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Guideline Summary
Guideline Title
Putting evidence into practice: evidence-based interventions to reduce family caregiver strain and burden.
Bibliographic Source(s)
Honea NJ, Brintnall R, Given B, Sherwood P, Colao DB, Somers SC, Northouse LL. Putting evidence into practice: nursing assessment and interventions to reduce family caregiver strain and burden. Clin J Oncol Nurs. 2008 Jun;12(3):507-16. [41 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

The Oncology Nursing Society (ONS) reaffirmed the currency of this guideline in 2013.

Scope

Disease/Condition(s)

Cancer

Guideline Category
Counseling
Evaluation
Management
Prevention
Clinical Specialty
Nursing
Oncology
Psychology
Intended Users
Advanced Practice Nurses
Nurses
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)

To provide recommendations to reduce family caregiver strain and burden

Target Population

Family caregivers of patients with cancer

Interventions and Practices Considered
  1. Cognitive behavioral interventions
  2. Psychoeducational interventions
  3. Psychotherapy interventions
  4. Supportive interventions
  5. Multicomponent interventions
  6. Discussing psychosocial issues
  7. Identifying available resources and discussing coordination of services
  8. Massage
  9. Respite/adult day care
  10. Teaching caregiver self-care
  11. Teaching pain management
  12. Teaching symptom management

Note: The following were considered but their effectiveness was unlikely: interventions directed at improving care recipient competence.

Major Outcomes Considered
  • Caregiver strain and burden
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

2008 Original Guideline

To ensure optimal study retrieval related to caregiver strain and burden, multiple databases were searched, including Ovid's MEDLINE®, PubMed, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL®). The search was limited to studies of adult oncology populations published in English in peer-reviewed journals from 1995–2006. Key search terms included caregivers, caregiving, family, spouse, burden, strain, cancer, oncology, intervention, randomized controlled trial, and review or meta-analysis. Review or meta-analysis articles were included only if they covered oncology populations. Finally, to ensure a comprehensive search, a medical librarian was consulted and a manual search was performed to evaluate the reference lists of retrieved sources.

2013 Reaffirmation

PubMed, CINAHL, Cochrane Collaboration and NCCN were searched from March 2008 through December 2012 using the search terms: (Therapy/Broad[filter] OR systematic[sb]) AND (Caregivers[majr] OR caregiver*[ti]) OR (("family member"[ti] OR "family members"[ti] OR spous*[ti] OR partner*[ti]) AND caregiv*) AND (cancer OR oncolog* OR neoplasms[mesh]).

Inclusion Criteria

  1. Full research report, systematic review, guideline or meta-analysis
  2. Study must report results of measurement of the topic of caregiver strain and burden
  3. The study examines an intervention aimed at affecting caregiver strain and burden
  4. Study sample must include caregivers of patients with cancer

Exclusion Criteria

  1. Grey literature
  2. Studies that describe caregiver concerns and issues, but do not include examination of an intervention
  3. Samples involving caregivers as parents of a child with cancer

Monthly auto alerts from all databases are received. Abstracts are reviewed against inclusion and exclusion criteria, and those meeting criteria are selected to be obtained. Further full article review is done by team members assigned, and any that does not meet criteria upon full review is eliminated.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Panels of advanced practice nurses, staff nurses, and doctorally-prepared nurse researchers reviewed the literature base in the identified outcome areas. Professional health services librarians assisted in the conduct of the literature searches. Based on their analysis, the panels then formulated a judgment about the body of evidence related to the intervention under consideration. Three major components were considered by the panels in classifying the collective evidence into one of six Weight of Evidence categories (see the "Rating Scheme for the Strength of the Recommendations" field):

  • Quality of the data, with more weight assigned to levels of evidence higher in the PRISM categorization (such as randomized trials and meta-analyses)
  • Magnitude of the outcome (e.g., effect size or minimal clinically important difference)
  • Concurrence among the evidence (based on the premise that an investigator has less confidence in findings in which the lines of evidence contradict one another)
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

To begin the review process, the senior researcher guided the Putting Evidence Into Practice (PEP) team through several literature reviews using the Critical Appraisal Skills Program (CASP©, Public Health Resource Unit) evaluation guide adapted by Guyatt, Sackett, and Cook. The CASP tool guided the team through a critical review of a study using specific criteria. Tables of evidence were created to identify key points of each study for consistency throughout the review (see tables posted at http://www.ons.org/Research/PEP/media/ons/docs/research/outcomes/caregiver/table-of-evidence.pdf External Web Site Policy). The use of consistent and objective criteria added structure to the synthesis process and trustworthiness to conclusions for the team.

