72 | pISSN: 1858-3598  eISSN: 2502-5791 

 

Jurnal Ners 
Vol. 13, No. 1, April 2018 
http://dx.doi.org/10.20473/jn.v13i1.7762 

This is an Open Access article distributed 
under the terms of the Creative Commons 

Attribution 4.0 International License  

Original Research 

Predictors of Family Stress in Taking Care of Patients with Schizophrenia 

Rizky Fitryasari1, Nursalam Nursalam2, Ah Yusuf2, Rachmat Hargono3 and Chong-Mei Chan4 

1 Doctoral Student, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia  
2 Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia 
3 Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia 
4 Department of Nursing Science, University of Malaya, Kuala Lumpur, Malaysia 

ABSTRACT 

Introduction: Taking care of schizophrenia patients is challenging and causes 
stress for the family involved. The study was conducted to identify the predictors of 
family stress present when taking care of a patient with schizophrenia. The ABCX 
Stress Theory of Hill was used as the theoretical framework. 

Methods: This study used a correlational design. The sample was 137 families who 
were caring for patients with schizophrenia at the Menur Mental Hospital, 
Surabaya, Indonesia. The sample was obtained by way of purposive sampling. The 
data was collected by a questionnaire and analysed by multiple regression to 
determine the relationship of the family’s structure, family knowledge, the burden 
of care, stigma, social support, the patient's illness duration, the patient’s frequency 
of relapse and the patient's severity level with family stress. 

Results: The results showed that the family’s stress was predicted by the family’s 
structure (p=0.029), stigma (p=0.000), the burden of care (p=0.000), and the 
patient’s frequency of relapse (p=0.005). The burden of care was the strongest 
predictor of family stress (Beta= 0.619). 

Conclusion: The patient's frequency of relapse and stigma were other kinds of 
family stressor. The stressors stimulated a negative perception, called the care 
burden. Limited adequacy of the family structure-function will inhibit the family in 
using other resources, creating family stress. Nurses may develop an assessment 
format that consists of the family stress predictors in order to create a nursing care 
plan specific to reframing the techniques of family stress management. 

ARTICLE HISTORY 

Received: Feb 27, 2018 
Accepted: June 26, 2018 

KEYWORDS 

family stress predictors; 
family; schizophrenia 

CONTACT 

Rizky Fitryasari 
 risqiv@yahoo.com.sg  
 Faculty of Public 
Health, Universitas 
Airlangga, Surabaya, 
Indonesia 

Cite this as:  Fitryasari, R., Nursalam, N., Yusuf, A., Hargono, R., & Chan, C. (2018). Predictors of Family Stress in Taking 
Care of Patients with Schizophrenia. Jurnal Ners, 13(1), 72-79. 
doi:http://dx.doi.org/10.20473/jn.v13i1.7762 

INTRODUCTION  

Schizophrenia is a chronic mental disorder and is a 
cause of morbidity. Schizophrenia is a persistent and 
serious brain disease that results in psychotic 
behaviour, concrete thinking difficulties, an inability 
to communicate, abnormal affection and difficulties 
in solving problems and meeting daily needs (Levine 
& Levine, 2009; G. Stuart & Sundeen, 2012). The 
prevalence of severe mental illness, including 
schizophrenia, according to Riskesdas (Kemenkes RI, 
2013) is 1.7 per 1000 inhabitants, meaning more 
than 400,000 people suffer from severe mental 
disorders in Indonesia. The incidence percentage of 
schizophrenia in East Java was 0.22%, while in 
Surabaya, it was was 0.2%. The incidence rate of 
schizophrenia is difficult to decrease due to the high 

recurrence rates. Based on a preliminary study at the 
Menur Soul Hospital of Surabaya conducted 
February-April 2016, the number of inpatients 
reached 5,925 patients, where 90% had 
schizophrenia. The data showed that 80% of patients 
with schizophrenia had been treated in previous 
psychiatric care or had a relapse (Medical Record RSJ 
Menur, 2016). 

