Comparing the experiences of rural and urban family caregivers of the terminally ill

Introduction: There are many challenges in delivering rural health services; this is particularly true for the delivery of palliative care. Previous work has identified consistent themes around end-of-life care, including caregiver burden in providing care, the importance of informal care networks and barriers imposed by geography. Despite these well-known barriers, few studies have explored the experience of palliative care in rural settings. The purpose of the present study was to compare the experiences of rural family caregivers actively providing end-of-life care to the experiences of their urban counterparts. Methods: Caregivers' perceived health status, the experience of burden in caregiving, assessment of social supports and the pattern of formal care used by the terminally ill were explored using a consistent and standardized measurement approach. A cross-sectional survey study was conducted with 100 informal caregivers (44 rural, 56 urban) actively providing care to a terminally ill patient recruited from a publicly funded community agency located in northeastern Ontario, Canada. The telephone-based survey included questions assessing: (i) caregiver perceived burden (14-item instrument based on the Caregiver's Burden Scale in End-of-Life Care [CBS-EOLC]); (ii) perceived social support (modified version of the Multidimensional Scale of Perceived Social Support [MSPSS] consisting of 12 items); and (iii) functional status of the care recipient (assessed using the Eastern Collaborative Oncology Group performance scale). Results: Rural and urban caregivers were providing care to recipients with similar functional status; the majority of care recipients were either capable of all self-care or experiencing some limitation in self-care. No group differences were observed for caregiver perceived burden: both rural and urban caregivers reported low levels of burden (CBS-EOLC score of 26.5 [SD=8.1] and 25.0 [SD=9.2], respectively; p=0.41). Urban and rural caregivers also reported similarly high levels of social support (mean MSPSS total score of 4.3 [SD=0.7] and 4.1 [SD=0.8], respectively; p=0.40). Although caregivers across both settings reported using a comparable number of services (rural 4.8 [SD=1.9] vs urban 4.5 [SD=1.8]; p=0.39), the types of services used differed. Rural caregivers reported greater use of family physicians (65.1% vs 40.7%; p=0.02), emergency room visits (31.8% vs 13.0%; p=0.02) and pharmacy services (95.3% vs 70.4%; p=0.002), while urban caregivers reported greater use of caregiver respite services (29.6% vs 11.6%; p=0.03). Conclusion: Through the use of standardized tools, this study explored the experiences of rural informal family caregivers providing palliative care in contrast to the experiences of their urban counterparts. The results of the present study suggest that while there are commonalities to the caregiving experience regardless of setting, key differences also exist. Thus, location is a factor to be considered when implementing palliative care programs and services. © K Brazil, S Kaasalainen, A Williams, C Rodriguez, 2013.

Research Protocol: A Randomized Controlled Trial of Functional Family Therapy: An Early Intervention Foundation (EIF) Partnership between Croydon Council and Queen's University Belfast

The paper presents a protocol for ‘A Randomized Controlled Trial of Functional Family Therapy (FFT): An Early Intervention Foundation (EIF) Partnership between Croydon Council and Queen's University Belfast’. The protocol describes a trial that uses FFT as an alternative intervention to current use of the youth justice system and local authority care with the aim of reducing crime/recidivism in young people referred to Croydon Council. The trial will take place over a period of 36 months and will involve up to 154 families. Croydon Council will employ a team of five Functional Family Therapists who will work with families to promote effective outcomes. The Centre for Effective Education at Queen’s University Belfast will act as independent evaluators of outcomes for families and young people. The work is supported from the United Kingdom Economic & Social Research Council/Early Intervention Foundation Grant Number ES/M006921/1.

A mixed methods study of the work patterns of full-time nurse practitioners in nursing homes

Aims and objectives: The aim of this study was to explore the integration of the nurse practitioner role in Canadian nursing homes to enable its full potential to be realised for resident and family care. The objective was to determine nurse practitioners' patterns of work activities. 

Background: Nurse practitioners were introduced in Canadian nursing homes a decade ago on a pilot basis. In recent years, government and nursing home sector interest in the role has grown along with the need for data to inform planning efforts. 

Design: The study used a sequential mixed methods design using a national survey followed by case studies. 

Methods: A national survey of nurse practitioners included demographic items and the EverCare Nurse Practitioner Role and Activity Scale. Following the survey, case studies were conducted in four nursing homes. Data were collected using individual and focus group interviews, document reviews and field notes. 

Results: Twenty-three of a target population of 26 nurse practitioners responded to the survey, two-thirds of whom provided services in nursing homes with one site and the remainder in nursing homes with as many as four sites. On average, nurse practitioners performed activities in communicator, clinician, care manager/coordinator and coach/educator subscales at least three to four times per week and activities in the collaborator subscale once a week. Of the 43 activities, nurse practitioners performed daily, most were in the clinician and communicator subscales. Case study interviews involved 150 participants. Findings complemented those of the survey and identified additional leadership activities. 

