Research in Nursing & Health, 2000, 23, 191–203

Family Caregiving Skill:

Development of the Concept
Karen L. Schumacher,1* Barbara J. Stewart,2† Patricia G. Archbold,2‡
Marylin J. Dodd,3† Suzanne L. Dibble3§

1
University of Pennsylvania School of Nursing, Nursing Education Building,
Philadelphia, PA 19104-6096
2School of Nursing, Oregon Health Sciences University, Portland, OR
3School of Nursing, University of California, San Francisco, CA

Received 28 May 1999; accepted 12 November 1999

Abstract: Families increasingly are expected to provide complex care at home to ill relatives.
Such care requires a level of caregiving knowledge and skill unprecedented among lay persons,
yet family caregiving skill has never been formally developed as a concept in nursing. The pur-
pose of the study reported here was to develop the concept of family caregiving skill systemati-
cally through qualitative analysis of interviews with patients (n 5 30) receiving chemotherapy for
cancer and their primary family caregivers (n 5 29). Open coding and constant comparison con-
stituted the analytic methods. Sixty-three indicators of caregiving skill were identified for nine core
caregiving processes. Family caregiving skill was defined as the ability to engage effectively and
smoothly in these nine processes. Properties of family caregiving skill also were identified. Con-
ceptualizing skill as a variable and identifying indicators of varying levels of skill provides a
basis for measurement and will allow clinicians to more precisely assess family caregiving skill.
© 2000 John Wiley & Sons, Inc. Res Nurs Health 23:191–203, 2000

Keywords: caregiving; family; skill; concept development; cancer; chemotherapy; home care

Aging populations and cost containment poli-
cies are changing health care delivery worldwide
and leading to growing international interest in
home care (Dittbrenner, 1995; Ehrenfeld, 1998;
Lee, Hwang, Pierce, & Fitzpatrick, 1997; Modly,
Zanotti, Poletti, & Fitzpatrick, 1997). Although
formal home health services will be a factor in
health care systems of the future, most of the care
of aged and ill persons will be provided by family
members (Nolan & Grant, 1989; Yamamoto &
Wallhagen, 1997). In the United States, as in many
countries, families are being called upon to pro-
vide ever more complex care to ill relatives. Such
care requires a level of knowledge and skill un-
precedented among lay persons (Barg et al., 1998;
Sims, Boland, & O’Neill, 1992). As a result of
these profound changes, family caregiving skill is
an increasingly important nursing concept with
significant clinical and research implications. Al-
though the skills needed by family members in
various clinical situations have been described
(Clark & Rakowski, 1983; Grobe, Ilstrup, & Ah-
mann, 1981; Hinds, 1985), and interventions to
enhance caregiving skills have been reported

This study was conducted while the first author was a postdoctoral fellow at Oregon Health
Sciences University. The authors gratefully acknowledge the families who participated in this re-
search.
Contract grant sponsor: National Institute for Nursing Research; contract grant number: F32
NR06969.
Contract grant sponsor: National Cancer Institute; contract grant numbers: F31 CA0999; R01
CA48312.
Correspondence to Karen L. Schumacher.
*Assistant Professor.
†Professor.
‡Elnora E. Thomson Distinguished Professor.
§Adjunct Professor.

