**2.2 Nursing intervention based on the psychoeducational stress management program.**

In the control group (CG), the nurses performed unstructured activities to respond to the difficulties of family caregivers, as usual.

In the intervention group, the nursing team was trained by the researcher to implement the psychoeducational program of the stress management process [18]. They were supported by two documents: "The Caregiver's Guidebook (*Cartilha do Cuidador*) and the "Nurse's Manual" (*Manual do Enfermeiro*).

The stress management program for family caregivers at home aims to help caregivers to develop skills to manage difficult or stressful situations they experience in caring for the elderly at home. The program comprises five steps:

Step 1: Participants'sensitization.

Step 2: Selection of a stressful situation and a goal to be achieved.

Step 3: Situation analysis: This analysis determines the choice of an adapted strategy to be put into practice in the next step.

Step 4: Selection of a strategy adapted to the situation and chosen action, following the presentation of several strategies that can help in the care setting. Step 5: Evaluation: The final step allows a return to the second step to evaluate how the goal established in that step was achieved. If the goal is not achieved, the stress management process is resumed to allow the caregiver to try another action, which will be evaluated again to direct their thinking until the chosen goal is achieved.

#### **2.3 Hypotheses**

Hypothesis 1 – The client system intervention group (IG) shows better results in the variables when compared to the client system control group (CG) at T2 (postintervention).

Hypothesis 2 – The client system intervention group (IG) shows better results in the variables between moments T2 and T3 when compared to the client system control group (CG).

#### **2.4 Instruments**

The data collection instrument was constituted by a questionnaire that includes scales translated and adapted to Portuguese with several parts.

Sociodemographic characterization of the family caregiver and the elderly regarding the following variables: sex, age, marital status, professional status, cohabitation, time of care provision, level of dependence on activities of daily living (ADL) [Basic (ADLB) and instrumental (ADLI)], coping with burden, and social support.

The ADL were assessed through questions, translated, and adapted to Portuguese [19], based on the original questionnaire.

The risk of caregiver burden was assessed by the Carers' Risk Assessment Scale [18]. Caregiver burden was assessed using the Zarit Burden Interview Scale (ZBI). The burden scale values were: no burden (<46), light (47–55), and heavy (>56) [20].

The Caregiver's Coping was assessed by the Carers' Assessment of Management Index (CAMI) [21], translated and adapted to Portuguese [15].

#### **2.5 Statistical analysis**

The intervention and the control groups of the client system were compared, using a multiple set of variables, at the three study moments. Initially, descriptive statistics were used: mean, median, standard deviation, coefficient of variation (for quantitative variables, and count of columns and percentages (for qualitative variables), followed by inferential statistics, such as the chi-square test (for qualitative variables) and the comparison of the mean values of the "t-test" (for quantitative variables).

When the conditions for applying the chi-square test were not met for the qualitative variables, Fisher's exact test was used.

The Mann–WhitneyU test was used for quantitative variables when there was no normality between the variables in the 2 groups. The nonparametric *t-*test was used if the normality of the variables in the 2 groups was verified, but their variance was not homogeneous (automatic SPSS procedure).

Both the Kolmogorov–Smirnov test and the Shapiro–Wilk test were used to test the normality of variables in the 2 groups. The significance level was set at 10% [22]. The statistical analysis was performed using the statistical package for the social sciences (SPSS), version 22 (SPSS Inc., Chicago, USA).

#### **2.6 Ethical considerations**

Authorization was obtained from the authors of the data collection instruments and the authors of the psychoeducational stress management program to apply them to the clients selected for the study.

The research protocol was approved by the clinical director of the grouping of health units, with favorable opinion n. 093/CES/INV/2014.

The participants were informed about the type of study and after clarification, all of them signed the free and informed consent form (ordinance 015/2013) [23]. The ethical principles of the declaration of Helsinki were considered throughout the process.

During the nursing intervention, ethical care was always ensured, while respecting the family caregiver's availability, individualization of care, belief in their potentials and resources, and the avoidance of value judgments.