Conclusion: Nurse practitioners undertake a range of primary health care and advanced practice activities which they adapt to meet the unique needs of nursing homes. Relevance to clinical practice: Knowledge of work patterns enables nursing homes to implement the full range of nurse practitioner roles and activities to enhance resident and family care.

Homeless young people, families and change.:Family support as a facilitator to exiting homelessness.

The families of homeless young people are most often portrayed as a precipitating factor in their homelessness. However, recent studies, particularly those taking a longitudinal approach, have drawn attention to the enabling role of family members and their positive influence on the housing trajectories of homeless youth. Drawing on selected findings from an ongoing longitudinal qualitative study of homeless young people in Dublin, Ireland, this paper aims to build on this relatively fertile area of research. We demonstrate the supportive role of the families of young people who experience homelessness (often as a consequence of difficult family environments) and specifically examine how family re-engagement is negotiated and achieved. The findings highlight a number of dimensions of transition and change. Prominent among these is the importance of renewed trust and communication. Young people and their parents also had to accept responsibility for areas of life that previously served to undermine their relationships and were implicated in the circumstances surrounding a young person's premature home-leaving. Tensions and resistances on the part of young people are highlighted, demonstrating the adaptive mechanisms at work as they attempt to re-engage with family members. The implications of the findings for social work intervention with homeless youth are discussed.

‘A picture of who we are as a family’: conceptualizing post-adoption contact as practices of family display

Social work has a central role in negotiating and supporting birth family contact following adoption from care. This paper argues that family display (Finch) offers a useful conceptual resource for understanding relationships in the adoptive kinship network as they are enacted through contact. It reports on an interpretative phenomenological analysis of adoptive parents' accounts of open adoption from care that revealed direct and indirect contact to be contexts in which they and birth relatives performed family display practices: communicating the meaning of their respective relationships with the adopted child and seeking recognition that this was a legitimate family relationship. The analysis explores how family display was performed, and the impact of validating or invalidating responses. It aims to illuminate these social and interpretive processes involved in adoptive kinship in order to inform social work support for contact. The findings suggest that successful contact may be promoted by helping adoptive and birth relatives validate the legitimacy of the other's kin connection with the child, and through arrangements that facilitate family-like interactions.

Supervisor Continuity or Co-Location: Which Matters in Residency Education? Findings From a Qualitative Study of Remote Supervisor Family Physicians in Australia and Canada

Purpose: Changes to health care systems andworking hours have fragmentedresidents’ clinical experiences withpotentially negative effects ontheir development as professionals.Investigation of off-site supervision,which has been implemented in isolatedrural practice, could reveal importantbut less overt components of residencyeducation. 

Method: Insights from sociocultural learningtheory and work-based learning provideda theoretical framework. In 2011–2012,16 family physicians in Australia andCanada were asked in-depth how theyremotely supervised residents’ workand learning, and for their reflectionson this experience. The verbatiminterview transcripts and researchers’memos formed the data set. Templateanalysis produced a description andinterpretation of remote supervision. 

Results: Thirteen Australian family physiciansfrom five states and one territory, andthree Canadians from one province,participated. The main themes werehow remoteness changed the dynamicsof care and supervision; the importanceof ongoing, holistic, nonhierarchical,supportive supervisory relationships; andthat residents learned “clinical courage”through responsibility for patients’ careover time. Distance required supervisorsto articulate and pass on their expertiseto residents but made monitoringdifficult. Supervisory continuityencouraged residents to build on pastexperiences and confront deficiencies. 

Conclusions: Remote supervision enabled residents todevelop as clinicians and professionals.This questions the supremacy of co-locationas an organizing principle forresidency education. Future specialists maybenefit from programs that give themongoing and increasing responsibilityfor a group of patients and supportive.

Social Work Home Visits to Children and Families in the UK: A Foucauldian Perspective

The home visit is at the heart of social work practice with children and families; it is what children and families' social workers do more than any other single activity (except for recording), and it is through the home visit that assessments are made on a daily basis about risk, protection and welfare of children. And yet it is, more than any other activity, an example of what Pithouse has called an ‘invisible trade’: it happens behind closed doors, in the most secret and intimate spaces of family life. Drawing on conceptual tools associated with the work of Foucault, this article sets out to provide a critical, chronological review of research, policy and practice on home visiting. We aim to explain how and in what ways changing discourses have shaped the emergence, legitimacy, research and practice of the social work home visit to children and families at significant time periods and in a UK context. We end by highlighting the importance for the social work profession of engagement and critical reflection on the identified themes as part of their daily practice.

