Implementation and evaluation of a new model of nursing practice in radiation oncology

Patients undergoing radiation therapy for cancer face a series of challenges that require support from a multidisciplinary team which includes radiation oncology nurses. However, the specific contribution of nursing, and the models of care that best support the delivery of nursing interventions in the radiotherapy setting, is not well described. In this case study, the Interaction Model of Client Health Behaviour and the associated principles of person-centred care were incorporated into a new model of care that was implemented in one radiation oncology setting in Brisbane, Australia. The new model of care was operationalised through a Primary Nursing/Collaborative Practice framework. To evaluate the impact of the new model for patients and health professionals, multiple sources of data were collected from patients and clinical staff prior to, during, and 18 months following introduction of the practice redesign. One cohort of patients and clinical staff completed surveys incorporating measures of key outcomes immediately prior to implementation of the model, while a second cohort of patients and clinical staff completed these same surveys 18 months following introduction of the model. In-depth interviews were also conducted with nursing, medical and allied health staff throughout the implementation phase to obtain a more comprehensive account of the processes and outcomes associated with implementing such a model. From the patients’ perspectives, this study demonstrated that, although adverse effects of radiotherapy continue to affect patient well-being, patients continue to be satisfied with nursing care in this specialty, and that they generally reported high levels of functioning despite undergoing a curative course of radiotherapy. From the health professionals’ perspective, there was evidence of attitudinal change by nursing staff within the radiotherapy department which reflected a greater understanding and appreciation of a more person-centred approach to care. Importantly, this case study has also confirmed that a range of factors need to be considered when redesigning nursing practice in the radiotherapy setting, as the challenges associated with changing traditional practices, ensuring multidisciplinary approaches to care, and resourcing a new model were experienced. The findings from this study suggest that the move from a relatively functional approach to a person-centred approach in the radiotherapy setting has contributed to some improvements in the provision of individualised and coordinated patient care. However, this study has also highlighted that primary nursing may be limited in its approach as a framework for patient care unless it is supported by a whole team approach, an appropriate supportive governance model, and sufficient resourcing. Introducing such a model thus requires effective education, preparation and ongoing support for the whole team. The challenges of providing care in the context of complex interdisciplinary relationships have been highlighted by this study. Aspects of this study may assist in planning further nursing interventions for patients undergoing radiotherapy for cancer, and continue to enhance the contribution of the radiation oncology nurse to improved patient outcomes.

Time to change consumer involvement in nursing research

The experiences of people affected by cancer are at the very heart of nursing research efforts. Because much of our work is focused on understanding how to improve experiences and outcomes for people with cancer, it is easy for us to believe that our research is inherently "person centered" and thus collaborative. Let's reflect on what truly collaborative approaches to cancer nursing research could be like, and how we measure up to such goals. Collaboration between people affected by cancer (consumers) and nurses in research is much more than providing a voice for individuals as participants in a research study. Today, research governing bodies in many countries require us to seek a different kind of consumer participation, where consumers and researchers work in partnership with one another to shape decisions about research priorities, policies, and practices.1 Most granting bodies now require explanations of how consumer and community participation will occur within a study. Ethical imperatives and the concept of patient advocacy also require that we give more considered attention to what is meant by consumer involvement.2 Consumers provide perspective on what will be relevant, acceptable, feasible, and sensitive research, having lived the experience of cancer. As a result, they offer practical insights that can ensure the successful conduct and better outcomes from research. Some granting bodies now even allocate a proportion of final score or assign a "public value" weighting for a grant, to recognize the importance of consumer involvement and reflect the quality of patient involvement in all stages of the research process.3

Atmosphere : a framework for contextual awareness

This article enhances existing approaches to present-day asynchronous awareness concepts by providing the means to explicitly represent and mediate contextual information. The resulting concept of contextual awareness takes different notions of the term context into account. Following a human-centered approach, the proposed methods serve as mediators for context between persons rather than automatically detecting context. Based on this variant of awareness, the atmosphere framework is introduced to provide mechanisms to deal with the problem of workload in tandem with contextual information. Atmosphere provides a highly tailorable structure and interface to deal with a wide variance of user and organizational requirements. The article closes with the description of a partial implementation of the framework and its evaluation.

