***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To evaluate the process of implementation of the modified London Stroke Carers Training Course ( LSCTC ) in the Training Caregivers After Stroke ( TRACS ) cluster r and omised trial and contribute to the interpretation of the TRACS trial results . The LSCTC was a structured competency-based training programme design ed to help develop the knowledge and skills ( eg , patient h and ling or transfer skills ) essential for the day-to-day management of disabled survivors of stroke . The LSCTC comprised 14 components , 6 were m and atory ( and delivered to all ) and 8 non-m and atory , to be delivered based on individual assessment of caregiver need . Design Process evaluation using non-participant observation , documentary analysis and semistructured interviews . Participants Patients with stroke ( n=38 ) , caregivers ( n=38 ) , stroke unit staff ( n=53 ) . Setting s 10 of the 36 stroke units participating in the TRACS trial in four English regions ( Yorkshire , North West , South East and South West , Peninsula ) . Results Preparatory cascade training on delivery of the LSCTC did not reach all staff and did not lead to multidisciplinary team ( MDT ) wide underst and ing of , engagement with or commitment to the LSCTC . Although senior therapists in most intervention units observed developed ownership of the LSCTC , MDT working led to separation rather than integration of delivery of LSCTC elements . Organisational features of stroke units and professionals ’ patient-focused practice s limited the involvement of caregivers . Caregivers were often invited to observe therapy or care being provided by professionals but had few opportunities to make sense of , or to develop knowledge and stroke-specific skills provided by the LSCTC . Where provided , caregiver training came very late in the inpatient stay . Assessment and development of caregiver competence was not commonly observed . Conclusions Context ual factors including service improvement pressures and staff perceptions of the necessity for and work required in caregiver training impacted negatively on implementation of the caregiver training intervention . Structured caregiver training programmes such as the LSCTC are unlikely to be practical in setting s with short inpatient stays . Stroke units where early supported discharge is in place potentially offer a more effective vehicle for introducing competency based caregiver training . LINKED TRACS Cluster r and omised controlled trial number IS RCT N49208824 The adoption of evidence -based hierarchies and research methods from other disciplines may not completely translate to complex palliative care setting s. The heterogeneity of the palliative care population , complexity of clinical presentations , and fluctuating health states present significant research challenges . The aim of this narrative review was to explore the debate about the use of current evidence -based approaches for conducting research , such as r and omized controlled trials and other study design s , in palliative care , and more specifically to ( 1 ) describe key myths about palliative care research ; ( 2 ) highlight substantive challenges of conducting palliative care research , using case illustrations ; and ( 3 ) propose specific strategies to address some of these challenges . Myths about research in palliative care revolve around evidence hierarchies , sample heterogeneity , r and om assignment , participant burden , and measurement issues . Challenges arise because of the complex physical , psychological , existential , and spiritual problems faced by patients , families , and service providers . These challenges can be organized according to six general domains : patient , system/organization , context / setting , study design , research team , and ethics . A number of approaches for dealing with challenges in conducting research fall into five separate domains : study design , sampling , conceptual , statistical , and measures and outcomes . Although r and omized controlled trials have their place whenever possible , alternative design s may offer more feasible research protocol s that can be successfully implemented in palliative care . Therefore , this article highlights " outside the box " approaches that would benefit both clinicians and research ers in the palliative care field . Ultimately , the selection of research design s is dependent on a clearly articulated research question , which drives the research process The aim of this editorial is to highlight several research priorities and key implication s for policy and practice that inform an agenda to improve family carer support . The development of systematic approaches to identify carers who are at risk of poor psychosocial outcomes  is a priority . Family caregiving should not be pathologised as an inherently negative experience ; however , it would be a breach of care if more than 40 % of carers who appear to meet the criteria for psychological distress1 are not offered suitable supports . Related to this is the urgent need for greater investment in bereavement research ; while bereavement support is integral to palliative care , it is typically under-re source d , under-investigated and not systematic ally applied . We know that routine intervention for all bereaved carers is not warranted . The