© 2000 John Wiley & Sons, Inc. 191

192 RESEARCH IN NURSING & HEALTH
(Archbold et al., 1995; Barg et al.; Cawley &
Gerdts, 1988; Edstrom & Miller, 1981; Mahoney
& Shippee-Rice, 1994), family caregiving skill
has not been developed formally as a concept.
Concept development of family caregiving skill
is essential in the current era in health care. As fam-
ilies become increasingly responsible for the care
of seriously ill members, interventions to assist
them must have a solid theoretical basis. Formal
knowledge development can make explicit the na-
ture of family caregiving skill, lay the groundwork
for a more systematic approach to the clinical as-
sessment of caregiving skill, and make possible
research in which caregiving skill is a variable.
The purpose of the analysis reported here was
to develop the concept of family caregiving skill
through qualitative analysis of interviews with
caregivers of family members with cancer. It was
part of a larger concept development project in
which we used both theoretical analysis and em-
pirical data to conceptualize the clinical phenom-
enon of doing family caregiving well. The ulti-
mate aim of the concept development project was
to lay a foundation for the development of an in-
strument with which to assess family caregiving
skill in clinical practice and research.
Our method was derived from the hybrid mod-
el of concept development (Schwartz-Barcott &
Kim, 1993). The hybrid model consists of three
phases: (a) a theoretical phase, (b) a fieldwork or
empirical phase, and (c) a final analytical phase.
In our project, the theoretical phase included ex-
tensive consideration of the appropriate conceptu-
al label for the phenomenon of doing family care-
giving well, using reflections on clinical practice
and preliminary analysis of clinical vignettes col-
lected in two earlier studies. Also during the initial
phase, we analyzed the literature on existing con-
cepts related to the clinical phenomenon of doing
caregiving well (Schumacher, Stewart, & Arch-
bold, 1998). This initial theoretical phase provid-
ed the background for the empirical phase, which
is the primary focus of the present report. The pur-
pose of the empirical phase was to define caregiv-
ing skill systematically, describe its properties and
dimensions, and identify indicators of skillfulness
using the open coding procedures of grounded the-
ory for concept development.
BACKGROUND
Caregiver burden has been the primary unifying
concept for extensive research on family caregiv-
ing (Given & Given, 1991; Nolan, Grant, &
Keady, 1996). Although burden is an important
concern, other aspects of family caregiving, in-
cluding the ability to provide care well, are rele-
vant clinically and need conceptual development.
The following vignette from a research interview
illustrates the importance of providing care well
for both caregiver and care-receiver well being:
A man with lung cancer was hospitalized on an
emergency basis for treatment of dehydration,
which had developed over the course of several
days at home following his first cycle of chemo-
therapy. Not realizing he was so ill, his caregiver
was distraught when he was hospitalized. As she
said,
That was a very bad day. In fact, that was the day I can-
celed. I went home. I canceled it and figured we’ll start
out again tomorrow because I wasn’t doing anybody
any good that day. All I could do was sit down and cry.
They admitted him to give him those IVs and they’re
telling me why didn’t I give him more fluids and why
didn’t I do this and I’m thinking, “My God!” They made
it sound serious and I guess it was and so all I could do
was cry and I went home. Canceled.
Asked to describe what had led up to the hospital-
ization, she replied:
Well, my thought was at home, that was my first expe-
rience at home after chemotherapy, they told me to ex-
pect him to be sick, they told me that he wouldn’t be
hungry, but to give him as much fluid as he could take.
So all these things happened and he’s not eating at all
and I’m thinking, “Well, how serious is this?” And I’m
thinking, “Well, the day after tomorrow I’m taking him
in. They’ll look at him and they’ll take care of it.” So
these things were happening that they told me about and
I’m thinking, “Okay, I guess we’re alright.” But I didn’t
call in and that’s what they [health care providers] were
upset about. I should have called in because he wasn’t
taking the fluids that he should. He wasn’t taking food
or fluids or anything, so he was in really bad shape. But
I didn’t know that. (Family Caregiving Study)
This vignette reveals the distress experienced
when there is an imputation of a “mistake” at
home. However, from the researchers’ perspective
this caregiver had not made a mistake, but rather
had been attempting to provide care unassisted in
a situation requiring more clinical skill than should
be expected of lay people, especially those new to
the caregiving role. Providing care well is impor-
tant to caregivers and developing caregiving com-
petency, knowledge, and skill is a central concern
for those in the process of becoming a caregiver
(Brown & Stetz, 1999). Barg and colleagues (1998)
found that 65% of the caregivers participating in a
psychoeducational intervention reported difficul-
ty to extreme difficulty with watching the patient
become more ill and not knowing what to do. This
issue was the most difficult aspect of the caregiv-
 FAMILY CAREGIVING SKILL / SCHUMACHER ET AL.
ing role. Seventy-four percent of the sample had
significant concerns about their ability to handle
the patients’ care in the future. Our own data sug-
gested that the ability to pinpoint areas in which
caregivers are having difficulty would facilitate
targeted and timely professional intervention.
Through our preliminary reading of data vi-
gnettes like the one above plus reflections on clin-
ical practice, we identified the clinical phenome-
non of doing family caregiving well for concept
development. Next, we undertook a review of the
literature to identify and analyze concepts already
in use that relate to doing family caregiving well
(Schumacher et al., 1998). Included were the con-
cepts of mastery (Lawton, Kleban, Moss, Rovine,
& Glicksman, 1989), self-efficacy (Haley, Levine,
Brown, & Bartolucci, 1987), preparedness (Arch-
bold, Stewart, Greenlick, & Harvath, 1990), com-
petence (Kosberg & Cairl, 1991; Pearlin, Mullan,
Semple, & Skaff, 1990), and quality of family
caregiving (Levine, Cartwright, Inoue, Stewart, &
Archbold, 1998; Phillips, Morrison, & Chae,
1990a, 1990b).
We concluded that although each of these con-
cepts pertains to “doing a good job” with caregiv-
ing, none precisely captured the phenomenon in
the data. For example, mastery has been defined
as a positive view of one’s ability and behavior
during the caregiving process (Lawton et al.,
1989), but also has the connotation of dominion,
superiority, victory, and getting the upper hand
(Webster’s New Twentieth Century Dictionary,
1983), which did not seem to reflect the experi-
ences of caregivers. Self-efficacy is defined as the
caregiver’s confidence regarding how well he or
she is managing the behavioral problems and dis-
abilities of the care receiver (Haley et al., 1987).
As such, it constitutes a self-perception. Our data
indicated that caregivers need professional assess-
ment and guidance to complement self-perception
at critical periods in caregiving. Thus, self-effica-
cy, although important, is not sufficient for a full
understanding of doing caregiving well (Schu-
macher et al., 1998). Preparedness has an antici-
patory connotation (Archbold et al., 1990), such
that family members may feel well prepared to
provide good care, but they may or may not be
concurrently in the caregiving role. Competence,
defined as the perceived adequacy of one’s per-
formance as a caregiver (Pearlin et al., 1990), also
has the connotation of being fit or qualified for a
job. This latter connotation did not appropriately
capture what was “going on” with participants
who were having difficulty with caregiving. They
were not so much incompetent as lacking experi-
ence with complex illness care problems. Quality
193
of family caregiving is a broad construct (Levine
et al., 1998; Phillips et al., 1990a, 1990b) that may
include providing care well as one of several di-
mensions.
Because none of these concepts fit the data pre-
cisely, we sought another conceptual label. Work-
ing iteratively between the interviews, additional
literature, dictionaries, and a thesaurus we con-
cluded that the term family caregiving skill was
congruent with the data and needed fuller concep-
tual development. We termed the concept caregiv-
ing skill rather than caregiver skill to place the fo-
cus on the behavioral processes of caregiving,
rather than on the caregiver as a person.
The phenomenon of skill acquisition has long
interested researchers in various disciplines. Proc-
tor and Dutta (1995) summarized research on a
wide range of psychomotor, cognitive, and prob-
lem-solving skills and defined skill as “goal-di-
rected, well-organized behavior that is acquired
through practice and performed with economy of
effort” (p. 18). Much of the research Proctor and
Dutta cited was conducted in laboratory settings,
although a few researchers investigated “real
world” skills such as those of violinists and radi-
ologists. Neither interpersonal skills nor skills
with family roles, such as parenting or caregiving,
were addressed in Proctor and Dutta’s review.
In nursing, Benner and colleagues (Benner,
1984; Benner, Tanner, & Chesla, 1996) have in-
vestigated skill development among professional
nurses. Although one must be cautious about
assuming too many commonalities between the
development of illness care skills among profes-
sional nurses and lay persons (Sims et al., 1992),
Benner and colleagues’ work provides sensitizing
insights for researchers studying family caregiv-
ing skill development. For example, the distinc-
tion they make between knowing that and know-
ing how suggests the importance of exploring
family caregivers’ day-to-day caregiving practices
rather than simply considering their cognitive
knowledge. Also, Benner and colleagues’ finding
of qualitative differences in skill among nurses
with varying levels of expertise suggests that sim-
ilar qualitative differences may exist among fam-
