Caregiving and care receiving among a technologically dependent heart failure population

Effectiveness of a videoconferencing group-based dyad acceptance and commitment therapy on the quality of life of chronic heart failure patients and their family caregivers: A study protocol for a randomized controlled trial

BACKGROUND

Chronic heart failure (CHF) poses a significant burden on both patients and their family caregivers (FCs), as it is associated with psychological distress and impaired quality of life (QOL). Acceptance and Commitment Therapy (ACT) supports QOL by focusing on value living and facilitates acceptance of psychological difficulties by cultivating psychological flexibility. A protocol is presented that evaluates the effectiveness of a dyad ACT-based intervention delivered via smartphone on QOL and other related health outcomes compared with CHF education only.

METHODS

This is a single-center, two-armed, single-blinded (rater), randomized controlled trial (RCT). One hundred and sixty dyads of CHF patients and their primary FCs will be recruited from the Cardiology Department of a hospital in China. The dyads will be stratified block randomized to either the intervention group experiencing the ACT-based intervention or the control group receiving CHF education only. Both groups will meet two hours per week for four consecutive weeks in videoconferencing sessions over smartphone. The primary outcomes are the QOL of patients and their FCs. Secondary outcomes include psychological flexibility, psychological symptoms, self-care behavior, and other related outcomes. All outcomes will be measured by blinded outcome assessors at baseline, immediately post-intervention, and at the three-month follow-up. Multilevel modeling will be conducted to assess the effects of the intervention.

DISCUSSION

This study is the first to adopt an ACT-based intervention for CHF patient-caregiver dyads delivered in groups via smartphone. If effective and feasible, the intervention strategy and deliverable approach could be incorporated into clinical policies and guidelines to support families with CHF without geographic and time constraints.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04917159. Registered on 08 June 2021.

Assessment of health-related quality of life in patients with heart failure: a cross-sectional study in Saudi Arabia

Background

As a precarious clinical condition and a public health problem, heart failure (HF) is associated with a significant burden of morbidity, mortality, and health care costs. As almost all of the published research has been conducted in Western countries, there is a need for culturally relevant studies in Saudi Arabia. This is the first study to investigate health-related quality of life (HRQoL) and its associated factors among Saudi patients with HF in the Qassim region.

Methods

A cross-sectional study was conducted at the only tertiary care hospital in the Qassim region of Saudi Arabia during the period from November 2020 to July 2021. The participants were interviewed face-to-face by trained interviewers using the standard validated 36-item Short-Form Health Survey (SF-36) questionnaire for HRQoL assessment. The data were analyzed using STATA version 16.

Results

The participants included 246 HF patients whose mean (SD) age was 56.7 (10.9) years. A majority of the respondents (80%, n = 197) were male, and 49% (n = 121) had an education level of less than secondary school. The median scores were high for the domains of social functioning (100 points) and bodily pain (75 points) and low for role-physical functioning (25 points). In general, the median scores for the physical and mental component summaries were 58.1 and 63.7, respectively. Patients with an education level less than secondary school were more likely to have a low physical component summary score (aOR 3.00, 95% CI 1.46–6.17), while female patients were more likely to have a low mental component summary score (aOR 2.67, 95% CI 1.38–5.16).

Conclusions

Health-related quality of life was found to be moderate among these HF patients. Periodic HRQoL assessment is recommended for HF patients to minimize their physical and psychological concerns, particularly for patients with low education levels and female patients.

Baseline Quality-of-Life of Caregivers of Patients With Heart Failure Prior to Advanced Therapies: Findings From the Sustaining Quality of Life of the Aged: Transplant or Mechanical Support (SUSTAIN-IT) Study

BACKGROUND

We compared health-related quality of life (HRQOL), depressive symptoms, anxiety, and burden in caregivers of older patients with heart failure based on the intended therapy goal of the patient: awaiting heart transplantation (HT) with or without mechanical circulatory support (MCS) or prior to long-term MCS; and we identified factors associated with HRQOL.

METHODS

Caregivers (n = 281) recruited from 13 HT and MCS programs in the United States completed measures of HRQOL (EQ-5D-3L), depressive symptoms (PHQ-8), anxiety (STAI-state), and burden (Oberst Caregiving Burden Scale). Analyses included ANOVA, Kruskal-Wallis tests, χ² tests, and linear regression.

RESULTS

The majority of caregivers were female, white spouses with ≤ 2 comorbidities, median [Q1,Q3] age = 62 [57.8, 67.0] years. Caregivers (HT with MCS = 87, HT without MCS = 98, long-term MCS = 96) reported similarly high baseline HRQOL (EQ-5D-3L visual analog scale median score = 90; P = 0.67 for all groups) and low levels of depressive symptoms. STAI-state median scores were higher in the long-term MCS group vs the HT groups with and without MCS, (38 vs 32 vs 31; P < 0.001), respectively. Burden (task: time spent/difficulty) differed significantly among groups. Caregiver factors (number of comorbidities, diabetes and higher anxiety levels) were significantly associated with worse caregiver HRQOL, R² = 26%.

CONCLUSIONS

Recognizing caregiver-specific factors, including comorbidities and anxiety, associated with the HRQOL of caregivers of these older patients with advanced HF may guide support strategies.

Evaluating emotional distress and health-related quality of life in patients with heart failure and their family caregivers: Testing dyadic dynamics using the Actor-Partner Interdependence Model

PURPOSE

1) To compare levels of emotional symptoms and health-related quality of life between patients with heart failure and their family caregivers; and 2) to examine whether patients' and caregivers' emotional symptoms were associated with their own, as well as their partner's health-related quality of life.

METHOD

In this cross-sectional study, 41 patients-caregiver dyads (78% male patients, aged 68.6 years; and 83% female caregivers, aged 65.8 years) completed all nine dimensions of the Brief Symptom Inventory and the Minnesota Living with Heart failure Questionnaire. Dyadic data were analysed for 6 sub-scales of the Brief Symptom Inventory, using the Actor-Partner Interdependence Model.