Schizophrenia, not only cause suffering for the 
patients, but also for the people who are closest to 
the patient as well. Usually, the family is the most 
affected by the mental disorder. In the interviews 
with 10 families of patients during the preliminary 
study at Menur Hospital, 100% stated that the family 
experienced high tension during the treatment of the 
schizophrenic patients at home. The families feel 
anxious, sad, depressed and angry when faced with 

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uncontrollable patient behavior. The families also 
complained about being physically exhausted by 
having to keep up with the patient at all times. 
Additionally, 4 out of 10 families complained of 
frequent headaches, hypertension, and gastritis after 
more than 2 years of treating patients with 
schizophrenia. The families felt like there was a lack 
of time to do activities because they must always 
keep with the patients with schizophrenia every day. 
The situation experienced by families over a long 
period of time can cause the family to experience 
stress and anxiety (Biegel, 1995; Stuart & Sundeen, 
2005). Suhita's (2015) study of 87 family members 
acting as the main caregiver in East Java's Kediri City 
stated that 75% had moderate to severe stress. 

With the presence of schizophrenia patients 
being a stressor in the family system, 67.8% of them 
feel pressure (Darwin, Hadisukanto, & Elvira, 2013). 
Families, as the main caregiver, are susceptible to 
psychological problems, fostering family conflict and 
mutual abuse. 76.7% of families show negative 
symptoms, including depression and influencing 
family behavior when treating patients at home. The 
family often induces irritation due to their inability 
to cope with the burden. This is done by blaming the 
patient and disregarding the patient's condition 
(Brillianita & Munawir, 2014; Pharoah, Mari, 
Rathbone, & Wong, 2010). 

Stress experienced by the family is caused by the 
high burden of care, including feeling worried about 
the patient's condition related to their health status, 
future, financial condition, and the fulfillment of 
their daily needs. The financial condition of the 
family experienced problems during the treatment of 
a 12-month schizophrenia patient, as a result of 
financing the treatment, the fulfillment of the 
patient's needs, hospital transportation and 
accommodation costs (Djatmiko, 2007; Ennis & 
Bunting, 2013; Hadryś, Adamowski, & Kiejna, 2011). 
The presence of schizophrenia patients makes the 
family face social stigma. Related to the stigma 
attached to both the patients and their families, 
37.5% of the families had a negative perception of 
the illness suffered by the patients with 
schizophrenia. The families are embarrassed and 
often excluded from community activities involving 
all family members. The magnitude of the burden, 
the strength of the stigma both from the family and 
society, the lack of support for the family and the 
fluctuating condition of the patients may cause 
family stress. There are many obstacles faced by the 
family when taking care and living together with the 
schizophrenic patient. The lack of knowledge about 
schizophrenia, the social stigma and social 
alienation, the cost of treatment, the decrease of the 
families’ health, anxiety, depression, and other things 
are a series of social problems encountered in the 
family with the schizophrenic patient (El Tantawy, 
Raya, & Zaki, 2010; Suhita et al., 2015). An 
insurmountable family stress situation creates an 
unfavorable environment and causes the 
schizophrenia patients to relapse. The inability of the 

family to control the emotions and the existence of a 
stressful family life causes issues and continuous 
criticism is a cause of patient relapse (Akbar, 2008; 
Amaresha & Venkatasubramanian, 2012; Fadli & 
Mitra, 2013). 

ABCX Hill’s Theory, stated by Rice (1987), is the 
theory that was used in this research study. The 
theory explains if the families facing uncomfortable 
situations represented by the letter A, they will make 
an adaptation effort by utilising social support and 
personal strengths of the family which are described 
as letter B. Letter C explains the family's perception 
during a stressful event, which includes how the 
family defines the uncomfortable events in their life. 
The letter X represents the degree of crisis 
experienced by the family as a result of the 
interactions between letters A, B, and C. Based on 
this model, families who care for schizophrenic 
patient have limited resources and have a negative 
view of the situation. They will experience a crisis or 
more severe stress than other families who are faced 
with the same pressing event who are better 
adapted. 

The researcher, as a mental health nurse, tried to 
combine Hill’s theory with the assessment stage of 
Family-Centered Nursing theory (Friedman, 2003). 
Family-Centered Nursing is a family theory with a 
nursing care approach. An important step in this 
theory is the nurse's ability to conduct a family 
situation assessment, which includes assessing the 
family and patient factors. The family factors are the 
strength of the family structure, their economic 
capacity and the level of family knowledge about 
schizophrenia. The patient factors are the frequency 
of relapse, the duration of illness and the illness 
severity. Based on Hill's theory, Family-Centered 
Nursing theory (Friedman, 2003) and some of the 
studies discussed above, the burden of care, stigma 
and social support for families has the potential to 
affect the stress experienced by the involved 
families. This study aims to analyze the influence of 
family structure, economic ability, knowledge level, 
the burden of care, stigma, social support, the 
frequency of relapse, the duration of the illness and 
the patient’s severity level as the predictors of family 
stress. The results of the study are expected to 
contribute to nursing science in determining the 
stress’s predictors on the families who care for 
patients with schizophrenia. 

