Running head: MINDFULNESS

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A Study of Mindfulness Exercises for Informal Caregivers with Caregiver Strain
Jennifer M. Remetta
Bloomsburg University
Department of Nursing

Project Manager:

Lynn M. Painter, DNSc, RN

Clinical Expert:

Lauren Murphy, DNP, RN, ACNS-BC

Date of Submission: April 19, 2021

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Table of Contents

Abstract ……………………………………………………………………………………3
Chapter 1: Introduction ………………………………………………………………...…5
Background and Significance ……….………………………………………………….5
Problem Statement ……………………………………………………………….……11
Definition of Terms ……………………………………………………………………13
Chapter II: Review of the Literature ……………………………………………………..15
Theoretical and Conceptual Framework ……………………………………………...31
Chapter III: Methodology ……………………………………………………...………..34
Project Plan ……………………………………………………………………………34
Organizational Setting ………………………………………………………………...36
Patient Participation/Selection ………………………………………………………..37
Project Implementation ……………………………………………………………….37
Ethical Considerations ………………………………………………………………..38
Timeline of Activities ………………………………………………………………...39
Stakeholders Involved ………………………………………………………………..39
Measurement Instruments ……………………………………………………………40
Data Collection Procedures …………………………………………………………..40
Data Analysis ………………………………………………………………………...41
Resources Used for Project Completion……………………………………………...41
Chapter IV: Results……………………………………………………………………..43
Chapter V: Conclusion………………………………………………………………….49

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Abstract

Background: Cancer remains the second leading cause of death worldwide (World
Health Organization, 2018). Family and friends often find themselves accepting the caregiver
role with little or no training. Caregivers may experience both positive and negative effects of
caregiving. The consequence of providing this care creates a strain on many caregivers.
Increased physical and emotional stress may be detrimental to a caregiver and may lead to a
decreased lifespan. Studies have shown the positive effects mindfulness can have on one’s
emotional and physical well-being.
Purpose: The purpose of this quality improvement project was to identify caregiver
strain in informal caregivers of oncology patients and reduce strain thru the implementation and
practice of mindfulness exercises.
Methods: Convenience sampling was used to recruit participants. Participants were
asked to complete a demographic survey and baseline Modified Caregiver Strain Index (MCSI)
via Qualtrics. The MCSI consists of 13 questions to measure strain related to providing care.
Participants were instructed to practice a 10-minute guided mindfulness exercise daily for 14
days. After 14 days, participants retook the MCSI. The results were analyzed to assess if
mindfulness helped to decrease caregiver strain.
Findings: Seven participants completed the pre-mindfulness exercise survey, while nine
completed the post mindfulness exercise survey. However, only four sets of data could be
utilized for data analysis because only four individuals correctly utilized the same unique
identifier for both the pre- and post- tests. Due to the pre- and post- measurements of caregiver
strain, a paired t-test was conducted to analyze the effectiveness of mindfulness exercises in
decreasing caregiver strain. The p-value for the MCSI was not less than 0.05. However, a

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decrease in the mean indicated a decrease in caregiver strain. A total of seven of the questions
which fall within three domains resulted in positive improvements in decreasing caregiver strain.
The implementation of mindfulness exercises positively improved caregiver strain.
Conclusion: A quality improvement project to assist in decreasing caregiver strain was
implemented for informal caregivers caring for a loved one with cancer. The project explored the
concept of practicing a simple, brief, and convenient online mindfulness exercise to improve
caregivers’ well-being. Although, the project had a small sample size which was difficult to
showcase statistically significant results, improvements were seen in three of the five domains
measured within the MCSI. Overall benefits from practicing mindfulness align with the
promotion of psychosocial and physical well being.

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A Study of Mindfulness Exercises for Informal Caregivers with Caregiver Strain
Chapter 1: Introduction
Background and Significance
Cancer remains the second leading cause of death worldwide. In 2018, approximately 9.6
million deaths occurred due to cancer complications (World Health Organization, 2018). As a
result, from advances in medical technology and medical treatment of cancer, many individuals
have lengthened prognoses (Choi & Seo, 2019). Park and Look (2019) reported the expected
number of cancer survivors to increase to 19 million by 2024 due to both the United States’
aging population and advances in technology. Cancer not only affects the patient, but also
informal caregivers. An informal caregiver is an unpaid individual who cares for a family
member or friend (Young & Snowden, 2016). According to the National Alliance for Caregiving
(NAC) (2019), approximately 2.8 million Americans care for a family member or friend with
cancer (Wyatt et al., 2019). Choi and Seo (2019) reported that informal caregivers of cancer have
an increased burden of caring for a family member for an extended period of time. Caregiving is
associated with an increased risk for the development of somatic symptoms, such as, insomnia,
fatigue, gastric problems, loss of appetite, headache, and dizziness (Zavagli et al., 2016). Wyatt
et al. (2019) reported that providing care for a loved one diagnosed with cancer is more
emotionally stressful than other types of caregiving. In fact, as many as 50% of informal
caregivers of cancer report being “highly stressed.” (Wyatt et al., 2019). The strain and negative
impact from caregiving affects a caregiver’s lifestyle and may result in lifestyle changes (Or &
Kartal, 2019).
The significant, economic impact of cancer on society continues to rise. The Agency for
Healthcare Research and Quality (AHRQ) estimated that in 2017, the direct medical costs for

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cancer, including all health care expenditures, in the United States was $105.5 billion (U.S.
Department of Health and Human Services and Centers for Disease Control and Prevention and
National Cancer Institute, 2020). The projected total cost of cancer in the United States is
expected to increase to $458 billion in 2030 (“Our Aging Population,” 2015). Acute care
utilization is the single largest driver of spending in oncology care. Reimbursement from
commercial insurance companies and Centers for Medicare and Medicaid Services (CMS) has
diminished over recent decades due to changes in health care policy. The reduction of unplanned
acute care admissions during chemotherapy treatment is vital in proposed changes to CMS
reimbursement (Handley et al., 2018). Cancer treatment costs have greatly increased over the
past two decades resulting in financial challenges for patients, families, governments, and society
as a whole. The overall economic financial burden of cancer care on the United States health care
system not only effects patients, but also informal caregivers (Park & Look, 2019). The financial
strain of caregiving may result in depleting long-term savings or accruing more debt. Short-term
savings may also be used as 2 in 10 persons have left bills unpaid or late (American Association
of Retired Persons & National Alliance for Caregiving, 2020). Financial struggles have made
basic needs, such as, food problematic to obtain (American Association of Retired Persons &
National Alliance for Caregiving, 2020).
The downsizing of acute care hospitals, increasing expectations for more care being
provided at home, results in increased pressure of informal caregivers (Ferrell & Wittenberg,
2017; Zavagli et al., 2016). As reported by Swartz and Collins (2019), one in five adults will be
65 years or older by 2030 and will require assistance of daily living resulting in an increased
demand for informal caregivers. Increased risk factors for caregiver strain include around-theclock care, high or increasing care needs, and care transitions (Frederick, 2018). This gap in

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health-related needs falls to family members to assist their loved ones to obtain aid with ADL’s
(activities of daily living) care they require, such as: bathing, feeding, dressing and IADL
(instrumental activities of daily living); managing finances, transportation to medical
appointments, meal preparation, administering medications, and home maintenance (McIntyre &
Song, 2019). According to American Association of Retired Persons (AARP) and the NAC’s
report, Caregiving in the U.S. 2020, 99% of caregivers assisted with IADLs and 60% assisted
with ADLs. Often, family members abruptly fulfill the caregiver role with little or no training
and are required to be an extension of the health care team (Zavagli et al., 2016). Furthermore,
cancer caregivers are 72% more likely to perform medical and nursing tasks than non-cancer
caregivers (Wyatt et al., 2019). Taking on this new role, many may not feel adequately prepared,
be overwhelmed, or nervous about what is expected of them. Unfamiliar tasks, such as,
administering medications, assisting with bathing and meals, and performing medical and
nursing procedures may bring about an array of mixed emotions including anxiety, anger, and
sadness (Zavagli et al., 2016). According to Berry et al. (2017), caregivers who feel unprepared
to assume the role, have a lower sense of self-efficacy which increases the perceived strain.
Improving caregiver strain awareness and increasing support and interventions is critical to
refining a caregiver’s self-confidence (Berry et al., 2017).
According to AARP and NAC (2020), approximately 53.0 million adults, or one in five
Americans are caregivers in the United States. This total has increased from the total number of
caregivers in 2015, which was estimated to be 43.5 million. In 2020, the prevalence of
caregiving increased to 19.2% from 16.6% in 2015 due to the aging Baby Boomer population.
Wyatt, Lehto, and Sender’s (2019) research identified cancer caregivers as unpaid women who
are 53 years old in average and have a high school diploma. The median household income is

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less than $75,000 for cancer caregivers. On average, 32.9 hours per week of complex care is
delivered to the care recipient (Wyatt et al., 2019).
Healthcare and functional demands of care recipients have increased since 2015 (Wyatt et
al., 2019). Care recipients have reported needing more care due to long-term physical conditions,
mental health issues, and memory problems (American Association of Retired Persons &
National Alliance for Caregiving, 2020). The impact from caregiving does not only affect a
caregiver’s physical health, but also psychological well-being (Zavagli et al., 2016). According
to Li et al. (2016), caregivers suffer from social isolation, loneliness, chronic stress, anxiety, and
depression. The consequences of abysmal well-being may result in poor care received for the
care recipient. Li et al. (2016) identified a direct correlation between caregiver depression and
patient depression. Informal caregivers with depression may affect one’s emotions and aptitude
to function efficiently in the caregiver role. These increased demands reduce caregivers’ time to
constructively manage stress and promote positive psychological well-being. Tkatch et al. (2017)
reported care recipients have more frequent hospitalizations, lower quality of life, and higher
levels of mortality when their caregivers struggle with higher levels of strain. Due to a lack of
resources, time, transportation issues and stigma, many caregivers refuse to reach out for
assistance and support (Stjernswärd & Hansson, 2020). The increased prevalence of caregiver
strain is not effectively studied. Even though public awareness campaigns have increased over
the past decade to bring awareness of the importance of caregivers’ needs, the true magnitude is
unknown (Frederick, 2018).
Studies have shown the positive and negative impacts of caregiving (Gray et al., 2016;
Tao & McRoy, 2015). Positive effects include adaptation, resilience, a deepening of the
relationship between the caregiver and the patient and affection (Young & Snowden, 2017).

