This paper will discuss the definition, roles and evolution of the family caregiver, before delving into the topic of caregiver fear – including the sources, consequences and mechanisms for alleviation.

1. Understanding and
Alleviating Caregiver Fear
Lisa Herms, MSc, Research Analyst, Sodexo
Rachel S. Permuth, PhD, MSPH, National Research Director, Sodexo

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The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2016
In 2013, about 40 million family caregivers in the United States
provided an estimated 37 billion hours of care to an adult with
health-, disability-, or age-related limitations in daily activities.
The estimated economic value of this unpaid contribution was
approximately $470 billion.1
Aside from the economic value,
caregiving has also been linked with the quality of life and
health of patients.
Proper caregiving can help to reduce hospital readmissions and
enable quicker recovery. At the same time, poor – or rather
uninformed – caregiving has been linked with an increase in
readmission rates.2
The contribution of caregivers is, therefore,
unquestionably clear. In fact, many consider family caregivers
to be the very foundation of the U.S. health care system, as
they provide care and assist in recovery at home, and help
disseminate new multimodality treatment protocols.3
At the same time, the role of the caregiver can be extremely
difficult, stressful, daunting and overwhelming. To enable
caregivers to provide optimal treatment, the health care system
must also ensure that the caregivers are taken care of. This
means expanding the traditional view of providing care to go
beyond the patient – recognizing caregivers and the important
role they play.
In the effort to achieve better health outcomes and healthier
populations, the health care profession must acknowledge their
stressors and fears, and actively seek to alleviate them through
support, information, and other mechanisms or programs.
This paper will discuss the definition, roles and evolution of
the family caregiver, before delving into the topic of caregiver
fear – including the sources, consequences and mechanisms for
alleviation.
Many consider family
caregivers to be the very
foundation of the U.S. health
care system.
Definition of the
Caregiver
In this paper, we will focus on caregivers for discharged patients,
meaning those who accompany a loved one during and after
a treatment pathway. Of course, in reality, the concept of
caregiving is much broader. In particular, many of the themes in
this paper also have implications for caregiving in senior living
facilities.
Family caregivers, also known as informal caregivers, provide
a complex array of support tasks for a discharged patient that
extends across physical, psychological, spiritual and emotional
domains.4
Caregivers undertake multifaceted responsibilities
and roles, including those in Figure 1.5

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As such, they cannot be reproduced or utilized without permission. ©2016
Figure 1: Common Roles for Caregivers
The Changing Nature of
the Caregiver
In the wake of demographic shifts and medical advances, the
profile of patient caregivers is changing rapidly.
Women have historically been the primary contributors to
unpaid family-based caring. Yet, with an increasingly large
portion of women working out-of-home, the costs and strains of
caregiving are growing.
Living arrangements are changing and impacting the nature
of caregiving. Multi-generational households, which have
historically been the basis for flexible care arrangements, are
becoming rarer in industrialized countries. At the same time,
single-person households are increasing.
In addition, while caregivers may be able to meet their
charge’s daily needs, they may struggle with aspects of social
interaction that require the support of other individuals or local
organizations for routine practicalities, such as transport.
These factors contribute to a shrinking population of caregivers,
many of whom are subject to greater pressures, while the need
for caregivers continues to grow. As such, the changing nature
of caregiving is a source of fear for current and potential
caregivers who may be called upon to help their loved ones.
There is a shrinking population
of caregivers, many of
whom are subject to greater
pressures, while the need for
caregivers continues to grow.
• Hands-On Provider: Caregivers
sometimes themselves turn into service
providers, ranging from medication
administration, to accompanying
the patient to medical appointments,
running personal errands, managing
cooking, cleaning, assisting the patient
with personal hygiene and other
housekeeping tasks.
• Communicator: Communication
barriers often arise within certain
patient groups, including older patients,
patients with lower levels of education
and culturally disparate groups. The
family caregiver will often undertake
the role of communicator, serving as
the link between medical personnel and
the patients themselves, and thereby
ensuring patients feel safe.
• Decision Maker: Decisions about
treatment options, role changes and
finances are generally made by the
patient-family (patient-caregiver)
unit. Caregivers are often tasked with
making decisions either alongside or on
behalf of a patient.6,7
• Advocate: Caregivers often become
advocates for their loved ones. This
includes taking over administrative
tasks, such as care management,
managing insurance claims and bills,
actively seeking information and
contacting doctors.
• Social Support: One of the most
fundamental tasks of the caregiver
is to provide companionship and
socialize with patients, to make them
feel supported and retain a sense of
normalcy.

