“Family support for the older person”: Assessing the perception of the older person as care recipient through the implementation of the cordial older family nursing model

Abstract

Objective

To establish the perception of the older person as care recipients through the Cordial Older Family Nursing Model.

Method

This study used a qualitative phenomenological approach and in-depth interviews. A total of 18 participants between 65 and 85 years old from the work area of the Community Health Center in Harjamukti, Depok.

Results

The finding of this study highlighted five focal themes: (1) the various types of complaints made by the older person, (2) their ability to conduct daily activities, (3) the family support provided to them, (4) the grandchildren and in-laws who are being treated like the older person's own children, and (5) the expectations of old age among the older person.

Conclusions

Family support for the older person is proven to be a dominant theme among the participants. The evidence indicates older people acknowledge the positive impacts of the Cordial Older Family Nursing Model.

Introduction

The development of science and technology as well as the improvement in socio-economic status is correlated with the improvement in community health status, which increases life expectancy. This increase contributes to the rise in the number of the older person. World Health Organization (WHO) data from 2018 showed that approximately 1 million people reach the age of 60 each year all around the world, of whom 80% live in developing countries. The United Nations (UN) estimates that the number of older persons aged over 60 years will double from 600 million to 1.2 billion by 2025, then to 2 billion by 2050.¹

As a country, which has experienced an improvement in the life expectancy of its citizens, Indonesia has also seen significant growth in the number of older persons. The results of the 2010 population census projections predict that the percentage of Indonesian older person in 2035 will have reached 15% of the total population of the country.² The increasing number of older people is an early sign of a shift in population structure in the world, and in Indonesia, this will create its challenges.

‘Older person’ has been defined as the chronological age at which someone has finally reached full maturity in terms of size and function but is also showing signs of deterioration in several aspects, such as physically, psychologically, psychosocially and spiritually, which in itself raises health problems.³ Such problems experienced by the elderly affect their level of independence in carrying out daily activities. Kingston et al. (2017) state that there is a significant increase in the dependence of older people aged over 65. While male dependence on total care lasts for 2–4 years, the female older person only demands 1–3 years of care support. The majority of older person living in the community.⁴ Those with a high level of dependence need family help to meet their daily needs. The family, as the closest resource to the older people, is expected to facilitate and support them in their development phase, to maintain their health and well-being.⁵ In reality, however, not all older people receive family attention and support in meeting their daily needs.

The high level of dependency of the older person that is not provided by the willingness of the family triggers mistreatment, which is interpreted as intentional action resulting in danger or leading to the risk of serious harm directed at the older person, and the failure of caregivers to meet their basic needs.⁶ There are several types of mistreatment, namely: (1) physical activity that causes pain or injury; (2) acts that trigger emotional distress or psychosocial danger; (3) sexual violence; (4) financial exploitation; and (5) neglect.⁶

McDonald (2018) states that annually 8.2% (8,275,670) of older person in Canada experience mistreatment, of which 2.2% is in the form of physical abuse; 2.2% who experience physical torture; 1.6% who are sexually abused; 2.7% who are tortured emotionally; 2.6% who face financial exploitation; and 1.2% who report the occurrence of neglect.⁷ About 12% of 118 older people in Japan reported having been hit by caregivers who were also their relatives,⁸ and nearly 54% reported having experienced at least one type of psychological abuse. The most common issue with psychological abuse is that older people is treated as if they are forgetful.⁸ Friedman et al.⁹ highlighted some factors related to the occurrence of mistreatment in the older person, which are sociodemographic factors, family and social factors, physical health, mental health, and disability. Thus, an increased level of dependency of the older person is associated with an increase in cases of mistreatment experienced by them.

Investigations of mistreatment cases in Indonesia is still limited. Rekawati et al.¹⁰ (2007) conducted a trial of a model to detect abuse of the older person, which resulted in three assessment instrument formats, include (1) a health assessment instrument reviewed by health workers, (2) an interview instrument for the older person, and (3) an interview instrument for families. Research conducted by Rekawati (2014)¹¹ shows that nearly half of 135 older people (49.6%) in Cimanggis, Depok, West Java had experienced mistreatment. Among this 49.6%, 24.4% reported that they had received physical abuse, 45.2% financial exploitation, 74.8% psychological abuse, and 43.7% reported the occurrence of neglect. Psychological mistreatment was the type of mistreatment that occurred the most, which necessitates special caregiving based on family approaches.

