Development of an integrative empowerment model to care for patients with schizophrenia disorder

Abstract

Background:

The main factor that causes a family the inability to care for patients with schizophrenia disorder is inadequate family-centered empowerment. Nevertheless, the family-integrated empowerment model has not been developed yet. This study aims to develop a integrative empowerment model to care for patients with schizophrenia disorder.

Design and methods:

The mixed methods research design was divided into two stages. The first stage used a cross-sectional method with a questionnaire to 135 families who cared for patients with schizophrenia disorder using purposive sampling. Data analysis was obtained using Partial Least Squares (PLS). The second stage is a focused group discussion (FGD) conducted with six families, seven health workers, and six social workers, and discussions with two experts for model development.

Results:

The integrative empowerment-based family empowerment model is developed from Outside-in empowerment (path coefficient = 0.309; t = 3.292) and Inside-out empowerment (path coefficient = 0.478; t = 4.850). Family factors is the most potent variable in shaping Inside-out empowerment (path coefficient = 0.217; t = 2.309). Moreover, re-meaning of caregiving is the strongest indicator that builds the Inside-out empowerment variable (t = 42.643). The value of Q² is 0.433 indicates that this model can be generalized, since 61% of family ability to provide care for schizophrenia patients.

Conclusions:

Re-meaning of caregiving is the most potent indicator in shaping Inside-out empowerment, which is the strongest factor forming this model. Nurses assist families to be able to find activities that can generate positive meaning when caring for patients with schizophrenia disorder.

Introduction

Patients with schizophrenia disorder require long treatment and recovery, so they run out of supportive abilities and their family becomes helpless. ¹ Several health promotion programs for schizophrenia disorder care have been provided through education, early detection, continuity of care programs, and the Healthy Indonesia programs with a family approach. However, families still bring patients to spiritual medicine and traditional healers because they consider the cause of their conditions to be from evil spirits, witchcraft, curses, and disbelief.^2,3 Families also lack access to mental health services for their family members, so patients with schizophrenia disorder are sometimes not treated. ³ The main factor that causes families not to treat patients with schizophrenia disorder optimally is the inadequate family-integrated empowerment of schizophrenia disorder. ⁴ The development of an integrative empowerment-based family empowerment model for the ability of families to take care of, and prevent schizophrenia disorder relapse, both in terms of increasing skills, knowledge, rewarding experiences, and discovering a new meaning in caring for patients with schizophrenia disorder, has not been developed yet.

The phenomenon of schizophrenia disorder is like an iceberg that looks small on the surface, because families are still reluctant to take patients to healthcare facilities. ³ There is 21 million people suffering from schizophrenia disorder worldwide, which is 0.24 cases per 1000 population. ⁵ The relapse rate of patients with schizophrenia worldwide in the last 3 years has also increased from 28.0% to 43.0% to 54.0%. ⁶ Schizophrenia disorder in Indonesia has increased from 1.3 cases, to seven cases per 1000 population in 2018. Central Java has risen from 2.3% (2013) to 9% (2018), ⁷ and Semarang City has the highest prevalence, namely 0.79 per 1000 population in 2018. ⁸ The medical records of Dr. Amino Gondohutomo Regional Psychiatric Hospital show that in 2021 there was 765 patients with schizophrenia disorder undergoing treatment, with a re-admission rate of 19% within 0 days.