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The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2016
Sources of Fear
for Caregivers
The changing situation for caregivers is a major source of fear,
even though it may be largely unknown outside of the health
care sphere. However, there are several more concrete primary
drivers of caregiver fear.
The prevalence of specific fears differs depending on the specific
role of the caregiver and also the characteristics of the patients,
but a few fears are generally considered to be universal. When
listening to the experiences of caregivers, three very important
questions come up. These questions, and the specific fears they
can lead to, are displayed in Figure 2.
At the root of caregiver fear
is the loss of control and
loneliness associated with
being a caregiver.
Figure 2: Key Fears of Caregivers
Consequences of
Caregiver Fear
Consequences for Caregivers
The key struggle many caregivers face is loneliness. Loneliness
is a result of fear – fear of showing emotions, fear of reaching
out, and fear of appearing selfish. At the same time, stress and
fear can also result in caregivers not properly taking care of
themselves. This can include poor eating habits, not getting
enough sleep, not taking their own medications or tending to
their own chronic conditions, poor grooming, or a lack of social
interactions.
As a result, caregivers experience severe strains on their
physical and mental health. Between 10-20% of caregivers
indicate that their general health status has gotten worse
as a result of becoming a caregiver.8
An estimated 17-35%
of family caregivers view their health as either fair or poor.9
Research has also found caregivers to be at risk for fatigue
What if I fail?
What if I provide insufficient care?
What if I miss vital warning signs?
What if I don’t foresee and handle any complications?
What if I lose control?
What will happen to my loved one if I die?
What if the disease comes back?
What if I can’t handle it emotionally?
What if I feel ashamed?
What if I feel resentment toward my loved one?
What if I show my loved one that they are a burden?
What if I showcase emotions - especially despair?
What if I am selfish and need support for myself?

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As such, they cannot be reproduced or utilized without permission. ©2016
and sleep disturbances,10
immune system problems11
, slower
wound healing12
, higher blood pressure13
, and higher risks
for cardiovascular disease.14
Between 40% - 70% of family
caregivers experience clinical symptoms of depression, which
are often caused by loneliness and isolation.15
Not surprisingly, caregiving also negatively impacts the
caregiver’s work life. More than 1 in 6 individuals working
full or part time report that caregiving for 15 hours per week
significantly affects their work life.16
70% of working caregivers
suffer work-related difficulties due to their dual roles.17
Among
working caregivers, 69% report having to rearrange their work
schedules, decrease their hours, or take unpaid leave in order
to meet their caregiving responsibilities.18
Others turn down a
promotion, choose early retirement, or even give up working
entirely, to care for sick loved ones.19
Consequences for Patients
Research has identified a clear reciprocal relationship between
patient and caregiver fear.20,21
The patient’s distress affects their
caregiver’s distress, but also the caregiver’s distress affects the
patient – perhaps even more so.22-24
Caregivers may unwillingly project their fear onto their
patients. Seeing their caregiver suffer, a patient may feel like a
burden. This has negative implications for successful recovery.
Alternatively, seeing their caregivers “give up”, patients may
become afraid for their own coping mechanisms. If their
caregiver is in despair, how are they, the patients, supposed to
remain optimistic?
A large body of research has documented that when caregivers
feel more confident in their ability to provide care, patients
have better symptom management25
, better medication
management26
, spend less time in bed, have more energy, and
have a higher physical quality of life.27
By inference, a lack of
caregiver confidence has adverse effects on the patient.
Alleviating the Fear
of Caregivers
Given the negative repercussions of caregiver fear – both on the
caregiver and their charges – it seems clear that the next step
in the journey toward better health is a focus on the caregivers.
For everyone’s well-being, health care providers must work
toward recognizing, understanding and alleviating caregivers’
fear. The underlying mechanism of doing so is to implement
initiatives targeted at providing information and social support
to combat feelings of loss of control and loneliness.
With this in mind, two approaches can serve as starting points
(Figure 3):
Figure 3: Approaches to Caring for Informal or
Family Caregivers
Caring for Informal or Family Caregivers
Helping Caregivers
Achieve a Sense of Normal
Helping Caregivers
Provide Care
ƒƒ Employment-related
Factors
ƒƒ Provide Information,
Education and Training
ƒƒ Social Connection and
Support
ƒƒ Reduce the Caregiver
Burden
Between 10-20% of caregivers
indicate that their general
health status has gotten worse
as a result of becoming a
caregiver.

