Filial piety and older adult caregiving among Chinese and Chinese-American families in the United States: a concept analysis — TEI-tagged view

Chunhong XiaopersName, Patricia A. PatricianpersName, Aoyjai P. MontgomerypersName, Youhua WangpersName, Rita JablonskipersName, Adelais MarkakipersName (2024date). “Filial piety and older adult caregiving among Chinese and Chinese-American families in the United States: a concept analysis.” BMC Nursingtitle·j.

Object of study — filial pietyterm·dom as a cultural value in caregivingterm·key for aging Chinese and Chinese-Americanterm·key families in the United States

Research question — what filial pietyterm·dom means when caring for aging CCAsterm, and how to define and frame it operationally for nurses

Contribution — antecedentsterm·mth, attributes and consequences of filial pietyterm·dom in CCAterm caregivingterm·key, with an operational definition and a framework adapted from Kramer's caregiver adaptation model

Full text — tagged

Filial pietyterm·dom and older adultterm·key caregivingterm·key among Chinese and Chinese-Americanterm·key families in the United States: a concept analysisterm·key Abstract The culturally sensitive nursing practice has not embedded filial pietyterm·dom as a cultural value and stance pertaining to caregivingterm·key among aging Chinese and Chinese-Americanterm·key (CCAterm) families in the United States, yet it is critical for healthy aging among CCAsterm.

To understand filial pietyterm·dom when caring for aging CCAsterm and conceptualize an operational definition and framework.

A systematic search was conducted in CINAHL, PubMed, Scopus, and PsycINFO databases. Analysis of the concept of filial pietyterm·dom among CCAsterm used Walker and Avant’s methods. Twenty-six studies were selected in the final full-text analysis.

Synthesis of evidence identified four antecedentsterm·mth: (a) filial obligation as a ‘cultural gene’, (b) sense of altruism, (c) familial solidarity, and (d) societal expectation of ‘birth right’. Attributes included familial material and emotional support, obedience, pious reverence, and societal norms. Consequences were related to caregiver burdenterm·key, psychological and physical well-beingterm·dom, quality of life, and health equity.

Filial pietyterm·dom is an intrinsic desire to support aging parents and an extrinsic desire to adhere to Chinese societal moral tenets. The proposed operational framework “Caregivingterm·key for aging CCAsterm in the United States” merits further study.

Keywords: Filial Pietyterm·dom, Chinese and Chinese-Americanterm·key, Older adultsterm·key, Aging, Caregivingterm·key Introduction Filial pietyterm·dom is one of the most fundamental, yet relatively unknown, virtues that is universally found in diverse cultures throughout human history [ 1 ]. For families of Chinese origin, the concept of filial pietyterm·dom is interwoven into the upbringing and everyday functions of family life [ 2 ]. In “The Analects”, Confucius introduces “Filial pietyterm·dom (a culturally specific term in Chinese, XiaopersName/Hsiao)” as “the source of benevolence and humaneness” and describes it as an amalgam of physical care, love, service, respect, and obedience. Filial pietyterm·dom requires that adult children care for their aging parents’ physical, emotional and social needs as well as their happiness throughout their lives [ 3 , 4 ]. The concept embodies three bonding relationships within a family unit: son to father with reverent obedience wife to husband with mutual obligations, and younger to elder with authoritarianism [ 5 ]. Inferences from the literature show how filial pietyterm·dom might intersect with other cultures that have similar concepts of caring in the context of family, for example, Asian, African, Latin American, European, Native American, and Muslim cultures [ 6 – 9 ]. Intergenerational responsibility, obligation, reciprocity, and other related concepts are considered filial values [ 6 ]. For Chinese and Chinese-Americanterm·key (CCAterm) families living in the United States (U.S.), filial pietyterm·dom is a psychological factor associated with balancing the traditional Chinese culture with the new host culture [ 5 , 10 , 11 ].

Dimensions of filial pietyterm·dom Filial pietyterm·dom is the tenet that has defined familial relationships and caregivingterm·key duties across generations of CCAterm families and includes two dimensions: authoritarian and reciprocal.