RESULTS

There were no statistically significant differences in emotional symptoms and health-related quality of life between patients with heart failure and their caregivers. Patients' and caregivers' emotional symptoms were associated with their own health-related quality of life. Caregivers' anxiety, phobic anxiety, obsession-compulsion, depression and hostility negatively influenced their partner's (i.e. the patient's) health-related quality of life. There were no partner effects of patients' emotional symptoms on the health-related quality of life of caregivers.

CONCLUSIONS

The results of this study suggest that patients may be particularly vulnerable to the emotional distress, i.e. thoughts, impulses and actions of their caregivers. It may be possible to improve patients' health-related quality of life by targeting specific detrimental emotional symptoms of caregivers.

Depressive symptoms in the family caregivers of patients with heart failure: an integrative review

AIMS

Identify the occurrence of depressive symptoms in family caregivers of patients with heart failure and the correlation of other variables with depressive symptoms.

DESIGN/METHOD

The literature review was conducted in the Web of Science, Medline, LILACS and PubMed databases in March 2017. Papers published between 2004 and 2016, written in English, Spanish or Portuguese were included. The descriptors used were health, heart failure, depression, caregivers, and family.

RESULTS

26 papers were selected. 6% to 64% reported depressive symptoms. Depressive symptoms were associated with patients' and caregivers' characteristics. In most cases, depressive symptoms were greater among family caregivers than in the general population and were mainly associated with care burden and quality of life.

CONCLUSIONS

The studies report depressive symptoms in caregivers of patients with heart failure.

Family caregiving for persons with advanced heart failure: An integrative review

Objective

The unique needs of caregivers of those with advanced heart failure (HF) are not effectively being met, and reports of physical and mental health challenges are common. The objective is to identify the current state of the literature related to family caregivers of persons with advanced HF, ascertain gaps that require further exploration, and provide preliminary practice recommendations based on the results.

Method

Systematic review of quantitative and qualitative literature. A search of CINAHL, Medline, EMBASE, and PubMed identified 24 articles that met inclusion criteria. Data were analyzed using the constant comparison method and coded. Thematic analysis was used to develop themes.

Result

Sixteen qualitative and seven quantitative studies met inclusion criteria. Analysis of these studies identified six key areas: (1) undertaking a journey in a state of flux, (2) gaining strength, (3) forgetting oneself along the way, (4) seeking out sources of support, (5) preparing for end of life, and (6) finding closure.

Significance of results

The healthcare system currently struggles to meet the care demands of patients with chronic conditions such as advanced HF; as such, informal caregivers are undertaking key roles in the management of symptoms and promotion of the health of those with advanced HF. When caregivers are not adequately prepared for their role, both patient and caregiver well-being is compromised; therefore, a deeper understanding of the caregiving experience could assist in identifying the cause of caregiver anxiety and result in the development of strategies to minimize its effects. Overall, this review will also contribute to improving the current practice when working with caregivers of persons with advanced HF and serve as a basis for development of evidence informed interventions in the future.

'Who Cares?' The experiences of caregivers of adults living with heart failure, chronic obstructive pulmonary disease and coronary artery disease: a mixed methods systematic review

OBJECTIVE

To assess the experiences of unpaid caregivers providing care to people with heart failure (HF) or chronic obstructive pulmonary disease (COPD) or coronary artery disease (CAD). Design Mixed methods systematic review including qualitative and quantitative studies. Data sources Databases searched: Medline Ebsco, PsycInfo, CINAHL Plus with Full Text, Embase, Web of Science, Ethos: The British Library and ProQuest. Grey literature identified using: Global Dissertations and Theses and Applied Sciences Index and hand searches and citation checking of included references. Search time frame: 1 January 1990 to 30 August 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Inclusion was limited to English language studies in unpaid adult caregivers (>18 years), providing care for patients with HF, COPD or CAD. Studies that considered caregivers for any other diagnoses and studies undertaken in low-income and middle-income countries were excluded. Quality assessment of included studies was conducted by two authors.

DATA ANALYSIS/SYNTHESIS

A results-based convergent synthesis was conducted.

RESULTS

Searches returned 8026 titles and abstracts. 54 studies-21 qualitative, 32 quantitative and 1 mixed method were included. This totalled 26 453 caregivers who were primarily female (63%), with median age of 62 years. Narrative synthesis yielded six concepts related to caregiver experience: (1) mental health, (2) caregiver role, (3) lifestyle change, (4) support for caregivers, (5) knowledge and (6) relationships. There was a discordance between paradigms regarding emerging concepts. Four concepts emerged from qualitative papers which were not present in quantitative papers: (1) expert by experience, (2) vigilance, (3) shared care and (4) time.

CONCLUSION

Caregiving is life altering and complex with significant health implications. Health professionals should support caregivers who in turn can facilitate the recipient to manage their long-term condition. Further longitudinal research exploring the evolution of caregiver experiences over time of patients with chronic cardiopulmonary conditions is required.

TRIAL REGISTRATION NUMBER

CRD42016053412.

Family caregiving for persons with heart failure at the intersection of heart failure and palliative care: a state-of-the-science review

Many of the 23 million individuals with heart failure (HF) worldwide receive daily, unpaid support from a family member or friend. Although HF and palliative care practice guidelines stipulate that support be provided to family caregivers, the evidence base to guide care for this population has not been comprehensively assessed. In order to appraise the state-of-the-science of HF family caregiving and recommend areas for future research, the aims of this review were to summarize (1) how caregivers influence patients, (2) the consequences of HF for caregivers, and (3) interventions directed at HF caregivers. We reviewed all literature to December 2015 in PubMed and CINAHL using the search terms "heart failure" AND "caregiver." Inclusion criteria dictated that studies report original research of HF family caregiving. Articles focused on children or instrument development or aggregated HF with other illnesses were excluded. We identified 120 studies, representing 5700 caregivers. Research on this population indicates that (1) caregiving situations vary widely with equally wide-ranging tasks for patients to help facilitate their health behaviors, psychological health and relationships, and quality of life (QoL); (2) caregivers have numerous unmet needs that fluctuate with patients' unpredictable medical status, are felt to be ignored by the formal healthcare system, and can lead to distress, burden, and reduced QoL; and (3) relatively few interventions have been developed and tested that effectively support HF family caregivers. We provide recommendations to progress the science forward in each of these areas that moves beyond descriptive work to intervention development and clinical trials testing.