Comparing Social Work Students' Perceptions of Risk Using Online Discussion Fora: Lessons Learned from a European Pilot Project

Comparisons of international child welfare systems have identified two basic orientations to practice; a ‘child protection’ orientation and a ‘child welfare’ orientation, which are founded upon fundamentally different values and assumptions regarding the family, the origins of child care problems, and the proper role of the state in relation to the family. This paper describes a project which sought to compare how undergraduate social work students from three European Universities perceive risk in referrals about the welfare of children and to explore the impact of different cultural, ideological and educational contexts on the way in which risk is constructed by students. Students from Northern Ireland, Germany and Poland examined three vignettes via ten online discussion fora each of which provided a narrative summary of their discussion. The paper presents some findings from the analysis of the qualitative data emerging from the student discussions and draws out the lessons learned in terms of how the project was designed and implemented using online discussion fora.

Bereavement outcomes: a quantitative survey identifying risk factors in family carers bereaved through cancer.

Background: Enabling patients to die in their preferred place is important but achieving preferred place of death may increase the informal carer’s risk into bereavement. Aim: to determine risk factors of family carers bereaved through cancer in Northern Ireland. Design: These results form part of a larger QUALYCARE-NI study which used postal questionnaires to capture quantitative data on carer’s bereavement scores using the Texas Revised Inventory of Grief. Setting/participants: Participants were individuals who: registered the death of a person between 1st December 2011 and 31st May 2012; where cancer (defined by ICD10 codes C00-D48) was the primary cause; where the deceased was over 18 years of age and death occurred at home, hospice, nursing home or hospital in Northern Ireland. Participants were approached in confidence by the Demography and Methodology Branch of the Northern Ireland Statistics and Research Agency. Those wishing to decline participation were invited to return the reply slip. Non-responders received a second questionnaire six weeks after initial invitation. Results indicated that risk factors positively influencing bereavement outcomes included patients having no preference for place of death and carers remaining in employment pre or post bereavement. In contrast, patients dying in hospital, carers stopping work, being of lower socio-economic status and close kinship to the deceased negatively impacted on bereavement scores. Family carers should be adequately supported to continue in employment; priority should be given to assessing the financial needs of families from lower socio-economic areas; and bereavement support should focus on close relatives of the deceased.

Linking Family Engagement with a Rights Perspective: Macro Factors Influencing Practice

While child welfare practitioners in many countries are struggling to develop methods of effective family engagement, they operate within different national and cultural contexts which influence, both positively and negatively, the ability to engage with families. Increasingly, international comparisons are necessary to further understanding of the development of social work practice. This is particularly necessary because most countries utilize international frameworks (such as the United National Convention on the Rights of the Child) to provide guidance in the development of policies, programs, and interventions. Each country (and locality) struggles to advance practice to be more effective and humane. Our paper offers a comparative analysis focused on family-oriented and rights-based frameworks of different countries. Based on a review of current national policies and a review of the literature regarding family based practices, we examine similarities and differences among four countries: the United Kingdom, Sweden, the United States, and South Korea. These countries were selected because they have some similarities (advanced industrialized democracies, professional social work, formal child protection systems) but have some differences in their social welfare systems (policies, specific practices, socio-cultural context). These differences can be utilized to advance understanding regarding the promise and potential for family engagement strategies. We then discuss the utility of this comparison for theory-building in the arena of child care practice and conclude by identifying the challenges and limitations of this work.

Understanding the Needs of People with Dementia and Family Carers

This is the first in a short series that presents case study examples of the positive work achieved by trusts who participated in the Royal College of Nursing's development programme to improve dementia care in acute hospitals. When a person with dementia is in hospital, poor understanding of individual needs and preferences can contribute to a lack of person-centred care. Similarly, the needs of family carers can often be overlooked and staff do not always appreciate these needs at such a stressful time. This article illustrates how three NHS trusts have addressed these issues. To help staff get to know patients with dementia, Salford Royal NHS Foundation Trust has implemented a patient passport. Similarly, The Shrewsbury and Telford Hospital NHS Trust has implemented a carer passport that overcomes the restrictions imposed by hospital visiting hours. Royal Devon and Exeter NHS Foundation Trust also focused on carers, holding a workshop to elicit feedback on what was important to them. This was a useful means of engaging with carers and helped staff to realise that even simple changes can have a significant effect.

Growing Up in Taiwan: Counterfactual Models of Part-Time Work, Romantic Relationships, and Crime among Taiwanese Youth

