JKAN Journal of Korean Academy of Nursing J Korean Acad Nurs 2005-3673 2093-758X Korean Society of Nursing Science 10.4040/jkan.2018.48.5.601 jkan-48-601 Original Article Shifting of Centricity: Qualitative Meta Synthetic Approach on Caring Experience of Family Members of Patients with Dementia RyuYoung Mi1 YuMi2 OhSeieun3 LeeHaeyoung4 KimHaejin5 Department of Nursing, Baekseok University, Cheonan College of Nursing · Institute of Health Sciences, Gyeongsang National University, Jinju College of Nursing, Dankook University, Cheonan Department of Nursing, Hoseo University, Asan Department of Nursing, Suwon Women's University, Suwon, Korea Address reprint requests to : Kim, Haejin Department of Nursing, Suwon Women's University, 72 Onjeong-ro, Gwonseon-gu, Suwon 16632, Korea Tel: +82-31-290-8232 Fax: +82-31-290-8208 E-mail: kimhj@swc.ac.kr 012018 15012018 485 601621 230520180208201818092018 Copyright © 2018 Korean Society of Nursing Science 2018 This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License. (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium. Abstract Purpose

This study aimed to synthesize the caring experiences of Korean family members of patients with dementia through a qualitative meta-synthesis method.

 Methods

By searching through nine Korean and English databases, we compared 37 qualitative studies on caring experiences of family members of patients with dementia. The selected studies were synthesized through meta-synthesis, proposed by Sandelowski and Barroso (2007).

 Results

The meta-synthesis elicited four themes: tough life due to care for patients, changes in relationships, adaptation to caregiver's roles, and new perspectives of life through personal growth. Caregivers were shocked when a sudden diagnosis of dementia was made prior to any preparation on their part. They were tied to their patients all the time and their mind and body got exhausted. Their relationship with patients began to change and they looked at them differently. They experienced conflicts with the other non-caring family members and were alienated from them. They were also socially isolated. However, by building their own care strategies and utilizing social resources, they gradually adapted to their caregiver roles. Finally, they experienced personal growth and acquired a new perspective toward life by accepting their roles and finding meaning in their lives. Shifting the caregiver's centricity from themselves to the patient was the process of becoming human beings who actively constructed their realities while giving meaning to their painful lives and interacting with the environment.

 Conclusion

The results of the study can be useful for nurses in understanding the experiences of caregivers of the patients with dementia and in providing them with practical interventions.

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Ed.Lee JS, Lee OS, Koh MS, translatorsSeoulHyunmoonsac20021170 Figures and Tables

Flowchart of the search process.

Shifting of centricity: Caring experience of family members of patients with dementia.

