Prepared by louise kaplan, ph d, arnp, fnp bc, faanp senior p

1. Prepared by Louise Kaplan, PhD, ARNP, FNP-BC, FAANP
Senior Policy Fellow, Department of Nursing Practice and
Policy
[email protected]
Framework for How to Read and Critique a Research Study
1. Critiquing the research article
a. Title – Does it accurately describe the article?
b. Abstract – Is it representative of the article?
c. Introduction – Does it make the purpose of the article clear?
d. Statement of the problem – Is the problem properly
introduced?
e. Purpose of the study – Has the reason for conducting the
research been
explained?
f. Research question(s) – Is/are the research question(s) clearly
defined and if
not, should they be?
g. Theoretical framework – Is the theoretical framework

2. described? If there is
not a theoretical framework, should there be?
h. Literature review – Is the literature review relevant to the
study,
comprehensive, and include recent research? Does the literature
review
support the need for the study?
i. Methods – Is the design appropriate for the study? Does the
sample fit with
the research design and is the size sufficient? Was a data
collection
instrument needed? How were data collected? Were reliability
and validity
accounted for?
j. Analysis – Is the analytical approach consistent with the
study questions and
research design?
k. Results – Are the results presented clearly in the text, tables
and figures? Are
the statistics clearly explained?
l. Discussion - Are the results explained in relationship to the
theoretical

3. framework, research questions, and the significance to nursing?
m. Limitations – Are the limitations presented and their
implications discussed?
n. Conclusion – Are there recommendations for nursing
practice, future
research, and policymakers?
2. Determine the level and quality of the evidence using a scale
(several can be found
in ANA’s Research Toolkit www.nursingworld.org/Research-
Toolkit/Appraising-the-
Evidence )
3. Decide if the study is applicable to your practice
a. Can you use the results and recommendations in your
practice?
http://www.nursingworld.org/Research-Toolkit/Appraising-the-
Evidence
http://www.nursingworld.org/Research-Toolkit/Appraising-the-
Evidence
ISSUES AND INNOVATIONS IN NURSING PRACTICE
The meaning for elders of receiving family care
Janice D. Crist PhD RN

4. Assistant Professor, College of Nursing, The University of
Arizona Health Science Center, Tucson, Arizona, USA
Accepted for publication 11 May 2004
Correspondence:
Janice D. Crist,
College of Nursing,
The University of Arizona Health Science
Center,
1305 N. Martin,
PO Box 210203,
Tucson,
AZ 85721-0203,
USA.
E-mail: [email protected]
C R I S T J . D . ( 2 0 0 5 )C R I S T J . D . ( 2 0 0 5 ) Journal
of Advanced Nursing 49(5), 485–493
The meaning for elders of receiving family care
Aims. This paper reports a study undertaken to broaden nurse
clinicians’, policy-
makers’, and researchers’ understandings of what it means to
elders to receive family

5. care.
Background. The number of older people receiving assistance at
home will increase
tremendously in coming decades in proportion to the rapidly
increasing aged pop-
ulation. Seventy to 80% of the care received by elders is
provided by family
members. As more elders with fewer family carers are
predicted, nursing’s insight
into the family care phenomenon becomes even more important.
The literature
contains reports of specific aspects of family care. Most results
include reports of
elders dreading giving up their independence in the context of
Euro-American
United States society’s highly valued cultural norm of
independence. No studies
have explored elders’ views of the meaning of receiving family
care.
Methods. Hermeneutic interpretive phenomenology was chosen,
and a sample of
nine elders (five women and four men) was interviewed.
Participants were asked for

6. descriptions of their day-to-day experiences of receiving family
care in two to five
interviews, and were observed interacting with their family
carers in naturalistic
settings.
Findings. Elders living at home were found to incorporate help
from family mem-
bers comfortably into their lives. They viewed themselves as
autonomous and able
to maintain balance between autonomy and dependence on loved
ones.
Conclusions. Receiving family care may have positive meaning
for elders, especially
when the care is provided within the context of positive
relationships with family
carers. These findings are in contrast to previous reports. If
validated in further
research, they could be used to inform practice and policy in
health care systems
involved in collaborating with families to develop care
arrangements for commu-
nity-living elders.
Keywords: elders, family care, gerontological nursing,
qualitative research,

