ORIGINAL RESEARCH
Exploring conflict between caregiving and work for caregivers
of elders with dementia: a cross-sectional, correlational study
Yu-Nu Wang, Yea-Ing Lotus Shyu, Wen-Che Tsai, Pei-Shan Yang & Grace Yao
Abstract
Aim. To report the moderating effects of work-related conditions and interactive
family-care-giving variables, including mutuality and preparedness, on caregiver
role strain and mental health for family caregivers of patients with dementia.
Background. Few studies have examined the interrelationships among caregivers’
working conditions, care-giving dynamics and caregiver well-being.
Design. Cross-sectional, correlational study.
Methods. Data were collected by self-completed questionnaires from 176 primary
family caregivers of patients with dementia in Taiwan from May 2005–January
2006. Caregiver role strain and mental health were analysed by multiple
regressions using a hierarchical method to enter independent variables and twoand
three-way interaction terms after controlling for caregiver age and gender,
employment status, and work flexibility and the simple effect of each independent
variable.
Results. More preparedness was associated with less role strain for family
caregivers with less work/care-giving conflict. More care-giving demand was
associated with poorer mental health only for caregivers with low work/caregiving
conflict and with average and low preparedness, but not high
preparedness. For family caregivers with less work/care-giving conflict, more
preparedness decreased role strain and maintained mental health even when caregiving
demand was high.
Conclusion. These results provide a knowledge base for understanding complex
family caregiver phenomena and serve as a guide for developing interventions.
Future studies with longitudinal follow-ups are suggested to explore actual causal
relationships.
Keywords: dementia, family care, nursing, quantitative approaches, workforce
Issues
Introduction
Providing care to a family member with dementia has been
found to cause excess strain and distress for family caregivers
(Carradice et al. 2003). Having more difficulty reconciling
work and care-giving roles predicted family caregivers’
role strain (Wang et al. 2011). Moreover, the emotional
strain experienced by family caregivers predicted patients’
institutionalization (Coon et al. 2003).
Family caregivers in Taiwan, as worldwide (Schulz &
Martire 2004, Lawrence et al. 2008), occupy a pivotal
place in providing care to persons with dementia, although
the institutionalization rate for Taiwanese persons with
dementia has increased from 3•5% in 1991 to 20•6% in
2009 (Taiwan Alzheimer Disease Association 2010). In the
US, the demands of parent care and paid employment
frequently interfere with each other (Brody et al. 1987,
Stone & Short 1990, Stephens et al. 2001, Beitman et al.
2004). Many family caregivers in the UK want to both
work and care for their loved ones (Arksey et al. 2005),
but the pressure of their care responsibilities makes it difficult
for them to reconcile the two roles (Laczko & Noden
1993, Dautzenberg et al. 2000).
Family caregivers were found to be protected from the
harmful effects of care-giving by variables that moderate
interactions between caregivers and care receivers such as
relationship quality and caregiver preparedness (Williamson
& Schulz 1995, Schumacher et al. 2007), but no studies
have explored whether family caregiver outcomes would be
differently influenced by care-giving demand for different
combinations of caregiver’s relationship quality with the
care receiver, preparedness, and/or work-related conditions.
To understand the complex phenomenon of how working
conditions influence family care-giving, thus enabling more
precise identification of families at risk, this study was
undertaken.
Background
The impact of employment on family caregivers has been
well studied. For example, working caregivers of older persons
suffered financial and health costs due to care-giving
and were less productive, resulting in increased cost to business
(Mahoney & Tarlow 2006, Hawranik & Strain 2007,
Heitmueller & Inglis 2007). Conflict between parental care
and employment was reported for 38% of 278 US women
caregivers (Stephens et al. 2001). Greater on-the-job conflict
was related to higher role overload, worry, and strain for
caregivers of cognitively impaired older relatives (Edwards
et al. 2002). Women who care for older family members
suffered work-related disadvantages, including reduced
income, retirement benefits, and health benefits due to
greater involvement with elder care (Zhan 2005, Wakabayashi
& Donato 2006). On the other hand, among mid-life
and older American women caregivers in one study, the
association between informal care and depressive symptoms
was not modified by employment status (Cannuscio et al.
2004).
Among these studies on working caregivers, few
addressed interrelationships between paid employment,
well-being, and informal care, especially in non-white or
Asian family caregivers in Western societies and on the
Asian continent. In particular, no studies have fully clarified
the role of work-related conditions such as having a fulltime
job, work flexibility, and conflict between work and
family care-giving in predicting caregiver outcomes such as
role strain and health outcomes. Furthermore, working conditions
have not been explored in terms of their interactions
with family care-giving dynamics and their influence on
caregiver outcomes.
Family caregivers were found to be protected from the
harmful effects of care-giving by care-giving-interactive
moderating variables such as relationship quality and
caregiver’s preparedness (Williamson & Schulz 1995,
Schumacher et al. 2007). These variables play a role during
interactions between the family caregiver–care receiver dyad
and can provide a more dynamic picture of family care-giving
than contextual variables such as the family caregiver’s
characteristics or care receiver’s functional impairment. For
example, relationship quality was reported to moderate the
association between caregiver burden and depression; with
poorer relationship quality, caregivers’ affect was depressed
at both high and low burden, but with better relationship
quality, affect was depressed only at higher burden
(Williamson & Schulz 1995). Specifically, a three-way interaction
has been reported among care-giving demand, preparedness
for the care-giving role, and mutuality, which
was defined as relationship quality (Schumacher et al.