challenge is to discern those carers who are ‘ at risk ’ prior to the death of the patient and to identify suitable evidence -based strategies to assist them . Research indicates that carer re sources , rather than patient diagnosis or illness severity , are the primary predictors of carer burden and other carer outcomes . This implies that although the specific content may need to vary to suit the context , the core elements of family carer interventions may be relevant across disease groups . It is also apparent that the perceived quality of social support is more important than the size of the social network in improving carer outcomes .2 Current indications are that palliative care providers should assist carers by targeting social support and re sources and provide education that focuses on coping strategies and preparation for the carer role . In many countries , family carers are well prepared for the beginning of life when , for example , prospect i ve parents are routinely offered parenting classes . It is also not uncommon to assist carers prepare for and support relatives having major heart surgery . However , preparation for supporting a relative/ friend at the end of their life is not routinely offered . Carers typically want to know what the role entails , how to manage symptoms , signs of imminent death and re sources and strategies to sustain their own well-being . Given the majority of patients want to be cared for in their home environment , initiatives that assist carers to achieve this are needed . The period of time most people receive palliative care services is typically quite short ; hence , the challenge is to design interventions that are as brief as possible , readily accessible and easily delivered . The significant number of carers who support patients in the hospital/hospice setting should also not be neglected ; their needs are often hidden . Other valuable insights regarding how we deliver interventions are surfacing . For example , the conception that face-to-face carer support is the gold st and ard is being challenged . Emerging evidence suggests that telephone and video phone support may be equally effective in some circumstances.1,3 Emphasis on the development of a strategic , coordinated and priority-driven family carer research agenda is also important.4 The role of formal research collaborations may be a vehicle to foster this . Much of the carer research seems to be first-world centric . More attention needs to be directed towards family caregiving in under-re source d countries and in other under-represented population s such as ethnic minority groups . Several important policy and clinical matters warrant consideration if palliative care is to foster improved carer support . One of the core questions for policymakers and clinicians is whether or not it is feasible for palliative care to be expected to meet the needs of the patients ’ entire family . It has been recommended that given re source constraints , the focus should be on the primary family carer ( as identified by the patient ) and where possible extended to other family members.5 Consideration might also be given to revising expectations about the goal of family support . The current World Health Organization definition of palliative care advocates that families ’ quality of life be improved ; perhaps a more realistic objective may be to aim to reduce the psychosocial burden of primary family carers . A related question is how to effectively legitimise family carer support . Most family carers do not want to discuss their needs and concerns in front of their relative ; they therefore need one-to-one time with healthcare and socialcare professionals . It is also clear that many healthcare workers find supporting carers challenging . Hence , where pertinent , consideration should be given to the potential merits of officially recognising family carers as ‘ care recipients ’ ; therefore , they are formally acknowledged as ‘ worthy ’ within the healthcare system . This may help justify much needed re sources and allow healthcare workers to allocate time and where pertinent offer interventions . In 488855 PMJ27710.1177/0269216313488855Palliative MedicineEditorial CONTEXT Concerns about pain medications are major barriers to pain management in hospice , but few studies have focused on systematic methods to address these concerns . OBJECTIVES The objective of this study was to test the preliminary efficacy of the  Effective Management of Pain : Overcoming Worries to Enable Relief ( EMPOWER ) intervention , which included hospice staff education , staff screening of barriers to pain management at admission , and discussion about misunderst and ings regarding pain management with  family caregivers and patients . METHODS We conducted a pilot , cluster r and omized , controlled trial with four hospices . One hundred twenty-six family caregivers ( 55 interventions and 71 controls ) were interviewed at two weeks after admission . If patients survived three months after admission , caregivers were reinterviewed . RESULTS At two weeks , caregivers in the intervention group reported better knowledge about pain management ( P = 0.001 ) , fewer concerns about pain and pain medications ( P = 0.008 ) , and lower patient pain over the past week ( P = 0.014 ) and trended toward improvement in most other areas under study . Exploratory analyses suggest that EMPOWER had a greater effect for black subjects ( vs. whites ) on reducing concern about stigma . At three months , the intervention group trended better on most study outcomes . CONCLUSION EMPOWER is a promising model to reduce barriers to pain management in hospice The shift of health care burden from acute to chronic conditions is strongly linked to lifestyle and behaviour . As a consequence , health services are attempting to develop strategies and interventions that can attend to the complex interactions of social and biological factors that shape both . In this paper we trace one of the most influential incarnations of this ‘ turn to the complex ’ : the Medical Research Council ( MRC ) guidance on developing and evaluating complex interventions . Through an analysis of the key publications , and drawing on social scientific approaches to what might constitute complexity in this context , we suggest that such initiatives need to adjust their conceptualisation of ‘ the complex ’ . We argue that complexity needs to be understood as a dynamic , ecological system rather than a stable , albeit complicated , arrangement of individual elements . Crucially , in contrast to the experimental logic embedded in the MRC guidance , we question whether the R and omised Controlled Trial ( RCT ) is the most appropriate method through which to engage with complexity and establish reliable evidence of the effectiveness of complex interventions Background Being a family carer to a patient nearing the end of their life is a challenging and confronting experience . Studies show that caregiving can have negative consequences on the health of family carers including fatigue , sleep problems , depression , anxiety and burnout . One of the goals of palliative care is to provide psychosocial support to patients and families facing terminal illness . A systematic review of interventions for family carers of cancer and palliative care patients conducted at the start of this millennium demonstrated that there was a dearth of rigorous inquiry on this topic and consequently limited knowledge regarding the types of interventions likely to be effective in meeting the complex needs of family carers . We wanted to discern whether or not the evidence base to support family carers has improved . Furthermore , undertaking this review was acknowledged as one of the priorities for the International Palliative Care Family Carer Research Collaboration http://www.centreforpallcare.org . Methods A systematic review was undertaken in order to identify developments in family carer support that have occurred over the last decade . The focus of the review was on interventions that targeted improvements in the psychosocial support of family carers of palliative care patients . Studies were grade d to assess their quality . Results A total of fourteen studies met the inclusion criteria . The focus of interventions included  psycho-education , psychosocial support , carer coping , symptom management , sleep promotion and family meetings .  Five studies were r and omised controlled trials , three of which met the criteria for the highest quality evidence . There were two prospect i ve studies , five pre-test/post-test projects and two qualitative studies . Conclusions The systematic review identified a slight increase in the quality and quantity of psychosocial interventions conducted for family carers in the last decade . More rigorous intervention research is required in order to meet the supportive care needs of family carers of palliative care patients PURPOSE / OBJECTIVES To examine the impact of pain education on family members providing home care to elderly patients with cancer . DESIGN Quasiexperimental . SETTING Homes of selected patients from two California medical centers . SAMPLE Fifty family caregivers of patients experiencing cancer-related pain . METHODS The pain education program included three components : pain assessment , pharmacologic interventions , and nonpharmacologic interventions . Patients and their family caregivers were evaluated prior to initiation of the program and at one and three weeks following the interventions . MAIN RESEARCH VARIABLES Quality of life ( QOL ) ; knowledge and attitudes about pain ; and caregiver burden . FINDINGS Findings based on measures of QOL and caregiver burden demonstrated the physical and psychological impact of family caregiving and pain management . Comparison between elderly patients with cancer and family caregivers revealed the pain experience 's significant impact on family members caring for a loved one in pain . CONCLUSIONS The pain education program was effective in improving knowledge and attitudes regarding pain management . IMPLICATION S FOR NURSING PRACTICE Pain management is a priority for nurses , and use of interventions such as structured pain education improves QOL outcomes for elderly patients and their family caregivers OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for 
    Output:
    
It was not possible to discern any association between particular intervention characteristics and family carer outcomes .
Current evidence is limited , but overall suggests face-to-face educational interventions supported by written and /or other re sources have potential to improve carers ' knowledge and self-efficacy for pain management .