Issues related to caregiver burden and health vulnerabilities are a national concern (Centers for Disease Control and Prevention, & Kimberly Clark Corporation, 2008). The number of older Americans is projected to increase dramatically in the coming decades. One consequence of this demographic shift is that more families will be providing support for older adults, with more family caregivers likely to be older themselves (Reinhard, Brooks-Danso, Kelly, & Mason, 2008). Older adults often have their own health issues and may become overburdened physically, emotionally, and financially when they are also a primary caregiver for a loved one. Family caregivers need assistance with information, support, and advice from nurses and other health care professionals to successfully meet the demands of caregiving.
Essential knowledge and competencies for nurses and social workers were identified during a recent state of the science conference focusing on support of family caregivers (Kelly, Reinhard, & Brooks-Danso, 2008). A key tenet of support identified during the conference was that “family caregivers must be recognized as partners in care” (Reinhard et al., 2008, p. 4). The nursing profession is in an advantageous position to take action, not only by preparing nurses to interact with caregivers through partnerships, but also by developing and implementing theory-based nursing interventions to improve family caregiver health and well-being.
The purpose of this article is to describe the Self-Care TALK (SCT) intervention, the theoretical basis for the intervention, and the evidence supporting the intervention’s integrity, effectiveness for family caregiver-nurse partnerships, and to explore implications for research and clinical practice. A composite example of the SCT intervention in practice is presented, demonstrating relational conversation skills to cultivate partnerships between the gerontological nurse and family caregivers.
Self-Care Talk Intervention
The Self-Care for Health Promotion in Aging (S-CHPA) model provided the framework for the development of the SCT intervention (Teel & Leenerts, 2005a). SCT is a theory-guided nursing intervention developed to promote health among older caregivers by establishing partnerships with them. Using SCT in practice, nurses follow specific conversation skills to build partnerships with older caregivers. These four specific communication skills are listening with intent, affirming emotions, creating relational images, and planning enactment. The goal of the SCT intervention is to foster the development of partnerships between the nurse and the client, with the aim of building self-care skills for health among older adults (Leenerts & Teel, 2006).
The intervention is conducted by telephone and the dosage consists of six weekly education and support sessions to enhance self-care and health promotion. Sessions are based on core concepts in the S-CHPA model, such as environment, self-care ability, and self-care activity. The SCT sessions topics include practicing healthy habits, building self-esteem, focusing on the positive, avoiding role overload, communicating, and building meaning. Intervention protocols ensure a standardized approach for each session, while also allowing for individualization, given each caregiver’s unique environment, resources, and abilities. In addition, each caregiver is provided a resource manual of support materials for each session, which offers additional structure for the conversations and reference materials for the caregiver (Leenerts, Teel, & Shafton, 2007).
In carrying out the conversation-based intervention, specific conversation skills are used by the nurse. Related to Henson’s (1997) mutuality communication elements, the relational conversation skills include listening with intent, affirming emotions, creating relational images, and planning enactment (Leenerts & Teel, 2006). Relational conversation skills can facilitate nurses in building partnerships with caregivers. When the nurse listens with intent, he or she demonstrates presence with the caregiver, while also hearing information about personal environment, self-care abilities, current situation and habits, as well as the caregiver’s needs and concerns. When using the skill of affirming emotions, the nurse shows respect for the caregiver’s emotions and often demonstrates empathy for the caregiver. Creating relational images involves using words and conversation about life experiences that resonate with the caregiver and creates imagery for encouraging self-care activity. Planning enactment, the fourth communication skill, is when the nurse encourages the caregiver and reinforces realistic goals while helping the caregiver identify practical and accessible resources for health promotion.
Self-Care for Health Promotion in Aging Model
The S-CHPA model provided the framework for the development of the SCT intervention (Teel & Leenerts, 2005a). In response to an identified need for a model of self-care for older adults, Leenerts, Teel, and Pendleton (2002) developed the S-CHPA. In model development, the empirical and theoretical literature pertaining to self-care in community-dwelling older adults was analyzed and synthesized. The literature synthesis revealed five dimensions of self-care that are related to health promotion and well-being in aging. The five interactive dimensions of the model include Internal and External Environment, Self-Care Ability, Education and Support Intervention, Self-Care Activity, and Outcomes (Figure). Appreciation of the interrelationships among model dimensions is essential to using the model to guide practice (Teel & Leenerts, 2005b).
Figure. Self-Care TALK Intervention in Context of the Self-Care for Health Promotion in Aging Model.
