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Laurice Whack
Background: Family resilience refers to the ability of a family to overcome life transitions, stress, or adversity. Unfortunately, Chinese nurses currently do not have a valid short-form instrument for determining family resilience. This study aimed to translate the Revised Walsh Family Resilience Questionnaire (WFRQ-R) into Chinese and determine its reliability and validity among stroke survivors and stroke family caregivers.
Conclusions: The Chinese version of the WFRQ-R for stroke survivors and stroke family caregivers satisfied psychometric properties and can be used to assess family resilience throughout China.
Family resilience, which is the ability of family members to rebound from life transitions, stress, or adversity, enables family members to cope with a crisis through warmth, support, and cohesion (1). The Walsh Family Resilience (WFR) framework identifies three dimensions for family resilience: family belief system, family organization, and communication/problem-solving processes. Accordingly, a family belief system involves shared meaning-making efforts, a positive outlook, and transcendence and spirituality; family organization involves flexibility, connectedness, and economic and social resources; and communication/problem-solving processes involve clarity, emotional expression, and collaborative problem solving. Such fundamental processes can be expressed through different modalities and measures among families with varied values, resources, and adverse challenges (2). A clinical service framework for healthcare providers has been established from the WFR framework (3).
Family health workers have recently focused on family resilience research, which has resulted in the family being viewed in a more positive light by healthcare professionals (8). The concept of family resilience has been utilized for various populations over recent years, including those with breast cancers, adolescent cancers, youths with sickle cell disease, children with cleft lip, and children with autism spectrum disorder (9-13). The aforementioned studies indicate that support from family and friends, assistance from professional medical and nursing teams, and community services promote resilience of affected families. Families with higher resilience have been found to exhibit good quality of life, effective control over their treatment or rehabilitation options, increased use of available resources, and maintaining of good social connections (14,15).
Recent studies on family resilience among caregivers caring for individuals with chronic conditions have been encouraging (16,17), but there is a need to establish a tool that measures family resilience among Chinese families facing chronic illnesses.
One neurology specialist in stroke, one experienced rehabilitation therapist, and three nursing professors were invited to evaluate the content validity of the scale. Each expert determined the relevance of each item to the corresponding dimension based on a 4-point grading scale (4 points = very relevant, 3 points = strong correlation, 2 points = weak correlation, and 1 point = irrelevant). Scale content validity indices (S-CVIs) for the three subscales were then calculated by summing up the item-level content validity indices (I-CVI) and dividing it by the number of items (24).
Descriptive statistics were used to determine the sample characteristics and item distribution. Exploratory factor analysis was performed through principal component analysis with varimax rotation using IBM SPSS Statistics software (version 23.0). Generally, factors with eigenvalues >1.0 were retained (25), while items with factor loadings >0.4 were used to interpret a particular dimension (26). Confirmatory factor analysis was conducted via the maximum likelihood estimation using Amos Graphics software (version 23.0). The three-factor hypothesis model was similar to the original WFRQ-R. The fitness of the proposed model to the data was evaluated using the χ2/degrees of freedom (df) ratio (recommended criteria 0.90), root mean square error of approximation (RMSEA) (
All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Medical Ethics Committee of the First Affiliated Hospital of Jinzhou Medical University, China (No. 202018). All participants provided informed consent and voluntarily filled out the questionnaires. Participant details were rigorously kept confidential throughout the whole research process.
The family resilience could be influenced by many factors, and the resilience ability greatly affects the caregiver adjustment of stroke patients. The family resilience is also positively related to the continuous support from the relatives and comorbidities (30). Social support and psycho-education could help to build resilience (31). Objective stressors, appraisals, and caregiver resources are related to the quality of life of caregivers (32). The decrease of life quality of the caregiver could aggravate the burden, anxiety and depression of the caregiver (31). The burden comes from many factors, like clinical symptoms, cultural and lifeworld meanings (33). The imbalance between the burden and coping ability of caregivers make the caregiver frustrated (34). The relationship and MCS score are the two main predictors of burden (35). As for the caregivers of COPD patients, half of the patients has comorbidities and is taking medicine. About 75% of the caregivers have sought medical help during the course of a year when their caretakers were in charge (35). On facing the burden, the caregivers could feel fatigue and burnout (36). The heavy care burden increases the risk of vulnerability of the caregivers (37). The resilience is a ability to maintain psychological and physical stability and coping the disruptive event positively (38). The role of caregivers induces psychological problems (39). Reducing the burden and/or increase psychological adaptability could help caregivers stay mentally and physically healthy while facing difficulties in caring for patients with stroke. Positive psychology studies character strength, positive relationship and life purpose (40). It could improve the mental health and promote healthy behaviors. Based on the concept of positive psychology, caregivers need to maintain gratitude, mindfulness practices and active activities to promote life goals. These exercises and activities can enhance self-efficacy, self-control, persistence, immune function, cognitive ability, and neuroplasticity, as well as reduce pain, analgesic use, anxiety, depression, hostility, and stress (41-43).
Exploratory factor analysis of the WFRQ-R-CHI, which included three factors, showed that each item had one high load value on one of the three factors. These three factors were the same as that of the Italian version of WFRQ-R established by Rocchi (20). The WFRQ-R-CHI supported the Walsh family resilience theory and could evaluate the concepts of the Walsh family resilience theory. The results of confirmatory factor analysis showed that the fitness index of the model does not reach the most appropriate standard, but each index is within a reasonable range. It showed that the internal structure of the questionnaire is stable after being tested by stroke survivors and family caregivers.
The psychological distress could be induced by negative coping. Partial mediating effect of positive coping could reduce the psychological distress. The personality, like optimism and hope, could also affect the coping ability. The coping ability could also be promoted by teaching and experience. Social support could also enhance the coping ability (48). Patients with severe chronic diseases, such as stroke-induced disability or mental disorders, and their family members must pace themselves to avoid burnout, rebalance relationships, and establish caregiving cues (49). Further, all family members need to reorganize their needs and resources to survive the crisis and the long-term symptoms that accompany stroke (50).
Nurses may benefit from using the WFRQ-R-CHI to guide their evaluation of family resilience. Using this instrument, nurses may identify specific strengths and necessary resources (51). Family resilience is a dynamic process, given the continuous challenges brought by a chronic disease (52). In addition to chronic diseases, acute diseases, such as COVID-19 infection, are also brought acute threat to the family. The promoted family resilience could be source of healing power of belief and relationship on facing diseases (53).
One limitation of the current study was inclusion of stroke survivors and family caregivers, which did not permit a comparison with the results of the Italian version of the WFRQ-R for families contending with a general chronic disease. Nonetheless, this may be addressed in future studies that consider the role of a specific complication in challenging family resilience skills.
The present study showed that the WFRQ-R-CHI has sufficient psychometric properties for assessing family resilience among Chinese family caregivers and can be a valid tool through which nurses can observe how families manage their resources over time.
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