Canadian Journal of Nursing Informatics

An Online Stress Management Training Program as a Supportive Nursing Intervention for Family Caregivers of an Elderly Person

Francine Ducharme, RN, PhD 1
Véronique Dubé, RN, PhD(c) 1
Louise Lévesque, RN, MSc 1
Diane Saulnier, RN, MSc 1
Francine Giroux, MSc 2

E-mail: francine.ducharme@umontreal.ca

1. Faculty of Nursing, Université de Montréal and Research Centre, Institut universitaire de gériatrie de Montréal, 4565 chemin Queen-Mary, Montréal (Qc), Canada, H3W 1W5.

2. Research Centre, Institut universitaire de gériatrie de Montréal, 4565 chemin Queen-Mary, Montréal (Qc), Canada, H3W 1W5.

Abstract

The aim of this study was to evaluate the effects of a stress management training program offered online to family caregivers of an elderly person with impaired physical or cognitive autonomy. The effects evaluated concerned caregiver quality of life and learning of stress management skills. A total of 26 caregivers took part in the program, comprised of seven online individual sessions along with professional coaching and exchange among participants. The mixed research design used to evaluate the effects showed that caregivers perceived greater self-efficacy in dealing with caregiving demands and perceived their caregiver role to be less threatening and more challenging after completing the program. They also gained self-control over their situation, attained the goal they set at the start of the program, and reported lower health risks.

Qualitative data revealed that caregivers learned the key elements of stress management. Offering support via the Internet is an innovative intervention modality that allows nurses to reach caregivers who cannot or do not want to attend conventional supportive programs. It is recommended to offer this program at the onset of the caregiving trajectory to help caregivers learn, as soon as possible, how to deal with caregiving demands and promote their health.

Key words

Family caregivers, elderly, stress management, online training program, nursing

Introduction

In the Western World, aging demographics and a marked policy trend to keep autonomy-impaired persons at home for as long as possible means that more and more families are helping and caring for an elder (Commission of European Communities, 2005; Cranswick & Dosman, 2008). In Canada, there are more than five million family caregivers, often for an elderly person, who play an essential role in home support (Canadian Caregiver Coalition, 2010; Keefe, Légaré, & Carrière, 2007). A growing number of these caregivers belong to the generation of baby-boomers familiar with information and communication technology (ICT). Yet, according to a literature review by Topo (2008), society has been slow in applying this technology in the area of caregiver support. In this regard, nurses could contribute to the development of ICT-based intervention programs as they are in a pivotal position to support caregivers.

In the mid-90s, foreseeing that ICT would be a modality of the future for offering support to caregivers, Brennan, Moore, and Smyth (1995) developed an innovative nursing intervention program, the ComputerLink project, for family caregivers of a person with Alzheimer’s disease. Their results showed that the caregivers of elderly persons perceived this modality to be easy to understand and use. Similar findings were replicated in subsequent studies (Finkel et al., 2007; Lewis, Hobday, & Hepburn, 2010; Hanson & Clake, A., 2000; Smyth, Rose, McClendon, & Lambrix, 2007).

There are many advantages to using ICT to support clients and their families. It constitutes a flexible approach that allows nurses to support caregivers who are isolated geographically and who are most often excluded from support groups or counselling programs. It is also an approach accessible at any time of day by caregivers who lack the availability of conventional services (Beauchamp, Blair Irvine, Seeley, & Johnson, 2005; Wu, Foucounau, De Rotrou, Riguet, & Rigaud, 2009). Indeed, these caregivers often have a hard time leaving their homes because of their numerous care-related responsibilities, including administering medical treatments, assisting with activities of daily living, and providing supervision, particularly when the cared-for relative has memory impairment (see Ducharme, 2006).

There is also an emotional dimension to caring for a family member, which in nursing is referred to as the intangible aspects of care (Bowers, 1987). This includes what is done by caregivers to maintain a satisfactory and comforting relationship with their relative (Ducharme, 2006). According to an extensive body of research (Commission of European Communities, 2005; Ducharme, 2006; Pinquart & Sörensen, 2003; Schultz & Martire, 2004),.the demands of providing care to an elderly relative affect the quality of life of caregivers. Indeed, caregivers report being captive and exhausted and experience stress and insecurity over the care they must provide.