Following each guided critique using the CASP tool, studies were ranked from level 1 to 8 by rigor of the evidence, with level 1 indicating optimal evidence. To ensure clarity and consistency across topics, the assigned levels of evidence were validated with a leader/researcher dyad from another Oncology Nursing Society (ONS) PEP team who agreed with the team's analyses and conclusions.

Attention was then focused on rating the effectiveness of interventions in reducing caregiver burden. Accordingly, each intervention was given a weight of evidence to reflect its usefulness and value in making recommendations for practice.

Methods Used to Formulate the Recommendations
Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations

2008 Original Guideline

To develop an evidence-based approach to evaluating and relieving caregiver strain and burden, an Oncology Nursing Society (ONS) Putting Evidence Into Practice® (PEP) project team was formed. The team composition was based on guidelines developed by ONS and mirrored previous PEP teams. It consisted of one senior researcher and two advanced practice/staff nurse dyads. Other content-based expert researchers worked parallel to the resource team to develop recommendations for research and practice that could be used by oncology nurses at various points of care.

2013 Reaffirmation

The committee met on March 19, 2013. The team consisting of nurse scientists, advanced practice nurses and staff nurses write summaries of all references retrieved for the topic and appraise the evidence based on study design, settings and sample characteristics. All evidence findings for each intervention is synthesized. The synthesized information is provided to all team members for review, and after review, the team members meet via a web meeting and conference call to apply the PEP Weight of Evidence Classification criteria External Web Site Policy. In this meeting the group decides upon the classification of the evidence for each intervention found in the search, reviews the set of references to determine if any key references are not included, and ensures consistency of intervention definitions and associated evidence summaries. Further team communication and decision making is done via email and follow up phone conferences as needed.

Rating Scheme for the Strength of the Recommendations

Recommended for Practice

Interventions for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews, and for which expectation of harms is small compared with the benefits

  • Supportive evidence from at least two well-conducted randomized controlled trials that were performed at more than one institutional site and that included a sample size of at least 100 participants
  • Evidence from a meta-analysis or systematic review of research studies that incorporated quality ratings in the analysis and included a total of 100 patients or more in its estimate of effect size and confidence intervals
  • Recommendations from a panel of experts, that derive from an explicit literature search strategy, and include thorough analysis, quality rating, and synthesis of the evidence

Likely To Be Effective

Interventions for which the evidence is less well established than for those listed under "Recommended for Practice"

  • Supportive evidence from a single well conducted randomized controlled trial that included fewer than 100 patients or was conducted at one or more institutions
  • Evidence from a meta-analysis or systematic review that incorporated quality ratings in the analysis and included fewer than 100 patients, or had no estimates of effect size and confidence intervals
  • Evidence from a synthetic review of randomized trials that incorporated quality ratings in the analysis
  • Guidelines developed largely by consensus/expert opinion rather than primarily based on the evidence and published by a panel of experts, that are not supported by synthesis and quality rating of the evidence

Benefits Balanced With Harm

Interventions for which clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities

  • Supportive evidence from one or more randomized trials, meta-analyses, or systematic reviews, but where the intervention may be associated, in certain patient populations, with adverse effects that produce or potentially produce mortality, significant morbidity, functional disability, hospitalization, or excess length of stay

Effectiveness Not Established

Interventions for which there are currently insufficient data or data of inadequate quality

  • Supportive evidence from a well conducted case control study
  • Supportive evidence from a poorly controlled or uncontrolled study
    • Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
    • Evidence from non-experimental studies with high potential for bias (such as case series with comparison to historical controls)-Evidence from case series or case reports
  • Conflicting evidence, but where the preponderance of the evidence is in support of the recommendation or meta-analysis showing a trend that did not reach statistical significance

Effectiveness Unlikely

Interventions for which lack of effectiveness is less well established than for those listed under "Not Recommended for Practice"

  • Evidence from a single well conducted randomized trial with at least 100 participants or conducted at more than one site and which showed no benefit for the intervention
  • Evidence from a well conducted case control study, a poorly controlled or uncontrolled study, a randomized trial with major methodologic flaws, or an observational study (e.g., case series with historical controls) that showed no benefit and a prominent and unacceptable pattern of adverse events and serious toxicities

