Telehealth care was developed to provide home-based monitoring and

support for patients with chronic disease. The positive effects on physical outcome have

been reported; however, more evidence is required concerning the effects on family

caregivers and family function for heart failure patients transitioning from the hospital to

home.

Objective: To evaluate the effectiveness of nursing-led transitional care combining

discharge plans and telehealth care on family caregiver burden, stress mastery and family

function in family caregivers of heart failure patients compared to those receiving

traditional discharge planning only.

Design: This is a quasi-experimental study design.

Methods: Sixty-three patients with heart failure were assessed for eligibility and invited to

participate in either telehealth care or standard care in a medical centre from May to

October 2010. Three families refused to participate in data collection. Thirty families who

chose telehealth care after discharge from the hospital to home comprised the

experimental group; the others families receiving discharge planning only comprised

the comparison group. Telenursing specialist provided the necessary family nursing

interventions by 24-h remote monitoring of patients’ health condition and counselling by

telephone, helping the family caregivers successfully transition from hospital to home.

Data on caregiver burden, stress mastery and family function were collected before

discharge from the hospital and one month later at home. Effects of group, time, and

group � time interaction were analysed using Mixed Model in SPSS (17.0). Results: Family caregivers in both groups had significantly lower burden, higher stress

mastery, and better family function at one-month follow-up compared to before

discharge. The total score of caregiver burden, stress mastery and family function was

significantly improved for the family caregivers in the experimental group compared to

the comparison group at posttest. Two subscales of family function—Relationships between

family and subsystems and Relationships between family and society were improved in the

experimental group compared to the comparison group, but Relationships between family

and family members was not different.

Corresponding author at: NTU Telehealth Center, NTUH East Wing B Block, 3rd Floor, No. 7, Chung-Shan South Road, Taipei 100, Taiwan.

l.: +886 2 2356 2872; fax: +886 2 2356 2885.

E-mail addresses: [email protected] (W.-C. Chen), [email protected] (Y.-T. Dai), [email protected] (Y.-L. Ho).

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

20-7489/$ – see front matter � 2012 Elsevier Ltd. All rights reserved. p://dx.doi.org/10.1016/j.ijnurstu.2012.04.013

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L.-C. Chiang et al. / International Journal of Nursing Studies 49 (2012) 1230–1242 1231

What is already known about the topic?

Systematic review evidence supports the use of tele- medical monitoring in chronic heart failure to reduce total mortality and hospital admissions.

A structured discharge plan tailored to the individual patient may bring about a small reduction in length of hospital stay and readmission rates, and an increase in patient satisfaction. The impact on health outcomes is uncertain.

Caregivers of patients with heart failure experience caregiver burden due to physical, psychosocial, social and financial stresses.

What this paper adds

Telehealth care combined with discharge planning reduced the family caregivers’ burden, including the temporal, developmental, physiological, emotional, social, and financial burdens.

Telehealth care combined with discharge planning improved family caregivers’ mastery of stress compared to the control group who received only discharge planning, although ‘‘acceptance’’ was unaffected.

Telehealth care combined with discharge planning improved the family caregivers’ family function. Family relationships with the subsystem and society were improved while providing care for patients with heart failure, but not the relationship between family and family members.

. Background

Heart failure is a life-threatening and progressive ondition associated with multiple chronic diseases. This rogressive condition causes patients to require repeated ospitalisations, results in poor life expectancy and

paired quality of life, and represents a heavy burden family and society (AHA, 2008; Hunt et al., 2005).

atients with heart failure need advanced disease manage- ent and appropriate nursing care to help the patients and mily caregivers to successfully transition from the ospital to home (Davidson et al., 2007; Riegel and ickson, 2010).

The modern trend of using telehealth remote patient onitoring to improve chronic disease management was

eported to reduce hospitalisation days and emergency oom visits (Schwartz and Britton, 2011). Telehealth care

ay help the patients and families optimise adherence to erapy and promote early detection of signs and

ymptoms of cardiac decompensation. Four systematic eviews demonstrated that telemotoring in chronic heart ilure can reduce total mortality as well as the number

nd duration of hospital admissions for worsening heart

failure (Clarke and Sharma, 2011; Chaudhry et al., 2007; Inglis et al., 2010; Klersy et al., 2009). However, the costs of telemonitoring programs are higher compared to less complex programs (Chaudhry et al., 2007). Recently, two prospective studies indicated that telemedical interven- tional monitoring not significantly reduction in all-cause mortality (Koehler et al., 2011). These different conclusions provoked arguments that different telemedicine approaches cause various results (Anker et al., 2011). New technology requires appropriate clinical implemen- tation. Telehealth care providers should reconsider heart failure management and focus on crisis prevention and treatment and stabilisation and self-empowerment of patients, not only telemonitoring (Anker et al., 2011; Winkler and Koehler, 2010), but also providing health education, consultation, and supports by telenursing specials.

Nurses play an important role in providing indivi- dualised discharge planning for patients with heart failure (Vreeland et al., 2011; Manning, 2011). Compre- hensive transitional care for older adults hospitalised with heart failure is illustrated by Naylor and colleagues’ study to increase length of time between hospital discharge and readmission or death, reduce the total number of rehospitalisations, and decrease health care costs (Naylor et al., 2004). A systematic review of telehealth services demonstrated that nurses were able to improve heart failure patients’ self-care behaviours such as daily weighing, medication management, exer- cise adherence, fluid and alcohol restriction, salt restriction, and stress reduction (Radhakrishnan and Jacelon, 2011).

