Key Factors of Family Adaptation to the Illness of Family Members: An Integrative Review

stressors. Communication is a facilitating factor in cohesion and adaptability. 6 Families who exert tremendous effort toward coping with the daunting challenge of providing care for a family member during illness are actively engaged in the process of coping or adaptation. These families are well-aware of the requirement for a complete overhaul within the family in the transition from crisis back to sustainable family functionality with Abstract This is an integrative review aimed to synthesize and explore the factors related to the coping of family caregivers during the illnesses of family members in the Thai context. The researcher performed an integrative review. The sources of the articles reviewed included MEDLINE, Science Direct, CINAHL, and Clinicalkey The references cited for the articles selected were checked manually.The following keywords were used singularly, and in various combinations in both quantitative and qualitative studies: family function, family members’ illness, related factors, and family coping/adaptation. The criteria for the search included full-text articles published within ten years (2007-2018), and in the English language. The researcher’s search for the articles with keywords yielded 193 articles, eight of which met the inclusion criteria. According to the findings of the literature review, the factors for family adaptation during the illness of family members include several factors such as social support, family relationships, religious /spirituality, family hardiness, family striving, psychological distress/coping, health status, family functioning, and patient’s life skills. The findings of the study can motivate health care providers to try to manage the program to support family caregivers during the illness of family members. Further studies should address how to support families in adaptation to any crisis.

the aim of an added family well-being and satisfaction. 4,5 In other words, families with improved functions are better able to cope as they provide care for a family member during illness. Therefore, family functioning can be evaluated based on a family's ability to work as a family unit in adapting to a crisis. According to models of spousal and family systems, family functions can be divided into the following three categories: communication, cohesion, and adaptability. The way family members bond together through filial relationships and emotional attachments is known as family cohesion, whereas the way a family revamps its rules and practice in the face of changes or crisis, roles/relationships and hierarchy is known as adaptability. The aforementioned cohesion and adaptability are facilitated by family communication. 6 Understanding the factors related to family adaptation is essential for promoting family adaptation. However, previous studies have yielded limited knowledge about the factors associated with family adaptation. Based on the link to the caring science gap in the knowledge base, the research gap means to find out the gap based on practical and theoretical gap from previous literature and models. Interestingly, studies throughout the world provided inadequate assessments in factors associated with family adaptation. Most of the studies were conducted in the United States of America, this is inadequate for studying family adaptation that should study more for supporting families overcome any problems. 1,2,[9][10][11][12][13] Furthermore, some of these factors merit further examination. Hence, a systematic review is needed as a means of exploring the determinant factors associated with family adaptation during the illness of a family member. The findings of this study can be applied to the development of programs for supporting family adaptation in families during the illness of a family member.

Objective
To explore the factors related to family adaptation in families during the illness of family members.

Methods
This an integrative review aimed to synthesize and explore the factors related to family adaptation in families during the illness of family members based on relevant studies, published within the years of 2007-2018. The steps and methods used PRISMA's systematic reviews 7 to examine and unify literature utilized as follows:

Literature search
The researcher used the singular key terms and combinations of the same: family function, family members' illness, related factors, and family coping/adaptation.
1. The databases used in the search for literature were CINAHL, MEDLINE, ScienceDirect, and Clinicalkey from 2007 to 2018. 2. The inclusion criteria were based on PRISMA's systematic reviews 7 and Joanna Briggs Institute, 2014 8 (see Figure 1 and Table 1(whereas the exclusion criteria eliminated articles not related to the study, no-peer reviews, not containing families' adaptation, commentaries, narrative reviews, not English language version and duplicate studies. 3. Quality appraisal involved establishing inclusion criteria as shown in the eligibility of assessment of all articles used in this review by using PRIMA 7 (see Figure 1 and Table 1).
The primary search yielded 193 papers that were submitted to this review. A total of 3 duplicated papers were removed, while another 182 papers were excluded from the review (15 non-peer-reviewed articles, 81 articles with no patient outcomes, 44 articles that were commentaries and 42 narrative review articles. Lastly 8 full text articles met the inclusion criteria) see Figure 1  The screening process of the systematic literature  A mixed-methods approach.
• The burden of family caregivers was revealed to share a statistically significant correlation with the ADL dependence of the elderly (r = 0.488, p < 0.001), the spiritual well-being of family caregivers (r = 0.299, p < 0.05), family caregiver-elderly patient relationship quality (r=0.429, p < 0.01) and inadequate support from family members (r = 0.623, p < 0.001). • The ADL dependency of the elderly patients (b = 0.47, p < 0.001), caregiver-elderly patient relationship quality (b = 0.39, p < 0.01), and inadequate family support (b = 0.41,p < 0.001), predicted the extent of the family caregiver burden at 66% with statistical significance. • According to the findings, the risk and preventive factors (e.g. family/social support; spousal relationship quality, family cohesiveness, and communication both inside and outside the family) contributing to greater family vulnerability or resilience were revealed. • A negative correlation between caregiver health issues and family coping/adaptation score (r = 0.30, p < 0.01). Perceived caregiver stress scores were also found to be negatively correlated with the regulation of internal states (r = -0.419, p < 0.01) as well as scores for a family coping/adaptation (r = 0.30, p < 0.01). Furthermore, negative coping/adaptation scores were found to be negatively correlated with a family coping/adaptation scores (r = 0.254, p < 0.05). Positive correlations were found between internal states and family coping/adaptation (r = 0.517, p < 0.01), as well as social support and family coping/ adaptation (r = 0.348, p < 0.01) • Family time and daily routines (r = 0.32, p = 0.02), social support, (r = 0.34, p = 0.01), communication (r = 0.40, p = 0.00), family endurance