Not Recommended for Practice

Interventions for which ineffectiveness or harmfulness has been demonstrated by clear evidence, or the cost or burden necessary for the intervention exceeds anticipated benefit

  • Evidence from two or more well conducted randomized trials with at least 100 participants or conducted at more than one site and which showed no benefit for the intervention and excessive costs or burden expected
  • Evidence from a single well conducted trial that showed a prominent and unacceptable pattern of adverse events and serious toxicities
  • Evidence from a meta-analysis or systematic review of research studies that incorporated quality ratings in the analysis, included a total of 100 patients or more in its estimate of effect size and confidence intervals with demonstrated lack of benefit or prominent and unacceptable toxicities
  • Intervention discouraged from use by a panel of experts in the related subject, after conducting a systematic examination, quality rating and synthesis of the available evidence
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This guideline was accepted for publication on November 19, 2007.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse: Recommendations have been taken from the Oncology Nursing Society Putting Evidence Into Practice (ONS PEP) quick view resource (see the "Availability of Companion Documents" field). Refer to the original guideline document for full dosages, references, and other essential information about the evidence.

Recommended for Practice

  • Cognitive behavioral interventions

Likely To Be Effective

  • Psychoeducational interventions
  • Psychotherapy interventions
  • Supportive interventions
  • Multicomponent interventions

Effectiveness Not Established

  • Discussing psychosocial issues
  • Identifying available resources and discussing coordination of services
  • Massage
  • Respite/adult day care
  • Teaching caregiver self‐care
  • Teaching pain management
  • Teaching symptom management

Effectiveness Unlikely

  • Interventions directed at improving care recipient competence

Definitions:

Recommended for Practice

Interventions for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews, and for which expectation of harms is small compared with the benefits

  • Supportive evidence from at least two well-conducted randomized controlled trials that were performed at more than one institutional site and that included a sample size of at least 100 participants
  • Evidence from a meta-analysis or systematic review of research studies that incorporated quality ratings in the analysis and included a total of 100 patients or more in its estimate of effect size and confidence intervals
  • Recommendations from a panel of experts, that derive from an explicit literature search strategy, and include thorough analysis, quality rating, and synthesis of the evidence

Likely To Be Effective

Interventions for which the evidence is less well established than for those listed under "Recommended for Practice"

  • Supportive evidence from a single well conducted randomized controlled trial that included fewer than 100 patients or was conducted at one or more institutions
  • Evidence from a meta-analysis or systematic review that incorporated quality ratings in the analysis and included fewer than 100 patients, or had no estimates of effect size and confidence intervals
  • Evidence from a synthetic review of randomized trials that incorporated quality ratings in the analysis
  • Guidelines developed largely by consensus/expert opinion rather than primarily based on the evidence and published by a panel of experts, that are not supported by synthesis and quality rating of the evidence

Benefits Balanced With Harm

Interventions for which clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities

  • Supportive evidence from one or more randomized trials, meta-analyses, or systematic reviews, but where the intervention may be associated, in certain patient populations, with adverse effects that produce or potentially produce mortality, significant morbidity, functional disability, hospitalization, or excess length of stay

Effectiveness Not Established

Interventions for which there are currently insufficient data or data of inadequate quality

  • Supportive evidence from a well conducted case control study
  • Supportive evidence from a poorly controlled or uncontrolled study
    • Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
    • Evidence from non-experimental studies with high potential for bias (such as case series with comparison to historical controls)-Evidence from case series or case reports
  • Conflicting evidence, but where the preponderance of the evidence is in support of the recommendation or meta-analysis showing a trend that did not reach statistical significance

Effectiveness Unlikely

Interventions for which lack of effectiveness is less well established than for those listed under "Not Recommended for Practice"

  • Evidence from a single well conducted randomized trial with at least 100 participants or conducted at more than one site and which showed no benefit for the intervention
  • Evidence from a well conducted case control study, a poorly controlled or uncontrolled study, a randomized trial with major methodologic flaws, or an observational study (e.g., case series with historical controls) that showed no benefit and a prominent and unacceptable pattern of adverse events and serious toxicities

Not Recommended for Practice

Interventions for which ineffectiveness or harmfulness has been demonstrated by clear evidence, or the cost or burden necessary for the intervention exceeds anticipated benefit

