Electronic ISSN 2287-0237
Thailand is a country that enjoys a stable fertility rate. Moreover, advanced technology in medicine has led to improved human longevity. The number of elderly people in Thailand has continued to rise therefore, from 7.2 million in 2010 and is estimated to reach 11 million by 2020.2,3 The growth rate of the older population in Thailand is predicted to be high, at a rate of increase of more than 3% each year. With the increasing rate of the number of elderly people in Thailand of around 3-3.6% per year, the total number of elderly people will double within the next 17 to 23 years. Thailand is going to be an elderly society within the next 10 years. Overall, only 15% of persons aged 60 and above admitted that they needed some assistance with their daily living activities.2,3 Therefore, informal caregivers currently take on important roles to care for the elderly. In the giving of care, caregivers reported problems in physical, psychological or emotional and financial overload, affecting the quality of care for elderly people.4 The issue of the burden experienced by caregivers is not new and most of caregivers need to manage their emotions for an effective outcome of caring.5,6 Most caregivers are relatives who care for elderly parents or someone who cares for elderly people.7 As a result, caregivers are prepared themselves for caring, which means they were aware of the physical, psychological and environmental factors that they were facing.
The management of the emotions of caregivers is a major issue that health staff should be concerned with. If caregivers could manage their emotions effectively, this would be an important step to help develop a more positive outcome in caring. The risk indicators specified here, such as limited resources, giving care to a close loved one, and giving emotional support, could help to prevent informal caregivers from a heightened risk of emotional disorders. Therefore, the study of emotional management of caregivers working with the elderly is important. Whittemore and Knafl’s 20051 technical procedure was developed for the five steps of this methodology as the main conceptual design for the integrative reviews. At this stage of the approach our research questions followed the five stages1 which included: 1) How did we select the problem of the study?; 2) How was a literature search performed to select empirical data?; 3) What could we do to select evaluated data?; 4) How did the findings perform?; and 5) What were findings and limitations of the study?
This study is important as that there has not been many integrative reviews of the management of emotions for informal caregivers providing home care for the elderly. This article has been written to promote the quality of care in elderly people and to support the emotional management of caregivers who care for the elderly.
The review methodology followed the five stages set out by Whittemore and Knafl1: problem identification, literature search, data evaluation, data analysis and findings or presentation.
What was the purpose of this study?
How to manage emotional problems of caregivers for dependent elderly people.
Aim
The purpose of this study was to use an integrative review to explore and define the management of emotions of informal caregivers who care for elderly people. This study supports the delivery of a higher quality of care for the elderly who live at home. The results would help us to manage plans for future intervention studies and to develop action plans to support informal caregivers to meet their basic needs.
Strategies to enhance rigor in integrative reviews
Cooper8 calls on the researcher to meet the standard set by a methodology with rigor. There were several good documents to study and Cooper8 recommends in this case conducting a research review. This process consists of stages to formulate the problem, search strategy, data evaluation, data analysis and presentation of the findings. These processes may support the author to benefit from reviewing multiple sources. Nevertheless, Cooper’s framework8 was originally designed for a systematic review or meta-analysis method. In terms of an integrative review, this method was a challenge in combining diverse data sources and dividing it into inclusion and exclusion criteria. Therefore, this framework would be presented specifically to contribute to an integrative review. An integrative review was therefore chosen with an integration concept with samples provided of all the processes applied and presented by Whittemore and Knafl.9
Literature search
The literature search was conducted in May 2017 using CINAHL, PubMed, PsycINFO, SienceDirect, and manuals to recheck the references of retrieved articles. The literature search used combinations of the following key terms: “caregiver AND emotion AND aging” and “caregiver AND emotion AND aging AND qualitative.” Finally, there were five articles that met all the criteria for the article study questions.
Data abstraction/data evaluation
The empirical report included several types of method in qualitative design: grounded theory, case study, phenomenology, and qualitative approach. According to the data evaluation of Whittemore and Knafl1, they described the evaluation in overall terms of quality. We chose from 138 articles, and selected the exclusion criteria as: not in English, no full text, no qualitative approach, published for at least 10 years, irrelevant, considered a duplicate and/or representative of primary sources. Finally, we identified 5 articles to meet the criteria and that answered the questions of this study.
Data analysis
For data analysis, the author selected data from primary sources, including 5 articles. Then the author integrated the same themes under the study questions. The questions were characteristics of caregivers who cared for elderly people and the management of emotions of caregivers. The author drew on data synthesis from empirical data and/or evidence for creating new categories or themes. As a qualitative approach, that conversion and extraction data were divided into categories, and contributed to different patterns, themes, variations, and relationships.1 The methodological approach for analysis of the data was applicable with the diverse data that emerged from various methodologies in the integrative reviews. The data reduction, data display, data comparison, conclusion drawing, and verification10 were included in this approach.
Data reduction was the technique to extract coding from primary sources, including all abstracts, focuses, and organization of data and validation. Data display can be managed by graphs, charts, and tables to support the interpreted themes. It can be formed as matrices, graphs, charts, or networks and led to comparison throughout the initial sources. Data comparison was used to identify themes.
Conclusion drawing and verification were the conclusion of the themes that were developed into themes.
