Abstract
Background and objectives: Chronic renal failure has a progressive nature and there is always a need for a person to care for them. A caregiver, who is usually a patient's family member, may face many problems during the care process, which ultimately causes burnout. The aim of this study is to determine the effect of psycho-educational intervention on the caregiver burden of patients undergoing hemodialysis.
Methods: This study was a clinical trial that carry out on 105 caregivers of patients undergoing hemodialysis. The burnout questionnaire of Zarit was completed by the participants. The Caregivers were allocated randomly in two groups of intervention (discussion, workshops) and control. Two weeks after the completion of 6 sessions of the group discussion and 4 sessions of the workshop, caregiver burdon questionnaire of Zarit was completed again. Data was analyzed by using version 16 of spss software and parametric and non-parametric tests.
Results: Results showed that there was no significant difference between the three groups before intervention in the mean scores of burden (p=0.423). However, after the intervention there was significant difference in the mean scores of burden between intervention groups with control group (p<0.001). Tukey post hoc test showed no significant difference between the two intervention groups in the mean scores of burden (P=0.204).
Conclusion: The results of this study can be found that training classes such as group discussion had a significant reduction in the severity of caregiver burden. Therefore, it is recommended that in the health system planning attend to the role of family members in the treatment of these patients also benefit from this training method.
Keywords: Psycho-educational intervention, Caregivers Burden, Hemodialysis
Received: 2017.9.23 Revised: 2018.10.18 Published: 2019.01.16
Corresponding Author: Associate Prof., Maternal and Childhood Obesity Research Center, Department of Medical Surgical Nursing
Address: Urmia University of Medical Sciences, Urmia, Iran E-mail: hemmatma@yahoo.com
Introduction
Caregivers are the people who are most involved in caring and helping the patient to adapt and manage chronic disease (1). They help to meet the daily needs of a sick person without financial support (2). These people can be a spouse, parent, child or any of the relatives of the patient (3). It is estimated that about 52 million Americans are caregivers for sick or disabled people (4). Economically, it is estimated that caring for adult and disabled patients are worth 196 billion $ over a year (5).
Considering the inevitable progressive nature and long-term treatment of chronic renal failure and changes in caregivers' performance, they often endanger the physical and mental health of the patients (6). According to the latest statistics, the number of patients with chronic renal failure in the world is estimated to be around 1.9 million, of which 1,455,000 undergo hemodialysis (7). According to the statistics in 2008, 16,600 hemodialysis patients existed in 355 hemodialysis wards in the country and 20 % is added to them annually (8).
The heavy responsibility for long-term care of the patient leads to a change in the caregiver's lifestyle and has a negative impact on her/ his emotional and social aspects and causes burnout (9, 10). According to the definition of the American Psychiatric Association, the burnout is a set of physical and psychological symptoms during which a person seems to be depressed and upset, depending on the different cultures, has different manifestations (11). Zarit defined the burnout as a multi-spectral response to the negative assessment and perceived stress of caring the patient (12).
Lack of awareness and ambiguity regarding the prognosis of the disease are the main risk factors for creating a burnout (13). Caregivers may take care of the patient without any readiness, support, and training (14, 15). This decreases the level of care and increases the psychological requirements (16).
Numerous interventional programs were designed to support caregivers, reduce negative aspects and increase the positive aspects of the care (17). Interventions such as training, support and psychotherapy can reduce the caregivers’ burnout, increase the quality of the provided care, as well as the physical and mental health of caregivers (18, 19). Training programs are recommended as a helpful solution for supporting and providing information to caregivers (3). On the other hand, caregivers are also interested in training and learning (20, 21). Training the caregivers can include providing information regarding the illness and employing communication and coping skills and problem solving (13). Group training programs are widely recommended as a valuable strategy to support the caregivers (22).
