Improving the quality of life and resilience of family caregivers of stroke survivors through education based on the Roy’s adaptation model: a randomized controlled trial

Abstract

Objective

The dependence of stroke survivors on family caregivers negatively affects the quality of life, resilience, and adaptation of these caregivers. This study was conducted to identify the effect of education on the quality of life, resilience, and adaptation of family caregivers of stroke survivors based on Roy’s adaptation model (RAM).

Study design and methodology

This randomized clinical trial, conducted in 2023, enrolled 104 family caregivers of stroke survivors. Participants were chosen using the available method and then assigned to either the intervention or control groups through the random block method. In the intervention group, participants received four education sessions and telephone follow-ups. Tools, including a demographic information form, the Roy’s Adaptation Model Assessment Form (RAM-AF), the Adult Carers Quality of Life Questionnaire (AC-QOL), and the Connor and Davidson Resilience Questionnaire (CD-RISC), were used. The final evaluation was performed two months after the intervention.

Findings

Most participants in both groups were female (56.1%), married (59.2%), and had a son or daughter relationship with the patient (73.5%). The average age of the participants was 40.61 ± 10.77 years. The scores for quality of life, resilience, and adaptation did not exhibit significant differences between the intervention and control groups before the intervention (P > 0.05). However, a significant difference emerged after the intervention (P < 0.001).

Conclusion

The results indicate that education based on RAM can enhance the adaptive response of family caregivers of stroke survivors and improve their physical, mental, and social health. (IRCT20230208057360N2 and date: 2023-06-21).

Introduction

Stroke is a neurological disorder that develops when brain arteries in the central nervous system are damaged. It ranks as the third most prevalent cause of disability and the second leading cause of mortality worldwide, according to the latest Global Burden of Disease (GBD) figures. These conditions significantly contribute to increased global healthcare expenditures [1]. In the chronic phase of stroke, stroke survivors, often facing the cognitive and physical challenges of stroke, rely on their caregivers for daily activities [2, 3].

In Iran, traditional cultural norms often demand that family members assume the role of caregivers for their loved ones [4]. However, the lack of preparation among family caregivers to fulfill this demanding role imposes a notable burden on them, ultimately adversely affecting their quality of life [5]. Quality of life encompasses various dimensions, including physical, psychological, social, and religious well-being [6]. Therefore, a decrease in quality of life can hurt the holistic health of family caregivers of stroke survivors [7].

Strengthening resilience is an essential strategy for enhancing the holistic health of family caregivers of stroke survivors [8]. Resilience is characterized by the capacity to adapt to challenges, and evidence shows that caregivers with high resilience quickly adapt to challenges and endure little stress and depression [9–11]. Studies have shown a decrease in resilience among family caregivers of stroke survivors, attributed to insufficient understanding of the disease and disabilities in providing adequate care for the patient [12, 13]. Reduced resilience can lead to caregiver maladaptation to the patient care role, which reduces the family’s ability to provide effective patient care, leads to readmissions in stroke survivors, and increases additional costs to health systems [10].

Family caregivers of stroke survivors are nursing clients requiring appropriate planning for comprehensive support, including providing resources and education to adapt to their role as caregivers [2, 14]. In light of the challenges posed by caring for a stroke patient, educating family caregivers should encompass all aspects of their Health, including physical, psychological, and social dimensions [15]. One of the nursing models that addresses adaptive coping against the stimuli faced by family caregivers through a holistic approach is Roy’s Adaptation Model (RAM) [16, 17].

RAM, developed by Callista Roy. Calista Roy views humans as biological, psychological, social, and adaptive systems that grow and evolve in a constantly changing environment, stating that the person’s integrity is at risk from three types of stimuli: focused, contextual, and residual [16, 18]. Calista Roy believes that humans use two subsystems, the cognator and the regulator, to adapt to changing conditions; these two subsystems are not directly visible, but their responses to stimuli can be observed and measured through the four modes of physiological, self-concept, role function, and interdependence. The physiological mode addresses an individual’s physical needs, while the self-concept mode encompasses their psychological and spiritual aspects. The role-function mode considers expectations and social responsibilities placed on the individual. Lastly, the interdependence mode focuses on the integrity of relationships and the perceived level of social support from the environment [19, 20].

Many experimental studies support using the RAM due to its applicability to different populations of patients, families, and individuals; hence, this model is considered superior to other models [21]. Through the framework provided by the RAM, nurses can observe and investigate ineffective behaviors and their stimuli in the four modes of the model and then, through nursing interventions such as education, manipulate stimuli in the domain of adaptation for family caregivers of the patients [22, 23].

