Factors Influencing Older Adults' End-of-Life Care Preferences.

The objective of this study was to explore factors influencing Taiwanese older adults' end-of-life (EOL) care preferences. A cross-sectional questionnaire survey was conducted in 2 geriatric wards of a veterans' hospital. Fifty-five older adults aged 65 years or older were included. Structured questionnaires were used to collect data regarding demographic characteristics, EOL care preferences, stages of change for advance care planning behaviors, and reluctance to burden others. The study revealed that nearly 60% of the participants preferred to let their spouses, adult children, or health care professionals make the decisions. Furthermore, 83.6% of the participants lived with their family members and were moderately to severely disabled with a certain degree of dependence on their family members. Sex, independence, discussion of advance care planning with family members, and completion of advance directives were significantly correlated with EOL care preferences. The regression model showed that the participants' discussion of advance care planning with their family members influenced their EOL care preferences. The results demonstrate that family is an essential consideration for older adults choosing EOL care. Accordingly, because Chinese culture focuses on family harmony, improving communication between older adults and their family members is crucial for promoting advance care planning.

The Differences and Perspectives Between Elderly Individuals and Their Surrogates Regarding End-of-Life Care: A Mixed Methods Study.

Background: Family members often take the place of decision-making for elderly individuals. Previous studies showed that family members could not predict elderly individuals' thoughts about end-of-life care. Objectives: The aims are to understand the differences and perspectives between elderly individuals and surrogates regarding end-of-life care. Design: A mixed methods study comprising a cross-sectional survey and field notes analysis. Setting: Two geriatric wards in a veterans hospital located in northern Taiwan. Subjects: Fifty-five pairs of elderly individuals and their surrogates. Measurements: Life support preferences questionnaire and field notes. Results: The quantitative data showed that the elderly individuals and their surrogates had proper consistency in cardiopulmonary resuscitation and surgery. However, their consistency was poor in antibiotics and nasogastric tube feeding. Four themes were identified in qualitative data: recognizing old age, struggling with hope and peace, worries and concerns, and control of life. Recognizing old age for both elderly individuals and their surrogates was critical. Elderly individuals and their surrogates may seek a ray of hope among aggressive treatments and struggle with hope and peace. A lot of worries and concerns were mentioned, including contextual concerns. Elderly individuals need to depend on their ability to control their life. Conclusions: The study highlights elderly individuals' and their surrogates' considerations for antibiotics and nasogastric tube feeding. Furthermore, elderly individuals expressed that it is different for making decisions for themselves or others; thus, future studies can further explore whether elderly individuals allow their surrogates leeway from their wishes.

The efficacy of a flipping education program on improving self-management in patients with chronic obstructive pulmonary disease: a randomized controlled trial.

Purpose: Self-management is widely used among patients with a chronic disease to control their condition. However, the self-management programs are less distinctive for patients with chronic obstructive pulmonary disease (COPD) than those with other chronic diseases. This study examines the efficacy of a flipping education program on improving self-management in patients with COPD. Patients and methods: A single-blinded, randomized controlled trial was conducted at a medical center in northern Taiwan from January 2015 to May 2016. Sixty participants were randomized to an experimental group and a control group. The self-management program with flipped teaching, customized action plans, and scheduled telephone interviews was implemented in the experimental group for three months. Conventional patient education was implemented in the control group. Disease knowledge, self-efficacy, the patient's activation level, and the impact of COPD were assessed at baseline, 1 month, and 3 months after the intervention. SPSS 22.0 was used for data analysis. Results: The results showed that the patients who received the flipping education program of self-management had statistically significant improvements in their disease knowledge (p<0.05), self-efficacy (p<0.01), and activation levels (p<0.01) from baseline to the 1 month and 3 months follow-up compared to the control group. Conclusion: The findings supported that flipped teaching could be applied to patient education in adults and that a nurse case manager can feasibly use this flipping education program of self-management to motivate and support patients with COPD to acquire self-management skills, carry out their action plans, and help them achieve beneficial behaviors in their daily lives.