Summary of the Studies Reviewed

No No. Author (Year) Purpose Methodology Participants Data collection method Results
1 Baek (2008) ) To identify common Constant Husband 7, wife Qualitative Comprehension of early-onset dementia, Symptoms
needs of family comparison 1, son 1, sister interview and characteristics of the patient, Responsibility
members of presenile methods 1 of caregiving the patient with ambivalence,
dementia patients Willingness to use social services
2 Chang To investigate the Not mentioned Husband 1, In-depth Cause for prevalence of dementia, Symptom of
(2001) characteristics of the wife 1, son 1, interview aimless wandering, Relationship between family
elderly with dementia daughter 1, members of patients, Positive aspect of family
and the services their daughter-in- members
caregivers want law 1
3 Chee & To understandings Thematic Daughter-in-law In-depth 1. Perceptions of dementing illness.
Levkoff of perceptions of approach 8, daughter 2 Interview 2. Cultural in uences on caregiving: Parental
(2001) dementia among caregiving vs seeking outside care,
Korean family Changing attitudes witnessed: emerging re-
caregivers and institutionalization of filial responsibility
cultural influence 3. Development and utilization of formal services for
on the practice of the elderly and family caregivers
care, and utilization
of formal services
for elderly persons
with dementia and
caregivers
4 Cheon & To understand Content analysis Husband 1, wife Focus group 1. Characteristics of wandering behaviors
Song the wandering 7, daughter 2 interview, 2. Strategies for wandering management
(2015) management individual
experience of family interview
caregiver of demented
elderly
5 Cho (2016) To understand the Inductive case Daughter-in-law In-depth 1. Pre-care stage: living together with demented
experience of study analysis 5 interview elderly with neither preparation nor notice
daughters-in-law who 2. Initial care stage: The duty and responsibility of
take care of parent- the daughter-in-law, sacrifice, enduring through
in-law with cognitive faith
disorders 3. Mid-care stage: neglect by parents-in-law, lack of
interest from husband and inlaws, regrets about
insufficient parenting, misperception, awareness
about others' judgement, lack of social service,
gradual exhaustion, holding one's temper back,
endless care, deteriorating financial status
4. Late care stage: being a role model to one's
children, taking better care of demented elderly
with sadness, regrets due to providing poor care,
self-criticism of the provided care 5. After care stage: maturing through faith and
service, finding meaning of one's life, actively
preparing for the caregiver's own future
6. The flow of emotion: denial, submission, conflict,
consciousness, growth
6 Chung To understand the Phenomenology Husband 4, wife In-depth Sudden diagnosis of dementia, Gradual hardships
(2007) experience of spouses 1 interview in caring for one's demented spouse, Burden of
who take care of providing continuous care, Assistance from close
spouse with dementia acquaintances, Disease does not affect love,
Feeling pity for the demented spouse, but stress
for oneself, Usefulness of social services, Hoping
for a cure, but regretting the lost time
7 Han (2013) To reveal deeply Narrative inquiry Daughter 1, In-depth 1. Feeling guilty when they did not take care of
guilt experience of wife 1, son 1, interview their patient at home, when they thought their
Christian dementia daughter-in- care was subpar, and when they were not good
family law 1 enough before God
2. Justifying oneself to overcome guilt, but asking
for God's redemption afterwards
3. Recognizing their own sinful character, coming
forward to God, and having a chance to perceive
their own mission
8 Jang (2014) To understand and Phenomenology Husband 4, wife In-depth Body moving like old machines, Swamp of despair
describe the caring 8 interview filled with hope, Time of sweetness after
experiences of spouse bitterness, Elderly couple in an empty nest, Lack of
of elderly people with understanding vs. empathetic feelings
dementia
9 Jeong To understand the Phenomenology Wife 9 Interview Dark clouds all of a sudden, Heavy burden like
(2010) experience of the lashing rain, Trying to keep out pouring rain
wives who care without an umbrella prepared, Desire to shelter
for their husbands oneself against the rain, Conflict and pain amidst
suffering from the thunderstorm, Staring at the sun shining
presenile dementia through clouds after rain stops
10 Kim (2015) To explore the essence Narrative inquiry Wife 1, son 2 In-depth After becoming caregivers, the participants' mental
of the family daughter- interview and physical health has deteriorated, gradually this
experience with in-law 1, lead to stress and depression
demented elderly daughter 1,
11 Kim (2002) To explore coping Content analysis Daughter-in- In-depth Family members' 11 coping strategies: seeking help,
strategies when family law 8, wife 5, Interview ventilating emotions, converting mood, relying
members who take daughter 3, on religion, treating the patient with affection,
care of the elderly sister/brother 1 mediating caring role, managing problematic
with dementia at behavior, redefining circumstances, wishing,
home face difficulties projecting, emptying the mind
in caregiving
12 Kim (2005) To understand Grounded Daughter-in- In-depth The coping process of family caregivers while taking
caregivers’ difficulties theory law 8, wife 5, interview care of the demented elderly (6 stages): problem
in coping strategies daughter 3, recognition, undertaking care, struggling, mental
sister 1 control, burden mediation, acceptance
13 Kim & Um To find out the Content analysis Daughter-in-law Focus group 1. It is necessary to prepare expansion of house
(2015) difficulties that 1, husband 1, interview work support, daily life service support and
dementia families daughter 4 effectiveness education related with cognition
feel when caring for improvement program for the families of the
elderly with dementia elderly with dementia
after establishment of 2. It is necessary to provide family therapy in order
the special dementia to release psychological pains of the families of
rating system the elderly with dementia
3. It is necessary to have responsible professionals
