Reaction

Copyright © eContent Management Pty Ltd. Contemporary Nurse (2013) 44(2): 21S-224.

Clinical indicators of 'caregiver role strain' in caregivers of stroke patients
A N A RAILKA DE SOUZA OLIVEIRA*, REBECA CORDEIRO RODRIGUES*, VANESSA EMILLE
CARVALHO DE SOUSA*, ALICE GABRIELLE DE SOUSA COSTA*, MARCOS VENÍCIOS
DE OLIVEIRA LOPES' AND THELMA LEITE DE ARAUJO*

*Federal University of Ceará, Fortaleza, Ceará, Brazil; ^General Hospital of Fortaleza, Fortaleza,
Ceará, Brazil; 'Nursing Department, Federal University of Ceará, Fortaleza, Ceará, Brazil
ABSTRACT: The main objectives of this study were to investigate the prevalence of the nursing diagnosis caregiver
role strain (CRS) in caregivers of patients with stroke and to identify the accuracy of this diagnosis's clinical indicators.
A total of42 stroke patient care^vers who provided in-home care services in a city in north-eastern Brazil. The sensitivity,
specificity, and predictive value of clinical indicators of nursing diagnosis 'CRS' were analyzed. Study participants were
mostly female, married and the daughters of stroke patients. CRS was present in 73.8% ofcare^vers. The presence of the
clinical indicators, specifically, lack of time to meet personal needs (p = 0.011), increased emotional lability (p = 0.001),
withdrawal from social life (p = 0.002), and changes in leisure activities (p = 0.002), presented high values for statistical
measures of diagnostic accuracy.

KEYWORDS: stroke, nursing diagnosis, caregivers, accuracy

S

troke is related to a high degree of disability
and functional dependence and is associated with a deterioration of the physical, cognitive, emotional, and social capacities of the
individual (Bocchi, 2004). Although the disease may affect the whole family, usually the
main responsibility for the care of the patient is
assigned to a single family member, known as
the main caregiver (Almeida et al., 2007). The
tasks assigned to the caregivers, the amendment
of routines and the time spent in care have a
negative impact on their quality of life (Ma &
Trombly, 2002), and contribute to a feeling of
overload (May, Lui, Ross, & Thompson, 2005;
Mccullagh, Brigstocke, Donaldson, & Kalra,
2005). The emotional impact experienced by the
caregiver may interfere with the care provided to
the patient and may be a predictor for a greater
number of hospitalizations among patients, a
longer hospitalization time and higher mortality
among caregivers (Balardy, 2005; Patterson &
Grant, 2003; Torti, Gwyther, Reed, Friedman,
& Schulman, 2004).
In general, the caregiver develops feelings of
insecurity, fear and anxiety because of the many
aaivities related to care, the lack of technical
preparation and the amount of time dedicated to
care (Bakas, Jessup, Williams, & Oberst, 2004;

Hankey, 2004; Sherwood, Given, Given, & Eye,
2005). In-home care of people with stroke has
become a common situation for many families.
Because of this, the evaluation of the health status
of these caregivers is an essential area of consideration in the nursing profession. The use of accurate clinical indicators is therefore an essential
tool for the identification of changes in the ability
of these individuals to offer care.
One of the ways to define the clinical indicators of a nursing problem is to use taxonomies that
represent nursing phenomena. In this area, the
NANDA International (NANDA-I) taxonomy
can assist nurses in describing nursing diagnoses
identified in specific praaice situations (NÁNDA
International [NANDA-I], 2009).
Thus, to characterize a nursing diagnosis, one
must identify clinical indicators that will predict it (Chang, Uman, & Hirsch, 1998; Grant
& Kenney, 1992). Effective clinical indicators
correctly differentiate people who have a nursing diagnosis from those who do not. In these
cases, some measures are used to characterize
the predictive ability of a clinical indicator.
Nurses must identify effective clinical indicators
to direct their attention and define their priorities. However, although there are studies related
to the overload of the caregivers of patients