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Geng et al. (2019) reported when caregivers acknowledge the caregiving experience as more
satisfying, better care was provided to the care recipient allowing for a deeper affection. In
return, the caregiver was able to provide better care for the care recipient. Life expectancy has
proven to be decreased as much as 10 years as a negative result of caregiving (Tao & McRoy,
2015). Li et al. (2016) stated “caregivers are hidden patients who have undergone both
substantial physical and emotional stress” (p. 292). The responsibility of caregiving can
contribute to physical and mental strains of the caregiving role. Caregiving can also have
negative impacts. Caregivers may suffer from depression, anxiety, insomnia, financial strain,
time constraints, and missed hours worked (Tao & McRoy, 2015). The physical impacts of
caregiving, such as, insomnia, fatigue, loss of appetite, and weight loss, place a high level of
stress and decreased quality of life in caregivers (Daken & Ahmad, 2018). According to Bien et
al. (2007), female caregivers are more likely to be depressed and unsatisfied in the role of
caregiving. A caregiver’s age can influence the positive and negative effects of caregiving, as
elderly caregivers have been statistically shown to have higher levels of burden (Prevo et al.,
2018).
According to Kim et al. (2007), positive effects of caregiving are higher in less educated
caregivers. Opposingly, Bien et al. (2007), concluded caregivers with a higher level of education
reported more positive impacts related to caring. Additionally, financial strain related to
caregiving reduces the number of employed hours worked and increased absenteeism from work.
Caregivers are instrumental in providing the daily needs of oncology patients; however, a
caregiver’s health can significantly impact the care recipient (Li et al., 2016).
Caregivers face many challenges when providing care for a loved one diagnosed with
cancer. It is estimated that 80% of this population expressed a desire to remain in their home as

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long as possible, but only one third attain their request to end of life (Mitchell et al., 2010; Tao &
McRoy, 2015). Providing care during end-of-life increased anxiety for many informal caregivers
which resulted in increased caregiver strain. This becomes a challenge for caregivers who try to
meet the requests of the care recipient (Mitchell et al., 2010). As incidences of cancer continue to
rise worldwide, informal caregivers accept the demands required to provide assistance to their
loved ones (Dionne-Odom et al., 2018). Although some caregivers find a higher meaning and
purpose when fulfilling the caregiver role, strain and stress coexist. AARP and NAC (2020)
reported one in four caregivers found it difficult to care for their own health as caregiving had
made their own health of poorer quality. As a result of caregivers’ declining health, this could
impact an already strained system and jeopardize larger system goals to improve health care. On
average, caregivers provide care for approximately 4.5 years (American Association of Retired
Persons & National Alliance for Caregiving, 2020).
The strain and stress of caregiving suggests caregivers may benefit from professional or
peer counseling, support groups, and respite care. According to Dionne-Odom et al., (2018), the
use of mental health services is low. However, studies show that caregivers use of mental health
services is less than 25% and 16-32% of cancer caregivers are diagnosed with depression and 4050% have anxiety symptoms (Dionne-Odom et al., 2018). Chronic stress and negative impacts
from caregiving will require an intervention to improve health-related quality of life for
caregivers. The lack of mental health utilization has brought an awareness to the need of
developing and increasing access to hassle-free interventions (Dionne-Odom et al., 2018).
Providing support and advocating for informal caregivers, (including medical benefits and
payment for care provided) impacts legislators, health care providers, researchers, and both
formal and informal caregivers assisting this population (Colby & Ortman, 2014). Little is

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known as to how cancer caregivers personally manage stress (Wyatt et al., 2019). One such
intervention that has shown to have positive results and is easy to implement is mindfulness
exercises (Li et al., 2016).
Complementary and integrative health (CIH) therapies, such as, mindfulness, are
becoming more popular in the United States. Wyatt, Lehto, and Sender (2019) studied CIH
therapies and the positive effects on informal cancer caregivers. CIH therapies have shown to
improve mood and sleep, reduce stress, and promote relaxation (Wyatt et al., 2019). Tkatch et al.
(2017) identified that many older adults are comfortable utilizing technology as a resource to
help improve their mental health. Feasibility from practicing online meditation demonstrated that
online interventions have been successful in improving social isolation and loneliness (Tkatch et
al., 2017).
Problem Statement
For loved ones diagnosed with cancer, family caregivers provide the essential health-care
support needed on a daily basis while at home. The changing dynamics of the health care system,
reimbursement regulations, and the increase incidences in cancer rates impacts caregivers of all
ages. Although caregiving has several positive effects, such as, psychological satisfaction and
growth, assessing a caregiver’s well-being is imperative to ensure the needs of caregivers are
met. A caregiver may not be able to provide care appropriately or may not have all of the
emotional or physical skills needed (Berry et al., 2017). The addition of mindfulness exercises
may reduce caregiver strain in informal caregivers of oncology patients.
Project Goals/Objectives
This quality improvement project was proposed to reduce caregiver strain in informal
caregivers of oncology patients through the implementation of practicing mindfulness exercises.

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The Modified Caregiver Strain Index (MCSI) was utilized in this project and it consists of 13
questions to measure strain related to providing care (Onega, 2018). The goal of this quality
improvement project was to engage caregivers in active participation of mindfulness exercises
and decrease caregiver strain. Consented caregivers were instructed to complete a 10-minute
guided mindfulness exercise and encouraged to practice daily for 14 days. Pakenham and Samios
(2013), proposed mindfulness nurtures acceptance of feelings and is effective on improving
several physical symptoms, including chronic pain, depression, psoriasis, and fibromyalgia.
Caregivers completed the MCSI before and after the implementation of the mindfulness exercise,
to assess the impact of the mindfulness intervention. Appraisal and dissemination of the results
of this quality improvement project aided in recommending that mindfulness exercise
information be made available to caregivers. Improving caregiver burden with effective stress
reduction modalities can reduce physical and emotional well-being and improve care provided to
the care recipient. This project was essential to promote and support informal caregivers during
the caregiving role.
The clinical psychologist at the cancer center of the large Northeast health care system
where the quality improvement project occurred, recognized the need to improve current
informal caregiver support. This project brought an awareness of informal caregiver strain by
implementing the MCSI for caregiver strain assessment. Furthermore, the amount of caregiver
strain experienced was highlighted by the caregivers of their oncology patients. This project
determined if mindfulness was an effective intervention to reduce caregiver strain. The PICO
question guiding this quality improvement project was: In informal caregivers of oncology
patients, does the addition of mindfulness exercises reduce caregiver strain?

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As an essential change agent, the DNP prepared APRN recognized the drive for
transformation while instilling values and empowering others to use their knowledge to help lead
change. To achieve stakeholder buy-in, open communication utilizing a feedback loop was
important to ensure effective communication amongst all stakeholders (Porter-O’Grady &
Malloch, 2018). All key stakeholders were included in the feedback loop with a clear and concise
overview of the project, timeline, individuals’ responsibilities, and results.
Caregivers required support and interventions to promote emotional and physical health.
If left unassisted, caregivers may experience increased health complications and even mortality.
Often, diagnoses are abrupt, and an informal caregiver may not be ready to accept the
responsibilities of caring for an ill-loved one (Zavagli et al., 2016). The MSCI assessment
enlightened caregivers as well as the staff at the oncology clinic to the amount of strain
experienced, and the use of mindfulness exercises were evaluated as a means of reducing the
strain.
Definition of Terms
The following theoretical definitions were used to guide this quality improvement
project:
Caregiver strain: the perception of persistent problems and a feeling of decreased wellbeing that results from providing prolonged care (Onega, 2018).
Care recipient: individual receiving care (Li et al., 2016).
Informal caregiver: a person who provides physical, practical, and emotional care
and/or support to a relative or a friend without financial reimbursement (Frederick, 2018).

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Mindfulness: awareness that emerges through paying attention on purpose, in the present
moment, and nonjudgmentally to the unfolding of experience moment by moment (Stjernswärd
and Hansson, 2020).
Conclusion
In chapter one, the background and significance of informal caregivers was introduced.
The awareness for identifying caregiver strain and providing caregivers with quick, easily
accessible interventions to promote well-being has been emphasized. The results were used to
improve current informal caregiver support and to build a program to benefit informal
caregivers. Chapter two provides a detailed literature review of caregiver strain.