to arrange the necessity of customized care
institution fit for dementia rating, to care for the
elderly with dementia at night and on weekends.
24 hour care support and education/information
sources are required for families of the elderly
with dementia
14 Kim (2016) To understand the Phenomenology Daughter 4, Interview Parents came on behalf of family vacancies.
experience of daughter-in- Parents were diagnosed with dementia without
menopausal women law 6 compensation for aging. Caregivers were too old
who care for parents to care for parents with dementia. Caregivers
with dementia were isolated from family due to demented
parents. Caregivers did not want to pass down
their responsibility in caring for demented parents
to their children. Caregivers planned a different
life compared to their parents
15 Kim (2013) To find out care Thematic Daughter-in-law In-depth More emotional stress than physical stress,
motivation, stress of analysis 10, daughter 2 interview Ambivalence felt by main supporters, Request
daughter-in-law and for social service. Difference in the degree that
daughter daughter-in-law taking care of demented elderly
and son accepted the disease of dementia
16 Kim KB & To understand the Ethnography Husband 3, wife In-depth Psychological conflict, Physical, social and
Lee KH experiences of 2, daughter 2, interview psychological pressure, Isolation, Acceptance,
(1998) caregivers and to daughter-in- Love, Hope
develop the nursing law 4, son-in-
theory related to law 1
caregivers
17 Kim (2001) To find out how stressed Constant Daughter-in-law In-depth 1. Behavioral coping strategies: direct behavior to
family members comparison 11, daughter interview deal with environment, and look for information
who take care of methods 2, wife 2, 2. Emotional coping strategies: effort to deal
demented elderly are husband 1 with denial belief and avoidance response to
and how they cope circumstances
with patients with 3. Coping strategies for social support: religious
dementia support, seeking help from one's extended family
18 Kim (2010) To understand the Phenomenology Wife 4, husband d In-depth Abrupt appearance of dementia, Unstable life due
experiences of 2 interview to dementia, Adaptation or coexistence with
spouses who are dementia for the caregiver, Life as a caregiver of
helping the spouse one's demented spouse, Still having hope
with dementia and
the meaning of their
experiences
19 Kim SY & To understand the Phenomenology Daughter-in- In-depth 1. The cause of the dementia to ‘environmental
Lee SH caregiving experiences law 4, son 1, Interview change’ and the introverted personality of the
(1998) of family members husband 1 elderly
with demented 2. Family caregivers left the demented elderly alone
patients and to help initially and then they recognized the symptoms
developing a family of dementia
education program 3. Coping responsess: having their moods fluctuate,
for them enduring and praying, avoiding the elderly,
hoping for release from responsibility, enduring
their conditions, accepting the elderly, taking an
objective view and taking safety measures
4. The long ordeal of coping with a demented
elderly person resulted in the loss of physical and
psychological well-being, ethical conflicts, family
conflicts, becoming desperate, rejection of the
aging process, sympathy and understanding for
the elderly, awareness that the support system is
important and hope of sharing their responsibility
20 Kim & Jun To understand Not mentioned Daughter 1, son In-depth 1. Understanding dementia and recognizing its
(1995) experience of family 1, daughter-in- interview symptoms
members with law 6 2. Coping strategies and management of dementia
dementia and to 3. Changes in relationships and ambivalent feelings
identify their needs about caregiving within family
and difficulties 4. Burden in caregiving and results afterwards
5. Isolation and needs of a family with a demented
patient
21 Kim (2007) To understand the Phenomenology Husband 1, wife In-depth 1. Understanding about elderly patients with
meaning and essence 3, daughter interview dementia by accepting dementia as a disease,
of the experience of 2, daughter- Self-definition & self-appraisal of caregiving
main family caregivers in-law 3, 2. Contemplating existential thoughts, Polarity of
who care for the granddaughter ambivalent feelings
demented elderly 1 3. Questioning of the transgenerational continuity
of filial piety, and Different experiences with the
formal care system
22 Lee (2006) To understand Phenomenology Husband 5 In-depth 1. Late discovery due to ignorance of dementia
husband's caregiving interview 2. Repentance at the negligence of their wives
experience and 3. Transition of their role from a husband to a
adaptation process to caregiver
care for a demented 4. Experiencing both physical and mental crises
wife because of troublesome behaviors
5. Recovering the suffering through various
resources
6. Adapting oneself to caregiving
7. Change and growth vs. the remaining crisis
23 Lee, Kim, & To understand the Phenomenology Husband 6 In-depth 1. Difficulty in recognizing their wife's disease
Ku (2007) caring experience of interview 2. Agony of caregiving as a husband and parent
husbands who provide 3. Economic struggles and desire to work
care to their wife with 4. Adaptation through self-change and social
presenile dementia supporting organizations
5. Need for rational and specialized services
24 Lee & Park To identify changes Not mentioned Daughter-in- In-depth Source of social support, Consciousness of
(2007) on social support, law 3, wife 3, interview caregiving, Family relationship
thought on daughter 4
the caregiving,
relationship with
other family members
after utilizing day care
facility
25 Lee & Ha To understand the Phenomenology 20 Family In-depth Burden of coping with the patient's actions,
(2008) experience of members with interviews Environmental difficulty related to the patient,
dementia patient’s defecation care Self-dilemma, Burden of weakness of general
experience of of dementia health, Effort of resolution in one's way
defecation care patients
26 Lee (1996) To understand the Phenomenology Daughter-in-law In-depth Isolation, Burden, Guilt, Fatigue, Adjustment,
essence of caring 1, wife 1 interview Spirituality, Maturation, Seeking information
