Resilience as a concept for understanding family caregiving of adults with Chronic Obstructive Pulmonary Disease (COPD): an integrative review

Abstract Aims This paper was a report of the synthesis of evidence on examining the origins and definitions of the concept of resilience, investigating its application in chronic illness management and exploring its utility as a means of understanding family caregiving of adults with Chronic Obstructive Pulmonary Disease. Background Resilience is a concept that is becoming relevant to understanding how individuals and families live with illness, especially long‐term conditions. Caregivers of adults with Chronic Obstructive Pulmonary Disease must be able to respond to exacerbations of the condition and may themselves experience cognitive imbalances. Yet, resilience as a way of understanding family caregiving of adults with COPD is little explored. Design Literature review – integrative review. Data sources CINAHL, PubMed, Google Scholar and EBSCO were searched between 1989–2015. Review methods The principles of rapid evidence assessment were followed. Results We identified 376 relevant papers: 20 papers reported the presence of the concept of resilience in family caregivers of chronic diseases patients but only 12 papers reported the presence of the concept of resilience in caregivers of Chronic Obstructive Pulmonary Disease patients and have been included in the synthesis. The term resilience in Chronic Obstructive Pulmonary Disease caregiving is most often understood using a deficit model of health.

Centre, 2010). Chronic Obstructive Pulmonary Disease (COPD) is now a major public health concern. More than 3 million people died of COPD in 2012, which is equal to 6% of all deaths globally that year (World Health Organization, 2005) COPD is common in later life: an estimated 3 million people have COPD in the UK. Although for approximately 2 million of this group their COPD remains undiagnosed (Healthcare Commission, 2006) 2535 people died from mesothelioma in 2012, and thousands more from other occupational cancers and diseases such as COPD (Health and Safety Executive, 2013). In Italy, 2.6 million people are diagnosed with COPD and there are 18,000 reported mortalities every year from this condition (Del Negro & Rossi, 2003).
Hospital-at-home and assisted-discharge strategies are safe and effective, and current Department of Health guidance recommends such approaches should be preferred as an alternative way of caring for patients with exacerbations of COPD. They otherwise need to be admitted to hospital (National Clinical Guideline Centre, 2010). However, this often leads to increased care responsibilities for families, who are required to carry greater care burdens for longer periods of time (Grant, Cavanagh, & Yorke, 2012). Approximately 43.5 million US adults provide an average of 19 hours of unpaid informal care per week for someone aged 50 and older (National Alliance for Caregiving, AARP, 2013; Sautter, Tulsky, & Johnson, 2014). Family caregiving refers to unpaid relatives or friends of a disabled individual who help that individual with his or her activities of daily living. The words may be prefixed with 'family' 'spousal ', 'child', 'parent', 'young' or 'adult' (Kumar, Matreja, Gupta, Singh, & Garg, 2012).

Caregivers of patients with COPD (Chronic Obstructive Pulmonary
Disease) must be able to respond to exacerbations and may experience cognitive, emotional, social imbalances, depression, anxiety and stress (Pearlin, Mullan, Semple, & Skaff, 1990;Simpson, Young, & Donahue, 2010;Zarit, Tood, & Zarit, 1986). Government policies should help informal caregivers to receive practical support so that they may continue to care for their beloved ones in the long term without damaging their own health and well-being, because informal caregivers provide a service that would significantly weight on health and social services in terms of costs (Pinto, Holanda, Medeiros, Mota, & Pereira, 2007).
Traditionally, nursing care has focused primarily on the negative impact that caregiving has on caregivers and to solve these problems on behalf of the caregiver (Day & Anderson, 2011). However, the problem-oriented approach to nursing care is no longer sufficient, and the growing focus on self-management of illness in chronic diseases, on patient-centred care, and patient empowerment is the proof of this (Rotegård, Moore, Fagermoen, & Ruland, 2010). According to the Health Assets Model, helping patients and caregivers achieve and maintain their health and wellness is essential. "An assets approach to health and development embraces a 'salutogenic' notion of health creation and in doing so encourages the full participation of local communities in the health development process" (Antonovsky, 1979;Morgan, Davies, & Ziglio, 2010;Morgan & Ziglio, 2007). Resilience is a concept that is becoming relevant for understanding how individuals and families live with illness, especially long-term conditions. Yet, resilience as a way of understanding family caregiving of adults with COPD is little explored.
The present paper will present an in-depth analysis of resilience as a concept for understanding family caregiving of adults with COPD to provide a clearer conceptual basis for research in this field. Greater clarity about the concept may also help nurses who work with caregivers to provide more effective support. COPD management should also focus on symptom management and home care throughout the course of the disease, not only on optimal drug therapy (Nakken et al., 2015).
Initially, a concept analysis was considered as a valuable and rigorous method to clarify the meaning and nature of resilience in this group as it can aid precise communication, critical thinking and the advancement of the knowledge base of nursing (Cahill, 1996). However, an initial review of the literature of family caregiving of adults with COPD revealed that the term 'resilience? is not used either by researchers or practitioners working in this field. It was decided, therefore, to adopt a broader perspective and conduct a review of the literature to examine the origins and definitions of the concept, investigate its application in other areas of chronic illness management, and explore its utility as a means of understanding family caregiving in adults with COPD.