One of the most common, active and modern methods of training is group discussion method (23), provided as an effective strategy in the field of health sciences (24). On the other hand, a workshop is a training tool that one of its advantages is to provide a large number of topics within a short time (25). The techniques, methods, and the workshop working way are such that they engage the participants in the process of problem-solving and conclusion and the lecturer will help participants in inferring concepts and issues (26).
In the study of Mollaoglu et al., home-based care training through group discussion was effective on burnout severity among caregivers of hemodialysis patients (13). In the study of Farahani et al., training the hemodialysis patients’ caregivers were effective in reducing the burnout and other care-related problems (27). In the study of Ghane et al., a supporting curriculum was effective in the life quality of hemodialysis patients’ caregivers (28).
Given that the number of people with kidney failure and their need for home care is increasing, the caregivers may face with the problems such as burnout needed to be paid enough attention to find effective and more practical training methods. In the studies, there is no comparison between training methods. This study aimed to determine the effect of psycho-educational intervention through two educational methods of group discussion and a workshop on burnout among caregivers of hemodialysis patients referring to educational centers of Urmia in 2015.
Materials and Methods
The present study was a pre-test/ post-test trial performed on caregivers of patients undergoing hemodialysis referring to Imam Khomeini and Ayatollah Taleghani educational centers of Urmia in 2016. The sample size in this study, according to Fallahi Khoshkanab et al. (29) was determined 93 people that with a probable loss of 10% increased to 105. The researchers, after arrangement with the relevant authorities, selected the samples including 105 caregivers of the patient based on the inclusion criteria of the study. They were selected randomly using the Excel program and based on the pre-prepared sampling framework including 400 (350 people in Taleghani Hospital and 50 in Imam Khomeini Hospital). The inclusion criteria were the following : the age of 18-60 years, having literacy, not having chronic mental and physical illnesses, as well as cognitive, hearing and vision disorders according to the person's statement. The rest of criteria were absence of psychedelic drugs, history of being caregivers at least for 6-month, no university education in medical sciences, life with a patient in one place, familiarity with Persian language, willingness to participate in educational sessions, no drug abuse, and lack of attendance in the similar educational classes. Exclusion criteria included absences of more than 2 sessions, patient deaths during the study, and getting the caregiver an illness requiring hospitalization during the study.
The data collection tool was a demographic questionnaire and Zarit Caregiver Burden Interview. The demographic questionnaire included gender, age, marital status, educational level, and relation to the patient, duration of care, monthly income and insurance coverage status. The Zarit Caregiver Burden Interview was composed of 22 questions and it can be used to measure the various aspects of burnout such as, individual (1, 2, 7, 10, 11, 17, 19, 20 and 21), social (3, 6,12 And 13), emotional (4, 5, 8, 14, 9, 18 and 22) and economic (15 and 16). This questionnaire was graded in 5-point Likert based (never= 0, rarely= 1, sometimes= 2, often= 3 and always= 4), and the scores of the participants in the test ranged from 0 to 88. Scores of 0-20 indicates a lack of burnout to a low-level burnout, 21-40 indicates a low to moderate level of burnout, 41-60 represents moderate to severe burnout, and 88-61 indicates the intensive burnout (12). Validity and reliability of this tool were investigated by Navidian et al. (2008) in Iran. The reliability was confirmed using a retest method with a correlation coefficient of 0.94, and the convergent validity was approved based on the positive and high correlation with Hamilton anxiety scale (r = 0.9) and Beck Depression Inventory (r= 0.67) (30). Furthermore, in the research of Kuhestani and Bagchi (2012), the content validity of this questionnaire was confirmed and the reliability of the questionnaire was approved using retest (0.85) and internal consistency and Cronbach's alpha (0.88) (31).