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Chapter II: Review of Literature

In this chapter, a review of existing literature on the topics of informal caregiving and
mindfulness was offered. This chapter explored the positive and negative effects of caregiving.
Informal caregivers accept the role, but often are unaware of the strain resulting from caregiving
(Zavagli et al., 2016). Literature related to caregiving was reviewed and found that there are
some identified positive aspects of caregiving, but there are more negative factors that lead to
caregiver strain. Literature related to the effects of mindfulness on reducing caregiver strain was
also reviewed and found mindfulness is a convenient intervention to help reduce caregiver strain.
Methodology
Electronic databases utilized for obtaining evidence was obtained through both the
University and organization’s Health System Libraries. Health science and psychology databases
included databases: Ovid Medline, APA PsycInfo (Ovid), Cumulative Index to Nursing and
Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews, and Agency for
Healthcare Research and Quality (AHRQ) were reviewed. MESH headings were composed of
caregivers, family, well-being, and mindfulness. Keywords utilized in the search include
caregivers, carers, family members, mindfulness, mindful awareness, oncology, cancer, positive
aspects, and negative aspects. After applying limiters of English language, scholarly peerreviewed journals, all geography, deduplication, and published between 2015 to present, 231
articles were retrieved. Abstracts and titles were reviewed to identify the suitability of the article.
Additional references were obtained and reviewed through relevant articles’ bibliographies. Ten
articles were selected, and an evaluation of evidence was completed to review data studied,
methodology utilized, strengths and weaknesses of the studies, and outcomes identified. The
studies reviewed identified the importance of practicing self-care when assuming the caregiver

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role. The conclusion of these studies identified a need for further exploration of what
interventions benefit caregivers in decreasing strain and the appropriate time to begin an
intervention.
Findings
The review of literature on informal caregivers found not all caregivers experience
negative effects of caregiving. Palacio and Limonero (2020) identified caregiving may result in
personal growth of informal caregivers of oncology patients. In contrast, a number of caregivers
may experience negative aspects of caregiving including psychological distress, poor health, and
unmet social needs (Grover et al., 2018). Mahmood et al. (2016), discovered brief, online
mindfulness interventions allowed caregivers to practice in the comfort of one’s home and at a
convenient time. Feasibility of mindfulness interventions aided in decreasing anxiety, depression,
and improving the caregiver’s quality of life and well-being (Tkatch et al., 2017).
Positive Aspects of Caregiving. Cobb et al. (2016) explored the positive and negative
aspects of informal oncological caregivers and non-oncological caregivers and evaluated if
gender was a factor in caregiver strain. A descriptive, correlational design was used for this study
with a sample of 111 informal caregivers. Participants were identified through a cancer center
and a community hospital on the same campus of the same academic health system. A majority
of informal non-oncological caregivers (38.5%) were 50-59 years of age and informal
oncological caregivers (29.2%) were 60-69 years of age. The greater part of informal nononcological caregivers (82.1%) and oncological caregivers (68.1%) were female. Participants
were primarily Caucasian, 92.3% for informal non-oncological caregivers and 90.3% for
informal oncological caregivers. Both groups of caregivers held a high school degree; informal
non-oncological caregivers (20.5%) and informal oncological caregivers (26.4%). The majority

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of caregivers’ current state of health was rated as good; informal non-oncological caregivers
(66.7%) and informal oncological caregivers (63.4%). Surveys were distributed via paper or
online method and included additional demographic variables included age, gender, ethnicity,
and race.
Positive aspects of caregiving identified included caregiver esteem resulted in satisfaction
in caring, feeling privileged to care for a loved one, and the importance of providing care. Study
instruments utilized were the Caregiver Reaction Assessment instrument (CRA) and the Positive
Aspects of Caregiving scale (PAC). The majority of caregivers were in the caregiver role for
more than one year and were unpaid. Caregiver esteem was perceived to be higher in caregivers
who reported working longer hours outside of the home and caregivers who did not live with the
care recipient. For most caregivers, this was their first experience in the caregiver role (Cobb et
al., 2016).
Race, age, and ethnicity impacted positive aspects of informal caregiving. Cobb et al.
(2016) identified male caregivers were less likely than women to report their physical health was
impacted by caregiving and older caregivers reported higher levels of family support. Nonwhites were found to have a more positive caregiving experience overall, higher caregiver
esteem and less physical health impacts than white caregivers. However, no identified
differences were found between informal oncological caregivers and non-oncological caregivers
with respect to impact on finance, health schedule, or caregiver esteem (Cobb et al., 2016).
Mosher et al. (2017) explored self-reported positive changes within the patient-caregiver
dyads. Individual, semi-structured qualitative interviews with 23 patients with advanced
colorectal cancer and 23 informal caregivers were conducted. The caregiver’s relationship to the
care recipient was spouse/partner (78%) and other family member was 22%. The majority of

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caregivers were female (87%) and caregiver race was primarily Caucasian (91%). Ninety-six
percent of caregivers were married, and the average caregiver was 56 years old. Caregivers
possessed an average of 16 years of education and the caregiver’s annual household income was
>$50,000. The average time since the patient’s colorectal cancer diagnosis was 25 months.
Seventy-four percent of patients had stage IV colon cancer and were treated with both surgery
(100%) and chemotherapy (100%) (Mosher et al., 2017).
Five positive themes were found and included, closer relationships with others, greater
appreciation of life, clarifying life priorities, increased faith, and empathy for others. Caregivers
reported closer relationships and support from others resulted in a greater emotional closeness
within their relationship. A greater appreciation of life was recognized that resulted from a
greater awareness of life’s conciseness. A cancer diagnosis brought an awareness of life’s
priorities, such as, focusing on meaningful relationships. Some participants recognized a greater
sense of increased faith, renewed church attendance, and regular devotional time. Increased
empathy for others was identified with a stronger connection to other individuals who were
diagnosed. Caregivers recognized the need to implement better health habits after a loved one’s
cancer diagnosis, including increased exercise, healthier eating, and preventative health
screenings (Mosher et al., 2017).
Grover et al. (2018) studied 30 caregivers of patients with acute myeloblastic leukemia
(AML). The average age of caregivers was 42.37 years, and more than half of the caregivers
were male (56.7%) and were married (86.7%). Caregivers allocated a daily average of 14.5 hours
in providing care to the care recipient (Grove et al., 2018).
Grover et al. (2018) discovered that caregiving was associated with positive aspects and
included motivation for the caregiving role and caregiving personal gains. A negative correlation

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was identified between financial burden, disruption of routine family activities and family
interaction, motivation for caregiving role, and caregiver satisfaction. Caregivers with lower
levels of caregiver strain had a more positive and appreciative attitude in the caregiver role. A
limitation of this study involved a small sample size of caregivers. In general, caregivers of AML
care recipients experienced both positive and negative aspects of caregiving. The importance of
decreasing strain and improving caregiving satisfaction had a greater impact on the overall wellbeing of caregivers (Grove et al., 2018).
Palacio and Limonero (2020) found caregiving resulted in personal growth of informal
caregivers of oncology patients. This quantitative study with a transversal design of one hundred
informal caregivers completed questionnaires pertaining to resilience, aspects of care, emotional
distress, spirituality, and posttraumatic growth. The majority of caregivers were women (86%),
with an average age of 46.52 years, married (54%), had a high school education (100%) and
lived in an urban area (89%). Most of these caregivers lived with their families (99%), were
housewives (39%), and were daughters of the care recipient (48%). Seventy-nine percent of the
caregivers were practicing Catholics and 32% had two children. A total of 66% of the sample
was active in the caregiving role for at least 12 months. The care recipients included the
following diagnoses: breast cancer (19%), lung and gastric cancer respectively 15% (Palacio &
Limonero, 2020).
Palacio and Limonero (2020) identified that informal caregivers of oncological care
recipients often encounter stress experiences due to increased responsibilities. Increased stress
may lead to anxiety, depression, and loss of control. However, positive relations were identified
between resilience, positive aspects of care, spirituality, and posttraumatic growth. Resilience
had a positive effect on posttraumatic growth and an appreciation for life. It had been defined as

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a natural coping style in times of trauma and stress. A positive relationship endured between
improved self-esteem, self-efficacy, and a more positive attitude towards life. Personal growth
increased a caregiver’s personal strength allowing for new possibilities to emerge. An increase in
personal strength enabled personal growth to develop and had been identified as a protective
factor for quality of life and emotional self-regulation. These positive relations influenced the
reduction of caregiver strain and allowed for the enhancement to the caregiver role (Palacio &
Limonero, 2020).
Several studies identified the positive aspects of caregiving (Cobb et al., 2017; Grover et
al., 2018; Mosher et al., 2018; Palacio & Limonero, 2020). Cobb et al. (2017) acknowledged
caregivers had both positive and negative aspects of caregiving. Caregiving experiences differed
between individual demographic factors, race, and ethnicity. Grover et al. (2018) found
motivation for the caregiving role to be a positive aspect of informal oncological caregivers.
Similarly, challenges faced in the caregiver role may have been a catalyst for personal growth
(Mosher et al., 2017). Any endeavor to decrease caregiver strain greatly impacted the overall
positive experience of caregiving. Palacio and Limonero (2020) distinguished the importance of
relating a meaning to the illness with the intention of developing protective factors in preserving
psychological health. Empowering caregivers to recognize one’s challenges within the role
benefitted caregivers in promoting self-growth and enhanced self-esteem. Moreover, Grover et
al. (2018) identified caregiving personal gains and caregiver satisfaction to be related to positive
aspects of the caregiving role.
Negative Aspects of Caregiving. Caregivers often experience unmet needs when caring
for a loved one. According to Sklenarova et al. (2015), unmet needs were defined as the
“requirement for some desirable, necessary, or useful action to be taken or some resources to be

