EN MATERIA DE PENSIONES
2. El informe del Pacto de Toledo y las propuestas del Gobierno Tanto en el Informe de la Comisión del Pacto de Toledo (especialmente en la
Due to the complex nature of caregiver experiences which vary across individuals, no one intervention will ever meet all caregivers‟ needs, and interventions will be required to have several different aspects that should be specifically tailored on a case by case basis. The current themes incorporated caregivers‟ cognitions (attitudes, perceptions) and behaviours. It can be argued, therefore, that the framework of Cognitive Behaviour Therapy (CBT) can be applied to caregivers of people with stroke via individualised treatment plans to target relevant unhelpful and unrealistic/negative beliefs and assumptions, as well as promoting cognitive and behavioural coping strategies. The main principle of the CBT approach states that the way people think and interpret the world, themselves and others affects their emotions and behaviour. Therefore, when such thoughts, underlying assumptions and core beliefs are maladaptive, they need to be challenged and consequently modified into more realistic cognitions (Beck, 1976; Ellis, 1962). In addition, CBT targets maladaptive behaviours that maintain difficulties through continual practice of adaptive behaviours (Wells, 2005). CBT is an effective approach for a variety of psychological problems such as depression, anxiety, chronic pain and eating disorders (e.g. Beck, 1995; Butler, Chapman, Forman & Beck, 2006; Clark, 1999; Leahy, 2006; Wells, 2005), and different types of CBT based intervention programs incorporating the insights generated from this study can be conducted with comparison to a waiting list control group. Findings from such studies will provide evidence of whether the needs and concerns of caregivers can be addressed in practice, which particular components of interventions are most efficient in reducing caregiver emotional burden and distress, and the most cost effective frequency, intensity, time and duration of CBT. In summary, particular components for future intervention studies include:
Providing psychoeducation about the nature of stroke and how to maintain a healthy lifestyle to reduce the risk of recurrent stroke.
Targeting relationship counselling between the caregiver and stroke survivor.
Addressing stroke survivor emotional difficulties as well as facilitating successful access to adequate formal support including stroke rehabilitation services like physiotherapy and speech pathology.
Providing training in effective coping strategies such as the ones demonstrated in this study, based on a CBT framework.
Health care providers and stroke caregivers
Another advantageous avenue for future research would be to conduct a focus group with health care providers (such as stroke nurses, neurologists and rehabilitation staff). Considering health professionals‟ perspectives, especially on doctor-patient communication, for example, would provide more information on ways to improve the relationship between caregivers and health professionals, inform future intervention programs and thus help to improve caregiver evaluation of these services and in turn, caregiver outcomes. Although the relationship and communication styles of health professionals have not been explored with stroke patients, let alone their caregivers, doctor-patient communication has been extensively researched in other health fields such as oncology (Ong et al., 1995). In fact, researchers have shown that there are particular communication and interpersonal skills that doctors can use to help patients and families better adjust to medical illnesses in terms of treatment adherence, psychological and emotional problems and satisfaction with formal care. Doctors are also found to be more satisfied with their work when utilising these skills (Maguire & Pitceathly, 2002). Some strategies include:
Showing an interest in the patients‟ psychosocial functioning.
Demonstrating honesty, compassion and empathy and,
Exhibiting an open willingness to provide time, information, and answer questions (Juraskova, Butow, Sharpe & Campion, 2007; Klitzman, 2006; Maguire & Pitceathly, 2002).
Arguments have also been made that suggest providing an optimistic perspective on the illness and prognosis may even help patients cope better (O‟Rourke, Barrett, Jones, Featherstone & Hughes, 2001), although this speculation awaits further examination. Therefore, this study has highlighted the importance of ongoing communication training for health professionals to be more cognisant of their communication style with stroke patients and family members. Such work has been shown to be effective for other medical conditions and hence may prove beneficial in the area of stroke.
Finally, the findings support the need for increased funding to enhance access to quality services and resources for caregivers and their families, including more thorough and systematic discharge planning. Prioritising funds in the area of community caregiving may potentially reduce the government health care cost burden in the long-term that will otherwise occur as a result of providing nursing home and other government funded facilities for stroke survivors and their caregivers, if caregivers‟ needs are not met.
Theoretical implications
In terms of theoretical implications, the themes proposed in this study are quite comprehensive and adequately represent the multi-dimensional nature of caregiving. White et al., (2004) attempted to develop a similar thematic model that represented multiple factors
influencing stroke caregivers‟ QoL. Their themes however, were based on a review of the
literature rather than an empirically conducted research study. Moreover, their model merely speculated relationships, and included gaps and sometimes vague descriptions of factors. Specifically, the model did not include any information on caregiver coping strategies or positive outcomes, and there was a minimal amount of information about the psychological experiences, cognitions and concerns of caregivers. Extending White et al‟s (2004) conclusions, the present study can more confidently confirm the complex nature of caregiving experiences, which include various factors related not only to the stroke survivor, but also caregiver factors such as personality characteristics, the social environment, and the health care system. All of which interacted in different ways according to the individual idiosyncratic profile. Hypotheses regarding the relationships between the themes generated in this study have also been developed and theoretically inform the examination of these relationships using statistical analyses in future quantitative studies.