Listening to People with Dementia: A Pastoral Care Perspective

SUMMARY

Pastoral and Spiritual Care approaches to the reduction of depression in residential aged care facilities are considered. They are examined through specific one-to-one pastoral care, through a pastoral care person in the team approach to care and through a one-to-many relationship for group spiritual and religious activities. The suggestions in this article are offered as extensions to a manual, Challenge Depression, on managing depression in residential aged care as a way of including pastoral and spiritual care as part of an integrated approach and as part of a stand alone approach of pastoral care.     

Counselling in primary care: a systematic review of the evidence

Primary objective: To undertake a systematic review which aimed to locate, appraise and synthesise evidence to obtain a reliable overview of the clinical effectiveness, cost‐effectiveness and user perspectives regarding counselling in primary care. Main results: Evidence from 26 studies was presented as a narrative synthesis and demonstrated that counselling is effective in the short term, is as effective as CBT with typical heterogeneous primary care populations and more effective than routine primary care for the treatment of non‐specific generic psychological problems, anxiety and depression. Counselling may reduce levels of referrals to psychiatric services, but does not appear to reduce medication, the number of GP consultations or overall costs. Patients are highly satisfied with the counselling they have received in primary care and prefer counselling to medication for depression. Conclusions and implications for future research: This review demonstrates the value of counselling as a valid choice for primary care patients and as a broadly effective therapeutic intervention for a wide range of generic psychological conditions presenting in the primary care setting. More rigorous clinical and cost‐effectiveness trials are needed together with surveys of more typical users of primary care services.     

Cultural safety in Muslim aged care: Taking the bull by the horns

ABSTRACT

Cultural safety is critical to providing holistic, person-centred care. Where “deep” or core cultural elements are primarily shaped and influenced by religion, it becomes important to recognise and understand the religious values and traditions in planning, designing, and delivering care. Such an approach is significantly important for communities essentially identified by their faith, such as the Muslim community. Muslims living in the West face challenges owing to their minority status and these are increasing in the current geopolitical context. These challenges contribute to individual Muslims and their families feeling vulnerable within an aged-care system that is mostly unfamiliar, and often confusing and frightening to them. This article attempts to make a case for cultural safety in the context of Muslim aged care. It does not offer an answer or a definite solution to the cultural risks Muslims may face in care settings. Rather, the article seeks to explore avenues for creating an environment of cultural safety without delving specifically into culturally safe care practices. It is only possible to offer culturally safe care when the environment in which care is to be delivered is respectful and supportive.     

Stigma and Barriers to Mental Health Care in Deployed Canadian Forces Personnel

Mental disorders are prevalent on deployed operations, but only a small fraction of those with problems access care due to a range of barriers. A survey measuring need for care, perceived barriers, and care-seeking propensity was administered to Canadian Forces personnel during deployment in Afghanistan. Complex characteristics of barriers to care on deployment were found: stigma had no association with care-seeking propensity; perceived structural barriers were associated with greater care-seeking propensity; and perceived structural barriers were greater in more isolated locations. Only negative attitudes toward care had the expected negative association with care-seeking propensity. Research and practical considerations are discussed.     

Care Ethics and Confucianism: Caring through Li

The role of li, or ritual, in Confucianism is a perceived impediment to interpreting Confucianism to share a similar ethical framework with care ethics because care ethics is a form of moral particularism. I argue that this perception is false. The form of moral particularism promoted by care ethicists does not entail the abandonment of social conventions such as li. On the contrary, providing good care often requires employing systems of readily recognizable norms in order to ensure that care is successfully communicated and completed through one's care‐giving practices. I argue that li performs this communicative function well and that the early Confucians recommend breaching li precisely when its efficacy in performing this function is compromised.     

Family Empowerment as a Mediator between Family-Centered Systems of Care and Changes in Child Functioning: Identifying an Important Mechanism of Change

We investigated the associations among perceived fidelity to family-centered systems of care, family empowerment, and improvements in children's problem behaviors. Participants included 79 families, interviewed at two time points across a one-year period. Paired samples t-tests indicated that problem behaviors decreased significantly across a one-year period. Hierarchical multiple regressions indicated that both fidelity to family-centered systems of care and family empowerment independently predicted positive change in children's problem behavior over a one-year period. However, when family empowerment is entered first in the regression, the relationship between fidelity to family-centered systems of care and change in children's problem behavior drops out, indicating that family empowerment mediates the relationship between family-centered care and positive changes in problem behaviors. Consistent with other literature on help-giving practices, family empowerment appears to be an important mechanism of change within the system of care philosophy of service delivery. Implications for practice and staff training are discussed.     

