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ARTICLE TITLE: Older adults’ influence in family care: how do daughters and aging parents navigate differences in care goals?

ARTICLE AUTHOR: Heid, Allison R.,

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Aging & Mental Health

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Older adults’ influence in family care: how do daughters and aging parents navigate differences in care goals?

Allison R. Heid, Steven H. Zarit & Kimberly Van Haitsma

To cite this article: Allison R. Heid, Steven H. Zarit & Kimberly Van Haitsma (2016) Older adults’ influence in family care: how do daughters and aging parents navigate differences in care goals?, Aging & Mental Health, 20:1, 46-55, DOI: 10.1080/13607863.2015.1049117

To link to this article: http://dx.doi.org/10.1080/13607863.2015.1049117

Published online: 27 May 2015.

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Older adults’ influence in family care: how do daughters and aging parents navigate

differences in care goals?

Allison R. Heid a,b *, Steven H. Zarit

b and Kimberly Van Haitsma

c,d

a New Jersey Institute for Successful Aging, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA;

b Department of

Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA; c College of Nursing, The

Pennsylvania State University, University Park, PA, USA; d The Polisher Research Institute, The Madlyn and Leonard Abramson Center

for Jewish Life, North Wales, PA, USA

(Received 4 December 2014; accepted 4 May 2015)

Objective: This study seeks to address how older adults influence their daily care when their preferences conflict with those of their adult daughter caregivers. Method: Using a sample of 10 dyads (N D 20) of an older adult and adult daughter, we utilize content analysis strategies to analyze in-depth, semi-structured interview data with QSR NVIVO to investigate how older adults influence their care, how daughters respond to such efforts of influence, and how dyads navigate differences in care goals. Results: When there is agreement in goals, dyads report tasks going well and both individuals’ requests are honored. When there are differences in care goals, daughters most frequently reason with their older parents, while parents walk away or ‘let go’ of their requests. Daughters report making decisions for their parents for health or safety-related needs. However, all dyads discuss differences in care goals, whereby parents are perceived as insisting, resisting, or persisting in care. Conclusion: Findings illustrate complex patterns of responses by families when navigating differences in daily care goals that carry important implications for research and the development of dyadic-based family interventions.

Keywords: family caregiving; preferences; care influence; qualitative

Introduction

As individuals age, they increasingly rely on the support

of others. Adult offspring often provide such support with

daily activities. However, children often express frustra-

tion around the fact that their older parents want to have

tasks done in their own way, even when it may compro-

mise their safety or well-being (Zarit & Zarit, 2007).

These situations often involve differences of goals. Yet,

there is little work to date on how families address older

adults’ preferences. Furthermore, work has yet to address

how older adults try to influence family members to get

the care they prefer and how family caregivers respond in

situations where preferences or goals differ. This study

takes a process-oriented approach to understanding such

phenomena in families.

Family care context

A growing body of evidence supports the need to provide

person-centered care to older adults, whereby the individ-

uals’ preferences and needs are placed at the center of

care delivery (Edvardsson, Varrailhon, & Edvardsson,

2014). However, less discussed is that the practice of pro-

viding person-centered care is embedded within the con-

text of aging, specifically, that older adults experience a

loss of physical and cognitive abilities and increasingly

rely on social support for managing daily tasks (Baltes,

Freund, & Li, 2005). Researchers drawing on different

perspectives, including sociological theory (Pescosolido,

1992), family systems (White & Klein, 2008), and dyadic

models (Berg & Upchurch, 2007) describe how adults

function within social systems and collaborate with others

when making decisions and responding to illness or dis-

ability. An individual interacts with a significant other or

supportive relative to develop joint coping responses

(Berg & Upchurch, 2007; Bodenmann, 1995; Krause,

2003). Person-centered care may arguably become dyad-

centered care, or family-centered care (Kuo et al., 2012),

and is shaped by the beliefs of both the individuals provid-

ing and receiving care.

Family members often step in to provide essential sup-

port to aging individuals across a diverse spectrum of

needs (Zarit, Femia, Kim, & Whitlatch, 2010). In such

instances, families are called to balance their needs with

their older relatives in care. Both an older adult and his/

her family member operate as individual complex systems

trying to achieve their own motivational goals in daily life

(Ford, 1994). For example, an older adult needs auton-

omy, competence, and relatedness, but so does his/her

family member (Deci & Ryan, 2000). Thus, families may

attempt to jointly cope with stressors, but one person’s

goals may not match the goals of the other partner sup-

porting care. In such cases, a clash of motivations may

ensue due to each person’s desire to achieve a different

goal (Ford, 1994). These conflicts in care likely carry

*Corresponding author: Email: [email protected]

� 2015 Taylor & Francis

Aging & Mental Health, 2016

Vol. 20, No. 1, 46�55, http://dx.doi.org/10.1080/13607863.2015.1049117

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important implications for the experience of strain and

burden for the caregiver, or well-being outcomes for the

older adult; yet little is known about this micro-level pro-

cess in families.