Quality of Work Life, Nurses' Intention to Leave the Profession, and Nurses Leaving the Profession: A One-Year Prospective Survey.

PURPOSE: To examine the associations among quality of work life, nurses' intention to leave the profession, and nurses leaving the profession. DESIGN: A prospective study design was used. METHODS: Participants were 1,283 hospital nurses with a purposive sampling in Taiwan. The self-reported questionnaire consisted of three questionnaires: the Chinese version of the Quality of Nursing Work Life scale, an intention-to-leave profession questionnaire, and a demographic questionnaire. Records of nurses leaving the profession were surveyed 1 year later. Data were analyzed by descriptive statistics and inferential statistics. FINDINGS: As many as 720 nurses (56.1%) had tendencies to leave their profession. However, only 31 nurses (2.5%) left their profession 1 year later. Nurses' intention to leave the profession mediated the relationship between the milieu of respect and autonomy, quality of work life, and nurses leaving the profession. CONCLUSIONS: The milieu of respect and autonomy describing the quality of work life predicts the nurses' intention to leave the profession, and together these predict nurses leaving the profession. CLINICAL RELEVANCE: This study illustrates that nurse managers could provide effective interventions to ameliorate the milieu of respect and autonomy aspect of quality of work life to prevent nurses from leaving their profession.

Creative approach for successful aging: A pilot study of an intergenerational health promotion program.

AIM: To develop and evaluate the effectiveness of an intergenerational health promotion program. METHODS: This was an action research project. A total of 34 participants attended the 12-week program and completed the pre-test and post-test. There were 16 middle-aged and nine older adults recruited from a district of Taipei, and nine young adults recruited from the principal investigator's university. The "Attitudes toward Aging Scale" and the "Spiritual Health Scale" were two assessment instruments used in the study. RESULTS: The results showed that there were significant improvements in the Attitudes toward Aging Scale for the young adult group (aged 18-29 years) and in the Spiritual Health Scale for the older adult group (aged 65-80 years). The evaluation showed that participants were satisfied with the program. CONCLUSIONS: The results of the present study provide future directions for successful aging and intergenerational learning. Geriatr Gerontol Int 2017; 17: 1799-1807.

Evaluation of a tablet-based instruction of breathing technique in patients with COPD.

PURPOSE: Tablet computers are a convenient audio-visual aid for patient education. Teaching patients with chronic obstructive pulmonary disorder (COPD) appropriate therapeutic breathing techniques and encouraging them to practice regularly has been recognized as an effective care strategy. The purpose of this study was to evaluate the effectiveness of using a tablet computer with the Breathing Easier Support Toolkit (BEST), a supplemental software application we developed that instructs and assists COPD patients during the process of respiratory retraining. PATIENTS AND METHODS: From May 2013 to September 2014, participants were randomly assigned to an experimental group (n=36) or a control group (n=35). Correct breathing technique, practice frequency, application of breathing technique, self-efficacy, quality of life, and patient feedback on the tablet-computer education were evaluated with blinded assessments at baseline and immediate, 1-month, and 3-month follow-up assessments after training completion. Data analysis consisted of basic characteristics and outcome indicators presented in terms of descriptive statistics; inferential statistics were estimated by generalized estimating equations. RESULTS: The participants were mostly male (83.1%) with an average age of 71.5 (SD=11.4). Both the experimental and control groups showed statistically significant improvement in correct breathing technique and application of breathing technique from baseline for each follow-up (p<0.001). A significantly increase in self-efficacy for the experimental group was found immediately after completing the breathing retraining program compared to the control group (p=0.045). CONCLUSION: Our tablet computer-assisted educational aid did not provide an improvement over the traditional method for teaching breathing techniques to elderly patients with COPD. The results only showed an immediate effect on the self-efficacy of the breathing technique. The elderly did not use the tablet computer actively and the research was conducted without intervention after discharge, which may be a reason why the effect did not last. Further research to evaluate the effectiveness of such a strategy for the elderly is needed in the future.

