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Effect of Support Group Intervention Applied to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes ■ Canan Demir Barutcu, PhD, RN ■ Hatice Mert, PhD, RN

This study was conducted to evaluate the effectiveness of support group intervention applied to the caregivers of individuals with heart failure on caregiver outcomes. Quasi-experimental research was conducted with 69 caregivers as control (n = 35) and intervention (n = 34) groups in the cardiology outpatient clinic of a university hospital. The intervention group participated in support group meetings structured according to the Neuman Systems Model, and the data were collected from both the intervention and control groups before the intervention and 3 and 6 months later. Caregivers in the intervention group had significantly lower burden scores compared with the control group in all subdimensions except objective personal care, in terms of the group × time interaction in a statistical way (P < .05). Caregivers in the intervention and control groups had similar scores of depression symptoms (P > .05). The burden of caregivers in the intervention group showed a statistically significant decrease compared with the preintervention in all dimensions at 3 months. Thus, it is suggested to extend the support group interventions for caregivers of patients with heart failure and conduct these interventions in a longer period. KEY WORDS: caregiver, heart failure, Neuman Systems Model, support group Holist Nurs Pract 2016;30(5):272–282

Heart failure is a frequent health problem whose incidence rate increases each year with high mortality and morbidity rates.1 It was reported that there were more than 5.8 million patients with heart failure in the United States, and 825 000 new cases, who were 65 years and older, are added to this number each year.2 It was also reported that there were more than 15 million patients with heart failure in Europe.3,4 Heart Failure Prevalence and Predictors in Turkey (HAPPY) study showed that the estimated prevalence of heart failure is 6.9% in Turkey.5

Heart failure is a disease that leads to low quality of life because of the patient’s failure to meet basic needs, change in body image, lack of self-care behaviors and activities of daily living, chronic

Author Affiliation: Department of Internal Medicine Nursing, Faculty of Nursing, Dokuz Eylül University, İzmir, Turkey.

The authors thank all the caregivers who participated in this study.

The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.

Correspondence: Canan Demir Barutcu, PhD, RN, Department of Inter- nal Medicine Nursing, Faculty of Nursing, Dokuz Eylül University, 35340 Inciraltı, Izmir, Turkey ([email protected]; canan.demir@deu .edu.tr).

DOI: 10.1097/HNP.0000000000000164

fatigue, sexual dysfunction, and concerns about the future. 6,7 As the stages of the disease progress, the patients require the help of others to meet their basic needs, with most of the care being provided by family members. Because heart failure requires a long period of treatment after the diagnosis, this affects not only patients but also caregiver families physically, psychologically, socially, spiritually and also causes an economic burden along with intense stress.8-12

Frequent hospitalization of patients with heart failure because of the effects of their intensifying symptoms, their cognitive deficiency, medication regimens, and implanted devices can all cause an increase in the stress levels and overall burden on caregivers, causing them to experience depressive symptoms and the impairment of their emotional and physical health.11

Although the importance of support in patients with heart failure is emphasized, physical, psychological, social, and economic burdens emerging on caregivers who provide support are ignored.8,11,13-15

In previous studies, it has been indicated that caregivers of patients with heart failure experienced social isolation and depressive symptoms and were unable to receive professional support and training even though they needed it desperately during this

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mailto:canan.demir@deuglobal advance �reakcnt @ne penalty -@M .edu.tr

Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 273

process.13,16-18 It has been indicated that caregivers’ increased knowledge about heart failure and care contributed to patients’ lifestyle change, decision making, self-care, compliance to medication, and communication with health care professionals. In addition, it was found that caregivers believe in themselves more, their worries decrease, and they support people whose care they are responsible for; this increases the life quality of the patient with heart failure.9,10,12,14,18-21 It has been found that the number of interventional studies performed on caregivers of heart failure patients was very low among international studies in the literature, and no studies could be found in Turkey on this subject. Although social support is very important for patients with heart failure, training and supporting caregivers providing support for patients is very important in terms of health care outcomes. This study was planned on the basis of this finding.

AIM

The objectives of this study were to examine the effects of the support group intervention

� on caregiver burden and � on depressive symptoms of caregivers of

individuals with heart failure.