According to systematic literature reviews (Powell, Chiu, & Eysenbach, 2008; Topo, 2008; Wu et al., 2009), ICT-based intervention programs have a modest effect on caregiver well-being and quality of life, as do intervention programs offered face to face or in a group setting (see Brodaty, Franzep, Green, & Koschera, 2003; Pinquart & Sörensen, 2006; Thompson et al., 2007). One reason given to explain these results is that the elements of the interventions might not be specific enough to meet the needs of caregivers (Zarit & Femia, 2008). However, when content is centred on learning different coping strategies, namely, problem solving and reframing, to deal with daily stress situations associated with the caregiver role, interventions have been shown to have a greater impact on caregiver well-being, whether they are offered via ICT (Beauchamp et al., 2005; Williams et al., 2010) or face to face (Gallagher-Thompson & Coon, 2007; Logston, 2008; Martin-Carrasco et al., 2009). It has also been reported that psycho-educational interventions offered on an individual basis were more likely than group interventions to have significant effects, the former being more targeted and personalized and could be delivered with greater intensity (Selwood, Johnston, Katona, Lyketsos, & Livingston, 2007).

To date, the vast majority of ICT-based intervention programs have been offered in a group modality rather than on an individual basis. Moreover, most of the programs have been computer-telephone systems for coaching, often accompanied by online videos (Topo, 2008). However, multi-component modalities do not allow drawing a clear link between a given element and program outcomes (e.g., effect of videos vs. effect of telephone contacts on caregiver-perceived stress). In addition, the vast majority of programs have been intended solely for family caregivers of persons with dementia (Topo, 2008), thus neglecting the needs of caregivers of an elderly relative with impaired functional autonomy. In this regard, Mesthenoes and Triantafillou (2005) noted that the caregiver role comprised a common core of needs, whether the cared-for relative presented a loss of physical or cognitive autonomy. Finally, Wu et al. (2009) observed that very few studies had examined caregiver learning via ICT and pointed out the necessity of taking this learning into account in order to measure how much of the content conveyed through this intervention modality was appropriated by caregivers.

Based on these findings, our research team developed an individual psycho-educational stress management training program offered online to family caregivers of persons with impaired physical or cognitive autonomy. The program was initially designed to be offered during home visits by healthcare professionals, particularly nurses from community health centres working with family caregivers of elderly persons with impaired autonomy (Ducharme, Lebel, Lachance, & Trudeau, 2006). The quasi-experimental design used to test the effects of this in-home stress management program showed significant effects on selected indicators of caregiver quality of life, namely, perceived challenge of the caregiver role, control by self, and use of social support (Ducharme et al., 2006).

Given these positive results, we adapted the program for online delivery. More specifically, the content was rendered interactive with the help of a technopedagogue. Then, within the framework of a pilot project, we field-tested and evaluated this innovative intervention modality from a qualitative point of view, that is, in terms of content, structure and process. Results demonstrated that this approach had great potential. According to caregivers, the main advantages of the online modality were its accessibility and its asynchronism (Ducharme, Trudeau, Rowan, Savard, & Lebel, 2009).

Knowing that this Online Stress Management Training Program was perceived positively from a qualitative perspective, we undertook to evaluate its effects on different indicators of the quality of life of family caregivers of an elderly person with impaired physical or cognitive autonomy and on how these caregivers learned stress management skills.

Theoretical framework and description of program

Theoretical Framework

The Online Stress Management Training Program is based on the transactional stress-coping model developed by Lazarus and Folkman (1984) widely used in the field of family caregiving (see Ducharme, 2006; Zarit & Femia, 2008). According to this model, the stress management process comprises two main elements: cognitive appraisal and coping. Stress occurs when a family caregiver cognitively assesses that a situation overwhelms his/her personal or social resources. In other words, cognitive appraisal is the assessment of how stressful or threatening a situation is with respect to well-being and quality of life. Coping represents a caregiver’s cognitive and behavioural efforts to deal with a situation appraised as stressful. These efforts can be aimed at resolving the problem, regulating emotions or both.

Coping strategies are effective if they “fit” the stressor type (Folkman et al., 1991). On the one hand, the use of emotion-focused strategies, such as avoidance or wishful thinking, can prove detrimental if they prevent caregivers from acting on elements of the problem that are amenable to change. On the other hand, the persistent use of problem-solving strategies in a situation not amenable to change or out of one’s control can exacerbate distress and exhaustion. In this case, using cognitive restructuring, that is, reframing the situation could produce positive results, including alleviation of stress and perception of physical and psychological well-being. Hence, an efficacious stress management intervention should afford a predominant role to the cognitive assessment of events in order to ensure a tight fit between the coping strategy to be used and the type of stressful event being confronted (amenable to change or not).

