To analyze the concept of excessive caregiving burden in caregivers of individuals with heart failure and to refine the NANDA-I diagnosis, Excessive caregiving burden.
Methods
A concept analysis based on Walker and Avant's framework was conducted, supported by an integrative review of studies retrieved from PubMed, the Virtual Health Library, Web of Science, and Scopus. Fifty-eight studies were included that supported identification of essential attributes, antecedents, consequents, and empirical referents. Model and contrary cases were developed.
Results
Six essential attributes, 13 antecedents, 28 consequents, and 12 empirical referents were identified. The essential attributes reflected a multidimensional response with negative impacts across psychological, functional, social, physical, and financial domains, compromising the caregiver's quality of life. The consequents supported identification and refinement of defining characteristics, including anxiety, sadness, worry, distress, social isolation, neglect of self-care, sleep disturbances, and exhaustion. The antecedents comprised both modifiable and non-modifiable factors, with the most frequent being lack of emotional, psychosocial, and professional support; severity of heart failure; the patient's functional dependence; and prolonged caregiving duration. Twelve empirical referents were identified, with the Zarit Burden Inventory and the Dutch Objective Burden Inventory being the most frequently used.
Conclusion
The study advances the understanding of excessive caregiving burden in caregivers of individuals with heart failure by clarifying its complex and multidimensional nature and refining its diagnostic components.
Implications for nursing practice
The refined diagnostic components may support nurses in the systematic assessment and identification of this human response, enabling the implementation of targeted, multidimensional interventions.
ÅgrenS.EvangelistaL.StrömbergA. (2010). Do partners of patients with chronic heart failure experience caregiver burden?European Journal of Cardiovascular Nursing, 9(4), 254–262. https://doi.org/10.1016/j.ejcnurse.2010.03.001
2.
AlaeiA.BabaeiS.FarziS.HadianZ. (2024). Effect of a supportive-educational program based on the COPE model on quality of life and caregiver burden of family caregivers of heart failure patients: A randomized clinical trial. BMC Nursing, 23(1), 1–10. https://doi.org/10.1186/s12912-024-01709-2
3.
BahramiM.EtemadifarS.ShahriariM.FarsaniA. K. (2014). Caregiver burden among Iranian heart failure family caregivers: A descriptive, exploratory, qualitative study. Iranian Journal of Nursing and Midwifery Research, 19(1), 56–63. PMCID: PMC3917186 PMID: 24554961
4.
BaikD.McIlvennanC. K.BakerC.CoatsH. (2022). Caregiving experiences of older family caregivers of persons with heart failure: A mixed methods study. Geriatric Nursing, 48, 51–57. https://doi.org/10.1016/j.gerinurse.2022.08.015
BidwellJ. T.HostinarC. E.HigginsM. K.AbshireM. A.CothranF.ButtsB.MillerA. H.CorwinE.DunbarS. B. (2021). Caregiver subjective and physiological markers of stress and patient heart failure severity in family care dyads. Psychoneuroendocrinology, 133, 105399. https://doi.org/10.1016/j.psyneuen.2021.105399
7.
BorgesB. E. C.DantasA. C.LucenaM. T. M.CarvalhoL. M.SilvaC. J. A.AraújoJ. N. M., Lopes, M. V. de O., & Vitor, A. F (2024). Clinical indicators of the nursing diagnosis caregiver role strain: A systematic review of accuracy. Nursing Forum, 2024, 5533177. https://doi.org/10.1155/2024/5533177
8.
Bozkurt ZincirS.SunbulM.ZincirS.Aydin SunbulE.OguzM.CengizF. F., et al. (2014). Burden and depressive symptoms associated with adult-child caregiving for individuals with heart failure. The Scientific World Journal, 2014, 641817. https://doi.org/10.1155/2014/641817
9.
BuckH. G.HowlandC.StawnychyM. A.AldossaryH.CortésY. I.DeBergJ., et al. (2024). Caregivers’ contributions to heart failure self-care: An updated systematic review. Journal of Cardiovascular Nursing, 39(3), 266–278. https://doi.org/10.1097/JCN.0000000000001060
10.
BuckH. G.HupceyJ.Juárez-VelaR.VelloneE.RiegelB. (2019). Heart failure care dyadic typology: Initial conceptualization, advances in thinking, and future directions of a clinically relevant classification system. The Journal of Cardiovascular Nursing, 34(2), 159–165. https://doi.org/10.1097/JCN.0000000000000548
11.