CONCEPTUAL, THEORETICAL, AND EXPERIMENTAL STRUCTURE OF THE RESEARCH

One of the important groups expecting care service from nurses are caregivers. Nursing care services include the assessment, planning and implementation of the interventions necessary for the protection and maintenance of health for all dimensions of an individual’s life (physiological, psychological, socio-cultural, developmental, and spiritual).22,23 In this regard, the Neuman Systems Model (NSM) provides a system-based and detailed conceptual framework as it looks at human beings with a multidimensional system understanding.

Variables used in this study were associated with the concepts and variables of the NSM. The core responses to study the caregiver burden were assessed with the Dutch Objective Burden Inventory (DOBI). Those who received at least 1.5 points or above from at least 1 subdimension of the DOBI were included in the study. Support group meetings were arranged for

caregivers to enhance resilience and reduce the care burden. This is called secondary prevention in the NSM. The characteristic of secondary prevention is that it is applied after a reaction against stress occurs; the aim is to support the individual and reduce the reaction level after the formation of stress. Guiding the support group members in using the communication techniques by regarding the problems transmitted into the group as opportunities and helping them solve the current problem using the problem-solving techniques are examples of secondary prevention.

The conceptual-theoretical-empirical structure of the study’s intervention can be seen in Figure 1.

METHODS

Design

The study adopted a quasi-experimental design.

Sample

The research was carried out in the cardiology polyclinic of a university hospital between March 2013 and January 2015. The sample consists of the caregivers of patients admitted to the university hospital because of heart failure. The inclusion criteria for caregivers were a person who provided care to a patient with heart failure identified as the primary helper with their daily activities, voluntarily accepted participation in the research, lived with the patient, was literate in Turkish, had no hearing or speaking impairment, and was 18 years and older. Because there is not a cut-off of the care burden scale and each subdimension score varies between 1 and 3, those who received at least 1.5 points or above from at least 1 subdimension of the scale were included in the sample; secondary prevention interventions were applied according to the NSM. Factors that disqualified caregivers from sampling were their diagnosis with any psychiatric disease and their care being provided to patients at a price. The aim for participants was to come to at least 3 meetings, and those who failed to complete the 3 meetings were excluded from the sample. The distribution of the research sample by intervention and control groups is shown in Figure 2.

Data collection process

The data collection process started with the control group data; after completing the control group data,

274 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2016

FIGURE 1. Conceptual-theoretical-empirical structure.

support group meetings started and the intervention group data were collected. The first data collected from the control group and the data collected in the intervention group before the first support group meeting constituted baseline data. Control group data were collected in 3 parts: (1) baseline, (2) first follow-up (3 months later), and (3) second follow-up (6 months later after baseline). Intervention group data were collected in 3 parts: (1) before the meeting (baseline data), (2) first follow-up (3 months after the intervention), and (3) second follow-up (6 months after the intervention). In the baseline stage, data were obtained using the caregivers’ demographic and care-related characteristics from the DOBI and Beck Depression Inventory (BDI), and in the first follow-up and second follow-up, data were obtained using the DOBI and BDI, in both the control and the intervention groups.

Intervention

Caregivers sat in a circle thus enabling face-to-face communication in group meetings, and the temperature, light, and air-conditioning of the environment were set appropriately. The participants were offered food and drink before the support group interaction while waiting for all participants to come and to ensure social interaction. The meetings were started with 42 caregivers in the intervention group, and the meetings were completed with 34 caregivers. The groups consisted of 6 to 12 people with 4 groups in total. Four support group meetings were held with

each group. The support group meetings were held once a week (90-120 minutes) in accordance with the request of the caregivers. The researcher conducted the meetings. Six questions, which are used to collect data in NSM, were used in meetings: What do you think your greatest problem is in terms of level of difficulty? How did your current situation affect your accustomed life style? Have you ever experienced a similar problem? If you have experienced, what was the problem and how did you deal with it? What do you think about your situation in the future considering your current situation? What can or do you do to help yourself? What do you want your family, friends, or others to do for you? Along with these questions, experience on exchange was made with questions asked by caregivers and researchers relating to the process and group members proposed solutions and provided support to each other for problems experienced.

Instruments

Demographic and care-related characteristics This form is composed of 10 questions regarding

caregivers’ sociodemographic characteristics: age, gender, marital status, educational status, employment, social insurance, economic condition, relationship to the patient, presence of a chronic disease, and care giving period.

