PONE-D-23-42012Unpaid Caregivers’ Process of Collaborating with Others during Older Adult Hospital-to-Home Transitions: A Grounded Theory StudyPLOS ONE

Dear Dr. Liebzeit,

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 [This work was supported by the Barbara and Richard Csomay Gerontology Research Award at the University of Iowa College of Nursing.].  

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this paper.

Introduction. The introduction establishes the reason for the study. Yet, the objective included in the abstract: “The objective was to examine caregivers’ process of collaborating with others during older adult hospital-to-home transitions.” The aim in the intro, are slightly different” This study aims to address this gap by examining unpaid/family caregivers’ process of collaborating with others, including other family members, healthcare professionals, and community, social, and professional networks, during older adult hospital-to-home transitions”. Consistency would help the reader.

My biggest concern is that the central justification for the paper, is based on two self-citations. Valuable though this previous work is, the authors should note, that the current paper, builds on previous work by same (almost identical) research team. It is only in the methods that a larger study is mentioned. The text on page 2. with the self-citations in full:

Prior qualitative research has focused primarily on caregiver involvement in healthcare interactions, inefficient discharge processes, and tasks (e.g., medical and nursing) related to the older adult care (3). However, emerging evidence suggests a more complex collaborative process during hospital-to-home transitions (11).

3. Liebzeit D, Jaboob S, Bjornson S, Geiger O, Buck H, Arbaje AI Ashida, Sato ; Werner, Nicole E. A scoping review of unpaid caregivers’ experiences during older adults’ hospital-to-home transitions. Geriatr Nur (Lond). 2023;53:218–26.

11. Liebzeit D, Geiger O, Jaboob S, Bjornson S, Strayer A, Buck H, Werner, N. . Older Adults’ Process of Collaborating with a Support Team during Transitions from Hospital to Home: A Grounded Theory Study. The Gerontologist. 2023 Jul 12;gnad096.

This brings me to the lack of an informative, well-structured lit review. The literature covered in the introduction may be sufficient for that task. However, as a reader, I want to know how the current study is contextualised within current literature about collaboration between unpaid/family/friend caregiver and paid/unpaid others in relation to older adults in/leaving hospital. Some explanation/definitions of informal/unpaid caregivers would be helpful. Including research about single/primary and group/family caregivers would add depth to the paper. It may also be useful to look at existing literature around caregiver self-care during transitions of the cared-for person e.g., home to hospital; home to residential care; discharge to home.

Methods:

It would be educative for the authors to provide an example from their data analysis to demonstrate the analysis process.

A table listing the main themes and subthemes, with examples of quotation would provide a summary of the findings.

Findings/Results:

The data is rich. The themes and subthemes are well-structured. It would be best to end each theme/subtheme with an interpretative comment, rather than with a participant quotation. This may mean rearranging rather than rewriting relevant theme/subthemes.

Discussion: The discussion needs development.

Please restate the purpose and summarise the key findings and then discuss each key finding in relation to the objective and relate these findings to prior studies. The authors need to show how the findings are consistent or contradictory with prior research – and as well as their own work. Where the results are contradictory, explain the possible reason.

The limits of self-citation are evident in this section. The opening paragraph begins with, “While prior qualitative research with this population has focused on the role of a single caregiver undergoing the transition process (3), our findings suggest a more complex team or “care network” structure of caregiving.” (p. 20). As noted earlier, reference (3) is a self-citation not acknowledged as the authors’ prior work. The results should be situated within the broader literature to support the authors’ claims. For example, such literature should include previous studies that critique and unpack the “primary caregiver” model.

Overall, this paper has the potential to be strong because the data is rich. A major downfall is the failure to adequately situate the study, and the results of the study, with the extensive existing literature about informal/family/unpaid caregivers' collaboration among themselves and with formal providers.

Reviewer #2: Summary:

The authors of this study sought to use grounded theory methodology to characterize and explore the process that unpaid/family caregivers undergo to collaborate with other people in order to support the hospital-to-home transition of an older adult. Interviews from 16 caregivers of older adults informed the development of a conceptual model that maps that process that caregivers undertake in the hospital to home transition. Findings identified the key role that collaboration plays in supporting this transition, and caregivers highlighted the role of family, friends, healthcare providers and larger social/professional networks in this process.

Strengths and Weaknesses

- The authors provide a strong justification for the need to explore caring through this network lens, and the need to intervene with support of caregiver’s network in order to support their caring role.

- The choice of grounded theory methodology is well supported throughout the methods,

- Methods- Line 101 page 4: This line is confusing. The authors should clarify if data saturation was reached for the parent larger study, or if the present analysis was a subset of individuals from the larger study and if data saturation was not used to decide when to end enrollment for the present analysis.

- Methods - Data analysis and credibility is well written.

- The three stages (identifying + learning, collaborating, supporting progress/planning) are well described and provide an interesting overview of the touchpoints with healthcare and community throughout this process. Seeing as there are subheadings under each stage, a summary paragraph would be helpful before proceeding into the next stage.