Authoritarian filial pietyterm·dom is associated with traditional ritual practice. It emphasizes family harmony and parent–child relationships across the lifespan as factors in the modeling of personality [ 3 , 12 ]. This dimension involves absolute obedience, suppressing individual interests to meet parental needs and happiness, and societal pressure [ 13 – 15 ]. Because authoritarian filial pietyterm·dom requires children to accommodate their parents’ wishes and requirements at the expense of their own desires, it has been identified as a risk factor for CCAterm caregivers’ mental health [ 16 ].

In contrast, reciprocal filial pietyterm·dom reflects children’s autogenous gratitude for their parent’s effort in raising them. In return, grown children care for their parents as they age without being restricted by family hierarchy [ 17 ]. This investment and reward reflect the attributes and consequences between children and parents, even extended family, such as an uncle, aunt, and siblings. The sense of filial pietyterm·dom stems from grown children’s appraisal of the family environment, thoughts, feelings, and behavior. This is a mutual exchange and accommodation occurring among children and parents in a ‘negotiable’ relationship. Reciprocal filial pietyterm·dom has been shown to be a protective factor for mental health through perceived parental support in muti-social contexts, such as sexual attitudes [ 18 , 19 ], career adaptation [ 20 ], and palliative care options [ 9 , 21 ].

Why understanding filial pietyterm·dom is important for nurses?

Given the linguistic and cultural needs, CCAsterm usually present in healthcare service in dyads; older adultsterm·key accompanied by family caregivers (usually their adult children). Within aging CCAterm families, the concept of filial pietyterm·dom is instrumental in determining patterns of caregivingterm·key as well as the role of caregivers. Confounded by the belief that only filial persons/children are reliable and trustworthy, it is not uncommon for CCAsterm to struggle with how to care for an aging family member, as they strive to balance family values with acculturationterm·key in the U.S. [ 16 ]. Hence, eldercare issues among CCAterm families are reported to be on the rise [ 22 , 23 ].

As frontline healthcare personnel, nurses communicate with CCAsterm and assess their care needs. Understanding filial pietyterm·dom as it pertains to aging and caregivingterm·key among CCAsterm is expected to bridge the cultural chasm in nursing knowledge and improve the quality of rendered services. Accommodating and integrating CCAterm culture is vital for effectively adapting aging and caregivingterm·key practices. Hence, this concept analysisterm·key has a two-fold aim: (a) to explore the dimensions of filial pietyterm·dom relevant to caring for aging CCAsterm as it pertains to nursing, and (b) to propose an operational definition and framework for nurses caring for aging CCAterm individuals and families.

Methods Concept analysisterm·key Walker and Avant’s [ 24 ] eight-step method was chosen to present an overview of applications and define relevant attributes of the concept of filial pietyterm·dom. This deductive method can generate a guide from a general phenomenon to an individual case application [ 25 ]. Studies were used to illustrate how filial pietyterm·dom affected the caregivingterm·key process, caregiver burdenterm·key, and caregivers' perceptions towards their elders. Last, an operational framework that described CCAterm caregivingterm·key adaptation was developed based on the most pronounced attributes and consequences.

Literature search A literature search was conducted using the following electronic databases: CINAHL PubMed, Scopus, and PsycINFO. In addition, Google Scholar was used to search for literature in the Chinese language. The search terms ‘filial pietyterm·dom’, and ‘XiaopersName/Hsiao culture’, ‘filial and Chinese aging’, and Chinese words of ‘XiaopersName’ or ‘Xiaoshun’ were used across all databases in a combination of Boolean strings. Articles written in English or Chinese language with an abstract in English and published from 2001-March 2023 were included. The studies that evaluated life span and care duty from the determinants of intergenerational relationships to guide the care duty were initiated by the book chapter in the Handbook of Chinese Psychology [ 26 ] We wanted to keep the literature current as this study took place in March 2023. We also wanted to define antecedentsterm·mth, attributes, and consequences of the concept from studies that more pertain to psychological effects on modern society structure within CCAterm groups so that the findings were more generalizable and meaningful. Therefore, we started literature published in 2001 after the psychological effect built after Ho’s book was published [ 26 ]. SciWheel (a reference manager program) was used for data harmonization, and the suggestion function of SciWheel was used for additional latest publication updates.