Measurement of Health-Related Quality of Life in Chronic Heart Failure, from a Nursing Perspective—a Review of the Literature

BACKGROUND

Living with chronic heart failure (CHF) is distressful and affects daily life. Because of the lack of a cure for CHF, there has been a progressive interest in using health-related quality of life (Hr-QoL) as an outcome measurement of the treatment in patients with CHF.

OBJECTIVE

The aim of this review was to describe the instruments/questionnaires used in different studies in the measurement of Hr-QoL in patients with CHF, and how they were put into operation as seen from a nursing perspective.

METHOD

MEDLINE and CINAHL databases were searched from January 1995 to June 2002, by using the keywords CHF, heart failure, QoL and Hr-QoL. A total of 33 articles were analysed.

RESULTS

Thirty-two different Hr-QoL questionnaires were found. Generic, disease-specific and battery approaches were different ways used to measure Hr-QoL. To assess/describe Hr-QoL, evaluate the impact of interventions and examine relations/predictors were three main objectives. However, different aspects of the concept Hr-QoL, influencing factors, how to implement the questionnaires and a lack of unified CHF criteria existed.

CONCLUSIONS

To create a guideline for the measurement of Hr-QoL in CHF patients is of great importance for nurses and might generate homogeneity in the measurement methods and promote the scientific approach in the nursing care process.

Technology Dependence in Home Care: Impact on Patients and Their Family Caregivers

BACKGROUND

The purpose of this review is to explore how home technology care affects patients, family caregivers, and quality of life (QOL).

METHODS

A literature search was conducted to identify studies of home parenteral nutrition (HPN) and other technology prescribed home care.

RESULTS

Technology dependence influences health-related QOL. Patients and their family caregivers must balance the positive aspects of being in the home environment with the challenges of administering complex therapies at home. Patients and caregivers need additional support to reduce the physical, emotional, social, and financial burdens they experience.

CONCLUSIONS

More research is needed to address effective interventions to reduce patient and caregiver burdens and to improve outcomes for technology-dependent individuals. A greater level of preparedness for managing home technology and technology-related problems may improve quality of life.

Effect of a multidisciplinary supportive program for family caregivers of patients with heart failure on caregiver burden, quality of life, and depression: A randomized controlled study

BACKGROUND

Caregivers of patients with heart failure experience burden and negative health outcomes. Adequate support for family caregivers improves their well-being and the quality of care provided to the patients. However, little is known about the benefits of interventions for caregivers of patients with heart failure in China.

OBJECTIVES

To test the effects of a multidisciplinary supportive program for family caregivers on caregiver burden, quality of life, and depression.

DESIGN

A randomized controlled design with repeated measures was used in this study.

METHODS

A total of 118 participants were randomized into experimental (n=59) and control groups (n=59) from May to December 2014 in one hospital in Chengdu, People's Republic of China. Participants in the experimental group received a 3-month multidisciplinary supportive program, consisting of three 60-min sessions of group classes, three 30-min peer support groups, and regular telephone follow-ups and consultations, while participants in the control group received usual care only. Outcomes were caregiver burden, quality of life, and depression. Data were collected at baseline, post-test (3 months after discharge), and 3 months after post-test (6 months after discharge). The repeated measures analysis of variance was used to examine the effects of groups, changes over time, and time-group interaction on outcome variables.

RESULTS

There were significant improvements in caregiver burden, mental health, and depression after post-test and 3 months after post-test in the experimental group. However, there was no significant improvement in caregivers' physical health at either 3 or 6 months following discharge.

CONCLUSIONS

A multidisciplinary supportive program for caregivers of heart failure patients had positive effects and provides a unique perspective of an intervention considering Chinese culture and customs.

Caring for Survivors of Prolonged Mechanical Ventilation

Approximately 54 million adults in the United States are involved in some form of family caregiving, with 15% of these individuals providing complex care in their homes. Therefore, it is essential to identify the nuances associated with complex community-based family caregiving. This study investigated family caregivers’ perceptions of caring for individuals who survived tracheostomy for prolonged mechanical ventilation. Using a quantitative approach, family caregivers (n = 15) reported that they were somewhat prepared for this experience. The findings suggested that family caregivers experience considerable physical and psychological effects throughout their caregiving careers. Despite physical and mental health challenges, the caregivers were able to derive personal gratification from complex care provision. The challenge before home care nurses is to prepare family members for their newly acquired caregiving roles, implement interventions that support their physical and mental well-being, and facilitate the engagement in health-promoting behaviors.

Factors and Interventions Influencing Health-Related Quality of Life in Patients with Heart Failure: A Review of the Literature

INTRODUCTION

Because of the lack of a cure for patients with chronic heart failure (HF), there has been a progressive interest in the use of health-related quality of life (Hr-QoL) as complementary end-point to mortality and morbidity.

AIM

The aim of this review was from a nursing perspective to describe Hr-QoL and the influencing factors of Hr-QoL, as well as to identify interventions aimed at influencing Hr-QoL in HF patients.

METHOD

Medline, Cinahl and PsycInfo databases were searched from 1995 to 2004. A total of 58 papers were included.

RESULTS

HF symptoms and activity status influence Hr-QoL negatively. However, several individual characteristics such as personality, gender and age must also be taken into consideration because different values might exist regarding what constitutes a good Hr-QoL. Nurse led interventions based on education, support and exercise can influence Hr-QoL positively. There is also a need of more studies about the effects of depression, sleep disturbances, support as well as education on Hr-QoL. There is also a need of exercise studies with larger sample sizes and older patients in higher NYHA classes.

CONCLUSION

Several individual factors impact Hr-QoL, therefore, must nursing interventions are individually adapted to the patient's resources.

Gender Differences in the Effects of Physical and Emotional Symptoms on Health-Related Quality of Life in Patients with Heart Failure

BACKGROUND

Physical and emotional symptoms are common in heart failure. These symptoms are theorized to affect health-related quality of life (HRQOL), but their impact is likely mediated by variables not yet explored. Moreover, gender may affect these relationships.