Resilience and work-life balance in first-line nurse manager

Purpose The aim of this study was to explore how first-line nurse managers constructed the meaning of resilience and its relationship to work-life balance for nurses in Korea. Methods Participants were 20 first-line nurse managers working in six university hospitals. Data were collected through in-depth interviews from December 2011 to August 2012, and analyzed using Strauss and Corbin's grounded theory method. Results Analysis revealed that participants perceived work-life balance and resilience to be shaped by dynamic, reflective processes. The features consisting resilience included "positive thinking", "flexibility", "assuming responsibility", and "separating work and life". This perception of resilience has the potential to facilitate a shift in focus from negative to positive experiences, from rigidity to flexibility, from task-centered to person-centered thinking, and from the organization to life. Conclusions Recognizing the importance of work-life balance in producing and sustaining resilience in first-line nurse managers could increase retention in the Korean nursing workforce.

Self-management support for people with chronic kidney disease: Patient perspectives

Background Self-management of chronic kidney disease (CKD) is crucial for health outcomes and people need to be effectively supported by healthcare professionals (HCPs). Some programmes designed to improve self-management have been implemented, but people with the disease are rarely consulted regarding what they desire from these programmes. Objectives To provide a synthesis of the literature on preferences for self-management support of people with CKD. Design An integrative review. Methods Four databases (MedLine, CINAHL, PsycARTICLES and PsycINFO) were searched using relevant search terms. Results The search strategy identified 1,913 records, of which 12 studies met inclusion criteria. Ten themes were identified as important areas to be addressed by self-management interventions. In addition, patient suggestions for implementation of such interventions are discussed. Conclusion The principles of a person-centred approach ought to frame the support provided by HCPs when supporting those with CKD to better self-manage.

Nuorten henkilökohtaisten tavoitteiden profiilit ja subjektiivinen hyvinvointi

Personal goals offer an important aspect of personality and motivation. Personal goals are conscious and subjectively motivated objectives by which a person directs his or her life over time. Personal goals are related to adolescents' subjective well-being. The aim of the present research was to find out, what kinds of groups of adolescents can be formed by the content of personal goals and how these groups differ in goal appraisals, meaningful life events and subjective well-being. The second aim of the study was to detect gender differences and differences between vocational and high school students in goal appraisals, meaningful life events and subjective well-being. Adolescents in upper secondary education (N=1144) were grouped together by the content of their personal goals using a person oriented approach and a cluster analysis. Clusters found in the analysis were named by the centre goal as (1) a property group, (2) a vocation group, (3) a future education and personal relationships group and (4) a selffocused group. Adolescents in the property group put a little effort into their career goal, they were not exhausted in school work and their subjective well-being was average. Adolescents in the vocation group felt progress in their career goal and put effort into it. They had goals related to life-style. They did not feel exhausted and their subjective well-being was average. The future education and personal relationships group put effort into their career goal and considered progressing in it. Personal relationships were important in their lives. They were exhausted in their school work but they did not feel cynicism. Their own health was one of their goals and they felt satisfaction in their life. Adolescents in the self-focused group did not put effort into their career goal nor considered progressing in it. They were exhausted and especially cynical in their school work. They suffered from almost clinically significant depression. They had low life-satisfaction and low self-esteem. The following gender and educational differences were found. Compared with boys, girls felt their career goal was more important and stressful, and girls also put more effort into it. Girls were more exhausted, depressed and they had lower selfesteem than boys. High school students felt more stress with their career goal than vocational school students. High school students were more exhausted, but still they felt more satisfaction with their lives. In practice, to cover adolescents' personal goals is a possibility to find distressed individuals who might be in need for extra support.

