Enhancing Preparedness and Satisfaction of Caregivers of Patients Discharged from an Inpatient Rehabilitation Facility Using an Interactive Website

FEATURE

Enhancing Preparedness and Satisfaction of Caregivers ofPatients Discharged from an Inpatient RehabilitationFacility Using an Interactive WebsiteKaron Stone1, DNP, CRRN, FNP-BC, CRRN

1 Veterans Health Administration, Savannah Georgia, USA

Keywords

Caregivers; family caregiving; education.

Correspondence

Karon Stone, 5 Crestwood Drive,

Savannah 31405, GA.

E-mail: [email protected]

Accepted June 23, 2013.

doi: 10.1002/rnj.123

Abstract

Purpose: Research indicates a need for improved caregiver preparation to pro-

vide care following a patient’s discharge from inpatient rehabilitation. The aim

of this project was to test the use of web-based resources to enhance the pre-

paredness and satisfaction of such caregivers.

Methods: A website was provided to caregivers with resources and e-mail

access to a rehabilitation nurse practitioner. Care recipients had the following

diagnoses: stroke, amputation, trauma/orthopedic, brain injury or debility. Pre-

paredness for caregiving was assessed before utilization of the website and after

discharge. Satisfaction of the resources was assessed after discharge. Measures

included the Preparedness for Caregiver Scale and the Client Satisfaction Ques-

tionnaire. Seventy caregivers completed the predischarge preparedness tool.

Thirty returned both tools postdischarge.

Findings: Analysis of pre–post test data indicated increased preparedness to

provide care after resource use, no increase meeting the caregiver’s personal

needs, and satisfaction with the resources provided. The caregivers of brain-

injured patients reported less preparation as caregivers than those who cared

for patients with other diagnoses. Although high interest was reported in using

e-mail with the nurse practitioner, the resource was not utilized.

Clinical Relevance: This preliminary study supports the clinical relevance of

Internet resources to improve caregiver preparation. With shortened hospital

stays, providing applicable and evidence-based websites and other online ser-

vices for caregivers can complement other healthcare services. More research

focused on preparing caregivers and supporting personal caregiver needs is

needed to evaluate the impact on overall rehabilitation outcomes.

Introduction

Healthy People 2020 objectives specifically recognize the

importance of promoting well-being of caregivers of people

with disabilities (Healthy People, n.d., p. 54). Preparing

caregivers before patients (care recipients) are discharged

from inpatient rehabilitation can improve caregiver per-

ceptions related to balancing competing needs and general

satisfaction in caring for their loved one. Such preparation

can improve both the quality of care given to patients and

caregivers’ quality of life (Shyu, Chen, Wang, & Shao,

2008). Caregivers’ discharge needs have been found to

predict hospital readmission and service use after dis-

charge (Shyu et al., 2004). The success of implementation

of a discharge plan is based on its ability to meet the spe-

cific needs and expectations of the caregiver during the

© 2013 Association of Rehabilitation Nurses

Rehabilitation Nursing 2014, 39, 76–8576

hospitalization of his/her loved one and subsequent care

at home (Bauer, Fitzgerald, Haesler, & Manfrin, 2009).

The Internet is becoming one of the most widely used

resources for health information (NCHS Press Room: A

blog of the National Center for Health Statistics (NCHS),

2010) to provide consumer information specifically

related to the healthcare and living needs of frail elders

and other dependent adults with disabilities. As noted in

Retooling for an Aging America (Institute of Medicine

(IOM), 2008b), Americans are generally not well prepared

to meet the complex medical and social needs of a grow-

ing frail population dependent on care by family mem-

bers and others. The Institute of Medicine’s (IOM) key

findings included the recommendation that healthcare

providers “better prepare informal caregivers to tend to

the needs of aging family members and friends” (Institute

of Medicine, 2008a). Societal trends and specific research

indicate that use of the Internet to meet information

needs for this population will almost certainly continue

to increase (Kernisan, Sudore, & Knight, 2010). Thus,

there is a critical need to explore and develop useful

interventions to promote better caregiver preparation,

especially for patients with long-term chronic conditions

or disabilities. This is especially important as available

time for members of the healthcare team to adequately

prepare patients and caregivers for discharge is becoming

less with decreasing lengths of hospital stays. Ensuring

satisfaction and preparedness for transition of care is

essential for a successful transition of care.