Content inclusion criteria for articles were as follows: (a) focused on Chinese or Chinese-Americanterm·key family, (b) related to a family member living with elders or providing care for elders, (c) related to adult caregivers (over the age of 18 years), and (d) presented a high level of evidence study. Using the adapted Hierarchy of Evidence for Intervention Studies classification, the level of evidence was appraised [ 27 , 28 ]. Articles with a low-level of evidence (level VIII), such as editorials, opinion letters, and expert committee reports, were excluded. The search yielded 258 articles from electronic databases and 20 from other existing systematic review articles and SciWheel suggestions. After removing duplicates and reviewing titles and abstracts, 69 full-text articles remained. A total of 26 studies met inclusion criteria and were chosen for synthesis, as shown in the PRISMA flow chart (see Fig. 1 below).

Filial pietyterm·dom among aging Asian families in the United States: Literature search strategy. PRISMA design source [ 29 ] Findings Synthesis of evidence from the sampled 26 articles identified antecedentsterm·mth (Table 1 ), defining attributesterm·mth (Table 2 ), and consequences (Table 3 ) for the concept of filial pietyterm·dom in caring for aging CCAterm individuals and families. The concept map of filial pietyterm·dom in caring for older CCAsterm is presented in Fig. 2 .

Antecedentsterm·mth of filial pietyterm·dom in caregivingterm·key/nursing Attributes of filial pietyterm·dom to caregivingterm·key/nursing among Chinese and Chinese-Americansterm·key Consequences of filial discrepancy between caregiver and care recipient among Chinese and Chinese-Americansterm·key Concept map: Filial pietyterm·dom in caring for aging CCAterm individuals and families Antecedentsterm·mth Based on Walker and Avant [ 24 ], antecedentsterm·mth were defined as events that must happen before the occurrence of filial pietyterm·dom. Table 1 represents data extracted from literature that informed antecedentsterm·mth. Initiation of filial pietyterm·dom, as defined by Ho, was found to be triggered by four antecedentterm·mth conditions [ 30 ]. First, thousands of years of Chinese heritage have shaped a ‘cultural gene’ of filial obligation within the family and extended society [ 30 – 32 ]. Second, parental altruism towards children has created harmonious family relationships from generation to generation [ 4 , 33 , 34 ]. Third, familial solidarity formulates individual strength into a higher level of family cohesiveness, especially when facing difficulties [ 16 ]. Lastly, societal expectations require that children show affection to elders as a birth right [ 60 , 61 ]. CCAsterm have experienced these antecedentsterm·mth before they consider long-term care, nursing home placement, or palliative care. We used definitions and examples in the systematic records (Table 1 ) to define a cluster of antecedentsterm·mth.

Defining attributesterm·mth Defining attributesterm·mth encompass the core of a concept and allow for easy identification [ 24 ]. Table 2 represents four attributes of filial pietyterm·dom that emerged: familial material and emotional support, obedience, pious reverence, and societal norm [ 3 , 62 , 63 ]. The first attribute described filial relationship as an age-based obligation to structure behavior towards caring parents. The second attribute, obedience, pertained to the hierarchy between older and younger generations [ 56 ]. Pious reverence referred to loyalty in family dynamics, requiring devotion and trust for family sustainability [ 13 , 35 , 37 ]. Lastly, filial pietyterm·dom encompassed societal stability and norms based on family order, solidarity, and harmony [ 64 ]. These attributes are associated with how caregivers respect “filial pietyterm·dom medicine,” assess their family relationships, act with filial duty, and adapt their care provision.

Consequences Based on sampled articles, filial pietyterm·dom had four main consequences on CCAterm adult caregivers: burden, psychological and physical well-beingterm·dom, quality of life, and health equity. Table 3 represents data extracted from literature that informed those consequences.

Caregiver burdenterm·key Perception of caregiver burdenterm·key was a sense of filial obligation towards meeting tangible and intangible needs in care, decision-making, and emotional support [ 7 , 16 , 36 , 38 – 41 ]; we found that filial pietyterm·dom mediated or partially mediated the caregiving burdenterm·dom and gain among caregivers. The burden of practicing filial pietyterm·dom was moderated by the sense of honor and reward [ 42 ]. A strong sense of filial obligation was significantly and positively associated with lower levels of developmental and emotional burden [ 16 , 39 ]. However, some caregiving burdensterm·dom were unavoidable, such as physical burden or the pressure of time when there were personal needs to be met. This objective burden presented a dilemma for families with only one child and families living in different locations [ 16 ]. Even though caregiver perception of the burden or caregivingterm·key experience varied, children who did not honor filial pietyterm·dom displayed an increasingly strong sense of guilt [ 43 ]. Several CCAsterm realized that they needed to adjust their expectations and understanding of practicing filial pietyterm·dom by simplifying parents’ and adult children’s physical and mental needs.