One of the reasons for the high rate of re-admission and relapse in patients with schizophrenia disorder is the family’s inability to treat and prevent relapse whilst the patient is at home. A past study found the family’s ability to provide care and prevent relapse in schizophrenia disorder is low (<50%). Schizophrenia disorder families can care for patients at a moderate level, 49.6%, while at a low level, 46.1%. ⁸ Family resistance to treating patients with schizophrenia disorder is still low at 48.2%. ⁹

The family’s inability to care for and prevent relapse in patients with schizophrenia disorder is due to the feeling of powerlessness which is experienced. The causes of a family feeling powerless is caused by various things, such as limited improvement within family function, the implementation of family empowerment ¹⁰ and few interventions that focus on the welfare of family caregivers. ¹¹ Families see parenting as a big problem and are helpless in dealing with situations and can feel unsure on how to treat schizophrenia disorder. ¹² The meaning of family care for patients managing schizophrenia disorder is still a burden and a stressor, ¹³ so the experience of caring for patients with schizophrenia disorder, which should be a family’s unique strength, is not interpreted positively as an inner resource for caring for patients. ¹⁴

The family empowerment model for patients with schizophrenia disorder will be developed using an integrative empowerment model. Integrative empowerment is a family empowerment model that values the inner strength and the unique experience of caregivers, while at the same time providing families with the skills and knowledge needed to care for family members with schizophrenia disorder. ¹¹ The basic components of integrative empowerment are Outside-in empowerment and Inside-out empowerment. Outside-in empowerment including equipping caregivers with knowledge, training, coping skills and family support to overcome difficulties and stressful situations encountered in long-term involvement in daily caregiving Inside-out empowerment including making meaning, life goals, positive family experiences, and self-reflection to help caregivers grow and practice new meaning in caregiving process by assessing the positive aspects of caregiving and pressure contribution to relationships. ¹¹

Four factors which influence family empowerment are patient factors, family factors, social environment factors, and health service factors. The patient factors, namely: schizophrenia onset and comorbidities. ⁶ The family factors, namely: education, knowledge, parenting history, socioeconomic, internal vulnerabilities, family-owned resources, family history of mental disorders, family emotional expressions and cultural values.^2,11 The social environment, namely: stigma, social networks and social support.^2,11 The health service factors, namely: access, infrastructure and health workers. ¹⁵

Mental health nurses can empower families by appreciating caregivers’ inner strength and unique experiences, whilst also providing families with the skills and knowledge needed to treat schizophrenia disorder. ¹¹ This study aims to develop a family empowerment model based on integrative empowerment in caring for patients with schizophrenia disorder.

Design and methods

Study design

Mixed method research design; the first phase is quantitative research with a cross-sectional approach. The influence of the patient, family, social environment, health services, Outside-in empowerment, Inside-out empowerment, integrative empowerment, and family ability to care for patients managing the schizophrenia disorder variables was used to build the model. In the second phase, the results of the PLS analysis in the first phase were used as a strategic issue as material for developing a model through FGDs with families, health workers, and social workers, as well as expert discussions with psychiatrists and mental health nursing professors.

Population, sample, and sampling methods

The population of this study was families who had family members with schizophrenia disorder and were routinely controlled at the outpatient clinic of Dr. Amino Gondohutomo Regional Psychiatric Hospital. The first phase sample is 135 families from families who cared for patients with schizophrenia disorder using a purposive sampling technique when collected in September 2022. The sample size in the first stage is calculated based on the “rule of the thumb,” namely the number of estimated parameters to be assessed multiplied by 5–10. In the first stage of this study, there were 27 parameters to be measured, then multiplied by 5, so the result was 135 respondents.

Most of the researchers suggest that the appropriate participants for group discussion range from 4 to 12 participants.^16,17 So, the sample of the second phase (FGD) are six families, seven health workers (one psychiatrist, one psychologist, and five mental health nurses), and six social workers (four psychiatric cadres and two civil service officers). The expert discussion was held with two experts: an expert practitioner who is a psychiatrist, and an academic who is a professor of mental health nursing.

Inclusion and exclusion criteria

The inclusion criteria were nuclear families (father/mother/child) who lived in the same house with patients with schizophrenia disorder, provided daily care, experienced treating patients with schizophrenia disorder for at least 1 year, aged 20–60 years, and underwent treatment more than three times, and were re-controlled at Dr. Amino Gondohutomo Regional Psychiatric Hospital. The exclusion criteria were families who could not read and write, had mental disorders or other chronic illnesses, and were unwilling to be research respondents.