Is a Majority Enough? Psychological Well-being and Its Relation to Academic and Prosocial Motivation, Self-regulation and Achievement at school

This cross-sectional study analyzed psychological well-being at school using the Self-Determination theory as a theoretical frame-work. The study explored basic psychological needs fulfillment (BPNS), academic (SRQ-A), prosocial self-regulation (SRQ-P) and motivation, and their relationship with achievement in general, special and selective education (N=786, 444 boys, 345 girls, mean age 12 yrs 8 mths). Motivation starts behavior which becomes guided by self-regulation. The perceived locus of control (PLOC) affects how self-determined this behavior will be; in other words, to what extent it is autonomously regulated. In order learn and thus to be able to accept external goals, a student has to feel emotionally safe and have sufficient ego-flexibility—all of which builds on satisfied psychological needs. In this study those conditions were explored. In addition to traditional methods Self-organizing maps (SOM), was used in order to cluster the students according to their well-being, self-regulation, motivation and achievement scores. The main impacts of this research were: a presentation of the theory based alternative of studying psychological well-being at school and usage of both the variable and person-oriented approach. In this Finnish sample the results showed that the majority of students felt well, but the well-being varied by group. Overall about for 11–15% the basic needs were deprived depending on the educational group. Age and educational group were the most effective factors; gender was important in relation to prosocial identified behavior. Although the person-oriented SOM-approach, was in a large extent confirming what was no-ticed by using comparison of the variables: the SEN groups had lower levels of basic needs fulfillment and less autonomous self-regulation, interesting deviations of that rule appeared. Some of the SEL- and GEN-group members ended up in the more unfavorable SOM-clusters, and not all SEN-group members belonged to the poorest clusters (although not to the best either). This evidence refines the well-being and self-regulation picture, and may re-direct intervention plans, and turn our focus also on students who might otherwise remain unnoticed. On the other hand, these results imply simultaneously that in special education groups the average is not the whole truth. On the basis of theoretical and empirical considerations an intervention model was sug-gested. The aim of the model was to shift amotivation or external motivation in a more intrinsic direction. According to the theoretical and empirical evidence this can be achieved first by studying the self-concept a student has, and then trying to affect both inner and environmental factors—including a consideration of the basic psychological needs. Keywords: academic self-regulation, prosocial self-regulation, basic psychological needs, moti-vation, achievement

Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications

Aim Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications. Methods The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities. Results The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols. Conclusions The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes.

University Students' Approaches to Learning, Self-Regulation, and Cognitive and Attributional Strategies : Connections with Well-Being and Academic Success

This dissertation empirically explores the relations among three theoretical perspectives: university students approaches to learning, self-regulated learning, as well as cognitive and attributional strategies. The relations were quantitatively studied from both variable- and person-centered perspectives. In addition, the meaning that students gave to their disciplinary choices was examined. The general research questions of the study were: 1) What kinds of relationships exist among approaches to learning, regulation of learning, and cognitive and attributional strategies? What kinds of cognitive-motivational profiles can be identified among university students, and how are such profiles related to study success and well-being? 3) How do university students explain their disciplinary choices? Four empirical studies addressed these questions. Studies I, II, and III were quantitative, applying self-report questionnaires, and Study IV was qualitative in nature. Study I explored relations among cognitive strategies, approaches to learning, regulation of learning, and study success by using correlations and a K-means cluster analysis. The participants were 366 students from various faculties at different phases of their studies. The results showed that all the measured constructs were logically related to each other in both variable- and person-centered approaches. Study II further examined what kinds of cognitive-motivational profiles could be identified among first-year university students (n=436) in arts, law, and agriculture and forestry. Differences in terms of study success, exhaustion, and stress among students with differing profiles were also looked at. By using a latent class cluster analysis (LCCA), three groups of students were identified: non-academic (34%), self-directed (35%), and helpless students (31%). Helpless students reported the highest levels of stress and exhaustion. Self-directed students received the highest grades. In Study III, cognitive-motivational profiles were identified among novice teacher students (n=213) using LCCA. Well-being, epistemological beliefs, and study success were looked at in relation to the profiles. Three groups of students were found: non-regulating (50%), self-directed (35%), and non-reflective (22%). Self-directed students again received the best grades. Non-regulating students reported the highest levels of stress and exhaustion, the lowest level of interest, and showed the strongest preference for certain and practical knowledge. Study IV, which was qualitative in nature, explored how first-year students (n = 536 ) in three fields of studies, arts, law, and veterinary medicine explained their disciplinary choices. Content analyses showed that interest appeared to be a common concept in students description of their choices across the three faculties. However, the objects of interest of the freshmen appeared rather unspecified. Veterinary medicine and law students most often referred to future work or a profession, whereas only one-fifth of the arts students did so. The dissertation showed that combining different theoretical perspectives and methodologies enabled us to build a rich picture of university students cognitive and motivational predispositions towards studying and learning. Further, cognitive-emotional aspects played a significant role in studying, not only in relation to study success, but also in terms of well-being. Keywords: approaches to learning, self-regulation, cognitive and attributional strategies, university students