Description of Program

The aim of our Online Stress Management Training Program is to empower caregivers to manage daily stress associated with caregiving. It allows caregivers to work individually while having the opportunity to exchange with other caregivers online. The seven psycho-educational sessions proposed last 60 to 90 minutes each and take place once a week at the caregiver’s convenience. Each session comprises specific individual objectives and learning activities in the form of exercises that correspond to the principal steps of the stress management process. Healthcare professionals (including nurses) play the role of online coach. They help participants virtually to complete these activities and are available to answer questions three times a week during set time slots that caregivers know beforehand. The content of each session is presented in Table 1.

Table 1: Content of Program Sessions

SESSION 1: Becoming familiar with the steps of the stress management process.

SESSION 2: Gaining awareness of the situation and identifying its gratifying and difficult aspects.

SESSION 3: Analyzing the situation and choosing one problem (stressor) that the caregiver would like to change; formulating a concrete goal to attain.

SESSION 4: Analyzing the context of the situation (personal, family and environmental factors or elements that contribute to thoughts and stress); determining whether the chosen stressor is amenable to change or not.

SESSION 5: Gaining awareness of the importance of choosing a coping strategy that “fits” the stressor; choosing a suitable strategy and trying it out.

SESSION 6: Evaluating whether the goal initially set was attained.

SESSION 7: Summerizing the stress management process on the whole and answering caregiver questions about the program.

Method

Design and hypotheses

This study was carried out in the province of Quebec (Canada) with French-speaking family caregivers of physically or cognitively vulnerable elderly persons. The mixed research design included quantitative measures taken one week prior to the start of the program (pre-test) and one week after its completion (post-test). It also included qualitative data collected at post-test in order to describe caregiver learning of the different elements of the stress management process.

The hypotheses were theoretically driven, that is, the outcomes selected for evaluation were drawn from the theoretical model of stress and coping proposed by Lazarus and Folkman (1984). They were also closely tied to the objectives and content of the program, as recommended by Zarit and Femia (2008). The first four hypotheses concerned caregiver quality of life and the fifth and last regarded caregiver ability to use coping strategies. We expected that, after completing the online training program, caregivers would:

(H1) have a significantly higher perception of their self-efficacy in managing their everyday problems;

(H2) perceive significantly less stress related to their caregiver situation;

(H3) attain the goal they set at the start of the intervention;

(H4) perceive lower health risks; and

(H5) use coping strategies significantly more often to deal with their problems (problem-solving strategies, including help seeking, and reframing strategies).

Sample

Participants were family caregivers who registered for the program online at the http://www.aidant.ca website designed by a team of nursing science researchers of the Research Centre of the Institut universitaire de gériatrie de Montréal (IUGM), in collaboration with the IUGM Centre of Expertise on Elder and Caregiver Health. Intended for a French-speaking general public, the website has been online since the fall of 2007 offering information and resources to caregivers of seniors with impaired autonomy. For the purpose of the project, a window was added to the website with an invitation to caregivers to sign up for the stress management training program.

Participants were selected according to the following inclusion criteria:

a) caregiver (spouse or offspring) self-defined as the one principally responsible (primary caregiver) for a family member 65 years of age or over with impaired functional or cognitive autonomy;

b) at risk for health problems as evaluated using the five criteria proposed by Nolan, Grant, Caldock, and Keady (1994), i.e.: the complexity of the care provided, caregiver perception of personal state of health, caregiver perceived stress, and caregiver perception of support received from family, friends and from formal services (see measures);

c) French-speaking;

d) no support group or psychotherapy while taking part in program; and e) able to use the basic functions of a home computer (word processing, high-speed internet and email).

To determine caregiver eligibility, the study coordinator emailed caregivers who registered for the program to ask them to complete two questionnaires on a secure web page, namely, the questionnaire on health risks and a sociodemographic questionnaire to describe the characteristics of potential participants.

The first 26 caregivers who registered for the program and who met the inclusion criteria made up the study’s sample. Nine caregivers (35%) dropped out between pre- and post-test. Most of these were caregivers living with a cognitively impaired elderly relative. The main reasons for withdrawing were lack of time (probably due to the fact that persons with a cognitive impairment require continuous supervision), deteriorating health of relative, and inability to use computer functions essential to program participation.