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Ana Railka de Souza Oliveira et al.
with stroke, few studies have been dedicated to
studying the nursing diagnosis of 'caregiver role
strain' (CRS).
The nursing diagnosis CRS was included in the
NANDA-I taxonomy in 1992 and is defined as
difficulty in playing the role of caregiver of family.
This inability is clearly a family diagnosis that can
be measured and predicted, and niuses can play an
important role in its prevention. Moreover, prevention can assist nurses in targeting more specific care
for people with stroke (Burns, Archbold, Stewart,
& Shelton, 1993). The clinical indicators (defining
characteristics) of this nursing diagnosis are divided
into four categories: caregiving activities; caregiver
health status (physical, emotional, and socioeconomic aspects); caregiver—care receiver relationships; and family process. A total of 36 clinical
indicators are listed in the NANDA-I taxonomy.
Then, the main objectives of this study were to
investigate the prevalence of the nursing diagnosis CRS in caregivers of patients with stroke and
to identify the accuracy of this diagnosis's clinical
indicators.
METHODS

Design and sample
A cross-sectional study performed with 42 caregivers
of patients with stroke followed in-home care services in the city of Fortaleza in north-eastern Brazil.
The study included caregivers of stroke patients
for at least 2 years. The Institutional Review Board
granted ethical approval. Caregivers gave their written consent before the beginning of data colleaion.
The study excluded caregivers of patients with other
neurological illnesses, chemical dependences, or
mental disorders not related to stroke.
Patients were consecutively selected and the
sample size was defined on the basis of a confidence coefficient of 95%, an absolute sample
error of 0.15 points, and a maximtun variance
equal to 0.5. These values were based on a previous study of caregivers of stroke patients that
used the caregiver burden scale (CBS) (Elmstahl,
Malmberg, & Annerstedt, 1996).
Measures
The CBS is a 22-item scale consisting of five factors: general strain; isolation; disappointment;

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emotional involvement; and environment.
These factors subjectively assess the burdens
placed on caregivers of chronically disabled persons. The caregiver is asked to check one of four
boxes (not at all, seldom, sometimes, often) to
provide a score of 1—4 for each question. A previous reliability study showed a high internal
consistency for the five factors with Cronbach's
alpha values between 0.70-0.87, except for the
factor of environment. A reproducibility study
showed kappa values of between 0.89-1.00,
except for the factor of environment with a
kappa value of 0.53 (Elmstahl et al., 1996). To
measure the overload of the caregivers, a mean
value is calculated for each factor. Medeiros,
Ferraz, Quaresma, and Menezes (1998) performed a study to validate and adapt the CBS to
Brazilian cultural milieu.
The explanatory variables included defining
characteristics and the dependent variable was
the nursing diagnosis of CRS. Each item in the
CBS was associated with a clinical indicator of the
nursing diagnosis, and these associations are summarized in Table 1. Some clinical indicators that
did not match the scale items were added to specific questions. These questions are highlighted in
Table 1 with a superscript number 1.
For the purpose of making diagnostic inferences, data collected from each patient during the
interview and the list of clinical indicators of CRS
were evaluated by six experts who were selected
based on Fehring criteria (Fehring, 1994). At this
stage, it is important to assess agreement among
experts to minimize misdassifying subjects as
either having or not having CRS. This system
consists of criteria with pre-defined values for each
characteristic applied for identifying an expert.
According to this rating system, the expert's profile should include nurses with at least a master's
degree in nursing and a defined area of clinical
expertise. Furthermore, in this study, the experts
had the knowledge and experience of nursing language required in diagnostic, outcomes and nursing interventions.
In nursing diagnosis research, the analysis
of accuracy is related to the nurse's confidence
that a specific indicator will determine the
validity of a particular diagnosis. Unfortunately,

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Caregiver role strain
TABLE 1 : RELATIONSHIPS BETWEEN ITEMS OF CAREGIVER BURDEN SCALE (CBS) AND CLINICAL INDICATORS OF NURSING
DIAGNOSIS CAREGIVER ROLE STRAIN

Clinical Indicators
Apprehension about the future regarding care
receiver's health
Apprehension about possible
institutionalization of care receiver
Apprehension about care receiver's care if
caregiver is unable to provide care
Difficulty performing required tasks