Luzes e sombras na construção de um caminho para pacientes incuráveis: a eutanásia à luz da bioética e do direito

A presente dissertação analisa a possibilidade da prática da eutanásia ativa e voluntária em pacientes com doenças incuráveis à luz da bioética e do direito. O trabalho é de natureza teórica e foi realizado através de pesquisa bibliográfica, que levantou publicações, nacionais e internacionais, inclusive na imprensa, sobre os temas tratados na dissertação, a saber: eutanásia, morte, vida, dignidade, autonomia, princípios bioéticos, liberdade. O levantamento bibliográfico compreendeu, preferencialmente, obras sobre filosofia, ética, bioética, medicina e direito, que permitiram a análise das questões teóricas envolvidas diretamente no estudo. Aborda-se o conceito de morte e suas transformações ao longo dos anos e as distinções necessárias entre os conceitos do fim da vida, que apesar de muito próximos tem suas especificidades. Apresenta-se os princípios bioéticos da não maleficência e da beneficência, com a finalidade de discutir os limites da intervenção médica sobre o paciente, bem como o princípio da autonomia na visão da bioética e do direito, com o intuito de demonstrar que o doente incurável é um ser autônomo, com vontades e desejos que devem ser respeitados. Examinam-se os direitos à vida e a liberdade para fins de ponderação em face do princípio da dignidade da pessoa humana. Diferenciam-se os princípios da sacralidade da vida e da qualidade da vida, na busca de uma integração entre eles e faz-se uma análise do Código de Ética Médica e da Resolução CFM n 1.805 de 2006, que autoriza a ortotanásia, para confrontar os limites da prática médica e da autonomia do paciente. Pontua-se o estado atual da criminalização da eutanásia no ordenamento jurídico brasileiro apontando-se o quão perversa pode se tornar essa criminalização para aquele que sofre e, que através da compaixão laica e da solidariedade deve-se buscar meios hábeis para se permitir a eutanásia, sem deixar de proteger os vulnerados de eventuais abusos. Utilizam-se os casos de Ramón Sampedro e Vincent Humbert, pessoas que por causa de um acidente ficaram tetraplégicas e solicitaram na justiça uma morte digna, para exemplificar os diversos conceitos utilizados nesse trabalho. Por fim, apresentam-se os requisitos pessoais e formais mínimos para que a declaração de vontade de um paciente incurável, que pede uma morte digna, seja respeitada, quando essa vontade é expressa de forma inequívoca por ele, tendo como exemplo, a legislação da Bélgica e da Holanda, onde a eutanásia é permitida observando-se determinados requisitos.

Percepções de alunos egressos de institutos de idiomas sobre seu conhecimento linguístico em exames de Inglês para mestrado e doutorado: um estudo à luz do sistema de avaliatividade