Transitioning heart failure patients from the hospital to home is a stressful event for family caregivers according to quantitative and qualitative studies. A systematic review of current instruments to measure caregivers of persons living with heart failure showed negative perceptions of caregiver burden, caregiver strain, and caregiver demand (Harkness and Tranmer, 2007). Measurements of caregiver burden are not sensitive to actual experiences of family caregivers of patient with heart failure, for example anxiety, fear, communication, and changes to daily life and relationships are not measured (Luttik et al., 2007; Hagan and Currey, 2007). Kang et al. (2011) systematically reviewed 10 qualitative studies related to caregivers’ experiences caring for patients with chronic heart failure and synthesised five key themes: sharing of caring; suffering from anxiety; being isolated; enjoying a good relationship; and searching for support. Telenurses could coordinate and integrate continuity of care as patients’ transfer from the hospital transit to home thereby relieving caregiver burden (Riegel and Dickson, 2010). Indicators of successful transitions are subjective well-being, role

Conclusions: The results provide evidence that telehealth care combined with discharge

planning could reduce family caregiver burden, improve stress mastery, and improve

family function during the first 30 days at home after heart failure patients are discharged

from the hospital. Telenursing specialists cared caregivers with the concepts of providing

transitional care to help them successful cross the critical transition stage.

� 2012 Elsevier Ltd. All rights reserved.

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L.-C. Chiang et al. / International Journal of Nursing Studies 49 (2012) 1230–12421232

astery, and the well-being of relationships based on the eleis’ transitional theory (Schumacher and Meleis, 1994). The American Nurses Association defines telehealth as

he removal of time and distance barriers for the delivery health care services or related health care activities. me of the technologies used in telehealth include: lephones, computers, interactive video transmissions, rect links to health care instruments, transmission of ages and teleconferencing by telephone or video.’’ (ANA, 97). The International Council of Nurses (ICN) describes

lenursing: ‘‘the use of telecommunications technology in rsing to enhance patient care. It involves the use of ctromagnetic channels (e.g. wire, radio and optical) to nsmit voice, data and video communications signals. It also defined as distance communications, using elec- cal or optical transmissions, between humans and/or mputers.’’ (ICN, 2001). The Department of Industrial Technology (DoIT) of the

vernment of Taiwan announced a ‘‘U-care project’’ in 06, and the Department of Health (DOH) executed the aiwan pilot Telecare project.’’ The reasons for aggressive licy in developing the Telehealth service were attributed

a low fertility rate, younger people remaining single, ng life expectancy and advanced medical technology in tter economic conditions in Taiwan. Elderly people in iwan prefer to age at home and to live in the community ther than stay in institutions, as staying in the institution eans isolation from their family members and close ends and requires leaving their familiar living environ- ent (Huang et al., 2008).

Previous reviews reported that telehealth service with scharge planning in transitional care for heart failure tients would increase self-management (Radhakrishnan d Jacelon, 2011), reduce the mortality rate and read- issions (Inglis et al., 2010), and limit the consumption of edical resources (Anker et al., 2011; Winkler and ehler, 2010). However, the effect of nurse-led transi- nal care in telehealth systems on family caregivers ring discharge still needs to be evaluated from rspectives such as burden, stress mastery and family nction.

. Burden of family caregivers caring for patients with heart

ilure

Heart failure is characterised by the heart’s inability to ntract, resulting in low cardiac output that results in ogressive heart function and sudden changes in vital ns (Carelock and Clark, 2001; Natanzon and Kronzon, 09). Low cardiac output limits organ perfusion, leading

reduced exercise capacity, fatigue, and shortness of eath. These symptoms limit patients’ daily activity (Hu

al., 2010), compromising their health (Tung et al., 2012) d threatening their lives with various symptomatic and ymptomatic arrhythmias (Cleland et al., 2002). Because tients with heart failure have multiple hospital read- issions, a poor prognosis and poor quality of life, there ay be a considerable increasing the caregivers’ burden an impact on the physical, psychological and social alth of family caregivers (Pressler et al., 2009). Family regivers have great responsibilities when providing

unpaid care for heart failure patient at home, including following the sign/symptoms of heart failure, detecting a change in condition, and providing necessary daily care. These responsibilities are associated with physical, psy- chological, and financial burdens. Additional support and guidance are particularly helpful during care transitions (Collins and Swartz, 2011; Bakas et al., 2006; Stewart, 2005). The most difficult tasks for family caregivers are those dealing with patients’ behaviour, emotional pro- blems and financial problems, while still making time for social activities (Bakas et al., 2006; Pattenden et al., 2007). The heavy burden and role changes affect caregiver health and family relationships, as reported in Kang and Nolan’s study on family caregivers of heart failure patients (Kang et al., 2011). Taking care of patients with heart failure at home leads to dependence on family caregivers and impacts family function, especially the relationships between family members and the integration of family members into broader social networks and the commu- nity. It is necessary to develop and evaluate interventions that can improve outcomes for family caregivers (Collins and Swartz, 2011; Pressler et al., 2009; Pattenden et al., 2007).

1.2. Telenursing care for patients with heart failure

Nurses play a significant role in the success of telehealth interventions (Dias et al., 2009; Naditz, 2009). Telenursing care helps vulnerable people such as the elderly or those with chronic conditions lead independent lives by providing them with consultation, assessment, telephone triage/telephone advice, emergency support, disease management, and homecare (Naditz, 2009; Jons- son and Willman, 2008; Lorentz, 2008). Telenurses have advanced special abilities to communicate with family caregivers and to provide the evidence-based professional consulting and supportive care based on technology that improves the efficiency of patients’ disease management (Dias et al., 2009; Hoglund and Holmstrom, 2008; Snooks et al., 2008).

Four previous systematic reviews indicated telemedical monitoring in chronic heart failure can reduce total mortality as well as the number and duration of hospital admissions for worsening heart failure (Clarke and Sharma, 2011; Chaudhry et al., 2007; Inglis et al., 2010; Klersy et al., 2009). Nurses implement telehealth inter- ventions that include reviewing transmitted clinical data, assessing individuals, coaching, and installing telehealth. Radhakrishnan and Jacelon (2011) reviewed fourteen studies and concluded that the proactive role of nurses in telehealth care for heart failure patients includes delivering contextually relevant heart failure knowledge, building heart failure self-care skills, and sustaining self- care behaviours.