| Origins and definitions of 'resilience'
Initially, a search for definitions of the term 'resilience' was conducted followed by a literature review on concept analyses defining resilience and related concepts in the period 1980-2015. Before 1990, most of the research on resilience was limited to children and adolescents; after 1990 more studies were conducted in adults (Tusaie & Dyer, 2004). Similarly, prior to 20 years ago, resilience was studied predominantly as a trait that people either did or did not have (Earvolino-Ramirez, 2007), whereas more recently it has been seen as a quality that can be developed (Hicks & Conner, 2013).
The term 'resilience' derives from the Latin word 'resilient' which means 'act of rebounding' present participle of 'resilire' 'to rebound, recoil,' (Online etymology dictionary). Oxford Dictionaries (online) defines resilience as 'The capacity to recover quickly from difficulties; toughness'. According to Merriam-Webster dictionary, resilience is 'an ability to recover from or adjust easily to misfortune or change' while WordNet.com describes the term as 'the occurrence of rebounding or springing back'. The ability to recover from an altered state or a sense of recovery and rebounding is common to all definitions.
The concept of resilience originated from early psychiatric literature (Earvolino-Ramirez, 2007) and has been applied to different biological and human activities or sciences, like ecology, engineering and business. Modern resilience studies originated among psychologists and psychiatrists during the 1980s and 1990s, who were concerned to challenge a deficit, pathological, model of stress and coping and understand how individual, family and societal strengths contribute to mental well-being. Health researchers also increasingly recognized that strengths and capacities are important resources for promoting good health (Lin, Rong, & Lee, 2013). Garcia-Dia, DiNapoli, Garcia-Ona, Jakubowski, and O'Flaherty (2013) defines resilience as 'a dynamic process that can be influenced by the environment, external factors and/or the individual and the outcome'. Family and community are listed as external factors that can influence the development of resilience. Four defining attributes have been identified for the concept of Resilience by Garcia-Dia et al. (2013): 'Rebounding', described as the ability to bounce back after facing a life altering event; 'Determination', described as a firm or fixed intention to achieve a desired end; 'Social Support and Selfefficacy', described as the belief in one's own ability to achieve a goal or overcome an event.
Resilient caregivers are proactive towards maintaining harmonious relationships with health care professionals, aggregate information and resources, and developing social networks (Lin et al., 2013). Caregivers, who face the challenges of taking care of their beloved ones, express their feelings relying on their social support networks to help them deal with their life situations (Garcia-Dia et al., 2013).
Sometimes, there can be unexpected pathways to resilience (Bonanno, 2004). Bonanno defines resilience as 'the ability of adults in otherwise normal circumstances, who were exposed to an isolated and potentially highly disruptive event, to maintain relatively stable and healthy levels of psychological and physical functioning, and the capacity for generative experiences and positive emotions'. Hicks and Conner (2013) analysed the concept of 'resilient ageing' and defined the antecedents, attributes and consequences of resilient ageing: antecedents to resilient ageing were found to be adversity and protective factors, while the core attributes include coping, hardiness and self-concept. Cowan, Cowan, and Schultz (1996) defined family resilience as 'an adaptive capacity or strength, postulating it as an adaptive capacity for balance in a family when confronting crises, and as a potential power of the family that activates flexibility, problem solving, and resource mobilization within the family'.
Resilience in the workplace has been progressively studied in the nursing profession (Benner & Wrubel, 1989). In addition, resilience is one of the individual and collaborative factors that are known to mediate stress in cancer settings (Zander, Hutton, & King, 2010).