experience of family
members of dementia
patients
27 Nam (2001) ) To understand the Template Daughter- In-depth 1. The caregiver was indifferent and uninterested
stressors and coping analysis in-law 7, interview about dementia, had an incorrect and subjective
strategies of family methods granddaughter knowledge of dementia, and failed to recognize
members who care 1, daughter 3, the symptoms in time
involved in caring for wife 1 2. Coping strategies include emptying one's mind,
demented elderly improving the environment, active response, and
tailored actions
3. Coping strategies for caregiving conflicts across
the family include avoiding family members who
do not cooperate, hoping that the demented
elderly will pass away, and blaming one's
situation and the demented patient
28 Oh & Kwon An in-depth Phenomenology Granddaughter Semi- 1. Some behaviors that the caregiver(s) find
(1999) understanding of the 1, daughter-in- structured difficulty in caring are: issues with communication
burnout process of law 1 interview due to decreased hearing ability, health issues of
family caregivers who the demented patient due to abnormal dining
care for patients with habits, aggressive language, wandering, lack
dementia of circadian rhythm, affective disturbance, fear
of being alone, and hardships in bathing and
changing clothes
2. The article encompasses the reactions and coping
strategies of the demented patient's caregiver(s)
against these difficulties
3. Although the caregiver(s) seemed to undergo
severe psychological distress, they expressed their
filial duty of taking care of the demented patient
as far as the patient is alive
29 Park (2007) To understand caring Phenomenology Daughter-in-law In-depth Beginning a life without me, Adding more rocks
experience of 4 interview to the burden on one’s back, Attempts and
daughters-in-law who management to unload the burden, Escape
provide care to their from caretaking via external dementia care on
parent-in-law weekends
30 Park (2013) To understand the Grounded Husband 7 In-depth - ‘Slowly accepting wife's dementia’
experience of theory interview 1. Recognizing changes (experiencing sudden
husbands who provide change due to neglect of dementia)
care to their wife with 2. Denial (doctor shopping, failing to accept reality,
presenile dementia seeking an alternate cure)
3. Striving (adjusting to reality, taking her roles of
mother and housewife, bearing the situation)
4. Acceptance (finding hope, finding the meaning
of life in caregiving, burn-out, sympathy)
31 Seo (2003) To understand Narrative inquiry Daughter-in-law Interview, Life without her own life, The lonely burdened life,
the experience 3 observation burdened life, The desire to break herself from
and meaning of her husband’s family members, Unwillingly doing
daughters-in-law who her duty, Expecting some compensation from her
care for mothers-in- husband, A sense of pride in doing her duties,
law with dementia Feeling exhausted
32 Song To examine in detail the Categorical Wife 5, son 1, In-depth Development of dementia, The difficulty of caring,
(2016) caring experiences of aggregation daughter- interview The form of support from family, Approaching the
primary caregiver of in-law 1, day and night care services, Changes made after
elderly households granddaughter r using the day and night care services, Satisfaction
with adult children 1 factors of the day and night care services,
and elderly couple Additional desire regarding the day and night care
households services, Views on using care facilities, Perception
on the government's policy to manage dementia
33 Song, Lee, To understand the Content Daughter-in-law Focus group 1. Temporary break from routine
& Cheon meaning of rest for analysis 2, wife 3, sister r interview 2. Direct help: taking care of oneself, receiving
(2010) a family that cares 1, daughter 2 economic help
for the elderly with 3. Psychological comfort: empathizing with others,
dementia comfort based on trust, resting together with the
demented patient
4. Valuables which cannot be obtained easily
34 Sung, Yi, To understand how a Content Daughter 31 essays 1. The confronting stage: severe negative feelings
Lee, & Jan family caring for the analysis 13, wife 9, written and exhaustion occurring after the patient’s
(2013) elderly with dementia daughter-in- by family diagnosis of dementia
overcome the law 7, son 1, caregivers 2. The challenging stage: major driving forces in
difficulties in caring sister 1 who adapt taking good care of their patients. It includes
well tender loving memories about the patients as
well as family and social supports
3. The integrating stage: genuine empathy for the
patients’ situation and the happiness of ‘here and
now’
4. Transcendental stage: new hope in the future
35 Woo (1997) To examine the Constant 9 (Husband, In-depth 1. The caregiver's relation to the patient before
subjective meanings comparison wife, daughter, Interview diagnosis of dementia affected the quality of the
of experience of methods daughter-in- current relationship and the patient's abnormal
main caregiver in the law, son) behavior
family in relation with 2. There is a conflict between the primary caregiver
demented elderly and secondary caregiver
and secondary family 3. The degree of responsibility varies depending on
caregivers who the caregiver is. Spouses tended to assume
full responsibility while children tended to expect
the entire family to participate in caretaking
4. While there are secondary caregivers, they were
of little help to the primary caregiver
5. Family conflicts lead to negative social support for
the primary caregiver
36 Yang & Han To explore the Phenomenology Wife 2 In-depth Heavy role, Limitation of social activities, Efforts to
(2015) experience of interview adaptation
caregivers of dementia
patients
37 Yi, Kim, & Yi To find out what the i Thematic Daughter-in- Secondary Androcentric view of family caregiving, Undervalued
(2004) caring experience as a content law 7, wife 2, data family caregiving by the family members, Self-
female caregiver is like analysis granddaughter rationalization in the context of family caregiving,
1 Family-centric care mechanism, Exemplary
caring within the family context, Inter-familial
relationships among women