Evidence highlights that as caregivers take on respon-

sibilities for a dependent older adult, they accrue great

power for persuasion and decision-making to influence

care (Pyke, 1999; Wilkinson, 2001), and that older adults’

own views are sometimes not taken into consideration

(i.e., Elliott, Gessert, & Peden-McAlpine, 2009; Persson

& W€asterfors, 2008). Particularly affected are those older adults who must rely on help with instrumental or per-

sonal activities of daily living (IADLs or ADLs; Baltes,

1996; Harnett, 2010). As parents become more dependent,

children may become dominant in decision-making

(Cicirelli, 2006; Morgan & Hummert, 2000; Pratt, Jones,

Shin, & Walker, 1989) and/or children may influence care

decisions or encourage dependency of older adults in care

(Baltes, 1996).

Daughters, in particular, are a primary group of care-

givers for older adults. Often described as the sandwich

generation, they frequently experience competing roles in

caring for a parent and are at risk for compassion fatigue

(Day, Anderson, & Davis, 2014; Martire, Stephens, &

Townsend, 2000; Simpson & Carter, 2013). Furthermore,

unique tensions between mother�daughter dyads around perceptions of aging and negotiating care have been docu-

mented (Fingerman, 1996; McGraw & Walker, 2004).

Yet, less is known about how daughters respond to older

adults’ attempts to direct their own behavior in care when

there are differences in care goals.

Responses to goal differences in care

More specifically, when there are goal differences in care,

daughters may define what is best for their relatives based

on their own assumptions and values. In some cases, this

presumption may not align with the older adults’ values

and caregivers may attempt to redirect their relatives’

behaviors. When an older adult attempts to act on a goal

and meets resistance from his/her caregiver (i.e., because

the caregiver has a different goal), the older adult may

attempt to influence care by resisting the caregiver’s sug-

gestion and insisting or persisting in acting on his/her origi-

nal goal, acting in a way that is commonly attributed to

stubbornness (Heid, Zarit, & Fingerman, 2015). If the older

adult persists in his/her preferred action or opinion, there is

likely to be a lack of collaboration in care (i.e., Berg &

Upchurch, 2007; Bodenmann, 1995; Krause, 2003). This

possibly frustrating sequence of behaviors may lead to rela-

tionship tension, relationship conflict, or decreased well-

being for the older adult or caregiver. Research has yet to

explore the process of how adult daughters respond when

they perceive an older adult acting in this way.

Present study

Given the number of daughter caregivers providing care

for older adults and the implications differences in care

goals may have for how families support each other, this

study seeks to expand our understanding of the process by

which older adults influence care, by conducting semi-

structured interviews with both daughter caregivers and

older adults. A better understanding of disagreements in

care and how older adults and caregivers navigate such

conflict may build our understanding of how to provide

family-centered care to older adults.

We focus on three primary research questions:

(1) How do older parents influence their care in families?

(2) How do daughter caregivers respond to such influ-

ence? and, (3) How do daughters and parents navigate

goal differences in daily care as a dyad, particularly when

a parent is perceived to insist, resist, or persist?

Method

Participants

A convenience sample of 10 dyads of an adult daughter

caregiver (aged 30�62) and her aging parent (two fathers; eight mothers; aged 61�90) were recruited from a Short- Term Rehabilitation Center between the months of Novem-

ber 2012 and February 2013 upon completion of a short-

stay visit for the aging parent. ‘Caregiver’ was loosely

defined as providing at least weekly assistance with inde-

pendent or personal activities of daily living to the older

parent to provide for a range of experiences. The older

adult was not required to be a certain age or have a specific

diagnosis, but was required to have no more than mild cog-

nitive impairment (as deemed by Center Staff of a 13, 14,

or 15 total score on the Brief Interview for Mental Status

(BIMS) cognition scale; Saliba et al., 2012). Given that a

specific diagnosis was not required, data were not system-

atically collected regarding reason for support; however,

participants shared reasons such as recovery from chemo-

therapy, a brain aneurism, or a recent fall. The daughters

and parents were not required to be living together but had

to be living in the community (i.e., not in institutional or

group living) upon the parent’s discharge from rehabilita-

tion (four dyads lived together in the sample). Study con-

sent and enrollment commenced approximately one month

after discharge from the Center. During recruitment,

14 families were referred, 13 screened eligible, and 10 par-

ticipated. Families who did not participate were no longer

eligible at scheduling (n D 1), did not return scheduling calls (n D 1), or were no longer interested after screening (n D 1). After 20 interviews, data reached saturation, no new themes were emerging, and recruitment was stopped.