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As such, they cannot be reproduced or utilized without permission. ©2016
Helping Caregivers Achieve a Sense of
Normal
To help caregivers cope with their loved one’s illnesses and
provide support, caregivers themselves must also be provided
with some form of support or assistance to help them achieve
or retain a sense of normal.
Employment-related Factors
Employment-related factors refer to any efforts that allow
caregivers to retain their employment status, while also
succeeding in their role as caregivers.
In today’s environment, the majority of informal caregivers
are employed when tragedy – or illness – strikes their families.
When events take an unexpected turn and a loved one requires
care after discharge from the hospital, this is a disruption from
the caregiver’s normal way of life, in more ways than one.
Amongst many other aspects is the disruption of a caregiver’s
normal employment situation. As discussed, research shows
that caregiving responsibilities can negatively impact work
roles, as caregivers struggle to adapt their employment
obligations to simultaneously be able to meet care demands.28
In an always-on society, it is very difficult, if not impossible,
to perform a job in the same manner as before, and
simultaneously take on the role of a caregiver. However, the
alternative – leaving their place of employment – may not only
be economically infeasible, but would be a further disruption
and source of anxiety for caregivers.
To alleviate caregiver fear, employers can help caregivers
achieve a sense of normal – by accounting for the fact that
they may need some special support or accommodations.
Employers can provide caregivers some respite from ongoing
activities, thereby serving as a buffer to distress and helping to
find a middle ground.29,30
Flexible scheduling and work arrangements, for example, can
help a caregiver juggle both their work life and their role as a
family caregiver, without requiring them to give up one over the
other. San Francisco has recently led the way in such an effort.
Its “Family Friendly Workplace Ordinance” prohibits caregiver
discrimination and gives employees the right to request flexible
or predictable working arrangements, to allow them to follow
their caregiving responsibilities for children, family members
with serious health conditions, or parents age 65 or older.31
Another example of an employment-related anxiety alleviation
mechanism is concierge-type services at the workplace that can
allow employed caregivers to make necessary arrangements
while they are at work. For example, Sodexo’s Circles program
offers employees an on-demand personal assistant in and out
of the workplace, to help ease their day-to-day demands, from
dry-cleaning to meal services and grocery delivery.
Concierge-type services at
the workplace can allow
employed caregivers to make
necessary arrangements while
they are at work.

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As such, they cannot be reproduced or utilized without permission. ©2016
Providing Social Connection
For caregivers, achieving a sense of normalcy also includes
having the ability to remain socially connected. Being
a caregiver, just like being a patient, is a very isolating
experience. It is vital that caregivers receive – and maintain –
some form of social connection. This can be done through
meetings and support groups or through a network of family
and friends. It is about providing an environment where
caregivers can “act selfish” (in their minds) and speak openly
about their struggles with those in similar situations.32
In
the words from the Mayo Caregiving Support blog: “when
caregivers share their fears and pain, door opens for hope”.33
Interventions aimed at providing group support and connection
for caregivers found decreased depression and anxiety, and
increased social support.34
In addition, simple interventions
that merely “checked up” on caregivers and relayed friendly
phone calls led to reduced burden and distress, likely due to an
opportunity for respite.35
Helping Caregivers to Provide Care
Caregivers are, for the most part, not trained professionals;
yet, they are tasked with responsibilities previously provided
by nurses and hospital staff. As such, it makes sense that
caregivers can benefit from some form of assistance in
providing care.
Providing Information, Education and Training
Information is a key source of empowerment, and yet
oftentimes, caregivers are not adequately informed about
their roles and responsibilities. Research finds many family
caregivers craving more information, because they feel
unprepared to provide the care expected of them. Caregivers
indicate needing, but not receiving, training for hands-on tasks
such as administering medications, managing side-effects
and complications, and changing wound dressings.36
They
also indicate a lack of information about proven ways to deal
with patients’ emotional concerns and seek further guidance
from professionals on how to engage with patients’ depression,
anxiety and uncertainty.37
Health Education Programs that aim to provide caregivers with necessary
information have been shown to successfully increase caregiver coping ability.