ily caregivers. Finally, their finding that skill de-
velopment occurs over a period of years among
professional nurses suggests that skill develop-
ment among family caregivers also requires prac-
tice and experience.
In family caregiving research, skill is usually con-
ceptualized in terms of coping skills rather than as
skill in providing care to the ill person (Gallagher-
Thompson & Devries, 1994; Toseland, Blanchard,
& McCallion, 1995). When care-providing skill is
194 RESEARCH IN NURSING & HEALTH
addressed, it is usually defined in terms of specif-
ic tasks, activities, or procedures. For example,
Grobe et al. (1981) identified the following skills
needed by caregivers of persons with advanced
cancer: ambulation, bowel management, comfort
care, dietary control, pain management, and
wound care. They reported that most family mem-
bers learned such skills through trial and error.
Clark and Rakowski (1983) categorized the skills
required by caregivers of frail elders into four broad
areas: (a) direct care; (b) (intra)personal tasks,
concerns, and difficulties; (c) interpersonal ties
with other family members; and (d) interaction
with broader societal and health care networks.
Such research demonstrates the broad scope and
multidimensional nature of the skills needed for
caregiving.
Dictionary definitions of skill include: The abil-
ity to use one’s knowledge effectively and readily
in execution or performance; a developed or ac-
quired aptitude or ability; smoothness and good
coordination in the execution of a learned motor
performance; performance that has become facile
and well integrated as the result of practice; an art,
craft, or science, especially one involving the use
of the hands or body (Webster’s New Twentieth
Century Dictionary, 1983). These definitions sug-
gest that skillfulness is a combination of art, sci-
ence, and craft, which is consistent with our obser-
vations of the complexity of caregiving. Further,
they imply that skill develops over time and that
skillful behavior becomes well integrated and
smooth with practice.
In summary, the initial theoretical phase of con-
cept development consisted of literature review
and analysis of existing definitions of skill in light
of interview data and clinical observations. The re-
sults of this phase of concept development were
(a) naming a concept congruent with the data and
(b) gaining a preliminary appreciation of what the
properties and dimensions of caregiving skill might
be. Once we had named a concept, we turned to
the empirical phase of concept analysis, which is
the focus of this report. The empirical phase con-
sisted of an in-depth qualitative analysis of the
data in order to further understand the properties
and dimensions of family caregiving skill and to
identify indicators of variations in skillfulness.
METHOD
Design and Data Sources
The database consisted of interviews conducted
by the first author in the course of two larger studies
of self-care and caregiving during chemotherapy.
The first study, the Pro-Self Study (Dodd et al.,
1988-92; Messias, Yeager, Dibble, & Dodd,
1997), tested the effect of a nursing intervention
on self-care behaviors for managing chemothera-
py side effects. Participants were persons receiv-
ing chemotherapy for the first time for a solid tu-
mor or lymphoma and their primary informal
caregivers. Participants had to be at least 18 years
of age, able to speak English, and willing to sign
an informed consent form. Data collection includ-
ed in-home interviews after each of the first four
cycles of chemotherapy to ask about strategies
used to manage side effects. As a research assis-
tant, the first author interviewed 10 patient/care-
giver dyads, and these data were used in the pre-
sent analysis.
The second study, the Family Caregiving Study,
was designed to develop a grounded theory of
family caregiver role acquisition (Schumacher,
1996). The study population and eligibility crite-
ria were identical to those in the Pro-Self Study. In
the Family Caregiving Study, patients and care-
givers again were interviewed in their homes mul-
tiple times across the course of chemotherapy.
However, the interviews were open-ended and
more in-depth than in the Pro-Self study, in order
to elicit more detail about caregiving processes.
A large volume of longitudinal qualitative data
was generated by these two studies (130 inter-
views with 30 patients and 29 caregivers). Al-
though not the primary analytic focus of either
study, many issues related to family caregiving
skill were evident upon even a casual reading of
the interview transcripts. Because of the wealth of
previously unanalyzed data on family caregiving
skill, we decided to use the combined data sets for
the present concept development study.
Sample
The majority of the caregivers were women
(62%), white (69%), and spouses of the ill person
(63%). Caregivers had a mean age of 53 years
(SD 5 15). The majority of the persons with can-
cer were also women (60%) and white (80%).
Their mean age was 60 (SD 5 12). All were being
treated with chemotherapy for the first time for
solid tumors or lymphoma.
Procedures
The procedures for both studies have been pub-
lished elsewhere (Messias et al., 1997; Schuma-
cher, 1996). Participants were recruited through
 FAMILY CAREGIVING SKILL / SCHUMACHER ET AL.
private medical oncology practices and clinics in
the San Francisco Bay Area. Informed consent
was obtained. Interviews were audiotaped and
transcribed verbatim.
Data Analysis
The grounded theory procedures of open coding,
constant comparison, and extensive memo-writ-
ing constituted the basic analytic techniques
(Strauss & Corbin, 1990). We did not proceed to
axial and selective coding and thus did not devel-
op a grounded theory. However, open coding pro-
cedures were used to identify properties, dimen-
sions, and indicators of skill through constant
comparison. Caregivers’ accounts of how they
managed specific care problems (such as fever,
nausea, vomiting, weakness, and depression) and
procedures (such as tube feedings, urostomy tube
irrigation, and administration of parenteral nutri-
tion) constituted the units of analysis for constant
comparison. This approach allowed us to identify
the multiplicity of caregiving processes used to
manage problems and to pinpoint areas of diffi-
culty. When caregiving difficulties occurred, they
often had a negative impact on caregiver and care
receiver alike, leading to suboptimal symptom and
side-effect management, emergency hospitaliza-
tions and/or unscheduled physician visits, delayed
treatment, safety risks, emotional distress for both
individuals, and conflict about illness manage-
ment between caregiver and care receiver. Com-
paring one account with others across the data set
allowed us to analyze caregiving processes in re-
lation to their results and to identify variations in
these processes that appeared to be related to out-
comes. The variations in how caregiving process-
es were carried out eventually formed the basis for
indicators of caregiving skill.
RESULTS
Indicators of Family Caregiving Skill
Sixty-three indicators of caregiving skill were
identified and categorized into one of nine care-
giving processes: monitoring, interpreting, mak-
ing decisions, taking action, making adjustments,
providing hands-on care, accessing resources,
working together with the ill person, and negotiat-
ing the health care system (Table 1). These 63 in-
dicators of caregiving skill are observable charac-
teristics of caregiving that signify the level of
skillfulness with which each caregiving process is
carried out. The processes themselves are not in-
195
dicative of caregiving skill, but rather are dimen-
sions of the caregiving role, which may be carried
out more or less skillfully. Although space does
not allow us to describe each indicator in detail,
we provide examples below to illustrate selected
indicators for each process.
Monitoring. Monitoring was defined as the
process of observing how the care receiver was
doing or “keeping an eye on things” to ensure that
changes in the ill person’s condition were noticed.
One inexperienced caregiver who at first did not
use a thermometer to monitor a fever, but instead
monitored temperature by feeling the care receiv-
er’s forehead, exemplified difficulties with moni-
toring. When she did begin using a thermometer,
she read it inaccurately, reporting that “I took his
temperature and it was okay. It was about 90 or
so.” She had difficulty finding the right amount of
vigilance, sometimes hovering more than was
necessary and at other times leaving the care re-
ceiver alone for too long. She tended to miss sub-
tle changes and to be rather global in her observa-
tions, making statements like “He just doesn’t
look good,” rather than observing more specifi-
cally that the care receiver was pale or weak or los-
ing weight. Also, she tended to rely on single cues
as to how the care receiver was doing, such as the
care receiver’s assertion that he was “fine.” More
skillful caregivers took into account multiple cues,
including both verbal statements and nonverbal
behavior.
Interpreting. Interpreting was defined as the
process of making sense of what was observed.
Skillful interpreting was a complex reasoning pro-
cess characterized by recognizing changes from
the normal or expected course of events and at-
tributing what was observed to some cause. The
vignette provided earlier exemplifies the difficul-
ties with interpreting the meaning of observations;
the caregiver did not recognize the early signs of
dehydration even though she noticed that the care
receiver was drinking little and becoming weak.
Skillful caregivers correctly attribute behavior
to its underlying cause. For example, a skillful
caregiver attributed the care receiver’s inability to
eat to the side effects of chemotherapy rather than
to a lack of will. A less skillful caregiver attributed
the care receiver’s inability to eat to a lack of appre-
ciation of her efforts to prepare appealing meals.
Another attributed weakness and fatigue after the
first cycle of chemotherapy to “getting old” rather
than to the chemotherapy. Later, however, this
caregiver was able to correctly attribute side ef-
fects to the treatment.
Making decisions. Making decisions was de-
fined as the process of choosing a course of action
196 RESEARCH IN NURSING & HEALTH

