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A Curriculum For Lay Caregivers Nursing Essay

The National Alliance for Caregiving points out that “the increase in the elderly population, coupled with the need to care for them, has led to the recognition of family caregivers in a more formal sense by the health care industry, government, and the community” (2010).  Being a caregiver is never an easy task.  There are many aspects to consider in caregiving that make it such a complex role, which then deems it to be a separate area of study and attention.  Because caregivers are often the first line of care for the elderly, they should be educated and possess the necessary knowledge and skills in order to maximize a positive caregiving experience.  Our curriculum strives to highlight the most significant areas of need when caring for the elderly population and how the caregivers can utilize this in their everyday practice.

Caregiving Defined

Our definition of caregiving is the act of attending to the physical, emotional, or financial needs of another individual who is unable to do so themselves due to a chronic disease, illness, or condition.  Our definition of caregiving is bi-factoral in that it also takes into account the degree to which the caregiver is able to care for his or her own physical, emotional, and/or financial needs so as to ensure successful caregiving.  

Caregiving is an honorable act of duty due to the great deal of responsibility that it entails, but it often takes a significant toll on the caregiver and leads to caregiver stress - the physical, emotional, and financial strain that results from caregiving.  Caregiver stress is not only associated with increased morbidity and mortality in caregivers, but also an increased probability that the elder will need to be placed in a long-term care facility or require in-home services (Parks & Novielli, 2000).  This thus indicates that caregiving is more than just caring for the unable elder, but it should also encompass the caregiver’s ability to attend to their own needs in order to ensure the highest quality of the caregiving experience.

Areas Indicating Assistance in the Elderly

According to Carol A. Miller, “...as people age, they become less and less like others of the same age.  Indeed, the most universal characteristic of increasing age is increasing uniqueness” (Miller, 2009).  This applies to the elderly in particular, who are a distinct sub-population that all have their own unique needs and concerns.  However, in light of this distinct uniqueness, there are four key areas that are the most prevalent concern when it comes to caring for the elderly - home safety measures, safe medication administration, continence concerns, and assurance of their financial welfare.

Home Safety

Firstly, home safety measures is a very vital aspect when caring for the elderly because there are nearly 1 million people over the age of 65 treated in hospital emergency rooms due to accidental injuries with everyday products (International Association of Certified Home Inspectors, 2006). As the older adult ages, they undergo physiological changes that result in thinner and less elastic skin, a decrease in their percentage of fat and muscle mass, a more porous bone structure that is brittle and lacks the ability to withstand stress, poor vision and hearing, and a decline in their coordination and sense of balance (Sullivan, 2002).  Because of these age-related changes, the elderly population is more prone to injuries and accidents in their home; these include accidents that are caused by a wide range of things - electrical cords or rugs to woodburning stoves or a lack of an emergency exit plan.  Many older adults need assistance in implementing home safety measures that adapts to these physiological changes in order to promote a safer environment for the elderly and lead to declines in accidents or injuries that result from preventable causes in the

home.

Medication Administration

Based on the Journal of the American Medical Association (2004), there are about 50 adverse drug events (ADEs) per 1,000 elderly people annually and hospitalizations from these events are 4 times higher in the elderly (Ruscin, 2009).  The trend in increased rates of ADEs in the elderly can be explained by the physiological changes that occur with aging – a reduction in renal or hepatic functioning, a decline in fat or muscle mass, slower absorption or distribution of medications, impaired memory, amongst others.  One of the other explanations of ADEs being common in the elderly is how they are often diagnosed with multiple pathological conditions that and therefore need multiple-drug therapy. This emphasizes a need for careful consideration when prescribing the elderly medications due to compliance issues and the increased risk of adverse drug reactions with existing drugs they are already taking. All these factors contribute to susceptibility of the elder to ADEs, thus emphasizing the need for partial or total assistance when it comes to ensuring safe medication administration. This can be done through the use of various forms of reminders such as daily pill organizers, using daily medication schedules, ensuring all of the different pharmacological prescribers are updated regarding their medication usage, or watching for signs or symptoms of an adverse drug event.