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provided, to attain optimal well-being” (p. 1513). Several domains of unmet needs transpired
into emotional, psychological, comprehensive cancer care, and information. A diagnosis of
cancer was a challenging time for both the care recipient and caregivers. Raised emotions
included anxiety and depression initiating caregiver strain. Sklenarova et al. (2015) led a crosssectional study to assess the unmet needs of cancer caregivers that included anxiety, depression,
and identify probable predictors of their supportive care needs. A total of 193 pairs of patients
and caregivers agreed to complete the survey. Survey response rate was 72.3%. Questionnaires
were excluded from the analysis if less than 60% of the items were completed. A total of 188
questionnaire pairs (97.5%) were subject to analysis. The average age of caregivers were 57.8
years, and 136 subjects were female (72.3%). Most caregivers living with the care recipient were
a spouse or partner (156 caregivers; 83%) and 77 caregivers (41.0%) were working (Sklenarova
et al., 2015).
A total of 43.6% of caregivers reported having less than 10 unmet needs disseminated
over four domains included, health care service, information needs, and emotional and
psychological needs. The highest unmet need of caregivers was addressing fears about the care
recipient’s physical or mental deterioration (52.7%). Likewise, other high-ranking unmet needs
encompassed managing concerns about the cancer coming back (44.6%) and working through
the caregiver’s feelings about death and dying (40.8%). Unmet needs of caregivers incorporated
the whole psychophysical aspect of the care recipient whereas the caregiver was not concerned
of one’s own emotional or physical state of health. Poignantly, every fifth caregiver reported
having a moderate or high unmet need in receiving emotional support for oneself (22.0%).
Moreover, the last ranked unmet caregiver needs were looking after one’s own health, including

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eating a balanced diet and adequate hours of sleep (20.4%). Sklenarova et al. (2015) identified
48.3% of cancer caregivers would accept psychological support if it were offered.
Caregivers were screened for distress, anxiety, and depression. Results found caregivers
to have significantly higher scores compared to patients. Positive screens for caregiver distress
were 69.1%, depression was 26.5%, and 34.9% for anxiety. Patients’ levels of distress were
54.1%, depression was 28.4%, and 26.3% for anxiety. There was no significant correlation
between sociodemographic variables including age, sex, and type of relationship. Sklenarova et
al. (2015) suggested that caregiver-tailored screening tools may benefit professionals in order to
offer caregiver-tailored help to this invaluable group (Sklenarova et al., 2015).
Caregiving is both emotionally and physically strenuous on the caregiver. A sense of
unmet needs in communication, information, and available support services was expressed by
informal caregivers (Frederick, 2018; Mitchell et al., 2010; Tao et al., 2015). Zavagli et al.
(2016) conducted a study utilizing self-report questionnaires focusing on domains of worry,
somatic symptoms, depressive and anxious symptoms, and strain. Domains of worry included
relationships, self-confidence, future, work, and financial. One hundred participants who were
enrolled in Bologna, Italy’s National Tumors Association (ANT), a free medical, nursing,
psychological, and social home care for cancer patients, participated in the study. The study
population’s average age was 49.8 years, and 73 participants were female. The majority of
caregivers were care recipient’s children (74%). Caregivers were in the caregiving role for an
average of 17.5 months and 86% were employed. The average years of education of the
caregivers was 13 years (54%) (Zavagli et al., 2016).
Zavagli et al. (2016) found a moderate, positive correlation between domains of worry
and physical symptomatology, including depressive and anxious symptoms, and increased strain

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levels. Worry was a critical variable for caregivers’ health and led to increased physical ailments
including, cardiovascular, immune, endocrine, and neurovisceral systems. Caregivers frequently
experienced worry in the caregiving role and daily life. A main factor in the domains of worry
was work, where caregivers felt they do not work hard enough or stress about making mistakes
at work. Balancing full-time work and caregiving increased strain. Many caregivers worried
about their occupation, fear of losing their jobs, and their future (Zavagli et al., 2016).
Literature aligns that the negative effects of caregiving do not change as a result of the
ailments of the care recipient. Caregivers of older adults are at risk for increased caregiver
burden and decreased well-being (Or & Kartal, 2019). Not all informal caregivers have the skills,
knowledge, and abilities to provide complex medical and nursing care to a care recipient.
Complex medical and nursing tasks are required, and more than half of all caregivers provide
this care (Tao et al., 2015).
Or and Kartal (2019) studied the effects of care burden on the well-being of family
members rendering care to older adults. The study was conducted in the Denizli urban region of
west Turkey. A cross-sectional design was used for this study, included a sample of 363 family
caregivers of older adults, and data was collected via in-person interviews. Demographic
characteristics of family caregivers were 71.6% female, a mean age of 48-54, and 60.3% had an
education status of primary school. The majority of the monthly income status was $250-499
(48.8%). The main relationship of caregivers to the elderly person was a daughter or daughter-inlaw (30.8%). A total of 51.0% caregivers denied having a chronic disease. A majority of
caregivers allocated at least one to six hours of daily care (44.9%) and received social support
(62.8%). Caregivers’ self-perceived health status was reported as good (57.6%).

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Or and Kartal (2019) identified a negative correlation between caregiver burden and the
well-being of the caregiver. As caregiver burden increased, caregiver well-being decreased.
Caregiver burden indicated to be a robust predictor of the caregiver’s well-being. Moderate
levels of caregiver burden were identified in this study and caregivers’ well-being was at a
respectable level. Non-caregivers reported higher levels of well-being. The importance of
lessening the caregiver burden to increase the caregiver’s well-being and effectiveness in the
caregiver role was essential. Caregivers who reported poorer health had increased caregiver
burden. Increased caregiver well-being demonstrated a significant relationship between a social
support system and perceived health status of the caregiver. Single, older caregivers were
identified as having increased well-being for the reason of having more time to care for
themselves and the care recipient. A strong social support system was vital in strengthening the
well-being and decreasing caregiver burden of caregivers (Or & Kartal, 2019).
Various studies showed the negative aspects of caregiving which effected many
caregivers (Or and Kartal, 2019; Sklenarova et al., 2015; Zavagli et al., 2016). Cobb et al. (2016)
acknowledged emotional and psychological support as the most challenging aspect of caregiving
and daughters of care recipients reported the highest effect impacted schedule and lack of family
support. Furthermore, Sklenarova et al. (2015) highlighted the heightened need of support for the
caregiver. Or and Kartal (2019) reported lower caregiver burden was identified in Turkey due to
a strong support system. This outcome may be due to the Turkish tradition of respecting and
protecting older adults. The demands of caregiving permitted caregivers to focus on the care
recipient rather than one’s own health and emotional needs. Sklenarova et al. (2015) discussed
caregivers neglected their own health due to worrying about the care recipient and future fears.
Consistent research showed worry, anxiety, and depression to be main factors that contributed to

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decreased caregiver well-being and increased caregiver strain. Zavagli et al. (2016) recognized
strain levels to be highest in correlation with caregivers’ psychophysical health and worry levels.
Further research is needed to investigate what are the specific worriers of family caregivers to
endorse one’s physical and emotional well-being.
Mindfulness: A State of One’s Inner Harmony. The concept of mindfulness was
grounded in Buddhist philosophies, nonetheless, it has been gaining more popularity in the
Western culture (Li et al., 2016). Mindfulness focuses on purpose in a non-judgmental way of the
present moment. In mindfulness, one is trained to consciously calm their mind to enjoy the inner
peace and connectedness to the present feelings and environment. Mindfulness may be as simple
as focusing on one’s breathing in order to decrease anxiety and can be practiced anywhere as the
ease of access makes its approach favorable (Li et al., 2016). Practicing mindfulness exercises
provides effective self-care and stress reduction from the aims of caregiving. The effects from
mindfulness have shown to help decrease physical symptoms from depression. The benefits of
practicing mindfulness prove to increase health and psychological well-being, while improving
cognitive functioning, and resilience (De Frias & Whyne, 2015).
Outcomes from practicing mindfulness have contributed to increased self-esteem, wellbeing, self-affirmation, and value while providing care. Stress and negative thoughts are
decreased while self-regulation is increased. Mindfulness teaches one to explore and compare the
differences between the past and present. Thus, increasing caregivers’ ability to cope with
challenges from caregiving, at the same time enhancing the ability to accept their current
feelings. The practice of mindfulness endorses positive thinking and changes the brain’s
mechanism to shield the negative effects from caregiving. Such protective factors promote
mastery control of their current situation and allow positive thoughts to be produced. Long term

