Perceptions of family caregivers on the implementation of the cordial older family nursing model: A qualitative study

Abstract

Objectives

This study aims to understand the perceptions of family members as caregivers on the implementation of the cordial older family nursing model.

Method

This study used a qualitative phenomenological study with an in-depth interview. A total of 18 Participants were selected using a purposive sampling technique. The data from the participants was acquired through semi-structured interviews. Subsequently, the data were analyzed using the Colaizzi method. This study has obtained approval from the research ethics committee.

Results

This study highlighted five focal themes, include (1) expressed emotions among caregivers, (2) caregivers of the older persons, (3) the impact of the cordial older family nursing model, (4) caregivers’ expression of gratitude toward the older persons, and (5) barriers to providing nursing through the cordial older family nursing model.

Conclusion

Family caregivers have some issues concerning how to provide care to older persons in wide-ranging activities. Post implementation of the cordial older family nursing model revealed that family caregivers showed positive values and attitudes such as emotional expression, types and means of care, and appreciation of the older persons.

Introduction

The development and improvement in the health sector have precipitated an increase in the life expectancy of people in various parts of the world, including Indonesia. A report by the United Nations states that the number of older persons in developing countries has reached 1.6 billion people.¹ Furthermore, a 2015 United Nations report states that the average projection of life expectancy of Indonesian citizens in the years 2020–2025 will reach 72.7% in years.¹

A report by the Central Bureau of Statistics shows an 8.97% increase in the number of older persons in Indonesia over the last five decades.² The increasing population has consequently triggered problems, such as the economic costs of aging populations, which is reflected in the high older person dependency rate. A report from the Ministry of Health's Data and Information Center reveals that the average older person dependency rate in Indonesia is 57.65%, which is a staggering proportion.³ Several major studies have reported that geriatric caregivers possess a high risk of being negatively affected physically, psychologically, socially, and financially.⁴ Based on these findings, can be interpreted that the increase in the number of the older person, coupled with the high older person dependency rate, causes an increase in the risk of family caregivers to the older person being mistreated.

The degradation of older persons’ physiological wellbeing is highly correlated with the changes that transpire concerning older persons and their families. Playing the role of main supporters, and as the closest group to an older person, it is expected that family members can facilitate the older persons to execute their development tasks.⁵ Changes that occur in older persons cause problems in the family. A study conducted by Oliver et al. found that 86% of caregivers experienced an increase in emotional expression indicated by anger, anxiety, a feeling of being underappreciated, sadness, hopelessness, and regretting being geriatric caregivers.⁶ The necessity for family members to undertake multiple roles-has caused an increase in the tension experienced when accepting and caring for older persons. In the words of Friedman, Bowden, & Jones, the tension experienced by family is a difficulty that comes with carrying out the role of caring for the basic needs of the older persons.

Psychological problems in the family often come as a consequence of health problems faced by older persons. Some studies have revealed that a severe disease of older persons results in an increased burden of their caregiver.^7–10 The cognitive changes resulting from chronic diseases of older person members of a family can take a toll on family life and satisfaction.¹¹ Such conditions trigger the occurrence of mistreatment of family members, which might cause a rise in tension and the feeling that taking care of the older person is a burden. In his study, AH elaborates that uncertain conditions resulting from increasingly severe illness can place pressure on family members, so that decision making and daily activities become disturbed.¹²

Families who are fully committed to geriatric care revealed a different concerning the coping strategies. The family caregivers who are most confident and positive are the most likely to employ coping strategies.¹³ Congruently, a study by Cruz et al. concludes positive aspects such as the sense of satisfaction felt by family members who provide care and support to their older persons.⁸

One study shows that a coping strategy undertaken by caregivers involves positive thinking and continuously learning about the problems they encounter.⁶ Engaging in discussion with family and friends about the problems faced is among the effective strategies for family acceptance of geriatric care.¹⁴ Hence, it can be interpreted that the existence of mutual support and the establishment of good communication will have a positive impact on the psychological condition of caregivers and older persons.