Continence-related Issues

It is found that “50% of all frail elderly persons and 60% to 80% of nursing home residents” are diagnosed to be incontinent (Miler, 2009).  Many caregivers and health care professionals tend to make assumptions that incontinence occurs as a consequence of aging and because of this misunderstanding, incontinence is under-diagnosed and health care professionals are not openly and effectively discussing about the topic with elderly clients (National Association for Continence, 2010).  This pattern often leads to worsening symptoms of incontinence and feelings of a loss of control, dignity, or self-esteem; when in fact, incontinence is preventable, could be improved or even cured. Elders need assistance in continence promotion measures, such as through performing kegel exercises, increasing mobility, watching for signs or symptoms of early incontinence, or receiving adequate and appropriate fluids and eating a healthy diet. Elders also need assistance when incontinence is already present by using set bathroom schedules to help regain continence, psychological or emotional support with distress associated with incontinence, or seeking medical help for more effective interventions.

Finances

One of the other areas that older adults may need partial or total assistance in is when it comes to their economic welfare.  With the elderly, there may be a decline in their financial competence - the degree to which they are able to manage their own financial affairs (Willis, 1996).  There can be a decline in the elderly’s financial competence if they have changes to their orientation of time, memory, judgment, calculating ability, or have a poor general knowledge of the current financial market.  In addition, one of the most prevailing factors that contribute to the elderly’s need of financial assistance is due to the fact that the older adult must retire at one point or another.  Because their usual means of income is cut off, they must then rely on pensions and Social Security or other sources of financial income to support themselves and pay for their necessary expenses. This is where a caregiver comes into the picture.  According to the National Caregivers Library (2010), “when it comes to finances, the typical caregiver helps with or arranges bill payments, deposits, insurance and benefit claims, savings and investment decisions, housing and adult day care, tax preparation, and countless other

financial duties.”

Caregivers at a Glance

It is found that about 46 million American adults or 22% of the population are currently providing unpaid assistance and support to an older adult in the community (Strength for Caring, 2006).  Although caregiving can be a task of anyone and can be paid or unpaid, majority of the caregivers that need specific focus on are those who are family caregivers, since most caregivers are related to the elder under their care and it is family caregivers who provide about 80 percent of all long-term care services in the U.S. (Strength for Caring, 2006).  Findings indicate that caregivers are prevalent across all economic levels and ethnic groups, but 59% to 75% of caregivers are female and over the age of 45 who provide more burdensome tasks compared to males (Family Caregiver Alliance, 2005).  According to the National Center on Caregiving, they also point out “evidence show[ing] that most caregivers are ill-prepared for their role and provide care with little or no support, yet more than one-third of caregivers continue to provide intense care to others while suffering from poor health themselves (Family Caregiver Alliance, 2005).  These findings identify characteristics in the individuals who care for elders and all indicate the need to support them with their caregiving responsibilities and their own health and well-being.

The Caregiver’s Needs

As President Obama stated on National Family Caregivers Month, caregiving is a “labor of love [that] can result in physical, psychological, and financial hardship for caregivers, and research suggests that they often put their own health and well-being at risk while assisting loved ones” (National Alliance for Caregiving, 2009).  In this quote, President Obama highlights the main caregiver needs that should be addressed:  their physical needs, their psychological needs, and their financial needs.

The responsibilities of the caregiver are high, with multiple demands on their time, energy, and effort; therefore, they often have difficulty balancing out the needs of caring for the elderly and meeting their own personal needs.  Unfortunately, this only results in stress and strain that make them prone to poor physical health outcomes.  This problem is reflected in the findings of the Center on Aging Society, where they found that “about one in ten caregivers report that caregiving has caused their physical health to worsen . . . [and] in 2005, three-fifths of caregivers reported fair or poor health status, one or more chronic conditions, or a disability...“ (Center on Aging Society, 2005).  As a result of this, one of the primary needs for the caregiver is to actively engage in promoting their physical health and well-being.  This can be done through regular checkups with their primary health care provider, updating their immunizations, regularly exercising, or eating a healthy diet.  