The caregivers who participated at both times of the study were mostly women in their early 60s with an average of 15 years of schooling (Table 2). Mean age and mean number of years of schooling of the dropouts were similar. In terms of kinship tie, 15 of the 26 caregivers were the care recipient’s daughter. One third of the caregivers lived with their elderly relative and three looked after a relative placed in a long-term care residential facility for more than three months. Most of the caregivers had been using the internet for more than three years. The cared-for relatives were mainly women with a mean age of 84 years; 17 were cognitively impaired (Table 2)

Table 2
Sociodemographic Characteristics of Caregivers and Cared-for Relatives

Quantitative measurement

Self-efficacy

The 15-item Self-Efficacy Scale (Kuhn & Fulton, 2004) was used to measure caregiver confidence in dealing with the relative’s daily care (e.g., personal hygiene, medication intake, help with feeding). The choice of responses ranged from 1 (not at all confident) to 5 (extremely confident). Three items from the original scale were excluded as they did not apply to the caregivers in our study. The French-language version of this instrument was used in one previous study involving French-speaking caregivers, obtaining an alpha coefficient of .89 (Ducharme et al., in press).

Stress appraisal

The Stress Appraisal Measure (SAM; Peacock & Wong, 1990) served to assess the following seven dimensions through four items each:

☸ perceived threat relative to being the caregiver of a frail relative (e.g., how much does this situation threaten you?),

☸ perceived challenge (e.g., how much can this caregiver experience make you a stronger person?),

☸ centrality of stressful situation (e.g., does this situation exceed your ability to cope?),

☸ control by self (e.g., are you capable of overcoming this situation?),

☸ control by others, that is, use of informal/formal support (e.g., are there people or organizations that you could turn to for help if needed?),

☸ uncontrollability (e.g., are the consequences of this situation beyond the control of any caregiver?), and

☸ global stress relative to being a caregiver (e.g., does this situation place you under greater stress?).

The French-language version of this 5-point Likert-type scale (1 = not at all, 5 = absolutely) was rigorously validated (Pelchat, Ricard, Lévesque, Perreault, & Polomeno, 1994). The alpha coefficients obtained in the “In-Home Stress Management” study (Ducharme et al., 2006) varied from .70 to .88, except for uncontrollability, for which the alpha was low (.59).

Health risks

As mentioned earlier, Nolan et al. (1994) proposed five criteria to assess the health risk that caregivers might run. The score could vary from 5 (no risk) to 20 (very high risk). Here is one item from the scale:

Do you find the care and help that you provide to be:

simple (1),
a little complicated (2),
moderately complicated (3), or
very complicated (4)?

The original English-language version of the instrument was translated into French following the parallel back-translation method (Haccoun, 1987).

Goal attainment

The Goal Attainment Scale (Rockwood, 1995) was used to evaluate whether the goals initially set by the caregivers were met. The instrument is sensitive to change (Rockwood, Stolee, & Fox, 1993). Caregivers had to assign a relative importance to a selected stressor and define beforehand what would constitute a better or worse outcome than expected regarding perceived stress relative to a situation. Scores could range from -2 to +2 (0 = is the expected result; negative and positive scores constitute, respectively, worse and better results than expected).

Coping strategies

The 38-item Carers’ Assessment of Managing Index (CAMI; Nolan, Grant, & Keady, 1996) was used to assess frequency of utilization of three coping strategies (problem solving, reframing and stress management) when confronted with stressors related to the caregiving situation. The scale was developed on the basis of an inductive study involving 100 caregivers and validated on a sample of 266. We used the French-language version of the CAMI employed in the “In-Home Stress Management Program” study, where some items of the original CAMI were excluded as the alpha coefficients of the subscales proved low.

The problem-solving subscale used comprised nine items (e.g., thinking about the problem and finding a way to solve it; alpha = .72).

The reframing subscale comprised nine items (e.g., realizing that the person cared for is not to blame for his/her predicament; alpha = .70).

The stress management subscale comprised four items (e.g., setting a little free time aside for yourself; alpha = .63).

Respondents rated frequency of utilization of these coping strategies on a scale of 1 (never/almost never) to 4 (very often/always).

Qualitative measurement

Post-training semi-structured qualitative interview guide

A post-training semi-structured interview guide was developed by the researchers to examine caregiver perception of their learning of the stress management process, as well as the conditions facilitating and constraining learning.

Here are a few examples of questions:

“In your own words, can you explain what the stress management process consists in?”

“Which coping strategy did you try out?”

“What are your thoughts on using internet ?”

“What did you like most about the training?”

“What did you like least about the training?”