MATERIALS AND METHODS  

Research Design 

This study used a correlation research design 
that explained the relationship of the factors causing 
family stress when treating patients with 
schizophrenia. The study was conducted from June 
through to September 2017. The study involved 137 
family members as respondents, who were obtained 
by purposive sampling. The inclusion criteria were 
the families being the primary caregivers of the 
patients, the patient being more than 20 years old 



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and them living in one house with the patient for at 
least one year. The patient should have been 
diagnosed with schizophrenia for at least three years 
(proven by medical records), and have already 
experienced at least one recurrence. The dependent 
variable was family stress, while the independent 
variables included family structure, knowledge level, 
care burden, stigma, social support, the patient’s 
duration of illness, the frequency of relapse and 
severity. 

Instruments  

The data was obtained through of a 
questionnaire. The demographic data was assessed 
using a single item: age. Economic status was 
measured using a closed questionnaire with 
questions about the average family’s fixed income in 
a month. The family’s structural variables were 
adapted from the family assessment questionnaire 
as according to Friedman (2003). The respondents 
were asked what is their role was when related to 
the patient (mother, father, spouse, child or other 
family member). 

Family knowledge about schizophrenia was 
measured using a questionnaire modified from 
McCubbin & Thompson (1991). Ten-item questions 
assessed the family knowledge related to the 
definition of illness, the effect on the family and the 
schizophrenia treatment. Each item was rated on a 
scale of 1 (strongly disagree) to 5 (strongly agree). 
The items were summed, with the higher scores 
indicating higher knowledge.  

The burden of care variable instrument was 
prepared based on the Caregiver Strain Index 
questionnaire (Thornton & Travis, 2003) and the 
concept of burden according to the World Health 
Organization (2008) modified according to the 
condition of the family who cared for the 
schizophrenia patient. The instrument consisted of 
eight-item statements on subjective and objective 
burden measured using a Likert-scale ranging from 1 
(never) to 5 (always). The stigma instrument was 
developed based on the stigma’s dimension 
(Goffman, 1963) and the definition of stigma (Link & 
Phelan, 2001). The instrument consisted of ten-item 
statements asking about labelling, stereotyping, 
separation and discrimination. They were measured 
on a five-point scale (1: strongly disagree to 5: 
strongly agree). The social support variable was 
obtained by way of a modified instrument of the 
Social Support Index (H. I. McCubbin, Paterson, & 
Glynn, 1987). The instrument consisted of ten-item 
statements focused on emotional, informational, 
instrumental and award support. Frequency was 
measured on a five-point scale (1: never to 5: 
always). 

The data from the patients was collected related 
to their illness history. The patient’s duration of 
illness was explained as the first time that the 
symptoms of schizophrenia appeared up to the 
current date, expressed in years. The frequency of 
relapse referred to the number of recurrences and 

hospitalisations within a year. The severity of illness 
was measured using the modified Brief Psychiatry 
Rating Scale (BPRS) (Overall & Gorham, 1988) 
1988). The questionnaire consisted of 18-item 
statements filled in by a doctor or nurse in charge, 
assessing the positive, negative and affective 
symptoms performed by the patient. Each item was 
rated on a scale of 1 (no symptoms) to 4 (severe). All 
items were added together, while ahigher score 
indicated higher severity symptoms. 

The family stress variable was measured using a 
modified questionnaire using the Symptom Rating 
Test (Kellner & Sheffield, 1973). The questionnaire 
consisted of a ten-item statement on the 
psychological and physical symptoms felt by the 
family over the last three months, rated in 5-point of 
scale ranging from 1 (never) to 5 (always). All items 
are totalled, with a higher score indicating a higher 
severity of family stress. All of the instruments had 
been already tested for validity and reliability, in a 
pilot study consisting of 25 respondents. Each item 
in the statements reached validity (r>0.514) and 
each questionnaire reached reliability as well (>0.8). 

