The Impact of Relationship Quality on Health-Related Outcomes in Heart Failure Patients and Informal Family Caregivers: An Integrative Review.

Journal of Cardiovascular Nursing

Vol. 30, No. 4S, pp S52YS63 x Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

The Impact of Relationship Quality on Health-Related Outcomes in Heart Failure Patients and Informal Family Caregivers An Integrative Review Stephanie A. Hooker, MS; Megan E. Grigsby, BA; Barbara Riegel, PhD, RN, FAHA, FAAN; David B. Bekelman, MD, MPH Background: Relationships can have positive and negative impacts on health and well-being. Dyadic relationships between heart failure (HF) patients and their informal family caregivers may affect both patient and caregiver outcomes. Objective: The aim of this study is to synthesize the literature to date on the associations between HF patient-caregiver relationship quality and communication and patient and caregiver health outcomes. Methods: An integrative review of the literature was conducted. Computerized literature searches in Medline, PsycInfo, CINAHL, Web of Science, and EMBASE yielded 13 articles of HF patients and caregivers. Included articles were reviewed and double-coded by 2 independent coders. Results: Included articles measured relationship quality or aspects of communication within an HF patient-caregiver dyad and used both cross-sectional and longitudinal designs. Results of the longest prospective study suggested that better relationship quality between HF patients and their informal family caregivers was related to a reduced risk for mortality in patients. Results of 11 of the 12 other studies were consistent to the reference study, suggesting that better relationship quality and communication were related to reduced mortality, increased health status, less distress, and lower caregiver burden. Conclusions: Relationship quality and communication seem to matter in the health and well-being of both HF patients and their informal family caregivers. More research is needed to elucidate mechanisms and to design effective relationship-focused interventions. KEY WORDS:

caregiving, dyads, heart failure, integrative review, spouses

C

hronic heart failure (HF) is a progressive, lifelimiting condition that negatively impacts health and well-being.1,2 Having a family member diagnosed with HF can also greatly impact the caregiver.3 For example, caregivers of patients with severe HF report greater psychosocial distress due to the illness compared with caregivers of patients with coronary artery disease.4 When caregivers are particularly burdened or depressed, patients are at a nearly 2 times greater risk of hospitalization and mortality over 6 months compared with patients whose caregivers are not particularly burdened Stephanie A. Hooker, MS Doctoral Student, Department of Psychology, University of Colorado Denver.

Megan E. Grigsby, BA Doctoral Student, Department of Psychology, University of Colorado Denver.

Barbara Riegel, PhD, RN, FAHA, FAAN Professor of Nursing, Edith Clemmer Steinbreight Chair of Gerontology, and Director, School of Nursing, Biobehavioral Research Center, University of Pennsylvania, Philadelphia.

or depressed.5 Caregiving burden is also positively associated with both patient and caregiver depression and caregiver stress.5,6 Moreover, caregivers who are strained are at a 63% greater risk of mortality than are noncaregiving controls.7 Given these wide-ranging negative outcomes, elucidating factors that reduce risks of these outcomes is essential to improve the health and wellbeing in both HF patients and caregivers. One way to think about improving HF patient and caregiver outcomes is to view the dyad as a relationship Ms Hooker is funded by the American Heart Association Southwest Affiliate Predoctoral Fellowship Award (14PRE18710033). Dr Bekelman is funded by a Department of Veterans Affairs Career Development Award (HSR&D CDA 08-022), the National Institutes of Health, National Institute of Nursing Research (R01NR013422), and the Department of Veterans Affairs Congestive Heart Failure Quality Enhancement Research Initiative. The views expressed in this article are those of the authors and do not necessarily reflect the views of the Department of Veterans Affairs or the US Government. The authors have no conflicts of interest to disclose.

David B. Bekelman, MD, MPH

Correspondence

Associate Professor of Medicine and Nursing, Department of Veterans Affairs, Eastern Colorado Health Care System, Denver; Department of Medicine and College of Nursing, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora.

DOI: 10.1097/JCN.0000000000000270

Stephanie A. Hooker, MS, Department of Psychology University of Colorado Denver Campus Box 173, PO Box 173364 Denver, CO 80217-3364 ([email protected]).