The aim of this project was to determine the usefulness

of an interactive website to improve preparedness and

enhance satisfaction for personal caregivers of patients

discharged from an inpatient rehabilitation facility.

Literature review

Family caregivers of members with a disability may feel

burdened and are often faced with difficulties in aspects

of daily care to meet the multiple needs of their loved

one. Researchers have found that caregivers often do not

feel adequately prepared to deal with the physical, cogni-

tive, and emotional needs of survivors of stroke or similar

disabilities. The transition from hospital to home has

been described as stressful and burdensome for family

caregivers (Shyu et al., 2008).

Shyu (2000a) found that family caregivers reported

various discharge needs in transition from hospitalization

to family care of frail elders at home. These needs

included the following: information on the care receiver’s

condition, symptom monitoring/management, personal

care delivery, emergency management, help in mastering

personal care skills, handling the care receiver’s emotions,

making the care receiver compliant, and setting up

continuing services, and emotional and manpower

support. In addition, caregivers’ discharge needs were

found to predict hospital readmission and service use

after discharge (Shyu et al., 2004).

Shyu (2000b) further found that caregivers need prepa-

ration to enter the caregiving role. During the phase

immediately after hospital admission, information for the

family caregiver is the predominant concern. Preparing

caregivers before discharge of their loved one can

improve their ability to balance competing needs of daily

life and satisfaction of their discharge needs. These

changes, in turn, can improve both the quality of care

given to patients and caregivers’ quality of life (Shyu

et al., 2008).

With shortened lengths of hospital and rehabilitation

stays, the caregiver’s role is vital following discharge of

the patient. Because increased responsibility for care may

negatively affect family caregivers’ health and perceptions

of the caregiving experience, it is imperative that nurses

better understand and practice effective planning for dis-

charge (Bull, Hansen & Gross, 2000). The findings of a

study by Bull and associates (Bull et al., 2000) provide

some evidence that caregivers may benefit from involve-

ment in discharge planning, particularly with respect to

their perceptions of the caregiving experience, overall

health, and vitality. This study further suggested that fam-

ily caregivers who reported greater involvement in dis-

charge planning also were more satisfied. Involvement in

planning for discharge might provide family caregivers

with information about what to expect following dis-

charge and provide opportunities for them to become

knowledgeable about care routines.

Bull and associates (2000) further identified patient

and family understanding of the patient’s condition, feel-

ing prepared to manage care after discharge, and being

involved in decisions related to discharge planning as

predictors of patient satisfaction. Client satisfaction is

considered an important outcome measure in managed

care environment faced with escalating healthcare costs,

shortened length of hospital stay, and competition among

hospitals.

Minimization of stress on, and distress of, the family is

an important aim of rehabilitation. Interventions might

help mobilize networks, create new sources of support,

decrease conflicts, and enhance quality of support. A crit-


Rehabilitation Nursing 2014, 39, 76–85 77

Karon Stone Caregiver Preparedness

ical review of intervention studies of caregivers of stroke

survivors concluded that the final aim of the intervention

should be active problem-solving strategies and to support

information-seeking behavior (Visser-Meily, Heugten, Post,

Schepers, & Lindeman, 2004).

Currently, the Internet is widely used for health infor-

mation. Visitors to a website targeting adults caring for

aging parents reported seeking both general information

on caregiving and specific assistance with custodial, medi-

cal, emotional, and financial aspects of caregiving (Kerni-

san et al., 2010). With emphasis on early discharge and

moving the patient’s care from organized health service

to home, the development of computer-based tools to

expand and extend services provided by nurses may be

used as a complementary approach to enhance caregiver

preparation. Online approaches can be accessible, ongo-

ing, and time-relevant in tailoring of content for the indi-

vidual, in addition to being an interactive and supportive

component. (Brennan et al., 2001).

The introduction of web-based patient–physician com-

munication has opened new opportunities to support

patients and promote self-management skills. Communi-

cation between doctors and patients through e-mail has

evolved quickly in recent years and has been studied from

the perspectives of both patients and physicians (Bennett

et al., 2005). Ling Leong, Gingrich, Lewis, Mauger, and

George (2005) found that e-mail communication was a

convenient form of communication with improved satis-

faction for both the patient and the provider. Allen, Iezz-

oni, Huang, Huang, and Leveille (2008) used principles

of self-management in an intervention aimed to engage

and empower patients to collaborate with their primary

care provider in managing their health conditions. The

intervention was delivered online by nurse electronic coa-

ches (e-coaches). It involved a standardized set of e-mails

and worksheets targeting self-efficacy, patient education,

and motivation to improve health. As patients and care-

givers become more accustomed to electronic communi-

cation, nurses can play an important role in developing

this new area to help patients and families in self-manag-

ing their health conditions (Allen et al., 2008).