The Lived Experiences of People With Chronic Obstructive Pulmonary Disease: A Phenomenological Study.

PURPOSE: This study explored the lived experiences of people with chronic obstructive pulmonary disease (COPD) following hospitalization for acute exacerbation or pneumonia. DESIGN AND METHOD: A phenomenological approach was adopted to collect data through semistructured interviews. Fourteen participants were recruited from a medical center in northern Taiwan. Data were collected from January 2013 to January 2014. Giorgi's phenomenological methodology was adopted to analyze the interview content. FINDINGS: Three phenomenological themes emerged: trapped in an invisible cage, torments in the winter, and striving for wellness. CONCLUSIONS: This study sought to elucidate the lived experiences of people with COPD, who perceived themselves as feeling an overwhelming sense of confinement. The interviewees displayed positive attitudes, indicating that people with COPD are willing to cope with their disease. Health practitioners should focus on educating people with COPD about their needs, encouraging them to be more positive, and assisting them in engaging in self-management. CLINICAL RELEVANCE: People with COPD can cope with the disease and seek alternative methods to improve their health. These positive attitudes could be used to encourage self-management in the future.

Cultural perspectives of older nursing home residents regarding signing their own DNR directives in Eastern Taiwan: a qualitative pilot study.

BACKGROUND: Chinese tradition and culture developed from Taoism, Confucianism, and Buddhism and have influenced ethnic Chinese for thousands of years, particularly thoughts on death. Many ethnic Chinese, particularly older people, refrain from discussing death-related concerns, making it difficult to obtain advance directives, including do-not-resuscitate (DNR) directives, signed independently by older people. This study explored the attitudes of older nursing home residents in Taiwan toward signing their own DNR directives. METHODS: This study adopted purposive sampling and collected data through in-depth interviews. The data were analysed using qualitative inductive content analysis, and the study location was a nursing home in Eastern Taiwan. RESULTS: A total of 11participants were recruited from a sample of 12 eligible participants. Most of the older residents in this study refused to make decisions independently regarding DNR directives. Content analysis of the interviews revealed four themes concerning refusing to sign DNR directives independently: not going against nature, accepting the results of cause and effect, viewing the family as a decision-making system, and practising self-effacement. Chinese cultural aspects, including Taoist, Buddhist, and Confucian philosophy, affected the autonomy of the older residents, and they relied on others to make decisions for them. CONCLUSIONS: Professionals must respect this family-oriented decision-making thinking of older residents because it reflects personal choice. Otherwise, healthcare providers may play a mediating role in coordinating and communicating between older residents and their families regarding EOL-care-related concerns, replacing the traditional practice of holding a family meeting.

Fever presentation and associated factors in patients with healthcare-associated bacteraemia.

Bacteraemia is a systemic infection associated with strong febrile immune reactions. Fever definitions, fever intensity and other factors might affect the recognition, management and prognosis of patients with bacteraemia. A prospective observational design was used to study 412 consecutive Taiwanese patients with healthcare-associated bacteraemia. The study variables were fever intensity, factors related to fever intensity, the association of physical function to thermogenic capacity and the sensitivity of three definitions of fever for identifying patients with bacteraemia. Age, Charlson comorbidity index (CCI) score, chills and pathogen types were predictors of fever intensity. Barthel index score, CCI score and pathogen types were predictors of chills, an indicator of thermogenic capacity. The sensitivity of three fever definitions (basal body temperature plus 1°C, ≥ 38°C and ≥ 38.3°C) to identify patients with bacteraemia was 93.3%, 83.5% and 71.4%, respectively. Clinicians can target patients with factors associated with blunted febrile response to bacteraemia for closer monitoring.

[An Investigation of the Role Responsibilities of Clinical Research Nurses in Conducting Clinical Trials].