Data Analysis 

Descriptive analysis was used for the 
respondents’ characteristic and for the variable 
description (Table 1 and 2). We used multiple 
regression analysis to identify the predictors of 
family stress during the treatment of patients. We 
created a p-value table between the independent 
variables and the dependent variable (Table 3). 
Based on this table, we removed economic status, 
family knowledge and social support from the 
regression model because these three independent 
variables have a p-value <0.25. Further testing was 
performed to determine which variables are valid for 
being a family stress predictor. A regression test was 
done until all of the variables had a value< 0.05. 
Valid variables that can be used as a predictor of 
family stress are family structure, maintenance 
burden, stigma and the frequency of relapse. The 
four variables have been able to prove the existential 
assumptions (mean: 0.000, SD: 5.824), 
interdependence assumptions (Durbin Watson: 
1.913), linearity assumptions (p = 0.000), 
homoscedasticity (norms of data spreads along or 
zero) data (normal distributed data and on PP 
Residual Plot of data spread around the diagonal 
line) and the multi-collateral assessment (VIF <10). 
The four independent variables were used in 
simultaneous regression analyses. The level of 
statistical significance was set at p <0.05. 

Ethical clearance 

The respondents were families who accompanied 
patients to the outpatient unit of the Mental Hospital 
of Menur. The participants were recruited on the 
basis of ethical principles. The participants involved 
in the study had previously received a written 
explanation of the purpose of the research, and the 
procedures, rights and obligations, benefits and 



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disadvantages involved in the study. Only the 
participants who had been given informed consent 
were involved in the study. This study was given 
ethical approval from the Ethical Committee of 
Menur Mental Hospital, number 423.4 / 
72/305/2017. 

RESULTS  

Characteristics of the respondent  

The characteristics of respondents have been 
presented in Table 1. The majority of respondents 
were between the ages of 46 to 65 years old. A lot of 
them were the mother of a patient with 
schizophrenia. The others were made up of their 
siblings, relatives, children, spouse and father. 
Almost half of the monthly family income was more 
than 4.000.000 IDR. Most of the patients had been 
diagnosed with schizophrenia for more than ten 
years and almost half of them were experience 
relapse one to three times each year. 

Variables description 

The variables’ description has been explained in 
Table 2. The average of family knowledge was 37.93 
(SD= 3.843). The family-felt burden of care average 
was 23.39 (SD=7.792). The family also experienced 
stigma from the environment, which averaged 25.09 
(SD= 6.358). The family receiving social support had 
an average of 31.10 (SD= 5.721). Schizophrenia 
patients had a level of severity of 28.11 (SD 6.954). 
The overall family experiencing stress had an 
average of 27.08 (SD=10.524) 

Variables’ correlation 

Pearson's correlation was computed between the 
family's stress and all of the research variables (table 
2). The result of testing on the nine research 
variables showed that there was a strong 
relationship between burden of care (r = 0.804; p = 
0.00) and stigma (r = 0.677; p = 0.00) on family 
stress. Subsequently, there was a weak correlation 
between the patient’s duration of illness (r = 0.193, p 
= 0.024), the patient’s frequency of relapse (r = 
0.392, p = 0.00) and the level of severity (r = 0.267, p 
= 0.002) with family stress. The variables of 
economic status, family structure, knowledge and 
social support are not related to family stress during 
the care of patients with schizophrenia. 

Predictors of family stress 

As shown in Table 4, the higher the burden of 
care (p = 0.000; Beta = 0.619), the more frequent the 
patient’s frequency of relapse (p = 0.005; Beta = 
0.145), the higher the perceived family stigma (p = 
0.000; Beta = 0.194) and the lower functioning of the 
family structure (p = 0.029; Beta = -0.106). The 
aforementioned will increase stress in the family. All 
of the independent variables may explain the 
variation of family stress as 69.4% (R2=0.694). The 
variable that has the greatest role as a predictor of 
family stress is the burden of care (Beta = 0.619). 