7. interpretive phenomenology
Introduction
It is estimated that between 1990 and 2030 the percentage of
the population in United States of America (USA) aged
65 years or older will increase from 12Æ5% to 20%. The
percentage of elders needing help with at least one activity of
daily living (ADL), for example, walking, getting outside,
bathing or showering, transferring, dressing or toileting, now
ranges from 10% for those 65–74 years to 50% for those 85
and older (Hobbs & Damon 1996). With the rapidly
increasing aged population, the number of people receiving
some assistance will increase tremendously in coming
decades. Seventy to 80% of the care received by elders is
given by family members (Scharlach & Kaye 1997). Family
carers devote and average of 20–40 hours per week to elders
over an average of 4Æ5 years (Family Caregiver Alliance
� 2005 Blackwell Publishing Ltd 485

8. 2001). As more elders with fewer family carers are predicted
(Spillman & Pezzin 2000), nursing’s insight into the family
care phenomenon becomes even more important.
Background
In response to the rapidly growing family care phenomenon,
a rich literature on family caregiving has developed. The
majority of research has focused on family care giving, with
fewer studies focusing on family care receiving. Published
studies have dealt with specific aspects, for example, Coeling
et al. (2003) reported on family carers’ and elders’ processes
for negotiating rules about the dyadic relationship. Parsons
et al. (1989) measured elders’ satisfaction with family care,
reporting that the quality of the relationship was more
important than level of elders’ impairment. Russell (1994)
identified ‘dependency work’ that elders performed to retain
control in their relationships with family carers. Becker’s
(1993) exploration of the meaning of living with chronic
conditions identified the importance of autonomy in the

9. context of being dependent; and Charmaz’s (1990) study of
chronically ill people revealed that relationships became even
more important as needs increased. None of these studies
explored the specific phenomenon of receiving family care.
Noticeably absent in the literature are elders’ voices about
what the experience of receiving this kind of care meant to
them. Research such as this is needed (Phillips 1996) and this
gap was the impetus for this study.
The study
Aim
The purpose of this study was to discover elders’ perspectives
of receiving family care, in order to improve practice, policy,
and research.
Methodology
A hermeneutic interpretive phenomenological approach was
chosen (Heidegger 1962/1975). The chiefly ontological goal
of this methodology is to increase understanding of shared
meanings for people with similar experiences, rather than the

10. epistemological goal to theorize, generalize or predict causal
relationships (Koch 1995, Annells 1996).
Participants
A convenience sample of nine elders, of whom five were
women and four men, in urban and rural areas of the Pacific
Northwest, was recruited. This means that transferability of
the findings are limited to similar informants in a similar
context. Six were Anglo-American, one Hispanic-American,
one Asian-American, and one American Indian. They were
recruited from three home health agencies, one adult day care
centre, and one neurological clinic. Elders were eligible to
participate in the study if they were aged 65 years or older,
and had an identified family member who provided daily
assistance with at least one ADL and/or management of
health problems. Participants needed to speak English, and be
cognitively intact or have only mild cognitive impairment/
dementia (in the case of two informants). The Short Portable
Mental Status Questionnaire (SPMSQ; Pfeiffer 1975) was

11. used to screen those who volunteered to participate. They
were accepted into the study if scores were 6 or better,
indicating a range of mild to no dementia. One elder was
excluded because her dementia measured more severe than
‘mild’ on the SPMSQ. Twelve people volunteered to parti-
cipate, but two withdrew before the initial interview.
Those with a variety of chronic illnesses were included
because shared meanings for people with chronic illness have
been found, regardless of type of illness (Charmaz 1990,
Gullickson 1993, ReNel & Magilvy 2000).
The participants had received family care for periods
ranging from 1 1/2 to 30 years. In hermeneutic interpretive
phenomenology, recruitment ends when findings within a
homogeneous sample become saturated. This has occurred
when interviews yield no additional data, or provide rich
descriptions of the same shared meanings (Benner 1994).
Saturation had clearly occurred by the time the ninth
informant had been interviewed in this study.