Psychological and physical well-beingterm·dom Filial pietyterm·dom caregivers reported a feeling of coercion, depression, anxiety, stress, abusive behavior, and even suicidal ideation stemming from their family, society, and cultural heritage [ 37 , 44 – 48 , 54 ]. Cohabitation with older CCAsterm and institutionalizationterm·dom presented a strain that reduced caregivers’ well-beingterm·dom [ 49 ]. Though there was no evidence of association between physical health of CCAterm caregiver and filial pietyterm·dom, adult CCAterm caregivers were prone to high blood pressure, diabetes, and heart disease [ 50 , 51 ]. Adult children who embraced filial pietyterm·dom and tried to meet their parents’ needs, known as Xiaoziterm·dom, experienced role strain [ 23 , 52 ]. Depression, anxiety, loneliness, negative or positive emotion, self-esteem and integrity, and sense of happiness were key components of psychological well-beingterm·dom for caregivers practicing filial pietyterm·dom.

Quality of life Findings varied with five articles showing positive effects on caregivers’ quality of life from practicing filial pietyterm·dom [ 10 , 53 , 55 , 65 , 66 ]. Decision-making regarding life changes was discussed within the family and was shown to benefit family-centered health care [ 53 , 65 ]. However, financial support and parent-children shared decision-making were limited to some families. Caregivers with limited financial resources reported that following a traditional filial pietyterm·dom structure reduced their quality of life [ 10 ]. Housework-help from children showed a more profound impact in quality of life for female caregivers, while financial support provided a better quality of life for male CCAsterm [ 66 ]. Negative effects in family relationships included reduced quality of life, family support and solidarity [ 55 ]. Filial behavior and discrepancy between quality of life and received types of support presented a paradox between male and female older CCAsterm [ 66 ].

Health equity Differences between aging in place (co-residing with their adult children) or institutional placement among groups of Chinese descent and their family caregiver dyads were attributed to the influence of filial pietyterm·dom [ 34 , 57 , 67 ]. Use of formal versus informal health care was associated with accessibility to services and resource availability for a CCAterm family [ 58 ]. Several social determinants affected health equity [ 59 ]. For example, urban versus rural, well-established versus developing CCAterm communities, and second-generation U.S.-based CCAsterm versus first-generation CCAsterm who had originally immigrated to the U.S. [ 13 , 58 , 68 ].

Exemplars The story of Andrew, presented as an exemplar in Table 4 and developed according to Walker & Avant’s methods, illustrates all the defining attributesterm·mth of the concept of filial pietyterm·dom. This model case illustrates filial pietyterm·dom as the pillar of family structure. Andrew showed respect, kindness, and dedication to his parents by providing material and emotional support. In respect of his father’s superior position as an elder, Andrew included him in decision-making, trusting his father’s rational advice and wisdom. A parent’s words are orders, and the level of being filial is measured by following the parent’s words. Taking care of his father at home demonstrated societal mores and home stability. Andrew’s case provides a lens of viewing an authoritative filial relationship between a CCAterm parent and adult child.

Model case [ 69 ] Alternatively, the borderline case story of Lee, presented in Table 5 , contains most of the defining attributesterm·mth, but not all of them. Intrinsically, Lee is motivated to care for her father as a family member and feels a sense of filial pietyterm·dom. Extrinsically, Lee is motivated to visit her father to prevent feeling social pressure and being criticized as an unfilial child. Lee’s case also reflects the reciprocal dimension of filial pietyterm·dom when a CCAterm parent and adult child prefer to jointly assess their needs and communication options to accommodate reality, respectively.