 

DISCUSSION 

Stress experienced by the family in assisting and 
treating patients with schizophrenia can be 
predicted using the variables burden of care, stigma 
from the environment, the patient’s frequency of 
relapse and the functioning within the family 
structure. The results of this study are in line with 
family stress according to Hill (Rice, 1987), which 
mentions that family stress is caused by the 
interaction between stressors, family perception, 
and the resources owned by the family. The patient's 
frequency of relapse and the stigma from the 
environment is a stressor for the family. Stressors 
cause a negative perception for the families in the 
form of care burden. A lack of adequate functioning 
in the structure of the family means that the family 
cannot utilise the resources they own, so then the 

Table 1. Characteristics of the respondents 
Variable Frequency Percentage 
Age (years)   

26-35 years old 19 13,9 
36-45 years old 20 14,6 
46-55 years old 34 24,8 
56-65 years old 43 31,4 
>65 years old 21 15,3 

Family’s 
structure 

  

Father 11 8.0 
Mother 41 29.9 
Spouse 13 9.5 
Child 18 13.1 
Siblings 30 21.9 
Relatives 24 17.5 

Family monthly 
income 

  

<3.500.000 IDR 54 39.4 
3.500.000 – 
4.000.000 IDR 

20 14.6 

> 4.000.000 
IDR 

63 46.0 

Patient’s 
duration of 
illness (years) 

  

3 years 16 11.7 
>3-5 years 18 13.1 
>5-10 years 31 22.6 
>10 years 72 52.6 

Patient’s 
frequency of 
relapse (times) 

  

1-3 X 63 46.0 
>3-5 X 41 29.9 
>5 X 33 24.1 

Table 2. Variables’ description 
Variable Mean SD 

Dependent Knowledge 37.93 3.843 
 Burden Care 23.39 7.792 
 Stigma 25.09 6.358 
 Social Support 31.10 5.721 
 Level of 

severity 
28.11 6.954 

Independent Family Stress 27,08 10,524 

 



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families experience stress when caring for patients 
with schizophrenia. 

The stressors perceived by the family comes from 
within the family, namely the patient’s frequency of 
relapse. The other stressors come from outside the 
family, including stigma. The findings of the study 
showed that out of all of the family members with 
schizophrenia, 46 % experienced a relapse at least 
one to three times and the others, more than three 
times. If repeated relapse continues in patients with 
schizophrenia, it can have negative consequences for 
the caregivers (Rexha, Jose, Golay, & Favrod, 2006). 
Recurrent schizophrenic patients exhibit 
uncontrollable behavior, such as being angry without 
cause, and suspicious excessive and unnatural 
behavior. The behavior is often exhibited not only at 
home, but also within the environment, which causes 
unrest in the community. An unpleasant response 
from the environment related to the patient’s 
behavior is the stigma towards patients with 
schizophrenia and their families (Ariananda, 2015). 

Stigma becomes a stressor for the families. 
Stigma is the assessment of a situation or object that 
is considered to be a bad thing, so their value is 
lower than that of a normal person. This assumption 
causes the family to experience discrimination and 
thus to lose the opportunity to engage in activities 
that are important in life. Stigma keeps the family 
impeded from the activities of daily life (Goffman, 
1963 in Heatherton, 2003). The dominant stigma felt 
by families in this research study were 

discrimination and separation. The local community 
treats the family differently, with them being 
disallowed from participating in community 
activities involving all of the family members. 
Community concerns about the uncontrollable 
behavior of schizophrenia patients cause people to 
distance themselves from the patients and their 
families during joint activities. Neighbours who live 
near the family also rarely visit and avoid 
communicating with the patients. The results of this 
study are in accordance with the research of 
Ariananda (2015), which conveyed that the 
community avoids interactions involving the 
presence of patients and their families. Stigma 
causes the family to have negative perceptions, 
affects their emotions and causes stress (Raguram, 
Raghu, Vounatsu, & Weiss, 2004; Singh, Matto, & 
Grover, 2016). The high amount of stigma and the 
patient’s frequency of relapse are stressors for the 
family, and affect the family's perspective of caring 
for schizophrenic patients at home. 

