Adult children’s experiences of family occupations following ageing parents’ functional decline

ABSTRACT

Background. Adult children often live separately from their ageing parents; however, family occupations between them may still be an important aspect of daily life. Previous research showed that, when ageing parents experience functional decline, their adult children’s everyday life is affected. Purpose. We aimed to provide insight into adult children’s experiences of family occupations when their older parents’ exhibit functional decline. Method. This study used a qualitative research design with a constructivist grounded theory approach. In total, 15 in-depth interviews were carried out in a Norwegian context with adult children, aged 47-64 years, whose parents were exhibiting increased functional decline and had received public reablement services as a result. Findings. Family occupations consist of visible aspects, such as “doing family occupations” together and for each other, and less visible aspects, including experiences of “ambivalence in doing without being asked” and “being in a state of readiness”. Our findings showed how adult children gradually assumed responsibility for the physical aspects of ‘doing’ in the family occupations. However, they expressed that their parents did not always accept or want to let go of the doing, even when they had difficulties performing physically. Family occupations are constantly changing, and they are metaphorically illustrated as an iceberg. Conclusion. Our findings advance understandings of adult children’s perspectives on family occupations. Adult children play an important part in maintaining family occupation by adapting, planning, and taking on an active role and a stand-by position in the family occupations.

背景：成年子女通常与年迈的父母分开生活；但是，他们一起进行的家庭生活活动仍然可能是日常生活的重要方面。先前的研究表明，当年迈父母的生活能力下降时，成年子女的日常生活会受到影响。

目的：我们的目的是深入了解成年子女在其父母表现出生活能力下降时，他们的家庭生活活动经历。

方法：本研究采用了基于建构主义扎根理论方法的定性研究设计。对年龄在47-64岁的挪威成年子女进行了共15次深度访谈。他们的父母表现出越来越严重的能力下降，并因此获得了公共培训服务。

发现：家庭生活活动包括看得见的方面，例如一起进行，并为彼此进行家庭生活活动，以及不那么看得见的方面，包括“没有被要求就做事的不确定性”和“处于准备状态”的经历。我们的研究结果表明，成年子女如何逐渐承担起家庭生活活动中“做事”体力方面的责任。但是，他们表示，即使父母身体上有困难，他们的父母也并不总是接受或愿意放弃做事。家庭生活活动在不断变化，且被比作冰山。

结论：我们的发现提高了对成年子女关于家庭生活活动看法的理解。成年子女通过适应、计划并在家庭生活活动中扮演积极角色和待机角色，在维持家庭生活活动中发挥着重要作用。

Antecedentes. Aunque los hijos adultos suelen vivir separados de sus padres ancianos, las ocupaciones familiares que realizan con ellos pueden seguir siendo un aspecto importante de su vida cotidiana. Investigaciones anteriores mostraron que, cuando los padres ancianos experimentan un deterioro funcional, se ve afectada la vida cotidiana de sus hijos adultos. Objetivo. Nuestro objetivo es proporcionar información sobre las vivencias de los hijos adultos en torno a las ocupaciones familiares cuando sus padres mayores experimentan deterioro funcional. Método. El presente estudio utilizó un diseño de investigación cualitativa con un enfoque constructivista de teoría fundamentada. En Noruega, se llevó a cabo un total de 15 entrevistas en profundidad con hijos adultos, de entre 47 y 64 años, cuyos padres mostraban un deterioro funcional avanzado, razón por la cual habían recibido servicios públicos de rehabilitación. Resultados. Las ocupaciones familiares poseen aspectos visibles, por ejemplo, “hacer ocupaciones familiares” juntos o apoyándose mutuamente, y aspectos menos visibles, que incluyen vivencias “ambivalentes al llevar a cabo [alguna ocupación] sin que se les pida” y “estar en un estado de preparación”. Nuestros resultados dan cuenta de cómo los hijos adultos asumieron gradualmente responsabilidades sobre los aspectos físicos del “hacer” en las ocupaciones familiares. Sin embargo, expresaron que sus padres no siempre lo aceptaban o no querían dejar de “hacer”, aun cuando tenían dificultades para desempeñarse físicamente. Las ocupaciones familiares cambian constantemente y se ilustran metafóricamente como un iceberg. Conclusión. Nuestros hallazgos profundizan la comprensión de las perspectivas de los hijos adultos respecto a las ocupaciones familiares. Estos desempeñan un papel importante en el mantenimiento de la ocupación familiar, adaptándose, planificando y ejerciendo un papel activo y guardando una posición de espera con respecto a las ocupaciones familiares.

