ARTICLE IN PRESS

Geriatric Nursing ■■ (2018) ■■–■■

Contents lists available at ScienceDirect

Geriatric Nursing
j o u r n a l h o m e p a g e : w w w. g n j o u r n a l . c o m

Creating a conceptual model for family caregivers of older adults

intervention research: A narrative review of learned resourcefulness,
resourcefulness, and the transtheoretical model
Meng-Chun Chen, MS, RN a,b, Mary H. Palmer, PhD, RN, FAAN, AGSF c, Shu-Yuan Lin, PhD, RN a,*
a Collegeof Nursing, Kaohsiung Medical University, 100 Shih-Chuan 1st Rd., Sanmin District, Kaohsiung, Taiwan 80708
b Department of Nursing, Chang Gung Memorial Hospital, Chiayi; 6 Chia-Pu Rd., West Section, Putz City, Chiayi County, Taiwan 61363
c
Helen W. & Thomas L. Umphlet Distinguished Professor in Aging; School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, CB 7460, Chapel Hill, NC 27599,
USA

A R T I C L E I N F O A B S T R A C T

Article history: Providing and maintaining optimal care is challenging for older family caregivers who are caring for dis-
Received 21 December 2017 abled older adults. Learned Resourcefulness can facilitate family caregivers’ self-help strategies, and
Received in revised form 15 February 2018 Resourcefulness can facilitate help-seeking from others. However, little is known about how older family
Accepted 19 February 2018
caregivers can effectively maintain and adapt self-help and help-seeking strategies over time, especially
Available online
as the dynamic nature of caregiving for disabled older adults demands change. To this end, the
Transtheoretical model (TTM) provides useful constructs that address family caregivers’ readiness to change
Keywords:
their self-help and help-seeking behaviors. This paper reviews relevant literature regarding Learned Re-
Learned resourcefulness
Resourcefulness sourcefulness, Resourcefulness, and the TTM. The proposed conceptual model incorporates constructs
Transtheoretical model from the TTM integrated with Learned Resourcefulness and Resourcefulness strategies to aid in the de-
Family caregivers velopment and testing of interventions that are designed to promote the quality of life and health of older
Disabled older adults family caregivers while they are providing care to disabled older adults.
© 2018 Elsevier Inc. All rights reserved.

Introduction on the family caregiver’s physical health.5 Specifically, older family

According to the World Health Organization, adults 60 years and
older account for 12 percent to 22 percent of the world’s popula-
tion, and this group is expected to increase from 900 million to 2
billion between 2015 and 2050.1 The United States (US) has ap-
proximately 49.2 million adults who are 65 years and older, which
accounts for one out of every 6.5 people.2 In the US, nearly one in
five family caregivers (i.e., caregivers who are members of the same
family as the person for whom they are providing care) provides
unpaid assistance to an older adult.3 As the aging population in-
creases, the prevalence of chronic diseases and resultant functional
disability will also increase. Functional disability reflects a dynamic
process that requires increasing assistance with activities of daily
living as well as psychological support.4 Much of that assistance
comes from family caregivers who often take on increasing respon-
sibilities over a long period of time, and the consequences of such
caregiving may include psychological stress and negative impacts
Conflicts of interest: The authors have no conflicts of interest in this work.
* Corresponding author. College of Nursing, Kaohsiung Medical University; 100
Shih-Chuan 1st Rd., Sanmin District, Kaohsiung, Taiwan 80708. Tel.: 886 7 3136900;
fax: 886 7 3218364.
E-mail address: m845008@kmu.edu.tw (S.-Y. Lin).
caregivers who are caring for disabled older adults may experi-
ence complex behaviors and processes over time that could
negatively affect their health. Nurses can help mitigate these neg-
ative effects by introducing supportive interventions for older family
caregivers with the aim to reduce the emotional and physical toll
that may stem from caregiving.
Three models are available that provide constructs and strate-
gies for nurses to employ for supportive interventions: learned
resourcefulness provides self-help strategies, resourcefulness fa-
cilitates help-seeking strategies to improve caregiving, and the
Transtheoretical model (TTM) addresses caregivers’ readiness to
make changes to their caregiving.6 Learned Resourcefulness inter-
ventions can help older family caregivers develop adaptive behaviors
to address some of the burdens related to caregiving. These inter-
ventions can also promote the health not only of the older family
member for whom they provide care, but also the family caregiv-
er’s own health.7 Researchers also have found that Resourcefulness
strategies are effective in helping older family caregivers cope with
stress and mitigate negative emotions8 and to provide better care
for their elderly relatives.9 However, little is known about ways to
implement and maintain such healthy behaviors and to adapt skills
to meet changing caregiving needs and conditions over the long term.
Thus, the incorporation of constructs from the TTM into older family