Borderline case [ 69 ] In contrast, the case story of Mr. A, presented in Table 6 , contains none of the defining attributesterm·mth, showing the outcome in the absence of filial pietyterm·dom. In the aging process, Mr. A's parents held onto their expectations rooted in the sense of filial pietyterm·dom in the family. Older CCAsterm and their adult children's unmatched knowledge and perception of filial relations brought a sense of care responsibility with full care needs and resources (material and psychological).

Contrary case [Hypothetical case] In summary, the model and borderline cases exemplify different degrees of and incentives for filial pietyterm·dom. Andrew desired to live with his father and personally take care of him physically. His commitment to filial pietyterm·dom is seen as a moral imperative. He knew that the honor of caring for his father would outweigh any burden he might experience. In contrast, Lee’s view of filial pietyterm·dom as not a moral imperative allows her to verbalize a rationale for having her father cared for by others. Last, the hypothetical case is based on previous studies which have demonstrated a high risk of suicide ideation among older CCAterm recipients in the United States [ 45 , 70 ].

Discussion This concept analysisterm·key explored filial pietyterm·dom through the lens of caregivingterm·key for aging CCAsterm in the U.S. Our aim was to explore the dimensions of filial pietyterm·dom relevant to caring for aging CCAsterm, with the intent of proposing an operational definition and framework for nurses. Filial pietyterm·dom was defined as an ethical and cultural component that influences CCAterm relationships and authority within a family and beyond [ 26 , 34 , 71 ]. The attributes of intergenerational filial relationships were found to be the guiding principles governing the Chinese pattern of socialization throughout the lifespan [ 72 ]. In the context of a multicultural society in the U.S., acculturationterm·key was viewed both as a strength and a weakness which might conflict with a family’s linear bond to filial pietyterm·dom [ 73 , 74 ]. The moral and social function of filial pietyterm·dom was often ignored as common sense or a “ritual” among CCAsterm and Asian society.

The antecedentsterm·mth identified in our review are not limited to the CCAterm community but are also demonstrated in other cultures. For instance, researchers found that authoritarian filial pietyterm·dom is different across cultures and reflects the birthright and indebtedness of CCAterm children to their older parents, especially those who were born and grew up in mainland China [ 75 ]. Li and colleagues demonstrated that Chinese culture influences intergenerational responsibilities through filial pietyterm·dom across Asian countries such as Singapore, Thailand, and Malaysia [ 9 ]. Similarly, Khalaila highlighted the positive effect of dual filial pietyterm·dom and how the underlying mechanisms worked against the harmful effects of caregivingterm·key stressors in traditional societies [ 7 ]. Richardson found strong negative feelings about nursing homes in Korean and Hispanic cultural-based groups, while also feeling isolated and without alternatives in caring for older adultsterm·key [ 76 ]. In Western cultures, most CCAsterm are either Christian or non-religious, and being pious to the family is critical to caregivingterm·key attitudes and behavior. The nature of child-parent relationships implied by filial pietyterm·dom is particularly important in aging care activities from children to their parents [ 6 ]. Whereas, in countries where Chinese culture is not dominant, CCAsterm face a dilemma when deciding whether to receive aging care in an institution, at home or even sending aging parents back to their country of origin. Therefore, filial pietyterm·dom is located at the intersection of culture, religion, and spirituality among different ethnic immigrant groups.

This literature review demonstrated a knowledge gap in assessing and appraising family health in terms of caregivingterm·key for CCAterm parents. Although results from the PINE study on CCAterm aging [ 77 ] have generated interest pertaining to CCAterm aging at the public health level, filial pietyterm·dom has not been examined as an important scientific concept in nursing care. The psychological influence of filial pietyterm·dom has been demonstrated by its moderating effect on culture in a palliative study [ 9 ]. Results from community-based participatory research suggested that being a receiver of filial pietyterm·dom was a risk factor for suicidal ideation [ 45 ] and negatively affected the elder CCAsterm’ life satisfaction [ 10 ]. Because of a strong sense of filial obligation [ 78 ], CCAsterm were most likely to care for family elders in their homes [ 33 , 79 ]. Meanwhile, CCAsterm had a higher risk for elder abuse, negligence, and suicidal ideation [ 48 , 57 ]. Elder mistreatment/abuse [ 80 , 81 ] and domestic violence were also related to the perceived cohesive family relationships associated with filial pietyterm·dom, even if that perception of cohesion was emotionally detrimental to caregivers [ 77 , 80 ]. Compared to other ethnic groups, CCAterm families were the least likely to use long-term care facilities since the stigma of being an unfilially adult child impacted decision-making for nursing home use [ 82 ]. It is notable that in China, parents can initiate a lawsuit if they believe their adult children are not practicing filial pietyterm·dom (Law of LaoNian QuanYi Bao Zhang #14). Yet, caregivingterm·key responsibilities for aging parents of CCAsterm living outside of China are perceived differently.

