Correlates of Perceived Social Support in Chinese Adult Child Caregivers of Parent Stroke Survivors.

BACKGROUND: Prevalence of stroke and traditional filial responsibility involve adult children in caregiving to their parent stroke survivors in China. Support resources are insufficient because of the shrinking size of family and the underdeveloped support system. PURPOSE: The aim of this study was to identify the correlates of perceived social support among adult child caregivers of parent stroke survivors in China. METHODS: A cross-sectional correlational design was used in this study. A nonproportional quota sample of 126 adult child caregivers was recruited from Zhejiang Province, China. Data were collected at either the hospital stroke units or the respondents' homes using structured questionnaires of caregiving dyadic demographics and caregiving characteristics, 14-item Activities of Daily Living, 15-item Mutuality Scale, and 12-item Multidimensional Scale of Perceived Social Support. SPSS 17.0 was used for analysis. RESULTS: Caregivers' mutuality, education, full employment or being retired, monthly income, having a co-carer, and having a father as the care receiver were significantly positively associated with caregivers' perceived social support. However, mutuality was not significantly associated with caregivers' perceived social support after the other factors were adjusted. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Adult child caregivers with higher levels of mutuality, education, or monthly income; who are fully employed or are retired; who have a co-carer; or who are caring for a father perceived more social support. Nursing strategies and social policies need to be directed to enhance caregiver mutuality and support caregiving efforts.

The Relationship Between Mutuality and Health-Related Quality of Life in Adult Child Caregivers in China.

The strain inherent in caregiving relationships between adult children and aging parents is a prominent issue in contemporary China due to a combination of demographic and socioeconomic changes. The purpose of this study was to explore how mutuality, a positive quality of caregiving relationships, contributes to the physical health and mental health (health-related quality of life [HRQoL]) of adult child caregivers [ACCs] of parent stroke survivors. A cross-sectional correlational study was conducted on a nonproportional quota sample of 126 ACCs, using questionnaires of demographics, the 15-item Mutuality Scale, and the Second Version of the Standard 12-Item Health Survey (SF-12v2). Higher mutuality was found to be correlated with better caregiver physical health and mental health. However, after adjusting for the covariates, mutuality significantly explained 4.6% of the variance of caregiver physical health (ß = .22, ΔR2 = .046, p < .01) but it did not significantly explain the variance of caregiver mental health. Although multiple factors correlate with Chinese family caregivers' HRQoL, this was the first study exploring the impact of caregiver-care receiver dyadic relationships on caregiver HRQoL in mainland China by using a mutuality scale with SF-12v2. Despite the fact that the Chinese tradition of filial piety can facilitate mutuality, socioeconomic changes and legislation that require adult children to care for aging parents appear to create high stress among family caregivers. Higher levels of mutuality contribute to better physical health in Chinese family caregivers. Therefore, culturally appropriate family nursing strategies and social policies in China could enhance caregiver mutuality and potentially promote their HRQoL, in particular physical health.

The Relationship Between Mutuality, Filial Piety, and Depression in Family Caregivers in China.

PURPOSE: Caregiving to parent stroke survivors in China is increasing and adult child-parent relationships are being challenged. The purpose of this study was to explore whether mutuality and filial piety have a protective role against caregiver depression. DESIGN: A cross-sectional correlational study was conducted with a nonproportional quota sample of 126 caregivers. Surveys were conducted at hospitals or in homes using structured questionnaires: the 15-item Mutuality Scale, the 4-item Filial Attitude Scale, the 9-item Filial Behavior Scale, and the 10-item Center for Epidemiological Studies Depression Scale. RESULTS: Higher mutuality and stronger filial attitudes were significantly associated with less caregiver depression after the covariates were controlled. Mutuality explained 5.5% ( p < .01) and filial attitude explained 4.6% ( p < .01) of the variance in caregiver depression. CONCLUSION: Mutuality and filial attitude may be protective factors against caregiver depression. IMPLICATIONS FOR PRACTICE: Supportive strategies can be implemented to enhance mutuality and filial attitude.