Theoretical foundation

The theoretical foundation for this project was the Tran-

sitional Care Model (TCM). The TCM is an evidence-

based model of care that has been tested and refined over

20 years, has been shown to improve health outcomes,

prevent avoidable rehospitalizations, enhance patient and

family caregiver satisfaction, and decrease healthcare costs

(TCM, n.d.). Transitional care refers to care and services

that promote the safe and timely transfer of patients from

one level of care to another or from one type of setting

to another, such as hospital to home (Naylor, 2000). The

TCM focuses on improving postdischarge outcomes for

high-risk, high-cost, high-volume patient groups.

TCM is built on the following key components:

• Focus on patient and caregiver understanding.

• Helping patients manage health issues and prevent

decline.

• Medication reconciliation and management.

• Transitional care, not ongoing case management.

This project utilized many of the key components of

the TCM by providing caregivers with tools for transi-

tion of care from Internet resources and providing an

option to communicate with the nurse practitioner

involved with the patient’s care by e-mail (as well as

continued other means of personal communication).

Although the full scope of this model was not used,

such as a Transitional Care Nurse (TCN) being directly

involved during the transition from hospital to home,

this project applied the TCM’s fundamental philosophi-

cal concepts focusing on improving postdischarge out-

comes. Naylor’s entire model is outlined elsewhere

(http://www.transitionalcare.info/).

Developing an effective intervention that assists care-

givers to effectively manage caregiving problems should

not only create and sustain caregiver involvement but also

provide opportunities for greater involvement by family

caregivers to become more knowledgeable and better pre-

pared to care for their family member. This project tested

whether resources that have been made available to the

caregivers enhanced their preparedness in the transition

from the inpatient setting to the home. This study fills a

specific gap by introducing web-based resources for care-

giver preparation and providing e-mail as an innovative

option to communicate with the healthcare provider dur-

ing transition of care.

Method

Design

This descriptive project used a before-and-after design to

assess the impact of a specific intervention on caregiver

preparedness. The clinical intervention included access to



Caregiver Preparedness Karon Stone

a website with resources and availability for caregivers to

communicate to the nurse practitioner who was involved

with the daily care by e-mail, both during and following

the inpatient rehabilitation experience.

Setting and sample

This project was conducted at a regional inpatient reha-

bilitation center. The hospital has 45 beds for adult

patients (age 18 and older) with diagnoses that include

the following: stroke, brain injury, amputation, joint sur-

geries, multiple trauma, and debility.

The caregiver (age 18 and older) of every patient who

was admitted during the data collection period was given

the opportunity to participate in the study, across a time

period from June 2011 through August 2011. Caregivers

of all patients admitted during that time period were eligi-

ble, with the exception of non-English-speaking caregivers.

Seventy caregivers consented to be participants and

completed the predischarge questionnaires. Thirty of the

original sample returned the postdischarge questionnaires.

Table 1 gives further data regarding caregivers and

patients.

Procedures

This study was approved by the hospital Institutional

Review Board as well as that of the associated university.

Permission was also given by the originators of both mea-

surement tools used as described below.

Caregivers were recruited by the investigator who is also

a nurse practitioner employed by the rehabilitation facility

and had daily involvement in the patient’s care. Because

the investigator was also a care provider where patient care-

givers were recruited, all attempts for controlling internal,

external, and construct validity were employed by giving

clear explanation that participation was voluntary, that

participants could withdraw at any time, and that not fully

participating and declining to participate would not affect

or impact the care of the patient. An informed consent

form (ICF) was given to every caregiver who participated.