In Taiwan, many telehealth care systems have been implemented since 2007 as part of a government campaign to replicate a feasible care model (Huang et al., 2008). One of those hospitals, the National Taiwan University Hospital (NTUH), has a division of Integrative Management of Cardiovascular Disease in the Telehealth Center, which was the site for this study (National Taiwan University

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L.-C. Chiang et al. / International Journal of Nursing Studies 49 (2012) 1230–1242 1233

ospital-TeleCare, 2011). The Telehealth Center in the TUH emphasises patient-centred care that integrates the atient’s electronic health record, physicians’ diagnostic nalysis, disease management according to heart failure uidelines and follow-up from the hospital to home. The lehealth centre can perform daily management and

nalysis of all data uploaded by the patient, including hysiological parameters such as heart rate, blood ressure, blood sugar, and electrocardiography (ECG). octors and nurses can monitor patient health through le-devices provided by the medical centre and thus

educe patient transportation time and increase the ability offer immediate help in emergency situations (National

aiwan University Hospital-TeleCare, 2011). Patients articipating in telehealth services receive appropriate are at all times from the on-duty physicians as well as lenursing specialist who provide necessary information

ia their mobile phones to assist with disease manage- ent. Patients are also able to consult their telenursing

pecialist via telecommunication to receive test results and btain advice with a 24-h service. Providing around-the- lock health care accessible from home promotes healthy ving and reduces complications in patients with chronic omorbidities and after surgery.

.3. Transition theory

This study was developed and guided by Meleis’s ansition theory (Chick and Meleis, 1986; Schumacher

nd Meleis, 1994). Changes in the health and illness status f individuals create a process of transition, and clients in ansition tend to be more vulnerable to risks that may

ffect their health and their families. Nurses can provide ssistance to ensure these life transitions are managed uccessfully (Meleis et al., 2000; Meleis, 2010; Schumacher nd Meleis, 1994). Returning home represents a substan- al stressful event for the family of heart failure patients arkness and Tranmer, 2007; Luttik et al., 2007; Hagan

nd Currey, 2007; Kang et al., 2011). Chick and Meleis 986) define transitions as, ‘‘The passage or movement om one state, condition or place to another.’’ Transition ften requires a person to incorporate new knowledge or lter behaviours, thereby changing the definition of self in e new social context (Meleis et al., 2000; Meleis, 2010).

ccording to Meleis et al. (2000) there are several rinciples of a successful transition, including awareness, ngagement, change and difference. The challenges for urses include understanding the transition process and eveloping interventions that are effective in helping atients regain stability and a sense of well-being (Meleis t al., 2000). Indicators of successful transitions are ubjective well-being, role mastery, and the well-being f relationships (Schumacher and Meleis, 1994). A uccessful transition involves not only a sense of individual ell-being with effective role mastery, but also the well-

eing of family relationships. Relationship well-being has een conceptualised in terms of family adaptation, family tegration, enhanced appreciation and closeness, and eaningful interaction (Meleis et al., 2000; Schumacher

nd Meleis, 1994). Therefore, in this study, we evaluated aregiver burden by measuring the subjective well-being

of family caregivers, stress mastery to measure role mastery, and the Feetham family function assessment to measure relationship well-being.

The objectives of this study were to evaluate the effect of nursing-led transitional care combining discharge planning and telehealth care on caregiver burden, stress mastery, and family function. Family caregivers of heart failure patients were evaluated and compared to care- givers of patients receiving only traditional discharge planning during the transition from hospital discharge to home.

2. Methods

2.1. Design

A two-group pretest–posttest design was used. Patients with heart failure have a critical situational and illness transition, as patients with the diagnoses of heart failure and acute myocardial infarction have the highest read- mission rates within 30 days among recorded by health insurance companies (Armola and Topp, 2001). Follow-up plans are suggested to decrease readmission rates within 30 days (Armola and Topp, 2001). Therefore, data were collected at the first contact with patients and families (discharge planning) and at 30 days follow-up at home. This design did not incorporate blinded randomisation since participation in telehealth care requires patients’ and families’ payment and cooperation. Every family in the experimental group paid 6000 NT dollars per month to receive the telehealth device and telehealth care from a cardiology telenursing specialist.

2.2. Participants

Patients with heart failure and their primary family caregiver were recruited as a dyad by a research nurse from the Heart Failure Center, cardiac surgical ward, or cardiac medical ward of a medical centre in northern Taiwan. Family caregivers were included in the study if they met the following criteria: (1) >18 years old and without cognitive impairment; (2) able to read and answer the questionnaire, as well as communicate in Taiwanese; (3) live with the heart failure patient for at least 6 months; (4) agree to participate and sign an informed consent; and (5) learn the related knowledge and skills, including measure- ment of daily physical parameters and uploading data to the telehealth centre (Fig. 1).

Caregivers were excluded according to the following criteria: (1) not related to the patient or were an employee (i.e., foreign housemaid or special nurse); and (2) could not appropriately use telehealth devices after receiving extensive education provided during discharge planning from telenursing specialists. Sixty-three heart failure patients were assessed for eligibility and invited to participate in either telehealth care or standard care in a medical centre between May and October 2010. Three patients refused to answer the questionnaire. Because telehealth care data were transmitted from home to the call centre via Internet (3G or WiFi), patients who did not have an Internet connection were placed in the traditional

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scharge planning group. Some family members could not ree on the use of home-based monitors or were ncerned about privacy issues; these patients were also aced in the traditional discharge planning group. The al sample included 30 families in the experimental

oup participating in telehealth care and 30 families in the mparison group (see details below). All 60 families mpleted the pretest and posttest without withdrawing. The sample size was estimated based on Cohen’s (1992)

ggested criteria for comparing the means of two groups ith a large effect size and a = 0.05, which indicated a cessary sample size of 26 for each group. Re-calculation

the power using the sample size of 30 for each group owed 61% power to detect a difference of 7.57 in group ean scores on Feetham’s Family Functioning Survey FFS; Roberts and Feetham, 1982) at a significance level lpha) of 0.05 using a two-sided z-test. These results sume two sequential tests using the O’Brien and Fleming 979) spending function to determine test boundaries.