0197-4572/$ — see front matter © 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.gerinurse.2018.02.012
 ARTICLE IN PRESS
2 M.-C. Chen et al. / Geriatric Nursing ■■ (2018) ■■–■■
caregiver supportive interventions (i.e., Learned Resourcefulness and
Resourcefulness) acknowledges the dynamic nature of disabilities
and care needs. The purpose of this paper is to describe the major
constructs and research findings related to Learned Resourceful-
ness, Resourcefulness, and the TTM and to propose a new integrated
conceptual model that acknowledges the dynamic nature of
caregiving provided by older adults for disabled older family
members.
Literature review of family caregiving of older adults research
Overview of Learned Resourcefulness literature regarding older
family caregivers
Learned Resourcefulness is the application of behavioral science
theory to improve the effectiveness of individual cognitive and be-
havior changes.10,11 Through Learned Resourcefulness, a person learns
how to adapt and cope with stress and achieve goals through in-
formal and formal learning experiences.10 Meichenbaum12 first
utilized the concept of Learned Resourcefulness to describe atti-
tudes that people could adopt as effective coping skills to address
internal and external daily stressful situations.12 Later, Rosen-
baum developed the ‘self-control schedule’ to measure Learned
Resourcefulness and noted that Learned Resourcefulness includes
self-direction, self-control, and self-efficacy as the means to enhance
a person’s ability to solve problems, handle stress, and promote
health.13,14 In terms of Learned Resourcefulness, focus on self-help
strategies and intrapersonal factors are ‘influencers’ on an individ-
ual’s behavior.14
According to Rosenbaum’s model, Learned Resourcefulness in-
cludes four dimensions: (1) cognition and positive self-statements
to control one’s own thoughts and emotions, (2) problem-solving
strategies, (3) the ability to extend (i.e., delay) the gratification of
one’s own needs, and (4) the development of perceived self-efficacy
Fig. 1. Modified conceptual framework from Learned Resourcefulness and Resourcefulness.
and belief in coping effectiveness (Fig. 1).14 Thus, in managing daily
stressful situations, people can employ positive self-thinking, apply
problem-solving methods, delay immediate gratification, and rec-
ognize that their efforts to regulate their behavior minimize the
negative effects that events may have on their ability to function.14,15
When people are motivated to make healthy behavioral changes and
to adapt to diverse circumstances, they may develop better adap-
tive functioning and become successful in achieving their goals.
Table 1 presents key information about studies that have applied
Learned Resourcefulness concepts and constructs to health and
coping strategies for older family caregivers who are caring for older
adults.7,16 For example, Rosswurm, Larrabee, and Zhang recruited
106 older family caregivers who provided care for older adults in
five communities to participate in a Learned Resourcefulness in-
tervention for five weeks (two hours sessions per week). The results
show that the Learned Resourcefulness intervention effectively im-
proved the older family caregivers’ competence, health, and quality
of life.7 Researchers in Taiwan recruited and observed 108 older
family caregivers who were caring for disabled older adults. They
found positive correlations between the concepts of Learned Re-
sourcefulness and health, and the caregivers’ burden was negatively
correlated with Learned Resourcefulness.16
Overview of Resourcefulness literature regarding older family
caregivers
Zauszniewski first introduced the theory ‘Resourcefulness’ with
regard to older adults,17 who described different ways that family
caregivers could learn how to handle and control stress.8 These
methods include cognitive and emotional coping strategies.18 In
essence, Resourcefulness incorporates two concepts, self-help (per-
sonal resourcefulness) and help-seeking (social resourcefulness), with
the aim that both strategies can be implemented to achieve the
goals of attaining, regaining, and sustaining good health (Fig. 1).8,11
Table 1
Learned Resourcefulness and Resourcefulness in family caregiver research.
Author/year Study purpose
Bekhet & Zauszniewski To investigate the relationships
2013,16 USA between positive cognition and
resourcefulness.
Bekhet 2015,21 USA To explore relationships among
perceived burden, resourcefulness, and
psychological well-being.
Chen et al. 2015,16 To investigate the relationships among
Taiwan caregiver burden, health status, and
learned resourcefulness for senior
caregivers of disabled older adults.
Gonzalez et al. 2014,22 To evaluate the effects of
USA resourcefulness in caregivers of family
members with dementia.
Kao et al. 2016,23 To investigate relationships among