Data extraction and synthesis
This study review studied an integrative review to determine the findings. [18][19][20] Data extraction and synthesis information followed the aim, study design, results, and conclusion. All criteria led to all findings. The PRISMA flow diagram was utilised and Joanna Briggs Institute, 2014 18 for criteria, to meet the standard of 8 studies with rigor.
The findings yielded by the literature review indicate multiple factors contributing to family coping/adaptation during the illness of a family member. The aforementioned contributing factors include family caregiver-patients relationship quality/ inadequate family support, 1 social support; spousal relationship quality, family cohesion and communication both inside and outside the family, 9 current health issues, perceived stress levels, coping skills/strategies, social support and regulation of internal states. 2 . Furthermore, high quality of communication is correlated with improved family coping skills/adaptation, 10 while religious beliefs/spiritual well-being, 11 striving for endurance, consolation, and restructuring of lifestyles, 12 family cohesion and coping with emphasis on findings solutions for problems, 13 family stress, patients' life skills, family function, praise from family members and family endurance are also related. 3 The literature review is presented in Figure 2.

Results and Discussion
Social Support : Based on the literature review, social support was found to share a positive correlation with family

Religious/Spirituality -Religious beliefs -Spiritual well-being -Seeking for meaning -Acceptance
Health status -Caregiver health issues -Patient's ADL dependence