Variables

The variables in the study consisted of independent variables, including patient factors, family factors, social-environmental factors, health service factors, Outside-in empowerment, and Inside-out empowerment, and the dependent variable was integrative empowerment-based family empowerment.

Instruments

This study used a cross-sectional approach in the first phase. The researcher developed and modified the instruments used in the first phase from several concepts and questionnaires. The original author permits to use or modify the instruments. Furthermore, researchers tested the 21 instruments developed by the researcher again in the validity and reliability tests. The results are valid for each statement item r count >r table (0.361) with a Cronbach alpha value >0.60.

The independent variables include patient factors assessed by a checklist sheet of disease onset and comorbidities history. Family factors were assessed with the Experience Caregiving Instrument (ECI). ¹⁸ A resource assessed with an Inner Resource Scale (SAS-I). ¹⁹ An internal vulnerability assessed with a Mental Health Inventory (MHI). ¹³ A family emotional expression assessed with a Berkeley Expressivity Questionnaire ²⁰ and a Cultural Values Questionnaire according to the concept of relapse by Ahmad et al. ² The social-environmental factors consisting of a Stigma Questionnaire adapted from the concept by Goffman, ²¹ a social network check sheet developed from the concept Zhou et al. ¹¹ and a Social Support Questionnaire developed from the concept of Friedman et al. ¹⁹ The health service factors consisted of the Appropriate Access and Infrastructure Questionnaire of mental health laws, ²² and a Health Worker Questionnaire adapted from the concept of family center care and family empowerment.^15,19 Outside-in empowerment consists of knowledge developed from the relapse concept of Ahmad et al. ² and Keliat ²³ skills coping using the Family Coping Questionnaire (FCQ), ²⁴ and interactions family using the Brief Family Relationship scale (BFRS) from Fok et al. ²⁵ Researchers developed Inside-out empowerment consisting of a meaning of parenting according to the concept of making meaning, ²⁶ Hert Hope Index (HHI), ²⁷ and Experience of Caregiving Inventory (ECI) ¹⁸ and self-reflection using the Pearline Mastery scale (PMS). ²⁸ Integrative empowerment consists of a management disease developed by researchers according to draft Zhou et al. ¹¹ and Keliat ²³ management stress parenting created according to draft Murison ²⁹ and explored the meaning of new questionnaire statements were developed according to the concept of integrative empowerment. ¹¹ The dependent variable is the ability of the family to care for patients with schizophrenia, namely: The Questionnaire for Meeting the Needs of Daily Activities from the Barthel Index, ⁸ the Questionnaire to assist social interaction from the Caregiving Tasks in Caring for an Adult with Mental Illness Scale (CTiCAMIS), ⁸ the questionnaires help productive skills developed from concepts Janardhana. ³⁰

Furthermore, the instruments the researchers used in the second stage, FGD and expert discussions, are shown in the questions guide below:

• (1). What are the possible causes of the patient, family, social environment, and health worker’s factors on the family’s ability to care for patients with schizophrenia disorder?

• (2). What are the families’ expectations for mental health services and the social environment to improve and support the family-integrated empowerment to care for patients with schizophrenia disorder?

• (3). What efforts can be made to overcome problems from patient, family, social environment, and health workers factors on the family’s ability to care for patients with schizophrenia disorder?

• (4). What interventions can be given to families to increase integrative empowerment in caring for patients with schizophrenia disorder?

Ethical issues and approval

Patients with schizophrenia disordered families were given detailed information about the aim of the study. Verbal and written consent was sought from the respondents before they filled out questionnaires. The respondents were ensured confidentiality and freedom of participation in the study. The Ethics Review Board approved the research at the health research ethics committee of Universitas Airlangga number 2637-KEPK on September 8th 2022, and Dr. Amino Gondohutomo Regional Psychiatric Hospital number 420/12375 on September 7th 2022.