Taiwan psychological distress, resourcefulness,
sleep disturbance, anxiety, and
depressive symptoms.
Musil et al. 2009,19 USA To examine the effects of social
support and resourcefulness in
relationships among family caregivers’
life stress, strain, and depressive
symptoms.
Musil et al. 2013,8 USA To examine the relationships among
intra-family strain, resourcefulness,
and depressive symptoms.
Rosswurm et al. 2002,7 To examine the effects of learned
USA resourcefulness intervention.
Zauszniewski et al. To evaluate the need to teach
2012,24 USA resourcefulness skills.
Zauszniewski et al. To examine the effects of
2014,18 USA resourcefulness training.
Zauszniewski et al. To examine the need for
2015,25 USA resourcefulness training.
Zauszniewski et al. To examine the effects of
2016,26 USA resourcefulness training on perceived
stress, depressive cognition, and
negative emotions.
Study design Sampling Subject number Main findings
Cross-sectional Convenience sample 82 caregivers (M = 57.46 years) Positive cognition explained 31% of the variance in
descriptive design of family members with resourcefulness, and as positive cognition increased,
dementia caregivers’ resourcefulness increased.
Secondary analysis Convenience sample 73 caregivers (M = 57.46 years) Psychological well-being was positively correlated with
from a cross-sectional of family members with positive cognition (r = .47, p < .001), social resourcefulness
descriptive study dementia (r = .45, p < .001), and personal resourcefulness (r = .46,
p < .001).
Caregiver burden was negatively correlated with positive
cognition (r = -.34, p < .001), social resourcefulness (r = .27,
p < .01), and personal resourcefulness (r = .25, p < .01).
Cross-sectional survey Convenience sample 108 caregivers (M = 74.03 Caregivers’ burden was negatively correlated with physical
years) and 108 disabled older health, mental health, and learned resourcefulness (r = -.52,
adults (M = 80.53 years) p < .001; r = -.32, p = .001; r = -.68, p < .001, respectively).
Physical health and mental health were positively correlated
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with learned resourcefulness (r = .40, p < .001; r = .23, p = .016,
respectively).
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58.60% reported that predictors of caregiver burden include
learned resourcefulness, health status, economic status, and
activities of daily living.
Randomized clinical Stratified random 102 caregivers, 50 Increased resourcefulness (p < .001) and decreased anxiety
trial sample experimental (M = 61.91 years) (p < .042) in caregiver at 6 weeks; increased caregiver
and 52 control group preparedness (p = .041) at 12 weeks.
(M = 58.46 years)
Cross-sectional, Convenience sample 200 caregivers Family caregivers with higher level of resourcefulness had
descriptive fewer instances of sleep disturbance, anxiety, and depressive
correlational design symptoms.
Cross-sectional survey Random and 486 caregivers (M = 57.1 years) More strain and less resourcefulness were associated with
supplemental more depressive symptoms for caregiver grandmothers. Social
convenience method support and resourcefulness can help protect caregiver
grandmothers from the effects of family-related stress and
strain.
Longitudinal study to Not mentioned 240 caregivers (M = 57.5 years) Family caregiver had a significant effect on depressive
extend cross-sectional symptoms and intra-family strain. Depressive symptoms
analysis decreased over time.
Quasi-experimental, Not mentioned 106 caregivers (M = 56.6 years) Learned resourcefulness training improved the family
time-series caregivers’ caregiving knowledge, self-perceived competence,
health, and quality of life.
Pre-test and post-test Convenience sample 126 caregivers (M = 58 years) Resourcefulness was significantly negatively associated with
trials perceived stress and depressive symptoms.
After resourcefulness training, 88% of caregivers perceived that
they needed more resourcefulness training.
Quasi-experimental Convenience sample 102 caregivers (M = 58 years) Reduced stress and depressive symptoms.
Improved quality of life.
Pre-test and post-test Convenience sample 138 women caregivers (M = 56 Less resourcefulness was associated with more stress and
trials years) of family members with depressive symptoms. Of the 63 caregivers who received
dementia resourcefulness training, 82% showed that they needed it, and
94% believed that other caregivers need resourcefulness
training.
Modified, partially Convenience sample 126 women caregivers (M = 56 Decreased stress, less depressive cognition, and fewer negative
randomized trial years) of family members with emotions.
dementia
3
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Fig. 2. Modified the Transtheoretical model conceptual model.
Previous research has shown that people who have greater re-