. Experimental group: telehealth care combined with

scharge planning

Every patient with heart failure received discharge ans created by a case manager before their discharge (see ction 2.4). After the case manager implemented the scharge plan, the telenursing specialist explained tele- alth care to the experimental group participants from troduction to implementation.

Telehealth care for heart failure patients was designed by a team of cardiac physicians and nurses in the division of Integrative Management of Cardiovascular Disease at the NTUH Telehealth Center. Patients in the experimental group were discharged with a telehealth device that connected them to a central platform at the NTUH. Patients with heart failure manifestations (sensation of breathing exertion, shortness of breath, leg oedema, fluid retention) and impaired left ventricular contractility (left ventricular ejection fraction 240% by echocardiography or Tc99m left ventriculography) were enrolled in the study. Family caregivers were trained by a telenursing specialist to measure patients’ physiological parameters at home and to upload these data to the Telehealth Center. These data were monitored 24 h per day, recorded, and analysed by telenursing specialist who informed on-duty physicians about the patients’ condition. Patients initially were followed up at an outward patient clinic (OPD) at a 4- week interval. Patients were managed according to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for heart failure management (ACC/AHA, 2001, 2005).

The telenursing specialist provided 24-h health educa- tion counselling and medical referral services by telephone for 7 days per week. They recorded the vital signs and the body weight every day. The telenursing specialist also gave the patients health education about the pathophysiology of heart failure, dietary therapy and limiting fluid intake. Patients uploaded measurements recorded by physiologic

Assessed for eligib ility (n=63)

Enrol lment

Included (n=63) Not meeting inclus ion crite ria (n=0) Refused to participa te (n=2) Trans fer to othe r ins titut e (n=1)

The fa milies participated in telehea lth care was allocated to experimental group (n =30) Rece ived discharge p lanning and one-month telehea lth care (n =30)

Families no t p articip ated in telehea lth care were allocated to compa rison group (n=30) Received on ly the dis charge planning (n=30)

Allocation

Lost to follow-up (n=0) Lost to follow -up (n=0) Fol low -up

Analyze (n=30) Analyze (n=30)

Analysis

Fig. 1. The flowchart of recruiting.

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L.-C. Chiang et al. / International Journal of Nursing Studies 49 (2012) 1230–1242 1235

ensors everyday and as needed from home. The physio- gic sensors included electrocardiogram, blood pressure,

lood sugar and oxygenation. The telenursing specialist iewed these data and gave feedback instructions includ- g controlling body weight, monitoring urine output, king medications as directed, controlling fluid intake and

xplaining medication side effects. If the symptoms and igns of heart failure (sensation of breathing exertion, hortness of breath, leg oedema, and fluid retention) or ody weight gain up to 1.5–2 kg per week developed, the lenursing specialist would arrange for the patient to visit e emergency station or be admitted after a discussion ith the physician. The telenursing specialist also formed attending physicians and patients if there were

ew onset of atrial or ventricular arrhythmias. The patient ould communicate with the telenursing specialist any- me when their condition changed. After discharge from e hospital, the telenursing specialist communicated with e patient within 48–72 h (Ho et al., 2007).

.4. Comparison group: traditional discharge planning only

Discharge planning was performed by a hospital-based ase manager who instructed the family caregivers to ssess patient signs and symptoms, taught relevant health are skills and assisted with the preparation of home cilities. If the family caregivers had problems, they could

ommunicate with the case manager by telephone as eeded. The case manager actively contacted the family aregiver to understand the patient’s condition and rovide health consultation two weeks after discharge. he case manager also covered the physical, psychological, nd social problems of families and patients; however, ese issues were not continually monitored through

ommunication with the health care team every week.

.5. Data collection

Data were collected from June to August 2010. One case anager provided the discharge plan with a consistent cus on patient-centred care. Six well-trained telenursing

pecialists monitored data and provided education and ounselling 24 h per day for 7 days per week. Telehealth are was provided with nurses on both day and night shift uty. One nurse researcher (the second author) collected ata from family caregivers on caregiver burden, stress astery, and family function at two times: during

ischarge planning (before patient discharge) and at the atients’ 1-month follow-up visit in the cardiac clinic.

.5.1. Caregiver burden

The Chinese version of the Caregiver Burden Inventory BI) (Chou et al., 2002; Novak and Guest, 1989) was used

assess caregiver burden (an indicator of caregivers’ ubjective well-being). The 28-item CBI has six domains: me burden; developmental burden; physiological bur- en; emotional burden; social burden and cost of care. esponses are rated on a self-reported 5-point Likert scale, ith higher scores indicating a greater burden. The ternal consistency (Cronbach’s a) for the subscales

anged from 0.73 to 0.86 (Chou et al., 2002; Novak and

Guest, 1989). In this study, the CBI subscales had Cronbach’s a-values ranging from 0.75 to 0.90.

2.5.2. Mastery of stress related to caregiver role

Mastery of stress in the caregiving role was measured by the Mastery of Stress Scale (MSS; Younger, 1993). This 89-item instrument has five domains: Certainty; Change; Acceptance; Growth; and Stress (Younger, 1993). It measures the ability of a human to respond to a difficult situation by gaining competence, control, and dominion over the stress. Responses to each question are rated on a 5-point Likert scale, with higher scores indicating greater mastery. The internal reliability (Cronbach’s a) of the five subscales ranged from 0.84 to 0.94, and the 2-week test– retest reliability was 0.84 (Younger, 1993).