Procedure

Institutional review board approval was obtained. Partici-

pants (N D 20) individually signed a written consent to participate and to have their interviews recorded. Parents

and daughters were interviewed separately at home or in a

place of their choosing without the presence of other indi-

viduals. In the case that family members needed to be

present, adjustments were made to meet the needs of the

participant (n D 1). The researcher conducted an open- ended, semi-structured interview followed by a brief

Aging & Mental Health 47

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demographic questionnaire. To avoid any unintentional

bias on part of the interviewer, dyads were randomized to

have either the daughter be interviewed first or the parent.

For half of the dyads (n D 5), the daughter was inter- viewed first, and for the other half, the parent was inter-

viewed first. Interviews were audio-recorded and

transcribed and lasted from 28 to 78 minutes.

Measures

Semi-structured interview

This study used a qualitative in-depth interview informed

by questions of Persson and W€asterfors (2008) in

interviewing nursing home caregivers about residents’

influence in care. Questions were translated from Swedish

to English, pared down, and adapted to include only ques-

tions related to study aims. Additional questions needed

to address the topic of goal differences were added. The

interview guide developed for the daughters was adapted

to create a parallel form for parents. The researcher used

follow-up questions to have respondents elaborate upon

answers. The order of questions was dependent on each

participant’s responses (see Table 1 for questions).

Demographic questionnaire

Participants were asked to indicate their age, race, marital

status, and highest level of education from 1 (less than

high school) to 6 (graduate degree). Gender of the parent

was coded as 0 (male) or 1 (female). Daughters were also

asked to rate their parents’ cognition using Pearlin’s

seven-item cognitive status scale (Pearlin, Mullan, Sem-

ple, & Skaff, 1990), as a check that individuals had no

more than mild cognitive impairment. Prior research has

found that this scale correlates highly with standard cogni-

tive screening tests (Aneshensel, Pearlin, Mullan, Zarit, &

Whitlatch, 1995). The seven items were: difficulty

remembering recent events, knowing the day of the week,

remembering his/her home address, remembering words,

understanding simple instructions, finding his/her way

around the house, and speaking sentences. Each item was

rated on a five-point scale from 0 (not at all difficult) to 4

(can’t do at all), and all items were summed to create a

total score of memory impairment. Parents were not self-

assessed for their cognitive impairment (see Table 2 for

descriptive statistics).

Data preparation and analysis plan

Data were transcribed and entered into QSR NVIVO 10, a

qualitative coding program (QSR International Pty. Ltd.).

Table 1. Interview questions for daughters.

1. First I’d like to understand a bit more about your caring situation with your [RELATIVE]. Why are you currently providing care for your [RELATIVE]?

2. What does a typical day in the life of caring for your [RELATIVE] look like? Describe how you help your [RELATIVE] on a given day.

3. When there are multiple people involved in making decisions in daily life, we know that things can be difficult. Some routines are established easily while others are not. We would like to hear more about how this works in your relationship. Describe one instance where you did see eye-to-eye with your [RELATIVE].

4. Describe another instance when this has occurred.

5. Describe one past instance where you didn’t see eye-to-eye.

6. Describe one present instance where you don’t see eye-to-eye.

7. Are there instances that your [RELATIVE] chooses to ignore something that you feel would make (his/her) life better, safer, or easier?

8. When you interact with your [RELATIVE], do you ever feel that your [RELATIVE] insists on doing things (his/her) own way even if it puts (him/her) at risk?

Note: Parallel questions were asked of the parent. Where the word ‘RELATIVE’ appears, the interviewer substituted ‘mother’ or ‘father’ when speaking with parents, and ‘daughter’ when speaking with parents.

Table 2. Sample descriptives.

Daughters Parents

M (SD) N (%) M (SD) N (%)

Age 51.20 (10.10)(range: 30�62) � 79.20 (9.09)(range: 61�90) � Caucasian � 10 (100.0) � 10 (100.0) Marital status

Married/partner � 6 (60.0) � 4 (40.0) Divorced � 3 (30.0) � 1 (10.0) Never married � 1 (10.0) � 0 (0.0) Widowed � 0 (0.0) � 5 (50.0)

Education 5.50 (0.85) � 4.30 (1.06) � High school graduate � 0 (0.0) � 3 (30.0) Some college � 2 (20.0) � 2 (20.0) College graduate � 1 (10.0) � 4 (40.0) Graduate degree � 7 (70.0) � 1 (10.0)

Employed � 8 (80.0) � � Memory problems � � 1.90 (1.66) � Note: N D 10 daughters and 10 parents; M D mean, SD D standard deviation; N D number of participants.