Among CCAterm families in the US, filial pietyterm·dom was a fundamental familial lineage and a moral obligation demonstrated by the action of taking care of aging parents. An intergenerational study of immigrant CCAsterm showed filial pietyterm·dom as a motivating factor for family health and healthy aging [ 17 ]. Prioritizing quantity and incorporating realistic expectations in cultures that are not dominated by Chinese culture has been suggested as an effective coping strategy for promoting older adultsterm·key’ well-beingterm·dom [ 83 ]. Adaptation and appraisal of the care obligation among CCAsterm in the U.S. were related to older CCAsterm’ and their adult children’s positive and negative health outcomes. Hence, an operational definition and framework to understanding and embedding filial pietyterm·dom into culturally congruent care for CCAterm families is proposed below.

Operational definition and proposed framework Based on attributes from the synthesis of sampled literature, the following operational Given that knowledge of filial pietyterm·dom is necessary for healthcare providers to address the adaptation of caregivingterm·key among CCAsterm, the investigators proposed an operational definition (Table 7 ) and framework (Fig. 3 ) to explain and measure CCAterm caregiver outcomes. A representation of the proposed framework, entitled “Caregivingterm·key for aging CCAterm individuals and families in the U.S.” is shown in Fig. 3 . The theoretical underpinning is Kramer’s [ 84 ] Conceptual Model of Caregiver Adaptation for understanding the mediation effect of filial pietyterm·dom in caregivingterm·key for CCAsterm. This decision was supported by evidence that people tend to maintain their basic cultural values and behavior regardless of the social framework [ 85 – 87 ]. Therefore, the proposed framework intends to operationalize filial pietyterm·dom as dual roles, a mediator of resources and role appraisal and a moderator of caregiving burdenterm·dom and role appraisal.

Operational Definition of Filial Pietyterm·dom Caregivingterm·key for aging CCAterm individuals and families in the U.S.: An operational framework. Adapted from Kramer [ 84 ] Measuring the concept of filial pietyterm·dom To examine the effect of filial pietyterm·dom in caregivingterm·key adaptation, three instruments for measuring filial pietyterm·dom are presented in Table 8 .

Instruments measuring filial pietyterm·dom for CCAterm caregivingterm·key adaptation Strengths and limitations A primary strength of this work was the analysis of attributes and antecedentsterm·mth of filial pietyterm·dom from the traditional Chinese social context, which provides a reference content of filial pietyterm·dom. The first author, CX, was able to access and synthesize literature in native Chinese language. Limitations include the small number of studies from the caregivingterm·key recipient's perspective, which presented a unilateral perception of filial pietyterm·dom. This was not surprising given the scarcity of research on CCAsterm’ well-beingterm·dom in the U.S. and across healthcare-related research. Second, in searching the literature, potential information bias could have occurred because measures for filial pietyterm·dom do not include contextual factors related to acculturationterm·key, growth environment, and societal components [ 88 , 89 ]. Third, instruments measuring filial pietyterm·dom were old, and not specifically applicable in the U.S. Existing studies have yielded mixed results regarding the effect of filial pietyterm·dom in caregivingterm·key outcomes [ 54 , 66 , 90 , 91 ]. Finally, given that Kramer’s caregiver adaptation conceptual model has not been tested, the proposed operational framework needs more evidence to support the hypothesis of benefits in the appraisal of caregiver outcomes.

Implications for future research / recommendations In spite of the rapid increase of CCAsterm in the U.S., little is known about filial pietyterm·dom by nurses and other healthcare providers. The majority of U.S. studies were conducted in large cities on the West Coast (i.e., San Francisco), and greater Chicago area where CCAsterm and other Asian families have access to more caregivingterm·key resources. On the contrary, in the Southeastern U.S., there are limited resources to support CCAterm family caregivers. This lack of knowledge has curtailed introducing this major cultural tenet as part of the standard health assessment of CCAterm families.

