Phronesis of nurses: A response to moral distress.

BACKGROUND: As moral action could help nurses reduce moral distress, it is necessary to carry out qualitative research to present the experiences in which nurses apply moral action. AIM: To describe and analyze the phronesis applied by nurses in the face of moral distress. RESEARCH DESIGN: The research participants were invited to participate in in-depth interviews. The research materials were based on the stories described by the research participants and recorded by means of first-person narrative. Narrative analysis was applied to interpret the nurses' phronesis. PARTICIPANTS: Twenty-seven nurses from Taiwan. ETHICAL CONSIDERATIONS: The Institutional Review Board of the Kaohsiung Medical University Hospital in Taiwan confirmed that this study passed the research ethical review. FINDINGS: According to the narrative analysis results, the phenomenon of moral distress contains difficulty, action, and idea transformation. The difficulty is the source of moral distress, action is the practice of moral courage, and idea transformation is the nurse's emotional movement. Action and idea transformation are collectively called phronesis in this study. DISCUSSION: Moral distress refers to a state of suffering caused by situations in which nurses cannot carry out their ethical intentions. Phronesis is the process through which nurses take actions and relocate the subjects and is an ethical way to find relief from moral distress. Starting with empathy and respectful attitudes arising from self-reflection, nurses may be helped to get relief from the suffering of moral distress. CONCLUSION: Phronesis can help nurses positively face the emotional strain of moral distress. This article puts forward a narrative method to complete the four steps of phronesis: write about the care experience, identify the difficulties in the stories, seek the possibility of action, and form a new care attitude, which could help nurses learn to reduce their moral distress.

Phenomenon of moral distress through the aspect of interpretive interactionism.

BACKGROUND: Most previous studies on moral distress focused on the factors that cause moral distress, paying inadequate attention to the moral conflict of nurses' values, the physician-nurse power hierarchy, and the influence of the culture. RESEARCH OBJECTIVE: To analyze the main causes for moral distress with interpretive interactionism. RESEARCH DESIGN: A qualitative study was adopted. PARTICIPANTS: Through purposeful sampling, 32 nurses from 12 different departments were chosen as the samples. ETHICAL CONSIDERATIONS: Approval from the Institutional Review Board of the Kaohsiung Medical University Hospital. FINDINGS: Moral distress is likely to occur in the following clinical situations: patients have no idea about their diseases; the medical decisions fail to meet the optimum benefit of patients; and patients with terminal cancers are not given a proper death. The reason why nurses become trapped in moral distress is that they fail to achieve moral goodness. Inadequate confidence, the physician-nurse power hierarchy, and the Oriental culture affect nurses' goodness-based intention for patients, which deteriorates moral distress. DISCUSSION: The main cause for moral distress is the moral goodness of nurses. If nurses' goodness-based intention for patients is inconsistent with the moral objective of achieving optimum benefit for patients, it leads to moral distress. Culture is an essential background factor of care for patients. In the Oriental culture, family members influence patients' right to know about their diseases, the choice of treatment, and patients' autonomy of not receiving cardio-pulmonary resuscitation. This results in moral distress in medical care. CONCLUSION: The occurrence of moral distress demonstrates that nurses have moral characteristics such as goodness and caring. It is suggested that appropriate educational strategies can be adopted to weaken the power hierarchy between physicians and nurses and enhance nurses' confidence and cultural sensitivity, so as to reduce the moral distress of nurses.

The effect of transcutaneous electrical nerve stimulation on increasing salivary flow rate in hemodialysis patients.

OBJECTIVE: To evaluate the impact of a transcutaneous electrical nerve stimulation (TENS) program for hemodialysis on patients' dry mouth and salivary flow rates. SUBJECTS AND METHODS: A single-blinded repeated measures study design was used. A total of 80 subjects were randomly assigned to a treatment group receiving a 250 µs; 50 Hz TENS program and a control group receiving a 50 µs; 2 Hz TENS program at acupoints ST 6 and TE17 three times a week for 3 weeks. Whole salivary flow rate and dry mouth intensity were measured totally five times for both groups, at pretreatment, after three, six, nineTENS sessions, and 1 week after the treatment was completed. RESULTS: After six TENS sessions were completed, whole salivary flow rates increased stably until the end of nine TENS sessions for the treatment group. In the follow-up week after treatment, there was significant increase as well. However, significant improvement in dry mouth intensity was observed at all post-tests than that at pretreatment in both groups. CONCLUSION: Whole salivary flow rates and improvement in dry mouth intensity were only observed during and 1 week after the TENS sessions. Further studies are needed to evaluate whether this method can offer a long-term effective nonpharmacological therapy for dry mouth-disturbed hemodialysis patients.