48 A.R. Heid et al.

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Transcripts were read to produce a base coding-tree for

both daughters and parents, initially using broad codes.

The coding schemes were then expanded as common

responses were identified throughout the process of analy-

sis to add codes increasing in specificity according to the

responses provided. Content analysis strategies were then

used to code the manifest content with the developed

themes regarding how parents influence their care, how

daughters respond to such efforts of influence, and how

dyads navigate differences in care goals (Graneheim &

Lundman, 2004). Each interview was coded indepen-

dently and then compared to his/her family member’s

responses to examine dyadic responses in daily life. Two

additional trained assistants coded a random subset of

interviews to ensure stability, reproducibility, and accu-

racy in application of the developed coding tree (n D 9; �80% agreement). Discrepancies between coders were discussed and resolved by agreement to ensure utilization

of a consistent coding structure. Responses by theme were

tallied for purely descriptive purposes to develop a sense

of frequency within the sample.

Results

Findings highlight how older parents influence care,

daughters’ responses to parents’ influence, and dyadic

responses to navigating goal differences. When there is

agreement in goals, dyads report tasks going well and

both individuals’ requests are honored. When there are

differences in care goals, daughters most frequently rea-

son with their older parents, while parents walk away or

‘let go’ of their requests. However, all dyads discuss dif-

ferences in care goals, whereby parents are perceived as

insisting, resisting, or persisting in care, and differential

patterns of response were evident.

Parents’ influence

The perceptions of older parents’ involvement in care

tasks and decision-making on a daily basis varied across

individuals, from deciding how to do most of their own

care tasks to only making decisions in a couple of areas

(i.e., dressing, waking). All participants cited that parents

were involved in deciding how to spend their time. Partic-

ipants almost universally referenced a need for the parent

to experience independence or autonomy in making deci-

sions and completing daily tasks (n D 9 parents; n D 10 daughters).

Well I know that she has to let go of me, you know, that I have to be independent. You know I see a lot of women my age…who are very much dependent on their children and that I never want to be (Parent, 1118).

Dyads reported that daughters and other individuals

(i.e., siblings) also made some decisions or that decisions

were made jointly (i.e., medical decisions). In these

instances, parents relied on their daughters or others for

their expertise:

I’m pretty much the decision maker and she knows even though she’s very independent and she likes to be able to make all of her decisions. She knows that it’s in her best interests to have me navigate everything (Daughter, 1111).

Parents’ reliance on others was not perceived to limit

their abilities, but rather as a support.

Within these daily decisions, dyads reported things

going well when there was agreement in care goals or tasks.

Now, for instance, yesterday she took all my winter clothes…Last year I did it all myself, I took all the sum- mer ones out on the bed, put all the winter ones in, folded the other ones, put them away. This year, she brought the boxes in and I said, ‘I can’t do that.’ ‘I know you can’t!’ [Laughs] (Parent, 1103).

When dyads had different goals (e.g., different percep-

tions on where the parent should live, the temperature of

the room, the social activities of the parent), however, the

responses and influence of the parent varied across fami-

lies and circumstances. The most common strategies that

dyads (both parents and daughters) described were parents

‘letting go’ (n D 82 citations) and ‘continuing to act on one’s own impulses’ (n D 58 citations). Other response strategies used included getting upset, arguing, brainstorm-

ing a solution, getting someone else to talk to the other

individual, using humor, waiting to talk about it another

day, and rewording the request (see Table 3 for a summary

of strategies discussed). Thus, when there was conflict,

parents were described as influencing care by being more

passive and relinquishing their request, but also through

active attempts to persist in their behavior or opinions.

Daughters’ responses to parents’ influence

In the face of differences in daily goals, daughters were

most frequently described by dyads as ‘reasoning with

their parent’ or ‘letting go.’ These behaviors were primar-

ily viewed as responses that were meant to honor the ‘best

interests’ of their parents.

He tried [to stand up on his own] at the beginning when he came home but I think he, now he realizes that all of us are looking out for his best interests. And he’s not fighting it like he was before (Daughter, 1117).