Data collection and measurements

The data collection in the first phase begins with an explanation of the research, and the signing of informed consent as a legal requirement for research ethics. Respondents filled out questionnaires with the researcher. In the second phase, focused group discussions (FGD) were conducted with families, health workers, and social workers, explaining the research and informed consent, and also asking several questions according to the FGD guidelines. The results of the FGD in the form of recommendations became material for discussion with two experts. The results of expert guidance and FGDs were compiled to become material for developing an integrative empowerment-based family empowerment model.

Statistical analyses

Data analysis uses Partial Least Squares (PLS) in the first phase. The PLS results are used to build an inner model of several forming factors and influencing variables based on t-statistical values (t ≥ 1.96) and path coefficients (−/+), to see the direction of influence or decline. These results are material for formulating strategic issues that researchers will discuss in FGDs and expert discussions in the second phase. The results of the FGDs and expert discussions were recorded and transcribed, then read repeatedly and looked at for keywords and silence in several categories, which gave rise to sub-themes and themes. The results are compiled into material for developing an integrative empowerment-based family empowerment model.

Results

Characteristics of the respondents

The general characteristics of the respondents are shown in Table 1. Table 1 shows that respondents are gender-balanced, middle-aged or productive, with sufficient education (Senior High School/Vocational High School), working primarily as private employees, and have the social security to care for patients with schizophrenic disorder. Family caregivers or informal caregivers are siblings of a schizophrenic patient, followed by the mother.

Table 1.

Characteristics of respondents at Dr. Amino Gondohutomo regional psychiatric hospital in 2022 (n = 135).

Characteristics of respondents		F	%	Characteristics of respondents		f	%
Gender	Male	68	50.4	Occupation	Civil servants	6	4.4
	Female	67	49.6		Pensionary	9	6.7
Age	Early adult	20	14.8		Entrepreneur	24	17.8
	Middle adult	69	51.1		Private employee	51	37.8
	Pre-elderly	46	34.1		Housewife	31	23.0
Social security	Non private	129	95.6		Labour	9	6.7
	Private	6	4.4		Unemployed	5	3.7
Family structure	Father	22	16.3	Education	Not completed elementary school	1	7.7
	Mother	31	23.0		Elementary school	28	20.7
	Child	14	10.4		Junior high school	29	21.5
	Siblings	53	39.3		Senior high school	52	38.5
	Husband	8	5.9		College	25	18.5
	Wife	7	5.2

Variables description

The results of this study show that at patient factors, 68.9% of patients do not have a history of comorbidities. In the family factors, no-one in the family has a history of mental disorders (85.9%), yet there are negative cultural values where they still go to alternative medicine (66.7%). The social-environmental factors found that 100% of families do not have social networks. At the same time, the health service factor shows that access to mental health services is relatively affordable in regard to the referral route (72.6%), and distance to health services (71.9%). The Outside-in empowerment variable found that most of the family’s knowledge of caring for patients with schizophrenia disorder was still lacking (57%). The Inside-out empowerment variable found that families interpreting parenting are still perceived as unfavorable (24.1%). The integrative empowerment variable shows that the disease management of patients with schizophrenia disorder is still in the excellent category, especially communication skills with patients (54.8%).

Nevertheless, the ability to explore new meanings is still in the excellent category in accepting the care situation (20.7%). This study also found that the ability of families to care for patients with schizophrenia disorder to fulfill ADL needs, for the most part, is the patients’ hygiene (40.7%). However, the ability of families to help social interaction still needs to improve in skills to build up patient relationships with the community (32.6%).