Hence, there is a growing need for providing culturally sensitive health care for the Asian-American population who share the same cultural values. The role of filial pietyterm·dom in caregiver burdenterm·key remains ambiguous, and the mental health of the CCAterm family caregiver is unknown. To fill the gaps, future studies should focus on the effect of filial pietyterm·dom in health care literacy and its influence on the well-beingterm·dom of CCAterm family caregivers. Developing psychometrically sound measurements with contextual factors is critical. Healthcare practitioners in primary care, inpatient, and long-term care settings need training on cultural sensitivity and humility to provide optimal care for older CCAsterm and their family caregivers. The development of family-centered care interventions is vital for CCAterm and Asian immigrant families who are most likely living in an intergenerational household.

Nurses, as the most trusted first-line healthcare providers, need to be aware of the importance of filial pietyterm·dom when discussing clinical concerns, care plans, and delegation of care with CCAterm families. With a rapidly aging population and growing migration trends, there is an undisputed need for raising health professionals’, and particularly nurses’, cultural awareness, competence, sensitivity, and humility in caring for aging immigrant individuals and populations [ 92 , 93 ]. The International Council of Nurses (ICN), the World Health Organization [WHO], the National Institute of Health (NIH), and the American Association of Colleges of Nursing (AACN) have all called for culturally congruent nursing care to address health care coverage and access inequities [AACN, 2008; ICN, 2007a; Douglas et al., 2014; NIH, 2021; WHO, 2008]. From a nursing perspective, familiarity with the concept of filial pietyterm·dom provides a foundation to offer culturally sensitive services to CCAterm individuals and their families.

Conclusion The permeating cultural value of filial pietyterm·dom affects help-seeking behavior, caregivingterm·key, family relationships, and caregiver health for CCAterm families. The evolution of filial pietyterm·dom has shown significant changes in expectations, attitudes, and emotions toward age-based obligations within immigrant Asian/CCAterm families undergoing acculturationterm·key. Attributes, antecedentsterm·mth, and consequences of filial pietyterm·dom were identified. Both model and borderline exemplars demonstrated the different dimensions of filial pietyterm·dom. Three instruments were found that directly and indirectly measure attributes of filial pietyterm·dom. The proposed operational definition of filial pietyterm·dom and model intends to address the need for culturally sensitive care and support to CCAterm families and caregivers.

Acknowledgements The authors would like to acknowledge Ms. Rebecca Billings, Librarian, for facilitating the extensive literature search.

Abbreviations Chinese and Chinese Americanterm·key United States The International Council of Nurses The World Health Organization The National Institute of Health The American Association of Colleges of Nursing Authors’ contributions C.X.: Conceptualization, methodology, conducting analysis, validation, writing-original draft preparation, revising, and editing the manuscript. P.P.: Conceptualization, data curation, and methodological expertise. A.P.M.: Content expertise, reviewing and editing. Y.W.: Content expertise, data curation, and review. R.J.: Content expertise and critically revised the manuscript. A.M.: conceptualization, draft preparation, reviewing, and critically revising the manuscript. All authors read and approved the final manuscript.

Authors’ information C.X.: Post doctoral Fellow, UAB School of Nursing; P.P.: Professor & Rachel Z. Booth Endowed Chair, UAB School of Nursing, Colonel, US Army (Retired); A.P.M.: Scientist I & Data Analyst, Department of Epidemiology, School of Public Health, UAB; R.J.: Professor& Nurse Practitioner, UAB School of Nursing; Y.W.: Professor and Sociologist in Social Work Department at College of State Governance, Southwest University, China; A.M.: Professor & Co-director PAHO/WHO Collaborating Center for International Nursing, UAB School of Nursing.

Funding Not applicable.

Availability of data and materials The datasets used and analyzed during this study are available from the corresponding author.

Declarations Ethics approval and consent to participate Not applicable (non-human subjects – literature review article).

Consent for publication Not applicable.

Competing interests The authors declare no competing interests.

Footnotes References Associated Data Data Availability Statement The datasets used and analyzed during this study are available from the corresponding author.