netten, & Gallo, 2010). These interventions can include such things as home care, personal assistance, carer training, socialisation and provision of assistive technologies.
Data collection and analysis Data was collected about the respite services using a questionnaire. An initial search failed to uncover any published respite questionnaires, therefore one was developed based on a review of the literature. Questions focussed on the characteristics of the respite service and on the health and social care support. Respite service questions addressed the provider, location and nature of the respite service. Open ended questions were used to explore the health and social care components of respite services focussing on education, social engagement opportunities, health and rehabilitation services, and any other support activities offered to either the care-giver or carerecipient. The questionnaire was reviewed by a panel of experts before use and then pilot tested on a small sample. Threats to internal validity of the questionnaire were minimised by using the literature as the foundation for its development and by having a panel of respite experts participate in the development process. Threats to external validity were minimised by ensuring a broad sampling strategy that recruited participants from a range of different respite providers in both metropolitan and regional centres. The questionnaire was distributed to respite coordinators by email or by post with a stamped addressed envelope included. If no response was
Design This descriptive study utilised a cross-sectional survey design to collect data on health and social care support offered during respite for older people using a questionnaire that was developed from the literature.
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received after a month, a second questionnaire was posted to the coordinator. Data was analysed in Excel using descriptive statistics to summarise responses. Open ended questions were analysed, using a simple thematic analysis that categorises similar responses, to allow presentation of findings in tables. Approval from the human research ethics committee was obtained before the commencement of the study. RESULTS A total of 439 questionnaires were distributed and 143 (32.6%) were returned by respite services from all regions of South Australia, the largest response came from respite services in the Adelaide metropolitan area (46.1%). Responses from remote or very remote regions of the state accounted for 10.4% of the returned questionnaires. Questionnaires were returned from a range of different organisations, the largest response came from residential care facilities (53.1%). Other organisations who responded included: combined services (13.4%); hospitals (8.4%); community health centres (6.3%); and home support services (6.3%). Responders described a range of different health and social support activities that were offered to clients as part of the respite service. These support activities were grouped into three broad areas: education; health services; and socialisation. In terms of the proportion of respite providers that offered this additional support, 45% of services offered education for carers, 68% offered health services for care-recipients and socialisation opportunities were offered to carerecipients by 90% of services and to family carers by 53%. No responders reported offering any health services to family carers. 1. Education Education for the family carer was offered by 45% of responders. This education concerned the provision of general information, advice, telephone support and education about specific health issues. The general information that was offered was described as the provision of pamphlets and handouts, informal education, skill development and access to library materials. The advice that was provided was described as information about medical and allied health services, accessing permanent placement and getting professional
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support. One responder reported offering a telephone support service so that family carers could seek expert advice outside of the normal respite contact hours. Education focussing on a specific health issue was provided by 11.2% of respite services and focussed on issues such as medication management, continence, wound care and fall prevention. Respite services also provided family carers with information about community-based services, how to access equipment and links to organisations such as the Alzheimer’s Association. 2. Health services Health services for care-recipients were offered by 68% of respite services. No responders reported offering any health services for family carers. Care-recipient health services involved having access to health professionals or being able to attend a specific health service. Health professionals that care-recipients were able to access during respite included: a physiotherapist; podiatrist; medical officer; speech pathologist; dietician; and nurse. Specific health services offered to carerecipients included medication management, diabetic review and wound management. Table 1 lists the type of health professionals and the range of specific health services that were offered to care-recipients. 3. Socialisation Opportunities for carers and care-recipients to socialise with other people or to engage in pleasurable activities were offered by many respite services. Socialisation opportunities for care-recipients were offered by 90% of services and included such things as outings, meals, crafts and music. Socialisation opportunities for family carers were offered by 53% of services and included such things as clubs, lunches, outings and leisure activities. The most common socialisation activity offered to carers and care-recipients was to be able to participate in the activities offered by a residential care facility to its residents. Table 2 lists the social engagement activities that were offered by respite services. DISCUSSION Findings of this study highlight a dimension of respite services that is not well described in the
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The provision of health and social care services for older people TABLE 1: HEALTH SERVICES FOR CARE-RECIPIENTS (N = 143)
TABLE 2: SOCIAL ENGAGEMENT (N = 143) Family carers
Health professional access
N
%
Physiotherapist Podiatrist Medical officer Speech pathologist Dietician Dentist or dental service Occupational therapist Nursing service Allied health service Social worker Pharmacist Audiologist
60 38 21 20 13 12 10 10 10 3 3 1
42 26.6 14.7 14 9.1 8.4 7 7 7 2.1 2.1 0.7
Specific health service access Medication administration or management Diabetic review, management or education Wound management Referral services Falls assessment and prevention Yoga or tai chi Counselling Palliative care Rehabilitation support Continence management Mental health service Denture clinic Optical service
N 4
% 2.8
4
2.8
3 3 2 2 1 1 1 1 1 1 1
2.1 2.1 1.4 1.4 0.7 0.7 0.7 0.7 0.7 0.7 0.7
literature. Some respite services only provide a period of rest for the family carer, others offer a broader base of support for both the carer and care-recipient. This study provides a description of the health and social care that is offered by some respite providers and gives a greater insight into the nature of the service and its clients. Health and social care A diverse range of health-related services for carerecipients were offered by 68% of respite providers. These services provided the opportunity for care-recipients to meet with health professionals or attend health-related services. There are reports in the literature about respite providers engaging care-recipients in health-related activities and
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N
%
Participate in activities of facility Lunches, morning and afternoon teas Days out and outings Carers support and social groups Leisure activity groups Retreats Festive activities Pampering Pampering Carers week Men’s group Art and craft groups Community shed programme Dementia club Veterans group Dance club