KEYWORDS:

• Occupational science
• Ageing parents
• Informal carers
• Interdependence
• Participation
• Reablement
• Substantive theory

In Western cultures, adult children and ageing parents typically live in separate households. However, they are often accessible to each other when necessary (Connidis & Barnett, 2019); this is also the case when the parents receive support from public health services after a decline in physical and cognitive function (Daatland & Veenstra, 2012). Previous health care research about families supporting older adults with decline in function have focused on caring as an activity rather than a dimension of an often dyadic relationship between the older adults and the family members (Larkin et al., 2018).

Studies on the topic tend to focus on the negative aspects of caregiving, such as the subjective burden family members experience as caregivers to their older parents (del-Pino-Casado et al., 2019) and difficulties managing their own life and coping with emotions (Akgun-Citak et al., 2020). Further, adult children providing care to their parents/family members experienced significantly higher levels of both depressive symptoms and unhappiness (Strawbridge et al., 1997), issues with work attendance (Gautun & Bratt, 2016), and important changes in their lifestyle (Conde-Sala et al., 2010).

In general, research indicates that taking care of and supporting older adults may influence adult children’s everyday lives. The present study aims to explore how adult children experience family occupation in a Norwegian setting when their parents receive a home-based, public reablement service-program due to functional decline. Reducing the knowledge gap in the understanding of family occupations may contribute to increased collaboration and co-creation between health care professionals and families in the future. It could also ensure that adult children and their parents maintain their quality of life and well-being.

Family Occupations

An increasing interest in family occupations has emerged in the field of occupational science, with studies taking place in different contexts. For instance, Segal (1999) explored families with children who had special needs and described family occupations as cultural chunks of activities created when the family was engaged in a common occupation, together. However, all family members did not always perceive the engagement in the same way, in neither purpose nor experience.

Kantartzis and Molineux’s (2014) ethnographic study in a small town in central Greece revealed that family occupations could also be understood as “not only [being] physically with others or for their immediate needs but … [including] the family in planning, discussion and doing, … constructed through the occupation and emotional presence of other family members both past and present” (p. 288). On the other hand, Bonder (2006) studied 31 community-residing older adults who described family occupations as exchanges, where older people sometimes did something for the family, the family sometimes did something for the older person, or sometimes they just did occupations together to have a good time.

Farias and Asaba (2013) showed that for immigrant families in Sweden, identity and culture were continually negotiated through family occupation. Moreover, in an ethnographic study of fathers of children with disabilities, Bonsall (2014) found that family occupations were conceptualised as an important aspect of daily life and could take part in building and defining families. In other words, family occupation could be understood through constructions of planning, being, exchanging, discussing, negotiating, and behaving towards each other or together, with actions conducted in relation to someone or something and linked to participation. In our study, we approached family occupations broadly, including all the doings and beings that adult children and their older parents, with declining function, share.

Family occupations when older parents exhibit a decline in function

Family occupations are important in everyday occupations for many older adults (Vik, 2015). However, there has been little focus on family occupations in the public reablement service-program (Hjelle et al., 2017; Jakobsen et al., 2019; Jakobsen & Vik, 2018), despite the fact that one of the aims of reablement is to focus on what older adults experience as meaningful occupations in their daily life (Tuntland et al., 2019). Older adults receiving reablement described social networks, such as the family, as essential for their participation in society (Magne & Vik, 2020); the families were both helpers and motivators for social participation. For older adults receiving rehabilitation services at home, support from family, friends, and neighbours influenced social participation more than the availability of accessible physical surroundings (e.g., home adaptations) and home care services (Witsø et al., 2011, 2012). Contact over the phone and family visits played a part in structuring older adults’ everyday life. Family and social support were significantly important when given in a manner that provided the older adults with a feeling of participation and collaboration (Vik et al., 2007).