AIM

To determine gender differences in the effects of physical and emotional symptom status on HRQOL.

METHODS AND RESULTS

Data from 51 men and 47 women with heart failure were analyzed using regression analyses. There were no gender differences in physical or emotional symptom status, or HRQOL, but there were differences in the dynamic relationships among the variables. In bivariate analyses, physical and emotional symptom status was related to HRQOL in both men and women. However, in women, physical symptom status was related to HRQOL, while in men depression affected HRQOL in multivariate analyses (p<.001, r(2)=.27; p<.001, r(2)=.40, respectively). Functional status measured by the New York Heart Association functional class mediated the effects of anxiety and depression on HRQOL only in women.

CONCLUSION

There were gender differences in the dynamic relationships among variables related to HRQOL. These results demonstrate the need for individualized, comprehensive evaluation of patient's HRQOL and symptom status in order to appropriately target interventions.

Psychometric properties of carer-reported outcome measures in palliative care: A systematic review

BACKGROUND

Informal carers face many challenges in caring for patients with palliative care needs. Selecting suitable valid and reliable outcome measures to determine the impact of caring and carers' outcomes is a common problem.

AIM

To identify outcome measures used for informal carers looking after patients with palliative care needs, and to evaluate the measures' psychometric properties.

DESIGN

A systematic review was conducted. The studies identified were evaluated by independent reviewers (C.T.J.M., M.B., M.P.). Data regarding study characteristics and psychometric properties of the measures were extracted and evaluated. Good psychometric properties indicate a high-quality measure.

DATA SOURCES

The search was conducted, unrestricted to publication year, in the following electronic databases: Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, EMBASE, PubMed, PsycINFO, Social Sciences Citation Index and Sociological Abstracts.

RESULTS

Our systematic search revealed 4505 potential relevant studies, of which 112 studies met the inclusion criteria using 38 carer measures for informal carers of patients with palliative care needs. Psychometric properties were reported in only 46% (n = 52) of the studies, in relation to 24 measures. Where psychometric data were reported, the focus was mainly on internal consistency (n = 45, 87%), construct validity (n = 27, 52%) and/or reliability (n = 14, 27%). Of these, 24 measures, only four (17%) had been formally validated in informal carers in palliative care.

CONCLUSION

A broad range of outcome measures have been used for informal carers of patients with palliative care needs. Little formal psychometric testing has been undertaken. Furthermore, development and refinement of measures in this field is required.

Psychometric properties of the Symptom Status Questionnaire-Heart Failure

BACKGROUND AND PURPOSE

Many patients with heart failure (HF) experience physical symptoms, poor health-related quality of life (HRQOL), and high rates of hospitalization. Physical symptoms are associated with HRQOL and are major antecedents of hospitalization. However, reliable and valid physical symptom instruments have not been established. Therefore, this study examined the psychometric properties of the Symptom Status Questionnaire-Heart Failure (SSQ-HF) in patients with HF.

METHOD

Data on symptoms using the SSQ-HF were collected from 249 patients (aged 61 years, 67% male, 45% in New York Heart Association functional class III/IV). Internal consistency reliability was assessed using Cronbach's α. Item homogeneity was assessed using item-total and interitem correlations. Construct validity was assessed using factor analysis and testing hypotheses on known relationships. Data on depressive symptoms (Beck Depression Inventory II), HRQOL (Minnesota Living With Heart Failure Questionnaire), and event-free survival were collected to test known relationships.

RESULTS

Internal consistency reliability was supported: Cronbach's α was .80. Item-total correlation coefficients and interitem correlation coefficients were acceptable. Factor analysis supported the construct validity of the instrument. More severe symptoms were associated with more depressive symptoms, poorer HRQOL, and more risk for hospitalization, emergency department visit, or death, controlling for covariates.

CONCLUSIONS

The findings of this study support the reliability and validity of the SSQ-HF. Clinicians and researchers can use this instrument to assess physical symptoms in patients with HF.

Family caregivers' inside perspectives: caring for an adult with a left ventricular assist device as a destination therapy

CONTEXT

Understanding the experience of caring for an adult with a left-ventricular assist device as a destination therapy (LVAD-DT) remains in its infancy.

OBJECTIVE/DESIGN

A hermeneutic-phenomenological inquiry guided by van Manen's methods was used to explore the LVAD-DT family caregiving experience.Participants/Setting-Seven family caregivers (1 man and 6 women) 50 to 74 years old who cared for an adult with an LVAD-DT in home settings. Recruitment and data collection occurred in an outpatient mechanical circulatory support center in the Midwest.

METHODS

Data were collected by means of face-to-face interviews using open-ended questions and 1 follow-up interview. Interviews were audio recorded and transcribed verbatim. Thematic analysis consisted of writing, rewriting, and reflecting across participants' data, which produced themes illustrating the experience and meaning of caring for an adult with an LVAD-DT. Themes were consensually validated. Procedures for trustworthiness are described.

RESULTS

Five main themes were identified from participants' experiences: (1) advanced heart failure is a life-changing event, (2) self-doubt about LVAD caregiving improves over time, (3) lifestyle adjustments come with time, (4) persistent worry and stress, and (5) caregiving is not a burden-it's a part of life. These main themes were elucidated by 8 subthemes in which participants described a process of adjustment despite persistent worry and stress and eventually accepted caregiving as part of their lives. Future studies are needed to explore caregiver burden, adaptation, and the effects of caregiving outcomes, such as emotional and physical health and overall quality of life.

How hospice staff members prepare family caregivers for the patient's final days of life: an exploratory study

BACKGROUND

There is widespread agreement that the families of hospice patients need to be prepared for the final days of life, yet current practices preparing families are not well described. Examining the gap between family needs and current practice will inform the development of effective preparatory interventions.

AIM

The purpose of the study was to describe how hospice clinicians prepare family for the final days of life, including (1) the content of the preparatory information, (2) strategies and timing of preparation, and whether the preparation is tailored, and (3) who prepares families.