Dutch Objective Burden Inventory The DOBI was developed by Luttik et al15 and it

measures objective and subjective burden in caregivers

Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 275

FIGURE 2. Study plan and data collection process.

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for patients with heart failure. The scale is composed of 38 items in total. It has 4 subscales including personal care (11 items), practical-related support (11 items), motivational support (10 items), and emotional support (6 items). Each item represents a specific caregiving task. Using a 3-point Likert scale format, caregivers were asked to rate both the frequency and perceived burden for each caregiving task. If a caregiver did not perform a specific task, no response was required for the subjective component of that specific item. Frequency responses represent objective burden and perceived burden scores represent subjective burden. Higher scores represent higher levels of caregiver burden. Mean objective and subjective burden scores are reported for each domain. Total scores for all components range from 1 to 3. Total scores for each component were computed by adding the items values in each component and then dividing them by the number of items in that component. The internal consistency of the components was calculated using the Cronbach α. The components of DOBI’s objective burden displayed α scores from 0.81 to 0.84.15 Unlike the initial DOBI validation study, the validity and reliability study in Turkey recruited both spousal and nonspousal caregivers on the version of the DOBI tested in this study. In the scale, practical support (second component) has an 8-item (15-22) factor load, lower than 0.30; for that reason these items are removed from the scale because they are not appropriate to the Turkish culture and health care systems. Validity and reliability of the forms used in the study included over 30 items, and the Cronbach α coefficient of the scale was found to be within reliable limits (minimum = 0.96 and maximum = 0.99).24

Beck Depression Inventory Beck Depression Inventory (BDI)-I is a 21-question

multiple-choice self-report inventory, with each answer being scored on a scale of 0 to 3 points. Higher total scores indicate more severe depressive symptoms. Participants choose 1 of the 4 statements describing how they felt over the past 2 weeks. The cut-off scores used are none to minimal depression, <10; mild to moderate depression, 10 to 18; moderate to severe depression, 19 to 29; and severe depression, 30 to 63.25 The BDI-I was validated in a clinical sample of 259 participants and has acceptable reliability (coefficient α = 0.80) and validity.26

Data analysis

Analysis was conducted using descriptive statistics in the Statistical Package for the Social Services SPSS 15.0 (SPSS Inc, Chicago, Illinois). χ 2 and t tests were used to determine differences between groups. To determine the effectiveness of the intervention, 2-factor repeated-measures analysis of variance and paired t test with Bonferroni correction were used when appropriate. In the statistical analysis, the burden and depression level scores for the caregivers were compared with respect to time, group and group × time interaction. Ethical considerations

Written permission from the Dokuz Eylül University Ethical Committee (246-GOA2011/22-19-30.06.2011) and the Dokuz Eylül University Hospital (334/25.05.2011) was also obtained. The objective of the research was explained to the participants and written permission was received from those agreeing to participate.

FINDINGS

Sociodemographic characteristics

With the exception of marital and employment status, the sociodemographic features of the caregivers in the intervention and control groups were found to be similar (Table 1). Whether marital and employment status affect the scale score averages was assessed using covariance analysis. It has been found that marital status does not significantly affect the variables (P > .05), whereas employment status significantly affects the variables (P < .05). The variance analysis in repeated measurements was performed by taking the employment and marital status variables under control. Initial score averages for the caregiver burden subdimension and depression symptoms of the caregivers in the control and intervention groups were similar (P > .05).

Effects of support group intervention on burden

Except for the objective personal care subdimension, a statistically significant difference in the third and sixth months in the care burden score for the caregivers in the intervention and control groups in all subdimensions was found. It was determined that the

Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 277

TABLE 1. Demographic and Clinical Characteristics of the Caregivers in the Intervention and Control Groups at Baseline

Demographic and Clinical Characteristics Control (n = 35)

Mean ± SD Intervention (n = 34)

Mean ± SD

Age, y 57.00 ± 10.71 52.38 ± 12.67 t = 1.636 P = .107 Care-giving period, y 8.25 ± 7.98 7.02 ± 5.70 t = 0.733 P = .466

n (%) n (%) Gender

Female 28 (80.0) 23 (67.6) χ 2 = 0.79a Male 7 (20.0) 11 (32.4) P = .371

Marital status Married 35 (100) 23 (67.6) χ 2 = 11.16a Single 0 (0) 11 (32.4) P = .001

