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. 2024 Jun 28;11(7):e2230. doi: 10.1002/nop2.2230

Post‐stroke family resilience is correlated with family functioning among stroke survivors: The mediating role of patient's coping and self‐efficacy

Wei Zhang 1, Ya‐Jing Gao 1, Ming‐Ming Ye 1, Lan‐Shu Zhou 1,✉
PMCID: PMC11212063  PMID: 38940513

Abstract

Aim

Family resilience and healthy family functioning are crucial for stroke survivors' rehabilitation. This study aimed to determine the mediating effects of self‐efficacy and confrontation coping on the relationship between family resilience and functioning among patients with first‐episode stroke.

Design

A cross‐sectional design was applied.

Methods

288 patients with first‐episode stroke were recruited from 7 hospitals in Shangqiu and Shanghai, China, from July 2020 to October 2020. A shortened Chinese version of the Family Resilience Assessment Scale, family adaptation, partnership, growth, affection and resolve questionnaire, Medical Coping Modes Questionnaire, and Self‐efficacy for Chronic Disease 6‐item Scale were used to collect the self‐reported data. The relationships among the studied variables were studied using spearman correlation and structural equation model.

Results

The average level of family functioning among stroke patients was 7.87 (SD = 2.32). About 26.8% (n = 76) of patients reported family dysfunction. The structural equation model showed that family resilience directly affected patients' satisfaction with family functioning (r = 0.406, p < 0.001) and indirectly affected the mediating role of patients' self‐efficacy and confrontation coping style (r = 0.119, p < 0.001). The model was with good fit (χ 2/df = 2.128, RMSEA = 0.065, GFI = 0.956, AGFI = 0.919, NFI = 0.949, and TLI = 0.956).

Conclusion

Family resilience and functioning among patients with first‐episode stroke are positively associated with the mediating effects of the patients' confrontation coping style and self‐efficacy between family resilience and functioning. The findings indicate that the professionals should pay special attention to families exhibiting poor family resilience or with patients who rarely use confrontation coping styles or with poor self‐efficacy since they are more likely to suffer from low functioning.

Keywords: confrontation coping, family functioning, family resilience, self‐efficacy, stroke, structural equation model

1. INTRODUCTION

Stroke is the second leading cause of disability and death across the world (Saini et al., 2021). The number of stroke survivors may significantly increase among the ageing population due to the improved survival rate (Jarva et al., 2021). Since the initial acute care in hospital, most families of stroke survivors may have to modify their family roles to accommodate stroke rehabilitation, thus challenging the adaptive capacity and placing multiple stresses on the original family functioning (Evans et al., 1994). Many families will face a difficult, lengthy, and demanding rehabilitative challenge (Chen et al., 2021). Moreover, family dysfunction may lead to substandard physical and mental health outcomes for stroke patients; a good family functioning positively influences stroke patient recovery (Epstein‐Lubow et al., 2009). Therefore, post‐stroke family functioning requires special attention.

In view of the short period of rehabilitation in hospitals and the lag in community services, the demands on families are increasing, and understanding and promoting post‐stroke family functioning is necessary (Chen et al., 2021). In theory, family‐centred psychosocial intervention could improve family functioning. However, family‐centred approaches are more difficult than interventions targeted at individual behaviours (Palmer & Glass, 2003). Family Process Theory (Gardner et al., 2001) indicates that family functioning involves the process of individuals dealing with family problems and executing family tasks. Shek (1999) suggested that individual‐ and family‐level understanding should be involved when focusing on family functioning as a whole unit. In this study, the mechanism of family functioning was explored from family and individual levels to develop family‐centred interventions combining the individual interventions targeted for improving family functioning.