Carleton-EagletonK.WalkerI.FreeneN.GibsonD. (2021). Meeting support needs for informal caregivers of people with heart failure: A rapid review. European Journal of Cardiovascular Nursing, 20(5), 493–500. https://doi.org/10.1093/eurjcn/zvaa017
12.
ChungM. L.LennieT. A.Mudd-MartinG.DunbarS. B.PresslerS. J.MoserD. K. (2016). Depressive symptoms in patients with heart failure negatively affect family caregiver outcomes and quality of life. European Journal of Cardiovascular Nursing, 15(1), 30–38. https://doi.org/10.1177/1474515114535329
13.
DiggleM. F. J.SchutzS.ButcherD. (2025). Bereaved caregivers’ experiences of end-of-life care for people with advanced heart failure: A narrative synthesis. Omega (Westport), 90(4), 1581–1608. https://doi.org/10.1177/00302228221124636
14.
DirikkanF.BaL.MutluE. (2018). The caregiver burden and psychosocial adjustment of caregivers of cardiac failure patients. Turkish Journal of Cardiology Archives, 46(8), 692–701. https://doi.org/10.5543/tkda.2018.66571
15.
DracupK.EvangelistaL. S.DoeringL.TullmanD.MoserD. K.HamiltonM. (2004). Emotional well-being in spouses of patients with advanced heart failure. Heart & Lung, 33(6), 354–361. https://doi.org/10.1016/j.hrtlng.2004.06.003
16.
DuranteA.GrecoA.AnnoniA. M.StecaP.AlvaroR.VelloneE. (2019). Determinants of caregiver burden in heart failure. European Journal of Cardiovascular Nursing, 18(8), 691–699. https://doi.org/10.1177/1474515119863173
17.
DuranteA.YounasA.CuocoA.BoyneJ.RiceB. M.Juarez-VelaR., et al. (2023). Burden among informal caregivers of individuals with heart failure: A mixed methods study. PLoS ONE, 18(11), e0292948. https://doi.org/10.1371/journal.pone.0292948
18.
EtemadifarS.BahramiM.ShahriariM.FarsaniA. K. (2014). The effectiveness of a supportive educative group intervention on family caregiver burden of patients with heart failure. Iranian Journal of Nursing and Midwifery Research, 19(3), 217–223. PMID: 24949057; PMCID: PMC4061619.
19.
GravenL. J.AbbottL.Boel-StudtS.GrantJ. S.BuckH. G. (2023). Classifying heart failure caregivers. Journal of Palliative Care, 38(1), 62–70. https://doi.org/10.1177/08258597221079244
20.
GravenL. J.AzueroA.AbbottL.GrantJ. S. (2020). Psychosocial factors related to adverse outcomes in heart failure caregivers: A structural equation modeling analysis. Journal of Cardiovascular Nursing, 35(2), 137–148. https://doi.org/10.1097/JCN.0000000000000634
GrecoA.PancaniL.SalaM.AnnoniA. M.StecaP.PaturzoM.D'agostinoF.AlvaroR.VelloneE. (2017). Psychometric characteristics of the Caregiver Burden Inventory in caregivers of adults with heart failure. European Journal of Cardiovascular Nursing, 16(6), 502–510. https://doi.org/10.1177/1474515117693890
HamedisereshtM.KhaliliY.AsghariR.TaghaviS.SeyedfatemiN. (2020). Evaluation of the reliability and validity of the caregiver burden questionnaire for heart failure (CBQ-HF) in Iran. Research in Cardiovascular Medicine, 9(2), 35–42. https://doi.org/10.4103/rcm.rcm_13_20
25.
HarknessK. I.TranmerJ. E. (2007). Measurement of the caregiving experience in caregivers of persons with heart failure. Journal of Cardiac Failure, 13(7), 577–587. https://doi.org/10.1016/j.cardfail.2007.03.013
26.
HayashiE.MitaniH.MurayamaH.AnzaiT.StuderR.CottonS., et al. (2021). Characterizing the role of and physical and emotional burden on caregivers of patients with heart failure: Results from a cross-sectional survey in Japan. Geriatric Nursing, 42(2), 379–385. https://doi.org/10.1016/j.gerinurse.2021.01.010
27.
HerdmanT. H.KamitsuruS.LopesC. T. (2021). NANDA International Nursing diagnoses: Definitions and classification 2021–2023 (12th ed.). Thieme Publishers.
28.
HerdmanT. H.KamitsuruS.LopesC. T. (2024). NANDA International Nursing diagnoses: Definitions and classification 2024–2026 (13th ed.). Thieme Publishers.