After meeting with the research samples and explaining the purpose and method of the research, the written consent was obtained from the samples and they were reminded that all information obtained from them will be kept confidential and the results will be published without mentioning the name. They were also informed that at any stage of the research, they could leave the study for any reason. In this study, the authorization was obtained from the Ethics Committee of the University of Medical Sciences (ir.umsu.rec code 1394.184). After the pre-test, the participants were randomly assigned to three groups of 35 (two intervention groups and one control group) by giving cards with English letters (A, B, C). In one of the intervention groups, a care-training workshop and in the other group, a care-based group discussion was held. The control group received the same routine training, however, in the end, they were provided training packages for acknowledgment their participation in the research.
Subsequently, the intervention groups were divided into smaller groups, so that the group discussion group was divided into 3 groups and the workshop group was divided into 2 groups. Six training sessions in the group discussion group were held for 2 h. On the other hand, in the workshop group, 4 sessions of 4 h were held. Considering the presence of the majority of patients, the classes were in the conference hall of Ayatollah Taleghani Hospital. The instructor in the workshop, as well as the group discussion sessions manager were the researchers. There was also a psychic nurse at the sessions. The scientific content of the two programs was the same. These topics were selected after reviewing guidelines, the nursing and scientific books and the relevant articles. The articles were submitted to 3 faculty members of the faculty of Psychiatric Nursing and 2 faculty members of the Department of Clinical Psychology of the University, and a panel was held with the participation of these people, the proposed amendments were collected and approved after applying (Table 1).
Table 1. Group discussion and workshop sessions
Session 3
Ways to increase self-confident |
Session 2
Principles of self-care |
First session
Familiarity with the end-stage renal disease |
Group discussion sessions
(6 sessions) |
Session 6
Increasing communication skills |
Session 5
Improving career skills |
Session 4
Reducing stress, managing time |
|
Session 2
Principles of self-care, ways to increase self-confident |
First Session
More familiarity with the end-stage renal disease |
Workshop sessions
(4 sessions) |
Session 4
Improving career skills, training increased communication skills |
The time of the holding the sessions was coordinated with the caregivers of the patients, one session each week. The arrangement of the chairs of the training session was in accordance with the educational method. In group discussion method, the arrangement was in a circular manner to facilitate the exchange of ideas between the participants and in the workshop group the tables and chairs were arranged unilaterally directed towards the trainer. In group discussion sessions, the researchers initially created a brainstorm in the minds of the audience by asking a question, and then the group discussion lasted for 2 h. In this way, the participants used each other’s experiences and ideas. Throughout group discussion the researcher while contributing to the discussion and presentation of his own ideas, also played the role of the group leader, and always tried to articulate the discussion to be proportionate to the discussion subject. In the end, the content was summarized with the help of the participants and the subject of the next session was presented.
The workshop is referred to a specific educational approach in which the formal academic teaching and information provision are minimized and the active learning of the participants is concentrated (32). In this study, each workshop session consisted mainly of three parts: lecture, group discussion and work in small groups, and the third section was the presentation of group work and community participation. In the first stage, the training workshop was started by presenting discussions by the researchers. At this stage, the researchers presented some questions while providing scientific-practical concepts to learners. In the next step, working groups with a maximum membership of 5 people in each group were formed, and each group was managed by one of the researchers. In the third stage, questions and operational exercises were responded. At the end of the interventions, the severity of burnout was measured in all three groups by post-test (Diagram 1).
The collected data was analyzed by SPSS V.16 using ANOVA for comparing the mean scores of burnout between the three groups after ensuring the normality of the data by Kolmogorov-Smirnov test and confirming the equality of variances by the Levine test and Tukey's post-test was used to compare the pairwise mean care scores between the groups. Comparison of mean scores of care burnout aspects between groups was calculated using the Kruskal-Wallis test and the pairwise mean scores of burnout aspects were compared between the groups using the Mann-Whitney test. It should be noted that P-Value of less than 0.05 was considered as the significance level.
Results
In this study, 105 caregivers of patients under hemodialysis participated. Of which 25 (14%) were male and 80 (86%) were female. The mean age was 11.55 ± 36.29 years. The results of the study indicated that there is no significant statistical difference between intervention and control groups in terms of demographic variables such as gender, age, marital status, educational level, monthly income and duration of care (Table 2).