Moral Distress Model Reconstructed Using Grounded Theory.

BACKGROUND: The problems of nurse burnout and manpower shortage relate to moral distress. Thus, having a good understanding of moral distress is critical to developing strategies that effectively improve the clinical ethical climate and improve nursing retention in Taiwan. PURPOSE: The aim of this study was to reconstruct the model of moral distress using the grounded theory. METHODS: Twenty-five staff nurses at work units who attend to the needs of adult, pediatric, acute, and critical disease or end-of-life-care patients were recruited as participants using theoretical sampling from three teaching hospitals in Taiwan. Data were collected using intensive, 2- to 3-hour interviews with each participant. Audio recordings of the interviews were made and then converted into transcripts. The data were analyzed using the grounded theory. RESULTS: In the clinical setting, the perspective that nurses take toward clinical moral events reflects their moral values, which trigger moral cognition, provocation, and appraisal. The moral barriers that form when moral events that occur in clinical settings contradict personal moral values may later develop into moral distress. In handling moral barriers in the clinical environment, nurses make moral judgments and determine what is morally correct. Influenced by moral efficacy, the consequence may either be a moral action or an expression of personal emotion. Wasting National Health Insurance resources and Chinese culture are key sources of moral distress for nurses in Taiwan. The role of self-confidence in promoting moral efficacy and the role of heterodox skills in promoting moral actions represent findings that are unique to this study. CONCLUSIONS: The moral distress model was used in this study to facilitate the development of future nursing theories. On the basis of our findings, we suggested that nursing students be encouraged to use case studies to establish proper moral values, improve moral cognition and judgment capabilities, and promote moral actions to better handle the regular pressures of moral distress in future clinical or workplace settings. Moreover, a better understanding of moral distress may help retain staff nurses.

Gauze versus solid skin barrier for tracheostomy care: a crossover randomized clinical trial.

PURPOSE: The aim of this study was to compare gauze and a solid pectin-based skin barrier to evaluate clinical outcomes and cost-effectiveness of care for tracheostomy wounds. METHODS: A randomized clinical trial with crossover design was conducted to compare gauze to a solid skin barrier for management of patients with tracheostomies. The main study outcomes were skin integrity, dressing change frequency, time required for dressing changes, product costs, and nurses' satisfaction. SETTING AND SUBJECTS: A convenience sample was recruited from 2 medical centers in Taiwan. Using permuted block randomization, patients undergoing tracheostomy were randomly allocated to 1 of 2 groups. One group received tracheostomy care with gauze for the first 6 days and a solid pectin-based skin barrier for the following 6 days. This regimen was reversed in the second group. RESULTS: Skin integrity was significantly better among patients managed with a solid skin barrier as compared to management with gauze (Z=-2.75, P= .006). No significant differences in dressing change frequency, time required for dressing changes, or product costs between the 2 groups were found. Nurses' satisfaction was significantly higher for the solid skin barrier as compared to gauze (Z=-2.31, P= .021, for group 1, and T=-1.97, P= .048, for group 2). CONCLUSIONS: The use of a solid skin barrier for tracheostomy care was associated with lower occurrences of impaired skin integrity and higher satisfaction among nurses when compared to gauze.

The impact of an interprofessional problem-based learning curriculum of clinical ethics on medical and nursing students' attitudes and ability of interprofessional collaboration: a pilot study.