Building Bridges with Accessible Care: Disability Studies,Feminist Care Scholarship,and Beyond

This article uses elements of autoethnography to theorize an in/formal support relationship between a friend with a physical disability, who uses attendant services, and me. Through thinking about our particular “frien‐tendant” relationship, I find the common scholarly orientations toward “care” are inadequate. Starting from the conversations between feminist and disability perspectives on care, I build on previous work to further develop the theoretical framework of accessible care. Accessible care takes a critical, engaged approach that moves beyond understanding “accessibility” as merely concrete solutions to create more inclusive forms of care. Care, in this context, is positioned as an unstable tension among competing definitions, including that it is a complex form of oppression. Accessible care draws on feminist disability perspectives and the feminist political ethic of care to build bridges in four areas: from daily experiences of disability and support to theoretical discussions; across feminist care research and disability perspectives; across divisions and anxieties within disability communities; and from the local to transnational applications. These bridges do not aim to resolve debates but allow us to travel back and forth between differing perspectives and demonstrate the tenuous possibility of accessible practices and concepts of care.     

Alcohol and Substance Use Disorders: Algorithms and Critical Pathways for Healthcare Delivery

Contemporary health care delivery is being driven by a changing health care market environments as well as by the availability of enhanced models of service delivery. Providers are using clinical algorithms and critical pathways to standardize clinical care and improve clinical services to patients. The article highlights the application of contemporary clinical models and demonstrates their utility in the context of substance use and abuse disorders. Clinical algorithms and critical pathways are advanced as guidelines in diagnostic and therapeutic processes for the delivery of quality health care to patients. Specific recommendations for the development and implementation of such initiatives are discussed in detail.     

Effects of early child‐care on cognition,language, and task‐related behaviours at 18 months: An English study

This study investigated the effects of different characteristics of early child‐care in England on the development of cognition, language, and task‐related attention and behaviour (orientation/engagement and emotion regulation during the Bayley assessment) at 18 months. Data were drawn from a prospective longitudinal study of 1,201 infants. As found in previous studies, socio‐demographic characteristics and maternal caregiving (especially ‘opportunities for stimulation’) were significant predictors of all child outcomes. There were also effects of quantity of individual and group care, and quality of non‐maternal care. Controlling for demographics and maternal caregiving, more hours of group care (nurseries) were related to higher cognitive scores, while more hours of individual care (e.g., grandparents, nannies etc.) were related to lower orientation/engagement scores. Non‐maternal caregiving was observed in a subsample of 345 children, and after controlling for all covariates as well as quantity and stability of care, quality of care was found to be predictive of higher cognitive ability and better orientation/engagement. Although the effect sizes were small in magnitude, in line with other similar studies, such modest effects from a large English sample are important when viewed in light of the widespread use of non‐maternal care during infancy and early childhood.     

Family-centered intensive case management: A step toward understanding individualized care

New York State's initial attempt at individualizing services occurred within the context of an experiment. We randomly assigned children 5–12 years old who were referred for out-of-home placement in treatment foster care to either treatment foster care, Family-Based Treatment (n=15), or to Family-Centered Intensive Case Management (FCICM) (n=27). FCICM used teams of case managers and parent advocates to provide in-home services. Flexible service dollars, respite care, and behavior management skills training were available to assist teams in individualizing care. Preliminary outcomes indicate that children in FCICM are doing as well or better than children assigned to FBT in their functioning and symptom reduction. Parents of children in FCICM have made gains, although not at a statistically significant level, in behavior management skills and family strengths that allow them to provide care for their children at home.     

Managed Care: Ethical Considerations for Counselors

Key factors and trends in health care will have an impact on the ethical practice of counselors. Ethical challenges to clinical practice presented by trends in managed care are discussed in relation to the American Counseling Association (1995) Code of Ethics and Standards of Practice. Recommendations for practice are also included.     

Caring and Evil

Nel Noddings, in Caring: A Feminine Approach to Ethics and Moral Education (1984), presents and develops an ethic of care as an alternative to an ethic that treats justice as a bask concept. I argue that this care ethic is unable to give an adequate account of ethical relationships between strangers and that it is also in danger of valorizing relationships in which carers are seriously abused.     