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effects of practicing mindfulness may benefit both the care recipient and caregiver (Geng et al.,
2019).
There are several different types of mindfulness programs including mindfulness-based
stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and brief mindfulness
sessions. Although MBSR and MBCT have been proven to be beneficial, both programs are
lengthy in time, run over eight weeks, and required in-person sessions (Mahmood et al., 2016).
Caregivers desire easy access interventions while limiting their time away from the care
recipient. A single session of brief mindfulness has been implemented outside of the clinical
setting and has shown to reduce aggressive responses to social threat and reduce the likelihood of
producing bias when judging other people’s behavior. Mindfulness may have significant effects
beyond the clinical setting and health psychology (Mahmood et al., 2016).
Mahmood et al. (2016) investigated the significance of a brief, five-minute, computerbased mindfulness session to assess its benefits. The findings of a brief, single-session, session
was successful in creating an increased state of mindfulness. Moreover, a five-minute
mindfulness session could easily be incorporated into everyday life, anywhere, and at any given
moment when needed. This study included three different randomized studies. Each study
utilized the Toronto Mindfulness Scale (TMS) before and after the mindfulness practice. The
TMS is a tool utilized to measure one’s level of mindfulness at a single point in time. All three
studies utilized the same five-minute mindfulness body scan audio file which focused on the
sensations of their bodies from foot to head. The audio file purposefully did not mention
mindfulness and was administered via a computer (Mahmood et al., 2016).
Study one consisted of 54 high school students, 51 females, two males, and one
unidentified ranging from 16 to 18 years. The average age of participants was 17 years.

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Participants were randomly placed into either the mindfulness (N = 27) or the control (N = 27)
group and the study was conducted in a large computer room. The control group was asked to
take a few deep breaths, wait four minutes, instructions were repeated and then participants were
allowed to complete the TMS via paper format. There were no significant differences noted
between groups. This study included limitations of the post TMS was completed immediately
after the mindfulness session. Participants may have possibly remembered their answers from the
pre-TMS and used the same answers post-TMS. Furthermore, the computer lab did not have any
dividers and participants may have distracted each other (Mahmood et al., 2016).
Study two consisted of 90 participants who were recruited from Amazon’s Mechanical
Turk (MTurk) and were randomly placed into either the mindfulness (N = 51) or control (N = 39)
group. Participants were able to login from any location to complete the pre-TMS, mindfulness
session, and post TMS at any time. The same five-minute mindfulness audio file was used, and
the mindfulness group had a significantly higher TMS score post intervention (Mahmood et al.,
2016).
Lastly, study three consisted of 61 participants (37 male and 24 female) ranging from 18
to 70 years were recruited from Amazon’s MTurk. The average age was 33.56 years. The
mindfulness group had 27 participants and 28 participants in the control group. Participants were
able to complete the intervention via computer at any time. Similarly, to study one, participants
completed the TMS before and immediately after the mindfulness session, but like study two, it
was delivered entirely online. Again, the mindfulness group reported significantly high TMS
scores than the control group. Mahmood et al. (2016) highlighted the value of implementing an
online, five-minute mindfulness session to obtain the benefits of mindfulness in a non-clinical
setting and at the caregiver’s own time. Participants may be more inclined to practice online

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mindfulness programs in the comfort of their own environments to increase the effectiveness of
the intervention. In return, this saved the caregiver time, costly expert training, and the
commitment to participate in lengthy courses.
Attendance and attrition may be a challenge in committing to in-person mindfulness
sessions. Tkatch et al. (2017) evaluated the feasibility of an online mindfulness intervention to
decrease caregiver burden and improve psychological well-being. This study also focused on
evaluating the intervention’s impact in relation to caregiver burden, quality of life (QOL),
psychological well-being, including stress, loneliness, anxiety, and social support. The
intervention was eight weeks in length and consisted of online mindfulness meditation, education
of self-care focusing on self-compassion. Online sessions were delivered twice weekly via
Smartphone or computer and three in-person sessions were offered. These sessions were offered
at the beginning, middle, and end of the study. Tkatch et al. (2017) focused on communitydwelling older adult caregivers in South Florida. Community-dwelling referred to older adults
who are living independently (Tkatch et al., 2017).
A total of 40 participants completed the program, however, only 22 completed the preand post-surveys. Analysis was based upon the 22 completed pre- and post-surveys. The average
age of participants was 71 years and ranged from 60-69 years (N = 6) to 80 plus years (N = 3).
The majority were female (80%), married (83%), lived with a family member (72%), and 85%
were retired/homemakers. While over 50% of participants attended more than half of the inperson sessions, the preferred method of delivery was online (Tkatch et al., 2017).
Positive correlations were seen between increased levels of attendance and positive
changes in social support and mental health. Overall, significant correlations were identified
between decreased stress, anxiety, and improved mental health. The online mindfulness sessions

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presented a positive correlation between caregiver burden, quality of life, and psychological
well-being. Quality of life was important to consider within the context of practicing mindfulness
with the intention of improving anxiety and depression. The outcomes exemplified the
noteworthy effects the online mindfulness sessions had of positively impacting caregivers.
Tkatch et al. (2017) confirmed the feasibility of primarily online mindfulness sessions of
community-dwelling older adult caregivers with the implementation of lower levels of intensity.
This type of delivery for mindfulness may be ideal for older adult caregivers who lack resources
to transportation or ability to leave the care recipient.
Caregiver strain is a risk for all caregivers. Hearn et al. (2019) conducted a randomized
controlled feasibility study with three-month follow-up to investigate the feasibility and efficacy
of web-based mindfulness training for caregivers of individuals with spinal cord injuries (SCI).
The design utilized a single center randomized controlled trial assessing the intervention at
baseline, postintervention, and three-month follow-up. Groups were blinded and placed either
into the mindfulness training group or the psychoeducational control group. Individuals were
allowed to complete the mindfulness training anytime and at the participants’ location of choice.
The web-based mindfulness training offered two prerecorded, 10-minute audio-guided
mindfulness sessions each day. Participants were asked to practice two times a day, six days a
week for a total of eight weeks. The mindfulness sessions focused on topics including breath
awareness and assimilation of mindfulness in daily life (Hearn et al, 2019).
Hearn et al. (2019) conducted the study in a community setting with 55 participants. The
intervention group had 28 participants and 27 participants in the control group. Most participants
were men (52.7%) with a mean age of 44 years, 51% were married and 29% were living

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together. Mainly, the participants were employed full-time (54.5%) or part-time (32.7%). Many
participants were Caucasian, British, Irish, or European (85.5%).
The psychoeducational control group received a weekly email for eight weeks which
included psychoeducational materials on SCI and chronic pain to augment one’s related care
needs. This attention control offered hypothetically significant meaningful interventions.
Participants were instructed to read the materials at times and locations fitting for them.
Significant group differences were seen at post-intervention and three-month follow-up.
Mindfulness training demonstrated positive changes in caregivers’ well-being related to severity
of depression, anxiety symptoms, psychological and social quality of life. The psychoeducation
control group also experienced positive effects from the psychoeducational training. However,
more significant results were discovered within the mindfulness training group. The mindfulness
training group incorporated a skills-based training which resulted in enhanced improvements in
psychological and social quality of life. Mindfulness encourages nonjudgmental observational
skills resulting in caregivers accepting time for self-care. The efficacy of online-based
mindfulness training has shown to be beneficial for SCI caregivers and decreased travel and time
commitment (Hearn et al., 2019).
Numerous studies researched the positive effects mindfulness intervention had on
decreasing stress, anxiety, and improving one’s self-growth and self-esteem (Hearn et al., 2019;
Mahmood et al., 2016; Tkatch et al., 2017). Mindfulness has been utilized and shown to be
effective in both clinical and non-clinical settings. Various studies showed the feasibility and
efficacy of delivering mindfulness interventions via online (Hearn et al., 2019; Mahmood et al.,
2016; Tkatch et al., s2017). Furthermore, Mahmood et al. (2016) highlighted the benefit of a
brief, online five-minute mindfulness session may have on one’s well-being. Brief, online

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mindfulness sessions are highly effective as lengthy mindfulness programs. Caregivers may have
increased peace of mind knowing there is no time commitment. Additionally, online programs
are valuable for caregivers who have lack of transportation. The research highlights that
mindfulness is a proven intervention to help both caregivers and care recipients.
Theoretical/Conceptual Framework
According to Chokkanathan and Mohanty (2017), the social determinants of caregiver
well-being had been elucidated by stress theories, contributing to additional improvements in
combating caregiver strain. Pearlin’s Stress Process Theory aligned with the framework for the
proposed implementation of mindfulness exercise to aid in decreasing caregiver strain. Pearlin’s
Stress Process Theory identified the impact different stressors may have on stress propagation.
Often, stressors do not occur alone, but rather in groups which may have a chain reaction that
may directly or indirectly impact a caregiver’s well-being (Chokkanathan & Mohanty, 2017).
Aneshensel (2015), conveyed Pearlin’s Stress Process theory pursued to explain the
effects stressors had on mental health. First, stressors injured mental help by devaluing personal
and social support resources. Second, these resources reduced the effects of revelation to
stressors. Two functions, such as, mediation and moderation demonstrated effects of stressors.
Mediation referred to indirect resources including, social resources and personal resources. These
indirect resources increased chronic stressors and as a result decrease resources. Moderation
denotes the impact resources may have on one’s mental health and the strength of the association
(Appendix A). These two factors clarify how stressors destruct mental health and why some
individuals are affected more by stressors than others. When individuals are in most need of
resources, stress has eroded these resources away. Pearlin discussed the effects of everyday
chronic stressors debilitate one’s mental health. Chronic stressors slowly develop, are taxing for