- Results – It is unclear in the results section how the ‘conditions’ and ‘consequences’ are intended to be woven into the three stages. Figure 1 attempts to indicate where these intersect with the stages, but more discussion of how conditions and consequences impact each stage of the transition is warranted within the text.

- Discussion – line 456 + 464-466. This work also identifies an important implication for healthcare providers, namely in understanding the benefits that social/professional networks can provide caregivers, asking about these networks and referring to community resources when there is an identified lack. There is some discussion of promoting the role of care networks, but there is room to further expand on the role that healthcare plays in helping caregivers access these networks.

- One the major limitations of this work is the lack of cultural diversity. This is referenced in the limitations section; however, the authors should consider exploring this limitation further. Care networks and their perceived impact/utility may different substantially between individualist and collectivist cultures.

Minor Comments

- The authors could comment on the later timeline (30-60 days) of post-discharge interviews and how this might have impacted responses and themes as well as whether this was a strength or limitation of their study.

- The authors should comment on how the study taking place during the COVID-19 pandemic may have affected study findings. For example, in many parts of the world, there were restrictions imposed to caregivers coming to hospital due to public health restrictions which may have affected the experiences of caregivers.

- It would be helpful for the reader if the authors were to delineate between ‘care in network’ and ‘care in social/professional networks’ earlier on. This comes up in the results section for ‘caring in social/professional networks’, but would be helpful to understand when describing ‘care in network’. Perhaps renaming to ‘shared caring in network’?

- In Table 1, sharing the employment status of participants would provide context into their capacity to provide care. Caregiver employment is referenced in Line 279 so the authors may have this data to share.

- Results - Lines 169 – 173. This section indicates first that caregivers learned their role during the transition, and then goes on to identify different ways of learning about their role, including during hospitalization. Would learning about their role not happen during the hospitalization, before the transition? Experiences which may have occurred while in hospital would be important to clarify here.

Reviewer #3: This paper reports a qualitative study looking at the role of caregivers during older adults' hospital to home care transitions. This is an important area to explore and this paper adds to the current literature. In particular, it offers a 3-stage process of what caregivers may go through, and some of the associated needs/gaps, and influencing factors. These can be tested in the future and may be addressed in future interventions.

MAJOR COMMENTS:

1. A relatively small sample size and does not appear to be diverse. This is appropriately stated as a limitation. I do not believe there is anything else the authors can do to address the limitations with the current data set (unless they plan to pursue further data collection).

2. As this study has its recruitment linked to a parent study (and given the relatively small sample size and lacks diversity), it would be important to give the readers some sense about what the parent study is about (who may be recruited to the parent study, or whether the parent study is descriptive or interventional). This will give the reader further context to interpret the data and claims made. The authors could provide more information about this in the manuscript.

3. The authors also did not give any sense of the amount of care (can be a range) provided by caregivers in the sample. This may be helpful for the readers to understand findings (e.g. one can imagine whether caregiver can care on own vs with a network may depend on the nature of tasks and amount of care required). I suggest the author make some comments about the amount of care caregivers are providing in a sample (a range would likely be needed I suspect).

4. For stage 2, it is unclear whether the categories (caring on own, caring with network, etc...) are mutually exclusive. I would also imagine that regardless of whether one is caring on own or with network, that they will interact with healthcare professionals (so unclear to me what type of caregiver is included/excluded in the caring with healthcare professionals category). Also, I imagine that any caregiver can access social and professional network (so I am unsure whether this implies in the data, there is a group of caregivers who primarily do this - but not caring on own or with network?)?? I think this requires further clarifications in the manuscript.

MINOR COMMENTS

5. The phrases "caring with network" and "caring with social and professional networks" are not self-explanatory. The authors did explain it in the middle of the manuscript (but did make several references to these concepts prior). Would recommend explaining these concepts earlier on in the manuscript.

6. Line 114: I think the author meant first :10-15 minutes (and not interviews)??

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Unpaid Caregivers’ Process of Collaborating with Others during Older Adult Hospital-to-Home Transitions: A Grounded Theory Study

PONE-D-23-42012R1

Dear Dr. Liebzeit,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Academic Editor

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Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Summary

The authors have addressed the reviewer comments. The structure of the results section is more clear, and providing definitions of the different types of caring has strengthened the conceptual model.

Minor revision

Results – Line 437 onwards. The presentation of the conditions and consequences of caring is not as a strong as the presentation of the stages of caring through the transition. Specifically, the conceptual model (Figure 1) does not incorporate how conditions intersect with the stages – this very well may be across all stages, but may be helpful to note. Consequences are only presented for Stage 2 – caring on own, and Stage 3 – Planning to provide long-term care and support. It may be helpful to descriptively state in the results which stages the consequences and conditions apply to, to reinforce the visual graphic.

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Reviewer #2: No

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