Iran Journal of Nursing

Introduction
Chronic kidney disease is an important global health concern. Hemodialysis is the primary treatment method for chronic kidney diseases. Patients undergoing hemodialysis experience a high level of disability, loss of function, and increased dependence on family members. Family caregivers play a critical role in the care and support of these patients. However, the caregiving demands and responsibilities can lead to significant care burdens, causing physical and mental health problems in caregivers and affecting the quality of patient care. Even prior to the COVID-19 pandemic, caring for patients with hemodialysis was a stressful experience. The pandemic exacerbated this care burden and caused caregivers to face additional concerns regarding the risk of infection in the hemodialysis centers. Patients undergoing hemodialysis are at a higher risk of mortality if they get infected with COVID-19. Furthermore, the pandemic-related restrictions increased caregivers’ responsibilities, reduced family communication, and increased the vulnerability of patients, all of which contributed to increased care burden on families. Given that nurses of patients in hemodialysis centers are in frequent contact with patients and their families, they can play a vital role in improving the quality of care and supporting families using interventions such as coping strategy training. Coping skills training has been shown to improve the understanding of stressful situations and positively affect the health of both patients and caregivers. Thus, this study aimed to investigate the effect of coping skills training on the care burden of family caregivers of patients undergoing hemodialysis. 

Methods 
This is a quasi-experimental study with a pretest-posttest design that was conducted in 2020 in the comprehensive treatment center for special diseases, affiliated to Birjand University of Medical Sciences. Participants were 60 family caregivers of patients undergoing hemodialysis (30 in the intervention group and 30 in the control group). The intervention consisted of six two-hour sessions of coping skills training on a weekly basis. The data collection was done before, immediately after, and one month after the intervention using three tools: A questionnaire surveying patients’ demographic information (age, sex, marital status, economic level, duration of disease, number of dialysis sessions, and hours of dialysis per week), a questionnaire surveying caregivers’ demographic information (age, sex, marital status, education level, occupation, history of chronic diseases, type of relationship with the patient, and financial status), and the Zarit burden interview (ZBI), with 22 items, rated on a 5-point Likert scale from never (0 points) to always (4 points). The ZBI score ranges from 0 to 88, with higher scores indicating a greater care burden; a score of 0-20 indicates low burden, a score of 21-40 indicates mild to moderate burden, a score of 41-60 indicates moderate to severe burden, and a score of 61-88 indicates severe burden. The ZBI evaluates the caregiver burden in two domains: subjective burden and objective burden. The objective burden subscale assesses the negative effects of the disease, such as disruption in family relations, limitations in social, work-related, and recreational activities, and financial problems. The subjective burden subscale assesses caregivers’ emotional reactions to the patient and care. Data analysis was conducted in SPSS software, version 19 using the Chi-square test, Fisher’s exact test, independent t-test, repeated analysis of variance, Bonferroni post hoc test, and Mann-Whitney U test. 

Results 
There was no significant difference between the intervention and control groups in terms of demographic information (P>0.05). The ZBI score in both groups was moderate to severe before the intervention. The ZBI score in the intervention group showed a significant decrease after the coping skills training compared to baseline (P<0.001). Furthermore, the total ZBI score and the scores of objective and subjective burdens significantly decreased in the intervention group after the intervention (P<0.001), but no statistically significant difference was observed in the control group. The analysis of variance indicated a significant difference in the total ZBI score and the scores of objective and subjective burdens over three time points (before, immediately after, and one month after) (P<0.05). The Bonferroni test revealed the lowest mean score was seen immediately after the intervention and the highest mean score was reported one month after the intervention, indicating the positive effect of the intervention. In contrast, the control group showed no significant difference over three assessment times (P>0. 05). 

Conclusion 
Although the care burden was relatively high in both groups before the intervention, the coping skills training significantly reduced it in the intervention group. These findings suggest that coping skills training has a significant effect on reducing the care burden of family caregivers of patients undergoing hemodialysis. In this regard, and given the critical role of nurses in providing psychological support, coping skills training should be included in the nursing education programs. 

Ethical Considerations
Compliance with ethical guidelines
Ethical approval was obtained from the ethics committee of Birjand University of Medical Sciences (Code: IR.BUMS.REC.1398.332).

Funding
This article was extracted from the master’s thesis of Fatemeh Khaledi, funded by Birjand University of Medical Sciences. 

Authors' contributions
Design and writing: Marzieh Mogharab, Fatemeh Khaledi, and Toktam Zia; performing intervention: Fatemeh Khaledi; Data analysis and interpretation: Gholamreza Sharifzadeh .

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the Deputy for Research of Birjand University of Medical Sciences, all the caregivers participated in the study, and all the staff of the comprehensive treatment center for special diseases in Birjand for their support and cooperation in this research. 


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