S52 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Dyadic Relationships S53

between 2 people. The relationships we have with others have been shown to impact health and longevity.8,9 In particular, relationship quality, or the extent to which social relations and communication are positive and satisfactory, is more important than the quantity of social relationships.10 For example, low levels of positive relationship quality (the extent to which their children (age Q16 y), spouse/partner, and friends/relatives love and care for them and are willing to listen) and high levels of negative relationship quality (the degree to which they are criticized and feel that too many demands are made of them) are related to an increased risk for mortality in the context of a chronic illness.10 This suggests that relationship quality and communication within a patientcaregiver relationship dyad may be important for health and well-being of both HF patients and caregivers. To date, most research into relationship quality and health has been conducted on marital relationships.11 Increased marital quality and positive relationships are related to decreased morbidity and mortality from serious illnesses12,13 and reduced effects of stress on physical and mental health.12,14,15 Conversely, negative dimensions of relationship quality, such as conflict and hostility, have direct negative effects on the immune, cardiovascular, neurosensory, and endocrine systems.13,16 Notably, evidence from other chronic illnesses (eg, cancer, Parkinson’s disease, Alzheimer’s disease, dementia) suggests that greater relationship quality between patients and caregivers is positively related to better health outcomes.17 This evidence from other chronic illnesses suggests that patient-caregiver relationship and communication quality may also influence HF patients’ quality of life and survival. Indeed, relationships and quality support seem to be beneficial for HF patients as well. For example, single HF patients are at a greater risk for readmission or death compared with those who are married.18,19 In addition, HF patients’ perceived social support is related to fewer hospital readmissions, lower mortality rates, lower risk of depression, and greater quality of life.20,21 Notably, lack of emotional support is related to a 3-fold increase in fatal and nonfatal cardiovascular events in the year after a HF admission.22 Thus, patients’ perceptions that they have strong social support networks are clearly important for their health and well-being. However, these results are not specific to patient-caregiver relationships, and questions remain about how HF patient-caregiver relationship quality affects caregivers as well. Thus, the purpose of the present review is to examine the associations between HF patient-caregiver relationship quality and communication and patient and caregiver outcomes in dyadic studies. Given the potential impact that caregivers have on patient health and outcomes and vice versa, studies that include both patients and caregivers (ie, that are dyadic in nature) may be especially important in better understanding how to

improve quality of care in HF. In addition, a recent statement23 from the American Heart Association recommends that caregivers be included in the care of patients with HF; therefore, a better understanding of their roles in HF care would be useful. Dyadic studies, although logistically difficult to conduct, provide a more complex, family systems approach to studying chronic illness and can therefore elicit useful information about how relationships impact health.24 This synthesis will help professionals working with HF patients and caregivers recognize potentially important dyadic relationship factors that can influence both patient and caregiver health.

Methods The integrative review methodology outlined by Whittemore and Knafl25 was used. Integrative reviews use systematic methods that summarize past theoretical or empirical literature to describe the state of the science and inform theory, practice, and policy development.25 A 5-stage process was used for this review: (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis, and (5) presentation. Problem Identification Our primary research question was ‘‘How does relationship quality between HF patients and their informal family caregivers influence important patient and caregiver outcomes (burden, quality of life, health status, and mortality)?’’ Relationship quality was defined as the degree to which caregivers find satisfaction within their relationships with patients, and vice versa. We also included articles that addressed communication within the dyad as an indicator of relationship quality, as previous research has shown that quality communication is related to relationship quality.26 Importantly, we included both patient and caregiver outcomes because we were interested in the bidirectional processes that occur within a patient-caregiver dyad. For example, a patient may cause a significant amount of burden for a caregiver, and in turn, the caregiver may miss work or experience a decline in health or well-being. Subsequently, the caregiver may be unable to provide optimal care to the patient, leading to lower patient health status. We hypothesized that better relationship quality would be related to better patient and caregiver outcomes. Literature Search Studies were included in the review if they (1) included HF patients and their respective informal family caregivers; (2) measured or described relationship quality and/or communication within the dyad; and (3) measured or described important outcomes, including burden, distress, health status, and mortality. These outcomes were

