Empowering Caregivers in Hemiplegia Care: A Quasi-Experimental Study for Enhancing Care-Competency Through Structured Educational Development Approach

Background: Caregiver competency for hemiplegic patients would be enhanced and sustained with structured educational approach with step-by-step competence confirmation and telehealth communication for follow-up. Aim: Evaluate the effectiveness of a structured educational development approach in enhancing the care competency among caregivers for patients with hemiplegia. Research Design: Quasi-experimental (one group pretest-posttest). Sample & Setting: 70 caregivers, purposively sampled, at neuropsychiatric and neurosurgery inpatient and outpatient units in Minia University Hospital, Egypt. Study Tools: 1) Structured interview questionnaire 2) Knowledge and practice competency tools (≥ 80% is cutoff competency score). Method: Pretest data was collected. Three educational sessions administered, each requiring competency before proceeding. A fourth session tested the third one, followed by two months of telehealth support, then a post-test. Results: Caregivers were mostly aged 30-39, female, married, housewives, with basic education, and reside in rural areas. Post-intervention, caregiver competency improved significantly: overall care competency rose from 11.4% to 75.7%; knowledge from 18.5% to 72.9%; practice from 21.4% to 81.4%. Knowledge scores increased from 13.5 ± 5.48 to 20.6 ± 2.75, practice scores from 37.4 ± 9.30 to 66.8 ± 4.5, and total care competency from 50.9 ± 14.78 to 86.4 ± 7.25. Effectiveness was 36.5% ± 16.46, with significant t-test values (p <0.001). Conclusion: The structured educational approach significantly increased the caregiver care competency for hemiplegic patients. Recommendations: Implement structured educational programs with telehealth follow-up for sustainable caregiver competency in inpatient discharge plans and outpatient services.


Introduction
Hemiplegia, characterized by paralysis of muscles on one side of the body, often results from damage to the brain's motor centers due to ischemia or hemorrhage.Stroke, the leading cause of hemiplegia, stands as the most common cause of permanent disability globally, severely impacting the lives of patients and their families Meanwhile, it would be highly beneficial for caregivers of hemiplegic patients to be wellprepared in care-competency through a structured educational development approach.This approach should begin with background knowledge,

Aim of the study
The purpose of the study was to evaluate the effectiveness of a structured educational development approach in enhancing the care competency among caregivers for patients with hemiplegia.

Scoring system
Every procedure of each package scored from 0 to 5 for the included items and competent participant means scored 80% (4 out of 5 points).
The scoring was as following: Zero: Unable to perform the procedure, 1: Performs the 10-30 % only of procedure steps, 2: Performs > 30 to 60% of the procedure steps, 3: Performs > 60% to 80 of all procedure steps, 4: Performs the procedure correctly and in order but lacks confidence and/or speed, and 5: Performs the procedure with confidence and precision.
All scores of the procedures summed-up with the maximum score is 75 then converted into a percentage score.A caregiver is considered competent if they achieve at least 80% of the total possible points (60 from 75).

Total care-competency Scoring system:
For care competency, a caregiver should achieve ≥ 80 of the points of both knowledge and practices.
Achieving a score of 80% or higher is frequently regarded as a critical benchmark in nursing education, reflecting that the learner has sufficiently mastered the necessary content and can apply it effectively in practice.The 80th percentile for knowledge and practice competence is Thus, by this approach, caregivers can meet the demands of their role with minimal risk of error while ensuring patient safety and quality of care.

Validity and Reliability
The tools of the study were given to a group of three experts in medical surgical nursing and two experts in the community health nursing community field.The tools were examined for content coverage, clarity, relevance, applicability, wording, length, format, and overall appearance.To ensure confidentiality and anonymity, all data were coded appropriately.

D) Pilot study:
The study was conducted among ten caregivers, who were excluded from the study sample to test the feasibility, clarity and applicability of the study tool also to test relevancy and clarity of the content, to calculate the time needed for conducting the study and to estimate the needed time to be filled in the tool.Each sheet took from 30:45 minute according to the response of the caregivers.The pilot study revealed that some items needed to be added which help in achieving the study aim and some items needed to be omitted.So, the needed modifications were carried out.