Thesis (Ph.D.)--University of Washington, 2015

Key-elements of family interventions for psychosis : a qualitative research

RESUMO:As perturbações psicóticas são doenças mentais complexas sendo influenciadas na sua etiologia e prognóstico por factores biológicos e psicossociais. A interferência do ambiente familiar na evolução da doença espelha bem esta realidade. Quando em 1962 George Brown e colaboradores descobriram que ambientes familiares com elevada Emoção Expressa (EE) contribuíam para um aumento significativo do número de recaídas de pessoas com esquizofrenia (Brown et al., 1962), estava aberto o caminho para o desenvolvimento de novas intervenções familiares. A EE inclui cinco componentes: três componentes negativos, i.e. criticismo, hostilidade e envolvimento emocional excessivo; e dois componentes positivos, i.e. afectividade e apreço (Amaresha & Venkatasubramanian, 2012; Kuipers et al., 2002). No final dos anos 1970 surgiram os primeiros trabalhos na área das intervenções familiares nas psicoses (IFP). Dois grupos em países diferentes, no Reino Unido e nos Estados Unidos da América, desenvolveram quase em simultâneo duas abordagens distintas. Em Londres, a equipa liderada por Julian Leff desenhava uma intervenção combinando sessões unifamiliares em casa, incluindo o paciente, e sessões em grupo, apenas para os familiares (Leff et al., 1982). Por seu turno, em Pittsburgh, Gerard Hogarty e colaboradores desenvolviam uma abordagem que compreendia a dinamização de sessões educativas em grupo (Anderson e tal., 1980). Para designar este trabalho, Hogarty e colaboradores propuseram o termo “psicoeducação”. As IFP começaram a ser conhecidas por esta designação que se generalizou até aos dias de hoje. Neste contexto a educação era vista como a partilha de informação acerca da doença, dos profissionais para os familiares. Nas sessões os profissionais eram informados acerca das manifestações, etiologia, tratamento e evolução das psicoses, bem como de formas para lidar com as situações difíceis geradas pela doença, e.g. risco de recaída. Os trabalhos pioneiros das IFP foram rapidamente sucedidos pelo desenvolvimento de novos modelos e a proliferação de estudos de eficácia. Para além dos modelos de Leff e Hogarty, os modelos IFP que ficaram mais conhecidos foram: (1) a Terapia Familiar-Comportamental, desenvolvida por Ian Falloon e colaboradores (Falloon et al., 1984); e (2) a Terapia Multifamiliar em Grupo, desenvolvida por William McFarlane e colaboradores (McFarlane, 1991). O incremento de estudos de eficácia contribuiu rapidamente para as primeiras meta-análises. Estas, por sua vez, resultaram na inclusão das IFP nas normas de orientação clínica mais relevantes para o tratamento das psicoses, nomeadamente da esquizofrenia (e.g. PORT Recomendations e NICE Guidelines). No geral os estudos apontavam para uma diminuição do risco de recaída na esquizofrenia na ordem dos 20 a 50% em dois anos (Pitschel-Walz et al., 2001). No final dos anos 1990 as IFP atingiam assim o apogeu. Contudo, a sua aplicação prática tem ficado aquém do esperado e as barreiras à implementação das IFP passaram a ser o foco das atenções (Gonçalves-Pereira et al., 2006; Leff, 2000). Simultaneamente, alguns autores começaram a levantar a questão da incerteza sobre quais os elementos-chave da intervenção. O conhecimento sobre o processo das IFP era reduzido e começaram a surgir as primeiras publicações sobre o assunto (Lam, 1991). Em 1997 foi dinamizada uma reunião de consenso entre os três investigadores mais relevantes do momento, Falloon, Leff e McFarlane. Deste encontro promovido pela World Schizophrenia Fellowship for Schizophrenia and Allied Disorders surgiu um documento estabelecendo dois objectivos e quinze princípios para as IFP (WFSAD, 1997). Não obstante os contributos que foram feitos, continua a existir uma grande falta de evidência empírica acerca do processo das IFP e dos seus elementos-chave (Cohen et al., 2008; Dixon et al., 2001; Lam, 1991; Leff, 2000; McFarlane et al., 2003). Também em Portugal, apesar da reflexão teórica nesta área e do registo de ensaios de efectividade de grupos para familiares – estudo FAPS (Gonçalves-Pereira, 2010), os componentes fundamentais das IFP nunca foram analisados directamente. Assim, o projecto de investigação descrito nesta tese teve como objectivo identificar os elementos-chave das IFP com base em investigação qualitativa. Para tal, conduzimos três estudos que nos permitiriam alcançar dados empíricos sobre o tema. O primeiro estudo (descrito no Capítulo 2) consistiu na realização de uma revisão sistemática da literatura científica acerca das variáveis relacionadas com o processo das IFP. A nossa pesquisa esteve focada essencialmente em estudos qualitativos. Contudo, decidimos não restringir demasiado os critérios de inclusão tendo em conta as dificuldades em pesquisar sobre investigação qualitativa nas bases de dados electrónicas e também devido ao facto de ser possível obter informação sobre as variáveis relacionadas com o processo a partir de estudos quantitativos. O método para este estudo foi baseado no PRISMA Statement para revisões sistemáticas da literatura. Depois de definirmos os critérios de inclusão e exclusão, iniciámos várias pesquisas nas bases de dados electrónicas utilizando termos booleanos, truncações e marcadores de campo. Pesquisámos na PubMed/MEDLINE, Web of Science e nas bases de dados incluídas na EBSCO Host (Academic Search Complete; Education Research Complete; Education Source; ERIC; and PsycINFO). As pesquisas geraram 733 resultados. Depois de serem