12. Data collection
Multiple, open-ended, in-depth interviews, observation, and
other methods were used to gain an understanding of what
selected experiences meant to participants. Informants were
allowed to control the pace and direction of dialogue with the
investigator and to describe experiences as they were lived,
rather than to offer reflected-upon, theorized, abstract
explanations (Mishler 1986).
Elders were asked for descriptions of their day-to-day
experiences of receiving family care. Between November
1998 and April 1999 two to five interviews were conducted
by the investigator with each elder, starting with a general
overview of family care experiences in the first interview and
gradually becoming more focused on emerging themes in
later interviews (Seidman 1991). Interviews lasted 30–
60 minutes. All were conducted in informants’ homes. When
carers occasionally made themselves available, elders were
J.D. Crist

13. 486 � 2005 Blackwell Publishing Ltd, Journal of Advanced
Nursing, 49(5), 485–493
observed interacting with them. Observations that occurred
naturally during the interviews were included with the
transcribed text and analysed simultaneously.
Data analysis
The analysis/interpretation was conducted during the same
period of time as the interviews by a data analysis team,
which was consulted during each phase of the work (Crist &
Tanner 2003). The interpretive team comprised three nursing
professors who were experts in either family care or
hermeneutic interpretive phenomenology. A research log
containing a record of all discussions and analysis decisions,
in the form of meeting minutes, was submitted to the team
after each meeting to verify emerging interpretations and
methodological decisions. The investigator’s and team’s
assumptions were acknowledged as much as possible and

14. considered during the interpretations of the narratives and
observations. Acknowledgement of team members’ preun-
derstandings is the forward arc of the hermeneutic circle
(Packer & Addison 1989). Team members discussed their
initial impressions of meanings emerging from initial
narratives. The team’s co-construction of the interpretation
is the return arc of the hermeneutic circle. This ‘movement of
uncovering’ (Packer & Addison 1989, p. 275) involved the
continuous and simultaneous examination of narratives
within the whole emergent interpretation, protecting the
integrity of the story within its particular context. Common
concerns, exemplars, or common themes across informants,
and paradigm cases were identified. Paradigm cases are
particularly compelling stories to which the team returns and
examines from new angles. For example, the meanings from
one elder’s narratives included positive relationships with her
carers, and her view that her life contained a balance between
autonomy and the need for help. Once demonstrated clearly

15. in her narratives, these patterns were more easily recognized
in other family care situations. Lines of inquiry were
identified during each analysis session to focus later inter -
views, either with the same or with subsequent informants,
keeping open to the text of current transcripts (Benner 1994).
Rigour
Evaluation of interpretive phenomenological research ‘con-
siders whether one’s concern has been answered’ (Packer &
Addison 1989, p. 279). Five criteria directed how to proceed
in the interpretive process: coherence, external evidence,
consensus, practical implications (Packer & Addison 1989)
and transferability (Lincoln & Guba 1985). Coherence was
judged by whether the report represented themes, exemplars
and paradigm cases consistently and with credibility. The
iterative process – the team’s reflection on and discussion of
the texts and developing interpretive report – ensured that
this criterion was met. Keeping detailed records of each step
of the iterative process and all methodological decisions

16. helped to evaluate the credibility of the report. The inter -
pretation was taken back to informants during the second or
third interview to evaluate external evidence. Each informant
was asked to reflect on themes that had unfolded through
analysis of their narratives. Their feedback confirmed the
interpretations. Consensus was ensured by the team’s com-
paring the emerging interpretations among individual mem-
bers, as well as with other researchers and other interested
parties, assuring anonymity and confidentiality. The practical
implications of the research findings were periodically eval -
uated by other experts during the interpretive process.
Emerging interpretations were taken back to elders during
the final interviews, and they confirmed the findings and their
usefulness. Experts, including gerontological teachers, doc-
toral students and home health agency interdisciplinary
clinical staff, confirmed the practical implications of the final
interpretation. The same experts also confirmed that mean-
ings for elders in the sample would be transferable to similar

17. elders in a similar context.
Ethical considerations
Approval for the study was obtained from the Institutional
Review Board. Initially, elders were contacted by telephone
by the investigator and asked for permission to come to their
homes. In the home, elders were informed of the purpose of
the study, their rights, including the right to withdraw at any
time for any reason without repercussion, and the investi -
gator’s legal requirement to refer the elder to the State’s Adult
Protective Services if abuse were suspected and to local
agencies if depression were suspected. Elders did not object to
these conditions of participation, and were asked to sign
consent forms. Pseudonyms have been used to protect
participant identity.
Findings
The findings gave a new perspective on the phenomenon of
receiving family care: (a) elders incorporated family care
comfortably into their lives while still viewing themselves as