Family functioning refers to day‐to‐day patterns within a family, representing the family's capacity to ensure a supporting environment for family members to thrive (Gawulayo et al., 2021). Smilkstein (1978) assessed individual's satisfaction with family functioning based on 5 domains—family adaptation, partnership, growth, affection, and resolve (APGAR). The domains reported by individual can be used to evaluate whether the family adequately communicates, give emotional support, adapt to, or problem‐solve with patient (Castilla et al., 2014; Gardner et al., 2001). A recent study showed that APGAR can also be used to assess family dysfunction at the family level (Takenaka & Ban, 2016), and thus enabled a fully understanding of family functioning.

The concept of family resilience has been promoted as an enduring force that changes family functioning dynamics due to the development of family strength perspective (Lee et al., 2004). Family resilience provides an opportunity to identify family resources and strengths and promote family functioning (Patterson, 2002). Walsh (2003) identified three domains in the key process of family resilience (shared family belief systems, family organizational patterns, and family communication and problem‐solving). Previous studies show that family resilience promotes family functioning through these three domains (Chang et al., 2015). A family resilience framework can guide clinical interventions (Walsh, 2012). Therefore, research on the effects of family resilience on family functioning among stroke patients is crucial to further develop psychological services that will prepare families for caregiving and support them in their ongoing adaptation to stroke.

Some literatures have also indicated that family resilience can mobilize other protective factors (such as family members' self‐efficacy and coping), thus affecting family functioning (Black & Lobo, 2008; Gralton et al., 2022). To the best of our knowledge, no study has reported on this field. In this study, we discussed the individual‐level protective factors of coping and self‐efficacy in the resilience process of family functioning from the perspective of patients with first‐episode stroke. These two factors can be targets for interventions and thus making them worthwhile to be studied.

Several studies have assessed the role of individual coping on family functioning among patients with chronic diseases, such as autism spectrum disorders (Meleady et al., 2020; Rea‐Amaya et al., 2017) and Rett syndrome (Lamb et al., 2016). The positive coping of family members is correlated with better family functioning. Moreover, family resilience influences the positive coping of patient with disease (Cui et al., 2022). Therefore, positive coping may mediate between family resilience and functioning. In this study, the patients were selected during hospitalization. This study focused on the positive medical coping style of patients (confrontation; the positive cognitive and behavioural ways applied to manage disease with the characteristic of being more controlling, competitive, and extroverted) (Feifel et al., 1987). We hypothesized that confrontation may mediate between family resilience and family functioning among stroke patients.

Self‐efficacy, the internal resources of a person (Hesamzadeh et al., 2015), is a predictor of family functioning (Scholten et al., 2020). Self‐efficacy is one's belief in their ability to achieve success in doing certain tasks (Bandura et al., 1999). A prospective study demonstrated that self‐efficacy to control symptoms and maintain function can improve family functioning among patients with coronary heart disease (Sullivan et al., 1998). Meanwhile, studies have demonstrated that family environment affects individual self‐efficacy (Al Ayyubi et al., 2018; Bradley, 2019; Mishra & Shanwal, 2014). Family resilience provides a supporting and healthy family environment. These findings indicate that family resilience positively affects individual self‐efficacy (Li et al., 2018). Therefore, we hypothesized that patient's self‐efficacy for managing chronic disease could mediate between family resilience and functioning.

Although studies have provided valuable evidence on the relationships among family resilience, coping style, self‐efficacy and family functioning, none has investigated the mediating effects of individual variables on the resilience process of family functioning, which limit information for family‐centred intervention. This study aimed to determine the mediating effects of patients' self‐efficacy and confrontation coping on the relationship between family resilience and functioning among stroke patients. Our hypotheses were as follows:

Family resilience positively predicts family functioning among patients with first stroke.

Confrontation coping mediates the relationship between family resilience and functioning.

Patient self‐efficacy for managing disease mediates the relationship between family resilience and functioning.

Patient self‐efficacy for managing a disease is positively associated with confrontation coping style of patients with first stroke.

2. MATERIALS AND METHODS DESIGN

2.1. Design

A cross‐sectional study with a suitable sample of patients with first‐episode stroke was conducted.