  • Evidence from two or more well conducted randomized trials with at least 100 participants or conducted at more than one site and which showed no benefit for the intervention and excessive costs or burden expected
  • Evidence from a single well conducted trial that showed a prominent and unacceptable pattern of adverse events and serious toxicities
  • Evidence from a meta-analysis or systematic review of research studies that incorporated quality ratings in the analysis, included a total of 100 patients or more in its estimate of effect size and confidence intervals with demonstrated lack of benefit or prominent and unacceptable toxicities
  • Intervention discouraged from use by a panel of experts in the related subject, after conducting a systematic examination, quality rating and synthesis of the available evidence
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is specifically stated for each recommendation (see "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Reducing caregiver strain and burden supports the mission of professional nursing through efforts to improve quality of life and other health outcomes for patients with cancer and their caregivers. Education, support, psychotherapy, and respite interventions have demonstrated the greatest effect in reducing caregiver strain and burden.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

This content published by the Oncology Nursing Society (ONS), reflects a scientific literature review. There is no representation nor guarantee that the practices described will, if followed, ensure safe and effective patient care. The descriptions reflect the state of general knowledge and practice in the field as described in the literature as of the date of the scientific literature review. The descriptions may not be appropriate for use in all circumstances. Those who use this content should make their own determinations regarding safe and appropriate patient care practices, taking into account the personnel, equipment, and practices available at their healthcare facility. ONS does not endorse the practices described herein. The editors and publisher cannot be held responsible for any liability incurred as a consequence of the use or application of any of this content.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Quick Reference Guides/Physician Guides
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Honea NJ, Brintnall R, Given B, Sherwood P, Colao DB, Somers SC, Northouse LL. Putting evidence into practice: nursing assessment and interventions to reduce family caregiver strain and burden. Clin J Oncol Nurs. 2008 Jun;12(3):507-16. [41 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2008 Jun 1 (reaffirmed 2013)
Guideline Developer(s)
Oncology Nursing Society - Professional Association
Source(s) of Funding

Oncology Nursing Society

Guideline Committee

Oncology Nursing Society Putting Evidence Into Practice® (ONS PEP) project team

Composition of Group That Authored the Guideline

Authors: Norissa J. Honea, RN, AOCN®, CCRP; RuthAnn Brintnall, PhD, AOCN®, CHPN, APRN-BC; Barbara Given, PhD, RN, FAAN; Paula Sherwood, PhD, RN, CNRN; Deirdre B. Colao, RN, BSN, OCN®; Susan C. Somers, BA, RN, BSN, OCN®; Laurel L. Northouse, PhD, RN, FAAN

Financial Disclosures/Conflicts of Interest

No financial relationships to disclose.

Guideline Status

This is the current release of the guideline.

The Oncology Nursing Society (ONS) reaffirmed the currency of this guideline in 2013.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from Oncology Nursing Society (ONS) Web site External Web Site Policy.

Print copies: Available for purchase from the Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275-1214; telephone, 412-859-6100; fax, 412-921-6565. The ONS Publications Catalog is available online at the Oncology Nursing Society (ONS) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Oncology Nursing Society's Putting Evidence Into Practice (ONS PEP) caregiver strain and burden evidence table. Available in Portable Document Format (PDF) from the Oncology Nursing Society (ONS) Web site External Web Site Policy.
  • ONS PEP caregiver strain and burden systematic review/meta-analysis table. Available in Portable Document Format (PDF) from the ONS Web site External Web Site Policy.
  • ONS PEP quick view for caregiver strain and burden. Available in Portable Document Format (PDF) from the ONS Web site. External Web Site Policy
  • Nursing-sensitive patient outcomes: the development of the putting evidence into practice resources for nursing practice. Available in Portable Document Format (PDF) from the ONS Web site External Web Site Policy.
  • Chemotherapy and biotherapy guidelines and recommendations for practice. Available in Portable Document Format (PDF) from the ONS Website External Web Site Policy.
  • Measuring oncology nursing-sensitive patient outcomes: measurement summary. Caregiver strain and burden. Available in Portable Document Format (PDF) from the ONS Web site External Web Site Policy.
  • ONS PEP weight of evidence classification schema. Decision rules for summative evaluation of a body of evidence. Available in Portable Document Format (PDF) from the ONS Web site External Web Site Policy.
Patient Resources

Patient-focused instruction sheets are available from www.thecancerjourney.org External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on December 1, 2010. The information was verified by the guideline developer on February 3, 2011. The currency of the guideline was reaffirmed by the developer in 2013 and this summary was updated by ECRI Institute on November 8, 2013.

Copyright Statement

This summary is based on the original guideline, which is copyrighted by the Oncology Nursing Society (ONS).

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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