The aforementioned studies demonstrate the important role of family and neighbours in older adults’ daily life, as perceived by older adults themselves. However, even though it is well known that older peoples’ functional decline influences their adult children’s lives, the specific ways in which adult children are affected and their experiences remain unknown. As many studies focus on family contribution and experiences in general, our study focused specifically on adult children’s experiences with the goal of answering the question: how do adult children experience family occupation when their older parents exhibit functional decline?

Methods

Study design

The study followed a cross-sectional design; epistemologically, our point of departure is constructivism. We operationalised our approach by following the constructivist grounded theory’s recommendations (Charmaz, 2014). Consequently, the data analysis and construction of the findings were interpreted by us as researchers. This approach is suitable when the purpose is to construct a substantive theory about processes associated with a phenomenon (Birks & Mills, 2015; Charmaz, 2014), such as family occupation when older parents experience functional decline.

Study context

The study was conducted in four Norwegian municipalities providing reablement to older adults. Reablement is a form of rehabilitation service targeting older adults living at home who have been experiencing a decline in functioning (Liaaen & Vik, 2019), often after an accident or illness (Aspinal et al., 2016). Reablement is provided by healthcare professionals working in the community (e.g., occupational therapists, physiotherapists, nurses, and home-carers) and consists of training in everyday occupations to regain independence and the ability to stay in one’s own home for a longer period of time (Glendinning et al., 2010; Langeland et al., 2015; Tuntland et al., 2019). Reablement is a time-constricted service, usually provided for a 4- to 6-week period.

Recruitment and selection

The inclusion criteria required that older parents must have participated in reablement regardless of the type of accident or illness they had. A purposeful sampling strategy was applied. We recruited participants by contacting their parents’ public reablement programs in collaboration with the healthcare professionals providing reablement services and in line with personal protection regulations in Norway. Older adults forwarded information about our study to their adult children, along with our requests for their participation. In some cases, health care professionals received permission from the older parents to contact their adult children by phone. The participants who consented to participate responded directly to the first author. The recruitment process took place in three rounds, as illustrated in Table 1.

Table 1. Participant Selection Criteria.

Exclusion Criteria (all rounds)	Rationale
Under 18 Does not speak nor read Norwegian Living in the same household as their parent(s) Spouse	Simplifies consent requirements, wanting experience from adults Required to understand the purpose of this study and the questions in Norwegian The research topic requires experiences from participants “living in separate home from parents” Focus on adult-children’s perspective
Inclusion criteria 1 (n=7); all rounds Has regular contact with their parents One of their parents has participated in reablement Does not need to have specific experiences about their parent’s reablement service	Has enough experience to be able to answer the question about family occupations with their parents
Inclusion criteria 2 (n=4) Siblings of previous participants in the study Sister-in-law of the previous participant in the study	Experiences of being close to the parents while having experience of living in a different place Could answer questions related to their experiences of occupations they do for and with their parents and siblings
Inclusion criteria 3 (n=4) Sons	In line with theoretical sampling (Charmaz, 2014), we sought participants able to illuminate and define the properties, boundaries, and relevance of the emergent categories

Given our interest in constructing a substantive theory, we used theoretical sampling in the different stages of the recruitment process (Charmaz, 2014). All participants signed consent forms before each interview. In total, 15 participants shared their experiences about family occupations (Table 2). Personal protection approval was obtained from the Norwegian Social Science Data Services (NSD), project No: 48413 and in line with professional ethical guidelines.

Table 2. Participant Demographics.