2.2. Participants

The potential participants were recruited from 7 tertiary hospitals in two Chinese cities‐Shanghai and Shangqiu. The inclusion criteria were: (1) Patients aged ≥18 years; (2) patients who were diagnosed with a first‐ever ischemic stroke and confirmed by CT or MRI; (3) patients with stable vital signs; (4) patients who had agreed to participate and given voluntary informed consents.

The exclusion criteria were: Patients diagnosed with: (1) transient ischemic attack (TIA) or recurrent ischemic stroke; (2) comorbidities such as severe organ dysfunction, malignant tumours, dementia; (3) mental illness, aphasia, blindness, deafness, or cognitive disorders, which affect communication.

2.3. Data collection

The study was approved by REDACTED. Data were collected by two research assistants from July 2020 to October 2020. The staff from the inpatient neurology department helped to identify the eligible patients. Patients who were in stabilization after the acute stage would be considered during their hospitalization. All the participants were recruited via face‐to‐face interviews. The study purpose was explained to all participants before data collection. The potential participants voluntarily signed the informed consent and were allowed to withdraw from the study at anytime. The patients were encouraged to complete the questionnaire (10–20 min) independently to ensure accuracy. Research assistants helped those who had difficulty reading and filling in the questionnaires item by item and recorded their answers correspondingly. The key variables, including: (a) family functioning; (b) family resilience; (c) confrontation coping; (d) self‐efficacy; and (e) social‐demographic and disease‐related characteristics, were collected.

2.3.1. Family functioning

The patients' satisfaction with family functioning was evaluated using APGAR (Smilkstein, 1978). APGAR is a 11‐point scale ranging from 0 to 10, and a higher score represents a higher level of satisfaction with family functioning. Scores of 0–3 indicate severe family dysfunction, 4–6 indicate moderate family dysfunction, and 7–10 indicate good family function. The family APGAR had been previously applied in Chinese stroke patients with a Cronbach's α value of 0.86 (Yang et al., 2021).

2.3.2. Family resilience

The Family Resilience Assessment Scale (FRAS) was designed by Sixbey (2005) based on Walsh (2003)'s Family Resilience Model to assess family resilience. It has 54 items and six subscales. The shortened Chinese version of FRAS (FRAS‐C) consists of 32 items and 3 subscales, utilizing social resources (USR) and maintaining a positive outlook (MPO) and family communication/problem‐solving (FCPS) (Li et al., 2016). Each item is rated on a 4‐point Likert scale from 1 (strongly disagree) to 4 (strongly agree). A higher score indicates a greater family resilience. The psychometric property of FRAS‐C has been reported in families with breast cancer survivors with a Cronbach's α value of 0.96 (Li et al., 2018).

2.3.3. Confrontation coping

The Medical Coping Modes Questionnaire (MCMQ) was developed by Feifel et al. (1987) to assess coping styles of patients. The MCMQ consists of 20 items and 3 subscales (resignation, avoidance, and confrontation), which is rated on a 4‐point Likert scale from 1 (never) to 4 (fully met). The score range of confrontation subscale is 4–20. A higher average score in confrontation subscale shows that the patient often uses confrontation coping style. The MCMQ has been previously used in stroke patients, with Cronbach's α value of confrontation of 0.78 (Han et al., 2021).

2.3.4. Self‐efficacy

The Self‐Efficacy for Chronic Disease 6‐item Scale (SECD6) was developed by Lorig et al. (2001) to assess patients' confidence in their abilities to manage their symptoms (fatigue, pain, emotional distress, and health problems) while doing activities and confidence in managing chronic disease. The average item score ranges from 1 (with no confidence at all) to 10 (with absolute confidence). The Chinese version of the SECD6 has been reliably used to assess self‐efficacy of different populations with chronic diseases (Jiang et al., 2020), including stroke patients (Cronbach's α = 0.94) (Tsai et al., 2021).