18. autonomous; (b) they had positive relationships with their
family carers; (c) the acceptability for them of receiving
family care was tied closely to positive relationships between
them and their carers and (d) most elders believed that they
were able to maintain a balance between sometimes receiving
Issues and innovations in nursing practice Elders receiving
family care
� 2005 Blackwell Publishing Ltd, Journal of Advanced
Nursing, 49(5), 485–493 487
more care than they needed and maintaining their own
autonomy.
Incorporating family care while maintaining autonomy
A specialized meaning of ‘independence’ became evident
early in the study. When elders said that independence was
important to them, they meant that they still retained some
control or ‘autonomy’ although they received family care.
Nurses have traditionally measured independence as the level
of a client’s functional ability; for example, as being able to

19. take a bath without needing help. The elders in this study,
although functionally impaired and dependent on family
members to carry out some of their ADLs, still viewed their
lives as autonomous.
Ms Canta was aged in her early 70s and had relocated
from another state, bought property, and built a house to
live near her daughter. Her daughter, son-in-law, and their
daughters lived in a mobile home on the property. Her
daughter had visited her every day for a month to change
dressings on an abdominal wound. Ms Canta’s conscious
reflections including the word ‘independent’ conveyed that
she valued not being dependent: during the second of three
interviews, she claimed,
I am very independent. I like to have my own place. I like to do
my
own things when I want, and the way I want. I am that way.
However, her actions showed that she also valued being close
to her family and she had chosen to live next door to her
daughter, who later became her family carer. Ms Canta’s

20. narratives and the choices she had made in her life revealed
that she defined ‘independence’ as the freedom to make
choices and to arrange her life as she wished, even within the
context of receiving family care.
Ms Post, who was in her 80s, had a progressive disease that
caused weakness of the limbs. Her family carers were two
younger male relatives with whom she lived. She said,
Course I can’t get around like I used to; I don’t see like I used
to; so,
you just kinda mellow out. I take life as it comes. You live with
what
you got!
For her, ‘living with what you got’ included accepting family
care. For example, she described her frustration about not
being safe walking to the door to welcome visitors, but her
narratives revealed that she had the autonomy in deciding
who could come to visit. Most elders had integrated receiving
family care into their daily lives so seamlessly that they did
not mention it. When they indicated an awareness of

21. receiving family care, as Ms Post did in her five interviews,
their statements were either positive or neutral. For most of
those in the study, being care receivers was not part of their
self-image; rather, they focused on other aspects of their lives.
In contrast to others in the study, it was difficult for one
informant to ‘live with what you got’. Mr Elloway was aged
in his 70s and had become unable to walk due to what he
considered an error during surgery 2 years before the initial
interview. He currently needed several daily medical proce-
dures and assistance with most ADLs. He focused on his
physical disabilities, viewed his life as disrupted by his
disability and dependence, and no longer recognized any
continuity with his former, autonomous life. Contrast cases
such as this helped to illustrate more clearly the common
meanings being uncovered in the overall interpretation (van
Manen 1990, Benner et al. 1996).
Ms Johnson was in her 80s, a widow, and had a chronic
illness that could be stable for months and then develop

22. unexpectedly into an emergency situation. She lived alone in
a mobile home park, but a constellation of extended family
members, some living in the same city and others in the same
state, provided intermittent care as needed. Without prompt-
ing, Ms Johnson volunteered that it was important to her that
she was ‘independent.’ She led an autonomous life, including
attending dances held at her mobile home park and never
asking directly for help from her carers. Like most other
elders in the study, she continued to maintain a sense of
autonomy, which she valued highly, while receiving family
care.
Positive relationships with family carers
There were important similarities in the situations of elders
who accepted family care easily. The most obvious of these
was their positive relationships with their carers. For exam-
ple, Ms Johnson said that she only occasionally asked for
help; but, for the most part, she viewed her family carers as
anticipating her needs:

23. Oh, she volunteers, yes. I don’t ever ask. I just bawl her out,
see, ‘You
don’t have to do all that! It isn’t that dirty!’ ‘Oh, just shush and
sit
down!’ ‘OK!’ No, she volunteers everything. I never ask her.
Only I
might ask her to stop at the store and get me something…But
she’ll
always ask, ‘Can I get you this?’ or, ‘Can I stop at the store?’
She’s
available. She’s willing to do anything for me.
It was apparent that, although Ms Johnson’s autonomy was
important to her, she viewed the care she received as
embedded in mutually caring family relationships that
included her family carers’ constant availability and willing-
ness to help.
Mr Kelly had been healthy all his life; but had slowed down
in the previous 2 years because of several illnesses and
J.D. Crist
488 � 2005 Blackwell Publishing Ltd, Journal of Advanced
Nursing, 49(5), 485–493

24. fluctuating energy. Now aged in his 80s, his need for
family care also fluctuated, ranging from total and constant
assistance with most ADLs to being able to bathe without
assistance. He was matter-of-fact about the help he received
from his wife. He revealed that he wished he could do more,
yet showed that he did not question his wife’s helping him:
‘[chuckling] I’m used to her!…No, it doesn’t bother me.’
When prompted with ‘…you’re used to your wife helping
you…’, he replied, ‘Oh yeah, that’s second nature!’ His
comments showed that the care he received was acceptable
because of his close relationship to his wife. Family care was
thus viewed by most elders as support that carers wanted
to give, and as a positive continuation of relationships.
Mr Elloway’s story contrasted with this positive interpret-
ation, and his five interviews did not show evidence of
closeness to or enjoyment of his caregiving spouse.
Positive relationships between elders and their carers
resulted in personal growth. For example, Mr Lewis had
been a professional man most of his life. He was in his early

25. 70s, and had abruptly become disabled. Being dependent on
his wife, as he slowly recovered from aphasia and multiple
disabilities, taught him to be patient. He viewed himself as
acquiring this quality, which he had not had in the past. He
was learning that his connection to his wife-carer helped him
accomplish his new rehabilitative goals with prolonged
progress and a slower approach to life. A positive family
care context facilitated his willingness to incorporate receiv-
ing family care into his life.
Acceptability: elders’ and family carers’ positive
relationships
Most elders did not view family care as help with specific
tasks, but as help inherently available as part of the
relationship. The care that elders received reinforced the
belief that they were loved, and the largely effortless
acceptance of family care was facilitated by their familiarity
with their carers. They trusted and were comforted by their
carers because they had a shared history with them. Ms Post,

26. for example, was continuously motivated to do as much as
possible, for example putting away the dishes. She acknow -
ledged her acceptance of family care in the context of positive
relationships:
We’ve always been a close family…It is hard to have people
help you.
But I’ve gotten to the place where I’ve got to have it, and I
know I
have to have it, so I try and make the best of it.
Mr Kelly was grateful for the help his wife gave him, and
valued this even more because it was given specifically by his
wife, with whom he had a very close relationship:
[Care by his wife] is better than to have to have somebody come
and
do it all…You know, when I was complaining about being a
burden,
and, not being able to do anything, [wife] cut this out for me
once
[hands the investigator a cartoon drawing from the newspaper of
a
little girl and boy arm-in-arm]. The caption reads: ‘Love
is…being

27. thankful for every day spent together’. (Love is 1998)
Receiving care from his wife intensified Mr Kelly’s affection,
appreciation and commitment to his marital relationship.
Mr Elloway, however, felt more discomfort when someone
close, such as his wife, gave him care. He preferred hired
carers’ help, which he considered part of their job:
If you had a legitimate caregiver that’s getting paid dollars for
doing
it, it’s routine…I wouldn’t want to do it, for a person. But if
you got a
caregiver that’s just doing it out of…I can use the word ‘love’
or
‘necessity’, or anything you want!…She doesn’t care for it, I
know.
And I don’t care for it either…I still have a guilt feeling when
somebody has to, or, when she has to work on me, not when
the…[home care nurse] comes, she’s a pro, she knows what
she’s
doing, it’s like when a nurse takes care of you in the hospital.
Mr Elloway’s statement that his wife ‘worked on him’
revealed his view that he was ‘broken’. His words also
suggested that, from his point of view, his wife’s care was an

