Caregiver Training and Skill Development

STUDY PURPOSE: To explore whether family-involved interventions for reducing burden and improving caregiver skills improve five outcomes for adult patients diagnosed with cancer or memory-related disorders (more specifically, to explore the benefits of psychosocial interventions delivered by family or a caregiver as compared to usual care or wait-listed care for those patients), and to identify the benefits of a caregiver or family psychosocial intervention as compared to a different family-related intervention or patient-directed intervention for those patients

• FINAL NUMBER STUDIES INCLUDED = 27 
• SAMPLE RANGE ACROSS STUDIES: 12–476 (median of 120 dyads/sample)
• TOTAL PATIENTS INCLUDED IN REVIEW = 3,345 patients in analysis for 26 trials
• KEY SAMPLE CHARACTERISTICS: Patients: the average age was 60 years (range: 46–71 years); 80% were married; 51% were male, and the majority had prostate cancer; 49% were female, with most having breast cancer; 79% were white. Family members: the average age was 56 years (range: 49–62 years); 61% were female; no other family caregiver data reported

PHASE OF CARE: Multiple phases of care

APPLICATIONS: Palliative care 

The systematic review, focused on five interventions for cancer, indicated some support for family-involved interventions over usual care for decreasing patient anxiety and depression. Weak evidence was found for better patient outcomes with family-involved interventions as compared to patient-focused or health education/psychoeducational interventions. Family-involved interventions, directed toward specific subgroups of patients and those involving teaching of skills to meet patient needs, may be more effective for alleviating cancer symptoms and depression and anxiety than usual care. Little evidence was found that symptom management (e.g., pain, fatigue, nausea), quality of life, or relationships adjustment between the patient and family caregiver improved following interventions examined for the systematic review. Only 2 of the 27 trials received a “good” quality evaluation, mandating caution in applying findings to practice.

The systematic review found heterogeneous studies and evidence that family-involved interventions improved patient depression but had little effect on their anxiety and physical health.

• Study findings resulted from 25 of 27 trials (RCTs) deemed as “poor” or “fair” in quality without observational evidence to support other findings.
• Some studies focused on interventions specific to improving caregiver and family health, which was not the review focus.
• Study samples were limited to those with cancer or memory-related illness.
• Non-inclusion of large-scale interventions similar to those used by the Department of Veterans Affairs
• Lack of data to assess the intervention effect on healthcare utilization
• Limited study generalizability

Current evidence indicates that targeted interventions for specific conditions, behaviors, and symptoms of the cancer experience may improve patient outcomes and minimize caregiver burden. Previous evidence has shown that psychosocial/psychoeducational interventions with caregivers reduce caregiver strain and burden. Findings from this systematic review provide some evidence that such interventions aimed at the family, rather than the individual caregiver or caregiver/patient dyad, may not substantially improve caregiver outcomes, while skill training for family members may be helpful. Additional work in this area is needed to determine the best foci and method of delivery of these types of interventions.

• N = 67
• MEAN AGE = 59.6 years
• MALES: 41.5%, FEMALES: 58.5%
• KEY DISEASE CHARACTERISTICS: Patients had hematologic cancer (e.g., leukemia, lymphoma, myelodysplastic syndrome) or other oncologic illness and received care for at least five weeks
• OTHER KEY SAMPLE CHARACTERISTICS: 61.5% were spousal caregivers, and 16.9% were “offspring” caregivers; patients agreed to have their main caregiver involved in the study, and patients had approval for study participation from the doctor/psychological dyad

• SITE: Six acute care units, five different settings  
• SETTING TYPE: Multi-site  
• LOCATION: Clermont-Ferrand, France

• PHASE OF CARE: Active treatment

• Randomized, controlled trial
  • Patient-caregiver dyads were assigned to the experimental or control group using randomization software

• SF-36 health survey (patients and caregivers self-administered)—used to assess eight health dimensions
• Zarit Burden Scale (caregivers self-administered)—used to assess three dimensions of burden
• Questionnaire for satisfaction of hospitalized patients (patient self-administered)—used to assess eight factors related to scope of hospital experience