Integrative empowerment model

The hypothesis test results of the first phase are described in Figure 1. The patient factors make a stronger impact on Inside-out empowerment (path coefficient = 0.244; t = 3.284) than on Outside-in empowerment (path coefficient = 0.186; t = 2.364), but do not affect the families’ ability to care for patients with schizophrenia disorder (path coefficient = −0.065; t = 1.048). Family factors make a stronger impact on Inside-out empowerment (path coefficient = 0.217; t = 2.309) than Outside-in empowerment (path coefficient = 0.210; t = 2.191). The social-environmental factors make a strong impact on Outside-in empowerment (path coefficient = 0.179; t = 2.064) but do not affect Inside-out empowerment (path coefficient = −0.035; t = 0.314). Health service factors make a stronger impact on Inside-out empowerment (path coefficient = 0.340; t = 3.564) than Outside-in empowerment (path coefficient = 0.220; t = 2.651). The dominant factors that directly contribute to Outside-in and Inside-out empowerment variables and indirectly contribute integrative empowerment are family factors and health service factors. Inside-out empowerment makes a strong impact on integrative empowerment-based family empowerment (path coefficient = 0.478; t = 4.850) compared to Outside-in empowerment (path coefficient = 0.309; t = 3.292). Moreover, re-meaning of caregiving is the strongest indicator that builds the Inside-out empowerment variable (t = 42.643). Integrative empowerment-based family empowerment strongly impacts families’ ability to care for patients with schizophrenia disorder (path coefficient = 0.625; t = 9.023).

Figure 1.

Family empowerment model based on integrative empowerment on PLS test.

Development integrative empowerment-based family empowerment model

Furthermore, the development of an integrative empowerment-based family empowerment model for the ability to care for patients with schizophrenic disorder is shown in Table 2.

Table 2.

Development of an integrative empowerment-based family empowerment model.

Structure	Standard	Development
Patient factor	1. Onset 2. Comorbidity 2	The family recognizes the signs and symptoms that appear in patients early and reduce the potential frequency of relapse.
Family factor	1. Socio-economic 2. Parenting experience 3. Resources 4. Internal vulnerabilities 5. Cultural values .2,11	1. Changing negative caring experiences and minimizing susceptibility to depressive feelings 2. Positive cultural values 3. The family expresses its emotions normally 4. Aspects of spirituality as part of family resources.
Social environment factor	1. Stigma 2. Social support . 2	1. Reducing the stigma that comes from the family and society 2. Families open themselves to the surrounding community.
Health service factor	1. Access to health services 2. Infrastructure 3. Health workers 15	1. Families reach access to the nearest mental health services and seek help from a mental health worker 2. Government regulations that prioritize mental health programs.
Outside-in empowerment	1. Knowledge 2. Coping skills 3. Family interaction 11	Strengthening knowledge of how to care for and family coping skills in coping with the burden of parenting and building family interactions through counseling.
Inside-out empowerment	1. Remeaning parenting 2. Self-reflection 11	Strengthening the ability to interpret and self-reflect through aspects of spirituality, patient acceptance, and family emotional expression.
Integrative empowerment	1. Disease management 2. Management of parenting stress 3. Exploring new meanings 11	Exploring new meanings through communication skills, advocacy and medication awareness, stress management techniques, as well as increasing family awareness about the meaning of caring which can enhance Integrative Empowerment.
Family caring ability	1. Meeting the needs of ADL 2. Help social interaction 3. Helps productive skills 31	1. Assistance in self-care, empowering patients to perform ADLs, and providing re-inforcement 2. Involve patients in activities in the family and community environment according to their hobbies and abilities

Integrative empowerment-based family empowerment

The final results of this study resulted in the development of an Integrative Empowerment-based Family Empowerment model, which is shown in Figure 2.

Figure 2.

Final model from integrative empowerment-based family empowerment.