A review of studies has shown that a few studies have explored the impact of education on family caregivers based on the adaptation model. According to a survey by Nezameslami et al., RAM-based education improved the quality of life of home caregivers of psychiatric patients [24]. Additionally, Hatami et al. showed that RAM-based education can increase resilience in mothers of children treated with chemotherapy [25]. A literature review has demonstrated that no study has been found addressing the impact of RAM-based education on the quality of life and resilience of family caregivers of stroke survivors. This study aimed to identify the effect of RAM-based education on the quality of life and resilience of family caregivers of stroke survivors. Additionally, this study identified the impact of RAM-based education on the adaptation of family caregivers of stroke survivors as a secondary outcome.

Materials and method

Research design

This study employed a randomized clinical trial design with a pretest–posttest method and included both the intervention and control groups without blinding procedures.

Research population and setting

This study included 104 family caregivers of stroke survivors who received care in two neurology departments at Besat Hospital, Hamadan, in northwestern Iran. The data were collected from June 22 to December 27, 2023.

Sample size calculation

The sample size for the study was determined based on Jamali et al.’s study [26], with a confidence level of 95% and a power of 80%. Considering a potential loss of 10% in study samples, the sample size was calculated using the following formula: $n=\frac{{\left({-z}_{1-\frac{1}{2}},+,z_{1-\beta }\right)}^2\left({\sigma }_1^2,+,{\sigma }_2^2\right)}{{\left({\mu }_1-{\mu }_2\right)}^2},$ μ₁ = 44.41, μ₂ = 53.94. The estimated sample size was 104 individuals, resulting in 52 individuals allocated to each intervention and control group.

Randomization

Participants who met the inclusion criteria were selected using a convenience sampling method from two neurology wards. They were then randomly assigned to the intervention or control group through block randomization. A total of 26 quadruple blocks (e.g., AABB, ABBA) were generated using an online randomization tool (www.sealedenvelope.com) and enclosed in sealed, opaque envelopes. At each allocation step, one envelope was randomly drawn by the researcher, and the sequence inside was used to immediately assign the next four participants to their respective groups. This procedure was repeated until the required sample size was reached (Fig. 1).

Fig. 1.

Participant flow and data collection process diagram

Inclusion criteria

To be eligible for participation, family caregivers must meet several criteria: they must assume the primary caregiving role for the patient, be at least 18 years old, possess literacy skills with proficiency in reading and writing in Farsi, have access to a mobile phone, lack academic education in the medical sciences, and not have any family members of the patient engaged in the medical sciences. Additionally, caregivers should not have a history of mental illness. As for the patients, inclusion criteria require them to have experienced their first stroke (ischemic or hemorrhagic) with a definitive diagnosis from a neurologist, Be 45 years of age or older including middle-aged and aging patients, have spent at least 24 h in the neurology department since admission, and have a Barthel index score less than 75.

Exclusion criteria

The exit criteria include the following for family caregivers: unwillingness to sustain cooperation in the study, receipt of additional training programs by either the caregiver or the patient beyond the standard hospital training course, irregular attendance in training sessions, and the occurrence of significant life crises for the patient caregiver, such as divorce or the loss of loved ones. Similarly, for patients, the exit criteria involve events that necessitate discontinuation before the final evaluation, including death or hospital readmissions.

Measurement

The measurement tools included a demographic information form, the Adult Carers Quality of Life Questionnaire (AC-QOL), the Connor-Davidson Resilience Scale (CD-RISC), and Roy’s Adaptation Model Assessment Form (RAM-AF).

Demographic information form

The demographic information form comprised 11 items designed to collect demographic information from family caregivers and their patients. The items covered age, the Barthel Index, type of stroke, having aphasia, gender, marital status, education, occupation, residence, afflicted with chronic illnesses, and caregiver-patient relationships. The questionnaire underwent face validity assessment by ten nursing faculty members.

Adult Carers Quality of Life Questionnaire (AC-QoL)

The Adult Carers Quality of Life Questionnaire (AC-QoL), developed by Joseph et al., aims to assess caregivers’ quality of life across eight dimensions. These dimensions include support for care, caring choice, caring stress, money matters, personal growth, sense of value, ability to care, and carer satisfaction. The questionnaire comprises a total of 40 questions, with each dimension consisting of 5 questions. Responses are recorded on a 4-point Likert scale, ranging from “never” (0) to “always” (3). Scores for each dimension range from 0 to 15, while the overall questionnaire score ranges from 0 to 120. For questions with negative aspects, scoring is reversed to account for them. Higher scores indicate a better quality of life for caregivers, while lower scores signify the opposite. Joseph et al. conducted initial validity and reliability assessments, reporting a Cronbach’s alpha of 0.94 for the total scale, with values ranging from 0.78 to 0.89 for each dimension [27]. Safaei et al. validated the scale in Iran, demonstrating Cronbach’s alpha of the total scale of 0.89 and Cronbach’s alpha and McDonald’s omega coefficients above 0.7 for all dimensions [28]. In the current study, the Cronbach’s alpha coefficient for the’ questionnaire yielded a value of 0.93.