No difference was seen in quality of life scores between the control (N = 34) and experimental (N = 33) patient-caregiver dyad groups at the first testing. Evaluation (pre- and post-test scores) supported improved quality-of-life scores in the experimental group patient-caregiver dyads as compared to those in the control group. Patients in the experimental group showed significant improvement on two of six dimensions (physical role [p = 0.039] and general health [p = 0.037] on the quality-of-life measure. Experimental group caregivers showed significant improvement on six of eight dimensions (physical role, emotional role, vitality, mental health, social functioning, and general health, all p < 0.05) on the quality-of-life measure. The average score of burden of care in the experimental group (M = 16, SD = 9.9) was significantly lower than that of control group (M = 31.4, SD = 14.9) at last evaluation (p < 0.001). Evolution scores for burden also showed significantly (p = 0.004) less perceived burden among experimental group caregivers as compared to control group caregivers. Patient satisfaction scores of patients in the experimental and control groups showed no difference, except patients in the experimental group showed a significant improvement in relationship with nurses (p = 0.037) because of program involvement.

Nurse-provided educational interventions tailored to caregiver needs and patient expectations may minimize caregiver burden and improve patient and caregiver quality of life. These interventions, if provided during patients’ acute setting care, may pave the way for more effective patient home care by informed and involved caregivers.

• Small sample (less than 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable
• Other limitations/explanation: Authors acknowledge strict inclusion and exclusion criteria that influenced the loss of 110 of 265 participants initially assessed for the study. Author conclusions note a need for a less rigorous program to meet patient and caregiver needs for those who do not meet more stringent criteria found in an RCT used in this study. Whether nurses who were members of the research team delivered the intervention and could connect knowledge of individual patients/caregivers to study results is unclear. Which of the four teaching categories influenced caregiver quality of life and burden the most also is unclear.

Nurses who deliver evidence-based, tailored educational interventions to family cancer caregivers may increase patient-caregiver quality of life and minimize caregiver burden during cancer care. Stronger nurse-patient relationships, based on interaction during caregiver task teaching, may facilitate patient care satisfaction and coping during the cancer experience.

To test the effects of early integrated palliative care ([PC] plus oncology care) versus oncology care on caregivers’ distress and quality of life (QOL).

Patients in the intervention group met within the first four weeks of diagnosis with a PC-certified MD or APN and at least once monthly until the patient died; PC providers had the ability to contact patients in the intervention group by phone if an in-person visit was not possible, they also added more visits as needed. The PC visits focused on interventions with patients that were discussed in a different study that was referred to. Caregivers were not required to attend the PC visits but were encouraged to. Seventy-one percent of PC visits were attended by caregivers.

• N = 275   
• AGE: Mean = 57 years (SD = 13.6)
• MALES: 31%  
• FEMALES: 69%
• CURRENT TREATMENT: Not applicable, other
• KEY DISEASE CHARACTERISTICS: Incurable lung cancers or noncolorectal gastrointerstinal cancers
• OTHER KEY SAMPLE CHARACTERISTICS: Caregivers were 18 years and older, mostly White, Catholic, married to the patient, with a college education. Able to respond in English with minimal use of translator (minimal use not defined)

• SITE: Single site   
• SETTING TYPE: Outpatient; if patient were admitted to Massachusetts General Hospital, the PC team followed them during hospitalization
• LOCATION: Massachusetts General Hospital

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

Randomized nonblinded clinical trial. Randomization using 1:1 stratified by cancer type. Researchers/clinicians learned of assignment after it was done by the Office of Data Quality staff.

Caregiver mood and anxiety were assessed using the Hospital Anxiety and Depression Scale (HADS); the QOL was assessed using SF-36. Measurement of outcomes occurred at week 12 and week 24 post-enrollment.

At 12 weeks, caregivers in the intervention group has significantly lower total psychological distress (anxiety and mood) assessed by HADS total scale score (adjusted mean difference = -1.45, 95 CI [-2.76, -0.15], p = 0.029; the difference seems to be driven by the lower depression scores on the subscale level (adjusted mean difference = -0.71, 95% CI [-1.38, -0.05], p = 0.036). At 24 months, no significant differences between the two groups for any of the outcomes (total psychological distress, depression, anxiety, and QOL). Using terminal decline model (which factors in missing data and deterioration in caregivers outcomes closer to death), caregivers in the interventions group has significantly lower HADs-total (and lower scores on the subscales, depression and anxiety) (95% CI [4.11, 9.58]). No differences in QOL still under this model between the two groups of caregivers.

Early Integrated PC to patients with incurable cancer decreases their caregivers' psychological distress (anxiety and depression) but not QOL.