Daughters further discussed that they responded dif-

ferentially to their parent when faced with a conflict

depending upon the scenario and context. Daughters

talked of their need to preserve the health or safety of their

parents. In these situations, daughters reported stepping in

to make decisions in the face of differences in goals (n D 9 daughters).

Things related to safety or personal hygiene, like needing the bathroom, and no he’s not just going to soil his pants like that and things related to therapy. Like if the therapist needs him to move his arm even though it hurts, or his leg, or exercises, those things I try not to give up on… Anything else I think should be negotiable or like pick your battles (Daughter, 1108).

Aging & Mental Health 49

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Table 3. Response strategies employed by daughters and parents when experiencing goal differences in daily care.

Response strategy Daughters Parents

Total citations

in the sample

Let it go or apologize, and walk away

71 (n D 17) 82 (n D 19) 153 Okay step away from this one [Laughs]

(Daughter, 1113) I let it go…I don’t worry about things I can’t

change, only what I can (Parent, 1115)

Reason with other or talk it out

96 (n D 17) 37 (n D 16) 133 I said, ‘…even in an emergency I can’t even get

there, you know in a short amount of time.’ So there has to be somebody 7 days a week and there has to be somebody 4 days double time and that’s what…the nurses have assessed (Daughter, 1111)

Well she’s a type who needs an explanation. She needs an intellectual discussion (Parent, 1106)

Continue to act on own ideas or behaviors

49 (n D 13) 58 (n D 14) 107 We just keep butting heads it doesn’t get nasty.

It doesn’t get mean. It just gets like whose going to hold their ground the longest (Daughter, 1117)

Sometimes she’ll say, ‘Oh you don’t have to wear that. Wear something better.’ ‘No, I don’t want to wear something better.’ But I end up wearing what I want (Parent, 1103)

Argue or yell 24 (n D 12) 37 (n D 12) 61 Maybe I didn’t when I was little, but I’m not

little anymore, so I do [argue/yell] (Daughter, 1119)

We actually sort of had a…blow up this weekend…I was kind of blind-sighted when she started to basically yell at me that I hadn’t come over or something you know, early enough to help her (Daughter about parent, 1116)

Get upset 21 (n D 10) 25 (n D 17) 46 She’s not happy (Parent about daughter, 1118) Well, I kind of said a few things and I cried and got

upset and she was upset (Parent, 1104)

Brainstorm a new strategy to accomplish request

12 (n D 8) 12 (n D 6) 24 I’m like, ‘Yea, but not really, let’s look at it’…

And say, ‘Well, so if you’re out on, you know you’re going to be out on Tuesday, your doctor’s appointment’s two hours, check the movie schedule the day before, maybe you go from the doctor’s office to the movies’ (Daughter, 1112)

With the bathroom, the concession was he now uses the potty seat in the hallway or in the den or wherever he is, that was his concession, because he was saying by the time I get upstairs I don’t have to go anymore (Daughter about parent, 1117)

Wait and ask again later or another day

12 (n D 7) 8 (n D 4) 20 I mean I just walk away from it until the next

morning and then just start over again (Daughter, 1119)

Well I just kind of let it slide, but I know it is going to come up again because it’s the same problem and you know it hasn’t been solved (Parent, 1105)

Use humor to distill tension

7 (n D 3) 6 (n D 4) 13 And this time around, [I] just made a joke, ‘Oh

okay, good you could use a third or fourth short sleeve blue blouse, I’ll put it in the short sleeve blue blouse section of the closet,’ you know and so we’re both laughing, joking, it’s funny (Daughter, 1107)

Sometimes we’ll make like little jokey comments about, you know, ‘Boy that was a lot of noise, and I was biting my tongue’ (Parent, 1104)

Re-word the request differently

8 (n D 4) 1 (n D 1) 9 I just try to do it in a way that I remind her or I

just make a suggestion and she’s more receptive to that then somebody telling her, ‘You need to do this and you’re not doing this’ (Daughter, 1113)

She’ll try to keep bringing it up and then we just keep pushing it back down (Daughter about parent, 1109)

Get someone else to ask

6 (n D 3) 0 (n D 0) 6 It’s almost like she has to validate what I say…

Like I was making her walk, like she didn’t really need exercise. Well when the therapist came and said, Yea, this is not far and there’s no reason why you can’t maneuver this, ’cause you’re going to make that knee stiffer than you’ll never be able to walk again’ (Daughter, 1101)

Note: Numbers in each cell represent the frequency the strategy presented in the transcripts; the values for n represent the number of transcripts the response strategies were cited in for daughters or parents respectively. Each comment is followed with a descriptor of whether a daughter or parent made the remark and within which dyad the individual was from. Numbers reflect random values given to each dyad for readers to be able to link responses of daughters and parents within a single family.