29.
HodsonA. R.PeacockS.HoltslanderL. (2019). Family caregiving for persons with advanced heart failure. Palliative & Supportive Care, 17(6), 720–734. https://doi.org/10.1017/S1478951519000245
30.
HookerS. A.GrigsbyM. E.RiegelB.BekelmanD. B. (2015). The impact of relationship quality. Journal of Cardiovascular Nursing, 30(4), S52–S63. https://doi.org/10.1097/JCN.0000000000000270
31.
HookerS. A.SchmiegeS. J.TrivediR. B.AmoyalN. R.BekelmanD. B. (2018). Mutuality and heart failure self-care. European Journal of Cardiovascular Nursing, 17(2), 102–113. 10.1177/1474515117730184
32.
HuX. L.HuX. Y.SuY. L.QuM. Y. (2018). Quality of life among primary family caregivers of patients with heart failure in Southwest China. Rehabilitation Nursing, 43(1), 26–34. https://doi.org/10.1002/rnj.290
33.
HuX. L.HuangW. X.SuY. L.QuM. Y.PengX. C. (2017). Depressive symptoms in Chinese family caregivers of patients with heart failure: A cross-sectional study. Medicine (Baltimore), 96(13), e6480. https://doi.org/10.1097/MD.0000000000006480
34.
HumphreyL.KulichK.DeschaseauxC.BlackburnS.MaguireL.StrömbergA. (2013). The caregiver burden questionnaire for heart failure. Health and Quality of Life Outcomes, 11, 84. 10.1186/1477-7525-11-84.
35.
JacksonJ. D. S.CottonS. E.Bruce WirtaS.ProencaC. C.ZhangM.LahozR.CaladoF. J. (2018). Burden of heart failure on caregivers in China: Results from a cross-sectional survey. Drug Design, Development and Therapy, 12, 1669–1678. 10.2147/DDDT.S148970
36.
KhaninezhadL.ValieeS.MoradiY.MahmoudiM. (2024). The effect of a caring program based on Pender’s health promotion model on caregiver burden in family caregivers of patients with chronic heart failure: A quasi-experimental study. Journal of Education and Health Promotion, 13, 303. https://doi.org/10.4103/jehp.jehp_1024_23
37.
KimK. A.ParkJ. S.SeoK. W.ChoiE. Y.AhnJ. A. (2022). Factors affecting quality of life. Medicine, 101(35), e30042. 10.1097/MD.0000000000030042
38.
LacerdaM. S.PradoP. R.BarrosA. L. B. L.LopesJ. L. (2019). Sintomas depressivos em cuidadores familiares de pacientes com insuficiência cardíaca: Revisão integrativa. Revista Gaúcha de Enfermagem, 40. 10.1590/1983-1447.2019.20180057
39.
LahozR.ProudfootC.FonsecaA. F.LoefrothE.CordaS.JacksonJ., et al. (2021). Caregivers of patients with heart failure: Burden and determinants of health-related quality of life. Patient Preference and Adherence, 15, 1153–1164. https://doi.org/10.2147/PPA.S297816
40.
Leal SoaresF.AraújoJ. N. M.SilvaC. J. A.DantasA. C.LucenaM. T. M.BorgesB. E. C., et al. (2024). Perfil epidemiológico das internações por insuficiência cardíaca no Brasil entre 2019 e 2023. Brazilian Journal of Implantology and Health Sciences, 6(4), 887–896. https://doi.org/10.36557/2674-8169.2024v6n4p887-896
41.
LeeA. A.AikensJ. E.JanevicM. R.RoslandA. M.PietteJ. D. (2020). Functional support and burden. Health Psychology, 39(1), 29–36. 10.1037/hea0000802
42.
LiuY. C.ChouM. C.ChiangM. C.HangC. L.ChenS. M.ChungM. L.LinC.-Y.HuangT.-Y. (2024). A biomarker of stress and self-reported caregiving distress predict poor quality of life in family caregivers of patients with heart failure. Journal of Cardiovascular Nursing, 39(6), 543–551. https://doi.org/10.1097/JCN.0000000000001050
43.
LopesM. V. O.SilvaV. M.AraújoT. L. (2013). Validation of nursing diagnoses: Challenges and alternatives. Revista Brasileira de Enfermagem, 66(5), 649–655. https://doi.org/10.1590/S0034-71672013000500002
44.
LuttikM. L.JaarsmaT.VeegerN.TijssenJ.SandermanR.van VeldhuisenD. J. (2007). Caregiver burden. European Journal of Heart Failure, 9(6), 695–701. 10.1016/j.ejheart.2007.01.006
45.