The ICF was verbally explained to the caregiver by the

Table 1 Caregiver and Patient Information

Gender

Age

Range

Relationship with

Patient

Diagnosis of

Patient

Computer

Experience

Required Assistance

of Patient

Caregivers

Total: 70

Male 12/70

(17.1%)

Female 58/70

(82.9%)

18–34:

14/70 (20%)

35–44:

14/70 (20%)

45–54:

18/70 (25.7%)

55–64:

4/70 (20%)

65 over:

10/70 (14.3%)

Spouse:

12/70 (17.1%)

Child:

35/70 (50%)

Parent:

3/70 (4.3%)

Other:

20/70(28.6%)

Very Little:

5/70 (7.1%)

Somewhat:

28/70 (40%)

Very experienced:

6/70 (51.4%)

Unknown:

1/70 (1.4%)

Patients

Total: 70

Male 25/70

(35.7%)

Female 45/70

(64.3%)

18–34:

5/70 (7.1)

35–44:

6/70 (8.6%)

45–54:

12/70 (17.1%)

55–64:

9/70 (12.9%)

65 over:

38/70 (54.3%)

Stroke:

36/70 (51.4%)

Orthopedic:

13/70 (18.6%)

Brain Injury:

5/70 (7.1%)

Spinal Cord:

6/70 (8.6%)

Amputation:

3/70 (4.3%)

General:

6/70 (8.6%)

Unknown:

1/70 (1.4%)

Total Assistance:

3/70 (4.3%)

Maximum:

13/70 (18.6%)

Moderate:

9/70 (12.9%)

Minimal:

2/70(2.9%),

Unknown:

43/70(61.4%)




investigator. The ICF gave an explanation of the purpose of

the project, how to gain access to the website, location of

available computers at the hospital, and explanation of

when to mail the stamped addressed postquestionnaires to

the investigator. The ICF also listed benefits and advanta-

ges, potential risks, explanation of confidentiality, partici-

pation and authorization to participate or decline without

consequence. Caregivers were encouraged to use the web-

site even if they did not participate in the study.

Measures

The primary outcome measures of this project were care-

giver preparedness predischarge and postdischarge and

satisfaction of the intervention postdischarge. The com-

pleted prequestionnaire as well as a demographic measure

were obtained at the time of that the ICF was obtained,

within the first week of the patient’s admission. The post-

questionnaires were completed within 2 weeks after dis-

charge. The two measures included the Preparedness for

Caregiver Scale (Zwicker, 2010) and the Client Satisfac-

tion Questionnaire (Pascoe & Attkisson, 1983).

The Caregiver Preparedness Scale

The Caregiver Preparedness Scale is a 5-item Likert-type

scale that appraises caregivers’ perceptions about their pre-

paredness to give care and to handle the stresses of caregiv-

ing. The Preparation for Caregiving Scale measures

caregivers’ sources and methods of learning, perception of

preparation to care for physical and emotional needs, and

preparation to arrange needed services. Responses are on a

1–4 scale (0-not at all prepared to 4-very well prepared).

The overall score is computed by summing the responses

and dividing them by the number of items answered; thus,

the total scores range from 0 to 4. Empirical evidence

supports its content and constructs validity and reliability

with older adults. Internal consistency has been reported

as moderate to high with alphas of 0.88–0.93 reported

(Zwicker, 2010). The questions from this tool are as

follows:

1. How well prepared do you think you are to take care

of your family member’s physical needs?

2. How well prepared do you think you are to take care

of his or her emotional needs?

3. How well prepared do you think you are to find out

about and set up services for him or her?

4. How well prepared do you think you are for the

stress of caregiving?

5. Howwell prepared do you think you are to make caregiv-

ing activities pleasant for both you and your familymember?

6. How well prepared do you think you are to respond

to and handle emergencies that involve him or her?

7. How well prepared do you think you are to get the help

and information you need from the healthcare system?

8. Overall, how well prepared do you think you are to

care for your family member?

9. Is there anything specific you would like to be better

prepared for?

The Client Satisfaction Questionnaire

The Client Satisfaction Questionnaire is an 8-item Likert-

type scale initially developed to assess general client

satisfaction with health services. Empirical evidence sup-

ports its content and constructs validity and reliability

with older adults. Cronbach’s alpha coefficients ranging

from 0.87 to 0.93 reported (Pascoe & Attkisson, 1983).

Demographic and General Questions

Predischarge demographic data and general questions

included age and gender of patient and caregiver, care-

giver’s relation to patient, patient’s diagnosis. Internet

questions included the following: Do you have access to

the Internet? If no, would you use a computer that is

made available in the rehabilitation hospital for the pur-

pose of the study while the patient is in the hospital?

How experienced is the caregiver with computer/internet?

Postdischarge general questions also included the fol-

lowing: How much assistance do patients require after

discharge, how many times patients gained access to web-

site, how many e-mails were sent, usefulness of website,

usefulness of e-mail access, is this the first time being a

caregiver to an adult, what type of support did they wish

they had, what suggestions would they give to another

caregiver?