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a lengthy period of time and have uncertain endings. Conversely, major life events explode
sharply, quickly arise and define when they start and end (Aneshensel, 2015).
Bluestein and Bach (2007) described objective and subjective stressors of caregiver strain
are credited to demographic attributes. Objective stressors included the physical demands of
caregiving while subjective stressors incorporated the emotional strains of caregiving. Levels of
strain are predisposed by modifiers which may include family support, social interactions,
community support, and financial demands (Bluestein & Bach, 2007).
Informal caregivers encounter many stressors while providing care for a care recipient.
Pearlin’s Stress Process Theory identified why stressors may impact some caregivers more than
others. Informal caregivers who experience positive effects from caregiving allowed a wider
variety of available resources. These individuals support healthy coping skills, such as, seeking
support from others. In return, stress levels decreased for these informal caregivers. The
emotional and physical ailments from increased caregiving stress depleted the acceptance of
available resources, including family support. The effects of high stress levels become cyclic and
affect one’s physical and mental health, finances, and work (Aneshensel, 2015). Decreasing
stressors during the caregiver role through mindfulness may provide enough support to allow
more positive resources to become available.
The conceptual framework, Plan, Do, Study, Act (PDSA) cycle was utilized in the
proposed DNP project to guide how the problem was best explored and the relationship between
variables (Appendix B). The PDSA cycle is a four-stage process which includes the plan for
change and observation, trialing the change on a small scale, analyzing the data to determine
what was learned, and refining the change according to what was learned (Melnyk & FineoutOverholt, 2019). The theoretical concepts of Pearlin’s Stress Process Theory and the conceptual

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framework of the PDSA cycle provided an important lens through which the evaluation of stress
and reaction were interconnected and formulated the foundation for the DNP project.
Conclusion
This chapter provided an overview of literature on both the positive and negative aspects
of caregiving and the benefits of online mindfulness exercises. The need for caregivers will
continue to rise as the world’s aging population increases (Frederick, 2018). The persistent
challenges in informal caregiving may manifest as health care continues transforming (Zavagli et
al., 2016). The magnitude of identifying caregiver strain with the aim of allowing caregivers to
fulfill the responsibilities of the caregiving role is vital. Practicing mindfulness may effortlessly
be incorporated into a caregiver’s daily routine. Thus, decreasing anxiety, depression, physical
ailments and increasing a caregiver’s quality of life and well-being. The DNP project was
supported by the theoretical framework of Pearlin’s Stress Process Theory and conceptualized
through the PDSA model. Identification of caregiver strain may be related to chronic and sudden
stressors as detailed by Pearlin’s Stress Process Theory in linking factors as to why some
caregivers are impacted more by stress than others. In the next chapter, the DNP project’s
methodology is reviewed.

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Chapter III: Methodology

Project Plan
The quality improvement (QI) project offered the implementation of mindfulness
exercises to assist in decreasing caregiver strain in a cancer center of a large health care system
located in Northeast Pennsylvania. According to Melnyk and Fineout-Overholt (2019), QI
projects utilize a systematic approach for problem solving with the goal of improving outcomes.
Practice-based evidence and QI have become rigorous and require a framework to determine and
understand the desired outcome (Melnyk & Fineout-Overholt, 2019). The Plan, Do, Study, Act
cycle (Appendix B) was utilized in guiding the QI project.
The PDSA cycle is a scientific method that follows a four-stage process to test and learn
about changes on a small scale. Primarily, a change is planned on a small-trial and cumulatively
builds knowledge about change in a structured way. External evidence was needed to support the
improvement in addition to refining the change based on what was learned and repeating the
testing. While small trials are used within the PDSA cycle, a greater chance of success stands on
a broader scale (Melnyk & Fineout-Overholt, 2019).
Plan
Informal caregivers may suffer both detrimental physical and emotional effects resulting
from the caregiving role. This identified the foundation for the QI project with the goal of
improving caregivers’ well-being through practicing a daily, guided mindfulness exercise. The
proposal to focus on the implementation of a quality improvement initiative to optimize
caregiver support using mindfulness exercises was supported by clinical observations and
experiential knowledge, a critical appraisal of research, and formal education.

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Do
The cancer center of a large health care system in Northeast Pennsylvania agreed and
welcomed the QI project. A longitudinal design was used for the foundation of the project in
which repeated measures were assessed over a three-month period. The QI project instructed
participants to practice a daily, 10-minute guided mindfulness practice in the comfort of one’s
own environment and at a convenient time that works best for the caregiver. Due to the recent
changes in the health system’s visitor policy, very few caregivers attended appointments with
loved ones attributable to the current novel pandemic, Covid-19. Enrollment and participation in
this study solely relied on promoting the project via flyers displayed in the cancer center and
placed in patient folders for patients to take home. Flyers were developed, approved, and
implemented (Appendix B). Informal caregivers had an opportunity to participate in the QI study
between September thru December 2020.
Study
The participants were chosen from a convenience sample of informal caregivers of
established clinic patients. Participants needed access to either a computer or Smartphone to
complete the demographic form, pre-Modified Caregiver Strain Index (MCSI) tool and the
mindfulness exercise video. The MCSI is a practical tool used to quickly screen for caregiver
strain. Immediately after completing 14 days of practicing the guided, 10-minute mindfulness
exercise, participants completed the post-MCSI tool. Data from participants was analyzed upon
conclusion of the study. The outcomes of the study were analyzed to explore the effectiveness of
the mindfulness exercise on caregiver strain. The goal of the QI project was to decrease caregiver
strain through mindfulness exercises. Following the conclusion of data collection, results were

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assessed, measured, and evaluated. According to Melnyk and Fineout-Overholt (2019), data
analysis should be systematic, consistent, and thorough.
Act
The magnitude of disseminating the findings to both researchers and clinicians who can
use the evidence in formulating practice guidelines or decisions regarding patient care is
essential (Melnyk & Fineout-Overholt, 2019). Analysis of the data was used as the foundation to
support changes for current caregiver resources and develop a policy. Long term, the
mindfulness practice would routinely be offered to all informal caregivers of established patients
of the cancer center. The project results were used to improve existing informal caregiver support
and foster a program to benefit informal caregivers. The clinical psychologist of the cancer
center and the researcher utilized the results to formulate changes and implement routine
mindfulness practices for caregivers.
Organizational Setting
The project occurred in the cancer center of a large health care system in Northeast
Pennsylvania. The cancer center provides northeast Pennsylvania with the largest team of
fellowship trained cancer specialists. Clinical trials and genetic testing are offered at the cancer
center. The health care system supports a culture of evidence-based practice and clinical practice
guidelines. A multidisciplinary team composed of hematologists, radiation oncologists, surgical
oncologists, specialty trained oncology nurses, and a clinical psychologist provide individualized
care plans incorporating, consultation, diagnosis, and treatment. Additionally, a weekly cancer
support group was available for patients and informal caregivers. These meetings provided
emotional support during difficult times and established a network for patients and informal

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caregivers. Even though these initiatives have been established, further caregiver support was
desired.
Patient Participation/ Selection
The anticipated patient population included informal caregivers who were 18 years of
age, caring for a loved one diagnosed with cancer, and who could read and speak English. The
caregiver either lived with or without the care recipient and assisted daily or provided total care.
Exclusion criteria for caregivers was less than 18 years of age and non-English speaking.
Participants enrolled anonymously in the QI project via a project link through Qualtrics. The
project link provided access to a consent form (Appendix D), demographics survey (Appendix
E), and the MCSI.
Project Implementation
The cancer center acknowledged the need to improve present caregiver support resources,
even though a cancer support group was already established. Convenience sampling was used in
the QI project. A flyer was displayed in the cancer center to promote the project, and patients
also received a flyer in the patient’s folder of important paperwork distributed at the end of the
clinic visit (Appendix C). The health care system’s visitation policy had changed due to Covid19 and it was recommended that patients attended appointments alone. If informal caregivers of
patients from the cancer center chose to enroll in the QI project, participants were asked to
complete a demographic survey and baseline Modified Caregiver Strain Index (MCSI) via
Qualtrics. The MCSI consists of 13 questions to measure strain related to providing care (Onega,
2018). Participants were instructed to practice a 10-minute guided mindfulness exercise daily for
14 days. After 14 days, participants retook the MCSI. The results were analyzed to assess if
mindfulness helped to decrease caregiver strain.