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

S54 Journal of Cardiovascular Nursing x July/August 2015 chosen because (1) mortality is considered the ‘‘single best measure of health’’27(p721) because it is 1 of the most reliable and a valid measures of health available and (2) health status,28 distress or depressive symptoms,29 and caregiver burden5 have all been shown to be related to mortality risk. Studies were excluded if they were unpublished manuscripts (abstracts or dissertations), case studies, reviews of the literature, or not available in English. Computerized literature searches in PsycInfo, Medline, CINAHL, EMBASE, and Web of Science were used to gather articles that used dyadic research designs in patients with HF and examined relationship quality. The search included all articles indexed in the databases through October 2014, without specifying a beginning date. Keyword, controlled vocabulary, or MeSH term combinations included (‘‘heart failure’’) AND (dyad* OR caregiv* OR spous* OR partner* OR couple*) AND (‘‘relationship quality’’ OR ‘‘marital quality’’ OR ‘‘relationship satisfaction’’ OR ‘‘marital satisfaction’’ OR ‘‘quality of relationship’’ OR ‘‘communication’’). In addition to the above keywords, searches in EMBASE were restricted to human, English language, and articles (or articles in press), and searches in Web of Science were restricted to journal articles. Initial search results returned 31 articles in PsycInfo, 66 articles in Medline, 37 articles in CINAHL, 110 articles in EMBASE, and 77 articles in Web of Science. This produced 205 unique articles that were considered for inclusion. As a first step,

titles and abstracts were reviewed to determine if the articles met the inclusion and exclusion criteria. The full text of the article was reviewed for inclusion if the abstract did not clearly state whether relationship quality or communication were measured. In addition, reference lists of relevant articles were reviewed to ensure that all appropriate studies were included in the review. This process yielded 13 studies; see the Figure for an overview of the literature search and selection of studies. Four of the studies were from 1 cohort, 2 studies were from another cohort, and 7 of the studies were from other cohorts. Data Evaluation In the data evaluation stage, we abstracted elements of each study and evaluated the quality of each study. Two independent reviewers (S.A.H. and M.E.G.) initially reviewed the 13 articles. A second reviewer (S.A.H., M.E.G., B.R., or D.B.B.) confirmed all of the reviews. Given that there is not a ‘‘gold standard’’ for calculating quality scores30,31 and studies identified for the review had diverse methods (eg, observational, qualitative), we did not calculate quality scores or calculate . statistics as indicators of interrater agreement. Instead, 2 reviewers (S.A.H. and M.E.G.) oversaw the process to ensure consistency in the information abstracted from the articles. A variety of factors were abstracted from each article; see Table 1 for the data that were extracted.

FIGURE. Overview of literature search and selection of studies.


Dyadic Relationships S55 TABLE 1

Data Extracted From Studies Included in the Review First author Year of publication Journal Sample size Proportion female Average or median age Comorbidities Population (recruitment) Type of study (eg, cross-sectional, longitudinal, intervention) How relationship quality or communication was measured Outcome Covariates Relevant results Strengths Limitations

Data Analysis and Presentation A constant comparison method was used to analyze the results. The study conducted by Rohrbaugh and colleagues32 was used as the reference study, and each subsequent study was compared with that study. The Rohrbaugh et al32 study was used as the reference study because (1) it included a multidimensional assessment of relationship quality that included both self-report and observer-rated measures; (2) it had a relatively large sample of married couples (N = 189); (3) it included a longitudinal outcome of 8-year mortality status; and (4) analyses were controlled for potential confounders, including HF severity and other psychosocial characteristics (ie, self-efficacy, psychological distress, hostility, neuroticism, social support). Thus, in comparing each study with the reference study, we compared (1) the measure of relationship quality or communication, (2) the study design (ie, sampling, sample size, etc), (3) the outcome, (4) the statistical analysis, (5) the results, and (6) the strengths and limitations. Results were grouped by each comparison category. Data from primary sources were displayed in tables to enhance the visualization of patterns. Finally, the reviewers drew inferences regarding the impact of relationship quality between HF patients and their respective caregivers on outcomes.

Results Measure of Relationship Quality or Communication Three studies examined data from the reference study cohort using the composite measure of self-reported marital satisfaction, self-reported marital ratings, selfreported useful illness discussions, and observed positivity in both patients and caregivers.33Y35 Two other studies also used multimethod assessments of relationship quality.26,36 The first36 measured the partner’s perception of marital quality (Relationship Assessment Scale),

