TRIFOLD AREA – THIS GUIDE WILL BE REMOVED BEFORE PRINTING – TRIFOLD AREA – THIS GUIDE WILL BE REMOVED BEFORE PRINTING – TRIFOLD AREA – THIS GUIDE WILL BE REMOVED BEFORE PRINTING – TRIFOLD AREA – THIS GUIDE WILL BE REMOVED BEFORE PRINTING – TRIFOLD Caregivers to Those with Traumatic Brain Injury: Identifying Caregiver Stressors and Effective Interventions: An Integrative Review Andrea VanOver DePaul University Dr. Yung-Me Lee, PhD, RN Discussion BACKGROUND MATERIALS AND METHODS Annually in the United States, about 1.6 million people sustain TBIs with 70,000-90,000 of those people experiencing long term impairments (Degeneffe, 2001). Traumatic Brain Injury According to the National Institute on Neurological Disorders and Stroke ( NINDS, 2016), TBI may be defined as a form of acquired brain injury that occurs when a sudden trauma causes damage to the brain. A caregiver may be defined as “a person(s) providing assistance and support to family members or acquaintances who have physical, psychological, or developmental needs” (Drentea, 2007). Caregiving also requires strong emotional support that includes listening, counseling, and companionship (Drentea, 2007). Overwhelming feelings of stress make caregivers vulnerable to depression, anxiety, and reduce their ability to deal with coping which will further complications of caregiving (Li & Shaffer, 2014). The stressors of psychological strains, social construct, and role adaptation all play a role in caregiver stress . It was also found that clinical interventions have proliferated but there still exists limited research regarding their effectiveness. It was found that in relation to caregiving, the new role is added and creates a greater domestic workload that may cause other major changes to social roles, family disturbances, decreased leisure time, and loneliness and social isolation. Along with stress, depression and anxiety have been reported in caregivers even after five years of caregiving for a loved one with TBI (Blake, 2008) Those who have lower income and education levels are more likely to be conducive to stress with caregiving. Many studies showed common interventions included information, counseling, support groups, and respite. Questionnaire studies and phenomenological studies have shown that caregivers often report a need for more accurate information from health professionals (Blake, 2008). Counseling was found to have positive effects on those suffering with caregiver stress. Support groups are among the most effective treatments for caregivers. The peer camaraderie and support allow individuals suffering from caregiver stress to feel accepted and less alone (Whittier, Coon, and Aaker, 2004). It was found that 32% of the respondents were already using respite care, and both caregivers and patients were quite satisfied with the care they received. Other studies have shown that 53% to 69% of informal caregivers who do not use respite care desired to (Smeets et. Al, 2012). Design This integrative literature review was utilized to explore major stressors of caregivers that health providers need to be aware of as well as clinical treatment for caregiver stress. An integrative literature review allows for various types of research that have been done on this subject to be included in the same study. This review includes many benefits including evaluating the strength of the scientific evidence that already exists, identifying the gaps in current research, furthering the need for future research. Literature Search Strategies The literature review was developed and conceptualized with the use of the following databases: Cumulative Index of Nursing and Allied Health (CINAHL), PsychINFO, Google Scholar, and ProQuest with an initial focus on treatment for caregiver stress. An additional search engine, Google Scholar, was used as the foundation along with searching for peer-reviewed, scholarly articles which helped expand the search. Identifiable terms used in the database search included:’ “psychological effects” and “caregiver”, “Caregiver stress” and “Nursing Interventions”, “effective treatment for caregiver stress,” “coping strategies for caregiver stress,” “Nursing,” “Chronical illness” and “Caregiver stress”, “Effects of” and “Caregiving” and “Family Caregiver Alliance”, and “Caregiving Statistics.” Inclusion Criteria The articles were first reviewed to identify any strategies to identify caregiver stress in caregivers of those with traumatic brain injury in a clinical setting. The inclusion for this criteria were as follows: Published between 2003 and 2016. Defining caregiver population as those who are family/friends and not from a paid career. Identifies traumatic brain injury and long-term care. Studies involved method(s) of identifying caregiver stress Documentation of interventions available for those with identified caregiver stress PURPOSE The purpose of this integrative literature review was to identify caregiver stressors and clinically proven treatments to reduce caregiver stress in caregivers to those with TBI. The following research questions were used: What are the most common caregiver stressors reported in caregivers to those with TBI? What effective interventions are identified to reduce caregiver stress? RESULTS Of 13 articles, three stressors were identified by caregivers: Psychological strains- Overwhelming feelings of stress make caregivers vulnerable to depression, anxiety, and reduce their ability to deal with coping which, then, will further complications of caregiving (Li and Shaffer, 2014 Social Construct- Age, ethnicity, gender, and employment status are all incorporated as psychosocial stressors Adaptation- Whole-family adaptations and how each of the family member handles and adapts to their new roles plays a major part in potential familial stress Of the six articles, four interventions were reported as effective in aiding caregiver stress. Information- It is imperative that caregivers become knowledge of access to information of available services, caregiver challenges and solutions, costs of care, implications and care needs, etc Counseling- It was found, across the board, that the goal of caregiver stress counseling is striving to relieve caregiver stress and anxiety and to improve relationship functioning Support groups- Support groups provide a sense of community so that caregivers feel free to share, interact, and learn from each other in a supportive environment Respite- Respite programs offer a periodic or temporary relief from daily challenges of caregiving. Nursing Implications Conceptual Framework Nurses are often responsible for providing education and evaluation due to their higher frequency of contact with patients. They should be able to identify and monitor potential radiating stressors that may progress as risk factors for family functioning. Assist in providing secondary and informational resources for family caregivers in multitudes of forms including written materials, videotapes, and even audiotapes (Hudson, Aranda, and Kristjanson, 2004). The Stress Process Model was used. The process of stress can be identified as combining three conceptual domains that are as follows: sources of stress, mediators of stress, and manifestations of stress (Pearlin, Lieberman, Menaghan, Mullan, 1981). This model is based off a longitudinal study that observed how life events, chronic life strains, self-concepts, coping, and social support systems come together to form a process of stress. Life events may adversely affect enduring role strains which, in turn, erode positive concepts of self that leave one vulnerable to experiencing symptoms of stress (Pearlin, Lieberman, Menaghan, Mullan, 1981). Conclusions Suggestions for Future Research It is important for the health provider and nursing staff to educate families, individually and, on the importance of recognizing declining mental and physical states not just of the patient, but also the caregiver. When it can be recognized, proper interventions can be put into place to replenish positivity. A health provider or ordered therapist may provide information on support groups, online or in person, to help caregivers feel like they are not alone This review found that stronger social support ties are less likely to experience depression and feelings of hopelessness. It is a necessity for medical professionals to be aware of the main stressors of caregivers and offer early interventions to prevent stress and low life satisfaction. The range of evaluations for caregivers (surveys, questionnaires, etc.) remains relatively unclear. This points out the apparent need in shifting funding of research to identifying the stressors of caregiving towards interventions that may potentially improve the lives of the caregiving family.