39 19 13 9 4 3 3 3 3 2 2 2 1 1 1 1
27.3 13.3 9.1 6.3 2.8 2.1 2.1 2.1 2.1 1.4 1.4 1.4 0.7 0.7 0.7 0.7
Care-recipients Participate in activities of facility Trips and outings Meals, teas and drinks Crafts, cookery & gardening Music Interact with residents in facility Bingo Sports and physical activities Spiritual activities Diversional therapy Social events Lifestyle programmes Movies Card and board games Poetry reading Footy tipping
N 39 21 18 10 9 9 9 7 6 4 4 3 3 3 1 1
% 27.3 14.7 12.6 7 6.3 6.3 6.3 4.9 4.2 2.8 2.8 2.1 2.1 2.1 0.7 0.7
assessments (Noyes et al., 2000), providing opportunities to attend health professionals (Pomeroy et al., 1999; Silverstein et al., 2010) and health services (Baumgarten et al., 2002). Health-related services were not offered to family carers by any of the respite providers in this study. This is an interesting finding given that respite is often considered to be a service that supports family carers. Attending to personal health needs can be a significant challenge for family carers because of the unremitting nature of caregiving. Reports and evaluations in
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the literature about respite are also silent about the provision of health-related services to carers by respite providers. However, as part of the national carers’ strategy demonstrator sites programme that was introduced across England in 2009, health and well-being checks for carers formed a key part of the strategy (Yeandle & Wigfield, 2011). This acknowledges that carers should not have to ignore personal health concerns because their caregiving duties do not allow the time to attend to them (Yeandle & Wigfield, 2011). These health check sites seek to prevent deterioration in the carer’s health, improve access to health and social care services, help sustain the caring relationship and improve carers’ ability to manage their own health (Joynes, Buse, Wigfield, & Yeandle, 2011). However, health support for family carers is generally poorly addressed in the respite literature. Education was offered to carers by 45% of respite providers, highlighting the important education component of respite services. Given that being a family carer is often an unexpected career (Pearlin & Anashensel, 1994), many carers will lack the knowledge and skills required to fulfil their caregiving role. Respite services provide an opportunity for family carers to learn how to do things properly by watching professional staff deliver care for their relative (Parahoo, Campbell, & Scoltock, 2002). One respite provider offered clients a telephone support service, extending the period during which expert advice could be sought. Being able to contact a familiar person when in need of information or advice may help minimise some of the challenges faced by family carers. This would be a valuable service for those carers with only limited family and social networks. Respite providers also assisted clients in other ways, helping them find other communitybased support services or obtain equipment. This type of assistance is critical given that carers and care-recipients are reluctant to access communitybased services (Cox, 1997; Gaugler et al., 2005; Zarit et al., 1998). Socialisation support was the most common additional activity offered by respite providers. This support was offered to care-recipients by 90% of services and to family carers by 53%. For carers this was most often achieved through their
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participation in activities offered by residential care facilities. However, some providers offered activities developed specifically for carers such as outings, lunch functions and special interest groups. Socialisation for care-recipient was most often achieved through a range of different activities such as outings, music, bingo, sports and social events. Given the risk of social isolation for older people (Hawton et al., 2011) and the negative impact that this isolation can have (Victor et al., 2000), keeping carers and care-recipients connected to the community, maintaining existing social networks and establishing new ones is an important component for health and wellbeing. Therefore this social care that is offered by respite providers is an important support strategy that could have a positive impact on the health and wellbeing of both carer and care-recipient. The nature of the service Respite is often presented in the literature as providing a period of rest and relief. It has been described as a temporary break from caregiving responsibilities and an opportunity for the carer to let go for a while (Chappell, Reid, & Dow, 2001; Perry & Bontinen, 2001; Strang & Haughey, 1999). However, the description that emerges from this study is one of a more comprehensive and complex service that offers clients access to a broad range of health and social care support. The findings suggest that some respite services appear to function more as informal community health centres that offer clients access to some primary health care services and links to other more formal health and community services. While there is evidence in the literature that other respite providers also offer a range of health and social care support services (Baumgarten et al., 2002; Fitzsimmons & Buettner, 2002; MacDonald, 1998; Noyes et al., 2000; Pomeroy et al., 1999; Silverstein et al., 2010), this aspect of respite is not well described. This study shows that respite services are concerned with much more than just providing a period of rest. The clients There is confusion in the literature about the clients of respite services. It is most often considered
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The provision of health and social care services for older people to be family carers (Carroll, Vetor, Holmes, & Supiano, 2005; Grant et al., 2003; van Exel, de Graaf, & Brouwer, 2008; Vecchio, 2008). However a dual client focus (Carroll et al., 2005; Kosloski & Montgomery, 1993; Lee et al., 2007; Noyes, 1996) and a whole of family approach (Yeandle & Wigfield, 2011) are also acknowledged. This study shows that respite is a service for both the family carer and the care-recipient. Both gain a benefit from the respite service, but the nature of the service differs for each. This finding reinforces the earlier statement that respite is a complex service that is offered to both carers and care-recipients. Implications Descriptions in the literature about respite and respite services are surprisingly sparse. This study provides a brief snap shot of the health and social care that is provided by respite services in South Australia. These findings highlight the expanded role that some services have adopted in their support of family carers and care-recipients. These findings highlight the potential to revisit how respite services are currently configured. The provision of education, social care services, opportunities for socialisation and links to the broader health system represent important strategies to support these people. With the ageing of the Australian population and the shift of care for older people back into the community, this broader base of support may have important implications for the future of community-based services. The findings of this study also highlight the need for further research into respite and respite services. A broad range of professionals offer a diverse health and social care service. However, respite remains poorly understood and the expanded role seems to reflect individual provider innovation rather than a formalised expansion of the service. The specific nature of the health and social care services and their impact on clients remains unclear. Further research is needed to better understand the potential impact of the broader service role of respite and to determine the optimal configuration of services.