communication within the dyad (Constructive Communication Scale), and observer-rated positive and negative exchanges during a marital interaction (Rapid Marital Interaction Coding System) in both members of the dyad. The second26 coded transcripts of an interview with the dyad using the Linguistic Inquiry and Word Count software to count (a) first person plural (we) and singular (eg, I) pronouns, (b) the ratio of we/I pronouns, and (c) plural active (we active), plural passive (us/our passive), singular active (I active), and singular passive (me/my passive) pronouns with total first-person pronouns as the denominator. The authors suggested that greater plural pronoun use (we/I ratio) was an indicator of better relationship quality and communication within the dyad. In addition, the authors measured self-reported communal coping (sharing the ‘‘problem’’ of the illness) and self-reported marital quality (Relationship Assessment Scale) in both members of the dyad. These studies were all from 2 cohorts. In contrast to the reference study, several studies used single measure indicators of relationship quality or communication. Four studies37Y40 used self-report measures of relationship or marital quality (Mutuality Scale of the Family Caregiving Inventory, the Dyadic Adjustment Scale, the Caregiver Esteem Subscale, and Cantril’s Ladder single-item quality of marital relationship), and 2 studies41,42 assessed self-reported communication concerns within the relationship. The last study was a qualitative study43 that classified the communication between patient-caregiver dyads as congruent, incongruent, or both. Congruence was defined as consistency in perspectives and was considered to be indicative of empathy from the caregiver to the patient. Study Design Like the Rohrbaugh et al32 study, 5 other studies used a longitudinal cohort study design; however, all studies had shorter follow-ups than the reference study did (ranging from 6 months to 4 years). Two of these33,34 were the same original sample as the reference study with a 4-year follow-up time. Two studies (same cohort)26,36 had 6-month follow-up from the same sample, and 1 study had 12-month follow-up data from a completely separate sample.42 Six studies used cross-sectional designs,35,37Y41 and 1 study used a qualitative design.43 Most studies had smaller (or equivalent) sample sizes than the reference study (which recruited 189 dyads), with samples ranging from 17 to 60 dyads. One study40 recruited a very large sample (N = 357). The mean age of the patients in the reference study (53 years) was the lowest compared with the rest of the studies (range, 65Y77 years). Similarly, with the exception of 1 study,37 the mean age of the caregivers in the reference study was the lowest (52 years) compared with that of other samples (range, 60.3Y69 years). Like the reference study, most patient samples were predominantly male. Only


S56 Journal of Cardiovascular Nursing x July/August 2015 1 study38 reported a predominantly female patient sample (70% female). Conversely, like the reference study, most caregiver samples were predominantly female (range, 70%Y95% female). The reference study included 100% spousal caregivers, like 7 other studies included in this review. Within the studies that also included nonspousal caregivers, it was typical that most caregivers included were spousal caregivers (range, 40%Y63%), followed by children (29%Y44%) and other relatives (4%Y16%). Outcomes The reference study used all-cause mortality as the primary outcome, as did the 2 other studies on the same cohort33,34 (see Table 2). Two other studies assessed health status (using the Short Form-36 in both patients and caregivers) and HF symptoms as the primary outcomes26,36 (see Table 3). Six of the studies used caregiver burden as the primary outcome,37Y42 measured by the Zarit Burden Inventory or the Caregiver Reaction TABLE 2

Assessment. Two studies measured psychological distress in both members of the dyad35,43 (see Table 4). Statistical Analysis The gold standard analytic technique in dyadic analysis is actor-partner interdependence modeling (APIM), as described by Rayens and Svavarsdottir.44 In APIM, 3 classes of variables are included in the model: (1) betweendyads variables, (2) within-dyads variables, and (3) mixed variables (variables that vary both between and within dyads). In general, APIM models are conducted within a multilevel or hierarchical regression model, which accounts for the intraclass correlation, or the extent to which there is variation within the dyads. None of the studies included in this review used APIM or accounted for the intraclass correlation in their models. Nonetheless, the reference study35 used a survival analysis with patient and caregiver relationship quality to predict a patient outcome (mortality). Similarly, the remaining studies on

Mortality Outcomes

First Author, Year, Country, Study Design

HF Patient Population Studied

Caregiver Characteristics

Coyne,33 2001, United States, longitudinal cohort design

N = 189; 26% female; mean age, 53 y (range, 29Y78 y)

N = 189; 74% female; mean age, 52 y (range, 29Y75 y); 100% spouses

Rohrbaugh,34 2004, United States, longitudinal cohort design

N = 191; 26% female; mean age, 53 (range, 29Y78 y)


Rohrbaugh,32 2006, United States, longitudinal cohort design, reference study



Strengths

Relationship Factor

Results

Marital quality composite: self-reported marital satisfaction, marital routines, and useful illness discussions and observed positivity during a marital interaction Same as above

Higher marital quality was associated with longer survival (at 4 y), especially for female patients.