Preoccupation with care routine

Impatience

Items of CBS scale
Do you worry about not taking care of your relative in the
proper way? Do you worry about the future of your relative?'
Do you worry about the type of aid and medical treatment
that your relative will receive?'
Do you worry about your relative not being taking care of?'
Do you find yourself facing purely practical problems in the
care of your relative that you think are difficult to solve? Have
you experienced economic limitations because you have been
taking care of your relative? Do you have difficulty performing
the tasks that your relative needs, such as dressings, dealing
with the sounding lead, tracheostomies or carrying out the
transferences (bed-chair, chair-bed)?'
Does the physical environment make it troublesome for
you to take care of your relative? Is there anything in the
neighborhood of your relative's home making it troublesome
for you to take care of your relative? Do you worry about
the tasks that you have to perform with the current housing
conditions of your relative?'
Do you feel embarrassed by your relative's behavior? Do you
sometimes feel impatient with the relative's behavior?'

Clinical indicators of CRS
Apprehension about the future regarding
caregiver's ability to provide care

Do you worry about not taking care of your relative in the
proper way? Do you worry that your relative might not survive
if you stopped caring for him?' Do you have questions about
how ill your relative is?'

Difficulty completing required tasks

Do you have difficulty making decisions?' Do you have
difficulty in your activities (your work is laborious, causing
suffering)?' Do you find it difficult to satisfactorily perform
your daily activities?'
Do you sometimes feel as if you would like to run away from
the entire situation you find yourself in? Do you feel tied down
by your relative's problem? Do you find it mentally trying to
take care of your relative?
Do you think you have to shoulder too much responsibility
for your relative's welfare? Do you feel nervous, tense or
worried?'

Impaired individual coping

Stress

Lack of time to meet personal needs

Frustration

Dysfunctional change in caregiving activities
Increased emotional lability
Increased nervousness

Do you think you spend so much time with your relative that
your time for yourself is insufficient? Has your social life, e.g.,
time with family and friends, been curtailed?
Do you feel that life has treated you unfairly? Had you
expected that life would be different than it is at your age?
Has your relative's problem prevented you from doing what
you had planned to do in this phase of your life? Do you feel
frustrated?'
Do you feel tired and worn out? Do you perceive changes to
your caregiving activities that should be corrected?'
Has your emotional state changed since you began to care for
the patient?' Have you cried more than usual?'
Do you feel more nervous recently?'
(Corxtmued)

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TABLE 1 : CONTINUED

Somatization

Do you think your own health has suffered because you have
been taking care of your relative? Do you feel pain anywhere
in your body?' Since you have been a caregiver, have you
noticed changes in your body or your health?'

Disturbed sleep

Do you sleep badly?' Do you wake up sometimes
during the night?' Do you fall asleep during the day?'

Headaches

After becoming a caregiver, have you developed
headaches?'

Diabetes

After becoming a caregiver, have you developed
diabetes?'

Cardiovascular disease

After becoming a caregiver, have you developed
cardiovascular disease?'

Rash

After becoming a caregiver, have you developed spots on
your skin or a rash?'

Hypertension

After becoming a caregiver, have you developed
hypertension?'

Fatigue

Do you find it physically trying to take care of your relative?
Do you feel tired all the time?'

Weight change

Have you lost weight lately?' Have you lost your appetite?'

Gastrointestinal upset

Do you have mild stomach cramps, vomiting, diarrhea, or
recurrent gastric ulcer episodes?' Do you have odd sensations
in your stomach?'

Withdrawal from social life

Do you avoid inviting friends and acquaintances home
because of your relative's problem? Has your social life, e.g.,
time with family and friends, been lessened? Have you lost
friendships?' ,

Changes in leisure activities

Have your social and leisure activities (e.g., leaving to rest or
to visit somebody) been modified or disturbed because you
have had the care of your relative?'

Low work productivity

Have you recently missed out on or canceled a commitment,
such as work, school, or something else because you have had
the care of your relative?' Have you worked less or left a job
because of the illness of your relative?'

Refusal of career advancement

Did you leave work to be a caregiver?' Did you refuse
some promotion at work because of having to care for your
relative?'

Difficulty watching care receiver go
through the illness

Do you feel fear for the future of your relative?' In case of the
death of the patient, do you know what steps to take?' Do
you perceive changes in your relative's health?'