The stress experienced by the family is influenced 
by the family's perception of the perceived stressors. 
The results showed that the families, in treating 
patients with schizophrenia, felt various forms of 
care burden. The perceived burden is the result of 
the perceptions regarding the presence of the 
schizophrenia patients and high stigma from the 
community. Treatment burden occurs as a result of 
the family interaction process with the sick family 
member in order to provide treatment. The burden 

Table 3 Inter-correlation of the variables 

 
Family 

structure Knowledge 
Burden of 

care Stigma 
Social 

Support 

Patient’s 
duration of 

illness 

Patient’s 
frequency of 

relapse 
Level of 
severity 

Family’s 
stress 

Monthly family 
income 

0.311** 0.481** 0.085 0.125 0.163 0.208* 0.098 -0.107 -0.093 

Family 
structure 

 0.492** 0.046 0.010 0.132 0.195* 0.016 0.038 -0.074 

Knowledge   -0.072 -0.102 0.291** 0.070 -0.019 -0.134 -0.159 
Burden of care    0.731** 0.027 0.173* 0.330** 0.189* 0.804** 
Stigma     -0.093 0.072 0.221** 0.234** 0.677** 
Social Support      0.086 0.027 0-.037 -0.027 
Patient’s 
duration of 
illness 

      0.507** 0.174* 0.193* 

Patient’s 
frequency of 
relapse 

       0.603** 0.391** 

Level of 
severity 

        0.267** 

**. Correlation is significant at the 0.01 level (2-tailed). 

*. Correlation is significant at the 0.05 level (2-tailed). 

Table 4. Regression of the family's stress on family structure, care burden, stigma and patient’s recurrence 
Independent Variables Dependent Variable: 

Family stress 
Beta p-value 

Family structure -0.106 0.029 
Burden of care 0.619 0.000 
Stigma 0.194 0.007 
Patient’s frequency of relapse 0.145 0.005 
R2=0.694;Adjusted R2 =0 .684 ; (p= 0.000 ) 

 

 



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felt is both subjective and objective (Chou, Fu, & Lin, 
2011). The treatment and care of schizophrenic 
patients takes a long time. The family, as the closest 
environment, should be able to accept the fact that 
sick family members should be helped to achieve 
better conditions for the patient. In line with the 
opinion of Chou (2011), this explains that the 
caregiver's perception of an objective burden is 
influenced by a number of care needs that must be 
met by the caregiver. The state of the schizophrenia 
patient is less independent and has many needs that 
must be fulfilled, both in relation to the needs of 
treatment and daily needs. This situation requires 
the family to provide time, energy, thought and 
funds. This situation creates an inconvenience for 
other family members. Families limit the time they 
have to work and interact with the social 
environment because they have to treat the patients 
with schizophrenia. Several studies have concluded 
that the suffering experienced by schizophrenia 
patients also interferes with the caregiver’s comfort 
because they feel burdened by the regular and 
continuous care (Fitrikasari, Kadarman, & Woroasih, 
2012; Maldonado, Urizar, & Kavanagh, 2005; Ochoa 
et al., 2008). The prolonged course of the disease, 
uncertain patient behaviour and family 
incompetence to care for the disease causes 
discomfort and affect the family's perspective. This 
study proves that the burden of patient care in 
relation to schizophrenia one of the predictors of 
family stress. The burden felt by the family is 
perceived negatively by the family as it is an 
uncomfortable situation and poses a threat to the 
stability of family life. Negative perceptions that 
continue to grow and that are not managed properly 
will cause the family to fall into a stressful situation. 

The process of stress in the family is also 
influenced by the resources owned by the family. 
The results showed that one family resource, namely 
the family structure, has a role in reducing family 
stress. The family structure is the strength that is 
owned by the family to arrange their values, 
communication patterns and family role as a lifestyle 
so then the family is able to perform its function 
properly (Friedman, 2003). The dominant family 
structure in this study was the role of the mother as 
the primary caregiver of the schizophrenia patients 
(29.9%), followed by sibling and child. The situation 
is influenced by the cultural structure of Indonesia 
that still holds true to strong family ties, so if there is 
one family member who is sick, then the nuclear 
family will take on the caregiver role to provide care. 
Parents or children as part of the nuclear family is a 
family structure that plays an important role in 
providing long-term care to family members who 
experience chronic disease, such as mental disorders 
(Karp, 2001; Sapin, Widmer, & Iglesias, 2016).  