The first dimension, Internal and External Environment, encompasses self-care ability, education, and self-care of each individual and includes seven components: self-concept, goals, motivation, images of health, physical condition, emotional condition, and cultural context. The second dimension, Self-Care Ability, refers to the individual’s readiness to care for self and includes problem solving, relating, independence, reconciliation, and consciousness. Education, the third dimension, connects the individual’s self-care ability and self-care activity. Education through effective partnerships between nurses and caregivers can facilitate the caregiver’s enactment of self-care abilities. Education and support strategies include exploration of self concept, identification of images of health, support of independence and interdependence, identification of current self-care behaviors, identification of self-care options, teaching of self-care skills, exploration of meaning in aging, and modeling of respect and caring. These strategies are incorporated by developing partnerships using relational conversation skills in the SCT intervention sessions: practicing healthy habits, building self-esteem, focusing on the positive, avoiding role overload, communicating, and building meaning. Self-Care Activity is the fourth dimension and includes behaviors that promote health, such as communicating, engaging in healthy lifestyle behaviors, building meaning, and socializing. The fifth dimension, Outcomes, includes well-being, connectedness, perceived physical health, and perceived mental health (Teel & Leenerts, 2005b). In using the S-CHPA model as a practice guide, the partnership that can be fostered between the nurse and the older adult is an essential element in achieving positive outcomes. The model has been tested using a self-care intervention to promote health and well-being of older adult spouse caregivers (Teel & Leenerts, 2005a).
Research Evidence Supporting the Intervention
Teel and Leenerts (2005a) have identified positive outcomes for older adult caregivers who have participated in the SCT intervention. The composite conversation included below provides an example of how relational communication skills are used in SCT to support caregivers in achieving a healthy lifestyle after taking on a new role as a family caregiver. By using theory-based interventions, caring attitudes, and strong communication skills in practice, gerontological nurses can support and potentially improve the health of older caregivers.
Offering support and counseling to family caregivers can provide significant emotional and psychological relief to caregivers and often delay nursing home placement of the care recipient. When the care recipient does require care in a long-term care setting, family caregiving does not necessarily end. Family caregiver support can be helpful through the nursing home placement transition (Gaugler, Roth, Haley, & Mittleman, 2008). Following nursing home placement, family caregiver involvement in care and the development of partnerships with staff improves the family caregiving experience (Maas et al., 2004).
Application of a Theory-Based Intervention
Using the S-CHPA model allows nurses to focus on the individual situation of the caregiver, identifying what is important from the caregiver’s perspective. The following conversation offers an example of each SCT session. The composite example demonstrates the use of SCT in practice and highlights the relational conversation skills that are used by the gerontological nurse throughout each session. The nurse talks with the individual caregiver by telephone, following standardized protocols for each session (practicing healthy habits, building self-esteem, focusing on the positive, avoiding role overload, communicating, and building meaning), refers to the SCT manual provided to the caregiver, and listens carefully, accumulating information about the caregiver’s specific situation. This approach allows for individualized treatment in teaching about health and self-care. The nurse records notes during each session and refers to them prior to subsequent sessions.
Mrs. C. is 67 years old, healthy, and cares for her 70-year-old husband, who had a stroke 6 months ago. Mr. C. has right-sided weakness and wears a leg brace for stabilization. Despite an inability to bathe, dress, or drive a car, he has returned to the office at the family-owned plumbing business. Mrs. C. works as the company bookkeeper and recently took over additional managerial duties. For leisure, Mrs. C. enjoys spending time with friends and grandchildren. Mrs. C. is concerned about a decline in her own physical activity since her husband’s stroke. When Mrs. C. inquired about the SCT study, she described participation as a first step to finding support in her new caregiving responsibilities.
The relational conversation skills are used by the gerontological nurse in all SCT sessions. During the first session, Mrs. C. commented about not having time to exercise. This theme is followed throughout the subsequent sessions.
Session 1: Healthy Habits
Nurse: Can you tell me about staying active and exercising to stay healthy?
Mrs. C.: I used to walk every morning and feel like a million bucks (relational image), but it has gone by the wayside. It is just too much. It seems every day I get up and take care of him and go the grocery store and the day is over. I don’t even have him to help carry the groceries in any-more.
Nurse: You have taken on a lot in caring for your husband (affirming emotions). It sounds like you miss walking and would prefer to exercise, if given the time (affirming emotions). All the things you do for your husband and activities you do without his help require physical activity.
Mrs. C.: I suppose it does.
Nurse: We can talk about time management and ways you may be able to fit in a walk for exercise since this is something you enjoy (planning enactment).
Session 2: Building Self-Esteem
Mrs. C.: My husband joined a wellness program. Maybe I could go with him and exercise.
Nurse: That would certainly be helpful for you, and you would be able to exercise on your own. Then, you might feel like you did when you were walking every morning, “like a million bucks” (creating relational image from Session 1).
Session 3: Focusing on the Positive
Nurse: How is the exercise plan coming along? Did you exercise with the wellness program?
Mrs. C.: Yes, I took my husband and decided to give it at try. I actually had a good time and felt good about going. I am just glad he is alive and can talk and walk.
Nurse: I am glad to hear you look at this so positively (affirming emotions). Good for you. I am so glad you were able to go. I hope you keep going and try to exercise a couple of times a week (planning enactment).
Session 4: Role Overload
Nurse: Were you able to exercise this past week?
Mrs. C.: My husband was sick last week and I did not exercise. My daughter is also in the hospital.
Nurse: That must take a lot of your time and energy (affirming emotions).
Mrs. C.: It does. At times I don’t know where the time goes. There is none left for me.