Educational level Primary 17 (48.6) 9 (26.5) χ 2 = 2.70a High school and more 18 (51.4) 25 (73.5) P = .100

Employment Employee 4 (11.4) 15 (44.1) χ 2 = 13.53a Retired 10 (28.6) 12 (35.4) P = .001 Unemployed 21 (60.0) 7 (20.6)

Social insurance Have 35 (100) 32 (94.1) P = .239b Have not 0 (0) 2 (5.9)

Economic status Income > expense 2 (5.7) 4 (11.8) χ 2 = 1.96 Income = expense 22 (62.9) 16 (47.1) P = .375 Income < expense 11 (31.4) 14 (41.2)

His/her relationship to patient Spouse 17 (48.6) 12 (35.3) χ 2 = 5.39 Adult child 13 (37.1) 21 (61.8) P = .067 Others (relatives, friend, etc.) 5 (14.3) 1 (2.9)

Chronic disease Have 14 (40.0) 17 (50.0) χ 2 = 0.35a Have not 21 (60.0) 17 (50.0) P = .553

Abbreviation: SD, standard deviation. aYates correction was made because the number is under 25. bCorrected Fisher χ 2 was used for that number expected under 5.

burden scores of the caregivers in the intervention group in the third and sixth months were lower than in the control group (Table 2). A significant difference was found in the intervention group in all subdimensions except for objective personal care subdimension in terms of the group × time interaction (baseline, third, and sixth months) (Table 2). The burden score averages of the caregivers in the third and sixth months in the intervention group were found to be lower than the baseline score averages.

Except for the subjective personal care subdimension, a statistically significant difference in the third and sixth months in the care burden score for the caregivers in the intervention and control groups in all subdimensions was found. The burden scores of caregivers in the intervention group in the third and

sixth months were lower compared with the control group. In terms of the group ×time interaction, a significant difference was found for the intervention group in all subdimensions except for subjective personal care subdimension (baseline, third, and sixth months) (Table 3). The burden score averages of the caregivers in the intervention group in the third and sixth months were found to be lower than baseline score averages.

Effects of support group intervention on depression

No statistically significant difference in the third and sixth months was found between the depression score averages for the caregivers in the intervention and

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TABLE 2. Means and Standard Deviations for DOBI Objective Subscales by Group × Time Interaction Effects

Group × Time Interaction EffectsBaseline Mean ± SD

3 mo postintervention

Mean ± SD

6 mo postintervention

Mean ± SD Fa P

Personal care Intervention group 1.87 ± 0.63 1.64 ± 0.38 1.74 ± 0.44 Control group 1.93 ± 0.73 1.90 ± 0.72 1.95 ± 0.74 1.731 .181

t 0.366 −1.882 1.407 P .715 .065 .165

Practical support Intervention group 1.89 ± 0.46 1.82 ± 0.40 1.86 ± 0.43 Control group 2.20 ± 0.37 2.16 ± 0.16 2.22 ± 0.22 9.441 .000b

t −1.141 3.631 3.129 P .259 .001b .003b

Motivational support Intervention group 2.46 ± 0.56 2.03 ± 0.36 2.05 ± 0.36 Control group 2.62 ± 0.29 2.70 ± 0.17 2.68 ± 0.18 24.871 .000b

t 1.496 9.641 8.942 P .141 .000b .000b

Emotional support Intervention group 2.70 ± 0.46 2.15 ± 0.36 2.23 ± 0.34 Control group 2.82 ± 0.60 2.77 ± 0.15 2.80 ± 0.07 10.731 .000b

t 0.943 9.222 9.469 P .349 .000b .000b

Abbreviation: SD, standard deviation. aRepeated-measures ANOVA with 2 between-group factor. bP < .05.

control groups (pretest t = −1.152, P = .253; posttest 1 t = −0.168, P = .867; posttest 2 t = −0.616, P = .540) (Table 4). A significant difference was found between the depression score averages in time in the intervention group in terms of the group × time intervention. As a result of further analysis, a statistically significant difference was determined between pretest and posttest 1 (t = 3.238, P = .003) and posttest and posttest 2 (t = −4.480, P = .000); no statistically significant difference was determined between pretest and posttest 2 (t = 2.183, P = .036).