N	Participants (relationship)	Age Group	Parents (relationship)	Distance to parent (minutes; walking or driving)
1	Daughter	40-49	Mother	2 min walking
2	Daughter	50-59	Mother	5 min by car
3	Daughter	50-59	Mother	5 min by car
4	Daughter	50-59	Mother	10 min by car
5	Daughter	60-69	Mother	30 min by car
6	Daughter	50-59	Mother	60 min by car
7	Daughter	60-69	Father	10 min by car
8	Daughter	50-59	Father	25 min by car
9	Daughter-in-law	40-49	Father-in-law	30 min by car
10	Son	50-59	Mother	2 min walking
11	Son	60-69	Mother	2 min walking
12	Son	40-49	Mother	2 min walking
13	Son	50-59	Mother	5 min by car
14	Son	50-59	Mother	10 min by car
15	Son	40-49	Father	15 min by car

Data collection and analysis

The first author conducted the in-depth interviews based on an open-ended interview guide. The interviews lasted 50–90 minutes; they were audiotaped and transcribed verbatim. After each interview, all the authors discussed the interview with an analytical focus on addressing action and process rather than theme and structure, which Charmaz (2014) emphasised as an important strategy in the process of constructing a grounded theory.

NVivo 12 software was used in the process of initial and focused coding. In the advanced process of coding, we worked with developing theoretical coding (Birks & Mills, 2015). We used extensive drawing and visual mapping in NVivo (mind-maps) and drawing on paper to support our data analysis in constructing a theory. Memos were written after each in-depth interview as well as throughout the different phases of the analysis. Memo writing provided an opportunity to ask questions for the development of categories, such as the following: what did the family occupation look like when the family participated in them?, and what did the family occupation consist of besides the doing aspect? Constant comparisons were made throughout the process, where different parts were compared and adjusted.

The various questions we asked supported us in achieving theoretical saturation of the core category, which is necessary for theory formation. According to Charmaz (2014), a substantive theory is ‘a theoretical interpretation or explanation of a delimited problem in a particular area’ (p. 344). This is the case in our study of family occupations with adult children supporting their older parents with functional decline. Based on the empirical findings, a metaphor of ‘an iceberg of family occupations’ emerged as an illustration for our substantive theory. The participant quotes reported to support that theory were translated into English by a bilingual occupational therapist and discussed with the co-authors to ensure accuracy.

Findings

An iceberg of family occupations

The substantive theory of family occupations is compared to an iceberg (Figure 1). The tip of the iceberg is the most visible part, consisting of doing familiar and common family occupations together and for each other. This part of the iceberg consists of both short and long occupations regarding time and complexity, from talking on the phone to going on a holiday together.

Figure 1. An Iceberg of Family Occupations: An Illustration of the Substantive Theory.

The larger part of the iceberg is below the surface and contains two parts. The first part, ‘Ambivalence in doing without being asked’, refers to occupations related to emotional processes and negotiations that adult children have with themselves and their parents. When the parents needed more support, assistance, or help, they had to decide how to perform new occupations in everyday life. The other part of the iceberg refers to occupations related to ‘Being in a state of readiness’. These occupations involve uncertainty and unpredictability in everyday life and could affect future family occupations.

Collectively, the iceberg’s less visible parts are related to what the adult children are doing that is not explicitly expressed but is, nevertheless, part of the co-creation process of what family occupations are and could be. Hence, all three parts of the iceberg are related to each other, indicating how to understand the complexity of family occupations from the perspectives of adult children supporting their parents with functional decline. The shape of the iceberg of family occupations changes based on how different family members contribute to the family occupations and on the changing conditions and functionality of the parents.

Doing family occupations

Doing family occupations was first and foremost about the ‘visible’ occupations the adult children did with their parents. The family occupations mentioned were characterised by aspects of being together, doing practical occupations with or for each other, and participating in family gatherings and social occasions related to family traditions. Occupations relating to holidays and weekends were emphasised. Examples mentioned were doing gardening together, going away together for a holiday, or visits to the cemetery. At the same time, the occupation of ‘popping by’ the parents to talk and drink a cup of coffee was mentioned as a common family occupation. Daily or weekly phone calls to check up on their older parents or update them on happenings in their everyday lives were also perceived as a common family occupation. Eating together was mentioned by several of the participants as a meaningful family occupation. One participant elaborated that her mother still cooked dinner for her:

I eat dinner together with her, at her place as she is making the food … She is very fond of cooking and she’s always done this. And in that way, it is very okay. It’s not because I don’t want to make dinner myself, but I stop by and eat dinner at her place two to three times a week, but it is because I think it is okay to know that she prepares dinner and has someone to eat with.