| Aims
The aim of this Integrative Review was to analyse peer-reviewed studies focusing on resilience in family caregivers of chronic disease patients, synthesize the findings and explore its utility as a means of understanding family caregiving of adults with COPD. The review considered the following questions: • Is the concept of resilience used in the literature focused on family caregivers of patients with chronic conditions?
• What are the terms used when describing caregiving of family caregivers of chronic conditions?
• Which type of model is used in these studies? A Deficit or an Assets Model of Health?
• Is the concept of resilience applicable to caregivers of COPD patients?
To manage and break down the research question, we used the PEO format (Bettany-Saltikov, 2012) to identify the key concepts in our research question, and define the inclusion and exclusion criteria (Bianchi et al., 2016

| Design
This is an integrative review (Whittemore & Knafl, 2005), and a Rapid Evidence Assessment (REA 2011). An updated integrative review method has the potential to allow for diverse primary research methods to become a greater part of evidence-based practice initiatives (Earle, 2011) (Whittemore & Knafl, 2005)

. A Rapid Evidence
Assessment is a rigorous method that gathers and reviews evidence in a streamlined systematic way (Blank et al., 2012).

| Search method
As well as exploring the concept of resilience, it was important also to examine the literature that used an alternative perspective to understand family caregiving in chronic illness. A literature review  was conducted using the following keywords: resilience, caregiver (or family caregiver), Chronic Obstructive Pulmonary Disease, and chronic disease. The databases used in the search were: CINAHL, PubMed, Google Scholar, and EBSCO.
First, we selected studies based on titles, keywords and abstracts. Then, we analysed the full-text articles. After collecting the evidence, the eligibility criteria were applied to the results and all identified references were screened independently by reviewers using an assessment according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff, & Altman, 2009) and PRISMA check list ( Figure 1).
Empirical and Theoretical articles were included if they met the following inclusion criteria: • Research articles related to resilience and caregivers or family caregivers in chronic diseases; • Articles focusing on resilience and caregivers of adults with COPD, resilience in caregivers in chronic diseases; • Written in English; • Published in a peer-reviewed journal; • Involving humans These inclusion criteria were used to obtain the most relevant papers, as literature relating to chronic illness is extremely extensive.

| Search outcomes
Our searches generated 435 potentially relevant papers. After duplicates were removed, the remaining records were 376.
Through abstract reading and analysing, 329 articles were excluded because they did not meet the inclusion criteria of the study.
Full paper appraisal (54) resulted in the exclusion of 34 articles, because they did not meet PEO criteria. Relevant papers (20) were analysed. Of these, 12 papers focused on COPD patients and caregivers, whereas eight focused on other chronic diseases ( Figure 1).

| Quality appraisal
The papers included in this review had quantitative, qualitative, and mixed-method study designs. The critical appraisal of the papers retrieved was conducted in three stages: assessment of relevance, data extraction and scoring for methodological rigour (Hawker,

| Data abstraction
In keeping with the REA methodology, data were extracted only on results and key data to conduct a quality assessment. For each paper, the following details were extracted: author, year of publication, title, population, design method, results, impact of the disease on caregivers/protective factors, deficit/assets model and scoring for methodological rigour (Blank et al., 2012).

| Synthesis
Data were extracted by one reviewer and checked by a second reviewer (Blank et al., 2012).

| Resilience in caregivers in chronic illness
To ensure that their physical and emotional health does not suffer and promote resilience, family caregivers need social and professional support while caring for their chronically ill beloved ones at home (Spence et al., 2008). In caregivers of patient with dementia, social support is described as a moderating factor of resilience. Different  Higher levels of personal mastery and self-efficacy, and increased use of positive coping strategies appear to have a protective effect on various health outcomes in dementia caregivers.

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T A B L E 1 (continued) (continues)