sourcefulness can cope with adverse situations and daily stress
constructively and have a better quality of life than those with less
resourcefulness.9,18 Table 1 presents key information about re-
search into the effectiveness of Resourcefulness interventions for
older family caregivers. This information indicates that the per-
ceived stress of recipients of Resourcefulness interventions and
training lessened, and that their own health and coping strategies
improved.8,18–26
In recent years, researchers have begun to conduct Resource-
fulness constructs and interventions for older family caregivers.11
For example, one study showed positive correlations among the con-
cepts of Resourcefulness, positive cognition, and good health.21
Bekhet16 found that positive thinking on the part of older family
caregivers for older adults is the key to increasing their resource-
fulness. Other studies have shown that older family caregivers’
burdens are negatively correlated with resourcefulness.19,21,24,25 In
a study conducted in the US, Gonzalez et al.22 observed 102 older
family caregivers of family members with dementia. The older family
caregivers engaged in a Resourcefulness intervention for six months
(twice a week for 60 minutes each session). These researchers found
that the effects of older family caregivers’ emotional outcomes (i.e.,
anxiety and depression) and role outcomes (i.e., reward and strain)
improved significantly over the six-week period.22 In another study
conducted in Taiwan, Kao et al.23 found that family caregivers with
higher levels of resourcefulness experienced fewer instances of sleep
disturbance compared to family caregivers with less resourceful-
ness. Other studies provide evidence that Resourcefulness
interventions for older family caregivers can mitigate stress,18,26 de-
pressive cognition,8,18 and negative emotions26 and can lead to a
better quality of life.18
According to this literature review, many studies have shown
that Learned Resourcefulness and Resourcefulness interventions
can help mitigate the negative effects of stress, depression, and
negative emotions and improve caregivers’ health status (see Table 1).
However, few studies have focused on using Resourcefulness
interventions specifically with older family caregivers of older
adults with dementia, and even less research has been undertak-
en that specifically targets caregivers who care for disabled older
adults. One limitation of the studies reviewed is the short follow-up
period (e.g., Gonzalez et al.22 conducted 12-week post-tests after
the intervention) regarding the efficacy of Resourcefulness inter-
ventions. More significantly, no longitudinal studies were found
that address the dynamic nature of caregiving and older family
caregivers’ readiness to change their behaviors to meet new and
often increased challenges that stem from caregiving. Thus, con-
sideration of a model, i.e., the TTM, that addresses changing needs
and the readiness-to-change concept, combined with Learned Re-
sourcefulness and Resourcefulness strategies, may provide constructs
to assist researchers in exploring ways for older family caregivers
who are caring for disabled older adults to maintain positive be-
havioral changes and adapt their skills to meet changing needs or
conditions over the long term.
TTM major constructs and applicability for dynamic
conditions
Transtheoretical model
The TTM, developed by Prochaska and DiClemente,27,28 has been
the predominant conceptual model that researchers have used to
design interventions and assess the readiness of an individual to
change his/her behavior,27 as shown in Fig. 2.6,27 The TTM includes
five stages of change and ten processes of change as well as the con-
cepts of decisional balance and self-efficacy.27 The five stages of
change are pre-contemplation, contemplation, preparation, action,
and maintenance. These stages identify an individual’s readiness
to change and offer a time dimension for an individual’s behavior
change process.29 The ten processes of change are consciousness
raising, dramatic relief, self-reevaluation, environmental reevalu-
ation, self-liberation, helping relationship, counter-conditioning,
reinforcement management, stimulus control, and social liberation.30
People move through the change stages by applying strategies from
these change processes. Prochaska later added ‘decisional balance’
to the TTM to reflect a person’s decisions regarding the benefits and
costs of engaging in a particular behavior.6 Prochaska and DiClemente
also modified the TTM by incorporating Bandura’s self-efficacy
theory about engaging in behaviors, i.e., confidence in carrying out
the new behavior(s). Researchers found that the TTM can be used
to understand the reasons that family caregivers who are at high
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Table 2
The Transtheoretical model employed in family caregivers research.