removidos os duplicados, 663 registos foram analisados e foram seleccionados 38 artigos em texto integral. No final, 22 artigos foram incluídos na síntese qualitativa tendo sido agrupados em quatro categorias: (1) estudos examinando de forma abrangente o processo; (2) estudos acerca da opinião dos participantes sobre a intervenção que receberam; (3) estudos comparativos que individualizaram variáveis sobre o processo; e (4) estudos acerca de variáveis mediadoras. Os resultados evidenciaram um considerável hiato na investigação em torno do processo das IFP. Identificámos apenas um estudo que abordava de forma abrangente o processo das IFP (Bloch, et al., 1995). Este artigo descrevia uma análise qualitativa de um estudo experimental de uma IFP. Contudo, as suas conclusões gerais revelaramse pobres e apenas se podia extrair com certeza de que as IFP devem ser baseadas nas necessidades dos participantes e que os terapeutas devem assumir diferentes papéis ao longo da intervenção. Da revisão foi possível perceber que os factores terapêuticos comuns como a aliança terapêutica, empatia, apreço e a “aceitação incondicional”, podiam ser eles próprios um elemento isolado para a eficácia das IFP. Outros estudos enfatizaram a educação como elemento chave da intervenção (e.g. Levy-Frank et al., 2011), ao passo que outros ainda colocavam a ênfase no treino de estratégias para lidar com a doença i.e. coping (e.g. Tarrier et al., 1988). Com base nesta diversidade de resultados e tendo em conta algumas propostas prévias de peritos (McFarlane, 1991; Liberman & Liberman, 2003), desenvolvemos a hipótese de concebermos as IFP como um processo por etapas, de acordo com as necessidades dos familiares. No primeiro nível estariam as estratégias relacionadas com os factores terapêuticos comuns e o suporte emocional,no segundo nível a educação acerca da doença, e num nível mais avançado, o foco seria o treino de estratégias para lidar com a doença e diminuir a EE. Neste estudo concluímos que nem todas as famílias iriam precisar de IFP complexas e que nesses casos seria possível obter resultados favoráveis com IFP pouco intensas. O Estudo 2 (descrito no Capítulo 3) consistiu numa análise qualitativa dos registos clínicos do primeiro ensaio clínico da IFP de Leff e colaboradores (Leff et al., 1982). Este ensaio clínico culminou numa das evidências mais substanciais alguma vez alcançada com uma IFP (Leff et al., 1982; Leff et al., 1985; Pitschel-Walz et al., 2001). Este estudo teve como objectivo modular a EE recorrendo a um modelo misto com que compreendia sessões familiares em grupo e algumas sessões unifamiliares em casa, incluindo o paciente. Os resultados mostraram uma diminuição das recaídas em nove meses de 50% no grupo de controlo para 8% no grupo experimental. Os registos analisados neste estudo datam do período de 1977 a 1982 e podem ser considerados como material histórico de alto valor, que surpreendentemente nunca tinha sido analisado. Eram compostos por descrições pormenorizadas dos terapeutas, incluindo excertos em discurso directo e estavam descritos segundo uma estrutura, contendo também os comentários dos terapeutas. No total os registos representavam 85 sessões em grupo para familiares durante os cinco anos do ensaio clínico e 25 sessões unifamiliares em casa incluindo o paciente. Para a análise qualitativa decidimos utilizar um método de análise dedutivo, com uma abordagem mecânica de codificação dos registos em categorias previamente definidas. Tomámos esta decisão com base na extensão apreciável dos registos e porque tínhamos disponível informação válida acerca das categorias que iríamos encontrar nos mesmos, nomeadamente a informação contida no manual da intervenção, publicado sob a forma de livro, e nos resultados da 140 nossa revisão sistemática da literatura (Estudo 1). Deste modo, foi construída uma grelha com a estrutura de codificação, que serviu de base para a análise, envolvendo 15 categorias. De modo a cumprir com critérios de validade e fidelidade rigorosos, optámos por executar uma dupla codificação independente. Deste modo dois observadores leram e codificaram independentemente os registos. As discrepâncias na codificação foram revistas até se obter um consenso. No caso de não ser possível chegar a acordo, um terceiro observador, mais experiente nos aspectos técnicos das IFP, tomaria a decisão sobre a codificação. A análise foi executada com recurso ao programa informático NVivo® versão 10 (QSR International). O número de vezes que cada estratégia foi utilizada foi contabilizado, especificando a sessão e o participante. Os dados foram depois exportados para uma base de dados e analisados recorrendo ao programa informático de análise estatística SPSS® versão 20 (IBM Corp.). Foram realizadas explorações estatísticas para descrever os dados e obter informação sobre possíveis relações entre as variáveis. De modo a perceber a significância das observações, recorremos a testes de hipóteses, utilizando as equações de estimação generalizadas. Os resultados da análise revelaram que as estratégias terapêuticas mais utilizadas na intervenção em grupo foram: (1) a criação de momentos para ouvir as necessidades dos participantes e para a partilha de preocupações entre eles – representando 21% de todas as estratégias utilizadas; (2) treino e aconselhamento acerca de formas para lidar com os aspectos mais difíceis da doença – 15%; (3) criar condições para que os participantes recebam suporte emocional – 12%; (4) lidar com o envolvimento emocional excessivo 10%; e (5) o reenquadramento das atribuições dos