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Barriers affecting the QI project included Covid-19, changes to the current visitor policy,
cancelation of the weekly cancer support group, and a lack of caregivers attending appointments
with loved ones.
Ethical Considerations
Collaborative Institutional Training Initiative (CITI) training was completed with a
certification obtained in June 2020. An application was submitted to the educational institution’s
Internal Review Board (IRB) for approval of the QI project in August 2020. IRB approval was
obtained from the educational institution and the health care system. Informed consent was based
on a 5th grade reading level and obtained through Qualtrics prior to commencing the DNP
project.
Compliance to maintain confidentiality followed through the Health Insurance
Probability and Accountability Act of 1996 (HIPAA). Participants were deidentified and coded
using an individual identification number. Data was collected through Qualtrics, a data collection
platform used for projects involving human subjects. An informed consent was provided online
and when the participant clicked on accept, it moved to the survey. To protect anonymity due to
electronic data, IP addresses were not stored. All data was recorded, stored, and protected in
electronic files via a data collection platform on a password protected computer. Strict adherence
of HIPAA was preserved to avert unacceptable disclosures.
Four basic ethical principles of health care included, beneficence, nonmaleficence,
autonomy, and justice which encompassed this project. Participants’ autonomy was respected as
the individual had the right to choose whether to participate in the project. The QI project carried
low risk of harming others or nonmaleficence. Beneficence was practiced with the goal of
improving one’s well-being and decreasing caregiver strain. Any informal caregiver who was

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eligible to participate in the project had a fair and equal chance to do so. Ethical principles
guided the significance of assessing the influence of evidence on participants and the way in
which evaluations were directed (Melnyk & Fineout-Overholt, 2019).
Timeline of Activities
An in-depth discussion occurred with the cancer center’s social worker on March 10,
2020, which comprised of current caregiver resources available at the cancer center. Upon
identifying a limited amount of informal caregiver resources available at the cancer center, the
idea of the QI project was discussed with the clinical psychologist and the operations manager of
the cancer center on March 27, 2020. Both supported the need to increase available caregiver
resources. An agreement for increased caregiver resources available at the cancer center was
identified and buy-in was obtained. A literature review was performed in June 2020 and a
detailed project plan was developed. CITI training was completed on June 7, 2020. The DNP
project oral defense occurred on August 4, 2020. IRB approval was received by the educational
institution in August 2020 and the health system organization in September 2020. The timeframe
for participants to partake in the study was from September-December 2020. Data was collected
through an online platform used for projects involving human subjects and analyzed. DNP
project goals were evaluated upon completion of the project. Defending the project is anticipated
in May 2021.
Stakeholders Involved
Upon identification of the problem, stakeholders were recognized to gain insight of the
proposed QI project. The proposed project was discussed with the clinical psychologist, social
worker, and operations manager of the cancer center to develop a project plan for
implementation and to identify possible barriers. Moreover, the informal caregivers of care

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recipients were the primary stakeholders in this QI project. The recognition of caregiver strain
was key for participation and enrollment. This was accomplished through multidisciplinary
meetings at the cancer center and via telemedicine appointments with patients and informal
caregivers.
Measurement Instruments
Data from the DNP project measured pre-post mindfulness exercise intervention. The
outcomes were measured using the Modified Caregiver Strain Index (MCSI). The MCSI consists
of 13 questions to measure strain related to providing care (Appendix F). Major domains
measured in this tool include financial, physical, psychological, social, and personal. In 1983, the
Caregiver Strain Index (CSI) tool was developed. The MCSI was created in 2003 as it clarifies
and updates many of the items on the CSI. Scoring is two points for each ‘yes’, one point for
each ‘sometimes’, and zero for each ‘no’ response. Scoring spans from 26 to 0. A higher score
implies a higher level of caregiver strain (Onega, 2018).
The MCSI has an internal reliability coefficient of .90 compared to the CSI’s coefficient
of .86 in 1983. The MCSI is brief, convenient, self-administered, and easy to score. Recognizing
the effects of caregiver strain may specify more individualized strategies for reducing caregiver
strain. Professional judgement may be needed to evaluate the level of caregiver strain because
the tool does not distinguish between low, moderate, or high levels of caregiver strain (Onega,
2018).
Data Collection Procedures
Participants were informal caregivers of patients who sought treatment at the cancer
center. The informal caregivers enrolled anonymously in the project via an online study link.
Enrollment was from September-December 2020. Contact information was given to participants

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if any questions or concerns arose. Participants were directed to complete a demographic form
and a baseline MCSI assessment. All participants were instructed to watch a 10-minute guided
mindfulness video daily for 14 days via YouTube which had been specifically developed for this
QI project. The video link was provided on the flyer. Subsequently, participants were instructed
to complete the MCSI post-mindfulness intervention after 14 days.
Data Analysis
The evaluation of results studied the effectiveness of mindfulness exercise to decrease
caregiver strain. Central tendency, or a descriptive summary of a dataset through a single value
that reflects the center of the data distribution, was used to compare the pre- and post-MCSI
scores. Indices of central tendency include the mode, median, and mean (Polit & Beck, 2017).
Interpretation of the frequency distributions and central tendency of the data could determine
patterns and was accomplished using descriptive statistical analysis. A paired t-test was used to
analyze the dependent groups of pre- and post-MCSI scores to determine if the mindfulness
exercises lead to a significant difference in MCSI scores between the groups. Additional data
analyzed included the number, age, gender of participants. Descriptive statistics were utilized to
organize and summarize the data to identify if the mindfulness exercise facilitated in decreasing
caregiver strain and increasing well-being.
Resources Used for Project Completion
Resources necessary for the completion of the project included buy-in from the
operations manager and clinical psychologist of the cancer center. Education and awareness of
caregiver strain on informal caregivers was positively received by stakeholders. Related costs for
the implementation included the production of the guided mindfulness video and distribution of
flyers. The information technology department of the educational institution was contacted to

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42

access Qualtrics. Qualtrics was free of charge to use through the educational institution. The
project did not acquire any additional time or other duties from staff at the cancer center or
additional work hour related costs.
Conclusion
This chapter reviewed the methodology for the proposed QI project. An overview of the
project plan including the conceptual framework of PDSA were discussed. Other considerations
to the methodology included the project setting, participants, project implementation, ethical
considerations, timeline of activities, stakeholders, measurement instruments, data collection
procedures, data analysis, and resources used for project completion. The next chapter discusses
the results of implementation of mindfulness exercises to decrease caregiver strain.

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Chapter IV: Results

Informal caregivers often experience somatic symptoms, financial strain, and lifestyle
changes as a result of caring for those with cancer. Simple, brief, and convenient online
meditation exercises have been successful in decreasing caregiver strain and increasing health
and well-being of informal caregivers (De Frias & Whyne, 2015). The overall purpose of this
quality improvement project was to reduce caregiver strain in informal caregivers of oncology
patients through the implementation of practicing mindfulness exercises. The following are the
results.
Sampling Procedure
Seven participants completed the pre-mindfulness exercise survey, while nine completed
the post mindfulness exercise survey. However, only four sets of data could be utilized for data
analysis. This was due to the fact that many participants failed to properly create and utilize their
unique participant identification codes, therefore comparing pre and post intervention scores was
possible for only 4 participants. Participants were 18 years of age and older and were recently
caring for a loved one diagnosed with cancer. Non-English-speaking individuals were excluded
from the project.
The number of participants in this project was greatly impacted by the COVID-19
pandemic. Due to the pandemic, the healthcare system changed visitation policies and
encouraged patients to attend appointments alone. Cancer support groups and caregiver support
groups were also cancelled. This greatly impacted the ability to recruit caregivers for this study.
Flyers were posted in the clinic and information was handed to the patients, but caregivers were
not directly told about this study.

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Informal caregivers enrolled anonymously in the project via an online study link through
Qualtrics from September until December 2020. Participants were instructed to complete a
demographic form and a baseline MCSI assessment prior to initiating mindfulness exercises. The
intervention of a 10-minute daily mindfulness exercise was encouraged for the participants to
practice at one’s own convenience. Upon completion of practicing the mindfulness exercise,
participants were instructed to complete the post- MCSI tool. Pre- and post- MCSI scores were
further analyzed to assess the benefits of a mindfulness exercise in decreasing caregiver strain.
Descriptive statistics were utilized to identify the outcome of mindfulness exercise in
decreasing caregiver strain. Central tendency, or a descriptive summary of a dataset through a
single value that reflects the center of the data distribution, was used to compare the pre- and
post- MCSI scores. Indices of central tendency include the mode, median, and mean (Polit &
Beck, 2017).
Qualtrics provided a spreadsheet of the data collected. Each participant was de-identified
and coded with a unique numeric code during the enrollment process. Data analysis began in
February 2021 and participant demographics were analyzed for central tendency. A paired t-test
analyzed the effectiveness of the intervention in decreasing caregiver strain. Statistical Package
for the Social Sciences (SPSS) software was utilized for data analysis.
Study Sample
Characteristics of the study participants (n=4) included 75% female (n=3) and 25% male
(n=1). The age range of 25-35 years was 25% (n=1), 45-54 years was 25% (n=1), and 65 years or
above was 50% (n=2). Informal caregivers living with the care recipient was 25% (n=1) and
75% (n=3) did not live with the care recipient. Most participants were divorced at 50% (n=2) and
75% (n=3) were employed full time at least 40 or more hours per week. The majority of informal

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caregivers had a college level education and held a Bachelor’s degree (n=2) or a Master’s degree
(n=1). Participants who described themselves as White/Caucasian was 75% (n=3) and Asian was
25% (n=1).
Post Intervention Scores
Data interpretation for the MCSI was analyzed using SPSS. Due to the pre- and postmeasurements of caregiver strain, a paired t-test was conducted to analyze the effectiveness of
mindfulness exercises in decreasing caregiver strain. P-value of less than 0.05 is regarded as
statistically significant for the paired t-test (Kim & Mallory, 2017). The p-value for the MCSI
was not less than 0.05 and was not considered statistically significant.
Due to a small sample size, individual questions were analyzed to assess improvements in
caregiver well-being pertaining to major domains; financial, physical, psychological, social, and
personal (Table 1). The mean scores for each question were analyzed. A decrease in the mean
indicated a decrease in caregiver strain. A total of seven of the questions which fall within three
domains resulted in positive improvements in decreasing caregiver strain. Those questions
assessed time restrictions, family adjustments, changes in personal plans, increased demands on
time, emotional challenges, work adjustments, and feeling overwhelmed.