DISCUSSION

Effects of support group intervention on burden

When the caregiver burden is assessed in all subdimensions, it was found that caregivers in the intervention group felt burden in terms of objective and subjective burden dimensions mostly in emotional, motivational, practical, and personal care support dimensions, respectively. Evaluating average scores after support group interventions, the most significant were obtained in dimensions in which

caregivers felt the highest level of burden (ie, support group interventions affected emotional, motivational, practical, and personal care support averages). It is believed that the support group interventions conducted were quite effective in decreasing caregiver burden. Three studies were encountered in the literature assessing caregiver burden using the DOBI. The first study was carried out by Luttik et al,15 who developed the scale, and only the objective section was studied; the authors found that caregiver burden is highest in the practical dimension, then the emotional, motivational, and lastly in the personal care dimension. In another study, in which validity and reliability of the scale was investigated for Canadian society, Makdessi et al27 evaluated caregiver burden solely in the objective dimension and found that caregiver burden was at its highest in the emotional dimension followed by practical, motivational, and personal care dimensions, respectively. In this sense, our findings are parallel with the results obtained by Makdessi et al27 in that the highest level of burden was found in the emotional dimension and the lowest level of burden was found in the personal care dimension. Other than these 2 studies, Hwang et al3 evaluated

Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 279

TABLE 3. Means and Standard Deviations for DOBI Subjective Subscales by Group × Time Interaction Effects

Group × Time Interaction EffectsBaseline Mean ± SD

3 mo postintervention

Mean ± SD

6 mo postintervention

Mean ± SD Fa P

Personal care Intervention group 1.81 ± 0.62 1.61 ± 0.36 1.65 ± 0.38 Control group 1.84 ± 0.72 1.85 ± 0.70 1.86 ± 0.70 10.351 .000b

t 0.193 1.747 1.549 P .848 .087 .127

Practical support Intervention group 2.34 ± 0.63 1.91 ± 0.36 1.98 ± 0.40 Control group 2.09 ± 0.58 2.08 ± 0.53 2.13 ± 0.53 0.042 .959

t 1.595 2.300 2.310 P .115 .025b .024b

Motivational support Intervention group 2.12 ± 0.52 1.87 ± 0.29 1.90 ± 0.31 Control group 2.22 ± 0.48 2.23 ± 0.48 2.24 ± 0.47 3.506 .033b

t 0.793 3.722 3.569 P .431 .000b .001b

Emotional support Intervention group 2.62 ± 0.58 2.10 ± 0.45 2.17 ± 0.45 Control group 2.73 ± 0.48 2.67 ± 0.47 2.70 ± 0.50 19.070 .000b

t 0.855 5.089 4.632 P .396 .000b .000b

Abbreviation: SD, standard deviation. aRepeated-measures ANOVA with 2 between-group factor. bP < .05.

caregiver burden only in the objective dimension using the inventory descriptively and found that 41% of caregivers provided support for patients in the emotional dimension and 40% of caregivers provided support for patients in the personal care dimension.

In the third and sixth months, burden of caregivers was lower than preintervention. The burden of caregivers on the sixth month has been found slightly higher than on the third month, however, lower than

preintervention. This situation shows that the intervention is more effective in a short time. In a study carried out by Garlo et al.28 with the caregivers of heart failure patients, it was found that the burden of the caregivers gradually increases in time throughout the 12-month monitoring period. Our results support this idea that the burden gradually increases. In the study carried out by Etemadifar et al,29 in which they examine the effect of the support

TABLE 4. Means and Standard Deviations for Beck Depression Inventory by Group × Time Interaction Effects

Group × Time Interaction Effect Beck Depression Inventory

Baseline Mean ± SD

3 mo postintervention

Mean ± SD

6 mo postintervention

Mean ± SD Fa P

Intervention group 15.58 ± 10.24 12.79 ± 6.26 13.67 ± 6.40 Control group 13.02 ± 8.12 12.51 ± 7.50 12.62 ± 7.64 6.208 .003b

t −1.152 −0.168 −0.616 P .253 .867 .540

Abbreviation: SD, standard deviation. a Repeated-measures ANOVA with 2 between-group factor. bP < .05.