Assumptions and limitations

Assumptions of this project regarding caregiver’s pre-

paredness and satisfaction by using the resources pro-

vided by this project are the following:

1. Caregivers want to be prepared for the role of caring.

2. Caregivers want to seek knowledge of the patient they

will be caring for.

3. Caregivers want reliable and timely options for com-

munication with healthcare providers.




4. Caregiver will be satisfied with Internet access to health

information, resources, and timely efficient e-mail responses.

Limitations of this project regarding caregiver’s pre-

paredness and satisfaction by using the resources pro-

vided by this project are the following:

1. Not all caregivers had access to the Internet at home.

2. Not all caregivers knew how to use the computer or

did not want to learn.

3. Not all caregivers continued in the project after they

agreed to be a participant.

4. This project was limited to a small sample size of

patients and caregivers from a specific care setting.

Analysis and results

The data from the pre- and postquestionnaires were com-

pared to show if the website and/or e-mail option

improved preparedness and enhanced satisfaction for per-

sonal caregivers of patients discharged from an inpatient

rehabilitation facility. The data also identified which care-

givers may be at higher risk for not being prepared by look-

ing at trends with age, gender, patient diagnosis, level of

function at discharge. Although there seemed to be a high

level of interest among participants to have the option to

use e-mail to communicate with the nurse practitioner,

only one participant actually used the e-mail resource.

Analysis comparing the pretest and posttest scores was

accomplished using the statistical model developed by Sa-

mawi, Vogel and Looney (Looney & Jones, 2003; Samawi

& Vogel, 2011). Their model uniquely and effectively

addresses statistical challenges of small sample sizes.

Table 1 gives the specifics for demographic informa-

tion for the caregiver and patient. This table gives age,

gender, relationship, diagnosis, computer experience, and

assistance required by the patient after discharge.

The Vogel-Samawi-Looney (VSL) data analysis of the

pre- and postdischarge responses of the Caregiver Pre-

paredness scale is shown in Table 2. The results of the

VSL analysis are given in Table 3. As indicated, the find-

ings of this study revealed improved preparedness of care-

givers with the following questions:

• How well prepared do you think you are to take care

of your family member’s physical needs?

• How well prepared do you think you are to take care

of his or her emotional needs?

• How well prepared do you think you are to find out

about and set up services for him or her?

• How well prepared do you think you are to get the help

and information you need from the healthcare system?

• Overall, how well prepared do you think you are to

care for your family member?

The following questions did not show improved pre-

paredness of caregivers:

• How well prepared do you think you are for the stress

of caregiving?

• How well prepared do you think you are to make

caregiving activities pleasant for both you and your family

member?

• How well prepared do you think you are to respond

to and handle emergencies that involve him or her?

A reliability analysis was performed on the Caregiver

preparedness prequestionnaire and the postquestionnaire.

For the prequestionnaire, Cronbach’s alpha was 0.939;

and for the postquestionnaire, Cronbach’s alpha was

0.942. In both cases, this indicates excellent reliability. A

reliability analysis was performed on the Satisfaction

Table 2 Summary statistics from the pre–post survey. These statistics are used in the VSL Analysis

Variable Mean_pre N_pre Mean_post N_post Var_pre Var_post Covariance

Question 1 2.24 70 2.93 29 1.20 0.71 0.182

Question 2 2.34 70 2.79 29 1.07 0.81 0.261

Question 3 2.21 70 2.93 27 1.33 1.07 0.556

Question 4 2.37 70 2.38 29 1.28 1.17 0.654

Question 5 2.50 70 2.62 29 1.21 0.82 0.499

Question 6 2.63 70 3.00 29 1.51 1.07 0.714

Question 7 2.44 70 2.97 29 0.86 1.03 0.555

Question 8 2.51 70 2.93 29 1.12 0.85 0.447

Scale 19.26 70 22.34 29 53.64 42.73 23.159

Scale = sum of the question responses for each individual. As there are eight questions scored 1–4, the minimum score is 8 and

the maximum score is 32. The average scale score on the pretest was 19.26 and the average scale score on the posttest was

22.34.




questionnaire, producing a Cronbach’s alpha of 0.881.

The average satisfaction scale score was 29.21 (lowest pos-

sible score is 8 and highest possible score is 32). A corre-

lation was computed between satisfaction and

postintervention scale. The correlation coefficient was

0.39 (p = .035). Although the correlation was statistically

significant, the association was relatively weak.