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As such, they cannot be reproduced or utilized without permission. ©2016
As a result, providing caregivers with information, education,
and training can have a significant impact on caregiver fear
alleviation. Strengthening their competence, and therefore
confidence, has been directly linked to alleviating fear and
improving caregivers’ mastery – the amount of control they feel
over forces impinging on them.38
Reducing Caregiver Burden
Family caregivers not only lack information and support for
fulfilling their duties as caregivers, but they also lack the
support they need to deal with their own emotional distress.
Oftentimes, caregivers indicate receiving less support than their
patients, despite the fact that they are clearly co-sufferers.40
Hospitals have partnered with Circles for on-site concierge
programs as a resource for patients and visitors. When a
loved one is admitted to a hospital, this resource assists the
caregiver with demands that still need to be met at home, such
as arranging pet care and, upon discharge, can make meal
arrangements to ensure the patient has proper dietary
needs met.
Other programs are designed to provide formal caregiving –
even if not full time – in order to take over some elements of
patient care and thereby give the caregiver a break. Programs
such as Comfort Keepers®
can be used not only to help the
patients, but also to relieve the caregivers by taking over the
caregiving role for a designated period of time.
One way to provide support is to
relieve the caregivers of some of
their duties.
“At Comfort Keepers®
, we not
only provide quality care for
our clients, we also address the
needs of their family caregivers.
We strive to make both parties
comfortable, safe, happy and
healthy so they may live the best
quality of life that is possible.
That is why respite care is such
an important part of our list of
care services.”
– Sarosh Mistry
CEO, Comfort Keepers Franchising, Inc.

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As such, they cannot be reproduced or utilized without permission. ©2016
Additional
Considerations to Care
for Caregivers
There is a decisive difference between programs that support
patients, and those targeted at their caregivers.
It is also important to note that the fears and needs of
caregivers change across the continuum of care. Throughout
the patient journey, there are many changes in the focus
of care, the individual responsible for care and the patient’s
self-care abilities. Therefore, family members who provide
supportive care also experience changes in their roles as
caregivers, and every phase – from in-patient acute care to
rehabilitation and post-discharge recovery – brings with it
new challenges and new anxieties. So to successfully alleviate
caregiver fear, it is vital to be aware of the changing needs
across the care continuum.42
Conclusion
It is clear that family caregiving does have negative and far-
reaching consequences, due to the fear and anxiety it induces
in the caregivers. Because of the interdependencies and far-
reaching effects of caregiver fear on the health care system
as a whole, it is evident that population and community-wide
health can be improved by concentrating on caregivers. Future
efforts should focus not only on the patients, but also on the
sources of anxiety of the caregivers, and steps that can be taken
to alleviate this fear. Taking care of the caregiver ultimately
improves outcomes for the patients, reducing readmissions, as
well as prevents future health problems whereby the caregivers
themselves turn into patients of chronic or mental illness.
Taking care of the caregiver ultimately improves outcomes for the patients.