28. act of duty rather than of love. He considered his wife as
performing tasks, not as helping a husband about whom she
cared. He found it easier to cope with his physical disability
by hiring a person to ‘work on’ his body.
Some of the interviews suggested that long-standing
familiarity and affection eased elders’ experiences that might
have been awkward with less familiar carers. During one
interview, Ms Post’s main family carer, who was in the
adjoining room, pointed out that Ms Post had changed his
diapers when he was a baby. Her laughing response was,
I paddled his butt (spanked him when, as a child, he
misbehaved)
many a time, too!
The exchange demonstrated the context of familiarity that
facilitated her comfort in receiving family care.
Balance: accepting more care than needed while
maintaining autonomy
Elders believed that they had a balance with regard to

29. carers’ performing some tasks that they thought they could
or should do for themselves. In a previous study (Crist
et al. 1998), some elders complained that family carers did
too much for them and would not let them do what they
themselves thought they could or ought to do. However,
elders in the present study accepted family carers’ helping
Issues and innovations in nursing practice Elders receiving
family care
� 2005 Blackwell Publishing Ltd, Journal of Advanced
Nursing, 49(5), 485–493 489
them when it might not have been absolutely necessary.
They sometimes chose not to do some things for the sake of
safety and conservation of energy. Ms Post, for example,
admitted that although she was tempted to do certain
activities, she was convinced that it was probably unsafe
for her because of her frailty and potential for falls. She
struggled with wanting to step down into the wash room to
get clothes out of the dryer, and reluctantly paid attention

30. to reminders from her carers:
Sometimes [chuckling] I get up to do something and they give
me
holy hell because I’ve gotten up to do it, when he would have
done it.
But, I figure, ‘Well, I’ll just go get it’, you know. [It] don’t
always
work [laughs].
Even when Ms Post was tempted to continue doing things for
herself, she acknowledged that her previous ways of doing
things without assistance needed to be modified. The positive
perspective with which she viewed receiving family care
helped her achieve a balance in what she felt she could do.
Her level of acceptance about her new level of dependence
was aided by a sense of humour.
Mr Kelly was aware of his energy limitations and, for him,
they justified his wife’s doing what he thought he could have
done:
She [chuckling] probably does too much. In some ways. What I
mean

31. by that is if I want a [glass of] water or something, I would go
get it,
but she will get it for me…Like with a bath, she has to help me.
No, it
doesn’t bother me. In some ways, sometimes maybe it does. I
think I
ought (to) do things, but I get so tired, you know.
Elders and their family carers revealed a comfortable
familiarity within their relationships, which allowed humour
to be used in promoting autonomy in the context of family
care. The familiarity and ease with which interactions
occurred made them appear to be a pattern that probably
had been effective in the past and had thus continued.
Narratives of Mr Lewis with his family carer contained this
lightness:
Mr Lewis: I’m teasing her!
Wife: He teases me a lot. Especially when he’s taking a shower.
He
likes to take the [showerhead] and squirt it at me [laughing].
Mr Lewis [mischievously shaking his head in denial]: I’m very
innocent.

32. Wife: He laughs and laughs…I’m just happy to have him here
[Mr
Lewis affectionately taps her on the knee with his cane].
This excerpt shows that a bath given by his wife, a form of
intimate personal care that represented Mr Lewis’s dependence
for many aspects of his life, meant to him that there was a
sustained mutual affection embedded in his receiving family
care.
When these elders accepted care that might appear unnec-
essary, they referred to rational reasons, for example, their
own safety or energy conservation. They allowed and even
embraced, with humour, insight and sensitivity, variations in
the ways tasks were accomplished, by them or others. They
did not see themselves as being forced to accept overbearing
or oppressive assistance. These elders felt there was a balance
between accepting help and maintaining autonomy, which
was accomplished through mutual caring and trust.
Discussion

33. These findings help gerontological nurses ‘create new visions’
(Benner 2000, p. 10) of receiving family care. Shared positive
meanings of receiving family care were uncovered, in contrast
to results of earlier descriptive or correlational studies that
report elders’ discomfort with receiving family care. An
important theme in literature has been the overwhelming
values held by many elders in Western society on individu-
alism, productivity, autonomy, competence, stoicism, and
privacy, even within kinship relationships (Bellah et al.
1986). Previous research has shown that when many elders
were no longer able to conform to these accepted norms, they
viewed themselves as failures or as indebted to family
members providing care for them (Kaufman 1983, Thomas
1993, Crist et al. 1998). The surprisingly positive meanings
that emerged were found across gender mix of elders/carers,
…