Clinical ethic situations in modern multiprofessional healthcare systems may involve different healthcare professions who work together for patient care. The undergraduate interprofessional education of clinical ethics would help to incubate healthcare students' ability of interprofessional collaboration in solving ethical problems. However, the impact from an interprofessional educational model on student's attitudes and confidence of interprofessional collaboration should be carefully evaluated during the process of curricular development. This study aimed to conduct a pilot interprofessional PBL curriculum of clinical ethics and evaluate the curricular impact on interprofessional students' attitude and confidence of collaborative teamwork. Thirty-six medical and nursing students volunteered to participate in this study and were divided into three groups (medical group, nursing group, and mixed group). Tutors were recruited from the Medical School and the College of Nursing. The pilot curriculum included one lecture of clinical ethics, one PBL case study with two tutorial sessions, and one session of group discussion and feedback. A narrative story with multiple story lines and a multiperspective problem analysis tool were used in the PBL tutorials. The students' self-evaluation of learning questionnaire was used to evaluate students' learning of clinical ethics and interprofessional collaborative skills and attitude. The internal consistency of the questionnaire was measured by Cronbach α, and the criterion-related validity of the questionnaire was evaluated through associations between the dimension scores with the student group by one-way analysis of variance test (ANOVA) test and Tukey-Kramer honestly significant difference (HSD) comparison. There was significant difference among different groups in students' ability and attitudes about "interprofessional communication and collaboration" (p = 0.0184). The scores in the mixed group (37.58 ± 3.26) were higher than the medical group (32.10 ± 4.98). In conclusion, our model for the interprofessional PBL curriculum of clinical ethics is practicable and will produce positive impacts on students' attitudes and confidence of interprofessional collaboration.

[Being a mother: encounters between mothers of children with Duchenne muscular dystrophy and nurses in Taiwan].

The role of "mother" is understood and represented differently by people from different cultures. In traditional Taiwanese society, mothers demonstrate their existence value by giving birth to and raising sons able to continue her husband's familial line. Sons bear the patriarchal name and care for their parents in old age. However, a son stricken, paralyzed and eventually killed by Duchenne muscular dystrophy (DMD) can destroy a mother's perceived value in this traditional social context. Mothers are thus soundless sufferers. Nurses have a critical role to play in giving encouragement and hope to mothers of children with DMD. Through their own difficult situation, these mothers can also highlight the value and importance of Taiwan's nurses, who work in conditions marked by overloading, high stress, and under-appreciation. Caring for women in critical need of empathy and support help nurses realize their own positive capacity to empower sufferers.

[Reflecting on nurse-patient relationships using core postmodernist concepts].

The task of defining, maintaining, and mutually adapting the nurse-patient relationship has been ongoing since modern nursing's earliest days. The nurse-patient relationship changes with social changes and paradigm shifts. Most medical centers today strive to incorporate the concept of partnership into the nurse-patient relationship in response to patient-centered medical care. What is the implication of this relationship? Is it suitable for all nurse-patient situations? What are the impacts on nurses and patients? How should nurses adapt to change in nurse-patient relationships? This article analyzes and reflects upon the nurse-patient relationship within a postmodernist framework guided by concepts of "deconstruction", "de-centralization", "multiplicity", and "inter-subjectivity." We derive a "dual-active" and "dual-expert" partnership between nurses and patients that centers on patient disease management. Core values of this partnership are respect and caring, and strategies include emancipation, enlightenment, and empowerment.

Development and validation of the paediatric cancer coping scale.

AIM: The purpose of this study was to develop and test the psychometric properties of the paediatric cancer coping scale in children with cancer. BACKGROUND: Coping is a mediator between stressful events and adaptation. However, existing tools cannot be used to assess and understand coping strategies in children with cancer in Taiwan. METHODS: A total of 229 children with cancer were recruited from three medical centres in Taiwan in 2008-2009. Internal consistency and test-retest reliability were estimated by Cronbach's alpha and intra-class correlation coefficient respectively. The factor structure was determined by exploratory factor analysis and confirmatory factor analysis. Pearson's correlation coefficient was employed to test the convergent and discriminate validity. RESULTS: The paediatric cancer coping scale demonstrated internal consistency (α = 0·91) and a 2-week test-retest reliability (intra-class correlation coefficient = 0·86). Its construct validity was confirmed by factor analysis, which extracted and defined three categories of coping strategies: cognitive coping, problem-oriented coping and defensive coping; these three factors explained 40% of the total variance with factor loadings ranging from 0·31 to 0·71. Convergent and discriminate validities were demonstrated by significant correlations among the coping, resilience and anxiety subscales. CONCLUSIONS: The paediatric cancer coping scale is a reliable and valid scale to measure and examine coping strategies in children with cancer.

Diabetes Empowerment Process Scale: development and psychometric testing of the Chinese version.