The support provided by the family will significantly improve the health condition of their older person family members. The Family Carer'sTraining Program (FCTP), a nursing model developed by Sahar, has shown that a family's ability to provide care and support is positively correlated with an improvement in the older person's health status. This evidence backs up the notion that the family's ability to act as caregivers can improve the quality of life of the older person. One form of intervention in this matter is the cordial older family nursing models.¹³ This intervention strategy is proven to be effective in increasing informational and family instrumental support, improving family coping strategies, and increasing the family's ability to avoid mistreatment.¹³ This study aims to explain the perceptions of family members acting as a caregiver on the implementation of the cordial older family-nursing model.

Method

Design

This research is a qualitative study that used a phenomenological approach and an in-depth interview. This approach is used to investigate the experiences and perceptions of caregivers on providing care and support to the older persons after the implementation of the cordial older family nursing model. The phenomenological approach may help the study to further elaborate and clarify the participants’ experiences, which will improve the richness of the research topic.¹⁵

Participants

The research participants were selected using a purposive sampling technique. After careful selection, 18 participants were considered eligible to serve as the research subjects in the intervention of the cordial older family nursing model in 2014 in Depok, Indonesia. It is important to note that the number of participants selected was determined by taking data saturation into account.

Data collection

The data from the participants was obtained through semi-structured interviews. Open-ended questions were used to explore family experiences and perceptions of providing care using geriatric family nursing models (Table 1). Participants were interviewed individually; each interview lasted around 15–25 min and was recorded digitally. Data collection was stopped when data saturation was reached.

Table 1.

Question script.

Please explain to me, how do you find the experience of being the caregiver of an older person?

Please explain to me the complaints expressed by the older person because of your service?

How do you take those complaints?

Please explain to me, how do you provide care to the older person?

Have you experienced any differences after employing the cordial older family nursing model?

Please explain to me about the difficulties faced by caregivers of older persons?

Do the family feel burdened?

Data analysis

This study employed the Colaizzi method to analyze the research data collected. The Colaizzi method describes the fundamental structure of the participants’ statements.¹⁶ In the first phase, each interview was recorded digitally using an audio recorder. Each participant's verbatim statement was read repeatedly to understand the meaning. When the meaning was established, the data were sorted into categories and hence derived into several main themes. The key statements acquired were integrated into the full description of the research phenomenon.

Ethical aspects

This study has obtained approval from the research ethics committee. The participants were provided with a clear explanation of the research. Subsequently, the participants signed the participant consent form. The researcher valued the privacy of the participants’ information highly.

Results

Table 2 outlines the demographic variables of the research participants. Participants were caregivers who had previously been trained in the cordial older family nursing model through lectures, discussions, role play, and real practices. A total of 18 participants were selected. The results of this study showed that most caregivers were females (77.8%) around 33.6 years old, were housewives (72.2%), were biological children of the older people (50.0%), and have provided caregiving support for more than one year (94.4%).

Table 2.

Characteristics of caregivers (n = 18).

Characteristics	n (%)Caregivers
Gender
Male	4 (22.2)
Female	14 (77.8)
Age, mean (SD)	33.6 years
Relationship with the older person
Partner	3 (16.7)
Biological children	9 (50.0)
Adopted children	2 (11.1)
Son/daughter-in-law	3 (16.7)
Other	1 (5.6)
Provide caregiver support
<1 year	1 (5.6)
>1 year	17 (94.4)
Profession
Entrepreneur	2 (11.1)
Private employee	2 (11.1)
Housewife	13 (72.2)
Other	1 (5.6)

By employing the open coding method to analyze the data, 111 meaningful statements, 69 subcategories and 16 categories were identified. Table 3 reveals the results of the data analysis of the perceptions of the caregivers after the implementation of the cordial older family nursing model. The five focal themes found were (1) expressed emotions among caregivers, (2) caregivers of the older persons, (3) the impact of the cordial older family nursing model, (4) caregivers’ expression of gratitude toward the older persons, and (5) barriers to providing nursing through the cordial older family nursing model.

Table 3.

Results of data analysis of caregivers’ perceptions after the implementation of the cordial older family-nursing model (n = 18).