Uncertainty regarding changed relationship
with care receiver

Are you sometimes ashamed of your relative's behavior? Do
you ever feel offended by or angry at your relative? Do you
think that your feelings have changed since you started caring
for your relative?'

Grief regarding changed relationship with
care receiver

Do you feel sad due to changes in your feelings?'

Family conflict

Did you leave a harmonious relationship with other relatives
because of the illness of your dependent relative?'

Concerns about family members

Does caring for your relative prevent you from giving other
family members the attention and the time that you would like
to give?'

'Question added.

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Caregiver role strain
there are no measures or techniques to serve as
a 'gold standard' for the identification of nursing diagnoses. Thus, after verifying the classification and agreement among experts, we
decided to use agreement among experts as the
gold standard for identifying the presence of
CRS. This strategy minimizes hias based on an
expert's individual opinion, as reported hy the
study of Guedes, Lopes, Araujo, Moreira, and
Martins (2011).
The experts have received the history of each
of the caregivers that was developed hy researchers
from the data instruments to collect, and determined which were the defining characteristics
present, and later have defined if the diagnostic CRC was present or not. Then, the presence
of nursing diagnosis was determined when the
majority, i.e., at least four experts, agreed on its
presence. During this stage, we defined the sensitivity, specificity, and predictive values for each
clinical indicator based on Lopes, Silva, and
Araujo (2012).
Analytic strategy
For descriptive analysis, we considered absolute and percentage frequencies. We applied the
Kolmogorov-Smirnov test to check for normality. We used the Chi-square test or the Fisher's
test when the expected frequencies were <5 to
measure for legitimacy between the clinical indicators and the nursing diagnosis. The analysis of
the accuracy of the clinical indicators was based
on measures of sensitivity, specificity, predictive
values (positive and negative), likelihood ratios
(positive and negative), and diagnostic odds
ratios (DORs) of the clinical indicators of CRS.
This analysis was applied to clinical indicators
that present a significant statistical relationship
to CRS.
These measures were defined in accordance
with Knottnerus (2002). The sensitivity represents the probability of the presence of a clinical
indicator in patients with the nursing diagnosis.
The specificity represents the probability of the
absence of a clinical indicator in patients without
the nursing diagnosis. The predictive value of a
clinical indicator, if positive, represents the probability of having the nursing diagnosis in patients

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with this clinical indicator. If negative, this
measure represents the probability of the absence
of a nursing diagnosis in patients without this
clinical indicator. The likelihood ratio represents
the probability of the presence or absence of a
clinical indicator in patients with a nursing diagnosis divided by the probability of this indicator
in patients without a nursing diagnosis. The DOR
represents the overall discrimination of a clinical
indicator and is equivalent to the ratio of the positive and negative likelihood ratios (NLRs). In the
present study, the significance level to be adopted
was 0.05.
RESULTS

Most caregivers were women (90.5%), married (57.1%) and patients' daughters (45.2%).
Of the total caregivers, 83.3% of caregivers
did not have paid jobs, and most state they
have abandoned the job to perform the role of
caregiver (40.0%). Furthermore, many caregivers were housewives (22.9%), and many
were retired (20.0%). The caregivers presented
a mean age of 46.39 years (SD = 15.60),
and the mean educational level was 10 years
(SD = 4.39). Eighty-one percent of caregivers
received professional orientation regarding the
care of stroke patients.
Only the variable marital status presented
statistical significance with the nursing diagnosis CRS (p = 0.028). The variables gender
(p = 0.277), age (p = 0.102), and education
level (p = 0.289) not presented statistical significance. The lack of statistical association with
other variables may have been influenced by the
sample size.
From a total of 27 clinical indicators identified, 10 presented a frequency above 50%:
apprehension about the future regarding the
care receivers health (100%); withdrawal from
social life (81.0%); changes in leisure activities
(81.0%); difficulty performing required tasks
(73.8%); increased nervousness (73.8%); preoccupation with care routine (66.7%); disturbed
sleep (64.3%); concerns about family members (64.3%); lack of time to meet personal
needs (61.9%); and increased emotional lability
(61.9%). The evaluators judged that 73.8% of