• Risk of bias (no blinding)
• Unintended interventions or applicable interventions not described that would influence results
• Intervention expensive, impractical, or training needs
• Questionable protocol fidelity
• Other limitations/explanation: The nature of the PC visits and what they involved were not described in the article. Authors referred reader to a previous research report. The fact that the number of PC visits may have varied widely between patients in the intervention group, calls to question if the frequency, not only the visit, affected the outcomes.

This was a compelling study for early palliative care--educating patients and their caregivers about benefits of early PC and addressing that the benefits extend beyond patients.

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.

To examine the effects of enhanced training on caregivers’ self-efficacy in managing patients' symptoms, stress, preparedness for caregiving, depression, and anxiety

Researchers structured and used enhanced caregiver training (CT) that taught caregivers how to manage patients’ symptoms and their own stress. This training added distress management to previously developed training that focused on managing patients' symptoms only. Training was done at the patients' bedside, one on one, with dyads (patients and their caregivers), and required one to two hours. Training on symptom management involved a manual process that started with a needs assessment to tailor the training to the patient’s situation, an interactive discussion that involved both the patient and the caregiver about how to manage symptoms, and concluded with a one-page hand out on each symptom. Training related to caregivers’ stress management involved a three-step behavioral rehearsal procedure. The nurse modeled how to implement the skill, and the caregiver practiced the skill and received constructive feedback. Finally, the caregiver practiced until she or he mastered the skill.

• N = 38 (intervention); 38 (control)
• AVERAGE AGE = 55 years (caregivers)
• MALES: 18%, FEMALES: 82%
• OTHER KEY SAMPLE CHARACTERISTICS: The majority of caregivers were adults, Caucasian, married, had at least some college education, and were the spouses of patients. The majority had a high level of health literacy, and the average length of caregiving was 19 months. A dyad was excluded if a patient was under hospice care.

• SITE: Single site    
• SETTING TYPE: Inpatient  
• LOCATION: Duke University Health System Oncology Units

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care

Randomized, controlled trial in which the intervention arm received enhanced CT and the control group received information about community resources

• Modified Caregiver Self-Efficacy Scale (CaSES) to assess confidence in caregiving abilities (13 items) and in stress management (one item)
• The Preparedness for Caregiving Scale (PCS), a subscale of the Family Caregiving Inventory (FCI)
• Profile of Mood States (POMS) to assess anxiety
• Center for Epidemiologic Studies–Depression (CES-D) scale
• Caregiver Reaction Assessment (CRA) to assess caregiver burden
• Rapid Estimate of Adult Literacy in Medicine (REALM-R) to assess health literacy

Significant difference was identified between the intervention and control groups in self-efficacy for managing patients' symptoms, caregiver stress, preparedness for caregiving immediately after the intervention. The intervention group scored higher on the previous outcomes. No differences in other outcomes were found, and the differences initially observed after the intervention were not sustained at two and four weeks after discharge.

Enhanced CT improved caregivers’ self-efficacy, stress management, and preparedness for caregiving immediately after the intervention. However, it did not lead to significant changes in anxiety, depression, or burden. No sustained effects of the intervention were observed for any outcomes.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: This was a well done trial despite the identified limitations.

Caregiver training given in a single dose may not be the best approach to improving caregiver outcomes. Training or interventions for caregivers should be tailored based on emerging needs after discharge, and they should not be exclusively based on the observed or anticipated needs prior to a patient's discharge from the hospital.

To (a) investigate the effects of an individualized caregiver training intervention on a caregiver’s self-efficacy in home care and symptom management, and (b) identify whether caregiver training would affect a caregiver’s psychological well-being (depression, anxiety, and quality of life)

After signing informed consent, dyads completed baseline questionnaires and were randomly assigned to either a treatment group or a control group. Interactive nurse–caregiver training for one to two sessions was offered when discharge was imminent. Immediately after caregiver training, caregivers completed questionnaires on self-efficacy. Follow-up questionnaires for caregivers and patients were completed at one week, two weeks, and four weeks after hospital discharge of patients.

The caregiver training intervention provided caregiver training for managing patients’ cancer symptoms with four major components: (a) prevention of infection, (b) pain control, (c) maintenance of nutrition, and (d) adequate elimination. The program was manualized, including a book for caregivers with “how to” pictures. Additional time and content were allocated to address specific homecare issues identified by caregivers. The training followed a consistent outline, but information shared was specific to needs of the patient and caregiver.