The Cordial Older Family Nursing Model is one of the family-based interventions, which was developed by Rekawati (2014). The model considers the urgency of family support and family coping strategies, as well a reduction in the level of burden felt by the family when providing care support for the older person, so that their health status can be improved. The intervention requires three activities to be properly executed to work, include the provision of information through training, suggestions, and counseling to families who are eager to provide support for the older person. The findings confirm the differences before and after the implementation of The Cordial Older Family Nursing Model were associated with mistreatment.

The model that has been developed requires evaluation steps to monitor its sustainability and success rate. Therefore, we are interested in examining the success rate of the model by exploring the perceptions of the older person who received care support using the model. The study aims to explore perceptions of the older person as the care recipients from families who apply The Cordial Older Family Nursing Model.

Method

The study used a qualitative phenomenological approach to explore the experiences and to understand the meaning of the perceptions of the older person as the care recipients from families who employ The Cordial Older Family Nursing Model.^12,13 The study explored the experience of older people who received The Cordial Older Family Nursing Model of care from their family. We used several qualitative approaches for data collection, namely interview guidelines, voice recorders, and notes. The in-depth interview method was chosen for the data collection since we seek to explore the experience of families who implement The Cordial Older Family Nursing Model. A voice recorder was used to record the interview of each participant, which lasted for about 15–25 min.

This study involved 18 participants, consisting of 13 women and five men in the age range of 65–85 years. The selection of the participants was made using the purposive sampling technique. The sampling criteria were as follows: (1) they were able to speak Bahasa (Indonesian language), (2) they were willing to be a participant, and (3) they were older people who live with their family who implemented The Cordial Older Family Nursing Model. The study used the Colaizzi method to analyze the data. This method consists of seven stages of analysis, include (1) preparation and re-reading of interview transcripts, (2) preparation of meaningful statements, (3) formulation of the meaning of formulations, (4) determination and preparation of categories, sub-themes, and themes, (5) in-depth description of the research result themes, (6) description of important structures of the phenomenon, and (7) validation of the research findings.^12,14 The research passed the ethical review of the Faculty of Nursing, University of Indonesia.

Results

The finding of the study highlighted five focal themes, which are (1) various types of complaints by the older person, (2) the ability of the older person to conduct daily activities, (3) family support for the older person, (4) grandchildren and in-laws who are treated like the older person's children, and (5) the expectations of old age among the older person.

Various types of complaints by the older person

The theme “various types of complaints by the older person” is depicted as the number of grievances reported by them; both physical and psychological issues were reported, which occurred due to the degenerative process. The physical problems faced by the older person were digestive, respiratory, integumentary and musculoskeletal, and issues with circadian rhythm and cardiovascular systems. One description of a physical complaint was drawn from a statement made by the eighth participant:

“…Well, that is what happens when you are old. Any problem might arise such as physical or other aspects. She is already 75 years old…” (P8)

Meanwhile, the psychosocial complaints identified in this study were fear, indifference to the diet, and feelings of sadness. The complaint is reflected by the third participant, who described his fear of travel due to his old age:

“I am not going anywhere… just stay at home… I am not even going to my sibling's house… grandma is old now…” (P3)

The ability of the older person to conduct daily activities

This theme was found in the majority of participants’ statements in the interviews. The older person was still able to perform their daily activities inside or outside the house, despite the complaints reported. Some of the participants were still able to do light housework, fulfill their needs independently, take care of other family members and carry out activities that they like in the house. The eighteenth participant described the activities he likes to do in the house:

“Yes, she loves to plant flowers…” (P18)

Furthermore, the older person was also able to productively generate their income, participate in religious activities and exercise outside the house. Those activities are reflected in the statement of one participant, who still wanted to work, even if the family prohibited it:

“… Yes, my father wants to do everything by himself; even though his son already told him to stop and rest, he would not listen. He does not like to rest and doing nothing. He said that it is better to be productive…” (P2)

Family support for the older person

The theme “family support for the older person” is illustrated as the perceptions of the older person regarding the support given by their families. The older person felt that they had enough family support in fulfilling their daily needs (instrumental), which is reflected in a statement made by the third participant:

“…Yes… all of them take part in providing care support for me… she (the daughter-in-law) cooks for me, washes my clothes… she does all of it…” (P3)

Families are also felt to support the older person in terms of health and treatment information (informational), which is reflected by the fifteenth participant:

“..My wife…my wife knows my routine, and she understands my schedule, when I should get to the doctor when I should register… she helps me a lot…” (P15)

The older person also acknowledged the financial support received from their families. They were provided money by their sons-in-law for everyday shopping and also given money by their grandchildren who worked. Financial support from the family is reflected in a statement made by the first participant:

“…My grandchild, yes, she is like that to me.. she has got a job now, thank god… when she has some money, she always gives part of it to me…” (P1)

The older person also appreciated the emotional support given by the family. The older they became, the more support they received, including advice from the eldest children to stay away from stressful situations, the sense of security created by the family for them, the recreation opportunities provided, the sense of love and affection, fun routine activities, and support in carrying out religious spiritual activities. The seventh participant reflected this emotional support:

“…ummm if I get angry, my child will give me some advice to not be mad; she will say “no need to be angry, mom, don’t overthink, no need to, use your money to buy anything you want to eat… don’t think too much”…” (P7)

Grandchildren and in-laws who are treated like the older person's children

The theme “grandchildren and in-laws who are treated like the older person's children” depicts the emotions and perception of the older person, who considers their grandchildren and in-law as their children. One older person woman felt that her daughter-in-law loved her a great deal, which is reflected in the following statement:

“…Especially my daughter-in-law who is sat behind me right now, she said to me “my mother-in-law is my heaven”…” (P10)

The older person also felt a strong spiritual bond with their grandchildren. The bond is reflected in a statement from the fourteenth participant:

“…Yes, sometimes I miss them… because I have been with them since they were little, the connection and bond never end…” (P14)

The closeness and affection that the older person felt from their grandchildren and sons- and daughters-in-law created the same feelings as if they were their children. The third participant reinforced this theme:

“…Yes, my grandchild is like my child.. my daughter-in-law is like my child as well… I do not see her as my daughter-in-law, but rather as my child…” (P3)

Expectations of old age among the older person

The theme “expectations of old age among the older person” demonstrates their hopes for their family and themselves. The older person wanted their families to be successful and to be pleased to take care of them when they no longer able to conduct daily activities. She also wanted her family to obey worship and to always get along with each other. The hope of the elderly for her family is reflected in a statement made by the first participant:

“…Yes, I hope my grandchild will finish school and achieve success.. and share some of her fortunes with me…that is it… and her father to be able to take care of her education…”(P1)

The older person also hoped for longevity, to not cause any trouble to their family, and still to be able to help other family members. The fifteenth participant illustrated this:

“…That is a wish… I hope all of us can support each other, to not be troublesome… that is what I fear the most.. for instance if I have a stroke, it is very dangerous…” (P15)

Discussion

Various types of complaints by the older person

According to Miller (2012), the aging process experienced by the older person causes a functional decline in their bodies. Aging negatively affects the older person's hearing, vision and digestion; their urinary, cardiovascular and respiratory functions; and their mobility and safety, integumentation, thermoregulation, sleep and rest, and sexuality.³ This finding is in line with the physical complaints felt by the participants regarding their digestive, respiratory, integumentary, musculoskeletal, sleep and cardiovascular systems. Moreover, the older person also experiences psychosocial changes,³ one related problem being fear of falling. Lavedán et al. (2018)¹⁵ maintain that this fear causes the occurrence of several falling incidents in the older person. The feeling was also experienced by the research participants, who described their fear of traveling due to their age.