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Ana Railka de Souza Oliveira et al.
Ten clinical indicators of
CRS described in NANDA-I
Clinical indicators
N (%)
p value taxonomy are not identified
in the caregivers in this study:
_
1. Apprehension about the future
42(100.0)
apprehension regarding posregarding care receiver's health
sible
institutionalization of the
34(81.0)
0.002
2. Withdraws from social life
care
receiver;
cardiovascular dis0.002
3. Changes in leisure activities
34(81.0)
ease;
rash;
weight
change; lack
0.021
4. Difficulty performing required tasks
31 (73.8)
of
career
advancement;
difficulty
0.021
31 (73.8)
5. Increased nervousness
watching
the
care
receiver
go
6. Preoccupation with care routine
28 (66.7)
0.723
through
the
illness;
uncertainty
0.034
27 (64.3)
7. Disturbed sleep
regarding changed relationship
0.034
27 (64.3)
8. Concerns about family members
with
the care receiver; and grief
9. Lack of time to meet personal needs
26 (61.9)
0.011
regarding
changed relationship
26 (61.9)
0.001
10. Increased emotional lability
with
the
care
receiver.
0.291
19(45.2)
11. Headaches
17(40.5)
0.151
Among the nine indicators
12. Gastrointestinal upset
0.477
17(40.5)
13. Family conflict
that could be legitimately con12(28.6)
0.018
14. Stress
nected to the identification of
11 (26.2)
0.696
15. Frustration
the diagnosis, five had positive or
9(21.4)
0.403
16. Anger
NLRs that were not significant,
17. Hypertension
9(21.4)
0.403
i.e., their confidence interval
0.657
8 (19.0)
18. Low work productivity
contained the value 1. Only the
7 (16.7)
0.161
19. Impaired individual coping
indicators of lack of time to meet
0.654
7 (16.7)
20. Fatigue
personal needs, increased emo0.172
6(14.3)
21. Felling depressed
tional lability, withdrawal from
1.000
5(11.9)
22. Apprehension about the future
social life, and changes in leisure
regarding caregiver's ability to
activities presented good values
provide care
for diagnostic accuracy measures.
1.000
23. Apprehension about care receiver's
3(7.1)
The withdrawal from social life
care if caregiver unable to provide care
(Se = 93.55%) and changes in
0.554
3(7.1)
24. Impatience
leisure activities (Se = 93.55%)
1.000
25. Somatization
2 (4.8)
1.000
presented a high value for sensi2 (4.8)
26. Diabetes
1.000
27. Difficulty completing required tasks
1 (2.4)
tivity, indicating individuals who
could appropriately be diagnosed
with CRS. The lack of time
patients with stroke precipitated the CRS nurs- to meet personal needs (PPV = 88.46%) and
ing diagnosis. A summary of clinical indicators increased emotional lability (PPV = 92.31%) are
clinical indicators with high positive predictive
identified in this study is depicted on Table 2.
Nine clinical indicators presented significant values, i.e., individuals with a high probability
statistical legitimacy with the nursing diagnosis of having CRS. Thus, individuals who care for
CRS: wididrawal from social life (p = 0.002); people with stroke should be evaluated for the
changes in leisure aaivities (p = 0.002); increased presence of four clinical indicators. The presence
emotional lability (p = 0.001); difficulty perform- of the first two can be used for screening, and
ing required tasks (p = 0.021); increased nervous- the presence of the last two can confirm the presness (p = 0.021); lack of time to meet personal ence of the diagnosis. Conversely, the presence
needs {p = 0.011); disturbed sleep (p = 0.034); of the first two clinical indicators may indicate
concerns about family members (p = 0.034); and a warning sign for the Riture occurrence of this
diagnosis (Table 3).
stress (^ = 0.018).