BACKGROUND: Clinical research nurses (CRNs) play an important role in improving the quality of clinical trials. In Taiwan, the increasing number of clinical trials has increased the number of practicing CRNs. Understanding the role responsibilities of CRNs is necessary to promote professionalism in this nursing category. PURPOSE: This study investigates the role responsibilities of CRNs in conducting clinical trials / research. METHODS: A questionnaire survey was conducted in a medical center in Taipei City, Taiwan. Eighty CRNs that were registered to facilitate and conduct clinical trials at this research site completed the survey. RESULTS: "Subject protection" was the CRN role responsibility most recognized by participants, followed by "research coordination and management", "subject clinical care", and "advanced professional nursing". Higher recognition scores were associated with higher importance scores and lower difficulty scores. Participants with trial training had significantly higher difficulty scores for "subject clinical care" and "research coordination and management" than their peers without this training (p < .05). Participants who had participated in a long-term trial-training course earned higher importance scores for "CRN four-subthemes role responsibilities" (p <.05) and lower difficulty scores for "subject protection", "research coordination and management" (p <.005) than their short-term course peers. "Recognition of overall responsibilities" and "receiving trial training" were the significant predictors of difficulty in performing CRN role responsibilities, explaining 21.9% of the total variance. CONCLUSIONS: To further promote CRN as a professional career in Taiwan, the findings of this study recommend identifying the core competences of CRNs and adding CRN-related study materials into the advanced nursing curriculum. Long-term and systematic educational training may help CRNs understand the importance of their role responsibilities, better recognize their professional role, and reflect these responsibilities in clinical practice.

Access site complications following transfemoral coronary procedures: comparison between traditional compression and angioseal vascular closure devices for haemostasis.

BACKGROUND: Vascular closure devices such as angioseal are used as alternatives to traditional compression haemostasis. Although the safety and efficacy of angioseal are confirmed, their use remains controversial because of the potential complications of these devices compared with those of traditional compression haemostasis. The aim of this study was to compare the access site complication rate, the predictive factors for these complications, and patient comfort levels after coronary procedures with traditional compression or angioseal haemostasis. METHODS: Data were collected from a cardiac unit in a medical center in northern Taiwan. A total of 130 adult patients were recruited and equally divided into two groups according to the method of haemostasis used after the coronary procedure: a traditional compression group and an angioseal group. We observed the incidence of access site complications, including bleeding, oozing, haematoma formation, and arteriovenous fistula formation. In addition, we used a 0-10 numeric rating scale to assess soreness, numbness, and back and groin access site pain after 1 h of catheter removal and immediately before getting out of bed. RESULTS: The overall incidence of complications was 3.8 % (n = 5), which was not significantly different between the two groups (p = .06). The propensity score--adjusted multivariate analyses revealed that the only independent predictor for access site complications was an age of >70 years (OR, 10.44; 95 % CI, 1.81-60.06; p = .009). Comfort levels were higher in the angioseal group than in the traditional compression group. CONCLUSIONS: Angioseal used after coronary procedures did not increase the incidence of complications relative to that associated with traditional compression haemostasis; however, it increased patient comfort levels. Health personnel should pay special attention to the predictive factor for access site complications after coronary procedures, such as age >70 years.

Correlation Between Body Temperature and Survival Rate in Patients With Hospital-Acquired Bacteremia: A Prospective Observational Study.