280 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2016

group training interventions on the burden of the caregivers of patients with heart failure, the burden of the caregivers in the intervention group decreased significantly in the first year when compared with preintervention; in addition, it was found that the caregiver burden score averages increased 3 months later. Again, this idea that caregiver burden increases in time was in parallel with the results of our study; that the burden decreases and even remains stable as a result of our interventions shows the effectiveness of the intervention made. In the literature, the support groups studies structured by the NSM were carried out with caregivers of patients with dementia30 and parents of disabled children.31 However, an NSM- based support group study conducted with caregivers of patients with heart failure could not be found. In this sense, our study shows the effectiveness of NSM-based support group interventions on reducing caregiver burden, and therefore it is one of the limited numbers of studies in the heart failure literature, and because it is the first support group intervention study conducted using the model, it is believed that it can fill the gap in the literature.

In this study, we attempted to reduce the care burden, which is accepted as the main response in this model. The intervention for the secondary prevention defined by Neuman was applied as the caregivers receiving a score of 1.5 points and above from the caregiver scale and was included in the study. Because it was thought that the flexible defense line in the NSM was broken due to caregiving stress and the normal prevention line was activated due to caregiving responsibility’s being a big stressor, interventions were performed with the aim of enhancing the resistance lines. The caregivers shared the physical, psychological, social, developmental, and spiritual stressors they experienced in this process in the support group meetings, and it was ensured that group members supported each other by making solution suggestions. That there is a decrease in the caregiver burden after the intervention confirms the proposition of Neuman that the main response can be reduced through secondary prevention. The caregivers frequently expressed their well-being emotion verbally after the support group meetings. It was expressed that the caregivers do not feel alone, feel stronger physically and psychologically, could cope with problems more easily, and the stress they experience was reduced after the meetings; however, these variables were not assessed in our study.

Effects of support group intervention on depression

A significant difference was detected between depression symptom scores of the intervention and control group caregivers in terms of the group × time interaction. The depression signs significantly decreased in the third month in the intervention group when compared with preintervention. As for the control group, the signs of depression scores of the caregivers increased and there was no statistically significant difference between the initial, third, and sixth month score averages.

Depression levels of the caregivers differ in the descriptive studies compared with caregivers of patients with heart failure in the literature. Moreover, the depression sign scores of heart failure caregivers are quite high in some studies,11,32 whereas the depression sign scores of the caregivers are low17,33-36

in others. The results of the studies examining the effects of the interventions on caregivers of patients with heart failure on depression signs are contradictory. According to the training intervention results by Schwarz et al37 on the caregivers of heart failure patients, it was found that the depressive symptoms of the caregivers did not decrease. In the study carried out by Dunbar et al,38 no difference between the intervention and control groups in terms of the depression sign scores for caregivers resulted from the training and support intervention. Likewise, in the support group intervention study conducted with caregivers of patients with heart failure by Cockayne et al,39 it has been found that the depression level of the caregivers does not decrease. Nonetheless, Jaarsma et al40 found that the interventions decreased the depressive symptoms of the caregivers in a study examining the depression levels in caregivers of patients with heart failure. It was found in our study that there was a significant decrease in intervention group caregivers’ depression symptoms in the third month. It is thought that the fact that caregivers shared the stressors in the psychological dimension they experienced in the support group meetings, which is 1 of the 5 variables of the NSM, and that group members offered solutions and provided support for each other was effective in reducing depression symptoms. However, considering average depression scores, a slight increase was observed in the intervention group in the sixth month compared with the third month. That depression is affected by many situational factors in the daily life process and thus the

Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 281

improvement can be difficult are considered the reason for this situation. The fact that an improvement was seen in depression, or even that it remained at the same level, could be interpreted as the interventions being clinically effective because depression is a concept that is influenced by a large number of factors and usually worsens through the caregiving process.

STUDY LIMITATIONS AND FUTURE RECOMMENDATIONS

The extension of support group studies aimed at heart failure patient caregivers and the qualitative evaluation of results is advised. Furthermore, support group interventions can be executed in a longer period, and in- terventions for the primary prevention level of the NSM model can be planned and tested with the participation of all caregivers in support group meetings.