TABLE 2: CLINICAL INDICATORS OF NURSING DIAGNOSIS 'CAREGIVER ROLE
STRAIN' IDENTIFIED IN THE SAMPLE

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Caregiver role strain
TABLE 3: SENSiTiviry (SE), SPECIFICITY (SP), POSITIVE PREDICTIVE VALUE ( P P V ) , NEGATIVE PREDICTIVE VALUE ( N P V ) ,
POSITIVE LIKELIHOOD RATIO ( P L R ) , NEGATIVE LIKELIHOOD RATIO ( N L R ) , AND DIAGNOSTIC ODDS RATIO (DOR) WITH
9 5 % CONFIDENCE INTERVALS FOR CLINICAL INDICATORS OF THE CAREGIVER ROLE STRAIN

Clinical indicators
Difficulty performing
recfuired tasks
Lack of time to meet
personal needs
Increased emotional
lability
Increased
nervousness
Disturbed sleep
Withdraws from
social life
Changes in leisure
activities
Concerns about
family members
Stress

Se

Sp

PPV

83.87

54.55

83.87

74.19

72.73

77.42

NPV

PLR [9S% Cl]

NLR [95% Cl]

DOR [95% Cl]

54.55

1.85(0.94-3.62]

0.30(0.11-0.78]

5.84(1.27-30.02]

88.46

50.00

2.72(1.01-7.30]

0.35(0.18-0.71]

7.06(1.58-^1.13]

81.82

92.31

56.25

4.26(1.20-15.12]

0.28(0.14-0.56]

13.58(2.69-115.83]

83.87

54.55

83.87

54.55

1.85(0.94-3.62]

0.30(0.11-0.78]

5.84(1.27-30.02]

74.19
93.55

63.64
54.55

85.19
85.29

46.67
75.00

2.04 (0.90-4.60]
2.06(1.07-3.98]

0.41 (0.19-0.85]
0.12(0.03-0.50]

4.74(1.10-23.51]
15.10(2.59-139.90]

93.55

54.55

85.29

75.00

2.06(1.07-3.98]

0.12(0.03-0.50]

15.10(2.59-139.90]

74.19

63.64

85.19

46.67

2.04 (0.90-4.60]

0.41 (0.19-0.85]

4.74(1.10-23.51]

92.31

39.39

37.50

92.86

1.52(1.06-2.19]

0.20(0.03-1.35]

6.77(1.10-180.26]

DISCUSSION

The sociodemographic characteristics to be
identified were similar to the caregivers' profile presented in international studies (Grant,
Elliot, Weaver, Bartolucci, & Giger, 2002; Lee,
Friedmann, Picot, Thomas, & Kim, 2007; Mak,
Mackenzie, & Lui, 2007; Morimoto, Schreiner,
& Asano, 2003; Smith, Lawrence, Kerr,
Langhorne, & Lees, 2004; Tooth, Mckenna,
Barnett, Prescott, & Murphy, 2005). The caregiver role is assigned to women, despite all the
social changes in family composition and the
new roles women have assumed. Thus, it is
common for women to become the caregivers,
even when they work outside the home. Such
responsibilities resonate with the implication of
greater limitations on free time and a social life,
maybe evidenced by some clinical indicators:
lack of time to meet personal needs; withdrawal
from social life; and changes in leisure activities
(Rudman, Hebert, & Reid, 2006; Visser-Meily
et al., 2009).
Another point to note is the age range of caregivers. Many caregivers are the same age as the stroke
patients, i.e., they are the independent elderly caring for the dependent elderly (May et al., 2005).
This rapprochement between the ages was not

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observed in the present study because the average
age of patients was different from the age of caregivers; however, although these caregivers were
young, most did not have outside jobs, which
corroborates reports from other studies (Perlini
& Faro, 2005). Unfortunately, in many situations caring for a family member does not relieve
the caregiver of his other work and family roles
(Brereton & Nolan, 2000).
On the other hand, the low educational level
of caregivers identified in this study may have
influenced how they received and processed the
information and guidance of the health team,
which will intervene with the care provided
(Resta & Budó, 2004). It is important to note
that most caregivers said that they learned to
provide care based on guidance from health
professionals. This finding is highlighted as a
factor in the learning process of the caregivers
(Gonçalves et al., 2005).
Care is a comprehensive activity because
the caregiver takes responsibility for household
chores and reconciles them with personal care,
which requires the ability to organize time and
to implement care (Smith et al., 2004). These
tasks include everything from personal hygiene
to administering finances for the family (Bakas