For other participants, as time passed, they were rarely invited over for dinner to their parents’ house. Instead, the adult children invited the parents or brought food with them. One son explained:

I pop by when I am in town … then I bring with me some takeaway sometimes, they have become quite a lot older the past few years. So that has changed a lot … only 1 year ago, we went out to eat at restaurants and I picked them up, but they’ve become frail. It seems as if they are more content with just getting food home and just keeping it easy. That’s how I am experiencing it at least.

The above quote illustrates how adult children play a part in maintaining family occupations by, for example, serving or bringing food to their parents in order to maintain a meaningful family occupation. Different life events occurring in the families could affect how family occupations play out and for whom in the family. An example was one daughter explaining it was the mother who always invited the family over for Sunday lunch; this way they regularly met each other. However, following their mother’s passing away, and a concern for her father being alone, she, her siblings, and grandchildren started going together for coffee and cake at her father’s on Saturdays instead.

Our findings showed how adult children gradually assumed responsibility for the physical aspects of ‘doing’ in the family occupations. However, they expressed that their parents did not always accept or want to let go of the doing, even when they had difficulties performing physically. In this process, emotional reactions from both the children and the parents could occur. For instance, one daughter described celebrating Christmas Eve differently when her mother had an active role in it:

I am quite adult myself and have grown children and I have found that since I am working full time, I do it quite easy and we probably decorate the tree a little different than what she’s used to. I don’t think the content in itself is such different. I think it is more than the times have changed and she’s reacting to a point where there is a large difference in how she now sits as the oldest in the family versus being the young adult having small children and being the active part … The roles are very different now and I think she feels a lot about not being a burden.

This quote reflects the complexity of maintaining family occupations, as experienced by adult children. When changes and adjustment occurred, they sometimes experienced tension because the changes in roles affected the meaning of the family occupation for parents and adult children.

Another aspect of doing family occupations was related to performing household chores in the parents’ house. For some adult children, doing housework at their parents’ place was a way of being together as a family, whether it was doing the laundry when they popped by or taking the garbage out while their parents were doing something else. One participant said that sometimes he worked from his parents’ place:

It happens sometimes that I bring my PC and get coffee and then I go into a spare room and sit down to work [in the parents’ house] … I think they think it is nice to have company and I might as well work from there as any other place really … then they have company over a longer period of time. Since the conversation is a bit limited anyway now … they soon run out of things to talk about. So being there without saying much, sitting there and working … then it is company for both them and me.

To sum up this category, some participants considered doing family occupations a positive way of being together as a family while maintaining family traditions, despite their parents’ functionality having declined and the roles having gradually changed.

Ambivalence in doing without being asked

This category refers to adult children’s ambivalence in taking over new occupations related to their parents. As shown in Figure 1, this part is illustrated as a part of the iceberg, but below the surface. The adult children discovered new occupations they perceived needed to be done for their parents as the parents were experiencing increasing difficulties in performing the occupations themselves. The adult children reflected on how they should deal with these new occupations; for example, when the parents could no longer drive a car, or had difficulties paying bills, getting themselves to the doctor, or doing the grocery shopping or other household chores. Some participants started doing these occupations with their parents. They could, for instance, combine shopping groceries for their parents with going to a café together. As a result, new family occupations emerged.

However, there were different ways of dealing with the fact that family occupations were increasingly related to supporting their parents’ everyday life. Some adult children felt they had to initiate the process of supporting their parents when needed. This entailed taking the initiative and offering help around the house, but also coming over for a visit. Several of the adult children stated that they helped in the parents’ house even if the parents had not directly asked for it: tidying, cleaning, and repairs around the house were typical occupations the adult children did without being asked. There were several reasons why the adult children chose to do occupations before the parents asked. First, they noticed a need for cleaning or tidying, a change in the expected standard of how they knew the parents preferred it to be:

Because it is kind of like their standards change a bit and they can’t see as well, what do I know, but it is a bit like I feel then that I need to help a bit. It is not often I do it on demand I must say.