BACKGROUND: Fever is a complex and major sign of a patient's acute response to infection. However, analysis of the risks and benefits associated with the change in body temperature of an infected host remains controversial. OBJECTIVE: To examine the relationship between the intensity of the change in body temperature and the mortality of patients with hospital-acquired bacteremia. DESIGN: A prospective observational study. METHOD: Subjects were hospitalized adult patients who developed clinical signs of infection 48 hr or more after admission and had documented bacterial growth in blood culture. The maximum body temperature (maxTe) during the early period of infection measurements (i.e., the day before, the day of, and 2 days after the day of blood culture) was used to indicate the intensity of the body temperature response. Patients were categorized as discharged alive or died in hospital. Cox regression analysis was employed to analyze the data. RESULTS: The cohort consisted of 502 subjects. The mean maxTe of subjects was 38.6°C, and 14.9% had a maxTe lower than 38.0°C. The in-hospital mortality rate was 18.9%. The highest in-hospital mortality was found in subjects with a maxTe lower than 38°C (30.7%). Multivariate Cox regression analysis determined that the maxTe and the severity of comorbidity are the two variables associated with in-hospital mortality. CONCLUSIONS: Lack of a robust febrile response may be associated with greater risk of mortality in patients with bacteremia. Clinicians must be vigilant in identifying patients at risk for a blunted febrile response to bacteremia for more intensive monitoring.

Quality of work life as a predictor of nurses' intention to leave units, organisations and the profession.

AIM: To examine the relationships between quality of work life (QWL) and nurses' intention to leave their unit (ITLunit), organisation (ITLorg) and profession (ITLpro). BACKGROUND: The high turnover rate among nurses presents a major challenge to health care systems across the globe. QWL plays a significant role in nurses' turnover. METHODS: A descriptive cross-sectional survey design was conducted via purposive sampling of 1283 hospital nurses and administering the Chinese version of the Quality of Nursing Work Life scale (C-QNWL), a three-ITL-type scale questionnaire, and a demographic questionnaire for individual- and work-related variables. Descriptive data, correlations, and ordinal regression models were analyzed. RESULTS: QWL predicted ITLpro and ITLorg better than ITLunit. Three QWL dimensions (work arrangement and workload, nursing staffing and patient care, and work-home life balance) were significantly predictive of all three ITL measures. However, the dimension of teamwork and communication was only predictive for ITLunit, not for ITLorg and ITLpro. CONCLUSIONS: Different patterns of QWL dimensions are predictive of ITLunit, ITLorg, and ITLpro. IMPLICATIONS FOR NURSING MANAGEMENT: The study provides important information to nurse administrators about the aspects of QWL that most commonly lead nurses to leave their units, organisations, and even the profession itself.

[A project to improve the completion rate of discharge-planning services for organ-transplant patients].

BACKGROUND & PROBLEMS: The average score for satisfaction with self-care instructions among transplant patients was 84 out of 100 in a 2010 survey of patient satisfaction with discharge-planning services. This score was significantly below the hospital average of 90. In addition, discharged patients made more frequent telephone inquiries to healthcare providers to ask questions about post-organ-transplantation self-care. A follow-up study targeted a sample of 30 discharged transplantation patients using hospital medical record reviews and telephone inquiries. This survey found a transplant instruction completion rate of 75% during discharge preparation and 69% accuracy among participants in answering self-care knowledge questions. Both figures were lower than expected. PURPOSE: The goal of this project was to increase the instruction completion rate from 75% to 100% and the percentage of correct answers to self-care knowledge questions self-care knowledge from 69% to 95%. RESOLUTIONS: This study integrated all relevant nursing information into a standardized discharge-planning service booklet that was given to inpatients for reference. Furthermore, a self-care checklist was developed and introduced. Finally, a standard procedure for delivering nursing instructions and a regular audit and follow-up monitoring system were established. RESULTS: The nurses' instruction completion rate rose to 100% and the percentage of questions on self-care knowledge correctly answered by patients increased to 98%. CONCLUSIONS: Adopting a patient-centered philosophy of care and a model of interdisciplinary collaboration effectively integrated resources and promotes nursing quality and quality of life for transplant patients. The project effectively improved the completing rate for post-transplant discharge-planning service instructions and enhanced the self-care knowledge of transplant patients.

Psychometric properties of the Chinese-version Quality of Nursing Work Life Scale.