familiares acerca dos comportamentos dos pacientes – 10%. Nas sessões unifamiliares em casa, as estratégias mais utilizadas foram: (1) lidar com o envolvimento emocional excessivo – representando 33% de todas as estratégias utilizadas nas sessões unifamiliares em casa; (2) treino e aconselhamento acerca de formas para lidar com os aspectos desafiadores da doença – 22%; e (3) o reenquadramento das atribuições dos familiares acerca dos comportamentos dos pacientes, juntamente com o lidar com a zanga, o conflito e a rejeição – ambas com 10%. A análise longitudinal mostrou que a criação de momentos para ouvir as necessidades dos familiares tende a acontecer invariavelmente ao longo do programa. Sempre que isso acontece, são geralmente utilizadas estratégias para ajudar os familiares a lidarem melhor com os aspectos difíceis da doença e estratégias para fomentar o suporte emocional. Por sua vez, foi possível perceber que o trabalho para diminuir o envolvimento emocional excessivo pode acontecer logo nas primeiras sessões. O reenquadramento e o lidar com a zanga/ conflito/ rejeição tendem a acontecer a partir da fase intermédia até às últimas sessões. A análise das diferenças entre os familiares com baixa EE e os de elevada EE, mostrou que os familiares com elevada EE tendem a tornar-se o foco da intervenção grupal. Por sua vez, os familiares com baixa EE recebem mais estratégias relacionadas com aliança terapêutica, comparativamente com os familiares com elevada EE. São de realçar os dados relativamente às estratégias educativas. Foi possível observar que estas tendem a acontecer mais no início dos grupos, não estando associadas a outras estratégias. Contudo é de notar a sua baixa utilização, a rondar apenas os 5%.O Estudo 3 (descrito no Capítulo 4) surgiu como uma forma de completar a análise do Estudo 2, permitindo uma visão mais narrativa do processo e focando, adicionalmente, as mudanças que ocorrem nos participantes. Com base nos mesmos registos utilizados no Estudo 2, codificámos de forma secundária os registos em duas categorias i.e. marcadores de mudança e marcadores emocionais. Os marcadores de mudança foram cotados sempre que um participante exibia comportamentos ou pensamentos diferentes dos anteriores no sentido de uma eventual redução na EE. Os marcadores emocionais correspondiam à expressão intensa de sentimentos por parte dos participantes nas sessões e que estariam relacionados com assuntos-chave para essas pessoas. Os excertos que continham a informação destes marcadores foram posteriormente revistos e articulados com notas e comentários não estruturados que recolhemos durante a codificação do Estudo 2. Com base nesta informação os registos foram revistos e, utilizando um método indutivo, elaborámos uma narrativa acerca da intervenção. Os resultados da narrativa foram discutidos com dados de que dispúnhamos, referentes a reuniões com os terapeutas envolvidos na intervenção em análise (Elizabeth Kuipers, Ruth Berkowitz e Julian Leff; Londres, Novembro de 2011). Reconhecemos que, pela sua natureza não estruturada e indutiva, a avaliação narrativa está mais sujeita ao viés de observador. Não obstante, os resultados deste Estudo 3 parecem revestir uma consistência elevada. O mais relevante foi a evidência de que na intervenção em análise ocorreram mudanças emocionais significativas nos familiares ao longo das sessões em grupo. Numa fase inicial os familiares tenderam a expressar sentimentos de zanga. Seguidamente, os terapeutas iam nterrompendo o discurso de reminiscências, direccionavam o discurso para as suas preocupações actuais e os familiares pareciam ficar mais calmos. Contudo, à medida que os 143 participantes “mergulhavam” nos problemas com que se confrontavam na altura, os sentimentos de zanga davam lugar a sentimentos de perda e angústia. Nessa altura os terapeutas enfatizavam o suporte emocional e introduziam progressivamente técnicas de reenquadramento para ajudar os participantes a avaliar de forma mais positiva as situações. Este trabalho dava lugar a sentimentos mais positivos, como a aceitação, apreço e a sensação de controlo. O Estudo 3 evidenciou também o que designamos como o “Efeito de Passagem de Testemunho”. Este efeito aconteceu sempre que um membro novo se juntava ao grupo. Os membros antigos, que estavam a ser o alvo das atenções e naturalmente a receber mais intervenção, mudam de papel e passam eles próprios a focar as suas atenções nos membros mais recentes do grupo, contribuindo para a dinâmica do grupo com as mesmas intervenções que os ajudaram previamente. Por exemplo, alguns membros antigos que eram altamente críticos nos grupos em relação aos seus familiares passavam a fazer comentários de reenquadramento dirigidos para os novos membros. Por fim, o Capítulo 5 resume as conclusões gerais deste projecto de investigação. Os estudos apresentados permitiram um incremento no conhecimento acerca do processo das IFP. Anteriormente esta informação era baseada sobretudo na opinião de peritos. Com este projecto aumentámos o nível de evidência ao apresentar estudos com base em dados empíricos. A análise qualitativa do Estudo 2 permitiu pela primeira vez, tanto quanto é do nosso conhecimento, perceber de forma aprofundada o processo subjacente a uma IFP (no contexto de um ensaio clínico que se revelou como um dos mais eficazes de sempre). Identificámos as estratégias mais utilizadas, as relações entre elas e a sua diferente aplicação entre familiares com baixa EE e familiares com alta EE.O Estudo 3 completou a informação incluindo aspectos relacionados com as mudanças