This situation is also in line with the research 
conducted in India, in that the core family in Asian 
families is strong enough that the family members 
consider caregiving as their moral obligation (Kate, 
Grover, Kulhara, & Nehra, 2012). Families have a 

tendency to regulate their family structure when 
they know that one member of their family is 
experiencing schizophrenia. Mothers who act as the 
household manager will have a greater parenting 
role compared to the fathers, who have to work for a 
living. Similarly, siblings, only when the family has 
no parents, become the managers of the household 
and will therefore be selected as the primary 
caregivers for the familial schizophrenia patient. 
Effective role sharing will help the families accept 
reality more quickly so as to reduce the stress 
experienced. An important role in the family when 
caring for a sick family member involves the process 
of making the decision to seek immediate solutions 
and to begin the treatment process (Carpentier, 
2013; Sapin et al., 2016). However, it is possible for 
there to be a conflict within the family due to an 
imbalance of role sharing within the family structure 
(Sapin et al., 2016; Widmer, 2010). The primary 
caregiver feels a heavier burden than the other 
family members who do not accompany the patient. 
Therefore, the family needs resources from outside 
of the family, such as social support from the 
environment. The social support received by families 
is a positive indicator of the family burden during 
the care of patients with schizophrenia (Chow, 2013 
in Poegoeh & Hamidah, 2016). The results of this 
study found that social support is not a predictor of 
family stress. According to Widmer (2010) and Sapin 
(2013), social support sourced from the 
environment (community and extended family) is 
very effective and necessary for the families caring 
for schizophrenia patients early in their treatment 
that does not impact on long-term care. Sadath 
(2017) explained that social support is not one of the 
factors that determines the emotional expression of 
families that have been predicted to experience 
family stress. This is because families have limited 
access to social support while caring for patients. 
Families who treat patients with schizophrenia tend 
to limit themselves in order to take advantage of the 
social support provided by the surrounding 
environment. The family assumes that the existence 
of the patient is a disgrace to the family (Hawari, 
2009), so the family feels that they do not want to 
tell anyone about the illness. In addition to these 
assumptions, families who have tried to ask for 
support from neighbours and their extended 
families, do not feel the benefit, so the family feels 
isolated and discriminated against by the 
environment. As a result of resource utilisation in 
reducing stress, families choose to optimise the 
family structure when caring for schizophrenic 
patients and do not use social support from the 
environment. 

Research implications 

The research findings reinforce the ABCX theory 
according to Hill (Rice, 1987). The frequency of 
patient relapse and the stigma experienced by the 
family were stressors. The presence of stressors is 
interpreted by the family as a burden of care. 



R. FITRYASARI ET AL. 

78 | pISSN: 1858-3598  eISSN: 2502-5791 

Families try to optimise the family's strength, called 
family structure, as a resource for managing 
stressors, but if the family may think that if the 
stressors are threatening to the family stability, then 
this may result in a family burden. This situation 
brings families into stressful situations. Nurses, as 
health professionals who are willing to interact 
directly with the family, can develop family nursing 
interventions, especially in relation to stress 
management. Nurses can do stimulations that helps 
the families to modify the family perceptions of the 
stressor, which was originally considered to be a 
challenge in treating patients with schizophrenia. 

The findings of the study have proven that the 
patient’s frequency of relapse, stigma, the burden of 
care, and family structure can predict the stress 
experienced by the families during the care of 
schizophrenic patients. Based on the theory of family 
centre and nursing (Friedman, 2003), the results of 
this study have implications for nurses. This is as 
they seek to conduct a family assessment which pays 
attention to the patient factors, especially the 
frequency of patient relapse. The nurses also must 
be attentive to the family factors, namely family 
structure and the family perceptions related to 
burden and stigma. The nurses should be able to 
identify the patient's relapse frequency, family 
structure, the burden of care and stigma as the 
family’s stress indicators, so they can help the family 
to manage stress.  

Research limitation 

This research has several limitations. The sample 
of the study was obtained from the families who 
accompany the patients to the outpatient unit. The 
perception of stress experienced by the family was 
strongly influenced by the situation and the acute 
condition of the patient at that time. This caused less 
access to the social support that was used. Another 
limitation is that the results of this study has a 
limited potential for generalisation, especially for the 
family’s stress when the patients are hospitalised. 

CONCLUSION 

The stress experienced by the family when taking 
care of patients with schizophrenia is determined by 
the family's perception of the stressor. Family stress 
can be predicted based on the patient frequency of 
relapse, the stigma felt by the family, the large 
burden of care and the family structure, which may 
not function optimally. Nurses as health care 
providers can develop an assessment format that 
focuses on the family stress predictors, helping them 
to develop family stress management that focuses on 
establishing positive perceptions and enhancing the 
functioning of the family structures, enabling them 
to manage the burden of care and stigma 
experienced. 

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