Table 1. Indicators of Skill in Family Caregiving Processes

Monitoring
1. Uses appropriate specificity
2. Notices subtle changes
3. Notices verbal and nonverbal indicators of care receiver well-being
4. Uses instruments for monitoring when appropriate
5. Uses appropriate vigilance
6. Makes accurate observations
7. Keeps a written record when appropriate
8. Notices patterns
Interpreting
1. Recognizes deviations from normal or expected clinical course
2. Recognizes that something is “different” or “wrong”
3. Judges seriousness of a problem
4. Seeks explanations for unexplained signs and symptoms
5. Asks detailed questions for the purpose of developing an explanation
6. Makes correct attributions
7. Uses a reference point in making sense of observations
8. Considers multiple explanations for an observation
Making decisions
1. Takes into account multiple illness care demands
2. Weighs competing illness care demands
3. Weighs the importance of conflicting priorities
4. Attends to multiple care issues at once
5. Thinks ahead about possible consequences of a given action
Taking action
1. Recurring actions are taken at effective intervals
2. Uses effective “reminders” to time actions
3. Paces actions to correspond with ill person’s pace
4. Times actions with respect to the rhythm of ill person’s responses to chemotherapy
5. Times actions with respect to ill person’s daily rhythm of responses
6. Times intermittent or one-time actions appropriately
7. Takes own needs into account in timing actions
8. Organizes multiple actions systematically
9. Develops routines to manage complex tasks
10. Organizes illness care tasks so that ill person can be involved if appropriate
11. Uses a system for remembering when actions are due
12. Uses different tracking systems for scheduled actions and actions that are taken as needed
13. Has the ability to take action on multiple issues at once
Making adjustments
1. Adjusts amount of food, PRN medications, rest, exercise, etc. until optimum comfort and symptom
management achieved
2. Modifies long-standing routines to accommodate illness situation
3. Modifies environment to accommodate illness situation
4. Tries multiple strategies until a solution to caregiving problems found
5. Uses “mistakes” as an opportunity for learning
6. Considers what led up to a “mistake” and alters what appears to be the source of the problem
7. Searches for an alternative when one illness care strategy no longer works
8. Uses creativity in problem-solving
Accessing resources
1. Seeks resources wisely; casts a broad net
2. Uses advice judiciously
3. Seeks authoritative resources when appropriate
4. Weeds out erroneous, inaccurate, or inadequate advice
5. Persists in obtaining resources until what is really needed is found
6. Takes initiative in seeking resources
7. Figures out which health care providers are most accessible, helpful, and knowledgeable
8. Makes own needs known

(continued )
 FAMILY CAREGIVING SKILL / SCHUMACHER ET AL. 197

Table 1. (Continued )

Providing hands-on care

1. Performs procedures safely
2. Performs procedures gently
3. Pays attention to ill person’s comfort
4. Takes the time needed with procedures to get the best results
5. The results of procedures are aesthetically pleasing
Working together with the ill person
1. Perceives when to take a more active role in illness care
2. Uses an incremental approach in taking on illness care tasks in order to preserve ill person’s sense
of personal agency
3. Perceives when to step back
4. Uses an incremental approach in stepping back from illness care tasks
5. Provides care in a way that is meaningful in the context of the care receiver’s personal history and identity
Negotiating the health care system
1. Evaluates care received in the health care system
2. Advocates for patient and/or self when necessary
3. Seeks assistance from health care providers in a timely way