individuais durante o programa. No final foi possível perceber que as IFP devem ser um programa por etapas. Nos Estudo 2 e 3, evidenciámos que numa fase inicial, os terapeutas dedicaram especial atenção para que os familiares tivessem espaço para partilharem as suas necessidades, disponibilizando logo de seguida estratégias para promover o suporte emocional e estratégias de coping. Num nível subsequente do programa, o trabalho terapêutico avançou para estratégias mais direccionadas para regular a EE, mantendo sempre as estratégias iniciais ao longo das sessões. Assim apesar de a educação ter sido um componente importante na IFP em análise, houve outras estratégias mais relevantes no processo. A evidência gerada pelos Estudos 2 e 3 baseou-se em registos históricos de elevado valor, sendo que os constructos subjacentes na época, nomeadamente a EE, continuam a ser a base da investigação e prática das IFP a nível mundial em diferentes culturas (Butzlaff & Hooley, 1998). Concluímos que as IFP são um processo complexo com diferentes níveis de intervenção, podendo gerar mudanças emocionais nos participantes durante as sessões. No futuro será importante replicar o nosso trabalho (nomeadamente o Estudo 2) com outras abordagens de IFP, de modo a obter informação acerca do seu processo. Esse conhecimento será fundamental para uma possível evolução do paradigma das IFP. ----------- ABSTRACT: Background: Psychotic-spectrum disorders are complex biopsychosocial conditions and family issues are important determinants of prognosis. The discovery of the influence of expressed emotion on the course of schizophrenia paved the road to the development of family interventions aiming to lower the “emotional temperature” in the family. These treatment approaches became widely recognised. Effectiveness studies showed remarkable and strong results in relapse prevention and these interventions were generalised to other psychotic disorders besides schizophrenia. Family interventions for psychosis (FIP) prospered and were included in the most important treatment guidelines. However, there was little knowledge about the process of FIP. Different FIP approaches all led to similar outcomes. This intriguing fact caught the attention of authors and attempts were made to identify the key-elements of FIP. Notwithstanding, these efforts were mainly based on experts’ opinions and the conclusions were scanty. Therefore, the knowledge about the process of FIP remains unclear. Aims: To find out which are the key-elements of FIP based on empirical data. Methods: Qualitative research. Three studies were conducted to explore the process of FIP and isolate variables that allowed the identification of the key-elements of FIP. Study 1 consisted of a systematic literature review of studies evaluating process-related variables of FIP. Study 2 subjected the intervention records of a formerly conducted effective clinical trial of FIP to a qualitative analysis. Records were analysed into categories and the emerging data were explored using descriptive statistics and generalised estimating equations. Study 3 consisted of a narrative evaluation using an inductive qualitative approach, examining the same data of Study 2. Emotional markers and markers of change were identified in the records and the content of these excerpts was synthesised and discussed. Results: On Study 1, searches revealed 733 results and 22 papers were included in the qualitative synthesis. We found a single study comprehensively exploring the process of FIP. All other studies focused on particular aspects of the process-related variables. The key-elements of FIP seemed to be the so-called “common therapeutic factors”, followed by education about the illness and coping skills training. Other elements were also identified, as the majority of studies evidenced a multiple array of components. Study 2,revealed as the most used strategies in the intervention programme we analysed: the addressing of needs; sharing; coping skills and advice; emotional support; dealing with overinvolvement; and reframing relatives’ views about patients’ behaviours. Patterns of the usefulness of the strategies throughout the intervention programme were identified and differences between high expressed emotion and low expressed emotion relatives were elucidated. Study 3 accumulated evidence that relatives experience different emotions during group sessions, ranging from anger to grief, and later on, to acceptance and positive feelings. Discussion: Study 1 suggested a stepped model of intervention according to the needs of the families. It also revealed a gap in qualitative research of FIP. Study 2 demonstrated that therapists of the trial under analysis often created opportunities for relatives to express and share their concerns throughout the entire treatment programme. The use of this strategy was immediately followed by coping skills enhancement, advice and emotional support. Strategies aiming to deal with overinvolvement may also occur early in the treatment programme. Reframing was the next most used strategy, followed by dealing with anger, conflict and rejection. This middle and later work seems to operate in lowering criticism and hostility, while the former seems to diminish overinvolvement. Single-family sessions may be used to augment the work developed in the relatives groups. Study 3 revealed a missing part of Study 2. It demonstrated that the process of FIP promotes emotional changes in the relatives and therapists must be sensitive to the emotional pathway of each participant in the group.