In this study, we developed and tested the psychometric properties of the Chinese-version Quality of Nursing Work Life Scale along seven subscales: supportive milieu with security and professional recognition, work arrangement and workload, work/home life balance, head nurse's/supervisor's management style, teamwork and communication, nursing staffing and patient care, and milieu of respect and autonomy. An instrument-development procedure with three phases was conducted in seven hospitals in 2010-2011. Phase I comprised translation and the cultural-adaptation process, phase II comprised a pilot study, and phase III comprised a field-testing process. Purposive sampling was used in the pilot study (n = 150) and the large field study (n = 1254). Five new items were added, and 85.7% of the original items were retained in the 41 item Chinese version. Principal component analysis revealed that a model accounted for 56.6% of the variance with acceptable internal consistency, concurrent validity, and discriminant validity. This study gave evidence of reliability and validity of the 41 item Chinese-version Quality of Nursing Work Life Scale.

[Conceptual model of teasing and bullying in adolescents].

Teasing and bullying incident levels have increased markedly in recent years according to international news reports. School and community-level action to stop and prevent bullying is a key focus of government education policy worldwide. Teasing is a usual facet of social interaction among youth and is related to bullying behavior. Although teasing and bullying are significant concerns, references for relevant concept analysis are lacking in the nursing field. To facilitate early screening to identify high-risk bullies and help victims effectively stop bullying events, concept analysis is needed to clarify and distinguish between the two concepts of teasing and bullying. The aim of this study is to integrate relevant published literature to determine the reasons for and relationships between teasing and bullying. We chose obesity as an example to construct a teasing and bullying conceptual model for adolescents and used this model to explore the related factors and health impacts of obesity. We found that both teaser intent and recipient perceptions correlated with bullying behavior. Duration and severity may induce teasing to become bullying. Because weight-based teasing is common among adolescents, we chose obesity as an example issue to demonstrate our adolescents teasing and bullying concept model. We then integrated the antecedent and consequential factors of teasing and bullying for obese adolescents. Weight-control strategies can stop school bullying if early interventions are performed in high-risk populations.

Effect of age on febrile response in patients with healthcare-associated bloodstream infection.

OBJECTIVE: This study aimed to determine the effect of age on febrile response in patients with healthcare-associated bloodstream infection (BSI). METHODS: This was a retrospective observational study using medical records as the primary source of data. Three indicators measured body temperature changes: basal body temperature (BBT), body temperature at infection onset (onset T), and maximum temperature (max T) during the infection period. RESULTS: In a sample of 230 patients there was no significant correlation between BBT or onset T and age. Max T was significantly correlated with age (r = -.191, p = .004). There was wide variation in onset T in all age groups. CONCLUSIONS: Age showed no effect on BBT and onset T, but blunted max T in patients with bacteremia. This variability in onset T in all age groups emphasizes the need for early recognition of subtle signs of infection and the need to use an individualized definition of fever.

Predicting quality of work life on nurses' intention to leave.

PURPOSE: The purpose of this study was to explore the relationship between quality of work life (QWL) and nurses' intention to leave their organization (ITLorg). DESIGN: A descriptive cross-sectional survey design was conducted using purposive sampling of 1,283 nurses at seven hospitals in Taiwan. Data were collected from March to June 2012. METHODS: Three questionnaires, including the Chinese version of the Quality of Nursing Work Life scale (C-QNWL), a questionnaire of intention to leave the organization, and a demographic questionnaire, with two informed consent forms were delivered to the nurses at their workplaces. Descriptive data, Pearson's correlations, and the ordinal regression model were analyzed. FINDINGS: Over half (52.5%) of nurses had ITLorg. Seven QWL dimensions were significantly negatively correlated with ITLorg (r = -0.17 to -0.37, p < .01). Significant predictors (p < .05) of ITLorg (the pseudo R(2) = 0.282) were being single, having a diploma or lower educational level, working in a nonteaching hospital. Four of the QWL dimensions--supportive milieu with job security and professional recognition, work arrangement and workload, work or home life balance, and nursing staffing and patient care--were also predictors of ITLorg. Three QWL dimensions were not predictors of ITLorg. CONCLUSIONS: This study showed that individual-related variables (being single, having a diploma or lower educational level), a work-related variable (working at a nonteaching hospital), and the four QWL dimensions play a significant role in nurses' ITLorg. After the QWL dimensions were added to the regression, the variance explained by the model more than doubled. CLINICAL RELEVANCE: To reduce nurses' ITLorg, nursing administrators may offer more focused interventions to improve the supportive milieu with job security and professional recognition, work arrangement and workload, work or home life balance, and nursing staffing and patient care.