O uso da língua materna (LM) faz parte dos exames do conhecimento de uma língua estrangeira (LE) tomados como instrumentos de avaliação em cursos de pós-graduação no Brasil que, em sua maioria, constam de tradução e compreensão leitora de um texto em Inglês. Porém, as abordagens adotadas em cursos de Inglês tendem a deixar a LM de fora do processo de ensino- aprendizagem. Outra questão importante inclui a qualidade e a abrangência da atenção dada à compreensão leitora, embora saiba-se que os cursos de Inglês trabalhem as quatro habilidades (falar, ouvir, ler e escrever) em sala de aula. Diante desse cenário, este estudo busca avaliar a percepção do percurso da aprendizagem de língua inglesa de treze participantes, quando confrontados com a necessidade de realizar provas de LI como parte da seleção para cursos de Mestrado e Doutorado. Aqui, voltamos nosso olhar sobre objetivos de uso do idioma especialmente para compreensão leitora, uma das possíveis ramificações do quadro teórico do Inglês para Fins Específicos (IFE). Neste sentido, apoiamo-nos em Hutchinson & Waters (1987, p. 19), que nos falam em aprendizagem centrada no aluno, nas necessidades trazidas por ele em determinado momento de sua vida profissional ou acadêmica.Para tanto, coletaram-se as percepções de treze participantes, por meio da técnica de Grupo Focal, a respeito do modo como aprenderam a língua inglesa ao longo de suas trajetórias. Utilizamo-nos, para analisar as realizações destes sujeitos, do Sistema de Avaliatividade, proposto por Martin & White (2005) dentre outros, no escopo da Linguística Sistêmico-Funcional, valendo-nos especialmente do domínio semântico de Atitude para investigar as opiniões expressas. Apesar de os participantes terem feito uso de todas as categorias do subsistema da Atitude, Afeto e Apreciação foram as mais recorrentemente utilizadas, já que suas falas revelam não apenas o modo como os sujeitos se sentiam e ainda se sentem quando no papel de alunos sob os métodos vigentes no mercado, mas também suas críticas aos métodos de aprendizagem de inglês. Obtivemos 10 índices de Apreciações Negativas aos cursos de idiomas a respeito da exclusão quase completa da LM em aulas, além de 11 Apreciações Negativas ao modelo de ensino de língua inglesa na esfera escolar.

Teaching Crossroads: 11th IPB Erasmus Week

In the wake of the latest news regarding IPB’s award for best Polytechnic Institute in Portugal, we would like to congratulate the IPB community who has always striven for the quality of the institution within the national and international academic milieu. We are, undoubtedly, bowled over by the 1st place in the national context (out of the 27 national institutions under evaluation) and the 7th position in the international scope. In fact, it is worth mentioning that the IPB has won this award, three years in a row, being in a leading position in the ranking promoted and sponsored by the European Union. This year’s edition has selected and evaluated over 1300 world higher education institutions. Teaching Crossroads intends thus to give a watershed contribution to the IPB’s successful and most valued pathway. Numbers indicate that Teaching Crossroads has had over 2550 downloads since it first came out. But let’s cut to the chase. Once again, we are delighted to present the 5th number of Teaching Crossroads. This wholly calculated and well-sustained editorial adventure started in 2012 when the first number of Teaching Crossroads first saw the light. This year’s publication includes the areas of Human Geography/anthropology, Information Technology and Forensics and Language and culture, focusing on minority languages. Alongside this, as in the two last previous numbers, we’ve included the specific area for International mobility, Intensive Programmes and Erasmus+ Mobility of Individuals, being the latter financed by the European Union within the Erasmus+ Programme, whereas the former is sponsored uniquely by the foreign partner institution, in this case, Lillebaelt Academy in Denmark. These types of programmes convey very positive and overarching ideas, resonant in cross-cultural and educational benefits, valuable for all the involved partners. We would very kindheartedly like to thank the authors for having contributed with much enlightening and serious articles on a wide array of areas. Pablo M. Orduna Pórtus’s article focuses on border culture and heritage management. The author’s study is placed on two borderlands of the Iberian Peninsula: Roncal Valley (Navarre) and Riverbanks of Douro. Going beyond the linear or physical conception of the border, the author centres his study on the metaphysical and symbolic ideas of the frontier that sustain his anthropological analysis. Michal Popdora manages to find evidence for his proposal of a new conception of teaching Image Processing, based on the student-centered approach. A hands-on experience on a Project-based Learning methodology sustains the teaching project. Grounded on “a forensic-flavored style”, using the author’s own words, he shows how students can become engaged in a highly effective learning process. Cláudia Martins is already a confirmed habitué of this publication, as in every Erasmus Week she delivers a lecture on Portuguese language and culture to visiting teaching and non-teaching staff. This time, the author decided to delve into a Portugal’s official language, Mirandese, spoken in a small designated area in the northeastern part of Portugal, Miranda do Douro and its surrounding area. The author gives account of some thought-provoking facts about the language, from the origin and the survival of the language, however still a minority language, up to the moment when it was acknowledged Portugal’s second official language, together with the challenges that nowadays faces. Luís Frölen Ribeiro, João Eduardo Ribeiro, Carlos Casimiro Costa, António Duarte, Carlos Andrade from the Polytechnic Institute and Arne Svinth, John Madsen, Morten Thomsen, Kent Smidstrup, Carsten John Jacobsen from the Lillebaelt Academy, in Denmark, participate in a joint project which they describe, outlining the main goals and gains of the project. To overcome teaching difficulties regarding the engineering degrees, a 12-ECTS joint course from Lillebaelt Academy and Polytechnic Institute of Bragança was created based on the Danish model. The course Product Development and Industrial Processing was hence created. Rui Pedro Lopes presents an insightful and acute account of the Internationalization programmes in Higher Education in Europe. At one go, the author describes his own experience as a visiting lecturer, within the Erasmus+ programme, to Università Politecnica delle Marche in Ancona, Italy, in a Master’s degree in computer science, bringing to light a personal reflection on the goals and benefits of the mobility for both students and teachers. Finally, the author puts forth some suggestions that would improve the whole mobility process. We sincerely hope to have stimulated you to keep on reading, upholding the belief that these texts can represent valuable sources for both teachers and students in their research work.