Table 2. Comparison of demographic characteristics between three groups of control, discussion, and workshop
Qualitative variables |
Control |
Group discussion |
Workshop |
Chi-square test |
Number (%) |
Number (%) |
Number (%) |
Gender |
Male |
10 (28.6) |
7(20) |
8(22.9) |
X2= 0.735
P= 0.692 |
Female |
25 971.4) |
28 (80) |
27 (77.1) |
Marital status |
Single |
10 (28.6) |
7 (20) |
9 (25.7) |
X2 = 0.716
P= 0.699 |
Married |
25 (71.4) |
28 (80) |
26 (74.3) |
Education level |
High school |
20 (57.1) |
18 (51.4) |
16 (45.7) |
X2 = 0.915
P= 0.633 |
Diploma and high |
15 (42.9) |
17 (47.6) |
19 (54.3) |
Monthly income |
Low |
22 (62.9) |
24 (67.6) |
24 (68.6) |
P = 0.391 |
Moderate |
11 (31.4) |
11 (31.4) |
11 (31.4) |
High |
2 (5.7) |
0 (0) |
0 (0) |
Relation with the patient |
Parent |
5 (14.3) |
7 (20) |
2 (5.7) |
X2 = 3.648
P = 0.724 |
Child |
12 (34.3) |
13 (37.1) |
16 (45.7) |
Spouse |
12 (34.3) |
10 (28.6) |
11 (31.4) |
Others |
6 (17.1) |
5 (14.3) |
17 (16.2) |
Quantitative variables |
Mean± Standard deviation |
Mean± Standard deviation |
Mean± Standard deviation |
ANOVA |
Age (year) |
36.14± 11.183 |
36.22 ± 11.671 |
36.51 ± 11.497 |
F= 0.011 P = 0.989 |
Duration of care (month) |
46/45 ± 34.526 |
52.22 ± 32.426 |
61.14 ± 44.566 |
F = 1.359
P = 0.262 |
Based on Kruskal-Wallis statistical test and ANOVA, the results showed that there was no significant statistical difference between the three groups of control, discussion and workshop in terms of mean scores of burnout and its aspects before the intervention (P> 0.05).
After the intervention, based on Kruskal-Wallis test and ANOVA, a significant statistical difference was found between the control, the discussion and the workshop group regarding the mean score of burnout and its aspects, except for the economic aspect (P< 0.05) (Table 3).
Table 3. Comparison of the mean scores of burnout and its aspects among the three groups of control, discussion, and workshop
Variable |
Control |
Group discussion (6 sessions) |
Workshop (4 sessions) |
statistical test |
Average rate |
Average rate |
Average rate |
Individual aspect |
Before intervention |
48.56 |
51.83 |
58.61 |
X2= 2.017 *P= 0.365 |
Before intervention |
68.04 |
41.20 |
49.76 |
X2= 9.154 *P= 0.0001 |
Social aspect |
Before intervention |
48.76 |
52.09 |
57.16 |
X2= 1.756 *P= 0.416 |
After the intervention |
65.40 |
45.29 |
48.31 |
X2= 9.212 *P= 0.010 |
Emotional Aspect |
Before intervention |
53.97 |
50.41 |
54.61 |
X2= 0.392 *P= 0.822 |
After the intervention |
61.83 |
42.80 |
54.37 |
X2= 7.057 *P= 0.029 |
Economic aspect |
Before intervention |
49.01 |
50.09 |
59.90 |
X2= 2.817 *P= 0.245 |
After the intervention |
58.34 |
45.76 |
54.90 |
X2= 3.324 *P= 0.190 |
Total burnoyt |
Before intervention |
Mean± Standard deviation |
Mean± Standard deviation |
Mean± Standard deviation |
Statistical analysis of variance analysis |
36.14 ± 11.183 |
36.22 ± 11.671 |
36.51 |