Care-related risk factors for hospital-acquired pressure ulcers in elderly adults with hip fracture.

OBJECTIVES: To identify care-related factors associated with hospital-acquired pressure ulcers (HAPUs). DESIGN: Prospective cohort study. SETTING: Nine hospitals in Baltimore Hip Studies network. PARTICIPANTS: Six hundred fifty-eight individuals aged 65 and older who underwent surgery for hip fracture. MEASUREMENTS: Skin examinations at baseline and on alternating days until hospital discharge. Participants were deemed to have a HAPU if they developed one or more new Stage 2 or higher pressure ulcers (PUs) during the hospital stay. RESULTS: Longer emergency department stays were associated with lower HAPU incidence (>4-6 hours: adjusted incidence rate ratio (aIRR) = 0.68, 95% confidence interval (CI) = 0.48-0.96; >6 hours: aIRR = 0.68, 95% CI = 0.46-0.99, both vs ≤ 4 hours). Participants with 24 hours or longer between admission and surgery had a higher postsurgery HAPU rate than those with less than 24 hours (aIRR = 1.62, 95% CI = 1.24-2.11). Surgery with general anesthesia had a lower postsurgery HAPU rate than surgery with other types of anesthesia (aIRR = 0.66, 95% CI = 0.49-0.88). There was no significant association between HAPU incidence and timing of transport to the hospital, type of transport to the hospital, or surgery duration. CONCLUSION: Most of the factors hypothesized to be associated with higher PU incidence were associated with lower incidence or were not significantly associated, suggesting that HAPU development may not be as sensitive to care-related factors as commonly believed. Rigorous studies of innovative preventive interventions are needed to inform policy and practice.

Clarifying and measuring filial concepts across five cultural groups.

Literature on responsibility of adult children for aging parents reflects lack of conceptual clarity. We examined filial concepts across five cultural groups: African-, Asian-, Euro-, Latino-, and Native Americans. Data were randomly divided for scale development (n = 285) and cross-validation (n = 284). Exploratory factor analysis on 59 items identified three filial concepts: Responsibility, Respect, and Care. Confirmatory factor analysis on a 12-item final scale showed data fit the three-factor model better than a single factor solution despite substantial correlations between the factors (.82, .82 for Care with Responsibility and Respect, and .74 for Responsibility with Respect). The scale can be used in cross-cultural research to test hypotheses that predict associations among filial values, filial caregiving, and caregiver health outcomes.

Development of a caregiver empowerment model to promote positive outcomes.

Family members caring for aging parents experience both negative and positive outcomes from providing care. Theoretical explanations for negative outcomes have been developed. There is need for models that explain and predict positive outcomes. This article describes the evolution of the Caregiver Empowerment Model (CEM) to explain and predict positive outcomes of family caregiving. Although empirical findings support positive outcomes of family caregiving, less attention has been given to theoretical rationale for positive effects. The CEM predicts that, in the presence of filial values and certain background variables, caregiving demands are appraised as challenges instead of stressors. Appraising caregiving demands as a challenge, finding meaning, and using certain types of coping strategies are posited to be associated with growth and well-being. The CEM extends our understanding of the complexity of the caregiving experience, and can serve as a framework to guide in developing and testing theory-based interventions to promote positive outcomes.

A bold adventure in innovation: an international off-campus master's degree program.

In response to the global shortage of nursing faculty, Loma Linda University School of Nursing offered an off-campus master's degree program to prepare nurse educators who would commit to remain in their home countries following graduation. The program was approved by the Western Association of Schools and Colleges to be offered in both English and Spanish. Students and faculty met for 1 month each year for 4 years at one of two international sites: Thailand or Argentina. Forty-five of 49 students completed the program. The cultural diversity in both cohorts enriched classroom discussions, social interaction, and student-faculty conversations. The program was a life-changing experience for all involved and helped to meet the global need for nursing faculty. The faculty reported that it broadened their world view and opened their minds to the potential for innovation to transform nursing education.

Use of pressure-redistributing support surfaces among elderly hip fracture patients across the continuum of care: adherence to pressure ulcer prevention guidelines.