For this study, the MSS was translated from English to Chinese, back-translated, and pretested by an experienced English translator (one English professor) as recommended by Brislin et al. (1973). The first Chinese version of the scale was back-translated to English by a native Chinese- speaking English professor to verify the research instru- ment. The back-translated English version scale was refined by two bilingual experts and agreed upon by Dr. Younger. The final Chinese version was pretested for readability and clarity among four monolingual Chinese- speaking family caregivers of heart failure patients. These family caregivers easily understood and answered all items. In this study, the subscales of the Chinese version MSS had Cronbach’s a-values ranging from 0.76 to 0.88.

2.5.3. Family functioning

Family functioning was assessed using the Chinese version of the Feetham Family Functioning Survey (FFFS) (Hohashi et al., 2008; Roberts and Feetham, 1982). The FFFS includes three subscales to assess the three aspects of family relationships: (1) relationships between the family and each family member; (2) relationships between the family and its subsystems (e.g., housework, support); and (3) relationships between the family and society (Roberts and Feetham, 1982). This conceptualisation is appropriate to measure relationships between family members and integration of family members within broader social networks and the community (Schumacher and Meleis, 1994). The Chinese version of the FFFS has 25 items that are rated according to the following three dimensions: (1) How much is there now? (b) How much should there be? (c) How important is this to you? For each dimension, the item is rated on a 7-point Likert scale with 1 corresponding to ‘‘little’’ and 7 corresponding to ‘‘much’’ (Hohashi et al., 2008). The reliabilities (Cronbach’s a) of the original vs. Chinese version of the FFFS for the three dimensions were 0.83 vs. 0.89, 0.74 vs. 0.77, and 0.72 vs. 0.73, respectively (Hohashi et al., 2008; Roberts and Feetham, 1982).

2.6. Ethical considerations

This study was approved by the Institutional Review Board of the hospital where the study was conducted (201005006R). Patients and their caregivers were informed of the study details and procedure, that their decision to participate was purely voluntary, that the right

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medical treatment and nursing care would be equal in th groups, and that they had the right to leave the study

any time. After indicating that they understood and cepted these conditions, they were asked to sign an formed consent agreement. Copies of signed agreements ere retained and restored by the researcher, patients, and mily caregivers.

. Data analysis

All data were analysed by descriptive and inferential tistics using SPSS 17.0 for Windows. Demographic data

r the experimental and comparison groups were mpared by chi-square analysis and independent sam- es t-tests. Scores for caregiver burden, Mastery of Stress ale, and family function were analysed for the two oups using the SPSS Mixed Model. For repeated

measurements, the mixed-model technique is better than the general linear model in dealing with missing data at follow-up and limited availability of variance–covariance structures (Chan, 2004). This type of design is called mixed-model ANOVA since it mixes between-groups factors (Fb), within-groups factors (Fw) and the interaction factor (Fin) both between groups and within time.

3. Results

3.1. Participants’ characteristics

The characteristics of the 60 family caregivers revealed no significant differences between the experimental and comparison groups in terms of gender, age, educational background, employment status, marital status, or religion (Table 1). Most family caregivers were over 40 years old

ble 1

mographic characteristics of family caregivers and patients by group.

Experimental, n = 30 Comparison, n = 30 x2 p

n % n %

amily caregivers ender 0.093 0.760

Male 7 23.3 10 33.3

Female 23 76.7 20 66.7

ge (years old) 27.289 0.852

18–39 6 20.0 4 13.3

40–59 9 30.0 17 56.7

60–79 14 46.7 7 23.3

�80 1 3.3 2 6.7 ducation 19.240 0.256

�High school 10 33.3 12 40.0 Bachelor’s degree 16 53.4 16 53.3

Master degree and above 4 13.3 2 6.7

mployment status 16.615 0.342

Retired 12 40.0 10 33.3

Student 0 0 2 6.7

Employed 18 60.0 18 60.0

arital status 0.544 0.461

Single/unmarried 4 13.3 4 13.3

Married 26 86.7 26 86.7

eligion 4.266 0.893

None 5 16.7 3 10.0

Taoism 5 16.7 6 20.0

Buddhism 19 63.3 19 63.3

Christianity 1 3.3 2 6.7

aregiving time 8.443 0.207

1 month 2 6.7 0 0

>1 month to 1 year 9 30.0 11 36.7

>1–5 years 16 53.3 17 56.7

>5–10 years 3 10.0 2 6.7

elationship to patient 15.280 0.760

Spouse 15 50.0 14 46.7

Sibling 0 0 1 3.3

Son/daughter 10 33.3 10 33.3

Daughter-in-law 4 13.3 3 10.0

Grandparent/grandchild 1 3.3 2 6.7

ealth status 0.136 0.713

No chronic disease 15 50.0 13 43.3

With chronic disease 15 50.0 17 56.7

atients ge (years) 10.195 0.599

40–59 7 23.3 13 43.3

60–79 23 76.7 17 56.7

ender 0.075 0.784

Male 10 33.3 10 33.3

Female 20 66.7 20 66.7

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0.0% vs. 86.7%) and the majority had a bachelor’s degree 3.4% vs. 53.3%). Most participants had worked before

ecoming a family caregiver. Caregivers in the two groups also did not differ

ignificantly in terms of their relationship to the patient r health status, nor did patients differ significantly in rms of health status or catheterisation. The majority of mily caregivers took care of the patient for more than 1

ear and less than 5 years (53.3% vs. 56.7%). Almost half of e caregivers were spouses (50.0% vs. 46.7%) and about

alf had at least one chronic disease (50.0% vs. 56.7%). The majority of the patients in this study were 60–79

ears old and married. There were ten male patients and

twenty female patients in each group. Most patients had at least one comorbid condition, with the majority having two to three comorbidities (76.7% vs. 66.7%). Only 13.3% of patients in the experimental group and 10.0% in the comparison group were catheterised and needed addi- tional caring activities (Table 1).