Not only does caregiving cause much physical stress, but declines in psychological health are found to be the most frequently studied consequences of caregiving (Schulz & Sherwood, 2008).  According to a Schulz and Sherwood’s study (2008), they found that there are “greater degrees of depression and stress and low ratings of subjective well-being in caregivers.” Due to the complex demands in meeting the needs of the older adult, caregivers can often find themselves isolated with feelings of frustration, guilt, or anger that only put their psychological health at risk.  Based on these findings, it is important that caregivers have the necessary resources to address these issues, which can be accomplished through adequate support from family, friends, or the community.  These measures can include utilizing other friends or family members that will assist with caregiving responsibilities, partaking in respite care, joining local support groups, connecting with other caregivers on Internet-based Discussion Boards, engaging in satisfying religious or recreational activities, or learning other specific coping skills to caregiving stressors.  

Lastly, caregiving in itself may come with an array of financial consequences.  One of the factors contributing to financial burden on the caregiver is the possibility of having to cut back on work hours that can result in not only declines in their income, but on benefits, promotions, or retirement contributions.  According to the National Alliance for Caregiving (2009), they noted that a 2007 study showed that caregivers for elders 50 years or older spent at least 10% of their income and 34% of caregivers spent some of their savings to caregiving costs (Flewell, 2010). In order to prepare for this, the caregiver must be financially supported for caregiving expenses such as through receiving funds from medical insurance coverages or Social Security and pension payments.  

To Be a Caregiver

All the individuals that make up the entire older adult population are heterogeneous and all possess their own individualized needs and concerns.  One of the most central aspects to caregiving is possessing general caregiving skills.  Some of the most common responsibilities of the caregiver are assisting the elder with their basic personal care in the form of Activities of Daily Living (bathing, dressing, etc.) or the more complex activities in the form of Instrumental Activities of Daily Living (medications, meal preparation, etc.).  The caregiver must know the capabilities and limitations of the elder and do what they can to maximize the independence of the elder.  In addition, because of the high rate of preventable injuries, accidents, and adverse drug events in the elderly population, the caregiver should be able to implement safety measures that are the most prevalent issues when caring for this vulnerable population.  These include assessing the home environment for safety concerns and adapting the environment to ensure this safety, using proper body mechanics when caring for the elder, or using safe medication administration practices.  Also important, the caregiver should be able to collaborate with the appropriate medical professionals and navigate their way through the health care system.  For example, they should know whom to talk to when meeting specific needs of the elder - the pharmacist(s) for drug prescriptions, the nurse and doctors for available treatment options, the social worker for home safety assessments, etc.

Another important aspect that the caregiver needs to be aware of is how to not only care for the elder, but just as important, himself or herself as well.  The caregiver should know how to care for themselves physically, which can be done through getting regular health check-ups with their primary care provider, updating their immunizations, using proper body mechanics, maintaining a healthy diet and regular exercise, etc.  On the other hand, it is also important that the caregiver know the high level of stress that accompanies caregiving and the skills or resources that they can utilize to help them effectively cope with this stress. Because of the high level of psychological stress associated with caregiving, it is important that the caregiver is aware of all the support resources that he or she has available to them - local support groups, respite care, caregiver discussion boards etc. - and should know various personal skills or methods they can practice to relieve this stress - partaking in religious or recreational activities, working with others who can assist with the caregiver’s tasks, or time management skills.

Another important aspect the caregiver should be familiar with are the financial and legal aspects of caregiving.  As for the financial aspect of caring for elders, the caregiver should be able to identify the various means of financial support that are available – this includes what medical insurances cover such as Medicare or Medicaid, looking into social security and pension benefits, being able to financially plan for the caregiving expenses or reviewing bank and financial arrangements, etc.  As for the legal issues of caregiving, the caregiver often faces complicating and confusing legal cases, especially if the elder is impaired or facing end-of-life issues.  The caregiver should be able to seek assistance in regards to elder laws from an attorney or legal aid group or use the resources available to them such as educational seminars and online information.  According to the National Alliance for Caregiving, they suggest finding an attorney, obtaining legal documents regarding the health of the care recipient, considering a power of attorney and other related legal documents, and looking into estate planning (Flewell, 2010).