Impact of the disease on caregivers/protective
factors Deficit/assets

Impact of the disease on caregivers/protective
factors Deficit/assets types of support seemed to relieve the physical and mental overload caused by stress (Dias et al., 2015).
The imbalance between illness burden and coping capacity in informal caregivers could lead to fatigue and even burnout (Proot et al., 2003). In addition, personal, relational and cultural factors can significantly affect the balance between coping capacity and illness burden, and therefore increase the risk of vulnerability (Simpson et al., 2010). Effective coping with discomfort and nursing needs can help caregivers and lessen the effect of stressors (Papastavrou et al., 2011). Caregivers who learn to accept the new chronic conditions of their beloved one, can redefine the issues related to the illness in a more manageable way and feel they can solve problems more easily (Redinbaugh, Baum, Tarbell, & Arnold, 2003). 'Family resilience' is defined as an enduring force that leads a family to change its dynamics of functioning to solve problems associated with stresses encoun- and propulsive force (Lee et al., 2004).
According to the 'Assets of Health Model', positive coping approaches need to be developed by caregivers to continue their caring role. The need to find ways of engaging with caregivers as part of nursing care approach is essential (Hynes, Stokes, & McCarron, 2012).
The focus appears to have shifted towards the creation of programs that test an intervention to empower resilience and prevention programs to disseminate resilient attitudes (Earvolino-Ramirez, 2007). Lin et al. (2013) analysed the concept of resilience among caregivers of children with chronic conditions and declared that 'the power of resilience enables caregivers to achieve balance, confidence and personal strength' and that 'caregivers tended to focus on the positive, and the caregivers' belief was that a child with a chronic condition is a special favour for them'. Caregiver resilience in the context of caring for chronically ill children can be defined in four main dimensions: disposition patterns, situational patterns, relational patterns and cultural patterns. Some caregivers seem to escape the negative outcomes that taking care of their beloved ones may trigger. Resilience and coping factors may protect caregivers from physical health risks. Therefore, resilient caregivers are proactive in gathering information, developing social support networks, and maintaining balanced relations and collaboration with healthcare professionals (Lin et al., 2013).
Resilience factors in dementia caregiving focus on 'the broad domains of personal mastery, self-efficacy and coping style' (Harmell, Chattillion, Roepke, & Mausbach, 2011). The gradual increase in the levels of personal mastery and self-efficacy, and the use of positive   (Weisser, Bristowe, & Jackson, 2015).

| Resilience as a concept for understanding family caregiving in COPD
COPD patients have some characteristics that are in common with other chronically ill populations in terms of high mortality, re-hospitalization risk and post-hospital need for care. COPD is a relatively unpredictable long-term illness with evident emotional consequences, therefore this type of patient population can indeed be challenging for caregivers (Pinto et al., 2007;Cain & Wicks, 2000).
Physical and functional limitations that COPD patients face on a daily basis, and especially towards the final stages of the disease, require the support of others. COPD patients and their informal caregivers are confronted with increasing limitations because of disease progression, and symptom exacerbations occur more frequently towards the final stages of COPD (Cain & Wicks, 2000;Nakken et al., 2015). COPD also has a profound and pervasive effect on family and friends, and caregivers of patients with chronic disease can experience a high degree of distress (Covinsky et al., 1994;Gabriel et al., 2014). In addition, family members often experience an overwhelming feeling of duty to care for their partners, which combined with a loss of intimacy can lead to psychological distress. (Marques, Jácome, & Cruz, 2015).
In Caress, Luker, and Chalmers's (2010) (Simpson et al., 2010). Simpson et al.'s (2010) results reflect substantial caregiver vulnerability in terms of an imbalance between burden and coping capacity, and included comments about the negative impact of the illness on the family, such as the increasing demands of illness on caregivers, and care recipients showing emotional control attitudes. These factors had a negative impact on relationship dynamics and identity. It is therefore important to develop a greater understanding of caregiving psychological distress to help clinicians to identify caregivers who may require more intensive assessment and support mechanisms (Grant et al., 2012). Currently, it is not possible to evaluate the prevalence of psychological distress but current evidence suggests that many factors are related to caregiver psychological distress (Grant et al., 2012).
In Wodskou, Høst, and Godtfredsen (2014) hospital admission for exacerbation was perceived as a difficult experience for several patients with COPD, but felt hospitalization was necessary. In addition, being discharged too soon was described as a factor that could lead to hospital readmission. Wodskou et al. (2014) therefore suggest further studies on the impact of caregiving on informal caregivers, also during and after acute events like COPD-related hospital admissions.
In Caress et al. (2010) COPD patients' perspective was to 'just carry on' as best they could despite troublesome symptoms and limitations in functioning. The daily life for most patients involved managing day-to-day demands linked to the symptoms of the disease.
Some patients reported having effective coping strategies to control their anxiety, fear and panic developed through the experience of past COPD symptoms exacerbations. However, for many, coping simply meant limiting those factors that sometimes led to a total cessation of an activity.
The complex interaction between the experience of living with COPD and communication patterns, emotional states, social support and social roles in the family emerged in Gabriel et al. (2014).
The results showed the need to develop family-based interventions for a functional adaptation to COPD that are focused on coping and adapting familiar paths to reduce vulnerability and facilitate a positive adaptation (Gabriel et al., 2014) In Meier, Bodenmann, Mörgeli, and Jenewein (2011), family caregivers provide crucial support to patients with COPD but they experience considerable burdens themselves.
The strains of a chronic disease like COPD should also be viewed from a couple's perspective. In pulmonary rehabilitation, the integration of the family member to the rehabilitation process can improve the coping strategies of the family in managing the disease, as well as the couple's sexual functioning and psychological distress (Marques et al., 2015).