Author/year Study purpose Study design Sampling Subject number Main findings

Etkin et al. 2008,32 USA To examine exercise behaviors
among family caregivers and
the degree to which aspect
influenced exercise.
Hildebrand & Betts To determine the
2009,33 USA proportionate stage of change
of low-income caregivers for
increasing children’s
accessibility to healthy
servings of fruits and
vegetables.
Lach & Chang 2007,31 To explore the experiences of
USA family caregivers of family
members with dementia on
safety in home care.
Tung et al. 2005,6 To examine the TTM’s
Taiwan constructs (i.e., changes stages,
self-efficacy, and perceived
benefits and barriers) relative
to physical activity as
applicable.
Quasi-experimental Not mentioned 208 caregivers Mental health and self-efficacy for
(M = 60.8 years) exercise were significantly positively
related to exercise levels.
Cross-sectional Convenience 238 caregivers 43% family caregivers were in pre-
descriptive design sample contemplation/contemplation stages
and 29% were in preparation stage for
increasing accessibility. Family
caregivers in action/maintenance
stages showed greater use of
behavioral process and self-efficacy
than in pre-contemplation/
contemplation and preparation stages.
A focus group design Convenience 39 caregivers of family Family caregivers identified safety
sample members with issues, management strategies,
dementia barriers, and factors that could
facilitate the management of safety
issues and the development of
interventions to improve safe care.
Identified the application of the TTM to
different stages of adopting actions to
improve healthy behavior.
Cross-sectional Convenience 108 caregivers Family caregivers in the later stages of
descriptive design sample (M = 52.2 years) the TTM had higher levels of self-
efficacy than in the earlier stages
(p < .05).