E) Fieldwork:
An official permission to conduct the study was obtained from the director of Minia university hospital.The researchers explained to the patient and the caregivers their ethical rights and got their consent.The study was conducted over a period of nearly five months starting from the first of March 2024 (caregivers' enrollment, follow-up).
The Present study was conducting in four phases:

I. Preparatory phase:
A review of recent current national and international related literature on various aspects of the hemiplegia was applied at this phase to design the study tool and to be acquainted with various aspects of the hemiplegia.

II. Assessment phase:
In the first meeting with caregivers, the

III. Planning and implementation phase:
A plan was formulated for each caregiver based on assessment phase and literature review,

IV. Evaluation phase:
It was conducted at neuropsychiatric diseases and neurosurgery units in Minia University hospital for caregivers after arrangement with them through phone for follow up, this phase was performed after 2 months of the fourth session of the structured educational development approach.
Caregivers were evaluated by using study tool II and tool III to measure the competency of caregivers in the care of hemiplegic patients.

Statistical design:
The collected data were tabulated, analyzed, and computerized by using SPSS (statistical package for the social science version 28).
Descriptive statistics included numbers, percentages, mean, and standard deviation.
Analytical statistics were applied as follows: 1. Chi-square: To compare categorical competencies before and after intervention and to assess associations between qualitative variables.

Paired T-test:
To evaluate the effectiveness of treatment methods pre-and post-intervention within the same group.
A p-value < 0.05 was considered statistically significant.

Limitations of the study:
There is no limitation in conducting the study but the study's small sample size and purposive sampling limit generalizability.
Conducted in a single hospital, the findings may not apply broadly.Additionally, the lack of a control group and focus on specific skills may overlook broader caregiving aspects.

Results
Table   The current study approach integrated both elements through a systematic and iterative training process.
As for the socio-demographic profile of To the best knowledge of the study researchers, there is no study with a similar approach, however, it can be supported by nearer ones.The current study shows a surpassing result.The same was reported by (Gurjar, 2019) who showed that less than three quarter of the caregivers had poor competence, one fifth of them had average competence and the minority had good competence of home care of stroke patients whereas in posttest more than half of the caregivers had average competence, one third of them had good competence and one tenth of them had poor competence of home care of stroke patients.
As for the relationship between caregivers' practices and their level of knowledge among the caregivers in hemiplegia, the correlation was not significant before the intervention.These results may be that, in pre-intervention, the theoretical