50 A.R. Heid et al.

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Daughters considered health and safety as paramount

needs in care, while parents did not talk about their need

for safety. A few parents referenced their concern about

the risk of having an accident (n D 3 parents), but more were concerned about being a burden to their daughters

(n D 6 parents).

That’s the hardest part, being a burden. I used to drive myself; I used to go to the market, now I can’t do any of that (Parent, 1115).

In these instances, parents talked about letting their

requests go to avoid adding stress to their daughters’ lives.

Dyadic responses to navigating goal differences and per-

ceived persistence, insistence, or resistance

All 20 participants described instances of goal differences

in daily care and specifically cited an example of the par-

ent being perceived as insisting and/or persisting in their

ways or opinions in attempting to accomplish a care goal,

or acting in a way that is commonly attributed to stub-

bornness. Dyads described such instances in regard to

daily care needs, such as parents insisting on doing physi-

cally challenging activities, personal care, or not changing

spending habits, as well as larger decisions such as mov-

ing to a new location or using a safety device. There were

dyad-to-dyad differences in how these behaviors were

navigated. Two examples are presented in Figure 1.

Figure 1 first depicts an instance where a daughter

describes the older parent as making a request (i.e., act-

ing), but the parent’s request is then met with resistance

on part of the daughter, and the parent reacts to assert her

intentions. At this stage, the daughter attempts to reason

with her parent and the parent relinquishes her request.

However, in the second instance, we see a process

whereby the older parent acts, meets some resistance, so

then reacts, whereby the child reasons with the parent, but

then the older adult continues to act on her own impulses.

In this latter case, the child then lets go of her request and

the elder’s goal is met. Ultimately to resolve conflicts,

dyads referenced that one or the other individual walked

away from the situation or let go of one’s request in order

to reach a resolution (n D 63 citations). The interviewer did not prompt dyad members to

reflect on scenarios that the other person mentioned. How-

ever, in examining within dyad accounts around naviga-

tion of everyday goal differences, some families did

mention the same scenario. In these instances, daughters

and parents described similar response strategies to the

conflict (i.e., brainstorming a new solution) but also some

differences in interpretation by listing additional strategies

used (i.e., parent continued insistence).

A lot of times it’s too hot or it’s too cold back there. I’ve tried to do different things to make adjustments but…she wants to put in a certain type of air conditioning unit. Now that’s in the front of our house and my husband and I have certain reservations about that. So that’s a point of conflict where you know she’ll try to keep bringing it up and then we just keep pushing it back down. I’ve tried to get a portable unit; it made too much noise… She tries to justify how it can be done to try to make it fit within our, you know, accepting it. ‘Oh, well we can hide the unit in the landscaping,’ and we’re just like, ‘No’ (Daughter, 1120).

We considered putting an air conditioner in here but it would be the air conditioner where there would be another little unit outside… And my son-in-law, didn’t really… want that on the house… and I was like, ‘Geez, I didn’t know that.’ So, then we started to explore other avenues, so it wasn’t a problem, you know it was just a disagree- ment that was you know averted because I didn’t realize he was against having that put on… .We even got…this portable air-conditioner thing that you put water on and put water in (Parent 1120).

Figure 1. Example patterns of responses to goal differences in care. Example 1: She’ll say, ‘Oh well you know, can’t you go to the library and get me these books?’ And I said, ‘Mom I can’t go because I need to, you know the weather’s turned bad, I need to go get some food and things like that.’ Like she may not realize what’s going on outside to drive in, and I’ll say, ‘The library’s in the total opposite direction.’ Like so, if I explain things to her, she’s pretty much, ‘Right’ (Daughter, 1101). Example 2: Well when they talked to me about going home, about leaving rehab I said, ‘I’m going home.’ And she said, ‘No, you’re not, you’re going to my house.’ And I said, ‘You know I’m not, I’m going home.’ And I came home (Parent, 1118). Note: Resistance refers to a difference in care goals.

Aging & Mental Health 51

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Discussion

This study sought to articulate how older adults influence

their daily care, how adult daughters respond to such

influence, and how family dyads navigate differences in

care goals. The findings demonstrate the difficulties older

parents and their adult daughters experience when navi-

gating care issues and the complex patterns of response

these individuals employ on a day-to-day basis in manag-

ing care. The results further our understanding of how

families respond to differences in care goals and carry

implications for how we can support families in providing

person-centered, or family-centered care, to older

relatives.