Same as above

Marital quality was positively related to patient self-efficacy and spouse confidence in patient. Marital quality reduced the relationship between spouse confidence and survival (at 4 y) to nonsignificance. Higher marital quality was related to greater survival at 8-y follow-up. Follow-up analyses indicated that marital quality was predictive of 8-y survival only in women.

Limitations

Physicians confirmed HF diagnoses.

Studies were longitudinal (8 y).

Marital quality was a composite that included self-reports from patients and spouses as well as observer ratings.

Caregivers were all spouses, and therefore, patients and spouses may have better psychosocial functioning than nonmarried patients did. Patients in the sample were younger than average community samples of HF patients, were primarily male (74% male patient couples), and may have had more severe illness limitations than the average HF patient sample does. All measures of marital quality were conducted at baseline; therefore, change in marital quality over time could not be examined.

Abbreviation: HF, heart failure.


Dyadic Relationships S57 TABLE 3

Health Status Outcomes

Author, Year, Country Study Design 26

HF Patient Population Studied

Rohrbaugh, 2008, United States, longitudinal cohort design

N = 57; 28% female; mean (SD) age, 67 (11.7) y

Rohrbaugh,36 2009, United States, longitudinal cohort design

N = 57; 28% female; mean (SD) age, 67 (11.7) y


Relationship Factor

Results

N = 57; 72% Pronoun use, communal female; mean (SD) coping (both members age, 66 (10.7) y; of the dyad), marital 100% spouses quality (both members of the dyad)

Spousal ‘‘we’’ talk was positively associated with positive changes in patient’s health and HF symptoms. Communal coping was not related to HF symptoms. Marital quality was positively associated with patient health and HF symptoms at baseline and prospectively at 6 mo. N = 57; 72% Partner’s perception of Patient distress was negatively female; mean (SD) marital quality (both related to marital quality but age, 66 (10.7) y; members of the dyad), not to the couples’ observed 100% spouses observed positivity during positivity during the marital a marital interaction interaction. Observed positivity was positively related to change in patient’s HF symptoms

Strengths

Limitations

Longitudinal Prospectively examined change in both symptoms and health status

Used several measures of relationship quality, including both self-report (marital quality, communal coping, and communication) and objective measures (positivity and pronoun use during a marital interaction)

Small, nonrandom sample of primarily male patient couples Baseline assessments done in person, whereas follow-up assessments were done by telephone. The change in method may have impacted the change in symptoms and health status. Word counts do not take semantic contextual factors into account and may miss underlying meanings.

Abbreviation: HF, heart failure.

the same cohort26,33,34 and in another longitudinal cohort35,36 used analyses that included both patient and caregiver variables (patient and caregiver relationship quality or communication) to predict patient (mortality, health status, distress) and caregiver (health status and distress) outcomes. Two other studies39,41 assessed both patient and caregiver relationship quality or communication concerns as predictors of caregiver burden. One study43 used a qualitative analysis of dyadic interviews, and the remaining 4 studies37,38,41,42 used caregiver predictors (relationship quality or communication concerns) to predict caregiver burden. Study Results In the reference study, marital quality was significantly related to greater survival at 8-year follow-up (P G .001); however, when stratified by gender, marital quality was related to survival only in female patients (P = .009). Approximately 60% of female patients in the high marital quality group were alive at 8-year follow-up, whereas fewer than 30% of female patients in the low marital quality of group were alive at 8-year follow-up.32 In the first study33 on this cohort, female patient couples had higher marital quality than male patient couples did. Adjusting for HF severity (New York Heart Association

class, left ventricular ejection fraction, and maximal oxygen consumption), marital quality significantly predicted survival at 4-year follow-up (P G .001). Seventy percent of patients with high marital quality were alive at 4 years compared with fewer than half of the sample with low marital quality. Again, the association was stronger for women than for men. Marital quality remained an important predictor of mortality after adjusting for spousal confidence in and patients’self-efficacy for self-care.34 Two studies (same cohort)26,36 examined the impact of relationship factors on patient health status. The first study26 showed that patients used more ‘‘I’’ talk than spouses did, and spouses used more ‘‘we’’ talk than patients did, regardless of gender. Controlling for patient and spousal depression and anxiety symptoms, total words, and total pronoun use, spousal ‘‘we’’ talk was positively associated with positive changes in patients’ health and HF symptoms, whereas patients’ ‘‘we’’ talk was not. These results were consistent with the reference study, suggesting that positive communication was related to improved health status. In another analysis with the same sample,36 patient distress was negatively related to marital quality but not to the couples’ observed positivity during the marital interaction. Controlling for