The control intervention consisted of an interactive nurse–caregiver standardized, manualized one-two session intervention focused on information about community resources for caregiving. This included but was not limited to home health agencies, respite care, and caregiver support services.

• The sample included 120 patient dyads (60 in treatment group and 60 in control group).
• Of the caregivers, 48% were 46–64 years of age; of the patients, 54% were 60–69 years of age.
• The caregiver sample was 17% male and 83% female; the patient sample was 71% male and 29% female.
• Patients had hematologic malignancies.
• Of the caregivers, 84% were white, 89% were married, 60% had education beyond high school, 64.6% were not working outside the home, and the patient for whom they cared was a spouse.
• Of the patients, more than 80% were white, 88% were married, and almost 90% had education beyond high school.

• Single site
• Outpatient setting
• Duke University Hospital in Durham, NC

• Multiple phases
• Home care; after hospital discharge; survivorship

A randomized controlled trial design was used.

• Lorig’s Self-Efficacy Scale: Noted prior assessed reliability (0.94) and validity
• Hospital Anxiety and Depression Scale (HADS): No noted prior reliability and validity
• Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire (Instrumental and Physical subscales): No noted reliability and validity
• OARS Comorbidity Scale: No noted reliability and validity indices
• Caregiver Quality of Life–Cancer Scale (CQOLC): Noted earlier assessed internal consistency of 0.91   
• Memorial Symptom Assessment Scale (MSAS): No noted reliability and validity

There was increased self-efficacy immediately following the caregiver training intervention and higher self-efficacy and symptom management at four weeks after the intervention when compared to the control group. A significant group-by-time interaction (p = 0.008) was present in the training intervention caregiver group that showed decreased depression scores from baseline to time 3 (one week). However, significant differences between treatment and control groups were not found after time 3. A similar result occurred when analyzing the effect of the intervention on caregiver anxiety. In terms of the effect of the caregiver intervention on patient’s physical symptoms, the overall intervention over time did not significantly improve symptoms. There was also no significant effect of the intervention on caregiver quality-of-life scores in both the control and caregiver training groups.

Caregivers have a major role in the outcome of a successful transition from hospital to home. This study provides information about caregiver training that improved their self-efficacy when addressing symptom management of a family member with cancer. More research is needed to determine the most effective caregiver training to manage patients’ symptoms at home.

• Nurses delivering the caregiver training intervention and the control intervention were not blinded.
• Assessment of the delivery of control and caregiver training intervention did not occur.
• The sample was mostly white, educated, and married.
• Caregivers were not observed providing actual home care and symptom management interventions.

Caregiver training for the patient’s home care and symptom management is critical in bridging the transition for patients from hospital to outpatient care. Nurses play a key role in this caregiver training tailored to specific caregiver and patient needs. Evidence-based information about the most effective training, including decisions about frequency, dosing, timing, formatting of information, and preparation of the nurse, is needed to improve caregiver quality of life and psychological well-being.

To evaluate the effectiveness of thee Tracheostomy Care Anxiety Relief through Education and Support (T-CARES) educational program for decreasing caregiver anxiety and increasing caregiver competence with tracheostomy suctioning

T-CARES is a one-hour course for caregivers about caring for a tracheostomy. The course is offered once a week in the hospital unit in a group setting. It involves an 18-minute video, group discussion, hands-on practice, and a return demonstration of tracheostomy care. The course covers the following topics: the introduction to airway anatomy, components of a tracheostomy tube, tracheostomy suctioning, stoma care, changing the ties securing the tracheostomy, cleaning the inner cannula, preparing for the unexpected, reinsertion of the tracheostomy tube after accidental decannulation, how to handle a mucous plug, when to call the doctor, and self-care. Evaluations were done at baseline and postintervention.

• N = 11  
• MEDIAN AGE = 50. 8 years (range = 31–69 years)
• MALES: 64%, FEMALES: 36%
• KEY DISEASE CHARACTERISTICS: Caregivers of patients with head and neck cancer with new tracheostomies
• OTHER KEY SAMPLE CHARACTERISTICS: 90% Caucasian; 81% had a high school education or above; and 90% had no prior tracheostomy experience

• SITE: Single site    
• SETTING TYPE: Inpatient  
• LOCATION: Central Florida

• PHASE OF CARE: Multiple phases of care

Nonexperimental, self-selected to receive the intervention pre- and post-test pilot study

• State-Trait Anxiety Inventory (STAI)
• Suctioning competency checklist
• Course evaluation

Mean STAI scores dropped from 50.5 to 34.3 after the intervention (p = 0.008). All participants were able to perform nine of the 14 skills needed for tracheostomy suctioning. Course evaluations were positive.