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CONCLUSION To help minimise some of the negative aspects of the caregiving role, respite providers offer a range of community-based support services. This evaluation identified and described the health and social care support offered by respite providers in South Australia. These activities focus on the provision of education, health services and socialisation opportunities. The findings clearly highlight the dual client focus of respite, although there are differences in the nature of the service that is provided to clients. REFERENCES Arksey, H., & Bamford, C. (2007). Respite care for people with dementia: The range f models for getting a break. The Journal of Dementia Care, 15(3), 37–39. Arksey, H., Jackson, K., Croucher, K., Weatherly, H., Golder, S., Hare, P., … Sally, B. (2004). Review of respite services and short term breaks for carers for people with dementia. London, England: National Coordinating Centre for NHS Service Delivery and Organisation. Ashworth, M., & Baker, A. H. (2000). Time and space: Carer’s views about respite care. Health and Social Care in the Community, 8(1), 50–56. Bamford, C., Arksey, H., Poole, M., Kirkley, C., Hughes, J., & Corner, L. et al. (2009). Person- and carer-centred respite care for people with dementia: Developing methods of evaluating the effectiveness of different models. Southhampton, England: National Institute for Health Research Service Delivery and Organisation. Baumgarten, M., Lebel, P., Laprise, H., Leclerc, C., & Quinn, C. (2002). Adult day care for frail elderly: Outcomes satisfaction and cost. Journal of Aging Health, 14, 237–259. Bower, B. (1997). Social links may counter health risks: Research on how social isolation affects mortality in older adults. Science News, 152(9), 135. Broe, G., Jorm, A., Creasy, H., Casey, B., Bennett, H., Cullen, J., … Grayson, D. (1999). Carer distress in the general population: Results from the Sydney older persons study. Age and Ageing, 28, 307–311. Burge, P., Netten, A., & Gallo, F. (2010). Estimating the value of social care. Journal of Health Economics, 29, 883–894. Carroll, A. M., Vetor, K., Holmes, S., & Supiano, K. P. (2005). Ask the consumer: An innovative appproach
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practice implications. Aging and Mental Health, 4(2), 119–129. Grant, I., McKibbin, C. L., Taylor, M. J., Mills, P., Dimsdale, J., Ziegler, M., & Patterson T. L. (2003). In-home respite intervention reduces plasma epinephrine in stressed Alzheimer caregivers. American Journal of Geriatric Psychiatry, 11(1), 62–72. Hawton, A., Green, C., Dickens, A. P., Richards, S. H., Taylor, R. S., Edwards, R., … John, L. C. (2011). The impact of social isolation on the health status and health-related quality of life of older people. Quality of Life Research, 20, 57–67. Iezzoni, L. I., McCarty, E. P., Davis, R. B., & Siebens, H. (2000). Mobility impairments and use of screening and prevention services. American Journal of Public Health, 90(6), 955–961. Joynes, V., Buse, C., Wigfield, A., & Yeandle, S. (2011). Supporting carers’ health and well-being through innovative approaches. In S. Yeandle & A. Wigfield (Eds.), New approaches to supporting carer’s health and well-being: Evidence from national carers’ strategy demonstrator sites programme. Leeds, England: Centre for International Research on Care, Labour and Equalities, University of Leeds. Kosloski, K., & Montgomery, R. J. V. (1993). The effects of respite on caregivers of Alzheimer’s patients: One year evaluation of the Michigan model respite programs. Journal of Applied Gerontology, 12(1), 4–17. Lee, D., Morgan, K., & Lindesay, J. (2007). Effect of institutional respite care on the sleep of people with dementia and their caregivers. Journal of the American Geriatrics Society, 55(2), 252–258. MacDonald, G. (1998). Massage as a respite intervention for primary caregivers. American Journal of Hospice and Palliative Medicine, 15, 43–47. Noyes, L. E. (1996). Adult day care: Getting on that train into the 21st century. American Journal of Alzheimer’s Disease and Other Dementias, 11(5), 46. Noyes, L. E., Daley, P., & French, K. (2000). Community-based services help people in the early stages of Alzheimer’s disease and other cognitive impairments. American Journal of Alzheimer’s Disease and Other Dementias, 15(5), 309–313. Parahoo, K., Campbell, A., & Scoltock, C. (2002). An evaluation of a domiciliary respite service for younger people with dementia. Journal of Evaluation in Clinical Practice, 8(4), 377–385. Pearlin, L. I., & Anashensel, C. S. (1994). Caregiving: The unexpected career. Social Justice Research, 7, 373–390. Perry, J., & Bontinen, K. (2001). Evaluation of a weekend respite program for persons with Alzheimer’s
