Hendrix, C.C., Abernethy, A., Sloane, R., Misuraca, J., & Moore, J. (2009). A pilot study on the influence of an individualized and experiential training on cancer caregiver's self-efficacy in home care and symptom management. Home Healthcare Nurse, 27, 271–278.

To formally evaluate whether a tailored and experiential training approach by an experienced nurse would enhance confidence (self-efficacy) of family cancer caregivers to provide home care and manage patients’ symptoms of illness

The study principal investigator (PI) provided a conceptually based, tailored, and patient-centered bedside intervention for family caregivers providing home care to patients with hematologic malignancies. Caregiver training included symptom management on prevention of infection, pain, poor nutrition, constipation/diarrhea, and management of medications for patient cancer symptoms. Interactive discussion on these topics occurred between interventionist (experienced nurse), caregiver, and patient. To encourage patient involvement in problem-solving symptoms, dyad participation was also incorporated into bedside training. Caregivers received an illustrated take-home manual on discussed topics. Discussion focused on nonpharmacologic interventions to improve patient comfort and meet other patient needs. Caregivers provided a return demonstration following nurse delivery of didactic teaching and skill performance (e.g., catheter care management) specific to patients’ home situation. Sufficient time was provided in the teaching encounter for patients and caregivers to ask questions and to allow satisfactory completion of the skills required for effective patient home care before patient discharge.

Assessment of the influence of the intervention occurred before and after PI training and one week following hospital discharge of the patients. Caregivers completed postintervention assessment within 24 hours of the PI’s didactic and skill performance presentation to caregivers.

• The sample (N = 16) was 15% male and 85% female.
• Sample age range was 44–80 years.
• Mean age was 62 years for both patients and caregivers.
• All patients had hematologic cancers and were admitted for chemotherapy or treatment of cancer-related acute conditions.
• Caregivers were connected to patients who were likely to be discharged soon and who were not actively dying; lived with patients in the same home and served as primary caregivers; and were English speaking and reading.
• The majority of caregivers were white and did not work outside the home; almost half were educated at the associate degree level or higher.

• Single site
• Multiple settings
• Southeastern U.S. regional medical center

Active antitumor treatment phase

A quasi-experimental, time-series design was used.

• Cancer Caregiver Self-Efficacy (Confidence) Questionnaire (CCSE): This 23-item tool was used three times in the study to assess caregiver confidence in completing a behavioral task or skill.
• No prestudy reliability and validity indices were reported.
• Cronbach’s alpha was 0.94 for the CCSE. Construct validity index of 0.77 (p < 0.001) was reported for the CCSE when the scores from the study sample of 16 were correlated with historical data including the Caregiving Preparedness Scale.

Total caregiver CCSE scores were significantly higher immediately after caregiver training (z = 4.49, p < 0.001) and one week after hospital discharge of patients (z = 3.22, p < 0.001). These higher scores reflect higher and some sustained levels of caregiver confidence to provide needed home care to patients comprising the sample. Although unanticipated, four patients died within one week of hospital discharge (20% attrition for study), producing a total sample of 16 from the initial sample of 20 patient–caregiver dyads for the one-week assessment.

Timely assessment and nurse-led interventions relevant to assessment findings may increase caregiver confidence to assume home care for patients with hematologic malignancies. Based on Bandura’s (1986) conceptual self-efficacy framework, this pilot study suggests that nurse-led individualized teaching and modeling of homecare skills at the patient’s bedside prior to discharge can sustain caregiver confidence for up to one week postdischarge of the patient. Caregivers and patients believed the intervention to be highly beneficial based on a 1:1 relationship with the nurse-teacher.

• The sample was small, with less than 30 participants.    
• Risk of bias existed because of no control group, no blinding, and no appropriate attentional control condition.
• Unintended interventions or applicable interventions that would influence results are not described.
• Findings are not generalizable.
• Subject withdrawals were greater than 10%.
• Involvement of the PI or study staff with the rounding oncologist during prerecruitment may have influenced individuals approached for the study (Were those with greatest needs referred for the study?)
• The acuity level of the sample patients and the functional health of caregivers to support their ability to provide home care are unknown.
• Whether training occurred the day of discharge or how variable the timing and length of the intervention was are unclear.
• Whether data from the 20 subjects were used in the pre- and post-analysis and then from the 16 for the pre-one week, or whether the 16 were used for all analysis, is unclear. The analysis section suggests that a mixed-effects model was used, suggesting that all data were used and missing data were modeled. More manuscript details would aid in interpretation of the study findings.
• Threats of maturation and selection also may affect internal validity of the study.

As part of their education, nurses learn about the teaching-learning process to optimally prepare patients, families, and communities about ways to improve personal and societal health. With early discharge of patients and the need for family members to often assume complex caregiving roles, there is a heightened need for nurses to use their knowledge of teaching-learning to assess and implement effective teaching to families during the cancer trajectory. Individualized and bedside teaching approaches, such as those found in this study, benefit patients and family members in both inpatient and outpatient settings. Study findings must be evaluated with caution due to the small sample size, one setting for data collection, and lack of control group. More specifically relative to sample size, additional replication of the study must occur to more clearly identify the influence of the individualized and experiential training program on diverse population groups related to ethnicity, clinic care type, education level, and gender (external validity). This would capture deeper understanding of needed components of tailored care in the healthcare team approach to efficiently meet caregiver and patient needs.