Figure 2 shows the development of an integrative empowerment-based family empowerment model to increase the family’s ability to care for and prevent the recurrence of patients with schizophrenia. The research results in stage one show that there is path analysis, which is a determinant of integrative empowerment-based family empowerment model development. Outside-in and Inside-out empowerment are two variables that strongly influence and contribute to integrative empowerment-based family empowerment. Outside-in empowerment contributes 30.9%, while the Inside-out empowerment variable makes a stronger impact contribution of 47.7%. Moreover, re-meaning of caregiving is the strongest indicator that builds the Inside-out empowerment variable (t = 42.643). The family and health service factors are the strongest factors that directly contribute to Outside-in empowerment, and Inside-out empowerment and indirectly contribute to integrative empowerment. Family factors contribute 21.1% to Outside-in empowerment and 20.2% to Inside-out empowerment. Health service factors contribute 22.1% to Outside-in empowerment and 33.5% to Inside-out empowerment. This research’s new findings also show that family empowerment based on integrative empowerment is very significant and contributes directly by 61% to increase the ability of families to care for patients with schizophrenia disorder.

Generalizability of the study

This study’s Q-square predictive relevance value is Q² 0.433 > 0, where the greater the Q² > 0 value, the better the relevance when applied to other areas. Therefore, the integrative empowerment-based family empowerment model can be generalized into different research locations.

The goodness of fit of model development

The goodness of fit test of the constructed model assesses the prediction capability of the integrative empowerment model for schizophrenia patients. The value of Q² above 0 indicates that the Predictive Relevance (Q²) model has a good or significant prediction (Table 3) since 61% of the family’s ability to provide care for schizophrenia (Figure 1) patients can be explained by variables of Outside-in and Inside-out empowerment, family, and health service factors. This result indicates that the development of this model is structured by data derived from the actual data.

Table 3.

Generalizability of the study.

	SSO	SSE	Q² (=1−SSE/SSO)
X family empowerment Integrative Empowerment	405.000	266.207	0.433
Y family ability to caring for patients	405.000	308.826	0.527

Discussion

The integrative empowerment model was developed on two components, Outside-in empowerment and Inside-in empowerment. This study shows that Inside-out empowerment has influence and contributes stronger to forming integrative empowerment-based family empowerment. The study’s results by Zhou et al. found that the narrative group that received Inside-out empowerment had more power to increase their inner resources, perceived control, and levels of hope. ¹¹ Narrative groups also empower caregivers using processes of self-exploration, self-actualization, and the search for meaning from the inside out empowerment.

Re-meaning of caregiving is the most potent indicator in shaping Inside-out empowerment, which is the strongest factor forming this model. Re-meaning of caregiving is an inner resource that families can use as an internal resource for caring for schizophrenic patients. The re-meaning of caregiving is developed through spirituality, where religion functions in long-term adaptation to the family, including maintaining self-esteem and self-confidence, providing a sense of meaning or purpose, providing emotional comfort and calm, and generating an overall sense of hope. ³² Personal trust from the family is related to self-confidence in the existence of God, faith and belief in the power of God will give the best for him and belief in his positive abilities which will give strength to the family when experiencing difficulties and stress due to caring for patients with schizophrenic disorder. ³³

Besides that, family self-reflection is a form of Inside-out empowerment. The ability to self-reflect can be done through patient acceptance and good self-control. Family acceptance of patients can be done by inviting them to communicate and reducing stigma. Research by Mamnuah shows that the role of the family in preventing relapse of patients with schizophrenia disorder is to accept, provide assistance, hope, and communication with the family. ³⁴ Meanwhile, family self-control is by displaying normal family emotions when dealing with the mental condition of patients with schizophrenia disorder. Self-control, the desire to care for patients and family self-evaluation enable families to function optimally to carry out family health duties, namely caring for patients with schizophrenic disorder while at home. The results of the study by Wang et al. ³⁵ show that patients with schizophrenic disorder who live in families with an environment that provides encouragement and praise can increase life satisfaction which supports patient recovery. A supportive family environment can be done with self-reflection through good self-acceptance and control.