based on one’s observations and interpretation of
the situation. In this analysis, we focused on day-
to-day care decisions rather than on treatment
choices. Although less emotionally intense than
treatment choices, the day-to-day decision-making
process was complex and required the ability to
make judgements and set priorities. When multiple
possible courses of action existed, skillful care-
givers were able to make choices that did not in-
volve unnecessary risk; less skilled caregivers
tended to make choices that placed the care receiv-
er at risk for harm. For example, one caregiver
dropped the care receiver off at the door of the clin-
ic and went to park the car. The care receiver was
too weak to walk to the clinic, and because no one
was present to assist him, he almost fell. The care-
giver did not weigh alternative ways of getting the
care receiver into the clinic or think ahead about
what might happen. Instead, she dropped the care
receiver off at the front door, adhering to a former
pattern of behavior, which was not safe in the pre-
sent illness context. A more skillful caregiver no-
ticed that the care receiver was too weak to walk to
the car after a treatment, weighed the options, and
decided to ask a nurse for a wheelchair.
Taking action. Taking action was defined as
the process of carrying out caregiving decisions
and instructions. Carrying out decisions and in-
structions skillfully was characterized by good
timing, effective tracking methods, and a high lev-
el of organization. Exemplifying good timing
through effective pacing of her actions was a care-
giver who noticed that it took all day for the care
receiver to eat a container of yogurt but did not
urge him to eat faster. Another caregiver paced
morning medications slowly, in synchrony with
the care receiver’s ability to take them. It seemed
like a long “rigmarole” to her. However, it worked
effectively for the care receiver, who previously
had had retching when trying to take his medica-
tions quickly.
The use of a system for keeping track of when
actions were taken and when they were due was
another characteristic of skillful caregiving. Sev-
eral caregivers learned that they needed to write
down when medications were given and when the
next dose was due. Caregivers also learned that
medications to be given as needed required a
tracking system different from that required by
scheduled medications. One caregiver kept track
of a complex regimen of scheduled medications
by placing them in a commercial pillbox. Howev-
er, she had difficulty keeping track of as-needed
medications until she developed a written system.
Providing hands-on care. Providing hands-
on care was defined as the process of carrying out
nursing and medical procedures. Providing hands-
on care skillfully was characterized by attention to
both safety and comfort. Skillful caregivers were
meticulous in their concern for safety. Checking
for the proper placement of nasogastric tubes, at-
tending to safety in the bathroom, and preventing
falls exemplified attention to safety. Skillful care-
givers also paid attention to the comfort of the ill
person. Describing the irrigation of his urostomy
tube by his wife, one care receiver said, “She does
better than the nurses. They’re in a hurry. It hurts
when they shoot the stuff and you can feel it when
it hits your kidney. But when she does it, I don’t
even know she’s doing it. She does it real good.”
Other caregivers paid attention to comfort by han-
dling the care receiver’s body gently, placing pil-
lows “just so,” and insuring that the care receiver
was neither too warm nor too cold.
198 RESEARCH IN NURSING & HEALTH
Procedures carried out skillfully also had an es-
thetically pleasing quality. As one care receiver
said, “The dressing change is hard for me to do.
But (Caregiver) does it simply and beautifully.” In
this statement she alludes to the smoothness and
seeming effortlessness of the skillful use of one’s
hands, as well as the aesthetically pleasing results.
Making adjustments. Making adjustments
was defined as the process of progressively refin-
ing caregiving actions until a strategy that worked
well was found. Making adjustments was ongo-
ing, because what worked well at one time did not
always work as well when the caregiving situation
changed. Frequent adjustments were necessary
because of the extraordinarily dynamic caregiving
situation during chemotherapy. Caregivers often
referred to the process of making adjustments as
“trial and error.” However, our data suggest that
for skilled caregivers trial and error was a pro-
gressive problem-solving process. Less skillful
caregivers tended to persist with strategies that did
not appear to be working.
Skillful caregiving often involved making ad-
justments in the amount of something—the most
effective amount of antiemetic, or the amount of
food to place before the care receiver, the amount
of tube feeding to give in a day, or the relative
amounts of exercise and rest. One caregiver made
progressive adjustments in the amount of antieme-
tic so that the care receiver did not feel “goofy” but
was not experiencing much nausea either. Anoth-
er caregiver progressively reduced the amount of
tube feeding, so that the care receiver had less ab-
dominal discomfort while still maintaining her
weight. Skillful caregivers fine-tuned amounts so
that the care receiver experienced optimal well-
being. Such fine-tuning occurred over time with
much “trial and error” and patience. Less skillful
caregivers tended not to do this kind of fine-
tuning.
Another indicator of skill in making adjustments
was the persistent use of multiple strategies until a
solution to a problem was found. Less skillful care-
givers tended to get frustrated when their initial at-
tempts at problem solving did not work. One care-
giving problem for which solutions were often
short-lived was providing adequate nutrition.
Many caregivers thought they had found some-
thing the care receiver would eat, only to have him
or her develop a distaste for that food in a few days.
Skillful caregivers took this in stride and found
something else the care receiver would like for a
few more days. Skillful caregivers used a great deal
of creativity in dealing with these hard-to-solve
problems. For example, several developed their
own recipes for “super milkshakes” when their
care receiver did not like commercial nutrition
supplements. They described the milkshake ingre-
dients and other details of preparation to the inter-
viewer with the great satisfaction that comes from
creative solutions to difficult problems.
Accessing resources. Accessing resources
was defined as the process of obtaining what was
needed to provide care, including information,
equipment and supplies for home use, assistance
from community agencies, help with housework,
and assistance with personal care. Skillful access-
ing of resources was exemplified by one man who
wanted information about nutrition for persons
with cancer. He asked questions of health care
providers and colleagues at work whose families
had experienced cancer, inquired at a health foods
store, and went to two support groups. He took ini-
tiative, cast a wide net, and judiciously evaluated
the information he received. He used suggestions
that he considered helpful in his situation and did
not use other suggestions. Less skillful caregivers
were more passive, using fewer resources and
seeking resources less widely. They tended to use
whatever personal resources were at hand, rather
than seeking out new resources, even when the
“handy” resources did not meet their needs.
Skillful accessing of resources also involved
being able to find just the right thing. For exam-
ple, one dyad needed a car that was large enough
to accommodate a wheelchair and other equip-
ment but energy efficient enough to fit into the
household budget. The cost of operating the car
was an issue because of the long drive into the city
multiple times weekly over an extended period of
time. The caregiver cast a broad net, made many
inquiries, and eventually found just the right kind
of car at an affordable price.
Working together with the care receiver.
Working together with the care receiver was de-
fined as the process of sharing illness-related care
in a way that was sensitive to the personhood of
both care receiver and caregiver. The process of