Procedure

The professional coaches (four nurses and one social worker) all had at least a Bachelor’s degree, as well as experience working with caregivers of elderly people. They received one day’s training on the stress management approach. Their role consisted in supervising the learning activities and exercises of the caregivers and responding to their queries during predetermined two-hour time slots three times a week. They also supervised exchanges among caregivers.

Given that the caregivers were not supposed to receive any other type of psychological support during the study period, an “SOS button” on the training website allowed caregivers in the event of an emergency to contact a member of the research team during normal work hours, that is, Monday to Friday, from 8:30 a.m. to 4:30 p.m. The availability of an SOS button on a website was indispensable in order to be able to support the caregivers in precarious or crisis situations and refer them rapidly to appropriate resources. The caregivers had to sign a study participation consent form sent to them by mail. The form was approved by the Research Centre’s Ethics Committee.

The standardized measures were taken at pre- and post-test via a secure web page. The qualitative data related to what was learned were collected at post-test in the course of a recorded 45-minute telephone call by an external interviewer trained by a member of the research team.

Data analyses

Descriptive statistics (means, standard deviations, percentages) were calculated first. Then, except for goal attainment, the hypotheses were tested using the Wilcoxon signed-rank test. This is a non-parametric test recommended in cases of repeated measurements on a single sample. The test involves comparing mean differences between measurements but does not require the assumption of a normal distribution. The hypothesis regarding level of goal attainment was tested by calculating the percentage of caregivers in each of the categories of the Goal Attainment Scale described above.

The qualitative interviews were transcribed and placed on electronic support to be coded according to the method proposed by Huberman and Miles (2003). This consists of identifying units of meaning by noting the statements in the transcription deemed significant with respect to the objectives pursued (caregiver perception of their learning of stress management, conditions facilitating and constraining training). The study coordinator developed a coding system based on the questions of the semi-structured qualitative interview, which was later used in the thematic content analysis of the data collected. A member of the research team later reviewed the coding and minor changes were made.

Results

Quality of life

As shown in Table 3, there were significant differences between mean scores at pre- and post-test (Table 3). More specifically, caregivers at post-test perceived themselves to be more self-efficacious in dealing with caregiving situations. They also perceived their caregiver role to be significantly less threatening and more challenging. They gained self-control over their situation and they reported lower health risks. All caregivers perceived that they had achieved the objective they had set at the start of the program, scoring higher than 0 on the Goal Attainment Scale.

Table 3
Comparison of Participants at Pre- and Post-Test on Outcome Variables: Results from the Wilcoxon Signed Rank Test

Other hypotheses concerning selected dimensions of the SAM were not supported. Indeed, the difference in mean scores did not prove significant for perceived centrality and uncontrollability of the situation. However, the results indicated a trend toward higher perceived control by others (i.e., use of informal/formal support) and lower perceived global stress after completing the training program, with the difference in scores being marginally significant (p of 0.06 and 0.07, respectively).

Learning abilities

Learning relative to coping strategies

The hypotheses concerning the acquisition of coping skills were not supported. There were no significant differences between pre- and post-test mean scores regarding use of the three coping strategies (Table 3).

Learning relative to stress management process

According to the vast majority of caregivers, the program taught them to reflect upon their caregiver situation, to pinpoint a stressor and to analyze it in order to gain a precise understanding of it. They learned also the importance of distinguishing the aspects of a stressor amenable to change or not in order to be able to choose a coping strategy that fits the situation.

The following are caregiver comments excerpted from the interview transcripts (numbers in parentheses are caregiver identification codes):

“I understood that the nature of the problem must be defined in order to resolve it through the use of a suitable strategy.” (015)

“In order to find a solution, you first have to define what the problem is. By pointing out and naming what exactly is stressing you, you can break the problem down and see better which approach to use.” (010)

“I learned to distinguish between events you can do something about and those you can’t, in which case it’s better to change how you look at the situation than to whine or suffer over it.” (026)

Although caregivers pointed out the relevance of the stress management process in dealing with their problems, some found that the process of reflection and the analysis were rather difficult elements that required time and that forced them to face up to their situation rather than ignore it:

“The only hard thing about it is taking the time to stop everything in order to go through the process.” (011)

“The stress management process isn’t easy; it’s hard stopping everything and asking yourself the right questions.” (012)

However, some caregivers mentioned that the process was transferable to other difficult situations:

“What’s nice is that you can apply the process to different situations. I’ve already begun to see what I can do to improve my situation at work with this method.” (010)

“The process is clear and rather easy to apply in different situations.” (021)

Where coping strategies are concerned, the most often used were those involving reframing, even though the notion of reframing was unknown to most of the participants.