DESIGN

Conventional content analysis guided this study. Individual interviews using semi-structured questions were conducted.

SETTING/PARTICIPANTS

In all, 19 hospice clinicians who provided care in the home setting from two hospice agencies in the United States participated.

RESULTS

Preparatory messages included information on signs of impending death, symptoms, implications of the symptoms, what to expect next, and instructions on what to do. Commonly used strategies included listening, engendering trust, repetition, collaboration with other disciplines, and demonstrations. Staff tailored content and delivery of messages on patient, family, and hospice factors. Preparation usually occurred over time. All hospice staff provided preparatory information, but there are some differences by discipline.

CONCLUSIONS

Most content previous identified as necessary for preparedness is part of the current preparation. The knowledge of the current practice in preparing families can be used to develop systematic means of assessing the factors related to timing and tailoring, which may assist in developing preparatory messages that are effective and timely.

A new instrument to measure quality of life of heart failure family caregivers

BACKGROUND AND PURPOSE

Family caregivers of heart failure (HF) patients experience poor physical and mental health leading to poor quality of life. Although several quality-of-life measures exist, they are often too generic to capture the unique experience of this population. The purpose of this study was to evaluate the psychometric properties of the Family Caregiver Quality of Life (FAMQOL) Scale that was designed to assess the physical, psychological, social, and spiritual dimensions of quality of life among caregivers of HF patients.

SAMPLE AND METHODS

Psychometric testing of the FAMQOL with 100 HF family caregivers was conducted using item analysis, Cronbach α, intraclass correlation, factor analysis, and hierarchical multiple regression guided by a conceptual model. Caregivers were predominately female (89%), white, (73%), and spouses (62%).

RESULTS

Evidence of internal consistency reliability (α=.89) was provided for the FAMQOL, with item-total correlations of 0.39 to 0.74. Two-week test-retest reliability was supported by an intraclass correlation coefficient of 0.91. Using a 1-factor solution and principal axis factoring, loadings ranged from 0.31 to 0.78, with 41% of the variance explained by the first factor (eigenvalue=6.5). With hierarchical multiple regression, 56% of the FAMQOL variance was explained by model constructs (F8,91=16.56, P<.001). Criterion-related validity was supported by correlations with SF-36 General (r=0.45, P<.001) and Mental (r=0.59, P<.001) Health subscales and Bakas Caregiving Outcomes Scale (r=0.73, P<.001). Evidence of internal and test-retest reliability and construct and criterion validity was provided for physical, psychological, and social well-being subscales.

CONCLUSIONS

The 16-item FAMQOL is a brief, easy-to-administer instrument that has evidence of reliability and validity in HF family caregivers. Physical, psychological, and social well-being can be measured with 4-item subscales. The FAMQOL scale could serve as a valuable measure in research, as well as an assessment tool to identify caregivers in need of intervention.

Personal beliefs, learned resourcefulness, and adaptive functioning in depressed adults

Learned resourcefulness and personal beliefs are significant predictors of adaptive functioning. The mediating effect of personal beliefs on the relationship between learned resourcefulness and adaptive functioning was validated in adults with depression. The findings from this study may provide the basis for developing a useful nursing intervention constituting resourcefulness skills with positive personal beliefs to help patients with depression improve their ability to function well in their daily activities.

ABSTRACT

Research has shown that patients with depression have difficulty with performing daily tasks and meeting their own personal care needs. According to Beck's cognitive theory of depression, such deficits in adaptive functioning are affected by disturbances in specific personal beliefs that reflect the process of regulating cognitions. Rosenbaum's learned resourcefulness theory proposed that adaptive functioning is influenced by learned resourcefulness, while learned resourcefulness is associated with the process regulating cognitions. This study aims to test the mediating effect of personal beliefs on the relationship between resourcefulness and adaptive functioning. The study involved a cross-sectional design. Participants consisted of 187 adults with depression in southern Taiwan. The data were collected through four instruments: Cognitive Triad Inventory, Self-Control Schedule, modified Community Living Skills Scale, and a demographic questionnaire. Both resourcefulness and personal beliefs were significant predictors of adaptive functioning, and personal beliefs mediated the effect of learned resourcefulness on the adaptive functioning of the adults with depression. The results validate the role played by personal beliefs in effecting learned resourcefulness and adaptive functioning among adults with depression and provide direction for designing nursing interventions that consider personal beliefs when teaching resourcefulness skills to adults with depression.

Caregivers' contributions to heart failure self-care: a systematic review

AIMS

The purpose of this study was to conduct a systematic review answering the following questions: (a) what specific activities do caregivers (CGs) contribute to patients' self-care in heart failure (HF)?; and (b) how mature (or developed) is the science of the CG contribution to self-care?

METHODS

MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Library and ClinicalTrials.gov were searched using the terms heart failure and caregiv* as well as the keywords 'careers', 'family members' and 'lay persons' for studies published between 1948 and September 2012. Inclusion criteria for studies were: informal CGs of adult HF patients-either as dependent/independent variable in quantitative studies or participant in qualitative studies; English language. Exclusion criteria for studies were: formal CGs; pediatric, adult congenital, or devices or transplant CGs; mixed diagnosis; non-empiric reports or reports publishing duplicate results. Each study was abstracted and confirmed by two authors. After CG activities were identified and theoretically categorized, an analysis across studies was conducted.

RESULTS

Forty papers were reviewed from a pool of 283 papers. CGs contribute substantively to HF patients' self-care characterized from concrete (weighing the patient) to interpersonal (providing understanding). Only two studies attempted to quantify the impact of CGs' activities on patients' self-care reporting a positive impact. Our analysis provides evidence for a rapidly developing science that is based largely on observational research.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

To our knowledge, this is the first systematic review to examine CGs' contributions in depth. Informal caregivers play a major role in HF self-care. Longitudinal research is needed to examine the impact of CGs' contributions on patient self-care outcomes.