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As such, they cannot be reproduced or utilized without permission. ©2016
References
1. Reinhard, S., Feinberg, L., Choula, R., & Houser, A. (2015).
Valuing the Invaluable: 2015 Update. AARP Public Policy
Institute. Retrieved from http://www.aarp.org/content/
dam/aarp/ppi/2015/valuing-the-invaluable-2015-update-
new.pdf
2. Jacob, S. (2013). The Puzzling Link Between Caregivers
and Hospital Readmissions. Healthcare Daily. Retrieved
4 February 2016, from http://healthcare.dmagazine.
com/2013/06/16/the-puzzling-link-between-caregivers-
and-hospital-readmissions/
3. Schumacher, K., Stewart, B., Archbold, P., Caparro, M.,
Mutale, F., & Agrawal, S. (2008). Effects of Caregiving
Demand, Mutuality, and Preparedness on Family Caregiver
Outcomes During Cancer Treatment. Oncology Nursing
Forum, 35(1), 49-56.
4. Honea, N., Brintnall, R., Given, B., Sherwood, P., Colao,
D., Somers, S., & Northouse, L. (2008). Putting Evidence
Into Practice®: Nursing Assessment and Interventions to
Reduce Family Caregiver Strain and Burden. Clinical Journal
Of Oncology Nursing, 12(3), 507-516.
5. National Cancer Institute. (2016). Family Caregivers in
Cancer: Roles and Challenges. Retrieved 4 February 2016,
from http://www.cancer.gov/about-cancer/coping/family-
friends/family-caregivers-hp-pdq#section/_10
6. Vachon, M. L. (1998). Psychosocial needs of patients and
families. Journal of Palliative Care, 14(3), 49.
7. Ferrell, B. R., Rhiner, M., Cohen, M. Z., & Grant, M. (1990).
Pain as a metaphor for illness. Oncology Nursing Forum,
18(9), 1303-1309.
8. Houser, A. N., & Gibson, M. J. S. (2008). Valuing the
invaluable: The economic value of family caregiving, 2008
Update. AARP Public Policy Institute.
9. Reinhard, S. C., Houser, A., & Choula, R. (2011). Valuing the
invaluable: The growing contributions and costs of family
caregiving, 2011 Update. AARP Policy Institute.
10. Jensen, S. (1991). Fatigue affecting family caregivers of
cancer patients. Cancer Nursing, 14(4), 181-187.
11. Kiecolt-Glaser, J. K., Glaser, R., Gravenstein, S., Malarkey,
W. B., & Sheridan, J. (1996). Chronic stress alters the
immune response to influenza virus vaccine in older adults.
Proceedings of the National Academy of Sciences, 93(7),
3043-3047.
12. Kiecolt-Glaser, J. K., Marucha, P. T., Mercado, A. M.,
Malarkey, W. B., & Glaser, R. (1995). Slowing of wound
healing by psychological stress. The Lancet, 346(8984),
1194-1196.
13. Canuscio, C., Jones, J., Kawachi, I., Colditz, G., Berkman,
L., & Rimme, E. (2002). Reverberations of family illness: A
longitudinal assessment of informal caregiver and mental
health status in the nurses’ health study. American Journal
of Public Health, 92(8), 1305-11.
14. Lee, S., Colditz, G. A., Berkman, L. F., & Kawachi, I. (2003).
Caregiving and risk of coronary heart disease in US women:
a prospective study. American Journal of Preventive
Medicine, 24(2), 113-119.
15. Zarit, S. H. (2010). Assessment of family caregivers: a
research perspective. A Report from a National Consensus
Development Conference Caregiver Assessment: Principles,
Guidelines and Strategies for Change 2006. 12–36.
16. Cynkar, P. & Mendes, E. (2011). More Than One in
Six American Workers Also Act as Caregivers Gallup.
Retrieved 4 February 2016, from http://www.gallup.com/
poll/148640/one-six-american-workers-act-caregivers.
aspx
17. National Alliance for Caregiving. (2009). Caregiving in the
US 2009. Washington, D.C.: AARP. Retrieved from http://
www.caregiving.org/data/Caregiving_in_the_US_2009_
full_report.pdf
18. Feinberg, L. (2011). Valuing the Invaluable: 2011 Update:
The Economic Value of Family Caregiving in 2009. AARP
Public Policy Institute.
19. National Alliance for Caregiving and AARP. (2009).
Caregiving in the US: A Focused Look at Those Caring for
Someone Age 50 or Older. Washington, D.C.: National
Alliance for Caregiving and AARP. Retrieved from http://
www.caregiving.org/data/FINALRegularExSum50plus.pdf
20. Northouse, L., Katapodi, M., Schafenacker, A., & Weiss, D.
(2012). The Impact of Caregiving on the Psychological
Well-Being of Family Caregivers and Cancer Patients.
Seminars In Oncology Nursing, 28(4), 236-245.