N = 179 (47 with HF); N = 179 (47 HF); 81% Communication 32% (HF) female; (HF caregivers) female; concerns mean (SD) age (HF), mean (SD) age (HF 75 (8) y caregivers), = 62 (14) y; 60% spouses

Garlo,42 2010, United States, longitudinal cohort design

N = 357; 75% female; Marital quality (Cantril mean (SD) age, 67 Ladder, 1 item) (12) y; 100% spouses or partners

N = 357; 25% female; mean (SD) age, 68 (11) y

Marital quality (self-reported marital satisfaction and marital routines)

Luttik,40 2007, the Netherlands, cross-sectional

N = 181, 73% female; mean age, 52 (range, 29Y75 y); 100% spouses

N = 193 (52 with HF); N = 193 (52 HF); Communication 30% female (HF); 80% (HF caregivers) concerns mean (SD) age (HF), female; mean (SD) age 75 (8) y (HF caregivers), 62 (14) y; 63% spouses


Relationship Factor

Fried,41 2005, United States, Cross-sectional

Rohrbaugh, 2002, United States, cross-sectional

35


Caregiver Burden and Distress Outcomes

Author, Year, Country HF Patient Study Design Population Studied

TABLE 4

Large sample Several measures of disease burden Data collected by independent interviewers

Patients and caregivers interviewed separately Systematic sample in a community with a limited geographic area.

Physician confirmed diagnosis of HF

Strengths

Median caregiver burden for Includes nonspousal HF caregivers = 8, compared caregivers with 4 for cancer and COPD caregivers. Caregiver desire for more communication was associated with greater caregiver burden both cross-sectionally and longitudinally.

Caregiver burden was higher in caregivers who desired more communication; however, when patients also desired more communication, caregiver burden was higher than when patients did not also desire more communication. Caregiver reported quality of marital relationship was negatively associated with caregiver burden; however, after controlling for HF severity, objective burden, and partner characteristics, marital quality was no longer significantly associated with burden.

Marital quality was negatively associated with distress in both members of the dyad.

Results


(continues)

Cross-sectional Only spousal caregivers Possibility that dyads may have discussed the questionnaires with one another because these were completed at home. 1-item measure of marital quality Results not separated by illness type Dropout related to worsening health or death Caregivers categorized into high- or low-burden groups, yet there is not an accepted cut-point for the categorization.

Cross-sectional Same-gender interviewer-interviewee pairings (male patients may be less likely to report distress to a male interviewer than to a female interviewer) Mostly self-report data (except LVEF and peak V˙O2 during cardiopulmonary stress test) Cross-sectional No clear clinical interpretation of the differences in burden scores between groups

Limitations

S58 Journal of Cardiovascular Nursing x July/August 2015


Relationship Factor

Results

N = 50; 70% female; Relationship quality Caregiver-reported relationship mean age, 60 y; (Caregiver Esteem quality was negatively 40% spouses 34% Subscale) associated with daughters, 10% sons, caregiver burden. 16% other relatives N = 23; 0% female; N = 23; 100% Relationship satisfaction Patient’s reported relationship mean (SD) age, 66 female; mean age (Dyadic Adjustment satisfaction was negatively (7) y not reported; Scale) associated with caregiver’s 100% spouses perceived burden and depressive symptoms. N = 17; 35% female; N = 17; 94% female; Patient-caregiver Dyads were classified as mean age mean age (parent-child congruence congruent (7), incongruent (parent-child dyads), dyads), 51 y (range, (4), both (5), and absent (1). 76 y (range, 30Y54 y); mean age Incongruence or absence of 60Y92 y); mean age (patient-partner communication was generally (patient-partner dyads), 69 y (range, associated with distress or dyads); 66 y (range, 37Y89 y); 59% spouses tension in the patient, 34Y89 y) caregiver, or both. N = 19; 37% female; N = 19; 95% female; Relationship quality Caregiver-reported relationship mean age, 69 y mean age, 59 y (range, (Mutuality Scale) quality was negatively correlated (range, 34Y989 y) 30Y89 y); 58% spouses with caregiver burden and depressive symptoms and positively correlated with benefit finding. The association between relationship quality and caregiver burden remained after controlling for depression.