A Curriculum for Lay Caregivers

Our agency is located in Southern Los Angeles, California and is directed towards lay caregivers in order to provide them with the necessary information, assistance, counseling, training, support groups, and respite care associated with caregiving.  Our program will present the most prevalent concerns when caring for the elderly such as home safety measures, safe medication administration, continence-related education, how to receive emotional support as a caregiver, and the financial and legal issues of caregiving.

Home Safety Measures

One of the most common causes of accidents or injuries in the older adult population is from unsafe home environments.  As part of this curriculum, we will educate caregivers of the common functional changes that occur in elders and how to make modifications in the elder’s home to adapt to these changes.  We will also provide knowledge on which insurances, such as through Medicare or Medicaid, that actually cover financial expenses when making certain modifications in the elder’s home.

The U.S. Consumer Product Safety Commission reports that nearly 1 million individuals over the age of 65 are hospitalized for injuries and accidents associated with the everyday objects in the home that could have been easily prevented (International Association of Certified Home Inspectors, 2006). The injuries from these accidents can be very debilitating or even fatal, yet are over simple reasons such as the lack of bathroom grab bars or non-slip rugs.  By educating caregivers of the common functional changes that occur with aging and the home safety measures to adapt to these changes, it gives the caregivers the knowledge and tools needed to ensure a safe home environment for the elder that can significantly prevent these injuries and accidents. Lastly, discussing which insurances financially assist modifications made to the home is important in order to reduce financial burden on the caregiver.

The Registered Nurse and Social Worker of our program will present the home safety portion of our curriculum.  The RN will deliver the education related to the functional changes that occur with aging since this is within his/her scope of practice and can provide the foundation of knowledge needed to understand why the elder is functionally at risk for falls and injuries. The Social Worker is best suited to deliver the home safety adjustments portion of our curriculum because he/she will identify areas that can put the patient at increased risk of injuries and what can be modified in the home to decrease this risk.  

Safe Medication Administration

Safe medication administration practices are essential to the preventing adverse drug events (ADEs) that can be debilitating or even fatal to the elderly.  In the topic of Safe Medication Administration in our curriculum, we will discuss what makes the elder prone to ADEs and the various methods to prevent ADEs such as: methods to increase compliance (IE. utilizing a pill organizer), how to properly read medication labels, questions that should be brought up to the elder’s prescriber(s), and education on the importance of maintaining the elder’s medication records.

Safe medication practices are vital to our curriculum due to the high rate of ADEs in the elderly, their age-related changes, and higher probability of hospitalization due to these ADEs. All these factors indicate that elders are prone to drug errors or reactions, but can be managed if caregivers are given a role in ensuring safe medication administration in the elderly. If the caregivers are taught the necessary knowledge or skills required to safely administer medications to the elder, they can help reduce these adverse drug events that are so common and debilitating to the older adult population.

A pharmacist involved in our program will present the safe medication administration portion of our curriculum.  A pharmacist is best suited to deliver this portion of our curriculum because he/she is familiar with the common causes of adverse drug events and what can be done in order to decrease this risk with medication administration in the elderly.  Because of this knowledge, pharmacists are able to identify methods that can be used to increase compliance and decrease the adverse drug events/reactions associated with medication taking.

Continence-related Education

The caregiver will be educated on the common causes or stressors to incontinence and various strategies to promote continence or improve or even cure existing incontinence.  Content includes methods such as: how to perform Kegel exercises, how to identify current voiding and elimination pattern, setting a bathroom schedule, how to choose appropriate diets or adequate or restricted amounts of fluids, or when to seek medical assistance.

Many caregivers and health care professionals tend to make assumptions that

incontinence occurs as a consequence of aging, but incontinence is actually preventable, can be

improved, or even cured (National Association for Continence, 2010).  Because of the health-related risks and psychological disturbances associated with incontinence, measures should be taken to prevent these occurrences or help manage incontinence if it is already present in the elder. By providing a foundation of knowledge as to the stressors of incontinence in the elderly, the caregiver can help raise this concern to the elder’s primary care provider or assess possible precipitating factors to incontinence in the elder.