Child and Family Team Meeting Characteristics and Outcomes in a Statewide System of Care

Systems of care (SOC) have relied on the wraparound care process to individualize community‐based services for children and youth with serious emotional and behavioral difficulties. A core element of wraparound care is Child and Family Team meetings (CFTs), which are designed to give youth and families a leadership role in developing and guiding their plan of care. The National Wraparound Initiative (NWI) has identified Practice Standards regarding CFT implementation. This study examined CFT characteristics and the association between those characteristics and youth and family outcomes in a statewide SOC. Participants were 363 youth (M_age = 10.89, SD = 3.72) and their caregivers. Families completed measures of youth and caregiver functioning and symptoms at enrollment and 6‐month follow‐up. Care coordinators completed a survey assessing CFT implementation and characteristics following each meeting. Multiple regression analyses were used to examine the relationship between CFT characteristics and youth and caregiver outcomes. Results indicated that a higher number of CFTs was associated with poorer outcomes, while a higher percentage of natural supports at meetings was associated with better youth outcomes. Number of days to the first CFT was associated with greater caregiver strain. Implications for CFT implementation within wraparound are discussed.     

An Existential Foundation for an Ethics of Care in Heidegger’s Being and Time

Martin Heidegger’s existential account of care in Being and Time (2010) provides us with an opportunity to reimagine what the proper theoretical grounding of an ethic of care might be. Heidegger’s account of care serves to deconstruct the two primary foundations that an ethic of care is often based upon. Namely, that we are inevitably interdependent upon one another and/or possess an innate disposition to care for fellow humans in need. Heidegger’s account reveals that both positions are founded upon an ontic (meaning factual existence), as opposed to an ontological (which refers to the nature of being), understanding of care. The distinctions between an ontic and ontological understanding of care are significant. Yet, I maintain that they are not completely incompatible. Both Heidegger and care ethicists contend that our existence with others is understood through a relational ontology. Furthermore, there are certain ontological structures from Heidegger which resonate with an ethic of care. Two key existential structures are leaping-ahead and being-guilty. These existential structures are latent in care ethics, and by explicitly revealing them I reinforce the connection between Heidegger’s account and care theory. Lastly, I develop the theoretical foundations of care ethics by proposing an existential ethic of care.

     

The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics

Abstract

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate.

Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions.

Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17?years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery.

Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions.

Discussion: The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.     

The ‘Connection’ Health Care Providers Make with Dying Patients

SUMMARY

The literature confirms illness and hospitalisation can become spiritual encounters for patients and their families. Further, it has been established that both patients and their families are better equipped to deal with loss and change if they have a healthily developed spiritual sense of self. The aim of the study sought to determine the benefit or otherwise of a previous model of spiritual care. It asked ‘from the perspective of the nurse and other health care providers, what constitutes spiritual care giving?’ An ethnography was undertaken where data consisted of field notes, interviews, records, and diary entries. This paper reports on interview data, from which themes were derived. The major theme titled their space is expressed via a new model of spiritual care. It was shown that when caring for patients and their relatives, nurses and other health care professionals enter the world of the other to determine the other's needs. In so doing they typify agapé (altruistic love), where the individual cares for a complete stranger as if that stranger were family. This connection with the patient and their family is the foundation for spiritual care.     

Integrating Care for Persons, Not Only Diseases

Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.     

Correlates of Parenting on a Neonatal Intensive Care Unit: Maternal Characteristics and Family Resources

The association of maternal characteristics, family resources, and receipt of prenatal care with parenting behaviors observed in a neonatal intensive care unit (NICU; n = 383) was assessed. The parenting behavior of mothers not receiving prenatal care (n = 128) was compared to that of mothers of the preceding and subsequent admissions (n = 256) by retrospective chart review. Parenting variables included frequency of visits to the NICU and evaluative ratings of parents' involvement with their infant. Parenting of the no-prenatal-care group was significantly less favorable than the control on all comparisons. Factor analysis supported a priori grouping of parenting variables. A stepwise multiple regression of maternal and family characteristics to the factor-derived variable, parenting, showed significant contributions for prenatal drug use and father involvement. Pediatric interventions assessing maternal social and behavioral characteristics are proposed.