risk of unhealthy behaviors may not be ready to attempt behav-
ioral change.31
The TTM, unlike Learned Resourcefulness and Resourcefulness,
does not explore interactions between personal and social net-
works, such as exchanges with social peer groups. Hence, when
investigating the use of the TTM in family caregiver research, re-
searchers may want to include constructs from these other
behavioral change theories to ensure that social factors are incor-
porated into the intervention. That is, the integration of certain
aspects of the TTM, Learned Resourcefulness, and Resourceful-
ness can help target the specific needs of older family caregivers
of disabled older adults by providing complementary solutions to
complex dynamic caregiving needs.
Evidence for use of the Transtheoretical model in family caregivers
research
The concepts that underlie the TTM have been thoroughly tested
in family caregivers researches; see Table 2.6,31–33 Validation of these
concepts also has been well reported. As seen in Table 2, several
studies show that the TTM can influence the behavior of family care-
givers. For example, Etkin et al.32 observed 208 family caregivers
in the US and found that a family caregiver’s good mental health
and self-efficacy are significantly positively correlated with all three
types of healthy exercise behaviors (i.e., strength training, walking,
and aerobic exercises).32 Hildebrand and Betts’s study conducted
in the US used the TTM to investigate attempts by family caregiv-
ers of children to provide healthy servings of fruits and vegetables
to children in their care. Their study assessed the stages of change
in 238 family caregivers of children in terms of their attempts to
make fruits and vegetables accessible to the children. The study
results show that 43 percent of family caregivers in the pre-
contemplation and contemplation stages used fewer processes of
change and used them less frequently and they exhibited lower levels
of self-efficacy under various situations than family caregivers in
the action and maintenance stages.33 Lach and Change held six focus
groups to explore the application of the TTM to health-related be-
havioral change and reported the experiences of 39 family caregivers
of family members who had dementia with regard to behavioral
issues in home care. These authors concluded that management
strategies and addressing stage-of-change barriers could help guide
family caregivers to adopt actions that improve healthcare-related
behavior.31 In addition, Tung, Gillett, and Pattillo’s study conducted
in Taiwan found that family caregivers in the later stages of the TTM
had higher levels of self-efficacy compared to family caregivers in
earlier TTM stages.6
Based on this literature review, the TTM was found to be useful
in facilitating and maintaining positive behavioral changes of family
caregivers. Furthermore, TTM constructs offer a time dimension and
include the readiness-of-change concept with regard to caregiving
behaviors. Unfortunately, little research has focused on the use of
the TTM to help family caregivers who are 65 years and older, which
is a focus of the current study.
Learned Resourcefulness, Resourcefulness, and the TTM
integrated conceptual model for family caregiver supportive
interventions
Learned Resourcefulness (which includes self-help) and Re-
sourcefulness (which includes self-help and help-seeking) are
strategies that focus on outcomes for individuals who intend to make
a behavioral change. An advantage of Learned Resourcefulness and
Resourcefulness is their effectiveness in helping people to imple-
ment healthy behaviors. The TTM of behavioral change contains a
key construct, i.e., the stages of change. This construct proposes that
people are at different stages of change (readiness) when they elect
to engage in healthy behaviors.34 Thus, an advantage of the TTM is
that it helps individuals to engage in positive behavior by chang-
ing their levels of readiness for change and to move through other
stages as their caregiving behavior changes. The benefits of Learned
Resourcefulness and Resourcefulness coupled with the benefits of
the TTM can be applied to tailor supportive interventions that focus
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6 M.-C. Chen et al. / Geriatric Nursing ■■ (2018) ■■–■■
Fig. 3. Proposed older family caregiver conceptual model incorporating constructs from modified Learned Resourcefulness, Resourcefulness, and the Transtheoretical model.
specifically on older family caregivers of disabled older adults.
Because research into older family caregivers of disabled older adults
focuses on complex behaviors and processes over time, a new con-
ceptual model must reflect this complexity and dynamic nature.
Thus, the advantages of incorporating key elements of the three sep-
arate models, i.e., Learned Resourcefulness, Resourcefulness, and
the TTM, could allow behavioral researchers to design effective
theory-based and proactive supportive interventions for older family
caregivers and disabled older adults (Fig. 3).
This paper thus offers a novel approach to older family care-
giver research that incorporates constructs from Learned
Resourcefulness, Resourcefulness, and the TTM. The resultant pro-
posed conceptual model (Fig. 3) allows for the long-term and
dynamic nature of caregiving and the modification of supportive
interventions for older family caregivers of disabled older adults to
cope with stress. The model also includes a time element and readi-
ness for change. In essence, the proposed conceptual model allows
aspects of the Learned Resourcefulness and Resourcefulness to com-
plement aspects of the TTM and vice versa. The resultant supportive
interventions can help to achieve positive outcomes for older family
caregivers of disabled older adults.
Conclusion
A comprehensive conceptual model could help guide innova-
tive research related to older family caregivers of disabled older
adults. Incorporating constructs from the Learned Resourceful-
ness and Resourcefulness conceptual models with those of the TTM
assists in developing complementary supportive interventions to
maintain positive behavioral changes and to modify existing skills
or adopt new skills to meet changing needs or conditions. Using
the new conceptual model also can help nurses be aware of the
stages of change and the readiness of older family caregivers to ini-
tiate new behaviors to provide optimal care and to promote the
caregivers’ own health.
Acknowledgements
We would like to thank Mary K. Brown for her editing assis-
tance. The authors acknowledge funding for this study by the Chang
Gung Memorial Hospital, Chiayi, Taiwan (CMRPG6G0171).
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