No significant relationships were found for the fol-

lowing: caregiver and patient age or gender, caregiver

and patient experience with computer, amount of assis-

tance patient needed, or number of times accessed In-

ternet. There was significance related to diagnosis. Refer

to Table 4 for analysis of pretest scale score based on

demographics. Posttest scores were significantly lower

with patients with diagnosis of stroke, orthopedic con-

ditions, spinal cord injuries, amputation and with great-

est significance for brain injury showing that caregivers

Table 4 Analysis of pretest scale score based on demographics.

Demographic variable

p-value for statistical difference in

pretest scale score

Caregiver age p = .280 not significant

Caregiver gender p = .166 not significant

Relation p = .859 not significant

Patient age p = .180 not significant

Patient gender p = .722 not significant

Diagnosis p = .025*

Experience p = .463

Assistance p = .088

Number of times

accessed Internet

p = .214

*In this case, the mean score for the category General is 11.0

and is statistically less than the score for Stroke

(mean = 20.3), Orthopedic (mean = 20.07), Spinal Cord

(mean = 19.17), and Amputation (mean = 26.0). It is interest-

ing that it is not statistically different from Brain Injury

(mean = 15.8).

Table 5 Descriptive responses to the question: “Is there any-

thing specific for which you would like to be better pre-

pared?”

Caregiver Responses

More education of care issues

It would be helpful to talk to a counselor

It would be helpful to have more family support

Getting up during the night to go to bathroom (not getting

enough rest)

Extra time it takes getting dressed and bathed before going

to work

Not having other family support

How to keep calm, not stress out, and not worry about stuff

Transportation and need encouragement

Paying bills, waiting on disability approval

Needing to know all available help and how to contact them

Need help for emotional [challenges] at home

Need sitters

Awareness of oncoming sickness

Caregiver is not a babysitter

More information about Medicare and benefits

Not to take the emotional stress of the patient personally

How to deal with the patient emotional stress about wanting

to go back to work when the employer will not permit it

Emotional needs

Need help not only from family but from the outside

More advice about being a caregiver

Table 3 VSL Analysis of pretest and posttest partially correlated data

Variable Mean_pre Mean_post Post-Pre Mean z-score p-value (FDR)

Question 1 2.24 2.93 0.69 3.39 .0007 (0.0063)*

Question 2 2.34 2.79 0.45 2.17 .0299 (0.0673)*

Question 3 2.21 2.93 0.72 2.99 .0028 (0.0126)*

Question 4 2.37 2.38 0.01 0.04 .9669 (0.9669)

Question 5 2.50 2.62 0.12 0.56 .5719 (0.6434)

Question 6 2.63 3.00 0.37 1.54 .1237 (0.1590)

Question 7 2.44 2.97 0.53 2.44 .0148 (0.0443)*

Question 8 2.51 2.93 0.42 1.98 .0474 (0.0711)*

Scale 19.26 22.34 3.08 2.08 .0386 (0.0694)*

*Indicates a statistically significant difference was detected. The FDR stands for the False Discovery Rate and is an adjustment to

the p-values to account for multiple tests. Based on the above table, the results in the posttest improved over the pretest with

respect to Questions 1, 2, 3, 7, 8 and the summative scale.




may not be as prepared taking care of brain-injured

patients.

Caregivers were given the opportunity to respond to

the open-ended question, “Is there anything specific for

which you would like to be better prepared?” Descriptive

responses to the question are listed in Table 5.

Conclusion and clinical relevance

Results of this preliminary study confirmed the value of

effective interventions to assist caregivers with prepared-

ness in caregiving to increase knowledge and success in

taking care of their family member. The focus of this pro-

ject was to provide resources to caregivers by the use of

the Internet. Patients and caregivers of this study also

received, as a matter of their general care, information

and education from nurses, case managers, and therapists

that is considered standard for any certified rehabilitation

inpatient rehabilitation facility. It is interesting to note

that the questions in the preparedness tool did not show

improvement with the personal needs of the caregiver in

this study. This also seemed evident from the caregivers’