Endurance/Hardiness
Family Functioning

Family Striving Patients' Life Skills
Family Adaptation coping/adaptation, while inadequate social support was found to have a negative correlation with the same. 1,2,9,10 This finding can be explained in that social/family support is a key source of mental support, hope and content. 1,2,9,10 Therefore, when family members are confronted with the illness of a family member, social support is used to promote coping, exchanges and sharing of experiences encountered in care where families can release their feelings about the burden of care and improve self-health care. 1,10 On the other hand, inadequate social support causes the negative feelings such as social isolation, a situation that has tremendous negative impact on family coping/ adaptation. 1 According to Schaefer et al. 14 family/social support contributes to perceived assistance in the form of material, emotional and informational support. It can be concluded, therefore, that family/social support is correlated with physical and mental health status, crises or stressful situations, self-confidence and depressive symptoms.
Family Relationships: According to the literature review, family relationships are associated with family coping/ adaptation, including family time and routine, caregiverpatients relationship quality, spousal relationships, family cohesion and family communication. 1,9,10 These findings can be explained in that family time and routines are important for family members to communicate and emphasize togetherness for creating equilibrium for the family system. McCubbin&McCubin 5 indicated in their Resiliency Model that celebrations and time together are an important resource that facilitates family adaptation and communication within the family while providing opportunities for families to eliminate tension and strain in addition to maintaining satisfactory levels of adjustment, adaptation, and family functioning. Moreover, this study found that the quality of the caregiver-patients relationship, spousal relationship, and family cohesion play important roles in family adaptation because family relationships can facilitate families in reducing feelings of caregiver burden1, improving a sense of help and support, sharing responsibility, spending time together and effectively communicating. Therefore, family relationship quality is positively correlated with family coping/adaptation. 9 Religious Beliefs and Spirituality: According to the literature review, religious beliefs and spirituality are associated with a family coping/adaptation consisting of religious beliefs, spiritual well-being, seeking meaning and acceptance. 1,10 These findings can be explained in that religious beliefs and spirituality are key sources of inner strength. Furthermore, religious beliefs and spirituality can assist people in finding the meaning of life, setting goals for the future and following set goals with greater drive and hope. These sources of inner strength can contribute to understanding and acceptance of illness and stressful life events. Thus, religious beliefs and spirituality influence family coping/adaptation. 1,10 O'Brien 15 explained the effects of religious beliefs and spiritual well-being during the illness of a family member. According to O'Brien 15 , religious practice is one of the factors contributing to the discovery of the meaning of spiritual experience in illness and causes patients to have spiritual well-being during illness. Spiritual well-being is, therefore, an essential factor in family coping/adaptation. 1,10 Family Endurance Hardiness : According to the literature review, family endurance or hardiness is associated with family adaptation. 3,10 This finding can be explained in that family endurance or hardiness is a vital factor for buffering stress. In other words, family hardiness is important to promoting feelings of internal strength, dependability, durability and overall ability to work together. 10 McCubbin & McCubbin 5 indicated that family hardiness has been recognized in the Resiliency Model as an essential defense and family resource in addition to performing a vital role in an effective family coping/adaptation.
Family Striving : One qualitative study in the literature review revealed that family striving is associated with family coping/adaptation. This family striving is aimed at achieving endurance, consolation and restructuring of lifestyles during crises or stressful situations. 13 The finding can be explained in that striving for endurance are the first step in the process of family adaptation. It is important to connect family members and stand beside one another during the illness of family members. Family members need to vow to take care of themselves and other family members, which is a key success factor in overcoming a crisis through adaptation. Striving for consolation is the second step in the process of adaptation and appears after striving for endurance. This process requires communication among family members in recovering from the illness. Open discussions and consolation are essential in supporting family members to manage stressful life events and achieve balance. Besides, restructuring lifestyles in the face of different circumstances is the final stage of the family coping/adaptation process as family members reassess and restructure their entire lifestyles with behavior modification aimed at seeking or maintaining good health. According to McCubbin&McCubin 5 , family members are unwilling to modify behaviors in response to crises when family support is inadequate. Thus family coping/adaptation is not only delayed but can even become damaged.
Psychological Distress and Coping : According to the literature review, some factors related to psychological distress and coping are related to family adaptation. These include psychological well-being, family stress, depression, negative coping styles, regulating internal state, problem-solving skills, problem-focused coping, and family appraisal of illness. 2,3,10,11,13 The finding can be explained in that psychological well-being serves as a source of inner strength to buffer stress and lead to positive coping behavior. In contrast, psychological distress and depression are factors with negative effects on family adaptation. 11 Moreover, regulating internal states, problemsolving skills and problem-focused coping are positively correlated with a family coping/adaptation because these factors enhance caregivers' ability to control internal states, promote positive coping strategies and achieve family adaptation. On the other hand, negative coping styles are negatively related to family adaptation since negative coping styles increase the strain of caregivers and impede a sense of selfcontrol. 11 Moreover, family appraisal of illness is negatively associated with family coping/adaptation, because caregivers perceive the caregiving role as inspiring with minimal stress. Positive family assessment of illness has the potential of preserving the physical and mental health of family members while making family coping/adaptation easier. 3 Health Status : According to the literature review, health status is associated with family adaptation. The factors involved in this category include caregiver health issues and the ADL dependence of patients. 1 This finding can be explained in that the health issues of caregivers generally exacerbate the distress of family caregivers in the caregiving role during the serious medical illness of another family member, while increasing a sense of physical activity limitations and a feeling of the caregiving as a burden. 2 Moreover, patients with a high level of ADL dependence increase the level of family caregiver burden with potential impact on family coping/adaptation. 1 Family Functioning : Based on the literature review, family functioning is associated with family adaptation. 3 This finding can be explained in that a high level of family functioning can decrease family stress, improve a patient's life skills and promote family coping/adaptation. 3 This conclusion also confirms the assertion of the resiliency model, which states that family functioning serves to predict the extent to which family members are satisfied with life. 5 If a family can function, family coping/adaptation is more likely to be successfully achieved.
Patients' Life Skills : The literature review revealed that patients' life skills are associated with family adaptation. 3 This finding can be explained in that patients' life skills are important factors in managing chronic illnesses and stressful life events. Patients' life skills have also been found to be indirectly and positively correlated with family coping/ adaptation in terms of family function. 3 In other words, patients with positive perceptions and skills can not only handle but overcome illness.

Conclusion
The findings of this study can facilitate health care providers in managing programs to support family caregivers during the illness of family members. Importantly, successful, strong family coping/adaptation requires that family caregivers or other family members solve this problem, particularly during the recovery phase composed of the following five stages: fight, acceptance, learning to live with chronic illness, sharing experiences and restructuring lifestyles. 16 However, this study has strength because the reviewer searched all databases for finding the key factors of family adaptation to the illness of family members. Limitations of the study such as this study cannot be freely generalized to populations in other countries because the studies mostly were set in the USA. Thus, the differences between cultures would lead to an increased likelihood of differences in the results. The role of the family is to use a health care team to support each phase of recovery and help family members to find balance or adaptation to maintain health. Importantly, family members should change and help one another to maintain family functionality. 17 Further studies should address how to support family coping/adaptation in any stressful situation or crisis.