Theme	Category	Definition	Example
Expressed Emotions Among Caregivers	The response of the caregiver on providing care and support, response of the caregiver when the older person is in a bad mood/emotional, response of the caregiver when the older persons have unhealthy habits.	Feeling or condition of the caregiver regarding the older person's behavior	It's just okay, it's a good feeling to take care of the older persons, but sometimes they can be fussy…
			..if we also become fussy, they will become more emotional, which will make us emotional, so there are these rising tensions between us, the caregiver, and the older persons,
			But we have to let it go since it is hard to prevent them from doing something they want.
Caregivers of older persons	Measures taken by the caregiver when the older person is taken ill, measures taken by the caregiver when the older person has received support from medical personnel (employing the cordial older family nursing model), means taken to provide care and support to the older persons, Daily actions of the caregiver; Support from the caregiver	The process of caregivers in caring for the health and daily needs of the older person	It is just like how you treat a sick person, in which you prevent them from eating unhealthy foods. If she gets sick, I bring her to the doctor. I am afraid if I mistakenly treat her, it will cost an even greater deal….
			She still washes her clothes, sometimes using the laundry machine, she is still able to do daily light activities,
			From my point of view, the older persons are happy when they see their children happy, no clashes or arguments, maybe that is it.
Impact of the cordial older family nursing model	Transformation in the older person's health conditions, Changes in the financial condition of the caregiver, Changes in the caregiver's behavior	The effect of applying the cordial older family nursing model	Very beneficial, because if the food that they want is not being given, I witness less coughing and fresher look on my father.
			Well, now I have never been there because it is very costly.
			The hard part for me is to leave him. I am working, but at the same time, I am constantly thinking about what he is doing at home. Because of that, I decided to quit the office.
Caregivers’ expression of gratitude toward older persons	Meaning of caring, the value of the older persons, the burden of the caregivers	Awareness of caregivers who are obliged to care for older person family members	It is an honor to be able to take care of our parents. I believe that it is our obligation as their children to take care of them.
			It is not that I feel burdened by it, because it is them who took care of us when we were still children. What we should do is to give them retirement so that they do not have to work for a living. It is we who should be supporting them financially.
Barriers in providing nursing through the cordial older family-nursing model.	The difficulty of being a caregiver; Influential factors	Conditions that hinder the caregivers in carrying out the cordial older family nursing model	That is the only difficulty sometimes when they are ill, they want to get better…
			It is tiring; to be honest, I am tired.

Expressed emotions among caregivers

This theme is defined as the response of the caregiver to the behavior of the older persons. Various emotions are exhibited by caregivers while caring for older persons such as dealing with older persons when emotional, and responding when older persons violate the treatment plan. Feelings expressed by caregivers in caring for older persons include happiness, confusion, sadness, and the feeling of wanting to provide the best for their relative. An example of an expression of feelings of a wife who cares for her older person partner is as follows:

Because I believe that it is my responsibility as his wife. Therefore, I shall make it my source of happiness. I feel comfortable doing it.

(Participant #15, female, wife)

In contrast to such expressions of acceptance about providing care and support to the older persons, some caregivers were found to be confused and sad. The expression was conveyed by caregivers who are aware of the older person's background. One example of this type of expression is from the niece of an older person:

Well, what am I supposed to do? She is all by herself; she does not have a husband. Therefore, it is inevitable for me to feel pity, it has become my responsibility as her niece because she is completely alone, she does not have any kid, and she has never been married. Since I am her closest relative, I am taking responsibility. I am taking care of her. Although I still feel sad seeing her condition.

(Participant #5, female, niece)

The caregivers expressed various types of emotions when the older person is emotional; these include anger, upset, patience, and understanding. An example of these mixed emotions is as follows:

We must always obey what he said. Sometimes it is upsetting because as a human being, we have our limit. Sometimes I try to be patient and understanding, but still, I feel annoyed by his behavior….

(Participant #11, female, child)

Feelings expressed by caregivers who did not utilize the cordial older family nursing model included anger, and a wish to supervise or give advice. An example of such an expression is as follows:

Yes, I just let her does what she wants to do. Preventing her is hard.