The geriatric registered nurse of our program will present the continence-related portion of our curriculum.  The geriatric nurse is best suited to deliver this portion of our curriculum because he/she would be more knowledgeable and experienced in regards to the functional changes that occur in the elderly, as well as the precipitating factors that contribute to continence issues.  

Emotional Support for the Caregiver

In the emotional aspect of our curriculum, we will direct it towards caregivers and how they can maintain their psychological well-being.  We will discuss how to locate a support group and what to look for in a support group according to individual preference, how to share ideas and get support by using the internet such as blogs and message boards, and identifying signs and symptoms of caregiver strain and strategies to overcome it.

Caregivers are not only limited to physical burnout, but are also at high-risk for emotional distress. Caregivers often find themselves isolated with feelings of guilt, frustration, or resentment. A caregiver needs to learn how to balance his/her personal life with the life of caring for the elder by learning various ways to replenish oneself and be emotionally and mentally healthy; this can be accomplished through providing emotional resources that the caregiver can refer to and utilize.

The primary psychotherapist of our program will present the caregiver emotional health aspect of our curriculum.  A psychotherapist is best suited to deliver this portion of our curriculum because they are trained in communication with clients in order to change ineffective behaviors that will thus improve their well-being.  

Financial and Legal Issues in Caregiving

In order to decrease the out-of-pocket expenses by the caregiver, our curriculum will teach a variety of financial resources and its differences.  We explain various financial benefits offered by organizations and insurances (IE Medicaid or Medicare) and how to properly manage the elder’s banking accounts (IE making deposits, financial planning). For legal issues, we will discuss various elder laws, and the importance of finding an attorney, obtaining legal documents regarding the health of the care recipient, considering a power of attorney and other related legal documents, and looking into estate planning.

Foremost, discussing the financial aspect of caregiving is an important area to consider because of the financial burden that caregivers face in order to meet the elder’s needs and their own personal needs. Since caregivers use 10% of their income and 34% of their savings for caregiving expenses (Flewell, 2010), this indicates a need to discuss the financial resources that are available to the caregiver in terms of reducing the expenses associated with caring for the elder. Discussing the legal aspect of caregiving is also vital, because the caregiver often faces complicating and confusing legal issues, especially if the elder is impaired or facing end-of-life issues.  Contingent on the elder’s physical and mental status, the caregiver faces a number of important legal issues - such as predetermining what to do when there is a crisis in the elder’s health or well-being, end-of-life issues, do not resuscitate orders, abuse issues, etc.  

The financial advisor and legal representative of our program will present this part of our curriculum. A financial and legal representative are best suited to deliver this portion of our curriculum because they can educate caregivers of what various medical insurances cover such as Medicare or Medicaid, discuss social security and pension benefits, and discuss tips to financially plan for the caregiving expenses, etc.  A legal representative should be familiar with elder laws and rights and the benefits of finding an attorney, obtaining legal documents regarding the health of the care recipient, considering a power of attorney, and looking into estate planning.

Length of our Program

The entire length of our curriculum is a 3-week course, where the class is in session for 4 days per week.  This will be a reasonable amount of time for caregivers to absorb the given information and highlight the most prevalent issues concerning caregiving.  Each topic will be a 2-day discussion - the first day will be a verbal presentation of the actual content and the second day will be a period for a re-demonstration and/or an open discussion where the speaker will touch base on the topics covered from the previous day.  

Conclusion

According to Parks and Novielli (2000), “by the year 2030, an estimated 20 percent of the U.S. population will be 65 years old older.  As the American population ages, a growing number of people will be serving as caregivers...”  With this increased demand for caregivers, there is a need to provide essential attention, assistance, and resources to properly manage care for elders and caregivers.  Caregiving is known to be a task that requires much time, effort, and sacrifice; yet it is a role that, if given the appropriate knowledge, skills, and strategies, can be a successful process for both the elder and the caregiver.

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