MakdessiA.HarknessK.LuttikM. L.McKelvieR. S. (2011). The Dutch objective burden inventory. European Journal of Cardiovascular Nursing, 10(4), 234–240. 10.1016/j.ejcnurse.2010.08.006
46.
McHorneyC. A.MansukhaniS. G.AnatchkovaM.TaylorN.WirtzH. S.AbbasiS., et al. (2021). The impact of heart failure on patients and caregivers: A qualitative study. PLoS ONE, 16(3), e0248240. https://doi.org/10.1371/journal.pone.0248240
47.
McIlfatrickS.DohertyL. C.MurphyM.DixonL.DonnellyP.McDonaldK.FitzsimonsD. (2018). ‘The importance of planning for the future': Burden and unmet needs of caregivers’ in advanced heart failure: A mixed methods study. Palliative Medicine, 32(4), 881–890. 10.1177/0269216317743958
48.
MolloyG. J.JohnstonD. W.JohnstonM.GaoC.WithamM. D.StruthersA. D.McMurdoM. E. T. (2008). Using the demand–control model of job strain to predict caregiver burden and caregiver satisfaction in the informal caregivers of heart failure patients. British Journal of Health Psychology, 13, 401–417. 10.1348/135910707X203363
49.
MooreC. D. (2010). Family functioning and caregiver burden. Journal of Family Social Work, 13(5), 451–462. 10.1080/10522158.2010.514681
50.
NelsonK. E.SaylorM. A.AndersonA.BuckH.DavisL. L.FeinglassJ., et al. (2022). We’re all we got is each other”: Mixed-methods analysis of dyadic family caregiving for patients with advanced heart failure. Heart & Lung, 55, 24–28. https://doi.org/10.1016/j.hrtlng.2022.04.009
PageM. J.McKenzieJ. E.BossuytP. M.BoutronI.HoffmannT. C.MulrowC. D., et al. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71
53.
PetruzzoA.PaturzoM.NalettoM.CohenM. Z.AlvaroR.VelloneE. (2017). Lived experience of caregivers. European Journal of Cardiovascular Nursing, 16(7), 638–645. 10.1177/1474515117707666
54.
PresslerS. J.Gradus-PizloI.ChubinskiS. D.SmithG.WheelerS.SloanR.JungM. (2013). Family caregivers of patients with heart failure: A longitudinal study. The Journal of Cardiovascular Nursing, 28(5), 417–428. 10.1097/JCN.0b013e3182563877
55.
RanJ.ZhouP.WangJ.ZhangY.YinC.WangY., et al. (2025). Global, regional, and national burden of heart failure and its underlying causes, 1990–2021: Results from the Global Burden of Disease Study 2021. Biomarker Research, 13, 16. https://doi.org/10.1186/s40364-025-00728-8
56.
SaundersM. M. (2008). Factors associated with caregiver burden in heart failure family caregivers. Western Journal of Nursing Research, 30(8), 943–959. https://doi.org/10.1177/0193945908319990
57.
SaundersM. M. (2009). Health-related quality of life. Journal of Community Health Nursing, 26(4), 173–182. 10.1080/07370010903259196
58.
StrømA.AndersenK. L.KorneliussenK.FagermoenM. S. (2015). Invisible care. Journal of Multidisciplinary Healthcare, 8, 271–277. 10.2147/JMDH.S82239
59.
StrömbergA. (2013). Caregivers in heart failure. Current Heart Failure Reports, 10(3), 270–275. 10.1007/s11897-013-0146-8
60.
SuksatanW.TankumpuanT.DavidsonP. M. (2022). Heart failure caregiver burden and outcomes: A systematic review. Journal of Primary Care & Community Health, 13, 1–19. https://doi.org/10.1177/21501319221112584
ZhuM.ZhangQ.LinL. (2025). Compassion fatigue. European Journal of Cardiovascular Nursing. 10.1093/eurjcn/zvaf144
67.
WalkerL. O.AvantK. C. (2018). Strategies for theory construction in nursing (6th ed.). Pearson/Prentice Hall.
68.
WangY.XuX.LvQ.ZhaoY.ZhangX.ZangX. (2024). Network analysis of dyadic burdens, psychological disorders, psychological resilience, and illness- or caregiving-related beliefs in patients with chronic heart failure and their caregivers. Journal of Cardiovascular Nursing. https://doi.org/10.1097/JCN.0000000000001098
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