PURPOSE: To estimate the frequency of use of pressure-redistributing support surfaces (PRSS) among hip fracture patients and to determine whether higher pressure ulcer risk is associated with greater PRSS use. DESIGN AND METHODS: Patients (n = 658) aged >or=65 years who had surgery for hip fracture were examined by research nurses at baseline and on alternating days for 21 days. Information on PRSS use and pressure ulcer risk factors was recorded at each assessment visit. Other information was obtained by interview and chart review. RESULTS: A PRSS was observed at 36.4% of the 5,940 study visits. The odds of PRSS use were lower in the rehabilitation setting (adjusted odds ratio [OR] 0.4, 95% confidence interval [CI] 0.3-0.6), in the nursing home (adjusted OR 0.2, 95% CI 0.1-0.3), and during readmission to the acute setting (adjusted OR 0.6, 95% CI 0.4-0.9) than in the initial acute setting. There was wide variation in frequency of PRSS use by admission hospital, even after adjusting for pressure ulcer risk factors. The relationships between PRSS use and pressure ulcer risk factors were not strong. IMPLICATIONS: In this study of hip fracture patients, adherence to guidelines for PRSS use was low and was based more on facility-related factors than on patient risk. There is an urgent need for health care providers to improve strategies for the prevention of pressure ulcers in high-risk patients.

Pressure ulcers in elderly patients with hip fracture across the continuum of care.

OBJECTIVES: To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the postfracture period. DESIGN: Prospective cohort study. SETTING: Nine hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged. PARTICIPANTS: Hip fracture patients aged 65 and older who underwent surgery for hip fracture. MEASUREMENTS: A full-body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed one or more new stage 2 or higher pressure ulcers after hospital admission. RESULTS: In 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). The adjusted APU incidence rate was highest during the initial acute hospital stay (relative risk (RR)=2.2, 95% confidence interval (CI)=1.3-3.7) and during re-admission to the acute hospital (RR=2.2, 95% CI=1.1-4.2). The relative risks in rehabilitation and nursing home settings were 1.4 (95% CI=0.8-2.3) and 1.3 (95% CI=0.8-2.1), respectively. CONCLUSION: Approximately one-third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare's policy of not reimbursing hospitals for the treatment of hospital-APUs. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals.

Validity of pressure ulcer diagnosis using digital photography.

The purpose of this study was to evaluate the validity of digital photographs for the assessment of the presence of pressure ulcers stage 2 or higher. Participants were 48 patients (28 white and 20 black) with pressure ulcers identified in the course of a wound specialist's routine clinical practice at the University of Maryland Medical Center. One pressure ulcer and one unaffected skin area were photographed on each participating patient. The gold standard diagnosis (stage 2 pressure ulcer vs. stage 1 or no pressure ulcer) was recorded by the wound specialist based on bedside examination. The photographs were reviewed blindly by another wound expert. The sensitivity of the blinded assessment was 97% (95% confidence interval [CI] 91-100%). The specificity was 97% (95% CI 92-100%). The sensitivity and specificity were both 100% in the white patients. In black patients, the sensitivity and specificity were 92% (95% CI 75-100%) and 93% (95% CI 82-100%), respectively. These results suggest that the use of photographic images to assess the presence or absence of a pressure ulcer stage 2 or higher has a high degree of validity. Since blinded outcome assessment is one of the cornerstones of good clinical trial design, photography offers the potential to strengthen future studies.

Assessing cross-cultural differences through use of multiple-group invariance analyses.

The use of structural equation modeling in cross-cultural personality research has become a popular method for testing measurement invariance. In this report, we present an example of testing measurement invariance using the Sense of Coherence Scale of Antonovsky (1993) in 3 ethnic groups: Chinese, Japanese, and Whites. In a series of increasingly restrictive constraints on the measurement models of the 3 groups, we demonstrate how to assess differences among the groups. We also provide an example of construct validation.

Transforming vulnerability.