(Participant #13, female, child)

Caregivers of the older person

This theme is defined as the process undergone by caregivers in caring for the health and daily needs of older people. Some of the care and support methods utilized by caregivers after the implementation of the cordial older family nursing model were (1) applying all the advice given, (2) applying only suggestions that are believed to be effective, and (3) using complementary care, and (4) seeking intervention according to peer experience. One example of the care and support provided by caregivers is as follows:

If I am not mistaken.. after she faced the illness, we have never allowed her to drink tea again. She is now following the doctor's instruction to drink mineral water and avoid sweets.

(Participant #6, female, adopted child)

Besides, some forms of treatment performed by caregivers of the older persons involve monitoring their food consumption, using medical and complementary therapies, conducting routine checks, monitoring drug activity and consumption, giving attention, and allowing the older person to conduct their daily activities. The statement below was acquired from a caregiver who revealed her attempt to prevent her older persons parent from working.

We even once prevented her from selling goods, but we could not provide any financial support, for instance, I could only give physical assistance.

(Participant #4 female, child)

The impact of the cordial older family nursing model

This theme is defined as the influence on caregivers of the application of the cordial older family nursing model. Some of the effects felt by caregivers were changes in the health of the older person and changes in the financial condition and habits of the caregivers. One example of changes felt by caregivers is as follows:

There are some changes indeed, for example now grandma can no longer drink coffee, eat spicy foods. She does not drink coffee any more…

(Participant #1, female, daughter-in-law)

An example of changes in the financial condition faced by the caregiver is as follows:

Well, now we are using the cinnamon because there was a time that she felt itchy and we used the cinnamon as a means to relieve the symptoms. She felt better because of it. It is a great alternative for us as we could not afford medicines from the pharmacy.

(Participant #6, female, adopted child)

An example of changes in the caregiver's behavior after the implementation of the cordial older family nursing model is as follows:

I was previously working in a company during the day, and my shift ends at night. When we left home in the morning, we found out when we came back from work that grandma was urinating there. I had to sacrifice my job and chose to take care of her. My younger sister provides financial support for me since I am unemployed.

(Participant #6, female, adopted child)

Caregivers’ expression of gratitude toward the older person

Appreciation is defined as the caregiver's awareness of his/her responsibility to provide care and support to the older person. An example of this feeling was expressed by a caregiver who looks after his older person parent:

..it is the obligation of us as their child to take care of them

(Participant #13, male, child)

Caregivers who express this feeling of gratitude toward their older person relatives do not feel burdened by their duties, although sometimes they feel tired:

Well, no, I am giving my heartfelt support to her, but sometimes I am annoyed by how she tends to cry when she is sick. I think it slows the healing process.

(Participant #6, female, adopted child)

Barriers to providing nursing through the cordial older family nursing model

Barriers are defined as conditions that prevent caregivers from carrying out the cordial older family-nursing model. Some caregivers do not experience difficulties because their older persons relative can still carry out daily care independently, as shown in the example below.

Nothing, grandma is still energetic, she can still do the things she regularly does, like reciting the Qur’an, walking around the neighborhood.

(Participant #1, female, daughter-in-law)

On the other hand, there are those who face difficulties when their older person relative is ill, as expressed in the following example:

Not at all. The only difficulty I face is when she is ill.

(Participant #7, female, child)

Also, several caregivers admitted that other factors prevented the cordial older family-nursing model from being practical. An example of such an expression is shown below:

Maybe the mother is on the state of boredom with the routine of eating a boiled white egg without any spices or salt.

(Participant #11, female, child)

Discussion

Expressed emotions among caregivers

The implementation of the cordial older family nursing model is expected to be able to improve the ability of caregivers in providing care and support in a patient, calm and polite manner.¹³ The feelings experienced by the caregivers while caring for the older persons were expressed as common feelings such as pleasure, confusion, sadness, and a feeling of wanting to provide the best for their relative. These findings support the results of previous studies.^4,6,17,18 The care provided by caregivers for the older persons was given because of the feeling of love and as an expression of reciprocity.¹⁹ Caregivers who happen to be the spouse, child or daughter-in-law of the older person express their happiness in providing care and support. Moreover, there is a cultural belief which assumes that parents should involve their children in their care and support, and this is proven to improve their health.²⁰

