The carer/key-worker enhanced relationship cycle: a theory of the reciprocal process

The increasingly important role of the family in providing home care for a relative diagnosed with dementia has become a recognised feature of contemporary heahh care. Few studies exist, however, that have examined the relationship these carers develop with the professional assigned to help them undertake care-giving. The relationship held with a key-worker may significantly influence their ability and motivation to undertake the tasks and lifestyle changes necessary for this role. This study's aim was to examine this relationship in detail and generate a theoretical explanation allowing a clearer understanding of the influential factors associated with creation and enhancement of this relationship. Grounded theory was considered the methodology best suited to this aim. Its principal advantage is that it allows the researcher to generate rather than simply test theory and it also provides the necessary degree of flexibility essential for such an exploratory study. In order to meet ethical approval requirements a purposive, rather than theoretical, sampling approach was used for the selection of carers. Approach into the carer sample was through the consultant psychiatrist who forwarded research packs to potential participants via the person with dementia. Eighteen carers met the entry requirements and were subsequently included within the study; along with their chosen key-workers who numbered eleven in total. The key-worker group were all front line workers from either a health or social care background. Nine of this key-worker group were qualified and registered worregistered workers while the remaining two were unqualified care workers working under the direct supervision of a registered social or health care professional. The carerlkey-worker pairs were interviewed in tandem and all interviews recorded. These were then analysed using the constant comparative method, a process helped by the use of NUD*IST computer software. The analysis progressed from initial data categories through to the final core category that provided an explanation of all subordinate data. This core category became the title for the theoretical framework that eventually emerged. Subsequently, a theoretical explanation of the relationship's development was generated along with how it impacted upon the care-giving environment. The theory began with the major category 'The Enhanced Relationship Drivers', which highlighted that while characteristics associated with this relationship were often obscure, there were significant qualities and actions that clearly enhanced the relationship. Once these were engaged both parties moved towards the closer 'therapeutic alliance' contained within the second major category area, 'Models of Action'. Here shared qualities and attributes were more successfully directed towards the care of the person with dementia. A direct outcome of this alliance was a potentially closer and more productive working relationship for both the carer and key-worker. This could result in the creation of an improved therapeutic milieu, minimising the more negative interpretations associated with care-giving. These more negative perceptions of care-giving were highlighted within the third major category 'Impact upon the World of Caring'. However, when the enhancing influences of the preceding major categories were enacted, a more 'Rewarding Care Experience' was possible. External mediators could impinge upon the relationship, either impeding or enhancing its development. These included factors such as the management style of the key-worker's employing authority, the availability of alternative support networks for the carer, as well as the educational/life experience of both members of this dyad. The derived theory has been diagrammatically represented to provide a clear demonstration of all theoretical links between codes and categories, facilitating a better understanding of the developed theory. The study provided a clear insight into the interpersonal processes associated with the carerlkey-worker relationship and how this relationship may more effectively be initiated, managed and strengthened. This theory has important implications for future research into similar psychosocial aspects of care-giving. These findings have ramifications for carer training as well as education and training courses preparing professionals to work more effectively with carers. It has implications for health and social care managers in terms of their level of awareness of the importance of this relationship and the need for investment in it. lt is important that this theory is exposed to more rigorous empirical study allowing for a more confident prediction that its propositions will produce the direct benefits for this relationship that this theory suggests.