“Reframing is what I used most. I tried to change my way of looking at things by asking myself whether I could replace the unhelpful thoughts that normally come to mind with helpful ones.” (010)

“For me, reframing was useful. Asking yourself whether you can actually change things about the situation, otherwise you have no choice but to change your perception of it. It’s a question of looking at the positive side of things.” (02)

“I liked reframing; it allowed me to seek out other ways of looking at the situation.” (031)

Learning about reframing allowed caregivers to attain their initial goal given that, in most cases, the goal had to do with improving their way of being with their relative at the emotional level. The following are some examples of the goals set by the caregivers:

“Feeling less annoyed with how my mother reacts or with what she says.” (009)

“Not to get mad or feel frustrated. Actually, not to take what my mother says personally.” (012)

As the goals to attain were of an emotional order, it was not surprising that the use of reframing allowed caregivers to change their way of being with their relative:

“I realized that what I expected from my husband was what I would expect from a normal adult. It just wasn’t realistic. That really helped.” (026)

“I was spending a lot of time looking for information on my father’s condition. The program had nothing to do with physical care but with being able to understand what’s going on with him and to accompany him better with what he’s going through.” (001)

“I realized that I wasn’t helping my mother, I was just controlling her.” (010)

To be sure, some caregivers found reframing rather difficult to apply given that it touched on emotions. Here is what these caregivers had to say in this regard:

“Reframing is the hardest method to use and master because it involves sentiment and emotion. However, I do think it’s super important to learn how to reframe things.” (024)

“I think that things just can’t be easy in a caregiver situation. There are affective ties with the persons we’re helping. It’s hard to be impartial and to look at things from another perspective.” (024)

Stress management strategies, like taking time out for oneself, were less often used. Moreover, caregivers seldom mentioned using problem-solving strategies.

Aspects of program most conducive to learning

Among the aspects of the program deemed most conducive to learning, all caregivers mentioned the importance of having regular exchanges with the coach, even though these took place in a virtual environment. More specifically, these exchanges guided the caregivers in their efforts to apply the stress management process and to complete the exercises, which appeared essential to facilitate learning.

The following are two commentaries that attest to the important role of the coaches:

“What gave me confidence was the coach when I submitted my exercises to her. She took the time to give me feedback, to encourage me, to highlight both my hits and my misses, like the lack of self-confidence that paralyzes me. I found that to be extremely helpful.” (009)

“The coach highlighted the key points and sized up my situation very well. And it was always positive. She directed me towards the next step in excellent fashion.” (020)

It was not surprising, then, that some caregivers mentioned that the program boosted their self-confidence.

“I realized that I had in me the wherewithal to understand and to adopt a positive attitude and to make helpful changes in the face of what I’m going through.” (031)

“This process, it’s a small step towards gaining self-confidence in my ability to deal with my new reality as a caregiver.” (019)

Other facilitating conditions mentioned by the caregivers included being able to access the program at their convenience and feeling at ease talking about their situation under the veil of anonymity provided by this modality:

“You follow the program when you want, when you’re ready to…, you don’t have to leave the house, to attend a group.” (021)

“I live in a small town where everyone knows everyone. In a group situation, it would be awkward. Instead, you’re home alone, no one to bother you, you’re not afraid someone might laugh at you, you’re not embarrassed.” (027)

Most constraining aspects of the program

The aspect of the program least appreciated by the participants had to do with too interaction among participants.

“If there’s one thing I might deplore, it’s the lack of interaction with the other participants.” (001)

This interaction was considered important by the participants to break their isolation and render their situation more normal to their eyes:

“Exchanges with others allow you to realize that you’re not alone. Just coming out with it makes you feel better.” (011)

“The other participants served as examples to me and having examples is important.” (010)

In sum, it emerged from the analysis of caregiver discourse that they learned the key elements of the stress management process, namely: reflecting upon and analyzing a situation deemed to be stressful and distinguishing aspects of the situation that are amenable to change from those that are not in order to choose appropriate coping strategies. For some caregivers, the process of reflection and analysis required by this process proved to be rather difficult but necessary in order to identify with precision the stressors that they would like to do something about.

At the qualitative level, reframing strategies were the ones most used by far and the ones that enabled caregivers to attain the goal that they had set at the start of the program, namely, improving their relationship with their relative. However, some caregivers stated that reframing strategies were hard to apply because they had to do with affective ties and the intangible aspects of care.