Conner-Davidson Resilience Scale (CD-RISC)

Connor and Davidson’s resilience scale comprises 25 questions distributed across five dimensions: Personal competence (8 questions), Tolerance of negative affect (7 questions), Positive acceptance (5 questions), Self-control (3 questions), and Spiritual influences (2 questions). The response range utilized for Connor and Davidson’s resilience scale follows a 5-point Likert format, with the options ranging from “not true at all” scored as 0, “rarely true” scored as 1, “sometimes true” scored as 2, “often true” scored as 3, and “true nearly all of the time” scored as 4, and the total score range for the scale varies from 0 to 100. A high score on the scale signifies increased resilience, while a low score suggests decreased resilience [29]. In the Iranian adaptation of the scale by Zarei et al., Cronbach’s alpha was reported to be 0.92 [30]. Additionally, our analysis revealed a Cronbach’s alpha coefficient of 0.92 for this scale, indicating high internal consistency.

Roy’s Adaptation Model Assessment Form (RAM-AF)

The form, created by the research team with insights from recent library sources, consists of 52 questions assessing the level of adaptation of family caregivers across four modes based on the Roy adaptation model: physiological, self-concept, role function, and interdependence. The items are assessed using a 5-point Likert scale, with responses designated as follows: never (0), very little (1), sometimes (2), often (3), and always (4). The physiological mode encompasses 19 questions assessing activities/rest, sleep, appetite, liquid intake, cardiac/respiratory status, immune function, concentration, excretion, and endocrine status. The self-concept mode involves 14 questions that explore feelings and attitudes during patient care, including problem acceptance, self-confidence, and emotional states. The role function mode, which involves 9 questions, investigates various aspects of the patient care role, managing responsibilities within and outside the home and meeting expectations from oneself and others. The interdependence mode comprises 10 questions to assess social interactions and receiving social support from family, friends, patients, and the professional care team. The scores for the physiological mode ranged from 0–76, those for the self-concept mode ranged from 0–56, those for the role function mode ranged from 0–36, and those for the interdependence mode ranged from 0–40. The score for the entire questionnaire ranged from 0–208. A higher score on the scale indicates a greater level of adaptation, while a lower score indicates a lesser level of adaptation. The reverse score was calculated for some questions with a negative aspect. To assess the validity of the questionnaire, ten faculty members from the Nursing and Midwifery Department in Hamadan were given the questionnaire. The questionnaire was distributed to 20 primary family caregivers of stroke patients to gauge reliability, resulting in Cronbach’s alpha values higher than 0.70 for all modes and a total scale value of 0.86.

Intervention

The intervention in this study comprised three key stages: pre-implementation, implementation, and final evaluation.

Pre-implementation

In the pre-implementation phase of the intervention, guided by a thorough literature review, the research team identified prevalent maladaptive behaviors and stimuli encountered by family caregivers across four RAM modes. Subsequently, the research team provided suitable educational content to empower family caregivers with the necessary skills to address these challenges effectively. The educational content and training booklet were reviewed and approved by ten faculty members specializing in neurology, nursing, and psychology.

Implementation

At this stage, family caregivers who met the entry criteria completed the demographic information form, the Adult Caregiver Quality of Life Questionnaire (AC-QoL), the Connor and Davidson Resilience Scale (CD-RISC), and Roy’s Adaptation Model Assessment Form (RAM-AF). In the intervention group, the primary researcher implemented the educational intervention based on RAM principles utilizing the nursing process, according to the study of Mansouri et al. [31]. Using the RAM-AF, maladaptive behaviors and stimuli were checked in each family caregiver across four modes: physiological, self-concept, role function, and interdependence. In the following phase, nursing diagnoses were developed, considering family caregivers’ maladaptive behaviors. Subsequently, in the planning stage, appropriate educational content was selected.

In the implementation phase, an education program for each family caregiver was conducted every other day through four individual sessions in the hospital’s training room. During each session, education related to one of the modes of RAM was provided to family caregivers (Table 1). The sessions varied in length, typically 30 to 45 min, and family caregivers’ questions were answered at the end of each session. Additionally, with the cooperation of the head nurse and ward staff, the rooms of patients in the intervention and control groups were separated within the ward to prevent interaction and the sharing of educational content.

Table 1.