AIM: This paper is a report of the development and psychometric testing of the Chinese version of the Diabetes Empowerment Process Scale. BACKGROUND: In people living with diabetes, empowerment can improve metabolic and psychosocial outcomes. A scale for measuring empowerment processes can also help healthcare professionals to optimize their empowering actions and would improve their interactions with people living with diabetes. METHOD: Based on literature reviews and interviews with people living with diabetes, a 27-item Chinese Diabetes Empowerment Process Scale was developed. Fifteen items were produced after item analysis and content validity testing. To test construct validity, concurrent validity and internal consistency, 211 outpatients living with diabetes completed the Chinese Diabetes Empowerment Process Scale, a Self-care Behaviour Scale and a Diabetes Empowerment Scale. Test-retest reliability was also analysed with 30 patients. The study was conducted in 2008 and 2009 in Taiwan. RESULTS: Confirmatory factor analysis indicated that a second-order factorial model with four subscales and 15 items best fitted the data. The four subscales were Mutual participation, Raising awareness, Providing necessary information and Open communication. Scores on the Chinese Diabetes Empowerment Process Scale correlated statistically significantly with those on the Self-care Behaviour Scale (r=0.21-0.40; P<0.01) and Diabetes Empowerment Scale (r=0.35-0.65; P<0.01). Reliability was supported by acceptable Cronbach's α (range: 0.73-0.91) and test-retest reliability scores (range: 0.75-0.83). CONCLUSION: The Chinese Diabetes Empowerment Process Scale has satisfactory validity and reliability for measuring the empowerment process of health professionals. Further studies are needed to test the applicability of the scale to other populations.

Biomarkers and perceived emotional stress in early-stage pregnant taiwanese women with nausea and vomiting.

The purpose of this study was to compare physiological and psychological reactions among Taiwanese women with different degrees of severity of nausea and vomiting (NV) during pregnancy. Based on their scores on the Index of Nausea, Vomiting, and Retching (INVR), 59 pregnant women ≥ 18 years of age, with single gestations and without diagnosed pregnancy complications or hospitalizations were divided into two groups: mild or less (scores 0-8, n = 33) and moderate or severe (scores 9-32, n = 26). A single blood sample was obtained early in pregnancy during a prenatal visit to examine the biochemical data related to NV and stress. The INVR and Perceived Stress Scale were also administered at this time. Human chorionic gonadotropin (hCG) and leptin levels were significantly different between the two groups, whereas IFN-α, IL-2, TNF-α, adiponectin, perceived stress, and cortisol showed no significant differences. The cutoff point between high and low levels of NV severity was consistent between INVR scores (psychological reactions) and hCG level (physiological reactions). Logistic regression analysis indicated that leptin levels accounted for 24.4% of the variance for NV in early pregnancy. A further multiple linear regression analysis showed that NV, first trimester pregnancy body mass index (BMI), and age explained 72.4% of the variance in leptin levels. The findings of this study add new information to the understanding of the biomarkers and perceived emotional stress in early-stage pregnant women with high and low severities of NV.

Voices from the frontline: Perceptions and needs of nurses involved in a nosocomial cluster of tuberculosis infection.

Little is known about the psychological aspects of health care workers who contract tuberculosis (TB). This study explored the perceptions and the needs of nurses who were involved in a nosocomial cluster of TB infection in Taiwan. Using a phenomenological research design, we conducted semistructured interviews with nine participants. The data management was processed by Colaizzi's method. The result reveals that nursing staff members who occupationally contracted TB undergo two phases. From the detection of their infection to recovery, they experienced different perceptions and needs. The hospital should be mandated to accommodate nurses' varying needs accordingly. Clinical-implication-related infection control strategies, grouped into three levels of prevention, are discussed.

[A discussion of concepts for promoting nursing core competencies].

The nursing curriculum model has evolved from the previous "content-based approach" to an "outcomes-based approach." As such, nursing faculty should pay to particular attention to changes in the working environment that their graduates can be expected to face. This paper developed a competency-oriented curriculum framework to address school and profession objectives. Concept analysis was used to clarify the characteristics of each competency and related concepts. Then, nursing faculties identified outcomes and desired target levels in line with student learning needs. Finally, teaching strategies and learning activities for class and clinical practice were developed. Competencies are not nurtured separately. Nursing faculty should provide adequate learning opportunities for their students in order to help students integrate healthcare knowledge, skills and attitudes successfully. In addition, the nursing faculty is responsible to guide students to emphasize quality of care and examine the association of such with professional competencies. Accumulating clinical experience and reflection will assist students to develop integrity and life-long learning abilities and graduate with solid professional competencies.