The ability of the older person to conduct daily activities

The older person participants in this study were still able to conduct some regular activities inside and outside the home, despite the physical or psychosocial complaints they suffered from. It is suggested that by performing daily activities alone, the older person reduce some of the signs and symptoms of aging, hence preventing the risk of chronic diseases.^16,17 Furthermore, this has been linked to an improvement in their quality of life.¹⁷ One of the physical activities carried out by the participants at home was gardening. Home gardening can improve their satisfaction in living life and reduce the risk of depression.¹⁸ On the other hand, the older person also carries out activities outside the home, such as generating their income, participating in religious activities, and exercising, which positively affected their health status. The older person who is active in physical, social and religious activities have a lower risk of the incidence of depression.¹⁹ Thus, activities carried out by the participants both inside and outside the home had positive impacts on their health, especially preventing the risk of depression.

Family support for the older person

Older person people who live with their family have a better quality of life than those who live in nursing homes.²⁰ Family support is of crucial importance for the elderly when facing their developmental stages, to improve their health and well-being.⁵ This study has uncovered several forms of support provided by families, namely instrumental, informational, financial and emotional. These results are in line with research conducted in rural areas of China, which found that family support had a positive effect on the health status of the older person, as is indicated by lower levels of mortality and incidences of cardiovascular disease, self-help and the ability to fulfill older person ADL independently.²¹ Financial support from the family is associated with decreased signs and symptoms of depression in the older person.²² Besides, emotional support also has a positive impact on the older person with heavy dependence, especially in terms of trust.²³ Emotional support from the family can also help the elderly to reduce the risk of loneliness.¹⁹ Furthermore, it was discovered in this study that family support had an impact on the health of the older person and their ability to engage in activities. Instrumental, informational, financial and emotional support has successfully engendered enthusiasm so that the older person can engage in activities despite the physical and psychosocial issues experienced.

Grandchildren and in-laws who are treated like the older person's children

Grandchildren and in-laws are members of the older person's family who play the role of caregivers at home. We found in the study that the older person regarded their grandchildren and in-laws as their children due to the support they received. These results are in line with research conducted in rural areas of China, which found a good bond between the older person and grandchildren of the first child, as indicated by instrumental, financial and emotional support.²⁴ The experience of grandchildren as caregivers of the older person is described as a satisfying and rewarding process. The grandchildren believe that they have provided their best support for the older person.²⁵ Besides, close ties between the older person and grandchildren occur because previously it was the older person who took care of their grandchildren. It was evident from a study that older person people who were once the caregivers of their grandchildren tended to have a better level of psychological well-being.²⁶

It was evident from this study that the relationship between the older person and their in-laws was well established. One older person woman even considered the daughter-in-law who lived with her as her child. The finding of this study is different from previous research, which states that the older person and their daughters-in-law are often involved in conflicts, which means the old people are more comfortable living with their daughters or sons-in-law.²⁷ However, the results of other studies show that the older person relies more on their daughters and daughters-in-law than their sons or sons-in-law for their care.²⁸ The close relationship between the older person and their grandchildren and in-laws takes place because of the support given to each other, which creates a sense of belonging and love.

The expectation of old age among the older person

This research also raises themes related to the older person's expectations in their old age. Hope is directed at the family and himself. Hope is negatively correlated with the incidence of stress in the older person, which means that the better the expectations, the lower the level of stress felt by them.²⁹ Therapy that optimizes the hope of the older person is also used in the psychological management of those who experience depression.³⁰ Positive expectations held by the older person about their families and themselves arise because of the good treatment received from the family.

Conclusion

“Family support for the older person” and “grandchildren and in-laws who are treated like the older person's children” are the two main themes which depict the most dominant perception expressed by all the research participants. The family caregivers in the study were those who implemented The Cordial Older Family Nursing Model. The focal themes arising from the study serve as signals that the older person sensed the positive impact of the model.

The research findings enable family caregivers to develop more comprehensive family-based interventions, which can optimize the health and well-being of the older person in the family. Future studies could further explore the perceptions of the older person, families and health personnel related to The Cordial Older Family Nursing Model so that these can later be developed into a broader range of interventions.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgement

This work is supported by Centre for Ageing Studies (CAS) Universitas Indonesia.