Sessions and educational content

Education sessions	RAM modes	Content of education program based on RAM
First session	Physiological mode	Education based on maladaptation behaviors and stimuli in the physiological mode of family caregivers, includes • improving sleep quality • exercising • controlling fatigue • boosting the body’s immune system • controlling diet and balancing appetite • improving fluid intake • improving urine and stool excretion
Second session	Self-concept mode	Education based on maladaptation behaviors and stimuli in the self-concept mode of family caregivers, including • strategies to maintain optimal psychological well-being, such as controlling stress, anxiety, depression • increasing self-confidence • psychological coping skills such as accepting reality, positive thinking, and spiritual coping
Third session	Role function mode	Education based on maladaptive behaviors and stimuli in the role function mode of family caregivers, includes • strategies for caring for a stroke patient based on the patient’s conditions • dividing caregiving responsibilities among family members • managing time • balancing work and life • addressing other roles that family caregivers may have inside and outside the home
Fourth Session	Interdependence mode	Education based on maladaptive behaviors and stimuli in the interdependence mode for family caregivers, includes • receive social support • appropriate interaction with family and friends, patient, and healthcare professionals • active Participation in Social Interactions

On the other hand, the intervention group received a booklet titled “How to Adapt to the Care of a Stroke Patient,” which included education on the four modes of RAM. After the last education session, two phone calls were made to family caregivers in the third and sixth weeks to follow up and evaluate the impact of the education provided on their maladaptive behaviors. During these two phone calls, the researcher answered the family caregivers’ questions and tried to strengthen their positive behaviors, correcting ineffective behaviors through retraining. However, the control group only received routine hospital education.

Final evaluation

The final evaluation occurred two months after the last education session, and participants completed the questionnaires in person at the hospital’s training room. In adherence to ethical considerations, following the completion of the questionnaires, the control group received the training booklet along with a dedicated individual education session.

Statistical analysis

After data collection, statistical analysis was performed utilizing SPSS software version 16. The normality assumptions were evaluated through both the Kolmogorov–Smirnov and Shapiro–Wilk tests. Descriptive statistics, encompassing measures such as the mean, standard deviation, frequency, and percentage, were employed to understand the data comprehensively. Inferential statistics were also applied, including chi-square, Fisher’s exact test, independent t-tests, and paired t-tests, for data analysis. A significance level of 0.05 was set for all statistical analyses.

Results

This study’s final analysis comprised 48 participants in the intervention group and 50 in the control group (Fig. 1). The findings revealed that a predominant portion of participants in both groups were female (56.1%), married (59.2%), and had a son-or-daughter relationship with the patient (73.5%). Additionally, the mean score Barthel index of the patients in the intervention and control groups was 34.16 ± 23.04 and 38.30 ± 25.06, respectively, with no significant difference observed between groups (p = 0.398). Furthermore, there was no significant difference in the other demographic characteristics of the patients and family caregivers between the intervention and control groups (P > 0.05) (Table 2).

Table 2.

The characteristics of stroke patients and characteristics of family caregiver (N = 98)