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Ana Railka de Souza Oliveira et al.
et al., 2004). The consequences of these new
activities are reflected in the personal lives of
caregivers, creating an overload due to the accumulation of family roles and functions that lead
to excessive physical, psychological and social
burdens (Ellis-Hill et al., 2009).
Evidently, this accumtdation of responsibilities can contribute to the occurrence of the following clinical indicators: concern for family
members; withdrawal from social life; changes
in leisure activities; lack of time to meet personal needs; difficulty performing required
tasks; increased emotional lability; disturbed
sleep; and increased nervousness. Specifically,
changes in leisure activities, lack of time to meet
personal needs, and withdrawal from social life
provoke family conflicts, loneliness and social
exclusion of the caregivers (Berg et al., 2005;
Silva-Smith, 2007).
Related to the adverse conditions and to the
absence of mechanisms for solving immediate
problems, the caregiver is subjected to a problematic situation that can lead to a psychosocial state
of disorganization. This is often accompanied by
negative feelings, such as fear, guilt and anxiety.
Such sentiments favor the presence of the clinical
indicator increased emotional lability; however,
this level of tension cannot be tolerated for long,
which leads to either a positive adaptation or an
adjustment to unhealthy emotional repercussions
(Berg et al., 2005). In the present study, most
caregivers of stroke patients were married, which
makes caregiving more difficult. In addition to
household chores, caregivers have to split their
time between the family (children and spouses)
and caring for the stroke patient. Many times, this
causes sleep and rest alterations that are evidenced
by the presence of the clinical indicators disturbed
sleep and increased emotional lability (Dewey
et al., 2002; Janet et al., 2004).
The clinical indicator apprehension concerning the future regarding the care receiver's health
was identified in all caregivers. That is, caregivers are concerned about what might happen to
their families. One can asstune that this occurs
mainly due to feelings of linkage (Costa, Alves,
& Lunardi, 2006). The commitment, responsibility and difficulty of being replaced (because

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of the insecurity and fear of leaving the family
member alone) cause the caregiver to move away
from activities that have significant meaning for
her (Bocchi & Angelo, 2008). Caring for a family
member frequendy causes antagonistic feelings in
a short amount of time: love and anger; patience
and intolerance; sadness; depression; shame; insecurity; negativity; loneliness; doubt about the
care; fear of getting sick; fear for the suffering
patient; and fear of the patient s death (Brereton
& Nolan, 2000).
Thus, clinicians should pay attention to
the presence of 'lack of time to meet personal
needs, emotional lability increased, withdrawal
from social life, and changes in leisure activities' which indicates the presence of CRS and
contributes to improving diagnostic accuracy by
determining sensitivity, specificity, and positive
and negative predictive factors. However, the
absence of stress indicator reduces the likelihood of an individual presenting the diagnosis
in question (Table 3).
On the other hand, the accuracy in question has
not been stiffidendy invesdgated in studies reading
nursing diagnoses and others studies are fundamental to better delineate the defining charaaerisdcs, and
too is necessary to conduct clinical validadon studies
in others contexts. When working with clinical indicators more accurately, we can develop intervendons
more effective to the reality in quesdon.
CONCLUSION

The study identified that 73.8% of family caregivers of patients suffering from stroke developed
CRS. The defining characteristics for more accuracy were: lack of time to meet personal needs;
increased emotional lability; withdrawals from
social life; and changes in leistue activities. This
study was limited by its methodological design,
which did not include a monitoring of the activities performed by caregivers. Another limitation is
that the caregivers in this study were part of the
home care program. In Brazil, the reality is that
most caregivers of stroke patients are not affiliated
with these programs. This fact may have meant
that these caregivers had a lighter workload because
they received support fi-om a professional health
team. There are few studies regarding CRS. Nurses

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Caregiver role strain
should recognize the need for new clinical evidence
to develop more specific care plans and improve
the effectiveness of implemented treatment.

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being discharged from hospital following a stroke.
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Elmstahl, S., Malmberg, B., & Annerstedt, L. (1996).
Caregiver's burden of patients 3 years after stroke
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Received 12 April 2012

Accepted 15 February 2013

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