Results or findings
Once the findings were identified, the first step was to develop the themes. Next, we looked for similarities and differences between all data from many articles to group the themes. Then, we looked for the conceptual idea that developed core themes. The data analysis included decrement, presentation, comparing, and drawing the summary for the data. After that we got four core themes to further explore emotional management of caregivers with elderly people as follows:
Theme 1 – Atmosphere of caring
This theme referred to the context or atmosphere for caring between caregivers and the elderly people they care for. The atmosphere of caring included caring relationships, feeling at home, and caring environments with respect. This category emerged in all studies.11 If the carers and care recipients had a negative feeling, this may lead to frustration in the relationship. This theme included interpersonal challenges, caring places or feeling at home, and caring environments or rural communities. Most caregivers who wanted to manage emotional health needed to have support from family members, the community and a good working environment. This theme would help caregivers to manage their emotional feeling in terms of the atmosphere and a warm and successful relationship.
P1: “The doing [care] was not the issue as much as the emotional overload.” “If everyone was happy, I’d be happy too.” “It was not that big of a deal. I meant I worked full time before; this was just like working full time in a different way.” “It was about trying to keep people’s sense of self-respect.”
P2: “We were supposed to stay in our own home.”
Theme 2- Coping
Coping was defined in terms of caregivers trying to solve the problems based on their religious belief and social support (friends) to accept everything that happened and spend their leisure time by using the ways that usually help them to cope. This theme emphasized coping which included 12 (Azman) 1) religious coping 2) emotional coping 3) acceptance 4) engagement in leisure activities and 5) traditional healing.
P1: “My neighbors were very good and caring.” “They always came over to my home to give support when I was down.They were always concerned about me.”
P2: “Erm..We needed friends to share our problems.” “I’m an Indian but all of my friends are Malaysian” “They were understanding and always helped or supported me when I was having a problem.”
Theme 3- The Potential to Care
The potential to care was defined in terms of caregivers believing in the process of democratic deliberation and decision-making and focusing on the caregiver’s decision. In other words, caregivers had the opportunity to agree which capabilities were more important to them. This theme composed of 1) capabilities in the context of caregiving employment 2) capability, caregiving, and emotions 3) the capability to care. The potential to care was the most interesting theme.14 If caregivers had more ability in how to care for the elderly, they would feel relief from stress and anxiety. They would have more power to control the worse situation and have more freedom. Caregivers could control and make a decision in all caregiving processes. These choices led to strong emotions and helped caregivers to manage their daily lives. An example of a conversation is shown below:
P1: “Residential care was assessed in terms of the emotional attachment to the care recipient. No matter how plush the latest Rest Home was or how many recreational activities were provided, they would not be able to give the love that family could.”
P2: “I found it a privilege, I found it hell, I found it a time of great sadness and a time when I knew what we had done was the right thing.”
Theme 4 – Understanding
A salient perspective in understanding was defined in terms of comprehending the love and reciprocity between elderly people and informal caregivers. That is, to understand the caregivers’ stressors, mediators, and outcomes. The emotional management also focused on talk therapy between caregivers and elderly parents in their care. This theme was composed of: 1) caregiving as a responsibility and prerogative;15 2) ambiguity surrounding care and worries, 3) kin-keeping with communication technology and; 4) negotiating knowledge and tension in rural care.13 Amin and Ingman15 report that discussing family problems helped in day-to-day life challenges. This method could solve guilt and help to support emotions of caregivers. An example of a conversation is shown below:
P1: “I didn’t know what the solution would be (when parents become unhealthy)?” “My parents lived alone, while my only brother lived in a different city.” “I couldn’t go home and stay with them; neither could they come live with me here.” “You know they could not be here without insurance.”
P2: “Everyone was very open and you could speak to anyone you met on the street without being introduced or anything.”
Strengths and limitations of the study
The strength of our study stemmed from the criteria to select all articles and to include qualitative research. The limitation of this study was that it had a small number of articles and focused only on a qualitative approach. Some studies did not use enough data to support their interpretations and conclusions. Other limitations were the procedures of analysis, synthesis, and drawing the summary which remained poorly executed.
Implications
This literature review provided an updated outline on effective management of emotions in caregivers of the elderly people, and contained no distinctive difference in needs, without regard to the cultural circumstance. This integrative review offered up beneficial information regarding the emotional aspects of caregivers of the elderly. Now policy makers are making moves to focus on the importance of the role played by informal caregivers who provide home care for elderly people. Therefore, the management to control emotions of caregivers remains important in the care of dependent elderly people in need of long-term care. This integrative review finding is important for future research in Thailand such as giving direction to any future study in conducting emotional management support programs to help caregivers taking care of elderly people and to support an effective relationship program for both elderly people and caregivers in terms of their psychological health.
This integrative review focused on surveying and determining the emotions of caregivers who provided home care for the elderly by applying the Whittemore and Knafl’s1,9 method and Cooper’s8 method. This review provided four themes: atmosphere of caring, coping, the potential to care, and understanding. The findings from this review also suggested that healthcare specialists can better support informal caregivers by managing the environment of care, supporting a strategy of coping, supporting their potential to care and supporting the strengths of this form of care. Caregivers need emotional support and need to know how best to manage their own emotions. Even with limited resources, there should be initiatives put in place in the near future to encourage the development of a more effective method for managing emotions of caregivers, and satisfaction in their work. Challenges for the future in the criteria of this research include supporting the emotional dimension of caregivers of the elderly in long-term care and in supporting an effective relationship program for both elderly people and caregivers in terms of their psychological health. Both the elderly and cargivers should receive effective support from community and government agencies to better meet the needs of elderly people in long-term care.