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Taylor, D. H., & Hoernig, H. (2006). Access to health care services for the disabled elderly. Health Services Research, 41(3 (Part 1)), 743-758. Tomaka, J., Thompson, S., & Palacios, R. (2006). The relation of social isolation, loneliness, and social support to disease outcomes among the elderly. Journal of Aging and Health, 18(3), 359–384. van Exel, J., de Graaf, G., & Brouwer, W. (2008). Give me a break: Informal caregiver attitudes towards respite care. Health Policy, 88, 73–87. Vecchio, N. (2008). Understanding the use of respite services among informal carers. Australian Health Review, 32(3), 459–467. Victor, C., Scambler, S., Bond, J., & Bowling, A. (2000). Being alone in later life: loneliness, social isolation and living alone. Reviews in Clinical Gerontology, 10, 407–417. WHO (2008). The world health report – Primary health care: Now more than ever. Geneva, Switzerland: Author. Wu, Z., & Rudkin, L. (2000). Social contact, socioeconomic status and the health status of older Malaysians. The Gerontologist, 40, 228–234. Yeandle, S., & Wigfield, A. (Eds.). (2011). New approaches to supporting carer’s health and well-being: Evidence from national carers’ strategy demonstrator sites programme. Leeds, England: Centre for International Research on Care, Labour and Equalities, University of Leads. Zarit, S. H., Stephens, M. A., Townsend, A., & Greene, R. (1998). Stress reduction for family caregivers: Effects of adult day care use. Journal of Gerontology: Social Sciences, 53B, S267–S277. Received 17 November 2012
Accepted 08 March 2013
ANNOUNCING LONGEVITY: SOCIOLOGICAL PERSPECTIVES ON HEALTH, ILLNESS AND SERVICE PROVISION A special issue of Health Sociology Review – Volume 23 Issue 1 – ii + 126 pages – ISBN 978-1-921980-25-1 – March 2014 Guest Editors: Pauline Savy (La Trobe University, Australia), Anne-Maree Sawyer (La Trobe University, Australia) and Jeni Warburton (La Trobe University, Australia) This special issue of Health Sociology Review examines the possibility and actuality of living to very old age. In our times, cultural discourses to do with maintaining health and independence for as long as possible pervade social policy and the personal narratives of ageing. Sociologically, these raise interesting, and often contentious, questions about the role of structural support systems, the delivery of appropriate health care, and the phenomenological experience of ageing and dealing with frailty and decline. • Ageing and health of particular groups eg Indigenous, migrant, • Dementia gendered groups, rural and remote populations • Living with common and chronic conditions including psychiatric conditions • Evaluation of specific care provision and levels eg acute hospital care, community care, long-term care and health promotion programs • Family relationships in old age and ill health • The ageing body, decline, dying and death • Professionalisation and specialisation, for example, changing role boundaries in aged care, workforce situations and impacts • Health and illness in the oldest generation • Ageing and medicalisation • Social, structural factors that promote or oppose longevity and wellness http://hsr.e-contentmanagement.com/archives/vol/23/issue/1/marketing/
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The provision of health and social care services for older people by respite providers DAVID EVANS School of Nursing and Midwifery, University of South Australia, Adelaide, SA, Australia
Abstract: Respite services have been established to support family carers by providing a break from the responsibilities of caregiving. However the literature and anecdotal evidence suggests that respite services offer carers much more than just providing a period of rest. This study was initiated to identify and describe the health and social care services that are offered to family carers and care-recipients by respite services in South Australia. The findings show that respite providers offer a service to both the family carer and care-recipient. Both groups are offered socialisation and engagement opportunities, and care-recipients have access to a diverse range of health care services. The description of respite that emerges from this study is that of a complex service offering much more than just a period of rest from caregiving duties.