T-CARES is an effective intervention for reducing caregiver anxiety and increasing caregiver competency of tracheostomy care.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no blinding) 
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Questionable protocol fidelity
• Other limitations/explanation: No mention of how these registered nurses and trainers were calibrated as trainers although the protocol was standardized in its content and delivery; no mention of how the registered nurses and trainers who helped caregivers learn were trained in a standardized way themselves

Nurse-developed caregiver educational programs may be useful in decreasing anxiety and increasing competency for the development of new caregiver skills required for quality patient care. Additional research in this area is indicated.

To assess the efficacy of two variant cognitive skills training (CST) interventions for the caregivers of patients with lung cancer to improve caregiver distress, self-efficacy, and strain

Following a baseline data collection period, participants (patient-caregiver dyads) were randomly assigned to either CST or a cancer education and support group. Trained research assistants blinded to participant treatment groups collected patient and caregiver assessments via telephone calls immediately after each treatment session and at four months post-study. Fourteen 45-minute, telephone-based sessions with individual dyads using speaker phones occurred over an eight-month period. All study patients continued regular healthcare visits informed by including educational information. Trained, registered nurses adhering to detailed and audiotaped treatment outlines received weekly supervision and evaluation from study psychologists. Dyads in the CST group received information about ways to manage disease symptoms, homework assignments, and a CD focused on stress management. The education and support dyad group received lung cancer disease and treatment information, including hospice and palliative care, in a supportive environment without focus on coping skills training.

• N = 233 dyads  
• MEAN CAREGIVER AGE = 59.3 years
• CAREGIVER MALES: 31%, CAREGIVER FEMALES: 69%
• KEY DISEASE CHARACTERISTICS: Caregivers of patients with a diagnosis of early stage lung cancer (non-small cell lung cancer stages 1–3 or limited stage small-cell lung cancer); median of 207.5 days since patient diagnosis; 81% with history of cancer surgery; more than half with stage 1 non-small cell lung cancer
• OTHER KEY CAREGIVER SAMPLE CHARACTERISTICS: 82% Caucasian; 44% college educated; 64% spousal caregivers living with patient

• SITE: Multi-site    
• SETTING TYPE: Multiple settings  
• LOCATION: Home telephone intervention, North Carolina

• PHASE OF CARE: Multiple phases of care

Randomized, controlled trial with blinding of intervention

• Profile of Mood States–B (POMS-B) measuring six aspects of mood (high Cronbach’s alpha)
• Caregiver Strain Index (CSI) measuring caregiver common stressors (high internal consistency and construct validity)
• Modified Caregiver Self-Efficacy in Symptom Management (CSESM) measuring caregiver perceived ability to help patient manage disease symptoms (high Cronbach’s alpha)

No significant demographic or medical variable differences existed between dyads in the CST and education and support groups. Caregiver outcome measures indicated significant main effects over time for the POMS-B anxiety subscale (p = 0.02) and self-efficacy (p = 0.01). Both intervention groups showed decreases in caregiver anxiety and increases in their self-efficacy to manage patient symptoms although no significant time to intervention occurred with hierarchical linear modeling. An exploratory moderator analysis showed the education and support intervention to most benefit the caregivers of patients with stage 1 cancer. The CST intervention most benefited the caregivers of patients with stage 2 or 3 lung cancer.

CST and education and support intervention improved patient and caregiver anxiety and efficacy although the lack of a nontreatment group prevented specific conclusions about either intervention approach. Influences of time and attention may have affected dyadic outcomes. More research on important intervention aspects and their operation for improved lung cancer clinical practice is needed.

• Risk of bias (no control group)
• Findings not generalizable
• Subject withdrawals ≥ 10% 
• Other limitations/explanation: The distinction between the education provided to the CST group and the education and support group was not clear.

Identifying effective caregiver support interventions to aid in the care of patients with lung cancer remains a priority because of high levels of patient and caregiver distress and low self-efficacy. Additional studies need to include diverse participants, structured protocols for data collection and evaluation, a standard care (control) group, and innovative recruitment and retention methods for caregivers to strengthen the clinical practice evidence for this group of caregivers.