3.2. Effects on caregiver burden

Data for each outcome variable at pretest (discharge) and posttest (one-month follow-up) are presented in Table 2 and Figs. 2–4. Caregiver Burden Inventory (CBI) was used to measure caregivers’ well-being, with higher scores

able 1 (Continued )

Experimental, n = 30 Comparison, n = 30 x2 p

n % n %

Marital status 0.489 0.565

Single/unmarried 0 0 1 0.3

Married 30 100 29 99.7

Disease status 12.410 0.901

Only heart failure 0 0 3 10.0

1 comorbidity 7 23.3 7 23.3

2 comorbidities 9 30.0 9 30.0

�3 comorbidities 14 46.7 11 36.7 Patient catheterised 0.513 0.474

No 26 86.7 27 90.0

Yes 4 13.3 3 10.0

able 2

ixed model: repeated measures of caregiver burden, mastery of role stress, and family functioning by group.

Outcome measure Pretesta Posttestb Between-groups, Fb (p) c Within-times, Fw (p)

d Interaction, Fin (p) e

Mean � SD Mean � SD

CBIf score Total

Experimental 43.93 � 12.39 23.27 � 10.91 �2.433 (0.382) �20.667 (<0.001**) 11.433 (<0.001**) Comparison 41.50 � 10.12 32.37 � 9.15

Time burden

Experimental 7.60 � 2.33 4.10 � 1.88 �0.233 (0.636) �3.500 (0.004*) 1.533 (<0.001**) Comparison 7.37 � 1.85 5.40 � 1.45

Development burden

Experimental 7.53 � 1.83 3.83 � 1.93 �1.633 (0.001**) �3.700 (<0.001**) 2.267 (<0.001**) Comparison 5.90 � 1.93 4.47 � 1.61

Physiological burden

Experimental 7.50 � 2.49 4.13 � 2.36 0.267 (0.627) �3.367 (<0.001**) 2.000 (0.002*) Comparison 7.77 � 1.89 6.40 � 1.63

Emotional burden

Experimental 7.60 � 2.54 4.17 � 2.17 0.167 (0.769) �3.433 (<0.001**) 1.833 (<0.001**) Comparison 7.77 � 2.00 6.17 � 2.04

Social burden

Experimental 6.33 � 2.41 3.10 � 2.16 �0.533 (0.301) �3.233 (<0.001**) 1.967 (<0.001**) Comparison 5.80 � 1.65 4.53 � 1.61

Cost of care

Experimental 7.20 � 2.66 3.97 � 1.97 �0.533 (0.357) �3.233 (<0.001**) 1.767 (<0.008*) Comparison 6.67 � 2.20 5.20 � 2.02

MSSg score Total

Experimental 336.57 � 19.66 378.53 � 23.53 2.233 (0.704) 42.933 (<0.001**) �22.733 (<0.001**) Comparison 338.17 � 25.25 358.63 � 22.16

Certainty

Experimental 56.63 � 3.86 64.73 � 5.77 3.000 (0.030) 8.100 (<0.001**) �5.600 (<0.001**) Comparison 59.63 � 5.14 62.13 � 6.13

Change

Experimental 54.67 � 3.70 61.37 � 5.39 0.567 (0.654) 6.700 (<0.001**) �4.267 (0.004**) Comparison 55.23 � 5.77 57.67 � 4.41

re no ex hi gr

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Fig

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L.-C. Chiang et al. / International Journal of Nursing Studies 49 (2012) 1230–12421238

flecting a lower level of well-being. The two groups did t differ significantly at pretest in outcome indicators, cept for developmental burden, which was significantly gher in the experimental group than in the comparison oup (Table 2). The significant group � time interaction (Fin = 11.433,

0.001) for total CBI score means family caregivers in the perimental group had a larger decrease in mean score of I (43.93–23.72) than the comparison group (41.5–32.37)

ter 30 days. The degree of improvement in each of the six regiver Burden Inventory (CBI) subscales (time burden,

development burden, physiological burden, emotional burden and cost burden) was significantly greater in the experimental group compared to the traditional discharge planning only group.

3.3. Effects on mastery of stress related to caregiver role

Family caregivers in both groups improved their mastery of stress within pretest and posttest (Fw = 42.933, p < 0.001). The significant group � time interaction (Fin = �22.733, p < 0.001) in total MSS score

ble 2 (Continued )

utcome measure Pretesta Posttestb Between-groups, Fb (p) c Within-times, Fw (p)

d Interaction, Fin (p) e

Mean � SD Mean � SD

cceptance

Experimental 55.73 � 5.21 62.03 � 6.71 0.767 (0.635) 6.300 (<0.001**) �0.700 (0.698) Comparison 56.50 � 6.11 62.10 � 6.82 rowth

Experimental 58.43 � 5.06 65.33 � 6.48 0.933 (0.544) 6.900 (<0.001**) �4.067 (0.007*) Comparison 59.37 � 7.00 62.20 � 4.90

tress

Experimental 111.00 � 12.70 125.27 � 10.94 �3.367 (0.278) 14.600 (<0.001**) �7.767 (0.018*) Comparison 107.47 � 11.51 114.30 � 12.78

FFSh score otal

Experimental 83.90 � 13.62 91.47 � 12.65 �3.267 (0.333) 7.400 (<0.001**) �5.767 (<0.001**) Comparison 80.80 � 13.04 82.40 � 12.78

elationship between family and family members

Experimental 30.20 � 4.51 32.20 � 4.43 �1.900 (0.155) 2.000 (<0.001**) �0.533 (0.295) Comparison 28.30 � 5.61 29.77 � 5.75

elationship between family and subsystems

Experimental 27.20 � 4.22 28.60 � 4.35 �0.533 (0.649) 1.400 (<0.001**) �1.500 (0.007*) Comparison 26.67 � 4.61 26.57 � 4.83

elationship between family and society

Experimental 26.67 � 5.82 30.67 � 5.21 �0.833 (0.557) 4.000 (<0.001**) �3.733 (<0.001**) Comparison 25.83 � 5.53 26.10 � 5.29 Measured at hospital discharge.