First, older parents appear to most commonly influ-

ence their care with adult daughters by being involved in

daily decision-making, finding agreement with their

daughter, and through passive response strategies in the

face of conflict (i.e., letting go of their request). In line

with previous work, parents in this study varied from one

another in their desire to be involved in decision-making

(Bastiaens, Van Royen, Pavlic, Raposo, & Baker, 2007;

Flynn, Smith, & Vanness, 2006). However, almost all par-

ticipants expressed the importance of maximizing the

parent’s independence and involvement in care. Parents

further influenced care when their requests were in agree-

ment with their daughters, a finding similar to that of Har-

nett (2010) with caregivers in nursing homes. When

parents and daughters had a shared goal, requests were

honored through collaboration. However, when faced

with differences in care goals, parents’ active attempts to

overtly achieve a goal-based outcome were often met

with reasoning by the daughter for why their behavior

should be reconsidered. Parents faced choices in these

instances of whether to continue to act on their goal or to

step back to avoid further conflict. In such instances,

parents most frequently described a process of stepping

back and letting their request go.

At first glance, such responses by parents of letting

their requests go to allow their daughters’ requests to be

honored seemingly relinquishes parents’ influence.

Daughters have great power in decision-making (Pyke,

1999; Wilkinson, 2001), and therefore may be using that

power to influence their parents’ actions and adjust their

parents’ goals. However, in line with the lifespan theory

of control and previous research, this strategy may repre-

sent an older adult’s attempt to assert secondary control in

a tense situation, relinquishing their attempts to overtly

control the outcome and instead relying on cognitive reap-

praisals of the situation to reconcile the difference in their

goals and the outcome (Heckhausen & Schulz, 1995). In

this regard, indirect control strategies, such as letting go,

could be viewed as a way to remain in control. Haley

(1963) describes similar situations where one person in a

relationship has less power than the other, but is able to

exert control through a paradoxical communication, i.e.,

by saying ‘I give you control,’ the person in effect retains

control. Findings are consistent with prior work that dem-

onstrates that older people are more likely to use loyalty

strategies than younger adults when faced with

relationship conflict (Birditt & Fingerman, 2005), and that

older adults often expect families to make long-term care

decisions as a means of extended autonomy (High, 1988).

Thus, it may be an adaptive strategy by older adults to

step away from tension when there are differences in

goals.

However, further work is needed to examine differen-

ces in definitions of what a resolution is or means or the

salience of a given goal for a given person. For older

adults, their use of passive or indirect response strategies

may carry a different meaning for them than it does for

daughters or may seem preferable in some instances more

so than others. Older parents may fear a loss of a relation-

ship with family members, particularly adult daughters

who are providing assistance, and therefore have the goal

of keeping the ‘waters smooth’ or ‘being easy,’ particu-

larly when a goal is low in importance (N. Pope, personal

communication, 7 November 2014). While an initial goal

for older adults may be a specified outcome (i.e., to have a

book picked up from the library), upon meeting resis-

tance, their goals may actually change to just wanting to

have a positive interaction with their daughters, thereby

changing their action and request. The initial pushback on

their first goal may no longer matter to older adults and

not carry implications for diminishing their requests.

Regardless, the evidence suggests that older adults use

more passive, indirect ways of influencing care outcomes,

as compared to a more active, reasoning approach used by

daughters. These findings carry implications for future

research, everyday care decisions, and complex negotia-

tions by dyads such as end-of-life decisions (Black et al.,

2009; Ditto et al., 2001).

Second, the finding that daughters cite a ‘best inter-

ests’ perspective is interesting as it may offer a rationale

for family caregivers’ actions. On a situation-by-situation

basis, daughters appear to practice flexibility in determin-

ing if the perceived negative outcome outweighs the pos-

sible benefit of the older adult making his/her own

decision. This is in contrast to evidence found with formal

caregivers, where the ‘best interest’ is often defined by the

institution’s rules to preserve safety and institutional effi-

ciency (Ulsperger & Knottneurs, 2011). When there are

differences in goals and daughters believe that a health or

safety-related issue is involved, they step in. This is con-

sistent with previous research that daughters influence

their mothers’ care with major health, finance, and hous-

ing decisions (Pratt et al., 1989) and that the use of more

direct communication strategies by daughters is perceived

as more effective for addressing older adults’ behaviors

(Morgan & Hummert, 2000). Yet, we do not know

whether parents agree with this action � is it a response by daughters based in worry to assure health and safety or

do parents also admit it is needed? More work is needed

to clarify the resolution in these instances in order to

determine whether both persons’ needs and values are

being honored in care.