The role of the coaches appeared essential for caregivers to complete their learning. However, the caregivers deplored the little interaction among participants. Finally, the online modality was appreciated for its flexibility.

Discussion

The aim of our study was to evaluate the effects of a stress management training program offered online to family caregivers of an elderly relative with impaired physical or cognitive autonomy living at home. The effects considered concerned various indicators of caregiver quality of life as well as the learning of stress management skills. A mixed research design was used, with quantitative and qualitative data collected, which allowed for a triangulation approach to data analysis.

After completing the program, the participants perceived positive changes in their quality of life. They felt more efficacious in dealing with their caregiving situations, which is in line with findings reported in other studies that investigated ICT-based interventions (Beauchamp et al., 2005; Finkel et al., 2007; Magnusson, Hanson, & Nolan, 2005a; Lewis et al., 2010). Furthermore, caregivers were better able to control the situations related to their caregiver role and perceived these as less threatening and more challenging. Most of the caregivers attained the goal they had set initially relative to the stressor they chose at the start of the program. In addition, they were less at risk for health problems. A trend also emerged suggesting that caregivers increased their use of social support and experienced less stress. A larger sample might have produced significant effects with respect to these two variables. Indeed, the studies by Beauchamp et al. (2005) and Williams et al. (2010) carried out with a large number of caregivers revealed a significant decline in stress level.

With regard to learning abilities, the qualitative data showed that caregivers learned the key elements of the stress management process. It seems reasonable to think that this learning helped to explain the positive effects of the program on several indicators of caregiver quality of life. Indeed, caregivers learned to reflect upon their situation, to select one particular stressor considered stressful, and to analyze this stressor with precision. Descriptive studies have shown that caregivers usually express their situations in a general, vague and imprecise manner and consequently feel helpless to deal with the situation (Lévesque & Gendron, 2003). In contrast, by attending the program, caregivers learned that a poorly defined situation was difficult to manage whereas a precise analysis allowed them to connect the stress they experienced to specific events. In doing so, caregivers were able to choose an appropriate coping strategy and, hence, to feel more efficacious in dealing with the daily care of their relative and more in control of their caregiving situations.

However, there was no significant change in the use of the three coping strategies, although the measure employed (CAMI) might not have been sufficiently sensitive to this. The fact remains, though, that few caregivers resorted to coping strategies involving problem solving or stress management. Data triangulation did shed light, though, on caregiver understanding and frequent use of reframing strategies. In this regard, after the program, caregiver comments attest to the ability to change perspective when a stressor is not amenable to change. Caregivers were aware of the fact that some ways of thinking about a stressful situation could breed painful thoughts. This new-found awareness led them to recognize the importance of identifying and altering dysfunctional thoughts and replacing them with more helpful ones. In other words, they realized that dysfunctional thoughts were detrimental to their quality of life. The fact that caregivers perceived their caregiver role as less threatening and more challenging was also a concrete example that they managed to change their point of view by applying reframing strategies.

Our program targets a process recognized in the caregiving literature to be effective in promoting caregiver well-being. The individual approach used has the merit of tailoring the program to each caregiver’s specific concerns. Personalization of intervention has been recognized as essential, according to a systematic review of the litarature on interventions delivered on the web (Lustria, Cortese, Noar, & Glueckauf, 2009). The presence of coaches and their experience appear to be essential factors in the success of this type of program offered in a virtual environment. In particular, the alertness of coaches in recognizing the elements of the stress management process in what caregivers say in order to provide feedback and praise their efforts in applying the method in their daily life is an essential condition to facilitate learning. Overall, the program may have afforded caregivers a sense of empowerment over their caregiving experience through a greater awareness of their capacity to change their perception and to attain their goal.

However, this study is not without limitations. These include, in particular, a small sample size and the fact that caregivers were compared against themselves before and after the program rather than against a control group. However, some of our results are similar to those obtained in a quasi-experimental study of the efficacy of the program offered as an in-home intervention (Ducharme et al., 2006). Another limitation regards the fact that the caregivers who took part in the study were highly educated. In this regard, Smith et al. (2007) found a higher education level to be associated with perceived greater ease of use. Therefore, it may be that our online program is suitable only for a specific subgroup of highly educated caregivers. Age does not seem to be a factor, however, as the data show that caregivers who dropped out had a mean age similar to those who stuck with the program. In this connection, Hanson and Clarke (2000) reported that older caregivers were able to use ICT effectively. A randomized control trial would yield further evidence of the program’s benefits.