The measurement of uncertainty in caregivers of patients with heart failure

BACKGROUND AND PURPOSE

Family caregivers of heart failure (HF) patients describe feelings of uncertainty; however, studies measuring uncertainty in caregivers of HF patients are extremely sparse. This study examined the validity and reliability of the Mishel Uncertainty in Illness Scale-Family Member form (PPUS-FM) in caregivers of HF patients.

METHODS

Caregivers (n = 50) of community-dwelling HF patients completed the PPUS-FM, Caregiver Reaction Assessment (CRA) and Hospital Anxiety and Depression Scale (HADS) in this cross-sectional study.

RESULTS

Significant correlations emerged among PPUS-FM and (a) CRA-schedule burden (p = .499, p < .01); (b) CRA-financial burden (p = .292, p < .05); (c) CRA-family burden (p = .385, p < .01); (d) CRA-health burden (p = .421; p < .01); and (e) HADS-depression scores (p = -.298, p <.05). Cronbach's alpha for the PPUS-FM was .89.

CONCLUSIONS

In this sample, the PPUS-FM had some evidence of construct validity and good internal consistency. However, the respondent burden and unidimensional nature of the PPUS-FM suggest that this tool needs further revision and testing for use with caregivers of HF patients.

Dose-dependent relationship of physical and depressive symptoms with health-related quality of life in patients with heart failure

BACKGROUND

Patients with heart failure (HF) have poor health-related quality of life (HRQOL). The vast majority of patients have physical symptoms, and about 30-40% have depressive symptoms. The combined effects of physical and depressive symptoms on HRQOL have not been examined fully in HF.

PURPOSES

To examine the combined effects of physical and depressive symptoms on HRQOL using repeated measures, controlling for covariates (i.e. age, education level, New York Heart Association (NYHA) functional class, financial status, and health perception).

METHODS

Patients (N = 224, 62 ± 12 years old, 67% male, 38% NYHA functional class III/IV) provided data on physical (Symptom Status Questionnaire) and depressive symptoms (Beck Depression Inventory II) at baseline and HRQOL (Minnesota Living with Heart Failure Questionnaire) at baseline and 12 months. Patients were divided into three groups based on presence of physical and depressive symptoms: a) no symptom group, b) one symptom group (dyspnea or fatigue), and c) two symptom group (physical and depressive symptoms). Repeated measures ANOVA was used to analyze the data.

RESULTS

The least squares mean scores of baseline and 12-month HRQOL differed significantly in the three groups after controlling for the covariates (26.4 vs. 36.6 vs. 53.1, respectively, all pairwise p values < 0.001). There was no time-by-group interaction or time main effect.

CONCLUSION

Physical and depressive symptoms have a dose-response relationship with HRQOL. Further research is needed to provide effective interventions to improve physical and depressive symptoms, in turn, HRQOL.

High nutritional risk is associated with worse health-related quality of life in patients with heart failure beyond sodium intake

BACKGROUND

The most desirable outcome in heart failure (HF) management is to improve health-related quality of life (HRQoL) as a patient-centred health outcome. Nutrition is assumed to be important in HF management, whereas there is little evidence that nutritional risk affects HRQoL, except for sodium.

PURPOSE

We aimed to determine whether nutritional risk is associated with worse HRQoL after controlling for daily sodium intake.

METHODS

A total of 134 consecutive patients with HF [age 63 ± 11 years, 35% female, 45% New York Heart Association (NYHA) class III/IV, ejection fraction (EF) 33 ± 13%] completed the Nutrition Screening Initiative (NSI) to assess nutritional risk and a 24-h urine sodium excretion assessment to estimate daily sodium intake at baseline. The Minnesota Living with HF Questionnaire was used to evaluate HRQoL at baseline and 6 months later. Hierarchical linear regressions were used to determine whether nutritional risk predicted HRQoL at baseline and 6 months later.

RESULTS

Seventy-eight (58.2%) patients had high nutritional risk as indicated by a total NSI score ≥ 6. Increased nutritional risk was independently associated with worse HRQoL at baseline and 6 months later (β = 0.33, p < 0.001; β = 0.35, p < 0.001, respectively), after controlling for age, gender, aetiology, body mass index, NYHA class, EF, total comorbidity score, prescribed medications, and daily sodium intake.

CONCLUSION

These findings show that higher nutritional risk beyond sodium intake affects worse HRQoL in patients with HF. Further work is required to provide specific dietary guidelines to improve health outcomes for patients with HF.

Social status, health-related quality of life, and event-free survival in patients with heart failure

BACKGROUND

Social status may impact health-related quality of life (HRQOL), hospitalization, and mortality in patients with heart failure (HF).

PURPOSE

To determine if social status was associated with HRQOL and event-free survival.

HYPOTHESES

Higher social status (quality of perceived support, emotional support, marital status, and economic status) is related to better HRQOL and event-free survival after controlling covariates (New York Heart Association [NYHA] functional class, comorbidity status, and age).

METHODS

Patients (N = 147, 61 ± 11 years old, 70% male, 62% NYHA class III/IV) provided data on HRQOL (measured by the Minnesota Living with Heart Failure questionnaire) and social status. Event-free survival data were collected by medical record reviews and patient or family interviews. Hierarchical regression analysis and survival analysis were used to test the hypothesis.

RESULTS

Better quality of perceived support, better economic status, better functional status, older age, and less comorbidity were related to better HRQOL (R2 = .365, p = <.001). Only economic status predicted event-free survival.

CONCLUSION

Attention should be given to those who have lower social support to improve HRQOL and those who have lower economic status to improve event-free survival.

Informal caregivers' experiences of caring for patients with chronic heart failure: systematic review and metasynthesis of qualitative studies

BACKGROUND

Increasing evidence suggests that family support for patients with chronic heart failure (CHF) contributes greatly to the disease management of CHF. In addition, the quality of the CHF patient's close personal relationships can influence CHF outcomes. However, caregivers cannot provide care alone and need guidance, support, and skills to manage care that is often complex. In this article, we provide a review of studies that have explicitly investigated these issues of informal caregivers to CHF patients.

OBJECTIVE

The objective of this study was to explore informal caregivers' views and experiences of caring for patients with CHF.