11. 11
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2016
21. Northouse, L. (2012). Helping Patients and Their Family
Caregivers Cope With Cancer. Oncology Nursing Forum,
39(5), 500-506.
22. Segrin, C., Badger, T., Dorros, S. M., Meek, P., & Lopez, A. M.
(2007). Interdependent anxiety and psychological distress
in women with breast cancer and their partners. Psycho-
Oncology, 16(7), 634-643.
23. Hagedoorn, M., Sanderman, R., Bolks, H. N., Tuinstra, J., &
Coyne, J. C. (2008). Distress in couples coping with cancer:
a meta-analysis and critical review of role and gender
effects. Psychological Bulletin, 134(1), 1-30.
24. Hodges, L. J., Humphris, G. M., & Macfarlane, G. (2005). A
meta-analytic investigation of the relationship between the
psychological distress of cancer patients and their carers.
Social Science & Medicine, 60(1), 1-12.
25. Campbell, L., Keefe, F., McKee, D., Edwards, C., Herman,
S., & Johnson, L. et al. (2004). Prostate cancer in African
Americans: relationship of patient and partner self-
efficacy to quality of life. Journal of Pain and Symptom
Management, 28(5), 433-444.
26. Lau, D., Berman, R., Halpern, L., Pickard, A., Schrauf, R., &
Witt, W. (2010). Exploring Factors that Influence Informal
Caregiving in Medication Management for Home Hospice
Patients. Journal Of Palliative Medicine, 13(9), 1085-1090.
27. Keefe, F., Ahles, T., Porter, L., Sutton, L., McBride, C., & Pope,
M. et al. (2003). The self-efficacy of family caregivers for
helping cancer patients manage pain at end-of-life. Pain,
103(1), 157-162.
28. Anastas, J. W., Gibeau, J. L., & Larson, P. J. (1990). Working
families and eldercare: A national perspective in an aging
America. Social Work, 35(5), 405-411.
29. Cameron, J. I., Franche, R. L., Cheung, A. M., & Stewart,
D. E. (2002). Lifestyle interference and emotional distress
in family caregivers of advanced cancer patients. Cancer,
94(2), 521-527.
30. Calhoun, P. S., Beckham, J. C., & Bosworth, H. B. (2002).
Caregiver burden and psychological distress in partners of
veterans with chronic posttraumatic stress disorder. Journal
of Traumatic Stress, 15(3), 205-212.
31. City and County of San Francisco. (2016). Family Friendly
Workplace Ordinance (FFWO). Retrieved 4 February 2016,
from http://sfgov.org/olse/family-friendly-workplace-
ordinance-ffwo
32. National Cancer Institute. (2016). Family Caregivers in
Cancer: Roles and Challenges. Retrieved 4 February 2016,
from http://www.cancer.gov/about-cancer/coping/family-
friends/family-caregivers-hp-pdq#section/_10
33. Lunde, A. (2014). Alzheimer’s Blog. Mayo Clinic. Retrieved
4 February 2016, from htp://www.mayoclinic.org/
caregivers-hope/expert-blog/bgp-20111584
34. Cassie, K., & Sanders, S. (2008). Familial Caregivers of
Older Adults. Journal Of Gerontological Social Work,
50(sup1), 293-320.
35. Davis, L. L., Burgio, L. D., Buckwalter, K. C., & Weaver, M.
(2004). A comparison of in-home and telephone-based
skill training interventions with caregivers of persons with
dementia. Journal of Mental Health and Aging, 10, 31-44.
36. Van Ryn, M., Sanders, S., Kahn, K., van Houtven, C., Griffin,
J., & Martin, M. et al. (2010). Objective burden, resources,
and other stressors among informal cancer caregivers: a
hidden quality issue? Psycho-Oncology, 20(1), 44-52.
37. Giarelli, E., McCorkle, R., & Monturo, C. (2003). Caring for a
Spouse after Prostate Surgery: The Preparedness Needs of
Wives. Journal Of Family Nursing, 9(4), 453-485.
38. Pearlin, L. I., & Schooler, C. (1978). The structure of coping.
Journal of Health and Social Behavior, 19, 2-21.
39. Toseland, R. W., McCallion, P., Smith, T., & Banks, S. (2004).
Supporting caregivers of frail older adults in an HMO
setting. American Journal of Orthopsychiatry, 74(3), 349-
364.
40. Northouse, L., Mood, D., Montie, J., Sandler, H., Forman, J.,
& Hussain, M. et al. (2007). Living With Prostate Cancer:
Patients’ and Spouses’ Psychosocial Status and Quality of
Life. Journal Of Clinical Oncology, 25(27), 4171-4177.
41. O’Hara, R., Hull, J., Lyons, K., Bakitas, M., Hegel, M., Li,
Z., & Ahles, T. (2010). Impact on caregiver burden of a
patient-focused palliative care intervention for patients with
advanced cancer. Palliative And Supportive Care, 8(04),
395-404.
42. Cameron, J. I., & Gignac, M. A. (2008). “Timing It Right”: A
conceptual framework for addressing the support needs of
family caregivers to stroke survivors from the hospital to
the home. Patient Education and Counseling,70(3),
305-314.