Effect of acupressure on thirst in hemodialysis patients.

BACKGROUND: Thirst and dry mouth are common among hemodialysis (HD) patients. This paper reports a study to evaluate the impact of an acupressure program on HD patients' thirst and salivary flow rates. METHODS: The acupressure program included placebo, followed by true acupressure each applied for 4 weeks. Twenty-eight patients (mean age 57.6, SD = 16.13 years) first received a sticker as placebo acupressure at two acupoints CV23 and TE17 three times a week for 4 weeks, and then received true acupressure in the same area for the next 4 weeks. Salivary flow rate and thirst intensity were measured at baseline, during and after treatment completion for both the placebo and true acupressure program. RESULTS: The true acupressure program was associated with significantly increased salivary flow rate (0.09 +/- 0.08 ml/min at baseline to 0.12 +/- 0.08 ml/min after treatments completion, p = 0.04). The mean thirst intensity also improved from 4.21 +/- 2.66 at baseline to 2.43 +/- 2.32 (p = 0.008) after treatment completion in HD patients. There was no statistically significant difference in pre-post program salivary flow rate; however, significant improvement in thirst intensity scores was observed (p = 0.009) in the placebo acupressure program. CONCLUSION: This study provides preliminary evidence that acupressure may be effective in improving salivary flow rates and thirst intensity.

Psychometric evaluation of the stress scale for parents with cleft lip and/or palate children--a preliminary study.

OBJECTIVE: To develop the Stress Scale for Parents With Cleft Lip and/or Palate Children in Taiwan and to evaluate the psychometric properties of the scale with a group of parents who have children with cleft lip and/or palate. DESIGN: In phase 1, qualitative procedures were conducted in constructing the item pool for the Stress Scale for Parents With Cleft Lip and/or Palate Children. Psychometric properties of the scale were assessed in phase 2. SETTING: Outpatient department of a children's hospital in northern Taiwan. PARTICIPANTS: Phase 1 included 21 parents of children with cleft lip and/or palate. Phase 2 included 184 parents of children with cleft lip and/or palate. INTERVENTIONS: The item pool was developed by interview, content analysis, and literature review. Problematic items were identified by item analysis. MAIN OUTCOME MEASURES: Exploratory factor analysis was used to examine the construct validity. Reliabilities were evaluated by Cronbach alpha and intraclass correlation coefficients. RESULTS: Thirty-three items with a content validity index greater than .80 were recognized. They were grouped into four categories by exploratory factor analysis and accounted for 42.34% of the total variance. Internal consistency reliability was high for the total scale (Cronbach α = .90) and ranged from .71 to .84 on the subscales. Test-retest reliability with intraclass correlation coefficient was .94 on the total scale (p < .0001, 95% confidence interval) and from .90 to .96 for the subscales. CONCLUSIONS: The Stress Scale for Parents With Cleft Lip and/or Palate Children appears to be a reliable tool with strong evidence of content and construct validity that may be useful in assessing parental stress in the caretakers of children with cleft lip and/or palate.

Coping experiences of adolescents with cancer: a qualitative study.

TITLE: Coping experiences of adolescents with cancer: a qualitative study. AIM: This paper is a report of a study of the coping experiences of Taiwanese adolescents with cancer. BACKGROUND: Cancer treatments have adverse effects and negatively affect adolescents' lives. Psychological coping strategies are antecedents to adjustment. Little is known about the essential structure of the coping experience in adolescents with cancer. METHOD: Ten adolescents aged 12-18 years who were receiving chemotherapy were interviewed in 2007. Open-ended interviews were conducted in a quiet in-hospital setting. Interview data were analysed using Giorgi's four-step procedures. FINDINGS: The essential structures of the coping experience were losing confidence and rebuilding hope. Losing confidence included sub-themes of physical and psychological suffering; rebuilding hope included sub-themes of thought restructuring, revaluing what I have, and envisioning hopeful images of the future. Interviewees vacillated between moving on and giving up, depending on the strength of their hope. A focus on rebuilding hope helped the adolescents to move on in the midst of many distressful events. CONCLUSION: Understanding adolescents' coping processes relative to cancer can facilitate the establishment of a more supportive milieu. The findings can provide guidance for instrument development on coping for adolescents with cancer and be useful in guiding intervention development to promote positive psychological adjustment.