written responses as well. The finding that caregivers of

brain-injured patients may not be as prepared as com-

pared with the other diagnosis treated in the inpatient

facility was remarkable. A person with a brain injury has

a very unpredictable course of recovery compared with a

patient who has had a stroke, amputation, or orthopedic

surgery. The physical recovery may be misleading in its

course ahead of cognitive recovery in some cases, and

families may not be adequately prepared for the cognitive

and behavioral changes. Personality changes, memory and

judgment deficits, lack of impulse control, and poor con-

centration are common effects of a brain injury that may

persist and be difficult to manage (Brain Injury Associa-

tion of America, n.d.). Families and caregivers often must

learn to adapt their communication techniques, estab-

lished relationships, and expectations. Finally, it is critical

that family members seek and receive support (family,

friends, support group, counselor) in dealing with their

own emotional responses and needs to caring for a head-

injured loved one (Family Caregiver Alliance, n.d.). Care-

givers of brain-injured patients who participated in this

project did not show improvement on the three questions

on the preparedness scale as related to personal stress and

this was also reflected in the written responses.

Regardless of diagnosis, caregivers are often faced with

unplanned circumstances that can be devastating and life

changing for all involved. More research is needed to

develop effective resources to prepare and support care-

givers. Kernisan et al. (2010) examined information

seeking at a caregiver’s website. Their study suggested that

the Internet may provide a valuable medium through

which caregivers can gain access to helpful information.

The critical review of intervention studies for caregivers

of stroke survivors by Visser-Meily et al. (2004) did not

show a definite conclusion of effectiveness of interven-

tions for caregivers, but did show more positive outcomes

with individual counseling, although time consuming.

One limitation of this study was the small sample size

that limits the generalizability of the findings. Neverthe-

less, this work demonstrated an effective beginning

attempt to test the usefulness of Internet resources that

optimize patient and caregiver opportunities for contact

and support from a nurse practitioner. It also confirmed

similar findings in the literature.

The Internet provides vast and diverse resources for

most any question or need. Published research and the

result of this study show the clinical relevance that com-

puter-based tools may complement services provided by

nurses and other healthcare providers and can be used as

an alternative approach in meeting patient and caregiver

outcomes. Healthcare providers can advocate these readily

accessible resources by introducing and guiding caregivers

to the most applicable and evidenced-based websites.

With ever changing and new developments in technology,

alternative options such as e-mail appear to be a good

option to consider for communicating with health pro-

viders to help improve discharge outcomes. More

research focused on preparing caregivers and supporting

personal caregiver needs is needed to evaluate the impact

on overall rehabilitation outcomes.

Key Practice Points� This preliminary study supports the clinical relevance of In-

ternet resources to improve caregiver preparation.

� With shortened hospital stays, providing applicable and

evidence-based websites and other online services for

caregivers can complement other healthcare services.

� This study fills a specific gap by introducing web-based

resources for caregiver preparation and providing e-mail

as an innovative option to communicate with the health-

care provider during transition of care.

� More research focused on preparing caregivers and sup-

porting personal caregiver needs is needed to evaluate the

impact on overall rehabilitation outcomes.




Acknowledgments

We acknowledge the following institutions and people for

their contribution: Memorial Health University Rehabili-

tation Institute, Savannah, GA. Elaine S. Marshall, RN,

PhD, Georgia Southern University, Statesboro, GA. Statis-

tician: Robert L. Vogel, PhD, Georgia Southern Univer-

sity, Statesboro, GA.

References

Allen, M., Iezzoni, L., Huang, A., Huang, L., & Leveille, S.

(2008). Improving patient-clinician communication about

chronic conditions: description of an internet-based

nurse e-coach intervention. Nursing Research, 57(2),

107–112.

Bauer, M., Fitzgerald, L., Haesler, E., & Manfrin, M. (2009).

Hospital discharge palnning for the frail older people

and their family. Are we delivering best practice? A

review of the evidence. Journal of Clinical Nursing, 18, 2539–

2546.

Bennett, J.A., Perrin, N.A., Hanson, G., Bennett, D., Gaynor,

W., Flaherty-Robb, M., et al. (2005). Healthy aging

demonstration project: nurse coaching for behavior change

in older adults. Research in Nursing & Health, 28, 187–197.

Brain Injury Association of America. (n.d.). Family &

Caregivers “Brain injury affects the whole family.” Retrieved

August 20, 2011, from: http://www.biausa.org/brain-injury-

family-caregivers.htm

Brennan, P., Moore, S., Gjornsdortti, G., Jones, J., Visovsky,

C., & Rogers, M. (2001). HeartCare: an internet-based

information and support system for patient home recovery

after coronary artery bypass graft surgery. Journal of

Advanced Nursing, 35(5), 699–708.