The family and health service factors are the strongest factors that directly contribute to Outside-in empowerment and Inside-out empowerment and indirectly contribute to integrative empowerment model. Family factors significantly influence Outside-in empowerment. This can happen because the components of knowledge, coping skills and family interaction can be built properly if the family has sufficient resources, especially on the spiritual and socio-economic aspects as well as positive parenting experiences, and the family does not have internal vulnerabilities, namely being free from feelings of depression. Inside-out empowerment is strongly influenced by health service factors, where access, infrastructure and health workers will support the family. Families with access to mental health facilities, adequate infrastructure based on patient needs, and skilled and responsive mental health workers to help and educate how to care have the strength and support resources to make their caring experience more positive and easy.

The integrative empowerment-based family empowerment model cannot be separated from Outside-in empowerment which consists of knowledge, coping skills and interaction within the family. Outside-in empowerment component also significantly influences the integrative empowerment-based family empowerment model. This could be because families will have good disease management skills, stress management and exploration of new meanings in caring for patients with schizophrenia disorder if supported by good caring knowledge, adaptive coping skills and the ability to build interactions between family members. Past research shows that Outside-in empowerment equips families with related knowledge, emotional coping skills, communicative skills, and awareness advocacy, including incorporating knowledge about schizophrenia and treatment, improving coping skills, communication skills and disease management. ¹¹ The past research results by Zhou et al. also found that the psychoeducational group who received Outside-in empowerment showed significant increases in family relationships, parenting burden, and coping skills compared to the control group. ¹¹

The re-meaning of caregiving in Inside-out empowerment can be carried out through spirituality, patient acceptance, and normal family emotions’ expression. Mental health nurses need to implement integrative empowerment-based family empowerment for families to increase their ability to care for patients with schizophrenic disorder, by making meaningful and positive caring experiences their strengths. Nurses assist families to be able to find activities that can generate positive meaning when caring for patients with schizophrenia.

This study uses two methods, Outside-in empowerment and Inside-out empowerment approaches, from now on referred to as integrative empowerment. This method has yet to be widely developed and researched. In addition, the researchers’ findings provide a solution for families to use their resources and positive parenting experiences by making meaning for treatment and preventing the recurrence of patients with schizophrenia disorder. Furthermore, this study’s Q-square predictive relevance value is Q² 0.433 > 0, where the greater the Q² > 0 value. So, the results of this study can be generalized, the integrative empowerment-based family empowerment model has relatively good relevance when applied in different research locations.

The limitation of this study is that researchers took data from families with much free time to accompany patients to control treatment. Hence, they are not caregivers caring for patients with schizophrenic disorder at home, so researchers are limited in accessing several measured variables, especially the family care experience variable.

Significance for public health

One of the reasons for the high rate of re-admission and relapse in patients with schizophrenia disorder is the family’s inability to treat and prevent relapse whilst the patient is at home. The main factor that causes families the inability to take care of patients with schizophrenia disorder is inadequate family-centered empowerment. Families take care of patients with schizophrenia disorder according to their habits and knowledge, without realizing that family care is a positive strength source for schizophrenia recovery and the caregivers’ health. ¹⁴ Unfortunately, the integrative empowerment-based family empowerment model has not been developed. This model is expected to strengthen the families’ ability to take care of and prevent relapse of patients with schizophrenia disorder, both in terms of increasing skills, knowledge, rewarding experiences and discovering new meanings of parenting.

Conclusion

In conclusion, this study found that Inside-out empowerment contributed significantly to the integrative empowerment-based family empowerment stronger than Outside-in empowerment. While the family and health service factors directly contribute to Outside-in empowerment and Inside-out empowerment and indirectly contribute to integrative empowerment. Mental health nurses need to implement integrative empowerment-based family empowerment for families to increase their ability to care for patients with schizophrenia disorder by making meaningful and positive caring experiences their strengths. Nurses assist families to be able to find activities that can generate positive meaning when caring for patients with schizophrenia. Families need to re-meaning caregiving through spirituality as an inner resource to strengthen families’ s ability to care for patients with schizophrenia disorder.