Given that the literature demonstrates significant dis-

crepancies within families in understanding older adults’

preferences (i.e., Reamy, Kim, Zarit, & Whitlatch, 2011),

52 A.R. Heid et al.

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the findings here support a need to determine what the

older adult would define as his or her own ‘best interests.’

If older adults also value preservation of their lives, then

daughters are helping to buffer against those environmen-

tal risks. But if older adults put precedence on the value of

doing as much as possible for as long as possible, over

length of life, room for intervention exists, as the process

of daughters exerting undue influence may lead to nega-

tive individual and relationship-based outcomes (Rook &

Ituarte, 1999). Furthermore, in this sample, daughters do

not want their parents taking risks, while parents do not

want to be a burden; such differences in goals likely leads

to misunderstanding or conflict. Within-dyad examination

of experiences further demonstrates differences in inter-

pretation and understanding of day-to-day care goals.

Interventions may help families navigate the discussion of

shared values and the issues around safety versus auton-

omy, in particular, and lead to a consensus view of what is

best for their family (Hoqstel & Gaul, 1991). In some

cases, honoring autonomy or the older adult’s preferences

may take precedence over the concern for health and

safety (Kane, 1995). Dyadic-based interventions such as

those conducted by Whitlatch, Judge, Zarit, and Femia

(2006) with individuals with early dementia may help

dyads understand each other’s needs and goals. Further-

more, family dyad interventions allow for the opportunity

of assessment of concordance in understanding of each

person’s perspectives in daily care to strengthen families’

abilities to respond to care needs (Hepburn, Tornatore,

Center, & Ostwald, 2001; Whitlatch et al., 2006).

Third, the findings demonstrate that parents encounter

goal differences with their daughters and often persist,

insist, or resist in the face of these differences, and that

such behavior evokes responses by family members. Con-

sistent with quantitative findings that document a high

prevalence rate of perceptions of middle-aged adults and

aging parents of parents acting in ways commonly attrib-

uted to stubbornness (Heid et al., 2015), all families

described instances where parents tried to influence care

with persistence, insistence, or resistance. Yet, findings

here illustrate the types of responses these behaviors by

older adults result in. Such goal tension may carry impli-

cations for individual and dyadic well-being, and may be

linked to increased experience of daily stress (Pearlin,

Liberman, Menaghan, & Mullan, 1981) or a deterioration

in relationship closeness or quality (Birditt, Miller, Fin-

german, Lefkowitz, 2009; Rook & Ituarte, 1999). Further

examination of the link between responses to such behav-

iors and clinical outcomes for dyad members is needed.

Limitations

This in-depth study is strengthened by its ground-up,

dyadic approach to understanding how older adults influ-

ence care. Such work informs our understanding of the

roles daughter caregivers and older adults play in govern-

ing care outcomes, how families respond to differences in

care goals, and the dyadic perceptions around older

adults’ behaviors to insist, persist, or resist in care (i.e.,

behaviors commonly attributed to stubbornness).

However, this work is not without limitation. While

homogeneity of the sample offers the opportunity to

understand these processes in greater depth, generaliza-

tions to a larger population are limited. Examination of

differences in care goals with quantitative data and a

larger more diverse sample would help to validate find-

ings presented here. In addition, expanding investigation

to non-daughter caregivers (e.g., sons) and pre-caregiving

relationship processes may offer key insight into gender

differences within families and how families navigate

goal differences in care over time. Furthermore, exploring

the impact of other relationship dynamics in the family

(e.g., spousal relationships) may also help to understand

the complex responses within families.

Conclusion

In the end, the findings extend the current literature and

highlight the different ways and processes by which older

adults influence care within the family caregiving context.

Results highlight between-dyad and within-dyad differen-

ces in perceptions and the complex pattern of responses

family members evoke in navigating daily care situations.

Findings from this study point to the need for continued

development of dyadic interventions that take into account

both family members’ perceptions in care to support fami-

lies in developing shared goals and strategies. Ultimately,

these day-to-day interactions form the basis of family rela-

tionships, and our understanding of them is key in support-

ing family caregivers and their older relatives at home.

Acknowledgement

The authors would like to extend their appreciation to the staff members of The Madlyn and Leonard Abramson Center for Jew- ish Life who supported project recruitment and to the families who participated in this study. In addition, this work was sup- ported by financial contributions of the Kligman Graduate Fel- lowship Endowment and the Donald H. Ford Endowment at the Pennsylvania State University.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by financial contributions of the Klig- man Graduate Fellowship Endowment and the Donald H. Ford Endowment at the Pennsylvania State University.

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