2.4. Data analysis

SPSS 23.0 and AMOS 16.0 were applied for data analysis after double checking. The data were expressed as frequencies, percentages, means and standard deviations. The correlations among family resilience, family functioning, confrontation coping style, and self‐efficacy were evaluated using spearman correlation analysis. The mediating role of self‐efficacy and confrontation coping style on the relationship between family resilience and family functioning was determined using a structural equation model. p < 0.05 indicated statistical significance.

3. RESULTS

3.1. Sample characteristics

Overall, 288 patients with first‐episode stroke were included (71.2% males and 28.8% females). The average age of participants was 61.85 (SD = 12.27) years old. About 63.5% of the participants lived in Shanghai, China. About 94.4% were patients with ischemic stroke. The socio‐demographic data of the participants are listed in Table 1.

TABLE 1.

Socio‐demographic and clinical characteristics of the participants (n = 288).

Variable N (%)/M ± SD
Age (years) 61.85 ± 12.27
Gender
Male 205 (71.2)
Female 83 (28.8)
Living city
Shanghai 183 (63.5)
Shangqiu 105 (36.5)
Education
Primary school or below 110 (38.2)
Junior high school 78 (27.1)
Senior high school 68 (23.6)
Colleges or above 32 (11.1)
Type of stroke
Ischemic 272 (94.4)
Hemorrhagic 16 (5.6)
Rankin scores
0 7 (2.4)
1 105 (36.5)
2 52 (18.1)
3 38 (13.2)
4 78 (27.1)
5 8 (2.8)
Working status
At work 58 (20.1)
Retired 145 (50.3)
Unemployed 85 (29.5)
Marriage status
Married 259 (89.9)
Without a partner 29 (10.1)
Family monthly income
≤3000 CNY 106 (36.8)
3000–5000 CNY 130 (45.1)
>5000 CNY 52 (18.1)
Type of payment
At own expense 35 (12.2)
Medical insurance 253 (87.8)
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Abbreviations: M, mean; N, number; SD, standard deviation.

3.2. Correlations among the study variables

The descriptive statistics of the study variables and correlation analyses are shown in Table 2. The mean score of APGAR was 7.87 (SD = 2.32), highest in the dimension of resolve, followed by adaptation, affection, partnership, and growth. About 26.8% of patients (n = 76) reported APGAR lower than 7. The mean level of RRAS‐C was 95.52 (SD = 11.10) and was positively correlated with the APGAR value and its dimensions. Patient self‐efficacy and confrontation coping were positively correlated with APGAR and FRAS‐C values (p < 0.05).

TABLE 2.

Descriptions and correlations among the family resilience, confrontation coping, self‐efficacy and family functioning of stroke patients (n = 288).

Variable M ± SD r
1 2 3 4 5 6 7 8
1. Family resilience 95.52 ± 11.10 –
2. Confrontation coping 17.50 ± 2.61 0.227** –
3. Self‐efficacy 43.64 ± 8.88 0.391** 0.169** –
4. Family functioning 7.87 ± 2.32 0.474** 0.277** 0.487** –
5. Adaptation 1.69 ± 0.52 0.337** 0.209** 0.295** 0.705** –
6. Partnership 1.55 ± 0.59 0.393** 0.207** 0.364** 0.835** 0.576** –
7. Growth 1.33 ± 0.65 0.451** 0.327** 0.463** 0.797** 0.385** 0.550** –
8. Affection 1.58 ± 0.58 0.360** 0.151* 0.361** 0.791** 0.508** 0.627** 0.496** –
9. Resolve 1.74 ± 0.50 0.370** 0.173** 0.337** 0.710** 0.611** 0.608** 0.424** 0.602**
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Abbreviations: M, mean; SD, standard deviation.

*Correlation is significant at 0.05 level, **Correlation is significant at 0.01 level.

3.3. Structural equation model

The validated model and the standardized effect among variables are shown in Figure 1. The model showed a satisfactory model fit (χ 2/df = 2.128, RMSEA = 0.065, GFI = 0.956, AGFI = 0.919, NFI = 0.949, and TLI = 0.956). The standardized direct, indirect, and total path estimates in the final model are listed in Table 3. Family resilience had the greatest direct effect on family functioning (r = 0.406, p < 0.001). Family resilience also indirectly affected family functioning (r = 0.119, p < 0.001). The path from self‐efficacy to confrontation coping style was non‐significant (t = 1.097, p = 0.273).