Second, the adult children perceived that their parents wished not to be a burden and hence did not ask for help, or that they indirectly requested help:

She might say ‘I [her mother] will carry the Christmas decorations downstairs’, which means ‘Can you carry the Christmas decorations downstairs because I do not manage that anymore’. But she thinks she can manage, so she’ll say, ‘I’m shopping, I’m doing this, I’m doing this and that’, but it is more of a hint for me.

This quote illustrates the dynamic between adult children and their parents, in a way where the parent participated in the occupation, but the child performed the physical part of it.

Third, by doing something without being explicitly asked, the adult children could assist their parents in doing things on their own. A son revealed the reason why he checks into his parents’ fridge to see if there was anything old that needed to be thrown out:

They mean [to say] they manage on their own in a way … ‘I don’t say much about that … ’ ‘I just go and do it’. They … mean … in a way, they have a lot of pride. That is related to what they ask for help for as well.

However, several participants stated there was a balance and consideration related to doing something without being asked. They expressed that their parents could directly ask for help to avoid the dilemma related to whether it was right to start helping parents before they asked for help. Some participants experienced gratitude from their parents for helping without being asked, while other parents expressed that they did not wish for the adult children to help or do occupations for them without being asked.

Being in a state of readiness

This less visible part of the family occupations iceberg entails how adult children need to be in a state of readiness to act if and when their parents were concerned or needed help. As time progressed, the adult children had to handle and tackle new challenges in everyday life when changes in their parents’ functional ability and health occurred. As previously mentioned, several of the adult children had already adapted and made changes to the family occupations so that the parents could still participate, for instance, by doing less of the physical part in the family occupation or adapting the physical surroundings to better match their parents’ abilities.

However, this remained a challenge since as parents’ functionality further declined, the adult children experienced difficulties compensating for the parents’ loss in functional abilities or their opportunities for social participation. Participants compensated for the parents’ loss in functional abilities by being in a state of readiness, whether it was about the traditional family occupations, such as Christmas celebrations, or in small chores, such as lifting the vacuum cleaner up the stairs or changing light bulbs. Even though some of the participants stated that their parents’ functional ability improved after reablement, a lot was still at stake if new falls or disease occurred. This could be potentially threatening for future family occupations. Several parents were described as fragile by their adult children. Therefore, anticipation, uncertainty, lack of predictability, and a need for control in everyday life were tied up to the everyday life of the adult children.

Adult children’s daily life was characterised by actions related to readiness, such as questioning “what is next?” Being in a state of readiness was about being available for the parents, such as being ready to head out if anything unforeseen occurred. This entailed both longer and shorter periods, depending on how the adult children considered their parents’ functioning and how the parents’ everyday life affected their adult children’s choice of occupations. Adult children stayed in constant state of readiness even when they were physically separated for their parents.

Second, a state of readiness implied always having the phone nearby in case something happened to the parents. Some of the adult children chose not to go for weekend trips to a cabin nor to go away for longer holidays without planning to have siblings or their own children available for the parents. Another option was to bring the parents along for a holiday, while dealing with the uncertainty that the planned travel could go ahead if the parents’ health did not improve.

Third, being in a state of readiness entails periodically attempting to make their parents feel secure and less unsettled in their everyday lives. Several participants explained how their parents spent more time planning everyday occupations and that it took less to throw them off balance and cause unsettledness. Some of the adult children chose not to tell their parents in advance when they planned to do occupations together; instead, they stopped by and thought of something there and then to avoid anxiety and worrying their parents in advance. The adult children also described how the parents could be unsettled for another event that occurred. For instance, a participant described her parents being anxious and having misunderstood a letter they received in the mail, thus, she “headed out to [her] parents and took time off from work”. At the same time, participants described feeling unsettled themselves after wondering how their parents managed when they were not present, particularly those who travelled a lot and were away because of work.