Evaluation of a caring education program for Taiwanese nursing students: a quasi-experiment with before and after comparison.

BACKGROUND: Caring is an essential component in nursing curricula. However, how caring can be accomplished effectively has rarely been taught to nursing students. OBJECTIVES: To examine acceptability and preliminary efficacy of a caring education program for nursing students in Taiwan. METHODS: Students were recruited to participate in a pre-post-test quasi-experimental study. Students self-selected into a control group (n=33) or an experimental group (n=35). The experimental group registered for a 13-week caring education program based on Watson's 10 creative factors through multiple teaching strategies. The Caring Behaviors Assessment (CBA) was used to collect data at weeks 1 and 13. Content analysis was used to reach the main descriptions of caring education from an experimental group of nursing students. RESULTS: The experimental group reported a significantly higher score of caring behaviors after participating in the education program (t=3.4, p=.00). The score of each CBA subscale in the experimental group was significantly enhanced from week 1 to week 13, except in the existential/phenomenological/spiritual dimension. Qualitative results supported that a caring education could help nursing students by building caring behaviors which could be adapted to clinical situations. CONCLUSIONS: The findings support the credibility of caring-focused teaching strategies and such focused caring programs are acceptable and show efficacy for nursing students.

Experience of problem-based learning in nursing education at Kaohsiung Medical University.

Nursing education must keep up with the rapidly changing medical landscape to support the competences of nurses in the areas of critical thinking, problem solving, and creativity. Problem-based learning (PBL) provides an appropriate strategy for nursing education innovation. Nursing curricula based on PBL remain in the growing stage in Taiwan. Kaohsiung Medical University introduced PBL into nursing education in 2002. The critical events in the process included: (1) nurturing key tutors; (2) using PBL teaching methods in an elective course--Oncology Nursing, and designing a new elective course--Symposiums Regarding Clinical Cases; (3) holding conferences inside and outside the school to promote PBL teaching methods; (4) linking e-learning and PBL teaching methods; (5) conducting PBL research; (6) establishing a committee of PBL, objective structured clinical examination, and teaching material review for the College of Nursing; and (7) setting up a required course--Nursing Ethics. We now have 12 key tutors in the College of Nursing. We have also completed two studies to evaluate the ability of students and to explore the experience of tutors. From our studies, we know that PBL can increase learner abilities in self-directed learning, critical thinking, and PBL performance. The approach helps students to cope with the changing medical landscape. Furthermore, tutors and teachers develop adequate PBL teaching skills. Based on the experience above, we believe that we are on the right path in terms of continuing tutor development, gradually increasing the number of PBL courses, and undertaking further research to promote PBL methods in Taiwan.

[Concept analysis of suffering].

Suffering is commonly encountered in nursing and is defined as an individual and subjective experience. It is a complex human response to which there are physical, psychological, social and spiritual aspects. Perception of suffering threatens self-integrity, and induces negative behaviors, such as personal changes in relation to value system, sense of reality, withdrawal, feelings of helplessness, and despair. A great deal of relevant literature explores the influence of suffering, but only a few articles analyze the concept of suffering. The purpose of this article, therefore, is to clarify the concept of suffering. In order to do this, we used the technique of concept analysis described by Chinn and Kramer (1995). It is hoped that the results of the study will enhance nurses' understanding of suffering and that its lessons may be adopted in clinical nursing.

[A family caregiver's experience of care-giving on her own: "face it", "accept it", "deal with it" and "let it go"].

"Aging in place" has become one of the important policies promoting long-term care in the community. In the aging societies of today, the need for family caregivers to care for the elderly has increased. How one woman coped with shouldering the heavy burden of providing long-term family care alone were the main interests of this case study. From interviewing the subject it was discovered that her attitude to the labor of love that is care-giving was the same as the four great vows for handling problems that Master Sheng Yen proposes: "face it", "accept it", "deal with it", and "let it go". Health professionals could help family caregivers to take things more easily and enter the state of "letting it go" by deeply understanding the perception of the caregiver, providing useful information, and encouraging the caregiver to make use of resources that are available for assistance.