Variables	Stroke patients		Results	Family caregiver		Results
	Intervention N = 48	Control N = 50		Intervention N = 48	Control N = 50
Age, M (SD)	70.02 (11.82)	69.30 (13.06)	t: 0.283 p: 0.775¶	39.08 (10.45)	42.08 (10.97)	t: −1.383 P: 0.170¶
Barthel Index, M (SD)	34.16 (23.04)	38.30 (25.06)	t: −0.898 p: 0.398¶	–	–	–
Stroke type
Ischemic	38 (79.2%)	40 (80%)	x2: 0.010 p: 0.918*	–	–	–
hemorrhagic	10 (20.8%)	10 (20%)		–	–	–
Having aphasia	29 (60.4%)	26 (52%)	x2: 0.705 p: 0.401*	–	–	–
Gender, n (%)
Male	23 (47.9%)	32 (64%)	x2: 2.573 p: 0.109*	20 (41.7%)	23 (46%)	x2: 0.980 p: 0.322*
Female	25 (52.1%)	18 (32%)		28 (58.3%)	27 (54%)
Marital status, n (%)
Married	35 (72.9%)	37 (74%)	x2: 0.015 p: 0.903*	26 (54.2%)	32 (64%)	x2: 0.980 p: 0.322*
Single	13 (27.1%)	13 (26%)		22 (45.8%)	18 (36%)
Education, n (%)
Illiterate	11 (22.9%)	19 (38%)	x2: 3.731 p: 0.289**	–	–	x2: 3.716 p: 0.144*
Primary	28 (58.3%)	21 (42%)		10 (20.8%)	19 (38%)
High school	7 (14.6%)	9 (18%)		21 (43.8%)	19 (38%)
University	2 (4.2%)	1 (2%)		17 (35.4%)	12 (24%)
Occupation, n (%)
Housewife	23 (47.9%)	15 (30%)	x2: 5.227 p: 0.271**	19 (39.6%)	15 (30%)	x2: 2.917 p: 0.595**
Employee	3 (6.3%)	1 (2%)		8 (16.7%)	6 (12%)
Retired	6 (12.5%)	8 (16%)		2 (4.2%)	3 (6%)
Unemployed	3 (6.3%)	5 (10%)		2 (4.2%)	1 (2%)
Other	13 (27.1%)	21 (42%)		17 (35.4%)	25 (50%)
Residence, n (%)
Urban	39 (81.3%)	35 (70%)	x2: 1.676 p: 0.195*	41 (85.4%)	42 (84%)	x2: 0.038 p: 0.846*
Rural	9 (18.8%)	15 (30%)		7 (14.6%)	8 (16%)
Having chronic illnesses, n (%)	45 (93.8%)	43 (86%)	x2: 1.605 p: 0.318**	10 (20.8%)	17 (34%)	x2: 2.127 p: 0.145*
HTN	40 (83.3%)	39 (78%)		–	–	–
Diab	15 (31.3%)	14 (28%)		–	–	–
HLP	12 (25%)	6 (12%)		–	–	–
Caregiver–patient relationship, n (%)
Brother/sister	–	–	–	4 (8.3%)	4 (8%)	x2: 4.300 p: 0.215**
Son/daughter	–	–	–	39 (81.3%)	33 (66%)
Spouse	–	–	–	4 (8.3%)	8 (16%)
Other	–	–	–	1 (2.1%)	5 (10%)

Italic values represent test statistics (e.g., t-values) used for comparing groups

^¶: P value derived from independent samples t test. *: P value derived from chi-square test. **: P value derived from Fisher’s exact test

HTN hypertension, Diab diabetic, HLP hyperlipidemia

Independent t-tests showed that, before the intervention, the mean total quality of life score was not significantly different between the intervention and the control groups (p = 0.682). However, after the educational intervention, this difference was significant (p < 0.001). Additionally, paired t-tests showed that, in the intervention group, the mean total quality of life score and the mean score on all the subscales except the Caring Stress and Money Matter subscale demonstrated a significant increase after the intervention compared to before, indicating improved quality of life (p < 0.05). However, no significant change was found in the control group (p > 0.05) (Table 3).

Table 3.

Mean of quality of life in family caregiver before and after education, based on AC-QoL Questionnaire

Subscale	Follow up	Group		t	P-value
		Intervention (N = 48)	Control (N = 50)
Support for caring	Pre-test	8.29 ± 3.17	8.56 ± 3.05	−.426	0.671*
	Post-test	10.85 ± 2.50	8.16 ± 2.62	5.193	<0.001*
	t P-value	4.614 <0.001**	−0.760 0.451**
Caring choice	Pre-test	9.97 ± 3.02	9.62 ± 3.35	.556	0.580*
	Post-test	11.66 ± 2.49	9.74 ± 3.88	3.641	<0.001*
	t P-value	3.423 0.001**	0.242 0.810**
Caring stress	Pre-test	9.00 ± 3.88	8.66 ± 4.23	.414	0.680*
	Post-test	9.77 ± 2.81	7.74 ± 3.40	3.208	0.002*
	t P-value	1.376 0.175**	−1.606 0.115**
Money matters	Pre-test	7.14 ± 3.03	6.86 ± 3.43	.436	0.664*
	Post-test	6.93 ± 2.48	6.14 ± 2.79	1.489	0.140*
	t P-value	−0.457 0.649**	−1.933 0.059**
Personal growth	Pre-test	8.43 ± 3.14	8.96 ± 2.56	−.904	0.368*
	Post-test	11.20 ± 2.89	8.78 ± 2.75	4.253	<0.001*
	t P-value	6.314 <0.001**	−0.392 0.696**
Sense of value	Pre-test	10.85 ± 3.20	10.30 ± 3.10	.870	0.387*
	Post-test	12.04 ± 3.27	10.70 ± 2.74	2.202	0.030*
	t P-value	5.777 <0.001**	0.900 0.373**
Ability to care	Pre-test	8.64 ± 2.94	8.72 ± 3.01	−.123	0.902*
	Post-test	10.10 ± 2.91	8.06 ± 2.41	3.792	<0.001*
	t P-value	5.314 <0.001**	−1.492 0.142**
Carer satisfaction	Pre-test	9.68 ± 2.69	8.92 ± 2.64	1.423	0.158*
	Post-test	10.56 ± 2.86	8.24 ± 2.36	4.387	<0.001*
	t P-value	3.157 0.003**	−1.564 0.124**
Total score of AC-QOL	Pre-test	72.04 ± 16.75	70.60 ± 17.92	.411	0.682*
	Post-test	83.14 ± 15.09	67.56 ± 13.98	5.305	<0.001*
	t P-value	6.223 <0.001**	−1.446 0.155**