Although the depression sign scores of the caregivers in the intervention group and the caregivers in the control group were found to be similar, the depression sign scores of the caregivers in the intervention group decreased significantly through the follow-up process. However, because the purpose of this study was to reduce depression levels of caregivers, it is thought that the duration of the study might have been too short to create the intended effect on depression, a condition that is slow to respond to intervention, and therefore studies with interventions carried out for longer periods are needed.

CONCLUSION

A statistically significant difference in the care burden scores of the caregivers in the intervention and control groups in all subdimensions except for objective and subjective personnel care subdimension was found. In terms of the group × time interaction, a statistically significant difference was found in time in the intervention group in all subdimensions except for the objective personnel care and subjective practical care subdimensions. The burden score averages of the caregivers in the intervention group were found to be lower than the baseline score averages.

REFERENCES

1. Jessup M, Abraham W, Casey DE, et al. Focused Update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: A report of the American College of Cardiology Foundation/American

Heart Association task force on practice guidelines developed in collab- oration with the international society for heart and lung transplantation. J Am Coll Cardiol. 2009;53(15):1347-1369.

2. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics. 2014 update: a report from the American Heart Association. Circulation. 2014;129(3):280-292.

3. Hwang B, Luttik ML, Dracup K, Jaarsma T. Family caregiving for pa- tients with heart failure: Types of care provided and gender differences. J Card Fail. 2010;16:398-403.

4. Clark AM, Savard LA, Spaling MA, Heath S, Duncan AS, Spiers JA. Understanding help-seeking decisions in people with heart failure: a qualitative systematic review. Int J Nurs Stud. 2012;49:1582-1597.

5. Değertekin M, Erol Ç, Ergene O, et al. Türkiyedeki kalp yetersi- zliği prevalansı ve öngördürücüleri: Happy Çalışması. Türk Kardiyoloji Derneği Arşivi. 2012;40(4):298-308.

6. Johansson P, Agnebrink M, Dahlström U, Broström A. Measurement of health-related quality of life in chronic heart failure, from a nursing perspective-a review of the literature. Eur J Cardiovasc Nurs. 2004;3: 7-20.

7. Bekelman DB, Havranek EP, Becker DM, et al. Symptoms, depres- sion, and quality of life in patients with heart failure. J Card Fail. 2007;13(8):643-648.

8. Molloy GJ, Johnston DW, Witham MD. Family caregiving and con- gestive heart failure: review and analysis. European J Heart Fail. 2005;7(4):592-603.

9. Luttik ML, Jaarsma T, Veeger N, et al. Caregiver burden in partners of heart failure patients: limited influence of disease severity. Eur J Heart Fail. 2007;9(6):695-701.

10. Dunbar SB, Clark PC, Quinn C, et al. Family influences on heart failure self-care and outcomes. J Cardiovasc Nurs. 2008;23: 258-265.

11. Saunders MM. Factors associated with caregiver burden in heart failure family caregivers. West J Nurs Res. 2008;30:943-959.

12. Pressler S, Pizlo IG, Chubinski SD, et al. Family caregiver outcomes in heart failure. Am J Crit Care. 2009;18(2):149-159.

13. Aldred H, Gott M, Gariballa S. Advanced heart failure: impact on older patients and informal carees. J Adv Nurs. 2005;49:116-124.

14. Bakas T, Pressler SJ, Johnson EA, et al. Family caregiving in heart failure. Nurs Res. 2006;55(3):180-188.

15. Luttik ML, Jaarsma T, Tijssen JG, et al. The objective burden in partners of heart failure patients: development and initial validation of the Dutch objective burden inventory. Eur J Cardiovasc Nurs. 2008;7(1):3-9.

16. Boyd KJ, Murray SA, Kendall M, et al. Living with advanced heart failure: a prospective, community based study of patients and their carers. Eur J Heart Fail. 2004;6(5):585-591.

17. Hooley PJD, Butler G, Howlett JG. The relationship of quality of life, depression and caregiver burden in outpatients with congestive heart failure. Congestive Heart Fail. 2005;11(6):303-310.

18. Bahrami M, Etemadifar S, Shahriari M, Farsani AK. Informational needs and related problems of family caregivers of heart failure patients: a qualitative study. J Educ Health Promot. 2014;3:113.

19. Dunbar SB, Clark PC, Deaton C, et al. Family education and sup- port interventions in heart failure—a pilot study. Nurs Res. 2005;54(3): 158-166.