Measured 30 days after return home.

Fb: the F value of between groups comparison.

Fw: the F value of within pre- and post-test.

Fin: the F value of the interaction of between groups and within pre- and post-test.

Caregiver Burden Inventory.

Mastery of Stress Scale.

Feetham Family Functioning Scale.

p < 0.05.

* p < 0.001.

41.5

0

5

10

15

20

25

30

35

40

45

50

1 2

CBI scale Means

Experimental group

Comparison group

23.27

32.37

43.93

C B

I s c a

le M

e a

n s

. 2. CBI of the experimental (received telehealth care) and the

Mastery of stress scale Means

378.53

358.63

336.57

338.17

310

320

330

340

350

360

370

380

390

1 2

M a

s te

ry o

f s tr

e s s s

c a

le M

e a

n s

Experimental group

Comparison group

mparison groups (tradition discharge planning only). Fig. 3. Mastery of Stress Scale of the experimental (received telehealth

care) and the comparison groups (tradition discharge planning only).

s in g ( im d

3

w b s s s b T b p

4

ti p im a tr c s h (J Ja c a c c c r s a r fr p

F

c

L.-C. Chiang et al. / International Journal of Nursing Studies 49 (2012) 1230–1242 1239

howed that family caregivers in the experimental group creased significantly more than that of the comparison

roup. Four of the five domains of stress mastery Certainty, Change, Growth, and Stress) significantly

proved for the experimental group; the Acceptance omain did not improve (Table 2 and Fig. 3).

.4. Effects on family function

For both groups, family function significantly improved ithin pretest and posttest (Fw = 7.40, p < 0.001) as shown

y the FFFS scores. The experimental group improved ignificantly more than the comparison group on the FFFS ubscale scores for ‘‘relationships between family and ubsystems’’ (Fin = �1.500, p = 0.007) and ‘‘relationships etween family and society’’ (Fin = �3.733, p < 0.001). elehealth care had no significant effect on relationships etween the family and family members (Fin = �0.533,

= 0.295) (Table 2 and Fig. 4).

. Discussion

The results of this study show that nurse-led transi- onal care combining telehealth care and discharge lanning significantly reduced family caregiver burden,

proved mastery of stress related to the caregiver role, nd improved family function. This facilitated successful ansition for family caregivers of heart failure patient

ompared to the comparison group. Previous primary and ystematic reviews focused on evaluating the patient’s ealth, self-care behaviours, and medication compliance erant et al., 2003; Inglis et al., 2010; Radhakrishnan and celon, 2011). Our findings emphasised the family

aregivers’ adaptation through continuous consultation nd monitoring by telehealth care. Some of the family aregivers participating in the telehealth care group ommented that they felt more secure monitoring the ondition of the patient; this is consistent with previous eports that participating in telehealth care provides a ense of security (Jonsson and Willman, 2008). Addition- lly, daily communication with telenursing specialist educed their uncertainty, especially since they could equently and quickly receive help and information from hysicians.

The developmental burden of family caregivers in the telehealth care group was significantly higher at pretest than that in the comparison group. This difference might have been due to the family caregivers in the telehealth care group tending to be older than in the comparison group, although this difference was not significant. In older families, family developmental tasks are higher than in younger families (Duvall and Miller, 1985). This might lead to increased caregiver depression (Caserta et al., 1996) and enhance the developmental burden. We expected that the heavier burden of caring for elderly patients with heart failure would motivate family caregivers to participate in and pay for telehealth care. Indeed, we found that telehealth care significantly increased caregiver and family function by reducing their care burden.

Previous studies have indicated that home-based primary care could reduce caregiver burden (Hughes et al., 2000), but failed to reduce the caregiver burden by exercise intervention (Molloy et al., 2006). Caregiver burden of the telehealth care group significantly declined not only for the total CBI score, but also in the six subscale scores, demonstrating that the telehealth care not only monitored the physical parameters of heart failure but also reduced caregiver burden compared to the comparison group. These results are consistent with reports that E-care (a telecommunications technology intervention) for family caregivers of people with dementia reduced their care burden and promoted well-being (Finkel et al., 2007) and a web-based family intervention for children with traumatic brain injury and their parents decreased their parents’ burden (Wade et al., 2005).

Family caregivers in both groups improved their mastery of stress related to the caregiver role over the month after discharge. Caregivers in the experimental group significantly improved in four domains in the Mastery of Stress Scale (Certainty, Change, Growth, and Stress) compared to the comparison group, but did not improve in the ‘‘Acceptance’’ domain. ‘‘Acceptance’’ is the third process of stress mastery in the theory of mastery (Younger, 1991). The definition of acceptance is to acknowledge events as true and normal and to agree to the terms of a situation in four situations: (1) to accept is to admit that crucial aspects of an event cannot be changed; (2) to suffer the impact of that realisation; (3) to give up any hopeless causes and expectations in the situation; and (4) to be predominantly free of longing for what has been lost; to change self rather than the event; and to find alternate sources of satisfaction for what is lost (Younger, 1991). In this study, we only followed family caregivers for one month. It is difficult to initiate acceptance of the critical situation of family members suffering from heart failure in a short-term intervention. Most families tried to provide their best care to maximise the patients’ health. They participated in this self-paid telehealth care in order to alter this complex situation. Therefore, the families still cannot accept or admit that this event cannot be changed, and they also cannot give up any hope and expectations in the situation. We believe that families need a long time to adapt to the patients’ life-threatening condition.