*: P value derived from independent samples t test (between-group difference)

**: P value derived from paired samples t test (within-group difference)

Independent t-tests showed that the mean total resilience score before the intervention was not significantly different between the intervention and the control groups (p = 0.819). However, after the educational intervention, this difference was significant (p < 0.001). Additionally, paired t-tests revealed that the mean total resilience score in the intervention group and the mean scores on all the subscales increased significantly post-intervention compared to pre-intervention (p < 0.05). In contrast, no significant change was observed in the control group (p > 0.05) (Table 4).

Table 4.

Mean of resilience in family caregiver before and after education, based on (CD-RISC) Questionnaire

Subscale	Follow up	Group		t	P-value
		Intervention (N = 48)	Control (N = 50)
Personal competence	Pre-test	19.79 ± 5.54	20.14 ± 5.20	−.321	0.749*
	Post-test	23.97 ± 4.48	19.34 ± 4.44	5.139	<0.001*
	t P-value	4.239 <0.001**	−1.123 0.267**
Tolerance of negative affect	Pre-test	15.06 ± 5.35	16.94 ± 4.80	−1.828	0.071*
	Post-test	19.45 ± 4.14	16.26 ± 4.57	3.622	<0.001*
	t P-value	4.884 <0.001**	−1.261 0.213**
Positive acceptance	Pre-test	14.43 ± 3.32	13.50 ± 3.35	1.389	0.168*
	Post-test	16.02 ± 3.12	13.76 ± 3.77	3.493	<0.001*
	t P-value	3.515 <0.001**	0.552 0.583**
Self-control	Pre-test	7.70 ± 2.21	7.46 ± 2.45	.526	0.600*
	Post-test	8.58 ± 1.84	6.76 ± 2.52	4.092	<0.001*
	t P-value	2.151 0.037**	−1.867 0.068**
Spiritual influences	Pre-test	5.68 ± 1.75	5.32 ± 1.59	1.086	0.280*
	Post-test	6.37 ± 1.46	5.16 ± 1.47	4.085	<0.001*
	t P-value	2.579 0.013**	−0.668 0.508**
Total score of (CD-RISC)	Pre-test	62.68 ± 14.92	63.36 ± 14.11	−.229	0.819*
	Post-test	74.60 ± 10.70	61.28 ± 12.36	5.694	<0.001*
	t P-value	4.821 <0.001**	−1.195 0.238**

*: P value derived from independent samples t test (between-group difference)

**: P value derived from paired samples t test (within-group difference)

Independent t-tests revealed that, before the intervention, the mean score for adaptation was not significantly different between the intervention and the control groups (p = 0.319). However, after the educational intervention, this difference became significant (p < 0.001). Additionally, paired t-tests revealed that the mean scores on the total adaptation and the mean scores on all the subscales increased significantly after the intervention (p < 0.001). However, no significant change was found in the control group (p > 0.05) (Table 5).

Table 5.

Mean of adaptation in family caregiver before and after education, based on Roy’s adaptation assessment form

Subscale	Follow up	Group		t	P-value
		Intervention (N = 48)	Control (N = 50)
Physiologic	Pre-test	53.43 ± 8.86	50.32 ± 9.53	1.675	0.097*
	Post-test	58.97 ± 6.62	52.78 ± 10.77	3.447	0.001*
	t P-value	4.607 <0.001**	1.963 0.055**
Self-concept	Pre-test	36.37 ± 7.39	35.54 ± 8.26	−.526	0.600*
	Post-test	41.43 ± 5.50	33.72 ± 6.80	6.159	<0.001*
	t P-value	5.362 <0.001**	−2.030 0.048**
Role function	Pre-test	20.79 ± 4.23	19.86 ± 5.32	.955	0.342*
	Post-test	25.20 ± 3.74	18.22 ± 5.19	7.660	<0.001*
	t P-value	6.948 <0.001**	−2.052 0.046**
interdependence	Pre-test	25.10 ± 5.80	25.84 ± 6.15	−.608	0.544*
	Post-test	28.91 ± 3.70	23.08 ± 4.22	7.265	<0.001*
	t P-value	4.689 <0.001**	−3.416 0.001**
Total score of Roy’s adaptation	Pre-test	135.70 ± 18.89	131.56 ± 21.90	1.002	0.319*
	Post-test	154.45 ± 12.38	127.80 ± 17.87	8.576	<0.001*
	t	7.806	−1.503
	P-value	<0.001**	0.139**

*: P value derived from independent samples t test (between-group difference)

**: P value derived from paired samples t test (within-group difference)

Discussion

This study aimed to identify the effect of RAM-based education on the quality of life, resilience, and adaptation of family caregivers of stroke survivors. The findings indicate significant improvements in the quality of life, resilience, and adaptation among family caregivers of stroke survivors following RAM-based education.