Substance use, gender, socioeconomic status and metabolic syndrome among adults in Taiwan.

OBJECTIVES: This study had two purposes: (1) To explore the mediating effects of substance use-as indicated by alcohol consumption, cigarette smoking, and betel-nut chewing-on the relationship between socioeconomic status (SES) and metabolic syndrome; and (2) to examine the way gender moderates any mediating effects of substance use. DESIGN AND SAMPLE: Secondary analyses were conducted on a cross-sectional national dataset. The data from 3,107 males and 3,081 females of Taiwanese were analyzed. MEASURES: The prevalence of metabolic syndrome, education level, occupation, age, body weight, body height, and behaviors were collected. RESULTS: In male subjects, SES had no direct effect on metabolic syndrome; however, cigarette smoking and betel-nut chewing, but not alcohol consumption, were found to have mediating effects on SES and metabolic syndrome. In females, SES was found to have a direct effect on metabolic syndrome; however, substance use had no mediating effects on the relationship between SES and metabolic syndrome. These differences, in males and females indicated that the mediating effect of substance use on the relationship between SES and metabolic syndrome is moderated by gender. CONCLUSIONS: Our study suggests that health care providers may need to provide gender-specific health promotion programs to prevent metabolic syndrome.

The effectiveness of telehealth care on caregiver burden, mastery of stress, and family function among family caregivers of heart failure patients: a quasi-experimental study.

BACKGROUND: Telehealth care was developed to provide home-based monitoring and support for patients with chronic disease. The positive effects on physical outcome have been reported; however, more evidence is required concerning the effects on family caregivers and family function for heart failure patients transitioning from the hospital to home. OBJECTIVE: To evaluate the effectiveness of nursing-led transitional care combining discharge plans and telehealth care on family caregiver burden, stress mastery and family function in family caregivers of heart failure patients compared to those receiving traditional discharge planning only. DESIGN: This is a quasi-experimental study design. METHODS: Sixty-three patients with heart failure were assessed for eligibility and invited to participate in either telehealth care or standard care in a medical centre from May to October 2010. Three families refused to participate in data collection. Thirty families who chose telehealth care after discharge from the hospital to home comprised the experimental group; the others families receiving discharge planning only comprised the comparison group. Telenursing specialist provided the necessary family nursing interventions by 24-h remote monitoring of patients' health condition and counselling by telephone, helping the family caregivers successfully transition from hospital to home. Data on caregiver burden, stress mastery and family function were collected before discharge from the hospital and one month later at home. Effects of group, time, and group×time interaction were analysed using Mixed Model in SPSS (17.0). RESULTS: Family caregivers in both groups had significantly lower burden, higher stress mastery, and better family function at one-month follow-up compared to before discharge. The total score of caregiver burden, stress mastery and family function was significantly improved for the family caregivers in the experimental group compared to the comparison group at posttest. Two subscales of family function-Relationships between family and subsystems and Relationships between family and society were improved in the experimental group compared to the comparison group, but Relationships between family and family members was not different. CONCLUSIONS: The results provide evidence that telehealth care combined with discharge planning could reduce family caregiver burden, improve stress mastery, and improve family function during the first 30 days at home after heart failure patients are discharged from the hospital. Telenursing specialists cared caregivers with the concepts of providing transitional care to help them successful cross the critical transition stage.