working together was influenced by the history of
the relationship, but it had illness-specific aspects
as well. For example, one young caregiver had dif-
ficulty dealing with illness-generated changes in
the father/daughter relationship. She told the in-
terviewer, “I gotta keep telling myself just to keep
it up (trying to provide care) and not listen to him
anymore. Because I do listen to him every time
’cause I’ve listened to him all my life and it’s just
a natural thing. I mean I’m the baby of the family.
I don’t know anything about taking care of any-
body.” She tried to make abrupt changes in their
relationship, going from being “the baby” to doing
what she thought best without listening. When the
 FAMILY CAREGIVING SKILL / SCHUMACHER ET AL.
care receiver resisted these changes, she retreated
to a low level of caregiving involvement. More
skillful caregivers took a gradual approach, result-
ing in smoother transitions in relationships. For
example, one caregiver carefully attended to the
care receiver’s desire for independence even while
he was experiencing growing difficulty with self-
care. She consciously “backed off” at times and
“stepped in” at other times. Early conflicts about
her role in illness care subsided as she adopted a
gradual approach that allowed him as much au-
tonomy as possible.
Skillful caregivers also knew when to step into
a more active role in illness care, sensing when the
care receiver was too ill to care for him or herself
and needed someone to “take over.” In several
dyads, the care receiver became more ill than he
or she realized but the caregiver was able to see
what was needed and take a more active role in the
illness care situation. For example, when one care
receiver asked her caregiver to call the physician
about severe nausea and vomiting, he replied,
“We’re better than that. I’m gonna take you to the
hospital right now.” She received treatment for de-
hydration.
Negotiating the health care system. Negoti-
ating the health care system was defined as the
process of ensuring that the care receiver’s needs
were met adequately. Although the responsibility
for insuring that needs are met does not rest sole-
ly with family members, the data revealed that
caregivers who were more skillful in “working the
system” were more likely to get what they need-
ed. For example, one caregiver, having waited in
the emergency room with the weary care receiver
for 3 hr, called the attending physician, worked out
a complicated problem involving communication
between the attending physician and the emer-
gency room physician, and eventually got the care
receiver admitted to the hospital.
Knowing when to call the nurse or physician
was an issue for many caregivers at home. Even
though they had been instructed to call if they
had questions, caregivers often wondered whether
symptoms were severe enough to justify calling,
and they wondered whether they would be per-
ceived as nuisances. Over time, however, care-
givers developed a sense of how best to work with
the health care provider by phone.
Definition and Properties
of Family Caregiving Skill
In the final analytic phase of the project, the results
of the qualitative data analysis were synthesized
with the earlier theoretical analysis to develop a
199
conceptual definition of family caregiving skill
and identify its properties. Family caregiving skill
was defined as the ability to engage effectively and
smoothly in nine core caregiving processes. Care-
giving was effective when it led to the best possi-
ble outcomes of care, such as optimal symptom
management, prevention of injury, early detection
of problems, and so forth. Although some out-
comes were beyond the control of caregivers,
skillful caregiving led to outcomes that were
optimal given the circumstances. Caregiving was
smooth when it flowed with the seeming effortless-
ness of actions honed through experience and prac-
tice. Skillful caregiving had a taken-for-granted
quality and often proceeded so smoothly that it
was transparent to caregivers and they did not
comment on it spontaneously to the interviewer.
Indeed, it initially was transparent to the re-
searchers, until constant comparison highlighted
the complexity of the processes “behind” caregiv-
ing that flowed so smoothly it appeared effortless.
Three properties of family caregiving skill were
identified. First, family caregiving skill was a
blend of previously developed skills, such as prob-
lem-solving, organizational and interpersonal
skills, and newly developed skills for illness man-
agement. Caregiving was most effective when
previously developed and newly acquired skills
were both brought to bear in the care of the ill per-
son. For example, one caregiver who had well-de-
veloped skills in household management easily
engaged in problem-solving around organizing a
complex medication regimen. A caregiver with
well-developed interpersonal skills provided ex-
ceptional support to her depressed care receiver. In
contrast, a caregiver who described difficulties in
many interpersonal relationships also described
difficulty with the interpersonal aspects of care-
giving.
Second, family caregiving skill involved inte-
grating knowledge about the ill person, including
important aspects of his or her identity, concerns,
and personal history, with knowledge about the
specifics of illness care. As one caregiver said,
“I’m looking at the man as a whole. I’m not just
looking at his cancer.” Another caregiver was pro-
viding care for a mother whose sociable and ad-
venturous personality had long been expressed
through travel. She felt depressed and “blah”
when confined to her home by illness. To improve
her mother’s mood, the caregiver subscribed to a
cable TV travel station so her mother could travel
vicariously. As the care receiver told the inter-
viewer, “Oh, yesterday, we got the best TV! We
saw Mississippi! We saw Switzerland! Oh, it was
great!”
200 RESEARCH IN NURSING & HEALTH
Third, family caregiving skill developed over
time and with experience. For example, at the
Time 1 interview, one caregiver was struggling
somewhat unsuccessfully with providing ade-
quate nutrition for a care receiver with little ap-
petite. The care receiver said,
I’m trying to put a little bit of food into my stomach. She
[Caregiver] likes to have me eat. BOOM! She brings a
whole plate of food and “I want you to eat.” I can’t do
it! I feel I’ve got to eat a little bit at a time. But she’s
from the old school where, “Okay. Here’s some food.
Make sure you eat it all.” You can’t do it! That’s why I
threw up the other day.
When asked what she did to help him eat better,
the caregiver replied, “I scold him.”
As the caregiver became more skillful, nutrition
care proceeded more effectively and smoothly. At
the Time 3 interview, the caregiver said,
The first day of chemotherapy he feels tired and sleepy.
I make sure he drinks a lot of water. And I offer him
food, but he doesn’t feel like eating afterward. Not much
that first day. The second day, he feels a little better.
He’ll have something to eat in the morning and if he
wants an egg, I give it to him. If not, I let it go. Some-
times he eats it, sometimes he doesn’t. It always takes
about 2 days to get back to himself.
During the Time 4 interview, when asked what she
did to manage the problem with eating, this care-
giver said,
I try to bake him things he likes at home. I try to make
something different every day, but lately he’s just stick-
ing with eggs and toast. I buy him baby food. He likes
that. Fruit, especially peaches, is his favorite.
Over time, the caregiver had begun to notice pat-
terns in the care receiver’s response to chemother-
apy, developed multiple problem-solving strate-
gies, and evolved an approach in which both the
timing and amount of food offered were effective.
Further, the struggle the caregiver was experienc-
ing with caregiving at Time 1 seemed to dissipate
and by Time 4 caregiving was flowing more easi-
ly, even though the illness situation continued to
present many challenges. In comparing the first
interview with later interviews, striking differ-
ences were evident in both the effectiveness and
the smoothness with which care was provided.
DISCUSSION
Increasing interest in the “doing” of family care-
giving is emerging in the research literature. This
interest in care provision expands the scope of re-