Synthesized Themes of Caring Experience of Demented Patient's Family Caregiver

Core themes Themes Sub-themes Studies
Shifting of Tough life due to Sudden diagnosis of dementia A1, A5, A6, A7, A8, A9, A10, A12, A13, A14, A16, A17, A18, A20,
centricity caring for patients without any preparation A22, A23, A30, A31, A32, A34, A36
Exhausted mind and body by A3, A6, A8, A9, A10, A14, A15, A16, A18, A19, A22, A25, A26, A29,
being tied to the patient all A31, A32, A34, A36
the time
Changes in Changes of the way to look A1, A2, A3, A5, A6, A7, A8, A9, A11, A12, A13, A15, A18, A20, A21,
relationships at the patient A22, A24, A25, A26, A28, A29, A31, A32, A34, A35, A37
regarding care Conflicts and alienation A2, A5, A6, A7, A8, A9, A10, A11, A12, A13, A14, A15, A16, A17,
caused by caregiver role A18, A19, A20, A21, A22, A24, A25, A27, A29, A31, A32, A34,
A35, A37
Social isolation A3, A4, A5, A8, A9, A10, A15, A16, A18, A20, A22, A23, A26, A29,
A30, A34, A36
Adaptation to Building own care strategies A2, A4, A5, A7, A8, A9, A11, A12, A16, A17, A19, A20, A21, A22,
caregiver roles A23, A24, A25, A26, A27, A28, A29, A30, A31, A33, A34, A36
Utilizing social support A1, A2, A3, A5, A6, A7, A8, A12, A13, A15, A17, A18, A21, A22,
A23, A24, A26, A29, A30, A31, A32, A33, A34, A35, A36
New perspectives Personal growth by accepting A5, A6, A7, A8, A9, A11, A15, A18, A19, A20, A21, A22, A23, A26,
of life through the situation A30, A32, A33, A34
personal growth Expanded perspectives of life A5, A7, A14, A16, A30, A34
through caregiving

A=Appendix.