Realizing an Applied Gaming Ecosystem: Towards Supporting Service-based Innovation Knowledge Management and Transfer

The EU-based industry for non-leisure games is an emerging business. As such it is still fragmented and needs to achieve critical mass to compete globally. Nevertheless its growth potential is widely recognized. To become competitive the relevant applied gaming communities and SMEs require support by fostering the generation of innovation potential. The European project Realizing an Applied Gaming Ecosystem (RAGE) is aiming at supporting this challenge. RAGE will help by making available an interoperable set of advanced technology assets, tuned to applied gaming, as well as proven practices of using asset-based applied games in various real-world contexts, and finally a centralized access to a wide range of applied gaming software modules, services and related document, media, and educational resources within an online community portal called the RAGE Ecosystem. It is based on an integrational, user-centered approach of Knowledge Management and Innovation Processes in the shape of a service-based implementation.

The meaning of medications:another look at compliance

Most research on compliance with medical regimens takes a doctor-centered perspective and proceeds from certain assumptions. This paper presents an alternative, patient-centered approach to managing medications, using data from 80 in-depth interviews of people with epilepsy. This approach focuses on the meanings of medication in people's everyday lives and looks at why people take their medications as well as why they do not. I argue that from a patient's perspective the issue is more one of self-regulation than compliance. When we examine 'noncompliance' beyond difficulties with 'side effects' an drug efficacy, the meanings of self-regulation include testing, controlling dependence destigmatization and creating a practical practice. What appears to be noncompliance from a medical perspective may actually be a form of asserting control over one's disorder.

The stress process in palliative cancer care:A qualitative study on informal caregiving and its implication for the delivery of care

Objective: The primary objective of this study was to examine how the comprehensive nature of the Stress Process Model could elucidate on the stressors associated with caring for a palliative cancer patient. Method: A qualitative research strategy involving home-based face-to-face interviews with 12 bereaved family caregivers was used to examine the caregiving experience. Results: The primary stressors associated with caring for the palliative cancer care patients stemmed from care recipient symptoms and personal care needs. The absence of adequate support from the formal health care delivery system was a consistent message from all participants. There was evidence of financial stress primarily associated with the purchase of private home care to supplement formal care. In contrast, the resources that family caregivers relied on to moderate the stressful effects of caregiving included extended family, friends, and neighbors. While the stress of direct caregiving was high, the study revealed that formal care was also a significant source of stress for family caregivers. Conclusion: It was concluded that an appropriately financed, integrated system of care that followed a person-centered philosophy of care would best meet the needs of the patient and his or her family. © The Author(s) 2010.