Quality of life

The findings of this study indicate a significant improvement in the quality of life experienced by family caregivers of stroke survivors following RAM-based education. Consistent with this study, Nezam Islami et al. demonstrated that education based on RAM improved the quality of life reported by family caregivers providing home care for psychiatric patients [24]. Moreover, several studies, including Abdelrahman et al. in vitiligo patients [32], Kavradim and Ozer in patients with myocardial infarction [33], and Mansouri et al. in heart failure patients [31], have demonstrated the positive impact of RAM-based education on the quality of life of these patient populations. Contrary to our findings, Becker et al.’s study concluded that home education did not improve the quality of life among family caregivers of stroke survivors [34]. The differences in the number of education sessions, conducting sessions without addressing individual caregiver needs, and not preparing educational content based on RAM principles explain the discrepancies between the outcomes of this study and our own. RAM may have a promising effect in addressing the holistic needs of patients and family caregivers, offering effective coping strategies to help them navigate their challenges and significantly enhance their care standards and quality of life [35]. Evidence has shown that the quality of life of family caregivers of stroke survivors is directly related to their preparedness to assume the role of patient care [5]. Moreover, family caregivers providing care to stroke survivors frequently encounter heightened levels of anxiety and stress, which detrimentally impact their quality of life [36, 37]. RAM-based education can enhance the preparedness of family caregivers to perform their caregiving role effectively and improve their mental well-being. Consequently, it contributes to enhancing their quality of life.

Resilience

Our study demonstrated a significant increase in the resilience score of family caregivers of stroke survivors following RAM-based education. In line with our study, previous research among various populations, including mothers of thalassemic children [38], mothers of children treated with chemotherapy [25], and mothers of children with intellectual disabilities [39], demonstrated that RAM-based education effectively enhanced the resilience scores of mothers who assumed the primary caregiving role for their children. However, in their study, Afshari et al. showed that online support education had no significant effect on the resilience of family caregivers of dementia patients [40]. The variation in the study population, type of educational intervention, sample size, and evaluation tool used could account for the disparities observed between the outcomes of this study and our own. The evidence indicates that the resilience of family caregivers of stroke survivors is related to their caregiving ability [13]. Since RAM-based education effectively improved the dimension of “caring ability,” this enhancement has also positively impacted the resilience exhibited by caregivers of stroke survivors.

Adaptation

The results of our study indicate that RAM-based education could enhance the adaptation of family caregivers of stroke survivors. By emphasizing improvements in the physiological, self-concept, role function, and interdependence modes, the RAM approach facilitates individuals’ appropriate responses to focal, contextual, and residual stimuli, providing a solid foundation for enhanced adaptation among clients. Hence, RAM-based education offers a promising framework for supporting the adaptation of family caregivers of stroke survivors.

Physiological mode

Studies have demonstrated that caring for a stroke patient can lead to physical health problems, including decreased sleep quality, fatigue, eating disorders, and weight changes, among family caregivers [41–43]. In this context, Perlick et al. discovered that educational interventions focusing on weight control, exercise, sleep hygiene, medical appointments, smoking cessation, and alcohol cessation can promote the physiological health of family caregivers of bipolar patients [44]. Poon et al.’s study demonstrated that interventions aimed at enhancing self-care, increasing activity levels, improving diet, and enhancing sleep quality could enhance the physical health of family caregivers of mentally ill individuals [45]. In our study, education aimed at enhancing sleep quality, reducing fatigue, promoting exercise, optimizing diet, and bolstering the immune system contributed to decreased physical issues and subsequently improved the physiological dimension.