Asian American immigrant women engaged in filial caregiving are at special risk for health problems due to complex contextual factors related to immigration, cultural traditions, and role transition. This study examines the experience of two groups of immigrant Asian American women who are caring for older parents. A total of 41 women (22 Chinese American and 19 Filipino American) were interviewed in a study based on Strauss and Corbin's grounded theory methodology. The women were determined to be loyal to their traditional culture, which included strong filial values, while adapting to a new culture. Through the struggle of meeting role expectations and coping with paradox, the women mobilized personal and family resources to transform vulnerability into strength and well-being.

Cultural differences in responses to a Likert scale.

Cultural differences in responses to a Likert scale were examined. Self-identified Chinese, Japanese, and Americans (N=136, 323, and 160, respectively) recruited at ethnic or general supermarkets in Southern California completed a 13-question Sense of Coherence scale with a choice of either four, five, or seven responses in either Chinese, Japanese, or English. The Japanese respondents more frequently reported difficulty with the scale, the Chinese more frequently skipped questions, and both these groups selected the midpoint more frequently on items that involved admitting to a positive emotion than did the Americans, who were more likely to indicate a positive emotion. Construct validity of the scale tended to be better for the Chinese and the Americans when there were four response choices and for the Japanese when there were seven. Although culture affected response patterns, the association of sense of coherence and health was positive in all three cultural groups.

Caregiving between two cultures: an integrative experience.

In 1995, more than half of elderly immigrants to the United States were born in Asia or the Pacific region. The purpose of this study was to describe the process of caring for elderly parents by Asian American women. Forty-one women (22 Chinese American and 19 Filipino American) caring for elderly parents were interviewed in a study based on Strauss and Corbin's grounded theory methodology (1990). Although the women were moderately acculturated, indications of being in transition were evident. Analysis of interview data led to development of a substantive theory of caregiving between two cultures, reflecting the paradox of living and caregiving by two sets of standards and worldviews. The primary strategies used to manage the caregiving challenges were connecting and calibrating. Through personal growth and finding meaning, the caregivers integrated the caregiver role into their lives and became more connected with their families and within themselves.

Synovial regeneration in the equine carpus after arthroscopic mechanical or carbon dioxide laser synovectomy.

OBJECTIVE: To compare synovial regeneration in the equine carpus after mechanical or CO(2) laser synovectomy. STUDY DESIGN: Arthroscopic partial synovectomy was performed in the radiocarpal and intercarpal joints. SAMPLE POPULATION: Twelve horses, 3 to 6 years of age, were randomly divided into 3 groups. METHODS: The antebrachiocarpal and intercarpal joints in each horse were randomly assigned a treatment such that each horse had one joint treated as a control (arthroscopic lavage), one in which a mechanical or CO(2) laser partial dorsal carpal synovectomy was performed, and one in which a combination of the mechanical and laser techniques was performed. The groups were euthanized for collection of specimens, respectively, at 1, 3, and 6 months postoperatively. The synovial membrane was evaluated grossly, histologically, and by transmission and scanning electron microscopes (TEM and SEM). RESULTS: The synovial villi failed to regenerate in all groups. At 1 month, the intimal cell layer was incomplete and the surface was still granulating. At 3 months, intimal regeneration was complete but more mature in the CO(2) laser synovectomy groups than in the mechanical synovectomy groups. Intimal regeneration was complete in all groups at 6 months. The subintima was replaced with fibrous tissue that separated the original subintimal vascular bed from the regenerated synovial surface. The CO(2) laser required preliminary training to operate effectively, and the air environment altered the intraoperative evaluation of the synovectomy site. CONCLUSIONS: Villous regeneration does not occur in horses after surgical synovectomy. All synovial membranes healed with a fibrous subintima and less populated intima. The CO(2) laser is capable of performing a more superficial synovectomy than that achieved with mechanical synovectomy using a motorized arthroscopic synovial resector. CLINICAL RELEVANCE: Mechanical or CO(2) laser synovectomy may be performed in the horse; however, additional evaluation is needed to determine the physiological significance of the lack of villus regeneration in this species. A combination of the resection techniques is not advised because of the increased risk of full-thickness capsular defects.