The Feetham Family Function Survey (FFFS) is appro- priate to measure the relationships between family

FFFS scale Means

91.47

82.4 83.9

80.8

74

76

78

80

82

84

86

88

90

92

94

1 2

F F

F S

s c a le

M e a n s

Experimental group

Comparison group

ig. 4. FFFS of the experimental (received telehealth care) and the

omparison groups.

m br an m pa co pl m gr th to an w so fa so co fa is cr et in fa di fa

de ca th ad (1 fa re th th be de ho th

pa by w ro pa w re alt sta se ge de kn ca ab als an lo he rig be

L.-C. Chiang et al. / International Journal of Nursing Studies 49 (2012) 1230–12421240

embers and the integration of family members within oader social networks and the community (Schumacher d Meleis, 1994). The total score of family function easured by the FFFS was significantly increased after rticipating in the telehealth care group after one-month mpared to the group that received only discharge anning. In fact, the relationships between family embers were not significantly better in the experimental oup compared to the comparison group. It is thought at this is due to telehealth care offering an outside agent

interact with family caregivers by daily communication d enhance family member contact within social net-

orks and the community. Telehealth care could improve cial interactions, but not for the relationships inside the mily. Although the relationships between the family and cial networks are important, telehealth care only ntacts the primary family caregiver, not the whole mily. Improving relationships inside the family members also necessary for family members suffering from a

itical health condition. Based on the suggestion of Wade al. (2004) that most families prefer face-to-face meet- gs compared to Internet-based meetings, we suggest ce-to-face interviews or meetings with the family to scover individual family problems or conflicts between mily members (Wade et al., 2004).

This study adapted Meleis’s transition theory for veloping a nurse-led transitional care to help family regivers of heart failure patients to successful passed rough the critical transition form hospital to home. The vantages of application Meleis’s transitional theory are ) to emphasise the temporal change of patient and their milies in situational change process; (2) that individuals quired the new knowledge and behaviours and change in e new social context during the transition process; (3) at providing three outcome indicators (subjective well- ing, role mastery, and well-being of relationships) to fine the successful transition. However, it is not clear w the knowledge, attitude, and caring behaviours affect e transitional process. The limitations of this study included: (1) family

rticipation in self-paid telehealth care may be influenced the economic situation; (2) the process indicators as

ell as the family caregiver’s perceptions, expectations, le engagement, knowledge and skills of caring for tients were not integrated into this study; (3) families

ere not randomly assigned into groups; (4) the nursing searcher collecting data was not blinded; and (5) hough the first 30 days after discharge are a critical ge, long-term follow-up is necessary in the future. A

lection bias caused by a lack of randomisation limits the neralisability of these findings. Further studies should be signed to explore the factors (i.e., economic status, owledge and skills of family) that may affect family regivers’ perceptions, cognition, resiliency and caring ility. Collecting data from multiple family members is o suggested in the further study designs in order to alyse the patient–caregivers relationship. Prospective

ngitudinal cohorts should be examined for the effects on alth outcomes and medical expenditures. Further orous sampling strategies from multiple sites could

conducted to recruit larger samples.

5. Conclusion

Based on Meleis’s transitional theory, nursing-led transitional care combining telehealth care and discharge planning could help family caregiver’s successful transi- tion in three outcome indicators—decreased family care- giver burden, increased stress mastery and improved family function in family caregivers of patients with heart failure one month after discharge compared to those receiving traditional discharge planning only. However, caregivers’ acceptance of the patient’s critical condition, and the relationship between family and family members did not significantly improve in the telehealth care group at the one-month follow-up. The advanced technology of telehealth care not only monitors the physical condition of patients with heart failure during the critical transition from discharge to home, but also improves the telenursing specialist-family caregiver partnership to help, support and empower family caregivers to achieve a successful transition. Telehealth care is not limited to remote monitoring using advanced high technology devices to examine physiological parameters; the nurses play a critical role as well. Telenursing specialists should include families into their practice with the concepts of providing transitional care to help patients and families successful cross the critical transition stage.

6. Implications for practice and policy

Integrated telehealth care combining with discharge planning provides better nurse-led intervention for family caregivers and better care of the family as a unit. Chronic disease is not only a personal event; it is a critical family event. Providing discharge planning to heart failure patients and their families might improve patient self- care and reduce readmission rates. Telemedical monitor- ing in chronic heart failure might reduce total mortality as well as the number and duration of hospital admissions for worsening heart failure. More integrative transitional care model should be developed, including discharge planning, telemedical monitoring and holistic nursing care.

Although the monthly cost of telehealth care is not too expensive, a discussion of reimbursement from health insurance companies should be included. The results of this study suggest nurse-led nursing care with advanced high technology systems could be used in more hospitals with government support. This role of telenursing specialist should be established by more studies in the future.

Conflict of interest: This is a follow-up evaluation study con-

ducted by the Tele nurse without conflict of interest.

Funding: This study is an action study that tele-nurse was a

graduate student and was supported by the advisor Dr.

Chiang for the cost of questionnaires print (NSC97-2314-B-

039-034-MY3); and the administrative support from the

Director of the Telehealth Center—Dr. Yi-Lwun Ho.

Ethical approval: Institutional Review Board of the study

hospital (201005006R).

A

T p N

R

A

A

A

A

A

A

B

B

C

C

C

C

C

C

C

C

C C

D

D

D

F

H

L.-C. Chiang et al. / International Journal of Nursing Studies 49 (2012) 1230–1242 1241

cknowledgements

This is supported the Tele-Health Center in National aiwan University Hospital. This study has some sup- orted by grants from the National Science Council (no. SC97-2314-B-039-034-MY3).

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Na

Na

Na

Na

No

O’B

Pa

Pre

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Ro

Ra

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