Nurse: It can be difficult to allow time for yourself (affirming emotions). It is important to take time for yourself. Next week we can talk about communicating your needs to others.
Session 5: Communicating
Nurse: How are you since we talked? Have you had some time for yourself?
Mrs. C.: Things are better this week, and I was able to exercise three times. I just need more time in the day. Time for me is limited and I can’t seem to get everything done.
Nurse: How do you feel about asking others for help when you need it?
Mrs. C.: It makes me feel bad. I am so used to taking care of everyone else I don’t even know what I need help with.
Nurse: It can be difficult when you have so much going on (affirming emotions). Have you ever tried to make a list of things to do? (offering a suggestion from the manual) Sometimes this helps in seeing what needs to be done and deciding who the best person is to help (planning enactment).
Session 6: Building Meaning
Nurse: Did you have some time for yourself last week?
Mrs. C.: Yes, I exercised with my husband and we had a good time.
Nurse: It is great that you enjoy exercising and spending time together (affirming emotions).
Mrs. C.: I even went for a massage and enjoyed every minute of it.
All four relational conversation skills are used in the SCT sessions to develop a partnership within the nurse-client relationship. Listening with intent is used consistently in each session to ascertain information about Mrs. C.’s self-care abilities. The gerontological nurse identified the relational image created by Mrs. C. as she described walking every morning and “feeling like a million bucks,” responding by affirming emotions with acknowledgment of the effort required to care for her husband. Planning enactment is demonstrated by assisting Mrs. C. to find new opportunities to exercise. Mrs. C. identified an approach to self-care by incorporating exercise back into her routine. This change led to an increase in the important self-care activity of exercise, which can promote healthy aging. Overall, the development of the nurse and caregiver partnership supports Mrs. C. through her caregiving experience and supported her in regaining a healthier lifestyle.
Implications for Research and Practice
The SCT intervention has the potential to generate new knowledge regarding the effectiveness of partnerships between nurses and caregivers. The idea of building partnerships between nurses and clients is a familiar concept for nursing. Little progress has been made, however, in applying theory and in identifying when partnerships are needed and how outcomes are affected (Charlton, Dearing, Berry, & Johnson, 2008; Hooks, 2006; Leenerts & Teel, 2006). Future research is needed to test the overall usefulness of SCT in practice and to identify appropriate practice settings for implementation of SCT. As a telephone-based intervention, SCT may be useful in several settings, including primary care, specialty, and community-based practices. Future studies of the SCT intervention could be used with older adults caring for individuals outside of the spouse role and in diverse caregiver populations. Consideration should be given to developing disease-specific manuals to provide resources and information regarding the care recipient’s condition and provide disease-specific community resources.
SCT provides an avenue to create partnerships with caregivers and provides nurses a standardized approach to support caregivers, while also individualizing each session. When SCT, a conversation-based intervention, is implemented in practice, there is a potential for the nurse to change delivery of the intervention as the nurse becomes more experienced with the intervention. The nurse’s skills and competence are developed as stories unfold from each caregiver during successive SCT sessions. In addition, the nurse’s personal experience and professional knowledge of caregiving experiences have the potential to affect the delivery of the intervention. This fidelity issue is particularly related to treatment delivery and can be addressed by careful training, use of standardized protocols, and monitoring of the intervention process (Kolanowski, Buettner, & Moeller, 2006). Due to the flexibility and individualization of the SCT intervention, future studies may focus on the adherence to the protocol and the competence of the interventionist’s skills to ensure intervention fidelity (Stein, Sargent, & Rafaels, 2007).
The development of the S-CHPA model, SCT intervention, and use of relational conversation skills in implementing SCT exemplifies the process and usefulness of theory-based nursing interventions. Zarit and Femia (2008) identified four characteristics necessary for effective caregiver interventions: having a psychological versus purely educational approach, being multidimensional, having flexibility, and providing the intervention in a sufficient dosage. The SCT intervention meets all these criteria for effective caregiver treatments.
SCT uses relational conversation skills to support discussions about the many aspects of self-care important in aging and caring. SCT is designed to be implemented by telephone to increase flexibility in time and location of intervention delivery. (The protocol is available through the second author at firstname.lastname@example.org.) The flexibility of this telephone intervention allows caregivers to participate in the intervention from a location convenient to them, usually their own homes, decreasing travel time to a health care facility. Interventions provided by telephone are becoming very popular and have been shown to be effective (Smith, 2008). The dosage schedule of one session per week has been shown to be satisfactory to caregivers, convenient, and conducive to learning about self-care (Teel & Leenerts, 2005a).
Theory-based nursing interventions, developed and tested in research and implemented in practice, are needed to improve the health and well-being of caregivers and their families. Using theory provides a means of maximizing efficiency in practice by organizing and prioritizing information and aids in predicting outcomes (Raudonis & Acton, 1997). Older adults are particularly vulnerable to health decline when their spouse or significant other experiences a decline in health, which requires that they take on caregiving responsibilities. SCT is a valuable theory-guided nursing intervention that has the potential to promote the health of older family caregivers through the development of nurse-caregiver partnerships.
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