Self-concept mode

Studies have highlighted the substantial psychological challenges faced by family caregivers of stroke survivors, including perceived burden, depression, and anxiety [46, 47]. In this context, the study conducted by Banitalebi et al. demonstrated that providing education aimed at enhancing adaptation to patient care, increasing self-confidence, reducing stress, and fostering spirituality positively impacted the self-concept of family caregivers of multiple sclerosis patients [48]. Additionally, the study conducted by Etamadi Far et al. demonstrated that education focused on increasing disease and treatment awareness, enhancing coping skills, providing self-care education, and boosting self-confidence decreased levels of anxiety, stress, and depression among family caregivers of epilepsy patients [49]. Additionally, Sotoudeh et al.’s study demonstrated that educating family caregivers on coping skills, including stress management, spirituality, and self-care, and providing disease and treatment awareness training could effectively reduce the caregiving burden experienced by family caregivers of hemodialysis patients [50]. In our study, we provided education focused on enhancing mental well-being, boosting self-confidence, and teaching coping skills such as accepting reality and spiritual coping to family caregivers. Indeed, our educational intervention has improved the psychological well-being of family caregivers, thereby positively influencing their self-concept mode.

Role function mode

The lack of preparation among family caregivers of stroke survivors, attributed to the lack of necessary knowledge and skills required for patient care, results in role strain [51]. Additionally, family caregivers frequently assume numerous responsibilities, including professional, familial, and personal obligations. The demands associated with caring for a stroke patient can pose challenges in effectively managing these diverse roles [52, 53]. In this context, Lee et al. demonstrated that providing education to enhance disease awareness and caregiving skills among family caregivers of dementia patients effectively reduced their role strain [54]. Additionally, Indra et al. reported that educating caregivers of schizophrenia patients about disease awareness and strategies for managing family problems improved the roles and performance of family caregivers [55]. Our study provided family caregivers with education in patient care, role division, time management, and achieving work-life balance, enabling them to fulfill their caregiving duties alongside other responsibilities. Therefore, it prepared family caregivers to fulfill their caregiving role effectively. Additionally, it contributed to reducing both role conflict and role strain experienced by family caregivers. Hence, this led to improvements in the mode of role function.

Interdependence mode

Family caregivers of stroke survivors may encounter challenges in obtaining the necessary social support from friends, family members, or healthcare professionals, thereby contributing to feelings of isolation among these caregivers [56]. In this context, the study conducted by Edrisi et al. revealed that education focused on support network enhancement and effective communication with healthcare providers positively influenced the perceived social support of family caregivers of stroke survivors [57]. In their study, Velloze et al. identified intervention strategies to reduce feelings of loneliness among informal caregivers of dementia patients, including providing emotional support, expanding social networks, and preparing psychoeducational materials [58]. Our education in interdependence mode aims to enhance social support and communication with friends, family, patients, and healthcare professionals to improve perceived social support and alleviate feelings of isolation in family caregivers. Therefore, this education improved the mode of interdependence among family caregivers.

Limitation

One of the limitations of the present study was the large number of items in the questionnaires, which may have led to participant fatigue and reduced accuracy in responses. This issue was mitigated by allowing ample time and providing a calm environment for completion. Another limitation was the relatively short follow-up period of two months, which may not fully capture the long-term effects of the intervention. Additionally, the study was conducted in a single center with a specific cultural and organizational context, which may limit the generalizability of the findings to other settings. Furthermore, the lack of blinding in the design may have introduced a potential bias in outcome reporting.

Conclusion

Our findings indicate that RAM-based education significantly enhances the quality of life and resilience among stroke survivors’ family caregivers while aiding their adaptation during patient care. Through RAM-based education, nurses can empower family caregivers of stroke survivors to deliver effective patient care while providing appropriate solutions to address the physical, psychological, and social challenges these family caregivers face. Hence, this approach strengthens the family caregivers’ ability to maintain their health and personal well-being while providing stroke patient care. Future studies should examine the long-term effects of RAM-based education and its applicability to other caregiving groups, such as caregivers of individuals with chronic illnesses. It is also suggested to explore the use of digital platforms and community-based settings for delivering RAM-based interventions. Qualitative studies may further enrich understanding of how RAM principles can be adapted in diverse caregiving contexts.

Author contributions

All authors contributed to the study design. Implementation of educational intervention and data collection was conducted by [AM]. [AM] and [AK] prepared the educational content and wrote the booklet. Data analysis was performed by [SK]. [MK], as a neurologist, provided scientific support and advice for this study. The manuscript was edited by [AK] and [AM]. All authors reviewed and approved the final version.

Funding

The funding for this study was provided by the Financial Vice Presidency for Research and Technology of Hamadan University of Medical Sciences, with grant number 1401120210232.

Data availability

Data will be accessible in case of a reasonable request from the corresponding author.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

This study received approval from the Research Ethics Committee of Hamadan University of Medical Sciences, and an ethics code (IR.UMSHA.REC.1401.933) was issued for this study. Additionally, all stages of the study were conducted in accordance with the ethical standards outlined in the 1964 Declaration of Helsinki and its subsequent amendments.

Informed consent

All participants in this study provided both written and verbal consent to participate. Additionally, written consent was obtained from each participant for the public publication of the data.