Despite these limitations, our study yielded encouraging evidence that an online training program with professional coaching and exchange among the caregiver participants has the potential to enhance certain dimensions of the quality of life of family caregivers and to facilitate learning stress management. Both quantitative and qualitative data support the relevance of offering this type of intervention through new technologies. Moreover, the results show that our program can support not only family caregivers of persons with dementia but also family caregivers of persons with a physical impairment. This online program appears particularly suited for caregivers who cannot attend support groups or counseling at a fixed time and place. It appeals also to caregivers who do not appreciate traditional support groups as they are uncomfortable revealing their problems face to face with other caregivers. Be it for caregivers of an elderly person living at home or in a long-term care facility, this stress management program seems transferable to different contexts of caregiver life. Finally, an online intervention reduces travel by nurses and allows a flexible organization of work, especially with scheduling of the coaching sessions offered caregivers.

In conclusion, at a time when the Internet is becoming more and more a part of daily life, this program can serve as a guide for nurses and other healthcare professionals to support caregivers through ICT. Indeed, nurses can virtually help caregivers to appropriate the stress management process that they can then transfer to other difficult situations experienced in their daily life with their elderly relative and to feel empowered. Presently, the lack of access to this modality constitutes a major barrier to promoting the quality of life of caregivers who cannot or do not want to participate in more conventional programs such a support groups. Our program should be considered as a complementary approach to regular community services.

We recommend that nurses implement this program at the onset of the caregiver role in order to help caregivers learn as soon as possible how to deal with the demands of caregiving and to promote their health. In this regard, one key finding from the ACTION (Assisting Carers Using Telematics Interventions to meet Older persons’ Needs) project implemented in Sweden by a research team in nursing was that “optimal benefit from ACTION occurs when the service support is introduced as early as possible within the caring process” (Magnusson & Hanson, 2005b, p. 647).

In recent years, more and more nurses have deplored the fact that there were still too many caregivers being considered solely as resources for maintaining elderly persons with impaired autonomy at home (see Ducharme, 2006). The time has come to consider them as potential clients of healthcare services with needs of their own from the start of the caregiver trajectory rather than waiting for them to be in a crisis situation or burnt out. A pro-active nursing approach, that is, one that offers early intervention at the outset of the care trajectory may help to prevent or at least diminish the risk that the demands of caregiving will affect caregiver quality of life in the long run. Health promotion is one of the values of the discipline of nursing and the implementation of interventions consistent with this is an integral part of the role of nurses. We hope that this study can be a source of inspiration for others to enrich nursing’s contribution to the application of ICT in both research and practice with a growing at-risk clientele of our healthcare system.

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Authors’ notes

The study was funded by the Fondation de l’Institut universitaire de gériatrie de Montréal, Desjardins Sécurité Financière and the Social Sciences and Humanities Research Council of Canada.

The authors wish to thank the professional coaches who participated in this study, namely, Marie Bertrand, Josette Gaudet, Annie Dugas and Denise Trudeau, as well as the electronic information managers of the IUGM Centre of Expertise on Elder and Caregiver Health.

Authors’ Biographies

Francine Ducharme, PhD (nursing)

is a member of the Canadian Academy of Health Sciences. She is a nursing professor at Université de Montréal and holder of the Desjardins Research Chair in Nursing Care for Seniors and Their Families. Her research focuses on the development and evaluation of support programs for family caregivers of elderly persons.

Véronique Dubé, MSc

is a clinical nurse specialist in gerontological nursing and a doctoral candidate in nursing at Université de Montréal. She is also a research coordinator at the IUGM Research Centre

Louise Lévesque, MSc

is Professor Emeritus in Nursing at Université de Montréal and Researcher Emeritus at the IUGM Research Centre. Her research explores the factors associated with the health of family caregivers of elderly persons.

Diane Saulnier, MSc

is the coordinator of two nursing research chairs at the Faculty of Nursing of Université de Montréal, including the Desjardins Research Chair in Nursing Care for Seniors and Their Families. She has held positions in the fields of research, management and teaching for many years.

Francine Giroux, MSc

is a statistician at the IUGM Research Centre.

EDITOR: June Kaminski

CITATION

Ducharme, F., Dube, V., Lévesque, L., Saulnier, D. & Giroux, F. (Spring, 2011). An Online Stress Management Training Program as a Supportive Nursing Intervention for Family Caregivers of an Elderly Person . Canadian Nursing Informatics Journal, 6(2). http://cjni.net/journal/?p=1344


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