20. Duhamel F, Dupuis F, Reidy M, Nadon N. A qualitative evalua- tion of a family nursing intervention. Clin Nurse Spec. 2007;21(1): 43–49.

21. Löfvenmark C, Karlsson MR, Edner M, Billing E, Mattiasson AC. A group-based multi-professional education programme for family mem- bers of patients with chronic heart failure: effects on knowledge and patients’ health care utilization. Patient Edu Couns. 2011;85(2):e162– e168.

22. Neuman B. The Neuman systems model. In: Neuman B, Fawcett J, eds. The Neuman Systems Model. 4th ed. Upper Saddle River, NJ: Prentice Hall; 2002:3-33.

282 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2016

23. Fawcett J. Contemporary Nursing Knowledge Analysis and Evaluation of Nursing Models and Theories. 2nd ed. Philadelphia, PA: F. A. Davis Company; 2005.

24. Demir Barutcu C, Mert H, Bektaş M. The psychometric properties of the Turkish Version of the Dutch Objective Burden Inventory. Asian Nurs Res. 2015;9(3):207-212.

25. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev. 1988;1:77-100.

26. Hisli N. Reliability and validity of Beck depression in- ventory in university students. Turkish J Psychiatry. 1989;7: 3-13.

27. Makdessi A, Harkness K, Luttik ML, Mckelvie RS. The Dutch objec- tive burden inventory: validity and reliability in a Canadian population of caregivers for people with heart failure. Eur J Cardiovasc Nurs. 2011;10(4):234-240.

28. Garlo K, O’Leary JR, Van Ness PH, Fried TR. Burden in caregivers of older adults with advanced illness. J Am Geriatr Soc. 2010;58 (12):2315-2322.

29. Etemadifar E, Bahrami M, Shahriari M, Farsani AK. The effective- ness of a supportive educative group intervention on family caregiver burden of patients with heart failure. Iran J Nurs Midwifery Res. 2014;19(3):217-223.

30. Demir G. Impact of Neuman Systems Model in Reducing Care Burden Primary Caregivers of Patients With Dementia [thesis]. Kayseri: Erciyes University Health Science Institute; 2012.

31. Tatar Yüksel Ç. Evaluation of Life Experiences of Parents of Disabled Children With Betty Neuman’s Systems Model [thesis]. Ankara, Turkey: GMMA Health Science Institute; 2008.

32. Pihl E, Jacobsson A, Fridlund B, Strömberg A, Måtensson J. Depres- sion and health-related quality of life in elderly patients suffering from heart failure and their spouses: a comparative study. Eur J Heart Fail. 2005;7(4):583-589.

33. Mårtensson J, Dracup K, Canary C, Fridlund B. Living with heart failure: depression and quality of life in patients and spouses. J Heart Lung Transplant. 2003;22(4):460-467.

34. Schwarz KA, Elman CS. Identification of factors predictive of hospi- tal readmissions for patients with heart failure. Heart Lung. 2003;32: 88-99.

35. Luttik ML, Leegte I, Jaarsma T. Quality of life and depressive symptoms in heart failure patients and their partners: the impact of role and gender. J Cardiac Fail. 2009;15(7):580-585.

36. Agren S, Evangelista L, Strömberg A. Do partners of patients with chronic heart failure experience caregiver burden? Eur J Cardiovasc Nurs. 2010;9:254-262.

37. Schwarz KA, Mion LC, Hudock D, Litman G. Telemonitoring of heart failure patients and their caregivers: a pilot randomized controlled trial. Prog Cardiovasc Nurs. 2008;23:18-26.

38. Dunbar SB, Clark P, Reilly C, et al. A trial of family partnership and ed- ucation ınterventions in heart failure. J Cardiac Fail. 2013;19(12):829- 841.

39. Cockayne S, Pattenden J, Worthy G, et al. Nurse facilitated Self- management support for people with heart failure and their family carers (SEMAPHFOR): a randomised controlled trial. Int J Nurs Stud. 2014:1207-1213.

40. Jaarsma T, Johansson P, Ågren S, Strömberg A. Quality of life and symptoms of depression in advanced heart failure patients and their partners. Curr Opin Support Palliat Care. 2010;4(4):233-237.