search from a limited focus on caregiving burden
to the whole constellation of caregiving tasks,
processes, and knowledge comprising the care-
giving role itself (Archbold & Stewart, 1996;
Archbold et al., 1990; Archbold et al., 1995; Giv-
en & Given, 1991). The emerging research on
caregiving as a complex role is significant for
nursing practice because nurses provide teaching
and support to family members as they take on the
caregiving role. Formal knowledge development
around caregiving links an important clinical phe-
nomenon with the rapidly expanding theoretical
knowledge base in nursing.
Fundamental to this knowledge development is
the recognition that some caregivers do caregiving
better than others, for reasons related to knowl-
edge, experience, level of engagement in caregiv-
ing and so forth. Thus conceptualization of the
variability in doing caregiving well is essential.
Further, given this variability in doing caregiving
well, it should be possible to measure it and locate
individual caregivers along a continuum of “good
care.” The ability to do so would then allow clini-
cians and researchers to identify caregiving diffi-
culties more precisely and target interventions to
specific difficulties.
Researchers have used both self-report by care-
givers and a professional perspective in studies re-
lated to doing caregiving well (Schumacher et al.,
1998). In the present study, we took the perspec-
tive of health professionals external to the care-
giving situation to analyze the data. Adopting a
professional perspective has important moral and
ethical implications and raises many issues about
values and power (Cromwell et al., 1996; Schu-
macher et al., 1998) that need further exploration.
On the one hand, assessment of the effectiveness
of caregiving by family members is a standard part
of the nursing role in a variety of clinical settings.
In this regard, clinicians need concepts and mea-
sures to make their assessments as precise and
replicable as possible. On the other hand, assess-
ment of caregiving behavior by a person external
to the situation may inadvertently or insensitively
take on a judgmental quality based on an inade-
quate appreciation of the caregiver’s perspective.
This tension around perspective exists in both re-
search and practice. Of note, however, is the fact
that in clinical practice, family members often
seek their nurse’s assessment of their care and ex-
pect the nurse to help them develop caregiving
skill. Thus, that nurses will assess caregiving skill
and intervene when needed is an expectation of
many clients as well as nurses. Ideally, profes-
sional assessment and caregivers’ perceptions to-
gether would constitute a comprehensive assess-
ment. At the present time, however, more tools are
 FAMILY CAREGIVING SKILL / SCHUMACHER ET AL.
available for caregiver self-report of self-confi-
dence or preparedness than for systematic nursing
assessment of caregiving skill.
The indicators of caregiving skill identified in
this study will comprise items for future instru-
ment development. The design of our project was
based on the premise that rigorous conceptual
work should precede any attempt at instrument
development. The importance of developing
sound conceptualizations of phenomena before
proceeding to measurement cannot be overstated.
A solid conceptual foundation increases the likeli-
hood that a measure will represent a phenomenon
as well as possible and facilitates interpretation
of research results obtained through use of an in-
strument. Because measurement development
occurs through successive revisions of an instru-
ment, we expect the indicators identified in this
study to be refined and modified through future
research.
The identification of nine processes requiring
family caregiving skill adds to the growing body
of research literature on the complex nature of the
caregiving role (Bowers, 1987; Given & Given,
1991; Stetz, 1987). Other researchers have de-
scribed the processes of monitoring, assessing,
recognizing, and interpreting (Albert, 1993; Brown
& Powell-Cope, 1991; Parcel et al., 1994; Stetz &
Brown, 1997), dealing with health professionals
and the health care system, seeking information,
and accessing resources (Brown & Stetz, 1999;
Bull & Jervis, 1997; Robinson et al., 1998), and
making decisions (Corcoran, 1994; Sims et al.,
1992). Our analysis provides additional validation
of the complex reasoning and behavioral process-
es required of family caregivers and supports Giv-
en and Given’s view that the caregiving role
should not be defined solely in terms of tasks or
procedures. In addition, our findings extend those
of other researchers by describing variability in
caregiving processes and conceptualizing this
variability in terms of skillfulness.
Conceptualization of family caregiving skill is
greatly needed in nursing. Teaching aimed at pro-
viding families with the knowledge and skill re-
quired to manage an illness at home is at the very
heart of nursing practice in many settings, includ-
ing home care, outpatient care, and hospital dis-
charge planning. The content of the knowledge
needed for illness care at home has been exten-
sively described, but knowledge alone does not
guarantee skillful caregiving. Rather, families
must put knowledge into practice and it is through
putting knowledge into practice that caregiving
skill can be observed. Ironically, the conceptual-
ization of family caregiving skill has remained
201
rudimentary, despite its centrality as a nursing con-
cern. For lack of a better understanding of family
caregiving skill, doing caregiving well is too often
thought of as compliance, as if good caregiving
was simply a matter following instructions. This
study demonstrates that skillful caregiving is com-
plex and involves much more than simply the
willingness or motivation to follow instructions.
Rather it is the capacity to identify caregiving prob-
lems and find solutions. In this respect, caregiving
skill involves active problem-solving, rather than
passive response.
The results of this study suggest an approach to
clinical assessment that differs from the usual
practice of determining whether caregivers are
correctly following instructions. Study results sug-
gest that clinicians should assess multiple care-
giving processes and target their interventions to
processes with which a caregiver needs help. For
example, clinicians could assess the process of
monitoring to determine how well a caregiver is
able to detect changes in the ill person’s condition.
Difficulties with monitoring could be pinpointed
through use of the indicators of skillful monitor-
ing and intervention could be targeted to a care-
giver’s specific difficulties. Because caregivers
may be skillful in some aspects of care and less
skillful in others, it is important to assess skill
across multiple caregiving processes, generating a
profile of skill rather than a global assessment.
Our results also suggest that brief periods of
nursing instruction may not be sufficient for the
development of caregiving skill. Rather, coaching
for skill development (Lewis & Zahlis, 1997) may
be needed, and coaching requires both time and
continuity in the helping relationship. Increasingly
limited access to professional nurses in the United
States raises serious concerns about whether fam-
ily caregivers can get the coaching they need in the
new health care system. Knowledge development
around caregiving skill provides clinicians with
theoretical and empirical evidence to support con-
tinuity and time as therapeutic imperatives.
Because this study targeted a circumscribed ill-
ness situation (i.e., caregiving during chemother-
apy for cancer), replication in other illness care sit-
uations is needed to establish similarities and
differences in caregiving skill across clinical pop-
ulations. Also, our study participants were primar-
ily white, middle-class North Americans. Other
ethnic groups and nationalities need to be studied
in order to understand the impact of sociocultural
and health system factors on family caregiving
skill. In spite of its limitations, this study has be-
gun the conceptual work needed on a nursing phe-
nomenon that is growing in importance as families
202 RESEARCH IN NURSING & HEALTH
become increasingly responsible for providing
care to ill relatives during unstable, often acute,
illnesses.
REFERENCES