Strengths

Includes nonspousal caregivers

Includes nonspousal caregivers

Included a conceptual model

Included both spousal and nonspousal caregivers

Abbreviations: COPD, chronic obstructive pulmonary disease; HF, heart failure; LVEF, left ventricular ejection fraction; V˙O2, maximal oxygen consumption.

Lum,37 2014, United States, cross-sectional

Retrum,43 2013, United States, qualitative

Trivedi,39 2012, United States, cross-sectional

Yeh,38 2012, United States, crosssectional


Caregiver Burden and Distress Outcomes, Continued

Author, Year, Country HF Patient Study Design Population Studied

TABLE 4

Limitations

Small sample Recruited from 1 academic medical center Cross-sectional

Small sample Qualitative interview may have missed positive aspects of HF that influences congruence

Small sample Cross-sectional Primarily caregiver perspectives (only 1 patient measure) Small sample Cross-sectional Only spousal caregivers


S60 Journal of Cardiovascular Nursing x July/August 2015 gender, illness severity, and partner depression and anxiety symptoms, greater observed positivity was related to decreases in patients’ HF symptoms. Again, these results were consistent with the reference study in that better relationship quality was related to a decrease in HF symptoms. Nine studies examined associations between caregiver burden or distress and relationship factors. Three cross-sectional studies found that the quality of the relationship between patients and caregivers was negatively associated with caregiver burden,37Y39 and 3 studies showed that relationship quality was negatively associated with distress or depressive symptoms.35,37,39 In contrast with the reference study, in 1 large sample (N = 357 dyads),40 the association between relationship quality and burden was no longer significant after controlling for relevant confounders (demographics, objective burden tasks, HF severity, and health status). Consistent with the reference study, 2 studies showed that greater communication concerns were related to greater caregiver burden or distress,41,42 and 1 qualitative study43 found a theme that when dyads’ communication styles were labeled as incongruent or absent, there was more discussion of tension or distress in the narratives of the patient, caregiver, or both. This was also consistent with the reference study. In sum, nearly all (11/12) studies had results that were consistent with the reference study.

Discussion This is the first review of relationship quality and communication in HF patient and informal family caregiver dyads. Although the research area is fairly young, evidence suggests that relationship and communication quality between patients and caregivers matters in the health and well-being of both patients and caregivers. The reference study in this review, a well-conducted cohort study, shows that HF patients with quality marriages live longer than do patients with poor quality marriages, and this is especially true for female patients.32 In addition to the reference study, 11 of 12 studies demonstrate that in dyads with better quality relationships and better communication, caregivers report less burden, both patients and caregivers report less distress, and patients experience improved health status and reduced risk for mortality. These results are consistent with the literature showing that social relationships are influential for health.8Y11 In addition, results are consistent with studies on the relationships between patients with other chronic illnesses and their informal family caregivers that has shown associations between relationship quality and health outcomes.17 It seems that the relationship dynamics between HF patients and caregivers similarly affect health outcomes as they do in other patients with chronic illnesses. The question remains: How does relationship quality between patients and informal family caregivers impact

dyads’ health and well-being? Dyadic relationship quality, such as marital quality, is hypothesized to improve health through a variety of pathways, including affective and social-cognitive processes, mental health, healthy behaviors, and physiological processes.45 When the relationship is positive, marriage provides positive well-being and is associated with positive effects on physiological mechanisms.12,13 It could be that positive caregiving relationships have the same effects on health and wellbeing. In addition, emerging evidence suggests that quality patient-caregiver relationships impact self-care, which in turn could improve health status and well-being.46 However, more research is needed to further understand the mechanisms relating relationship quality to health and well-being. There are several future directions for this line of research. First, including caregivers with different relationships to the patient (eg, sons and daughters, other relatives, and friends) is important because these individuals also play important roles in patients’ lives. Moreover, there is evidence that they are differentially affected by the caregiver role compared with spousal caregivers.47 Second, ensuring that female HF patients are represented in studies is important as they comprise half of all HF patients yet are underrepresented in research.48,49 Future studies should consider targeting female HF patients for recruitment. Third, research in this area should focus on developing and testing conceptual models of how dyadic relationships affect health. Only 1 research group39 has presented a conceptual model; however, larger sample sizes with more sophisticated statistical testing (eg, actor partner modeling, structural equation modeling) of these or other conceptual models are needed. Developing these models may also elucidate mediating factors that would better explain why relationships are important for the health and wellbeing of HF patients and their caregivers. Fourth, relationship and health factors should be measured in both members of the dyad. Some studies have already done this; however, others have focused more on caregivers than patients or vice versa. Capturing both perspectives is key to understanding the true nature of the dyadic relationship. Fifth, measuring relationship quality on both members of the dyad over time would be a key addition to the literature. Finally, intervention studies targeting relationship quality to improve health outcomes are needed. Despite the limitations noted above, the overwhelming majority of studies have shown positive relationships between relationship quality and mortality, health status, and distress, prompting the need for a randomized trial to confirm these outcomes. Larger-scale efficacy trials also have the potential to examine causal mechanisms. In regard to practice, providers should consider assessing whether an HF patient has an informal family caregiver and, if so, how the relationship between the