I have felt some uneasiness when I have been travelling, and I still do, that they are being looked after at home. I have an ally in the neighbour who checks on my father.

Fourth, participants experienced tension due to uncertainty about performing planned family occupations. Some participants described that their parents’ engagement and interest in family occupations was ambivalent and could be demanding to follow. One daughter spoke about her mother’s birthday celebration:

On Friday, it is her birthday. … She [her mother] thought she wasn’t going to have anything. I said, ‘You have to have some coffee at least and some cake. Aunty will probably be here, because she always used to come’. ‘Okay’, mother said. ‘And I shall fix it’, I said. And then she called on Wednesday, ‘No, she didn’t think so’. I had to tell the others that she wasn’t well. Because when she doesn’t see people she gets anxious. So, I just called and said they could arrive at 5 pm on Friday. And I would bring sponge cake and I ordered a gigantic sponge cake and we brewed the coffee. And then [when the daughter arrived] she had set the table. ‘Are you expecting guests’? I asked. ‘No’, she said, and did not know if anyone would come.

To sum up, both ‘Ambivalence in doing without being asked’ and ‘Being in a state of readiness’ highlighted aspects regarding the less visible occupations that, for some participants, were more demanding to handle.

Discussion

This study aimed to understand how adult children experience family occupations when their older parents exhibited functional decline. Our findings indicate that family occupations are more than a family unit engaged in doing occupations together, which is consistent with DeGrace’s study (2003). Our study’s most striking contribution is discovering the adult children’s extensive experiences of ambivalence in doing something without being asked by their parents and being in a state of readiness.

Adult children did family occupations with their parents and they were continuously planning future family occupations (e.g., future holidays and birthdays), while being uncertain about the possibilities of actually doing them. In line with Kantartzis and Molineux (2014), family occupations could contain planning, discussion, and the presence of other family members in both the previous and present time. In what follows, we will discuss the suggested substantive theory and the metaphor of family occupations as an iceberg.

It is our understanding that this ‘iceberg of family occupations’ is complex and multifaceted, in line with Bonder’s (2006) and Kantartzis and Molineux’s (2014) description of family occupations as interwoven between the family members and changing from day to day. Our study additionally indicates how family occupations intersect with other occupations that adult children participate in. Thus, family occupations could be understood as transactional, extending beyond individual experiences and encompassing social, physical, and cultural contexts (Dickie et al., 2006; Riley, 2012). However, they could be difficult to clearly distinguish from other occupations that adult children do.

Second, it may be challenging to grasp those less visible parts of the family occupations iceberg since it seems that adult children become ‘hidden enablers’ to professionals in the reablement services as well as to their older parents with functional decline. Previously, Hitch (2009) described the invisible elements of family occupations as relationships elements and the performance as visible elements of occupation. In our study, the invisible elements of doing without being asked and being in a state of readiness could be understood as a way for adult children to care for their parent-child relationship while preserving their parents’ autonomy. Such interpretation is supported by Bastawrous et al.’s (2015) finding that adult children caregivers’ well-being is uniquely impacted by the quality of the parent-child relationship and the combination of roles occupied.

An important finding in this study elucidates the relation between being and doing in the family occupations. Being and doing are concepts elaborated in the fields of occupational science and occupational therapy (Craik, 2020; Hitch et al., 2014; Hocking, 2020; Wilcock & Hocking, 2015). According to Hitch et al. (2014), “doing is often characterized as being ‘active’, a visible quality that is recognizable to observers. ‘Action’ in this context relates to physical doing” (p. 236). Our findings indicate a change in who does which parts of the family occupations, with the older parents increasingly ‘being’ and the adult children increasingly ‘doing’. The transition in who was performing an occupation has previously been described by Leven and Jonsson (2002), who found a shift from doing to “being in the atmosphere of the doing” (p. 151), which could be a lifestyle adjustment for older adults in nursing homes. Our study indicates that this transition also unfolds between adult children and their older parents with declining function, who are living at home.