Keywords: respite, carer, care-recipient, nursing, health, social
O
lder people account for significant proportion of the world population and this proportion is expected to increase over the next few decades. Accompanying this transition to an older population, age-related conditions are becoming a greater challenge for society. Approximately half of the people aged 80–84 years old have two or more chronic health conditions simultaneously (WHO, 2008). A consequence of these population changes is that there are more older people with complex care needs who are only able to continue living at home because a family member or friend acts as their carer. To help support these family carers, respite services have been established. Respite provides a short period of relief from the duties of care. Nurses play an important role in respite services, coordinating programmes, providing programme support and delivering nursing services to the clients. However, the role that nurses and other health and social care disciplines play in respite services is not well understood. Respite is sometimes portrayed as a relatively simple service offering of a period of relief for informal carers in the community. Yet despite this image, it is evident in the literature and in anecdotal evidence that respite providers also offer broader health and social care support. These additional services do much more than provide a break from caregiving responsibilities. While there are references to these services in the literature, they remain a
poorly understood component of respite. This paper reports the findings of an investigation into the health and social care support activities offered as part of the respite service for older people. FAMILY CARERS Becoming a carer is an unexpected responsibility for most people, one that brings many additional demands. There are both positive and negative experiences associated with being a carer. The positive aspects include companionship and the fulfilling, rewarding and meaningful nature of the role (Cohen, Colantonio, & Vernich, 2002). However, some carers describe a significant burden as a result of the caregiving role (Shim, Barroso, & Davis, 2011). Carers experience higher rates of depression and stress than noncaregivers (Pinquart & Sorenson, 2003). The constant demands of the caregiving role limit the opportunities to attend to personal needs. Living in the same house as the care-recipient is associated with negative psychosocial consequences (Covinsky et al., 2001) and the risk of social isolation (Robinson, Fortinsky, Kleppinger, Shugrue, & Porter, 2009). Studies suggest that 10–20%, or greater of older people may be socially isolated (Gardner, Brooke, Ozanne, & Kendig, 1999; Hawton et al., 2011; Victor, Scambler, Bond, & Bowling, 2000). This social isolation has a negative impact on health and wellbeing (Hawton et al., 2011; Victor et al., 2000) and may impact
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on a wide range of health outcomes (Tomaka, Thompson, & Palacios, 2006). Social isolation adds to the challenges faced by the carer because it is linked to an increased mortality (Wu & Rudkin, 2000) a greater risk of dementia (Fratiglioni, 2000), elevated blood pressure (Bower, 1997) and suicide (Centre for Disease Control and Prevention, 1996). Changes in society and in families, combined with the greater geographic mobility of society, suggests that social isolation will continue to increase (Tomaka et al., 2006). Many family carers are themselves older people and so have their own health issues. Older adults report a range of different barriers to accessing services and this can have a negative impact on their health and level of functioning (Taylor & Hoernig, 2006). Mobility limitations may increase an individual’s need for medical care while also hindering their access to services and fulfilling their health needs (Iezzoni, McCarty, Davis, & Siebens, 2000; Taylor & Hoernig, 2006). Caregivers and care-recipients are also reported to be reluctant to utilise community based services (Cox, 1997; Gaugler, Kane, Kane, & Newcomer, 2005) or commonly delay accessing them (Cox, 1997; Zarit, Stephens, Townsend, & Greene, 1998). It is therefore not surprising that being a carer is linked to increased mortality (Schultz et al., 1999) and poorer life satisfaction (Broe et al., 1999). With the ageing of the population there will be increased demands placed on community based health and social care resources. Carers and carerecipients will likely have greater difficulty accessing support services. Limited access to services and barriers to meaningful engagement with the community will increase the burden of the caregiving role as more carers are forced to negotiate the system on their own. RESPITE To help minimise the negative aspects of the caregiving role, a range of different communitybased services offer support to family carers and care-recipients. One of these services is respite, which provides a short break from the duties of care and time for the carer to rest and attend to their own needs. Periods of respite can improve
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the quality of life for the carer and care-recipient (Gitlin, Reever, Dennis, Mathieu, & Hauck, 2006) and bring some normality back into their life (Ashworth & Baker, 2000). Respite is a diverse service with poorly defined boundaries. It has been described as a soft service because of the difficulties in classifying and quantifying it (Bamford et al., 2009). Traditionally it has been viewed as relief from the duties of caregiving. However, it is also a blanket term that is used to describe a very diverse set of services (Lee, Morgan, & Lindesay, 2007). It is offered in range of settings, including community (Gottlieb & Johnson, 2000), institutions (Gottlieb & Johnson, 2000), specialist facilities (Arksey & Bamford, 2007; Bamford et al., 2009) and in the home (Chumbler, Dobbs-Kepper, Beverly, & Beck, 2000; Grant et al., 2003). There is no consensus on the overall aim of respite (Arksey et al., 2004), and there is some confusion about who the clients of the service are, family carer or carerecipient. Despite the call for a common language for respite (Noyes, 1996), it remains a conceptually broad and ambiguous service. While the primary purpose of respite is to provide a temporary relief from the responsibilities of care, it is evident in the literature and in anecdotal evidence that respite services also offer a range of health, education and socialisation support activities. The health services that are offered as part of respite include physiotherapy, speech therapy, nursing services, occupational therapy, psychological therapy and functional and physical rehabilitation (Baumgarten, Lebel, Laprise, Leclerc, & Quinn, 2002; Pomeroy et al., 1999; Silverstein, Wong, & Brueck, 2010). Exercise programmes are offered by some respite services (Baumgarten et al., 2002; Fitzsimmons & Buettner, 2002; Noyes, Daley, & French, 2000; Silverstein et al., 2010), as are complementary therapies such as massage (Fitzsimmons & Buettner, 2002; MacDonald, 1998), aromatherapy, sensory stimulation (Fitzsimmons & Buettner, 2002), guided imagery and humour (Noyes et al., 2000). Education (Silverstein et al., 2010), health promotion (Noyes et al., 2000), counselling and support groups (Baumgarten et al., 2002; Noyes et al., 2000; Silverstein et al., 2010) are also offered by
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some respite services. Socialisation activities as a component of the respite service have included social rehabilitation (Baumgarten et al., 2002), socialisation opportunities (Baumgarten et al., 2002; Noyes et al., 2000), crafts and games (Fitzsimmons & Buettner, 2002). Despite the references in the literature to these broader health and social care services as a component of respite, they have not been well described. Most commonly respite is presented as providing a period of relief from caregiving. In this context, respite is the ‘outcome’ of the service. However, respite as a ‘service’ to support the health and social needs of carers and care-recipients has not been well articulated. There are suggestions in the literature that respite offers a broad base of support, but its framework and structure remains ambiguous. This study was initiated to explore the health and social care support services offered by respite providers to family carers and care-recipients.
