1. Introduction
Congenital heart disease is one of the most important disorders and its prevalence is about 8 in 1000 in European countries. Congenital anomalies and congenital heart disease are the leading causes of child mortality in the world [1]. About 1-2% of babies are usually born with heart problems. According to global statistics, for every 1,000 births in the world, 8-9 babies have congenital heart disease, mild to severe [1, 2]. Caring for children with heart problems is a major psychological crisis for parents, especially mothers; it causes disability in the child and puts a high stress on the mother [3]. The results of Gray et al.’s showed that mothers with this type of children tolerate higher levels of anxiety and psychological problems than mothers with normal children [3]. 
Patients with heart problems and their caregivers, due to the consequences of disease and treatment, face with changes in their needs and require self-care to overcome their problems [4]. Adherence to self-care behaviors is important. Self-care education can improve patients’ functional abilities and disease processes. One type of self-care is spiritual self-care. According to studies, spiritual self-care may affect maternal care performance due to the lack of education in mothers prior to and during the care period. Studies emphasizes that in order for the mother to be able to understand the patient’s spirituality and meet her spiritual needs, it is necessary to determine and expand the mothers’ self-care knowledge [5, 6]. In this regard, this study aimed to determine the effect of spiritual self-care education on the care burden of mothers of children hospitalized in Intensive Care Units (ICUs) for open heart surgery 
2. Materials and Methods
This quasi-experimental study was performed on 60 mothers of children hospitalized in ICUs for open heart surgery in a hospital affiliated to Shahid Beheshti University of Medical Sciences. After explaining the study method and obtaining informed consent from all of them, they were asked to complete a demographic form and Zarit Burden Interview (ZBI). In the next step, the spiritual self-care education was presented through slide show, movie, and booklet for two weeks, four sessions each for 45 minutes. The sessions were held in the presence of the mothers and with the title of “helping yourself and the child with self-care education”. After one month, the questionnaires were completed again by the mothers and the information was collected. They were analyzed in SPSS V. 24 software using descriptive (frequency, percentage) and inferential (paired t-test) statistics at a significance level of P<0.05.
3. Results
The majority of participants (40%) had age between 36-45 years; 93% were married; 44.2% were employed; 41% had a high school diploma; 73.8% had monthly income between 1-2 million Tomans; 60.2% were living in their own house; 67.2% had 2-3 children and 47.2% had 3 children; and 100% had no history of childcare in cardiac ICUs. Before the intervention, 24.5% of mothers had very severe, 72.3% severe, and 3.2% had moderate care burden. After the intervention, this rate changed and only 32.5% had a severe care burden and 57.7% had a moderate care burden (Table 1). The Mean±SD of mothers’ care burden score before and after educational intervention were 62.3±7.6 and 42.1±3.8, respectively which indicates a significant decrease after the intervention. The results of the t-test showed a statistically significant difference between the mean pretest and posttest scores of care burden (P<0.001) (Table 2).

4. Discussion
The results showed that 72.3% of mothers had a severe care burden before the intervention (62.3±7.6). Khalifehzadeh et al. [7] in a study reported a moderate level of maternal care burden before the intervention (55.5±10.4), which was lower and better than the mean value reported in our study. Haghgoo et al. [8] also reported the moderate burden on family caregivers of patients with mental disorders. The reasons for the high level of care burden in the present study can be the low literacy, occupation (worker), and lack of caring for children with heart problems in the majority of the study samples and most importantly, a mother cannot adapt quickly to the birth of a child with congenital heart disease. Being in such a situation creates a heavy care burden in a mother. 
Spore [9] examined care burden of mothers in two control and intervention groups. His results showed that the mother cannot spend enough time with the family due to the high care needs of her sick child, which causes a high care burden. In his study, the average maternal care burden was between 35 and 45. This discrepancy can be due to the appropriate approaches to welfare and social services in the developed countries where both the government and the family members free the mothers from other tasks and responsibilities to take care of the child with all her power and time. 
Heydari et al. [10] in studying the effect of family-centered care on the burden of family caregivers in patients with epilepsy showed that the mean of care burden in the caregivers before the intervention was 37.24±13.5, which is in the moderate level and is not consistent with our result. It can be due to the type of disease. Epilepsy is a chronic and transient disease and mothers are often the primary caregivers of these patients at home; the risk of dying in epileptic patients is lower than in patients with congenital heart disease. Talebi et al. [11] in examining the effect of mindfulness-based education on the care burden and psychological capital of the parents of children with attention deficit hyperactivity disorder reported their severe care burden (93.46±61.15) before the intervention which is in agreement with our result.
After determining the amount of care burden and in order to improve its condition, educational intervention was performed for spiritual self-care. After the intervention, their burden was reduced from 62.3±7.6 to 42.1±3.8, and most of mothers (57.7%) showed a moderate care burden. Consistent with this result, Amakali et al. [12] in a study on 65 rural parents of children with heart diseases in Namibia who received the empowerment strategies for dealing with feelings of inability to care during 6 sessions showed that the ability to manage problems enables parents to provide quality care and facilitate optimal performance for children. Our result is also consistent with the results of Khalifehzadeh et al. [7] who showed that the amount of care burden after training was significantly reduced.
5. Conclusion
Spiritual self-care education can reduce the care burden of mothers with children hospitalized in ICUs for open heart surgery. It can prepare mothers for the role of caregiver and proper management of the care process.
Ethical Considerations
Compliance with ethical guidelines
This article ethically approved by the ethics Committee (Code: IR.IAU.TMU.REC.1397.082).
Funding
This article has extracted from the Master thesis of the first author, Department of Nursing, School of Nursing and Midwifery, Tehran Medical Branch, Islamic Azad University.
Authors' contributions
All authors contributed equally in preparing this paper.
Conflicts of interest
The authors declare no conflict of interest
Acknowledgements
The authors would like to thank staffs and administration of Islamic Azad University for their cooperation and providing data for conducting this research.