Family occupations can be meaningful for older adults and their adult children (Bonder, 2006; Munkejord et al., 2019; Vik et al., 2007). However, our study shows that in addition to the positive aspects of doing occupations together, tension, uncertainty, loss, and ambivalence were present and affected how the occupations were performed when challenges due to functional decline occurred (either physical or cognitive). It is possible that some elements of the iceberg hidden below the surface are associated with taboos in our culture, due to how the adult children played a part in solving the challenges that occurred during the family occupations without always mentioning it to their parents. This could be understood in relation to Bonder (2006), whose findings showed that receiving help or support was emotionally difficult for some older adults who worry about being too demanding and potentially being a burden.

Twinley (2013) used the term ‘dark side of occupation’ to depict how occupations are not necessarily positive, even though these occupations can be perceived as meaningful, purposeful, and engaging. With this in mind, our findings show that family occupations could contain a sense of burden, but also joy and meaningfulness for adult children when they did more occupations for their parents, especially if their parents did not acknowledge the adult children’s contribution to the family occupations. There might be an ambiguity between adult children’s experiences related to supporting older adults in the family, as earlier described by Carlsen and Lundberg (2018), where adult children also experienced both a heavy burden and joy while supporting their parents.

Finally, the iceberg metaphor implies that something could collide or melt away, in the same way as physical barriers or unexpected events could extinguish or threaten the opportunity to participate in family occupations. It is worth mentioning that our study was performed before COVID-19. It may be possible that this pandemic would have an impact on family occupations. Further studies need to explore how family occupations, for adult children and their older parent, are influenced by social distancing, different relationships, and from different family members’ perspectives. Additionally, future studies should include immigrant families. Nevertheless, the visible and less visible aspects of family occupations, presented in the metaphor, could potentially apply to other parts of the older populations. Additionally, the adult children’s experiences contribute essential information to health professionals about the importance of collaboration and co-creation regarding older adults’ families in maintaining their quality of life through the life course.

Methodological Discussion

We chose to use an illustration to present our substantive theory: An iceberg of family occupations. According to Birks and Mills (2015), utilising illustrations is relatively new in Grounded Theory. We are aware that this choice could affect the credibility of the study, as there is a risk of misunderstanding or misinterpretation of the metaphor by the reader. However, both Birks and Mills (2015) and Carpenter (2008) stated that using metaphors can have a positive role in increasing the accessibility of the theory for the reader. After reviewing the pros and cons of using the illustration, we decided to use it as it provided a way of understanding how family occupations are more than doing with and for each other, and it showed the complexity of hidden structures around family occupations. However, Charmaz (2014) stated that it is up to the reader to decide the quality and trustworthiness of our presentation through our findings. We have aimed at being open and transparent in our presentation.

This study is limited to a Nordic context. It is based on cross-sectional data accrued through individual interviews with the participants. Time-series or longitudinal data would have been preferable, but it was not attainable in this study. We are aware that other aspects could affect family occupations, such as demographics, policy, culture, and family relations. Our findings reflect the perspectives of adult children where the majority of their parents, who received reablement, were mothers. It is possible that the parents, other children living further away, and grandchildren could have experienced family occupations differently.

Conclusion

This study contributes to knowledge about family occupations between adult children and their older parents with functional decline. It shows that family occupations intersect with other everyday occupations that adult children do, and it can be hard to distinguish between them. Our findings indicate that adult children play a part in a complex process where they maintain the family occupations by doing more of the physical elements. In addition, adult children experience ambivalence in doing occupations without being asked and occupations related to being in a state of readiness. Using the metaphor of an iceberg could expand and enrich understanding of family occupations, including the contribution of the less visible aspects of family occupations for adult children and their parents with functional decline. This could have practical application in knowing that adult children may become hidden enablers for parents exhibiting functional decline.

Conflict of Interest

The authors report no conflicts of interest in this work.

Acknowledgements

The authors are grateful to the adult children, their parents, and reablement professionals for their contributions to the present research.