| DISCUSSION
The literature review undertaken provides a basis to understand adaptation and resilience in this population. Resilience is potentially a useful concept for understanding family caregiving in adults with COPD.
Exploring the interaction between patients and informal caregivers and paying attention to the needs of informal caregivers requires more research (Nakken et al., 2015). Caregiving in COPD patients can be seen as a process, and resilience in COPD caregivers can be described as an enduring ability or capacity that is exhibited as a strength of the caregiver when responding to acute exacerbations, chronic stresses and problem solving for symptoms management (Lin et al., 2013) and which can be further developed (Hicks & Conner, 2013).
The term 'resilience' in COPD caregiving is most often understood as using a deficit model of health. Conventional approaches to public health typically seek to identify aspects of burden and stress of the caregiver and fail to take into account the positive effects of ability to cope with caring for a person with COPD -as in other similar chronic conditions -can oscillate between positive and negative aspects of caring (El Masry et al., 2013;Harmell et al., 2011;Lin et al., 2013;Weisser et al., 2015). Caregivers may experience positive caregiving, not only experience distress. In fact, caring for a loved one can be considered as an opportunity for personal growth. Being able to help the patient stay at home as long as possible may be rewarding (Nakken et al., 2015). Family caregiving was found to be rewarding, with caregivers demonstrating a certain amount of resilience, despite the caregiving role entailed significant changes (Spence et al., 2008).
For the professional health care community to support caregivers, resilience must be fully explored in COPD caregivers. Major insight into the role of the home environment is needed to optimize domiciliary management programs (Nakken et al., 2015). A qualitative study may illuminate the complex individual, relational, societal and policy, factors that impact on family caregiving in this group. Current approaches are not enough, and health systems need to actively support caregivers of people with advanced COPD to relieve the burden of caring experienced by caregivers (Hynes et al., 2012;Marques et al., 2015).
A clearer understanding of the concept may support more effective clinical decisions, improve communication between the parties involved, health care professionals, patients and carers, and contribute to improve the planning of nursing care, facilitate clinical research and enhance nursing practice. A better understanding of the physical, emotional, spiritual and relational factors that increase caregivers' vulnerability can inform new chronic care models better able to support their efforts (Simpson, Young, & Donahue, 2010). Such work may help nurses to understand which supportive nursing interventions are more effective in helping caregivers of adults with COPD.

| CONCLUSION
The demand for informal caregivers is expected to rise by more than 85% over the next few decades because of the growing population of older adults (Sautter et al., 2014). International policies on longterm care management recommend several strategies to contrast the negative consequences of providing informal care (Grant et al., 2012).
Spouse caregivers in particular need professional support to better manage their daily life as a couple. This appears to the fundamental to ensure higher levels of resilience for the management of COPD.
Caring activities should be appropriately spread across patients, partners and health workers. The burden of this responsibility should not fall only on the informal family caregivers (Meier et al., 2011).
Professionals should give families a positive feedback from successful experiences of coping, since it strengthens the COPD family resources (Gabriel et al., 2014).
Effective coping with the hardships and demands of caring for family members affected by COPD can support caregivers and reduce the effect of stressors (Papastavrou et al., 2011). Despite the burden, carers can also develop a strong sense of duty to care, who describe the satisfaction they feel as 'being able to do something useful' (Spence et al., 2008). Focusing nursing care on a person's health assets, as well as on the positive sides of caring of a relative, together with the traditional approach of the assessment of care needs, can contribute to improved health behaviours and outcomes (Rotegård et al., 2010). If the health systems do not actively engage with caregivers, the current health policy approaches are insufficient to support people with advanced COPD or may even aggravate the burden of care and illness experienced by family carers (Hynes et al., 2012).
This paper has presented an in-depth analysis of the concept of 'resilience' in caregivers, by analysing in particular the possible applications to COPD caregivers. Positive coping strategies need to be developed by caregivers of COPD patients to enable them to continue their caring role. 'Family resilience is a resource for conquering difficulties, which often manifests in individuals as tranquility, hope and a positive outlook' (Lee et al., 2004). Therefore, caregivers of COPD adults may experience this when caring for their family members. The model of family coping, that incorporates both family resilience and family functioning, as a property and a process of change, respectively, could apply to caregivers of COPD adults. However, the caregiver population is very heterogeneous and this can make targeted interventions challenging. The stressors and progressive responsibilities that caregivers face on a daily basis, are complex and may consequently require researchers to consider more components, and therapeutic strategies based on evidence to better define the clinical outcomes (Harmell et al., 2011).