For both groups, family function significantly improved within pretest and posttest (Fw=7.40, p<0.001) as shown by the FFFS scores. The experimental group improved
significantly more than the comparison group on the FFFS subscale scores for “relationships between family and subsystems” (Fin=-1.500, p=0.007) and “relationships between family and society” (Fin=-3.733, p<0.001). Telehealth care had no significant effect on relationships between the family and family members (Fin=-0.533, p=0.295) (Table 2 and Figure 3).
4. Discussion
The results of this study show that nurse-led transitional care combining telehealth care and discharge planning significantly reduced family caregiver burden, improved mastery of stress related to the caregiver role, and improved family function. This facilitated successful transition for family caregivers of heart failure patient compared to the comparison group.
Previous primary and systematic reviews focused on evaluating the patient’s health, self-care behaviours, and medication compliance (Jerant et al., 2003, Inglis, et al., 2010,
Radhakrishnan and Jacelon, 2011). Our findings emphasised the family caregivers’
adaptation through continuous consultation and monitoring by telehealth care. Some of the family caregivers participating in the telehealth care group commented that they felt more secure monitoring the condition of the patient; this is consistent with previous reports that participating in telehealth care provides a sense of security (Jonsson & Willman, 2008).
Additionally, daily communication with telenursing specialist reduced their uncertainty, especially since they could frequently and quickly receive help and information from
physicians.
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 & 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 (Hunghes, 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 maximize 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 appropriate to measure the relationships between family members and the integration of family members within broader social
networks and the community (Schumacher & Meleis, 1994). The total score of family function measured by the FFFS was significantly increased after participating in the
telehealth care group after one-month compared to the group that received only discharge planning. In fact, the relationships between family members were not significantly better in the experimental group compared to the comparison group. It is thought that this is due to telehealth care offering an outside agent to interact with family caregivers by daily
communication and enhance family member contact within social networks and the
community. Telehealth care could improve social interactions, but not for the relationships inside the family. Although the relationships between the family and social networks are important, telehealth care only contacts the primary family caregiver, not the whole family.
Improving relationships inside the family members is also necessary for family members suffering from a critical health condition. Based on the suggestion of Wade et al. (2004) that most families prefer face-to-face meetings compared to internet-based meetings, we suggest face-to-face interviews or meetings with the family to discover individual family problems or
conflicts between family members (Wade et al., 2004).
This study adapted Meleis’s transition theory for developing a nurse-led transitional care to help family caregivers of heart failure patients to successful passed through the critical transition form hospital to home. The advantages of application Meleis’s transitional theory are 1) to emphasise the temporal change of patient and their families in situational change process; 2) that individuals required the new knowledge and behaviours and change in the new social context during the transition process; 3) that providing three outcome indicators
(subjective well-being, role mastery, and well-being of relationships) to define the successful transition. However, it is not clear how the knowledge, attitude, and caring behaviours affect
the transitional process.
The limitations of this study included: 1) family participation in self-paid telehealth care may be influenced by the economic situation; 2) the process indicators as well as the family caregiver’s perceptions, expectations, role engagement, knowledge and skills of caring for patients were not integrated into this study; 3) families were not randomly assigned into groups; 4) the nursing researcher collecting data was not blinded; and 5) although the first 30 days after discharge are a critical stage, long-term follow-up is necessary in the future. A selection bias caused by a lack of randomisation limits the generalisability of these findings.
Further studies should be designed to explore the factors (i.e., economic status, knowledge and skills of family) that may affect family caregivers’ perceptions, cognition, resiliency and caring ability. Collecting data from multiple family members is also suggested in the further study designs in order to analyze the patient-caregivers relationship. Prospective longitudinal cohorts should be examined for the effects on health outcomes and medical expenditures.
Further rigorous sampling strategies from multiple sites could be 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 transition in three outcome indicators--decreased family caregiver 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.