Participants Participants consisted of a convenience sample of coordinators of respite services in South Australia. Respite services were included in the study if they supported older people and their informal carers. Respite services that provided support to younger people or children and their family carers were excluded. Respite services were identified through key informants, internet searches, snowball sampling and by contact with residential care facilities. Services were identified in the metropolitan area and in rural and remote regions. The specific respite providers that were identified included: hospitals; residential aged care facilities; volunteer groups; town councils; community health centres; and home support services. In rural and remote regions it was more often a combined health service that was the provider of the respite service. Coordinators of these services were recruited by email or post and invited to participate in the study.
METHOD Aim The aim of this study was to identify and describe the health and social care services offered to family carers and care-recipients by respite providers. Health and social care were broadly defined as follows: (1) Health care was considered to any form of access to a health-related service (such as dental, podiatry or optical services) or access to a health care practitioner (such as nurse, physiotherapist or general practitioner). (2) Social care was broadly defined as interventions that support individuals by meeting needs or enabling them to meet needs that arise as a result of physical, mental or emotional impairment (Burge, Netten, & Gallo, 2010). These interventions can include such things as home care, personal assistance, carer training, socialisation and provision of assistive technologies.
Data collection and analysis Data was collected about the respite services using a questionnaire. An initial search failed to uncover any published respite questionnaires, therefore one was developed based on a review of the literature. Questions focussed on the characteristics of the respite service and on the health and social care support. Respite service questions addressed the provider, location and nature of the respite service. Open ended questions were used to explore the health and social care components of respite services focussing on education, social engagement opportunities, health and rehabilitation services, and any other support activities offered to either the care-giver or carerecipient. The questionnaire was reviewed by a panel of experts before use and then pilot tested on a small sample. Threats to internal validity of the questionnaire were minimised by using the literature as the foundation for its development and by having a panel of respite experts participate in the development process. Threats to external validity were minimised by ensuring a broad sampling strategy that recruited participants from a range of different respite providers in both metropolitan and regional centres. The questionnaire was distributed to respite coordinators by email or by post with a stamped addressed envelope included. If no response was
Design This descriptive study utilised a cross-sectional survey design to collect data on health and social care support offered during respite for older people using a questionnaire that was developed from the literature.
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received after a month, a second questionnaire was posted to the coordinator. Data was analysed in Excel using descriptive statistics to summarise responses. Open ended questions were analysed, using a simple thematic analysis that categorises similar responses, to allow presentation of findings in tables. Approval from the human research ethics committee was obtained before the commencement of the study. RESULTS A total of 439 questionnaires were distributed and 143 (32.6%) were returned by respite services from all regions of South Australia, the largest response came from respite services in the Adelaide metropolitan area (46.1%). Responses from remote or very remote regions of the state accounted for 10.4% of the returned questionnaires. Questionnaires were returned from a range of different organisations, the largest response came from residential care facilities (53.1%). Other organisations who responded included: combined services (13.4%); hospitals (8.4%); community health centres (6.3%); and home support services (6.3%). Responders described a range of different health and social support activities that were offered to clients as part of the respite service. These support activities were grouped into three broad areas: education; health services; and socialisation. In terms of the proportion of respite providers that offered this additional support, 45% of services offered education for carers, 68% offered health services for care-recipients and socialisation opportunities were offered to carerecipients by 90% of services and to family carers by 53%. No responders reported offering any health services to family carers. 1. Education Education for the family carer was offered by 45% of responders. This education concerned the provision of general information, advice, telephone support and education about specific health issues. The general information that was offered was described as the provision of pamphlets and handouts, informal education, skill development and access to library materials. The advice that was provided was described as information about medical and allied health services, accessing permanent placement and getting professional
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support. One responder reported offering a telephone support service so that family carers could seek expert advice outside of the normal respite contact hours. Education focussing on a specific health issue was provided by 11.2% of respite services and focussed on issues such as medication management, continence, wound care and fall prevention. Respite services also provided family carers with information about community-based services, how to access equipment and links to organisations such as the Alzheimer’s Association. 2. Health services Health services for care-recipients were offered by 68% of respite services. No responders reported offering any health services for family carers. Care-recipient health services involved having access to health professionals or being able to attend a specific health service. Health professionals that care-recipients were able to access during respite included: a physiotherapist; podiatrist; medical officer; speech pathologist; dietician; and nurse. Specific health services offered to carerecipients included medication management, diabetic review and wound management. Table 1 lists the type of health professionals and the range of specific health services that were offered to care-recipients. 3. Socialisation Opportunities for carers and care-recipients to socialise with other people or to engage in pleasurable activities were offered by many respite services. Socialisation opportunities for care-recipients were offered by 90% of services and included such things as outings, meals, crafts and music. Socialisation opportunities for family carers were offered by 53% of services and included such things as clubs, lunches, outings and leisure activities. The most common socialisation activity offered to carers and care-recipients was to be able to participate in the activities offered by a residential care facility to its residents. Table 2 lists the social engagement activities that were offered by respite services. DISCUSSION Findings of this study highlight a dimension of respite services that is not well described in the