METHODS

This is a systematic review and synthesis of qualitative studies describing informal caregivers' experiences in home-based care. Data sources were published literature written in English from electronic databases: PubMed, CINAHL (1982-2009), PsycINFO (1967-2009), EMBASE (1980-2009), and the Cochrane Library Database. Ten primary studies met the inclusion criteria.

RESULTS

A number of themes emerged. Five key themes were identified from synthesis of the studies: sharing of caring, suffering from anxiety, being isolated, enjoying a good relationship, and searching for support.

CONCLUSIONS

Caring for persons with CHF can affect the well-being of their informal caregivers, which may ultimately have consequences for the CHF patient's health. Further studies are needed to clarify these issues and to examine the role of informal caregivers in the management of CHF.

Caregiving for patients with heart failure: impact on patients' families

BACKGROUND

Factors that affect the impact of caregiving on patients' family members who provide care to patients with heart failure have not been adequately addressed. In addition, social support and positive aspects of caregiving have received little attention.

OBJECTIVE

To identify factors associated with the impact of caregiving.

METHODS

Self-report data were collected from 76 dyads of patients with heart failure and their family caregivers. Clinical data were obtained from medical records.

RESULTS

A sense of less family support for caregiving was associated with a higher New York Heart Association class of heart failure, being a nonspousal caregiver, lower caregivers' perceived control, and less social support. More disruption of caregivers' schedules was associated with higher class of heart failure, more care tasks, and less social support. Greater impact of caregiving on caregivers' health was related to more recent patient hospitalization, lower caregivers' perceived control, and less social support. Nonwhite caregivers and caregivers whose family member had fewer emergency department visits felt more positive about caregiving than did other caregivers. Social support had a moderating effect on the relationship between patients' comorbid conditions and positive aspects of caregiving.

CONCLUSIONS

Caregiving has both positive and negative effects on family caregivers of patients with heart failure. The findings suggest the need for interventions to increase caregivers' sense of control and social support. Family caregivers may need additional support immediately after patient hospitalizations to minimize the negative impact of caregiving.

Predictors of depressive symptoms in caregivers of patients with heart failure

BACKGROUND

Millions of family members deliver informal care and support to patients with heart failure (HF). Caregivers of patients with HF experience depressive symptoms, but factors associated with depressive symptoms are unknown. The purposes of this study were (1) to examine differences between caregivers with and without depressive symptoms in patients' characteristics and caregivers' functional status, caregiving burden (time devoted to caregiving, difficulty of caregiving tasks, and overall perceived caregiving distress), and perceived control; and (2) to determine predictors of depressive symptoms of caregivers.

METHOD

A total of 109 caregivers (mean age of 57 years; spousal caregiver, 79%) and patients with HF participated in this study. Depressive symptoms, perceived control, and functional status of both patients and caregivers were assessed using the Beck Depression Inventory II, the Control Attitudes Scale-Revised, and the Duke Activity Status Index, respectively. Caregivers' burden (time and difficulty of caregiving tasks and burden) were assessed using the Oberst Caregiving Burden Scale and the Zarit Burden Interview.

RESULTS

The 27.5% of HF caregivers with depressive symptoms (Beck Depression Inventory II score > or =14) had poorer functional status, lower perceived control, and higher perceived caregiving distress; experienced more caregiving difficulty; and spent more time in caregiving tasks than did caregivers without depressive symptoms. Controlling for age and sex in a multiple regression, caregivers' own functional disability (standard beta [sbeta] = -.307, P < .001), perceived control (sbeta = -.304, P < .001), and caregiver burden (sbeta = .316, P = .002) explained 45% of the variance in caregivers' depressive symptoms. Patients' New York Heart Association class and functional status did not predict caregivers' depressive symptoms.

CONCLUSION

Caregivers' poor functional status, overall perception of caregiving distress, and perceived control were associated with depressive symptoms. Depressed caregivers of patients with HF may benefit from interventions that improve caregivers' perceived control, address the caregiving burden, and improve or assist with caregivers' functional status.

Part 1: Home-based family caregiving at the end of life: a comprehensive review of published quantitative research (1998-2008)

The changing context of palliative care over the last decade highlights the importance of recent research on home-based family caregiving at the end of life. This article reports on a comprehensive review of quantitative research (1998-2008) in this area, utilizing a systematic approach targeting studies on family caregivers, home settings, and an identified palliative phase of care (n = 129). Methodological challenges were identified, including: small, non-random, convenience samples; reliance on descriptive and bivariate analyses; and a dearth of longitudinal research. Robust evidence regarding causal relationships between predictor variables and carer outcomes is lacking. Findings suggest the need for knowledge regarding: family caregiving for patients with non-malignant terminal conditions; whether needs and outcomes differ between family caregivers at the end of life and comparison groups; and caregiver outcomes in bereavement. Clear definitions of 'family caregiving', 'end of life', and 'needs' are required as well as greater application and testing of theoretical and conceptual explanations.

Indicators of health-related quality of life in heart failure family caregivers

Indicators of caregiver health-related quality of life (HRQL) were identified among 50 caregivers of older patients living with heart failure (HF). Using a cross-sectional design, caregivers were interviewed for perceptions pertaining to caregiver burden, depressive symptoms, patient disease severity, and HRQL. Caregiver burden explained 62% of the variance in caregiver HRQL, adjusted R(2) = .58, F (5, 44) = 14.54, p < .01. Caregiver depressive symptoms explained an additional 2% of variance in HRQL. Significant indicators of caregiver HRQL were in the burden domains of caregiver health and caregiver finances. The findings suggest the need for nurses to conduct caregiver health assessments to include screening for depression and assessment of the financial impact caregiving has on the caregiver. Interventions to improve caregiver health and lessen financial burdens should be investigated in future HRQL studies among HF caregivers.

The effects of depressive symptoms and anxiety on quality of life in patients with heart failure and their spouses: testing dyadic dynamics using Actor-Partner Interdependence Model

BACKGROUND

Depressive symptoms and anxiety are common in heart failure patients as well as their spousal caregivers. However, it is not known whether their emotional distress contributes to their partner's quality of life (QoL). This study examined the effect of patients' and partners' depressive symptoms and anxiety on QoL in patient-spouse dyads using an innovative dyadic analysis technique, the Actor-Partner Interdependence Model (APIM).