The importance of succession planning in family-owned Small and Medium Enterprises in Portugal

This work project addresses the importance of succession planning in family-owned Small and Medium Enterprises (SMEs). This is directly related with Human Resources Management (HRM) given that there is an HRM long term vision in order for the succession to be planned on time and benefit the companies. This study focused on SMEs since these are the entities that have a minor focus on HRM practices. A total of 22 in-depth interviews were conducted and analyzed. Selected SMEs owners/managers and successors/antecessors were interviewed with the purpose of acquiring more insight on the level of succession planning, using a qualitative methodology from which the process of succession was derived. This study unveils that the first step in this process is related to the definition of criteria to be a good successor, followed by the choice of possible successors, being the children the natural successors, but also considering other potential ones, and finally some considerations on the future of these companies.

Family relationships and learning experiences in anxious vs. non-anxious families: Are there differences ?

L'objectif principal de ce travail était d'explorer les relations parent-enfant et les processus d'apprentissage familiaux associés aux troubles anxieux. A cet effet, des familles ayant un membre anxieux (la mère ou l'enfant) ont été comparées avec des familles n'ayant aucun membre anxieux. Dans une première étude, l'observation de l'interaction mère-enfant, pendant une situation standardisée de jeu, a révélé que les mères présentant un trouble panique étaient plus susceptibles de se montrer verbalement contrôlantes, critiques et moins sensibles aux besoins de l'enfant, que les mères qui ne présentaient pas de trouble panique. Une deuxième étude a examiné les perceptions des différents membres de la famille quant aux relations au sein de la famille et a indiqué que, par comparaison aux adolescents non-anxieux, les adolescents anxieux étaient plus enclins à éprouver un sentiment d'autonomie individuelle diminué par rapport à leurs parents. Finalement, une troisième étude s'est intéressée à déterminer l'impact d'expériences d'apprentissage moins directes dans l'étiologie de l'anxiété. Les résultats ont indiqué que les mères présentant un trouble panique étaient plus enclines à s'engager dans des comportements qui maintiennent la panique et à impliquer leurs enfants dans ces comportements, que les mères ne présentant pas de trouble panique. En se basant sur des recherches antérieures qui ont établi une relation entre le contrôle parental, la perception de contrôle chez l'enfant et les troubles anxieux, le présent travail non seulement confirme ce lien mais propose également un modèle pour résumer l'état actuel des connaissances concernant les processus familiaux et le développement des troubles anxieux. Deux routes ont été suggérées par lesquelles l'anxiété pourrait être transmise de manière intergénérationnelle. Chacune de ces routes attribue un rôle important à la perception de contrôle chez l'enfant. L'idée est que lorsque les enfants présentent une prédisposition à interpréter le comportement de leurs parents comme hors de leur contrôle, ils seraient plus enclins à développer de l'anxiété. A ce titre, la perception du contrôle représenterait un tampon entre le comportement de contrôle/surprotection des parents et le trouble anxieux chez l'enfant. - The principal objective of the present work was to explore parent-child relationships and family learning processes associated with anxiety disorders. To this purpose, families with and without an anxious family member (mother or child) were compared. In a first study, observation of mother-child interaction, during a standard play situation, revealed that mothers with panic disorder were more likely to display verbal control and criticism, and less likely to display sensitivity toward their children than mothers without panic disorder. A second study examined family members' perceptions of family relationships and indicated that compared to non-anxious adolescents, anxious adolescents were more prone to experience a diminished sense of individual autonomy in relation to their parents. Finally a third study was interested in determining the effect of less direct learning experiences in the aetiology of anxiety. Results indicated that mothers with panic disorder were more likely to engage in panic-maintaining behaviour and to involve their children in this behaviour than mothers without panic disorder. Based on previous research showing a relationship between parental control, children's perception of control, and anxiety disorders, the present work not only further adds evidence to support this link but also proposes a model summarizing the current knowledge concerning family processes and the development of anxiety disorders. Two pathways have been suggested through which anxiety may be intergenerationally transmitted. Both pathways assign an important role to children's perception of control. The idea is that whenever children have a predisposition towards interpreting their parents' behaviour as beyond of their control, they may be more prone to develop anxiety. As such, perceived control may represent a buffer between parental overcontrolling/overprotective behaviours and childhood anxiety disorder.