What’s New and Important h This is the first review of HF patient and informal family caregiver dyad relationship quality and communication and important patient and caregiver health and well-being outcomes. h In 11 of the 12 studies reviewed, relationship quality and communication were positively related to the health and well-being of HF patients and their caregivers. h More research is needed to determine causality, elucidate mechanisms, and design effective relationship-focused interventions. h Asking about relationship quality may yield important information about the health and well-being of both the HF patients and their informal family caregivers.

patient and the caregiver is going. Empathic communication and problem solving strategies may reduce burden (eg, a referral for additional community services, engaging additional family). If the relationship quality and communication between the patient and the caregiver are poor, consider a referral to a support group, social worker, or behavioral health specialist. Strengths and Limitations The reference study was chosen because of several strengths, including its longitudinal cohort study design. Several other studies shared that strength, including the 2 other studies on the same cohort33,34 and 3 other studies.26,36,42 The reference study also had physicianconfirmed HF diagnoses, a strength shared by 3 other studies.33Y35 The reference study also used multiple assessments of relationship quality; this strength was shared by the other 3 studies using this cohort33Y35 and 1 other study.36 Finally, the sample of HF patient-caregiver dyads was fairly large (9100 dyads) in the reference study (N = 187), a strength shared by only 4 other studies.33Y35,40 Two studies had larger samples,41,42 but less than a third of their samples were composed of HF patients and results were not presented by chronic illness type. Other studies had strengths that the reference study did not. First, 5 studies37Y39,41,42 included nonspousal caregivers, which we considered a major strength. One limitation of the reference study was that patients were all married, which made the results less generalizable to patients with nonspousal caregivers. Several other studies shared this limitation.26,33Y37,39,40 In addition, although the reference study was longitudinal, marital quality was assessed only at baseline. Marital quality may have changed over time. This was true for all the longitudinal studies in this review; none of the studies showed how changes in relationship quality or communication were related to changes in health outcomes. Finally, the reference study included HF patients who were, on average, much younger than the average HF patient sample. The studies that used this cohort had this limitation as well.33Y35

Limitations of other studies included very small samples37,39,43 and the use of only 1 self-report measure of relationship quality or communication as the primary predictor.37Y42 Of note, the 1 study40 that did not find a relationship between marital quality and caregiver burden after controlling for confounders used a 1-item measure of marital quality. The 1-item measure demonstrated little variability, potentially leading to these results. There are important limitations of this review. There are few studies examining the associations between HF patient and caregiver relationship quality, and 4 studies are from 1 study cohort.26,32Y36 Moreover, the overwhelming majority of patients are male, Midwestern, and predominantly white. Female and minority patients from diverse regions are underrepresented. However, this is consistent with the bulk of research in cardiovascular disease.48,49 In addition, socioeconomic status is often not reported, making it difficult to judge generalizability. Although not necessarily a limitation, these studies use a variety of different relationship factor measures. Because many different aspects of relationship quality and communication seem to matter in the health and well-being of HF patients and caregivers, multidimensional measures of relationship quality should be used in studies examining the impact of relationships on patient and caregiver health and well-being outcomes in HF. Currently, there are no multidimensional measures available; thus, measuring several dimensions, such as perceived relationship quality, communication, and observed positivity in the relationship, is the best approach.

Conclusion Relationship quality and communication are associated with the health and well-being of HF patients and their informal family caregivers. However, it is unclear how these factors are related to improved health and wellbeing in both patients and caregivers. Future research should continue to include perspectives of diverse samples of both patients and caregivers to better explain the mechanisms accounting for the associations between relationship quality and communication and HF patient and caregiver health and well-being. In addition, efficacy trials testing interventions to improve patientcaregiver relationship quality and communication would provide causal evidence that relationship quality and communication improve patient-caregiver health and well-being.

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