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The provision of health and social care services for older people TABLE 1: HEALTH SERVICES FOR CARE-RECIPIENTS (N = 143)
TABLE 2: SOCIAL ENGAGEMENT (N = 143) Family carers
Health professional access
N
%
Physiotherapist Podiatrist Medical officer Speech pathologist Dietician Dentist or dental service Occupational therapist Nursing service Allied health service Social worker Pharmacist Audiologist
60 38 21 20 13 12 10 10 10 3 3 1
42 26.6 14.7 14 9.1 8.4 7 7 7 2.1 2.1 0.7
Specific health service access Medication administration or management Diabetic review, management or education Wound management Referral services Falls assessment and prevention Yoga or tai chi Counselling Palliative care Rehabilitation support Continence management Mental health service Denture clinic Optical service
N 4
% 2.8
4
2.8
3 3 2 2 1 1 1 1 1 1 1
2.1 2.1 1.4 1.4 0.7 0.7 0.7 0.7 0.7 0.7 0.7
literature. Some respite services only provide a period of rest for the family carer, others offer a broader base of support for both the carer and care-recipient. This study provides a description of the health and social care that is offered by some respite providers and gives a greater insight into the nature of the service and its clients. Health and social care A diverse range of health-related services for carerecipients were offered by 68% of respite providers. These services provided the opportunity for care-recipients to meet with health professionals or attend health-related services. There are reports in the literature about respite providers engaging care-recipients in health-related activities and
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N
%
Participate in activities of facility Lunches, morning and afternoon teas Days out and outings Carers support and social groups Leisure activity groups Retreats Festive activities Pampering Pampering Carers week Men’s group Art and craft groups Community shed programme Dementia club Veterans group Dance club
39 19 13 9 4 3 3 3 3 2 2 2 1 1 1 1
27.3 13.3 9.1 6.3 2.8 2.1 2.1 2.1 2.1 1.4 1.4 1.4 0.7 0.7 0.7 0.7
Care-recipients Participate in activities of facility Trips and outings Meals, teas and drinks Crafts, cookery & gardening Music Interact with residents in facility Bingo Sports and physical activities Spiritual activities Diversional therapy Social events Lifestyle programmes Movies Card and board games Poetry reading Footy tipping
N 39 21 18 10 9 9 9 7 6 4 4 3 3 3 1 1
% 27.3 14.7 12.6 7 6.3 6.3 6.3 4.9 4.2 2.8 2.8 2.1 2.1 2.1 0.7 0.7
assessments (Noyes et al., 2000), providing opportunities to attend health professionals (Pomeroy et al., 1999; Silverstein et al., 2010) and health services (Baumgarten et al., 2002). Health-related services were not offered to family carers by any of the respite providers in this study. This is an interesting finding given that respite is often considered to be a service that supports family carers. Attending to personal health needs can be a significant challenge for family carers because of the unremitting nature of caregiving. Reports and evaluations in
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the literature about respite are also silent about the provision of health-related services to carers by respite providers. However, as part of the national carers’ strategy demonstrator sites programme that was introduced across England in 2009, health and well-being checks for carers formed a key part of the strategy (Yeandle & Wigfield, 2011). This acknowledges that carers should not have to ignore personal health concerns because their caregiving duties do not allow the time to attend to them (Yeandle & Wigfield, 2011). These health check sites seek to prevent deterioration in the carer’s health, improve access to health and social care services, help sustain the caring relationship and improve carers’ ability to manage their own health (Joynes, Buse, Wigfield, & Yeandle, 2011). However, health support for family carers is generally poorly addressed in the respite literature. Education was offered to carers by 45% of respite providers, highlighting the important education component of respite services. Given that being a family carer is often an unexpected career (Pearlin & Anashensel, 1994), many carers will lack the knowledge and skills required to fulfil their caregiving role. Respite services provide an opportunity for family carers to learn how to do things properly by watching professional staff deliver care for their relative (Parahoo, Campbell, & Scoltock, 2002). One respite provider offered clients a telephone support service, extending the period during which expert advice could be sought. Being able to contact a familiar person when in need of information or advice may help minimise some of the challenges faced by family carers. This would be a valuable service for those carers with only limited family and social networks. Respite providers also assisted clients in other ways, helping them find other communitybased support services or obtain equipment. This type of assistance is critical given that carers and care-recipients are reluctant to access communitybased services (Cox, 1997; Gaugler et al., 2005; Zarit et al., 1998). Socialisation support was the most common additional activity offered by respite providers. This support was offered to care-recipients by 90% of services and to family carers by 53%. For carers this was most often achieved through their
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participation in activities offered by residential care facilities. However, some providers offered activities developed specifically for carers such as outings, lunch functions and special interest groups. Socialisation for care-recipient was most often achieved through a range of different activities such as outings, music, bingo, sports and social events. Given the risk of social isolation for older people (Hawton et al., 2011) and the negative impact that this isolation can have (Victor et al., 2000), keeping carers and care-recipients connected to the community, maintaining existing social networks and establishing new ones is an important component for health and wellbeing. Therefore this social care that is offered by respite providers is an important support strategy that could have a positive impact on the health and wellbeing of both carer and care-recipient. The nature of the service Respite is often presented in the literature as providing a period of rest and relief. It has been described as a temporary break from caregiving responsibilities and an opportunity for the carer to let go for a while (Chappell, Reid, & Dow, 2001; Perry & Bontinen, 2001; Strang & Haughey, 1999). However, the description that emerges from this study is one of a more comprehensive and complex service that offers clients access to a broad range of health and social care support. The findings suggest that some respite services appear to function more as informal community health centres that offer clients access to some primary health care services and links to other more formal health and community services. While there is evidence in the literature that other respite providers also offer a range of health and social care support services (Baumgarten et al., 2002; Fitzsimmons & Buettner, 2002; MacDonald, 1998; Noyes et al., 2000; Pomeroy et al., 1999; Silverstein et al., 2010), this aspect of respite is not well described. This study shows that respite services are concerned with much more than just providing a period of rest. The clients There is confusion in the literature about the clients of respite services. It is most often considered