Albert, S.M. (1993). Do family caregivers recognize
malnutrition in the frail elderly? Journal of the Amer-
ican Geriatrics Society, 41, 617– 622.
Archbold, P.G., & Stewart, B.J. (1996). The nature of
the family caregiving role and nursing interventions
for caregiving families. In E. Swanson & T. Tripp-
Reimer (Eds.), Issues in gerontological nursing: Vol.
1 (pp. 133 –156). New York: Springer.
Archbold, P.G., Stewart, B.J., Greenlick, M.R., & Har-
vath T. (1990). Mutuality and preparedness as pre-
dictors of caregiver role strain. Research in Nursing
& Health, 13, 375 – 384.
Archbold, P.G., Stewart, B.J., Miller, L.L., Harvath,
T.A., Greenlick, M.R., Van Buren, L., Kirschling,
J.M., Valanis, B.G., Brody, K.K., Schook, J.E., & Ha-
gan, J.M. (1995). The PREP system of nursing inter-
ventions: A pilot test with families caring for older
members. Research in Nursing & Health, 18, 3 –16.
Barg, F.K., Pasacreta, J.V., Nuamah, I.F., Robinson,
K.D., Angeletti, K., Yasko, J.M., & McCorkle, R.
(1998). A description of a psychoeducational inter-
vention for family caregivers of cancer patients. Jour-
nal of Family Nursing, 4, 394 – 413.
Benner, P. (1984). From novice to expert. Menlo Park,
CA: Addison Wesley.
Benner, P., Tanner, C.A., & Chesla, C.A. (1996). Ex-
pertise in nursing practice: Caring, clinical judgment,
and ethics. New York: Springer.
Bowers, B.J. (1987). Intergenerational caregiving:
Adult caregivers and their aging parents. ANS: Ad-
vances in Nursing Science, 9(2), 20 – 31.
Brown, M.A., & PowellCope, G.M. (1991). AIDS fam-
ily caregiving: Transitions through uncertainty. Nurs-
ing Research, 40, 338 – 45.
Brown, M.A., & Stetz, K. (1999). The labor of caregiving:
A theoretical model of caregiving during potentially
fatal illness. Qualitative Health Research, 9, 182–197.
Bull, M.J., & Jervis, L.L. (1997). Strategies used by
chronically ill older women and their caregiving
daughters in managing posthospital care. Journal of
Advanced Nursing, 25, 541– 547.
Cawley, M.M., & Gerdts, E.K. (1988). Establishing a
cancer caregivers program. Cancer Nursing, 11, 267–
273.
Clark, N.M., & Rakowski, W. (1983). Family caregivers
of older adults: Improving helping skills. The Geron-
tologist, 23, 637– 642.
Corcoran, M.A. (1994). Management decisions made
by caregiver spouses of persons with Alzheimer’s
disease. American Journal of Occupational Therapy,
48, 38 – 45.
Cromwell, S.L., Russell, C.K., Young, M.L., Luna, I.,
de Ardon, E.T., & Phillips, L.R. (1996). Uncovering
the cultural context for quality of family caregiving
for elders. Western Journal of Nursing Research, 18,
284–298.
Dittbrenner, H. (1995). International models of home
care: Focus on an aging world [editorial]. Caring
Magazine, 16(1), 1.
Dodd, M.J., Lindsey, A.M., Stetz, K., Lewis, B., Holze-
mer, W., Larson, P., Musci, E., Lovejoy, N., Dibble,
S.L., Paul, S., & Hauck, W.J. (1988–92). Self-care
intervention to decrease chemotherapy morbidity.
Research grant funded by the National Cancer Insti-
tute. University of California, San Francisco.
Edstrom, S., & Miller, M. W. (1981). Preparing the fam-
ily to care for the cancer patient at home: A home care
course. Cancer Nursing, 4, 49–52.
Ehrenfeld, M. (1998). Nursing and home care in Eu-
rope. International Nursing Review, 45, 61–64.
Gallagher-Thompson, D., & DeVries, H.M. (1994).
“Coping with Frustration” classes: Development and
preliminary outcomes with women who care for rela-
tives with dementia. The Gerontologist, 34, 548–552.
Given, B. A., & Given, C. W. (1991). Family caregiving
for the elderly. Annual Review of Nursing Research,
9, 77–101.
Grobe, M.E., Ilstrup, D.M., & Ahmann, D.L. (1981).
Skills needed by family members to maintain the care
of an advanced cancer patient. Cancer Nursing 4,
371–375.
Haley, W.E., Levine, E.G., Brown, S.L., & Bartolucci,
A.A. (1987). Stress, appraisal, coping, and social sup-
port as predictors of adaptational outcome among de-
mentia caregivers. Psychology and Aging, 4, 323–
330.
Hinds, C. (1985). The needs of families who care for pa-
tients with cancer at home: Are we meeting them?
Journal of Advanced Nursing, 10, 575–581.
Kosberg, J.I., & Cairl, R.E. (1991). Burden and compe-
tence in caregivers of Alzheimer’s disease patients:
Research and practice implications. Journal of
Gerontological Social Work, 18(1/2), 85–96.
Lawton, M.P., Kleban, M.H., Moss, M., Rovine, M., &
Glicksman, A. (1989). Measuring caregiving ap-
praisal. Journal of Gerontology: Psychological Sci-
ences, 44, P61–P71.
Lee, H.O., Hwang, A.R., Pierce, C.A., & Fitzpatrick,
J.J. (1997). International collaboration for home care
education, Part I: Creating the partnership. Journal of
Professional Nursing, 13, 256–261.
Levine, B.S., Cartwright, J., Inoue, I., Stewart, B.J., &
Archbold, P.G. (1998). Quality of family caregiving:
A new measurement strategy. Unpublished manu-
script, Oregon Health Sciences University, Portland.
Lewis, F.M., & Zahlis, E.H. (1997). The nurse as coach:
A conceptual framework for clinical practice. Oncol-
ogy Nursing Forum 10, 1695–1702.
Mahoney, D.F., & Shippee-Rice, R. (1994) Training
family caregivers of older adults: A program model
for community nurses. Journal of Community Health
Nursing, 11(2), 71–78.
Messias, D.K.H., Yeager, K.A., Dibble, S.L., & Dodd,
M.J. (1997). Patients’ perspectives of fatigue while
undergoing chemotherapy. Oncology Nursing Forum
24, 43–48.
 FAMILY CAREGIVING SKILL / SCHUMACHER ET AL.
Modly, D., Zanotti, R., Poletti, P., & Fitzpatrick, J.J.
(1997). Home care nursing services: International
lessons. New York: Springer.
Nolan, M.R., & Grant, G. (1989). Addressing the needs
of informal carers: A neglected area of nursing prac-
tice. Journal of Advanced Nursing, 14, 950 – 961.
Nolan, M., Grant, G., & Keady, J. (1996). Understand-
ing family care. Buckingham, UK: Open University
Press.
Parcel, G.S., Swank, P.R., Mariotto, M.J., Bartholomew,
L.K., Czyzewski, D.I., Sockrider, M.M., & Seilheimer,
D.K. (1994). Self-management of cystic fibrosis: A
structural model for educational and behavioral vari-
ables. Social Science and Medicine, 38, 1307–1315.
Pearlin, L.I., Mullan, J.T., Semple, S.J., & Skaff, M.M.
(1990). Caregiving and the stress process: An
overview of concepts and their measures. The Geron-
tologist, 30, 583 – 594.
Phillips, L.R., Morrison, E.F., & Chae, Y.M. (1990a).
The QUALCARE Scale: Developing an instrument
to measure quality of home care. International Jour-
nal of Nursing Studies, 27, 61–75.
Phillips, L.R., Morrison, E.F., & Chae, Y.M. (1990b).
The QUALCARE Scale: Testing of a measurement
instrument for clinical practice. International Journal
of Nursing Studies, 27, 77– 91.
Proctor, R.W., & Dutta, A. (1995). Skill acquisition and
human performance. Thousand Oaks, CA: Sage.
Robinson, K.D., Angeletti, K.A., Barg, F.K., Pasacreta,
J.V., McCorkle, R., & Yasko, J.M. (1998). The de-
velopment of a family caregiver cancer education
program. Journal of Cancer Education, 13, 116 –121.
203
Schumacher, K.L. (1996). Reconceptualizing family
caregiving: Family-based illness care during chemo-
therapy. Research in Nursing & Health, 19, 261–271.
Schumacher, K.L., Stewart, B.J., & Archbold, P.G.
(1998). Conceptualization and measurement of doing
family caregiving well. Image: Journal of Nursing
Scholarship, 30, 63–69.
Schwartz-Barcott, D., & Kim, H.S. (1993). An expan-
sion and elaboration of the hybrid model of concept
development. In B.L. Rodgers & K.A. Knafl (Eds.),
Concept development in nursing (pp. 135–157).
Philadelphia: W.B. Saunders.
Sims, S.L., Boland, D.L., & O’Neill, C.A. (1992). De-
cision making in home health care. Western Journal
of Nursing Research, 14, 186–200.
Stetz, K.M. (1987). Caregiving demands during ad-
vanced cancer. Cancer Nursing, 10, 260 –268.
Stetz, K.M., & Brown, M.A. (1997). Taking care: Care-
giving to persons with cancer and AIDS. Cancer
Nursing, 20(1), 12–22.
Strauss, A., & Corbin, J. (1990). Basics of qualitative re-
search: Grounded theory procedures and techniques.
Newbury Park, CA: Sage.
Toseland, R.W., Blanchard, C.G., & McCallion, P.
(1995). A problem solving intervention for caregivers
of cancer patients. Social Science and Medicine, 40,
517–528.
Webster’s new twentieth century dictionary (2nd ed.).
(1983). New York: Simon and Schuster.
Yamamoto, N., & Wallhagen, M.I. (1997). The contin-
uation of family caregiving in Japan. Journal of
Health and Social Behavior, 38, 164 –176.