(
Kawahira et al., 2022).Annually, 15 million people worldwide suffer from stroke, with 5 million deaths and another 5 million left permanently disabled, placing significant burdens on caregivers and communities.Hemiplegia can also result from other neurological conditions, such as traumatic brain injury, brain infections, brain tumors, and spinal cord injuries (Swikriti et al., 2024).Hemiplegic paralysis exacerbates postural instability and impairs balance control, significantly affecting mobility, daily functioning, and overall quality of life.Patients often experience a range of physical, cognitive, and emotional changes, necessitating a comprehensive and compassionate approach to care.Caregivers, including family members, friends, or professional healthcare workers, play a vital role in the rehabilitation process and in ensuring optimal patient outcomes (Kawahira et al., 2022).Caring for hemiplegic patients is both profound and challenging.The family caregiver is crucial to the patient's recovery and daily wellbeing, as their responsibilities vary based on the patient's needs and level of dependency (Dharma et al., 2021).Effective caregiving requires understanding the physical, emotional, and psychological needs of hemiplegic individuals.In addition to physical care, caregivers must provide emotional support, create a positive environment, and encourage patient independence.However, there is often a gap in caregiver knowledge and training, particularly among informal or unpaid caregivers, which can lead to suboptimal care, increased caregiver burden, and poorer patient outcomes (Predebon et al., 2021).Telehealth has emerged as a vital tool in modern healthcare, offering significant benefits for caregivers of hemiplegic patients.By utilizing telecommunication technologies, healthcare professionals can provide continuous support, education, and monitoring to caregivers, regardless of their geographic location.Telehealth facilitates real-time consultations, enabling caregivers to seek advice and assistance promptly, which is crucial for managing acute issues and ensuring adherence to care plans.Moreover, telehealth platforms can offer virtual assistance, reinforcing caregivers' skills and knowledge through interactive and accessible means.This approach not only enhances the competency of caregivers but also promotes a sense of confidence and autonomy in managing the complex needs of hemiplegic patients (Haleem et al., 2021).
embedded in the guidelines of evidence-based quality indicators used in nursing education programs (Spector et al.,2020).This threshold is also recognized as a Benchmark for Ethical Care Competence in Basic Nursing Education, ensuring high-quality, ethically sound care (Yoshioka and Kaneko, 2020).
Internal consistency of interview questionnaire was assessed with the Cronbach's alpha coefficient.Cronbach's alpha coefficient of 0.00 indicates no reliability and a coefficient of 1.00 indicates perfect reliability.Research proposal was approved from ethical committee of the Faculty of Nursing at Minia University, Egypt (Approval No: REC2024311).Oral informed consent was obtained from the caregivers who are willing to participate in the study after explaining the nature and purpose of the study.Participants were assured that their participation was voluntary, and they had the right to withdraw from the study at any time.
researchers introduced themselves to the participants, and clarified the nature and the purpose of this study.Participations' approval was obtained.Each caregiver was interviewed individually by the researchers to collect the sociodemographic characteristics (Tool I) and caregivers' knowledge and practices regarding hemiplegia (Toll II & III).
the researchers prepared the training places, teaching aids and media (picture, and handouts).An Arabic educational training booklet has been developed by researchers based on determined needs, baseline assessment and relevant literature.It was written in a simple Arabic language and supplied with photos and illustrations and provided at the end of each session to help the caregivers to understand the content, and then revised by a group of expertise in community health nursing for the content validity.The intervention, conducted by the researcher over 4 subsequent sessions, varied in start dates based on hospital discharge and followup appointments at the Neurology units.Sessions were held either individually or in groups.Each caregiver should achieve ≥ 80 for the previous session before beginning the subsequent one.If competency was not achieved, another attendance and evaluation was conducted.A variety of teaching methods were employed, including brainstorming, discussion, demonstration, and redemonstration.Caregivers were informed about the content and duration of the upcoming session at the end of each meeting.It provided caregivers with a foundational understanding of hemiplegia, including its definition, causes, and effects on daily life.It covers the condition's impact on motor and sensory functions, the resulting challenges in mobility, communication, and self-care, and the emotional and psychological toll on individuals.This knowledge is essential for caregivers to effectively support and empathize with those affected.b) Practice: Basic Patient Care & mobility and safety This contains two packages: 1) basic patient care: that contains bed bath, oral hygiene, measuring blood pressure and monitoring vital signs procedures.2) mobility and safety: that includes transferring to and from chairs, body mechanics, positioning techniques and use of assistive devices.It focused on practical care skills and safety measures.Caregivers learn techniques for positioning, transferring, and assisting with mobility and personal care, such as hygiene and dressing.The session also covers safety precautions to prevent falls and injuries creating a supportive environment that promotes independence.The session also highlights the importance of caregiver self-care and stress management to maintain their own well-being.Evaluation of the last session and setting up the telehealth communication means for follow-up and Support: To ensure continuous learning and support, accessible tele-health communication means were established either telephone-based or web-based.Caregivers could regularly consult with healthcare professionals, ensuring they had ongoing guidance and could address any emerging concerns promptly.
caregivers in the current study, more than two thirds of individuals aged 30-39 years, which could suggest a demographic trend where middle-aged individuals are more likely to assume caregiving responsibilities (Zwar, König, & Hajek, 2024).Gender distribution shows a higher proportion of female caregivers, aligning with broader caregiving trends where women typically assume such roles more frequently than men (Pacheco, Schnyder, and Zanini, 2024).The relationship to the patient reveals that more than two-fifths were daughters and more than one third were sons, daughters and sons were the primary caregivers, reflecting traditional family dynamics where offspring are the primary support for elderly or ill family members (Shu et al., 2021).Most caregivers were married, possibly indicating the support structure needed for effective caregiving is more commonly found among married individuals which aligns with previous studies (Freedman et al., 2024) Caregivers come from diverse educational backgrounds with nearly thirty percent having basic education and twenty having a university education.Housewives rated the highest percentage among caregivers which highlights the role of non-working family members in caregiving duties.The split between extended and nuclear families points to caregiving occurring in both traditional and more modern family structures.All caregivers reported insufficient monthly income which underscored the financial challenges associated with caregiving.The majority reside in rural areas, which might suggest limited access to professional healthcare support in these regions.Lastly, an almost equal distribution of caregivers living with the patient or nearby reflects the close proximity often required for before the intervention, the present study showed that about one in each ten was competent.Post-intervention, there is a marked improvement with more than three quarters of caregivers becoming competent, suggesting the intervention was highly effective.Additionally, from the aspect of mean scores, mean scores increased about thirty percent in knowledge, about forty percent in practice, and about thirty-seven in total care-competency.This dramatic improvement highlights the value of structured educational programs in enhancing caregiver competency.The substantial increase in both knowledge and practice competencies post-intervention underscores the efficacy of the training provided.