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The provision of health and social care services for older people to be family carers (Carroll, Vetor, Holmes, & Supiano, 2005; Grant et al., 2003; van Exel, de Graaf, & Brouwer, 2008; Vecchio, 2008). However a dual client focus (Carroll et al., 2005; Kosloski & Montgomery, 1993; Lee et al., 2007; Noyes, 1996) and a whole of family approach (Yeandle & Wigfield, 2011) are also acknowledged. This study shows that respite is a service for both the family carer and the care-recipient. Both gain a benefit from the respite service, but the nature of the service differs for each. This finding reinforces the earlier statement that respite is a complex service that is offered to both carers and care-recipients. Implications Descriptions in the literature about respite and respite services are surprisingly sparse. This study provides a brief snap shot of the health and social care that is provided by respite services in South Australia. These findings highlight the expanded role that some services have adopted in their support of family carers and care-recipients. These findings highlight the potential to revisit how respite services are currently configured. The provision of education, social care services, opportunities for socialisation and links to the broader health system represent important strategies to support these people. With the ageing of the Australian population and the shift of care for older people back into the community, this broader base of support may have important implications for the future of community-based services. The findings of this study also highlight the need for further research into respite and respite services. A broad range of professionals offer a diverse health and social care service. However, respite remains poorly understood and the expanded role seems to reflect individual provider innovation rather than a formalised expansion of the service. The specific nature of the health and social care services and their impact on clients remains unclear. Further research is needed to better understand the potential impact of the broader service role of respite and to determine the optimal configuration of services.
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CONCLUSION To help minimise some of the negative aspects of the caregiving role, respite providers offer a range of community-based support services. This evaluation identified and described the health and social care support offered by respite providers in South Australia. These activities focus on the provision of education, health services and socialisation opportunities. The findings clearly highlight the dual client focus of respite, although there are differences in the nature of the service that is provided to clients. REFERENCES Arksey, H., & Bamford, C. (2007). Respite care for people with dementia: The range f models for getting a break. The Journal of Dementia Care, 15(3), 37–39. Arksey, H., Jackson, K., Croucher, K., Weatherly, H., Golder, S., Hare, P., … Sally, B. (2004). Review of respite services and short term breaks for carers for people with dementia. London, England: National Coordinating Centre for NHS Service Delivery and Organisation. Ashworth, M., & Baker, A. H. (2000). Time and space: Carer’s views about respite care. Health and Social Care in the Community, 8(1), 50–56. Bamford, C., Arksey, H., Poole, M., Kirkley, C., Hughes, J., & Corner, L. et al. (2009). Person- and carer-centred respite care for people with dementia: Developing methods of evaluating the effectiveness of different models. Southhampton, England: National Institute for Health Research Service Delivery and Organisation. Baumgarten, M., Lebel, P., Laprise, H., Leclerc, C., & Quinn, C. (2002). Adult day care for frail elderly: Outcomes satisfaction and cost. Journal of Aging Health, 14, 237–259. Bower, B. (1997). Social links may counter health risks: Research on how social isolation affects mortality in older adults. Science News, 152(9), 135. Broe, G., Jorm, A., Creasy, H., Casey, B., Bennett, H., Cullen, J., … Grayson, D. (1999). Carer distress in the general population: Results from the Sydney older persons study. Age and Ageing, 28, 307–311. Burge, P., Netten, A., & Gallo, F. (2010). Estimating the value of social care. Journal of Health Economics, 29, 883–894. Carroll, A. M., Vetor, K., Holmes, S., & Supiano, K. P. (2005). Ask the consumer: An innovative appproach
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Accepted 08 March 2013
ANNOUNCING LONGEVITY: SOCIOLOGICAL PERSPECTIVES ON HEALTH, ILLNESS AND SERVICE PROVISION A special issue of Health Sociology Review – Volume 23 Issue 1 – ii + 126 pages – ISBN 978-1-921980-25-1 – March 2014 Guest Editors: Pauline Savy (La Trobe University, Australia), Anne-Maree Sawyer (La Trobe University, Australia) and Jeni Warburton (La Trobe University, Australia) This special issue of Health Sociology Review examines the possibility and actuality of living to very old age. In our times, cultural discourses to do with maintaining health and independence for as long as possible pervade social policy and the personal narratives of ageing. Sociologically, these raise interesting, and often contentious, questions about the role of structural support systems, the delivery of appropriate health care, and the phenomenological experience of ageing and dealing with frailty and decline. • Ageing and health of particular groups eg Indigenous, migrant, • Dementia gendered groups, rural and remote populations • Living with common and chronic conditions including psychiatric conditions • Evaluation of specific care provision and levels eg acute hospital care, community care, long-term care and health promotion programs • Family relationships in old age and ill health • The ageing body, decline, dying and death • Professionalisation and specialisation, for example, changing role boundaries in aged care, workforce situations and impacts • Health and illness in the oldest generation • Ageing and medicalisation • Social, structural factors that promote or oppose longevity and wellness http://hsr.e-contentmanagement.com/archives/vol/23/issue/1/marketing/
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