Illustration of Data Analysis

Findings and interpretation from individual qualitative studies Synthesized subthemes Synthesized themes
Chee & Levkoff (2001) Caregivers experience many burdens including fatigue, lack of free time and Exhausted Tough life due
sleep, anxiety about their own health, and psychological instability mind to caring for
Chung (2007) Gradual hardships in caring for one's demented spouse; burden of providing and body patients
continuous care by being
Jang (2014) Body moving like old machines (Tired body moving continuously without rest, tied
trained body from day-to-day caring); jail without bars (Battle without any to the
winners or losers) patient
Jeong (2010) Heavy burden like lashing rain (Caregivers were not able to leave the patient all the
alone due to their problematic behaviors and dependency); staring at myself time
wet from the rain, feeling sad, and having self-doubt (Pains and sadness
due to endless confrontation with the patient, feeling sorrow because of the
inescapable burden)
Kim (2015) After becoming caregivers, the participants' mental and physical health has
deteriorated. Gradually, this lead to significant distress and depression.
Kim (2005) Stage of undertaking care (Families with dementia patients usually determine a
designated caregiver. The caregivers are rarely to be prepared to take part in
the caregiving, which thereby led plenty of practical difficulties and experienced
lots of trial and errors.); stage of struggling (Since the intensity and frequency
of the patient’s problematic behaviors increase over time, the caregiver and
the family have serious role conflict, which can be metaphorically expressed
as ‘desperate fight with the disease and hardships.’); stage of mental control
(Significant deterioration in the patient’s cognitive and physical functioning
induced unspeakable distress and negative responses including powerlessness,
profound despair, frustration and resentment.)
Kim (2016) Caregivers were too old to care for parents with dementia. (Caregivers
experience sleep deficit, chronic fatigue, and bodyache. They were not able to
have their own life and respite due to caregiving.)
Kim (2013) Caregivers experience financial, psychological/emotional, and physical distress
due to the following: patient’s problematic behaviors, cognitive and physical
functioning deterioration, the in-law families’ indifference, misunderstanding of
the disease and care, and emotional disturbances such as depression
Kim KB & Lee KH (1998) Caregivers were suffering from psychological conflict; physical, social and
psychological pressure; and self-consciousness related to the stigma against
dementia.
Kim (2010) Difficult journey of caring for demented patients and psychological turmoil;
experiencing decline of own health
Kim SY & Lee SH (1998) Having their moods fluctuate; enduring and praying; hoping for release from
responsibility, enduring their conditions
Lee (2006) Experiencing both physical and mental crises because of troublesome behaviors
Lee & Ha (2008) Burden of coping with the patient's actions and weakness of general health
Park (2007) Beginning a life without me; adding more rocks to the burden on one’s back
Seo (2003) Life without her own life; the lonely, burdened life; unwillingly doing her duty;
feeling exhausted
Sung, Yi, Lee, & Jang (2013) Severe negative feelings and exhaustion occurring after the patient’s diagnosis of
dementia
Chee & Levkoff (2001) One of the most difficult aspects is that I can no longer have free time for myself Social Changes in
Cheon & Song (2015) Tied to the patient all day long isolation relationships
Cho (2016) Ostracized from friends and social life regarding care
Jang (2014) Decreased communication with friends after they learned about the caregiver's
spouse having dementia, and worsening relationships
Jeong (2010) Feeling of social isolation, inconvenience due to limited radius of activity
Kim (2015) Avoiding social interactions
Kim (2013) Lack of social life and time for hobbies
Kim (2010) Disconnected from society
Kim & Jun (1995) Difficulties arising from lack of free time
Lee (2006) Unable to interact socially for a prolonged time, breaking old relationships,
loneliness and social isolation
Lee, Kim, & Ku (2007) Withdrawal from social relationships and feeling trapped
Lee (1996) Difficulty in not only going out but also participating in social life
Park (2007) Becoming distant from the outside world
Park (2013) No one to regard as a confidante, infrequent social interactions, avoiding
meeting with friends
Sung, Yi, Lee, & Jan (2013) ) A lack of opportunity to interact with society lead to depression and isolated life
Yang & Han (2015) Not participating in meetings due to caregiving, lack of activity due to time
restraints