METHOD

A total of 58 dyads (patient: 43% in males, mean age 62 years, mean ejection fraction 34% +/-11, 43% in New York Heart Association III-IV) participated in the study. Depressive symptoms and anxiety were assessed using the Brief Symptom Inventory. QoL was assessed using the Minnesota Living with Heart Failure Questionnaire. Dyadic data were analyzed using the APIM with distinguishable dyad regression model. In APIM, actor effect is the impact of a person's emotional distress on his/her own QoL. Partner effect is the impact of a person's emotional distress on his/her partner's QoL.

RESULT

Depressive symptoms exhibited actor effect of both patients (P<.001) and spouses (P<.001) and only partner effect of patients (P<.05) on QoL. Patients and spouses with higher depressive symptoms had poorer QoL. Patients whose spouses had higher depressive symptoms were more likely to indicate their own QoL was poorer. Anxiety has similar actor and partner effects on QoL as depressive symptoms.

CONCLUSION

Interventions to reduce depression and anxiety and to improve patients' QoL should include both patients and spouses.

Quality of Life in Caregivers Providing Care for Lung Transplant Candidates

Context

Caregivers are essential members of the health care team who provide care, valued at more than $250 billion each year, to millions of persons who require assistance with health and daily care. Patients with respiratory diseases who are waiting for a lung transplant are required to have an identified caregiver. The caregivers are rarely studied.

Objective

To explore the relationships among the health status of caregivers of lung transplant candidates, caregivers' reaction to caregiving, and caregivers' perceived quality of life.

Design

This descriptive study examined the quality of life of lung transplant caregivers from a multidimensional perspective.

Setting and Participants

Twenty-nine dyads of lung transplant candidates and their caregivers were recruited from a Midwestern medical center.

Measures

Data were collected by self-report: caregivers completed the Quality of Life Index, SF-12 health survey, Profile of Mood States-Short Form, and the Caregiver Reaction Assessment.

Results

Caregivers reported favorable levels of quality of life, physical health, and mood during the pretransplant waiting phase. However, problem areas for caregivers during this time included fatigue, depression, and the financial impact of the transplant. Data analyses indicated that depression, caregiver general health, impact on finances, and lack of family support had the greatest effect on caregivers' quality of life. Nurses are urged to recognize the role of caregivers in the transplant process, ask about and listen to caregivers' needs, and include caregivers in the plan of care.

Quality of life in patients with heart failure: ask the patients

BACKGROUND

Heart failure (HF) is a progressive clinical condition that results in substantial impairment of quality of life (QOL). Helping patients maintain optimal QOL is essential. QOL reflects patients' subjective perceptions about the impact of a clinical condition and its treatment on daily life; however, definitions in the literature vary widely and few reflect the patient's perspective.

PURPOSE

The study explored how patients with HF define and perceive QOL.

METHODS

Qualitative data were obtained from 14 men and 6 women with HF (mean age 58 +/- 10 years) using semistructured open-ended interviews. The interviews were analyzed using content analysis.

RESULTS

Patients with HF defined QOL as their ability to 1) perform desired physical and social activities to meet their and their family's needs; 2) maintain happiness; and 3) engage in fulfilling relationships with others. Patients perceived a variety of factors as positively or negatively affecting QOL: physical (symptoms and good or poor physical status), psychologic (mood and positive or negative perspective), economic (financial status), social (social support and ability for social activities), spiritual, and behavioral (self-care). Patients perceived that HF had a serious impact on QOL, but most evaluated their QOL as good nonetheless.

CONCLUSION

Patients' definition of QOL reflected not only the impact of HF on their daily life but also their active pursuit of happiness. Patients' self-evaluation of QOL reflected the negative impact of HF and patients' altered expectations of what constituted good QOL.

Factors associated with caregiver burden in heart failure family caregivers

Fifty caregivers and 41 heart failure patients participated in a study examining the association of caregiver characteristics and the caregiving environment on caregiver burden. Using a cross-sectional design, caregivers were interviewed face-to-face using a caregiver characteristic/demographic tool designed for this study, the Centers for Epidemiological Studies Short Depression Scale, the Caregiver Reaction Assessment questionnaire, and the New York Heart Association Functional Classification Guide to obtain the caregiver's perception of patient disease severity. Patient medical records were assessed following caregiver interviews for patient demographics, comorbidities, and ejection fraction percentages. Significantly higher levels of burden were found among Caucasian caregivers, those caring for other relatives besides the patient, unemployed caregivers, and single- versus two-family caregivers (respite caregiving). Fifty-one percent of the variance in caregiver burden was accounted for by the variables caregiver advanced age, higher caregiver hours, more caregiver physical health problems, higher levels of caregiver depressive symptoms, and more patient comorbidities. This article concludes with implications for nursing practice and future research.

The Objective Burden in Partners of Heart Failure Patients; Development and Initial Validation of the Dutch Objective Burden Inventory

Background: Measures on objective caregiver burden in partners of Heart Failure patients are hardly available and never include HF specific aspects.

Aim: The main objective of our study was to develop an inventory that assesses the objective caregiver burden of partners of HF patients, including the full range of potential care giving demands.

Methods: To develop the inventory, six domains of caregiving demands were identified. Items for the domains were generated from the literature, expert opinion and existing scales. The original 50-items self-report inventory was administered to 321 partners of HF patients. Demographic data of HF partners were collected by questionnaire. Clinical data of the HF patients were collected by chart review.

Results: Component analysis led to exclusion of 12 original items and to a meaningful four-factor solution with a total explained variance of 43%. The components reflected four different kinds of care giving tasks; personal care, emotional, motivational and practical (treatment related) support. They demonstrated good internal consistency and initial validity was supported by a pattern of meaningful associations with external variables.

Conclusion: The Objective Burden Inventory is a promising inventory to assess objective care giving tasks performed by HF partners, including emotional and motivational support. It provides information on the caregiver situation that may help to develop effective interventions.