Bull, M., Hansen, H., & Gross, C. (2000). Predictors of elder

and family caregiver satisfaction with discharge planning.

The Journal of Cardiovascular Nursing, 14(3), 76–87.

Family Caregiver Alliance. (n.d.). Coping with behavior

problems after head injury. Retrieved January 15, 2011,

from: http://www.caregiver.org/jsp/content_node.jsp?

nodeid=396

Healthy People. (n.d.). Healthy People 2020 objective topic

areas, page 54. Retrieved January 15, 2011, from: http://

healthypeople.gov/2020/topicsobjectives2020/pdfs/HP202

0objectives.pdf

Innovative Care Models. (n.d.). Retrieved January 15, 2011,

from: http://innovativecaremodels.com/care_models/21/

impetus

Institute of Medicine. (2008a). Fact sheet: retooling for aging

America. Retrieved January 15, 2011, from http://www.iom.

edu/-/media/Files/FactSheetRetoolingforanAgingAmerica

Building theHealthCareWorkforce.ashx

Institute of Medicine (IOM). (2008b). Retooling for aging

America: building the health care workforce. Retrieved

January 15, 2011, from http//www.iom.edu/Reports/2008/

Retooling-for-an-Aging-America-Building-the-Health-Care-

Workforce.aspx

Kernisan, L., Sudore, R., & Knight, S. (2010). Information-

seeking at a caregiving website: a qualitative analysis. Journal

of Medical Internet Research. Jul-Sep; 12(3), e31.

Ling Leong, S., Gingrich, D., Lewis, P., Mauger, D., & George,

J. (2005). Enhancing doctor-patient communication using

e-mail: a pilot study. The Journal of the American Board of

Family Practice, 18(3), 180–188.

Looney, S.W., & Jones, P.W. (2003). A method for comparing

two normal means using combined samples of correlated

and uncorrelated data. Statistics in Medicine, 22, 1601–1610.

Naylor, M. (2000). A decade of transitional care research with

hospitalized elders. Journal of Cardiovascular Nursing, 14,

1–14.

NCHS Press Room: A blog of the National Center for Health

Statistics (NCHS). (2010). NCHS releases 33rd annual

report card on nation’s health. Americans turning to

internet for health info. Retrieved February 18, 2010, from

http://nchspressroom.wordpress.com/page/2/

Pascoe, G., & Attkisson, C. (1983). The evaluation ranking

scale: a new methodology for assessing satisfaction.

Evaluation and Program Planning, 6, 335–347.

Samawi, H.M., & Vogel, R. (2011). Tests of homogeneity for

partially matched-pairs data. Statistical Methodology, 8, 304–

313.

Shyu, Y.I. (2000a). The needs of family caregivers of frail elders

during the transition from hospital to home: a Taiwanese

sample. Journal of Advanced Nursing, 32(3), 619–625.

Shyu, Y.I. (2000b). Role tuning between caregiver and care

receiver during discharge transition: an illustration of role

function mode in Roy’s adaption theory. Nursing Science

Quarterly, 13, 323–331.

Shyu, Y.I., Chen, M.C., Liang, J., Lu, J., Wu, C., & Su, J.

(2004). Predictors of functional recovery for hip fractured

elders at twelve months following hospital discharge: a

prospective study on a Taiwanese sample. Osteoporosis

International, 15, 475–482.

Shyu, Y.I., Chen, M.C., Wang, H.P., & Shao, J.H. (2008). A

family caregiver-oriented discharge planning program for

older stroke patients and their family caregivers. Journal of

Clinical Nursing, 17(18), 2497–2508.

Transitional Care Model (TCM). (n.d.). Retrieved January 15,

2011, from: http://www.transitionalcare.info/

Visser-Meily, A., Heugten, C., Post, M., Schepers, V., &

Lindeman, E. (2004). Interventions studies for caregivers of




stroke survivors: critical review. Patient Education and

Counseling, 56(3), 257–267.

Zwicker, D. (2010). Try this: best practices in nursing care to

older adults. Preparedness for caregiving scale. Hartford

Institute for Geriatric Nursing, New York University of

Nursing. Retrieved January 15, 2011, from http://

consultgerirn.org/uploads/File/trythis/try_this_28




Documents

Enhancing Preparedness and Satisfaction of Caregivers of Patients Discharged from an Inpatient Rehabilitation Facility Using an Interactive Website