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Table 1
Paired Samples t-test

Many questions that showed improvements fell within the psychological domain (Figure
1). Personal time restrictions had a pre- MCSI mean of 1.00 and a post- MCSI mean of 0.75. The
impact caregiving had placed on caring for a person who has changed so much from his/her
former self had a pre- MCSI mean of 1.25 regarding and a post- MCSI mean of 1.00. This
displayed an improvement in the caregivers’ well-being. Additional demands placed on the
caregiver from other family members had a pre- MCSI mean of 1.50 and a post- MCSI of .75.
This presented a positive outcome from the implementation of mindfulness exercises. Further
areas of improvement focused on social and personal domains. Family adjustments had a preMCSI mean of 1.00 and a post- MCSI mean of .75. Job requirements were significantly impacted
with a pre- MCSI of 1.00 and a post- MCSI of .50. This presented a positive improvement from
practicing mindfulness exercises.
Other domains of improvement for caregivers’ well-being were social and personal.
Adjustments to family routines showed a pre- MCSI mean of 1.00 and a post- MCSI mean
of .75. Furthermore, work adjustments had the most significant improvement with a pre- MCSI

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47

mean of 1.00 and a post- MCSI mean of .50. Questions regarding changes to personal plans and
feeling completely overwhelmed both had a pre- MCSI mean of 1.25 and a post- MCSI mean of
1.00. The implementation of mindfulness exercises positively improved caregiver strain.
Figure 1
Comparison of Pre- Post- MCSI Scores

Conclusion
In chapter four, a summary of the findings for the quality improvement project was
analyzed. The data answered the project question, “In informal caregivers of oncology patients,
does the addition of mindfulness exercises reduce caregiver strain?” Although, the results were
not statistically significant, participants did have a decrease in caregiver strain in the domains of

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psychological, social, and personal. Descriptive statistics were presented to conclude the
effectiveness of mindfulness exercises to reduce caregiver strain. Chapter five will discuss
implications, findings, and recommendations to clinical practice.

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Chapter V: Conclusion

The number of cancer survivors is expected to increase to 19 million individuals by 2024
due to advances in technology and the United States’ aging population (Park & Look, 2019). By
2030, one in five adults will be 65 years or older and will require assistance of daily living. The
need for increased informal caregivers has been identified as the structure of health care is
incessantly changing. Family members often take on the role of informal caregiver abruptly and
may not feel effectively prepared, be overwhelmed, or unsure of expectations (Zavagli et al.,
2016). Zavagli et al., (2016) reported the impact from caregiving not only affects the caregiver’s
physical health, but also affects psychological well-being. Mindfulness, or the ability to focus on
purpose in a non-judgmental way of the present moment, has proven to be beneficial in
decreasing anxiety, improving cognitive functioning, and resilience (De Frias & Whyne, 2015).
Chapter five contains a summary of the findings with recommendations and conclusions
of the findings. The goal of this quality improvement project was to engage caregivers in active
participation of mindfulness exercises to decrease caregiver strain. This project was essential to
promote and support informal caregivers during the caregiving role. Additional actions and
recommendations for nursing practice are given and suggestions for future research are provided.
Implications
This quality improvement project supports previous research of the benefits and
significance of practicing mindfulness exercises in decreasing caregiver strain. Although the
results were not statistically significant, improvements were seen in three of the five domains
measured within the MCSI. A decrease in the mean indicated a decrease in caregiver strain. Half
or 50% (n=2) of the sample had a decrease in caregiver strain while the other 50% (n=2) had an
increase in caregiver strain. A total of seven of the questions that fall within three domains

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50

resulted in positive improvements in decreasing caregiver strain. Areas of improvement included
time restrictions, family adjustments, changes in personal plans, increased demands on time,
emotional challenges, work adjustments, and feeling overwhelmed. Mindfulness exercises
allotted participants to improve areas of well-being, such as, psychologically, socially, and
personally. Participants uncovered improvements in accepting whom the care recipient once was,
to whom the care recipient has become after a cancer diagnosis. Personal time restraints and
additional demands placed on the caregiver improved as a result of practicing the mindfulness
exercise. Family adjustments, routines, and job requirements displayed an improvement in the
well-being of caregivers. Participants had the most positive impact in work adjustments, personal
plans, and feeling completely overwhelmed. These recognized benefits from practicing
mindfulness exercises have the possibility to improve the well-being of an immeasurable number
of informal caregivers of cancer patients. Nurses and other health care providers should provide
informal caregivers with information regarding the benefits of incorporating mindfulness
exercises into one’s daily routine. This information could be provided during appointments when
caregivers accompany patients.
Implications for future research include a replication of the study with a larger sample
size. This will assist in identifying the significance of benefits mindfulness exercises offer in
improving well-being. Changes to promoting and recruitment of the project would benefit from
face-to-face interaction with possible participants. This would not only increase the sample size,
but also help to clarify any questions. Research confirms the positive outcomes from mindfulness
exercises as it supports individuals of all ages. Recommendations are given to conduct future
research in informal caregivers of palliative patients.

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Sustainability
Although the results were not statistically significant, the findings align with the efficacy
of practicing mindfulness exercises in decreasing caregiver strain. The implementation of
mindfulness exercises in informal caregivers with caregiver strain has the ability to improve
one’s well-being, cognitive functioning, and resilience (De Frias & Whyne, 2015). Practicing
mindfulness exercises is sensible, feasible, and convenient for caregivers. The benefits from
practicing mindfulness have been reported to decrease depression and somatic symptoms (Daken
& Ahmad, 2018). The approach is ideal for caregivers with time restrictions, transportation
issues, and physical limitations. When caregiver strain is decreased, caregivers have more
satisfaction in caring, feel privileged to care for a loved one, and understand the importance of
providing care. Caregivers demonstrated a higher level of self-esteem and aligned with positive
aspects of caregiving when strain was decreased (Cobb et al., 2016).
The results from this quality improvement project will be presented to the clinical
psychologist and operations manager at the cancer center. Discussion can occur with the social
worker to disseminate the findings and to assist in providing mindfulness exercises as an
additional resource in decreasing caregiver strain. A brochure can be provided to caregivers
explaining the benefits mindfulness exercises provide. The social worker can practice a simple
mindfulness exercise with caregivers during a meeting to explore its simplicity. The clinic nurse
can discuss the benefits of mindfulness exercises with the patient and caregiver during office
visits. Educational pamphlets with the mindfulness exercise link can be made available as a
resource for both patients and caregivers in the clinic. Dissemination of findings will also be
discussed with the healthcare providers at the clinic during a monthly staff meeting. Providers
can encourage caregivers to practice mindfulness as part of one’s daily routine. A plan to

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disseminate the findings during a poster presentation at an oncology conference has been
identified.
The results of this project provide evidence to support mindfulness as an effective way to
promote the well-being of informal caregivers while decreasing caregiver strain. This study
aligns with previous studies that support the feasibility and noteworthy benefits of practicing
online mindfulness sessions to decrease anxiety and depression related to caregiver strain (Hearn
et al., 2019; Mahmood, 2019; Tkatch et al., 2017).
Limitations
Several limiting factors were identified with the design and implementation of this
project. The novel Covid-19 pandemic had a major impact with obtaining a large number of
participants for this project. Potential participants were unable to meet face-to-face with the
author of this project. This barrier may have resulted in a lack of promotion for this project,
communication, and clarity of participant expectations. Instructions may have been unclear when
participants were required to create a unique, individual identification number which was used to
de-identify participants. Only four sets of data could be analyzed at the end of the data collection
period due to incomplete data sets. A small sample size made it difficult to show results as
statistically significant in mindfulness exercises assisting to decrease caregiver strain.
Conclusion
A quality improvement project to assist in decreasing caregiver strain was implemented
for informal caregivers caring for a loved one with cancer. The project explored the concept of
practicing a simple, brief, and convenient online mindfulness exercise to improve caregivers’
well-being. Although, the project had a small sample size which was difficult to showcase

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statistically significant results, improvements were seen in three of the five domains measured
within the MCSI. This project aligns with past research regarding the benefits from practicing
mindfulness to promote psychosocial and physical well-being of informal caregivers.

53

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Appendix A
Pearlin’s Stress Process Model

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Appendix B
Plan-Do-Study Act Cycle

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Appendix C
Participant Recruitment Flyer

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Appendix D
Consent Form

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Appendix E
Demographic Survey

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Appendix F
Modified Caregiver Strain Index