This study also reveals the various feelings expressed by caregivers after the implementation of the cordial older family nursing model. The feelings of the caregivers were expressed emotionally. These findings are following previous research which found that feelings of sadness, confusion, and anger were exhibited when the older persons did not meet the expectations of the caregiver.⁶ Feelings of anxiety, depression, stress, and bad relationships have also been found to occur, due to uncertainty in care.^6,21,22

Caregivers of the older person

Various types of care provided by caregivers were following the trained family nursing care model. Coping strategies in the cordial older family nursing model are in the form of stressor identification procedures, self-relaxation, and physical exercise.¹³ Some caregivers allowed their older person relatives to use herbal treatments.²³ Caregivers also provided medical and herbal treatments simultaneously that were adjusted according to doctor's advice.^24–26 Caregivers maintained that the supervision of drug use is a form of care for older persons. Research conducted by S. Zyoud et al., revealed that older person people who live with family caregivers receive better quality of care than those who live alone.²³ Support by visiting and helping an older person with their needs is also believed by caregivers to help increase energy and overcome stress.^4,6 Caregivers also acknowledged that support from family members could reduce stress during the provision of care and support.²⁷ However, some caregivers admitted that the care training provided was only carried out under their own beliefs. Actions provided by performing maintenance of various information, namely the results of peer experience with the same problem.²⁸

The impact of the cordial older family nursing model

The research findings showed the transformation of the habits and activities of the caregivers after the implementation of the cordial older family nursing model. Some of the changes that occurred were related to behavior in maintaining health. Caregivers and older persons tend to communicate frequently about health with medical personnel.⁶ Besides, the study witnessed changes in the financial conditions of the caregivers after performing various treatments for their older person relatives. This changing because some of the caregivers had to sacrifice their jobs to take care of their older person parents.^29,30 Some studies also show that caregivers ignore their own needs to provide maximum care for older persons.^19,29,31,32 Collectivism is highly valued in some cultures so that caregivers are more concerned with the interests of others than themselves.³³ Collectivist values might explain why it is considered important for a child to care for his/her parents, and for a partner to support his/her spouse. This finding also confirms the results of several previous studies which outline the importance of studying older persons care about understanding how to overcome the problem of self-care.^34–36

Caregivers’ expression of gratitude toward the older people

According to the results of this study, it is evident that the caregivers did not consider taking care of their older person relatives to be a burden. They maintain that it is their responsibility to support their aging parents.³⁷ The way to respect children as caregivers is to maintain the feelings of the older person. This finding is supported by several studies which found that caring for parents is a responsibility, as well as a way to maintain dignity.^37–39

Moreover, some couples have been found to use methods of care that maintain positive interactions. Some studies have explained that maintaining interaction between partners improves the security and daily life of the older persons.^37,40 In this study, the caregivers did not feel burdened during treatment for the older persons, because the older persons were appreciated and recognized as parents.³⁷

Barriers to providing nursing through the cordial older family nursing model

The research findings demonstrate that the caregivers neither face difficulties nor feel burdened by taking care of their older person relatives because most of the older person people can still conduct daily activities without requiring any assistance. This particular finding is similar to the results of previous studies which found that older people who are economically and physically dependent on their family can increase the burden on their family caregivers.^29,40 However, the caregivers in this study acknowledge that they face several challenges when assisting older persons. It was expressed that difficulties arose when older person relatives were ill or became a little emotional. As a result, the caregivers became exhausted when providing care and support.⁴¹ The present research findings enable nurses and other medical personnel to understand family caregivers of older persons better. The perceptions expressed by family members relating to taking care of older persons are a useful source of information for medical personnel about the benefits of the implementation of the cordial older family nursing model.

Conclusion

This study investigates the perception of caregivers after the implementation of the cordial older family nursing model. Family caregivers have numerous options concerning how to provide care to older persons in wide-ranging activities. Post implementation of the cordial older family nursing model revealed that family caregivers showed positive values and attitudes such as emotional expression, types and means of care, and appreciation of the older persons. There is a need for further studies on the perception, after the implementation of the cordial older family nursing model, of caregivers who look after older people with the same health issue.

Conflict of interests

The authors declare no conflict of interest.