FIGURE 1.

FIGURE 1

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The structural equation model of family resilience, confrontation coping, and self‐efficacy and family functioning among stroke survivors. FCPS, family communication/problem‐solving; MPO, maintaining a positive outlook; USR, utilizing social resources.

TABLE 3.

The standardized total, direct, and indirect influences of a model evaluating relationships among the family resilience, confrontation coping, self‐efficacy and family functioning of stroke patients (n = 288).

Model pathway Estimate SE 95% confidence interval p
Lower Upper
Total effect
Family resilience → family functioning 0.53 0.053 0.414 0.621 <0.001
Direct effect
Family resilience → family functioning 0.41 0.059 0.287 0.516 <0.001
Family resilience → confrontation coping 0.17 0.068 0.034 0.300 0.017
Confrontation coping → family functioning 0.13 0.057 0.018 0.240 0.022
Family resilience → self‐efficacy 0.36 0.055 0.248 0.466 <0.001
Self‐efficacy → family functioning 0.26 0.059 0.142 0.372 <0.001
Indirect effect
Family resilience → family functioning 0.12 0.028 0.069 0.183 <0.001
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Abbreviation: SE, standard error.

4. DISCUSSION

To the best of our knowledge, this is the first study to examine the individual‐level mediators between family resilience and functioning among families of patients with first‐episode stroke. This study found that family resilience directly and positively affected patients' satisfaction with family functioning. Moreover, patients' confrontation coping and self‐efficacy had a mediating role in the relationship between family resilience and functioning.

In this study, 26.8% of patients rated their families as dysfunctional, indicating that post‐stroke families may suffer from dysfunction. Dysfunctional families may undermine the functional and mental health outcomes of stroke survivors, as well as the well‐being of their caregivers (Isaacs et al., 2018). Therefore, nurses should facilitate early family functioning after the stroke. Herein, family functioning was highest in the dimension of resolve, indicating higher patient satisfaction with the commitments that family members established. However, family functioning was lowest in the dimension of growth, suggesting that the patients perceived low emotional growth due to changes in the family. Therefore, emotional growth of the families should be enhanced post‐stroke. It is also crucial to understand the predictors and influencing factors of family functioning for further intervention strategies.

Moreover, family resilience directly affected family functioning among stroke patients, indicating that fostering family resilience can avert/reduce family dysfunction and promote family functioning post‐stroke. Previous researches also reported similar results (Chang et al., 2015). Therefore, family resilience strategies, including positive thinking, accepting changes, creating supportive family relationships, and building social relationship (Van't Noordende et al., 2021), can promote family functioning post‐stroke. Furthermore, family resilience was lowest in the dimension of utilizing social resources post‐stroke, similar to Lei and Kantor (2021)'s finding with families of children with autism spectrum disorder. Therefore, resilience‐based interventions, especially those assisting families to identify their potential social resources and providing opportunities to practice specific methods to improve positively utilizing, are crucial for family functioning post‐stroke.

Stroke patients' confrontation coping mediated between family resilience and functioning. These results showed that family resilience directly affect patients' confrontation coping style, consistent with (Power et al., 2016)'s study on parents with mental illness. Therefore, from a family level, increasing family resilience might provide a supporting environment for patients to adopt confrontation for managing stroke. The results also indicated that families with stroke patients who adopted the confrontation coping style had better functioning. Confrontation is a form of problem‐focused coping (Sampogna et al., 2018), where patients with first‐episode stroke try to face and address problems positively, thereby enhancing the confidence of other family members in facing stroke, thus improving the family functioning. Therefore, family functioning after stroke can be improved by enhancing self‐esteem and internal health locus of control (Zou et al., 2017) to increase confrontation coping.