(
Zygouri et al., 2021) who found that occupational roles significantly impact the acquisition of caregiving skills, with those in caregiving-related professions or with prior caregiving experience showing better outcomes post-training.Moreover, the flexibility of housewives' schedules might afford them more time to engage with and apply the training materials, as suggested by the findings of (Bijnsdorp et al., 2022) which highlighted that nonworking caregivers often had better outcomes due to their ability to dedicate more time to caregiving tasks.Interestingly, our study found no significant differences in competency improvements related to age, gender, type of family, and place of residence.This suggests that structured educational intervention can be equally effective regardless of these demographic variables of the of the caregivers.The current study results are in line with some previous studies; a study by (Pucciarelli et al., 2021), which found no significant differences in caregiving outcomes across different age groups, a study by (Seok & Lee, 2024), which found minimal gender differences in caregiving outcomes when both males and females received equivalent training and a metaanalysis by (Ploeg et al., 2017), which reported that structured caregiver interventions were equally effective across different residential settings and family compositions.However, this finding contrasts with some prior research, such as that by (See Toh et al., 2022), which indicated that younger caregivers often adapt more quickly to training programs than older caregivers.This discrepancy could be a result of interplay of different contextual factors.Conclusion The present study demonstrates the significant impact of a structured educational development approach on enhancing the care competency of caregivers for hemiplegic patients.The findings indicate substantial improvements in both knowledge and practice post-intervention, with total care competency increasing markedly from preintervention levels.The results underscore the necessity of implementing structured educational programs for caregivers, as these interventions not only elevate competency but also ensure sustained improvement through continuous support via telehealth.Recommendations Based on the results of the current study, the following recommendations are suggested: 1-Hospitals and healthcare facilities should integrate structured educational development programs for caregivers into standard care protocols either in discharge planning or follow up visits, especially for those attending to hemiplegic patients.2-Post-training telehealth follow-ups are essential to reinforce learning and provide ongoing support, ensuring sustained caregiver competency through community and medical nurse.3-Healthcare policymakers must advocate for the inclusion of caregiver education in healthcare planning to enhance patient outcomes and caregiver well-being.4-Further research can be conducted and replicated in other healthcare institutions on а larger representative group of caregivers to explore the long-term effects of structured educational interventions on caregiver competency and patient outcomes, as well as making generalization of the findings.

El-Tallawy et al., 2013). Shehata et al., (2016) reported
in the care they provide, connect them with the community resources they may need (Rico-Blázquez et al., 2022).This may help decrease the stress and emotional burden associated with caregiving (Magwood et al., 2020).Consequently, biopsychosocial competencies, effective and safe care for hemiplegic patients can be emphasized.inequality.In Egypt, the high prevalence of stroke and resulting hemiplegia underscores the urgent need for comprehensive support systems for both patients and caregivers.The Egyptian census estimates that around 1.4 million Egyptians have disabilities.Egypt, the most populated nation in the Middle East, has a high stroke prevalence rate of 963 per 100,000 inhabitants (Mohamed et al., 2023).Hemiplegia occurs in 88% of stroke survivors, with an annual stroke incidence in Al Quseir estimated at 181 per 100,000 (

(Williams et al.,2020):
knowledge and practice based on the guidelines of evidence-based quality indicators for the programs of nursing education (Spector et al.,2020) and the recommendation of Ethical Care Competence in  Effect size = 0.

Caregivers' practices tool regarding hemiplegia:
checklists that cover 15 procedures in 4 progressive packages of procedures: 1) basic patient care: includes bed bath, oral hygiene, measuring blood pressure with digital one, and monitoring vital signs (temperature, pulse, and