The stroke patients' self‐efficacy for managing chronic diseases also had a mediating role between family resilience and functioning. Better family resilience correlated to higher patients' self‐efficacy for managing stroke, demonstrating that family resilience shapes individual' self‐efficacy (Bandura & Watts, 1996; Sayyadi et al., 2017). Interventions targeting at fostering family resilience might also increase patients' self‐efficacy. Additionally, patients' self‐efficacy was closely associated with family functioning, consistent with previous studies (Scholten et al., 2020). However, 35.4% of patients reported low self‐efficacy in managing stroke (SECD6 <7) (Fan & Lv, 2016), possibly because the impact of the first‐episode stroke leads to functional limitations in the fields of communication, cognition, emotions, motor control or mobility (Szczepańska‐Gieracha & Mazurek, 2020). Therefore, tailored intervention should be provided during hospitalization to increase self‐efficacy in patients with first‐episode stroke, which may improve family functioning post‐stroke.

Contrary to our hypothesis, the direct path from self‐efficacy to confrontation coping was non‐significant in this model. However, previous studies showed that self‐efficacy is positively related to better coping (Amirshamsi et al., 2022; Wu et al., 2021). This difference might be because the study was conducted during hospitalization, shortly after the attack of stroke. The patients are in a passive role of receiving care from their family members during this period, and their coping styles might be influenced by many other factors apart from self‐efficacy. However, further qualitative study or multi‐centre quantitative study should verify the results.

This study had some limitations. First, the patients were recruited through convenience sampling from urban areas of two cities, which might limit the generalizability of the results to the rural areas. Second, patients with severe communication difficulties were excluded, indicating that some important information might have been lost. Therefore, further studies focusing on these patients with other assessment methods are needed. Third, this is a quantitative study based on a cross‐sectional design, qualitative studies assessing the daily life of family members is needed in the future for a fully understanding of family resilience and functioning.

5. CONCLUSION

This study demonstrated the role of family resilience in predicting family functioning among patients with first‐episode stroke. Patients' confrontation coping and self‐efficacy had a mediating role in the relationship between family resilience and functioning. The study model enhanced the understanding of family functioning from a family strength and individual‐level perspective. Therefore, these findings can help healthcare professionals to identify vulnerable families and develop tailored resilience‐based interventions for strengthening family functioning. Incorporating studies on post‐stroke families and applying various family therapy techniques can help nurses in their clinical work. This study explains family functioning from the perspective of family resilience and individual characteristics and can help in the combination of family‐level and individual‐level interventions targeted at improving family functioning. Therefore, nurses should pay special attention to families with poor family resilience or those with patients who rarely use confrontation coping styles or with poor self‐efficacy since they are more susceptible to suffer from low functioning. Family resilience‐based interventions combining individual interventions on their coping and self‐efficacy may promote family functioning post‐stroke.

AUTHOR CONTRIBUTIONS

Wei Zhang: Conceptualization; Methodology; Interpretation of data; Writing the original draft; Approval of the final version. Ya‐Jing Gao & Ming‐Ming Ye: Data acquisition and analysis; Review and editing; Approval of the final version. Lan‐Shu Zhou: Conceptualization; Methodology; Review and editing; Approval of the final version.

FUNDING INFORMATION

The study was funded by the youth program of the National Natural Science Foundation of China (grant number 71904197) and the Sailing project of Naval Medical University.

CONFLICT OF INTEREST STATEMENT

No conflict of interest has been declared by the authors.

6. ETHICS STATEMENT

This study was approved by the Ethics Review Board of Second Military Medical University.

ACKNOWLEDGEMENTS

We appreciate the cooperation of all study participants during the data collection process.

Zhang, W. , Gao, Y.‐J. , Ye, M.‐M. , & Zhou, L.‐S. (2024). Post‐stroke family resilience is correlated with family functioning among stroke survivors: The mediating role of patient's coping and self‐efficacy. Nursing Open, 11, e2230. 10.1002/nop2.2230

Wei Zhang and Yajing Gao are joint first authors.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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