2007). The joint functions of mutuality and preparedness
protected family caregivers of people with cancer from
adverse outcomes. Moreover, more mutuality and more
preparedness jointly protected family caregivers from the
negative impact of high care-giving demand. Finally, family
caregivers were vulnerable to even low care-giving demand
when both mutuality and preparedness were low (Schumacher
et al. 2007).
However, the mechanisms by which these interactive
family care-giving variables and work-related conditions
jointly or independently moderate family caregiver outcomes
have not been investigated. Specifically, no research
has documented how the conflict between work and caregiving,
relationship quality and caregiver’s preparation
interact to influence the association between care-giving
demand, caregiver health, and caregiver strain.
The study
Aim
The study purpose was to explore the moderating effects of
work-related conditions and interactive family-care-giving
variables, including mutuality and preparedness, on caregiver
mental health and role strain. Caregiver mental health
and role strain were dependent variables and caregiver age,
gender, employment status, work flexibility, care-giving
demand, mutuality, preparedness, and work/care-giving
conflict were independent variables. Conflict between work
and family care-giving was selected as the potential moderating
variable due to its interactive nature between work
and family care-giving. To be specific, we were interested in
whether less work/care-giving conflict, better mutuality, and
better preparedness protected caregivers of elders with
dementia from adverse outcomes when care-giving demand
was high. We hypothesized that: (a) caregivers with little
conflict between work and care-giving, a good dyadic relationship,
and/or well prepared for the caregiver role would
experience low levels of role strain and better mental health
outcomes, even when care-giving demand was high; and (b)
caregivers with more work/care-giving conflict, a poorer
dyadic relationship, and poorer preparedness would experience
greater role strain and poorer mental health outcomes
with increasing care-giving demand.
Design
A cross-sectional, correlational study design was used.
Sample
Family caregivers of patients with dementia were recruited
by convenience sampling from the neurological clinics of
two hospitals, one 3700-bed medical centre and a 555-bed
teaching hospital, which serve urban, suburban, and rural
areas of northern Taiwan. Recruitment from neurological
clinics, where outpatients diagnosed with dementia are
most commonly treated, was similar to previous community-
based studies on Taiwanese family caregivers of
patients with dementia (Ko et al. 2008). Inclusion criteria
for elders with dementia were: (a) age 65 years or older; (b)
diagnosed with dementia by a neurologist or psychiatrist;
and (c) cared for in a home setting, not institutionalized.
Inclusion criteria for family caregivers were: (a) age
18 years or older and (b) primarily responsible for providing
direct care or supervising care of the frail elder. The
minimum estimated sample size was 142 participants for an
alpha of 0•05, 16 predictors including all interactions, a
small effect size of 0•15, and power of 0•8 (Cohen 1992).
Of 250 family caregivers enrolled in the study, 176
(70•4%) completed the questionnaire, with 162 (92%) from
the medical centre and 14 (8%) from the teach
ORIGINAL RESEARCH
Exploring conflict between caregiving and work for caregivers
of elders with dementia: a cross-sectional, correlational study
Yu-Nu Wang, Yea-Ing Lotus Shyu, Wen-Che Tsai, Pei-Shan Yang & Grace Yao
Abstract
Aim. To report the moderating effects of work-related conditions and interactive
family-care-giving variables, including mutuality and preparedness, on caregiver
role strain and mental health for family caregivers of patients with dementia.
Background. Few studies have examined the interrelationships among caregivers’
working conditions, care-giving dynamics and caregiver well-being.
Design. Cross-sectional, correlational study.
Methods. Data were collected by self-completed questionnaires from 176 primary
family caregivers of patients with dementia in Taiwan from May 2005–January
2006. Caregiver role strain and mental health were analysed by multiple
regressions using a hierarchical method to enter independent variables and twoand
three-way interaction terms after controlling for caregiver age and gender,
employment status, and work flexibility and the simple effect of each independent
variable.
Results. More preparedness was associated with less role strain for family
caregivers with less work/care-giving conflict. More care-giving demand was
associated with poorer mental health only for caregivers with low work/caregiving
conflict and with average and low preparedness, but not high
preparedness. For family caregivers with less work/care-giving conflict, more
preparedness decreased role strain and maintained mental health even when caregiving
demand was high.
Conclusion. These results provide a knowledge base for understanding complex
family caregiver phenomena and serve as a guide for developing interventions.
Future studies with longitudinal follow-ups are suggested to explore actual causal
relationships.
Keywords: dementia, family care, nursing, quantitative approaches, workforce
Issues
Introduction
Providing care to a family member with dementia has been
found to cause excess strain and distress for family caregivers
(Carradice et al. 2003). Having more difficulty reconciling
work and care-giving roles predicted family caregivers’
role strain (Wang et al. 2011). Moreover, the emotional
strain experienced by family caregivers predicted patients’
institutionalization (Coon et al. 2003).
Family caregivers in Taiwan, as worldwide (Schulz &
Martire 2004, Lawrence et al. 2008), occupy a pivotal
place in providing care to persons with dementia, although
the institutionalization rate for Taiwanese persons with
dementia has increased from 3•5% in 1991 to 20•6% in
2009 (Taiwan Alzheimer Disease Association 2010). In the
US, the demands of parent care and paid employment
frequently interfere with each other (Brody et al. 1987,
Stone & Short 1990, Stephens et al. 2001, Beitman et al.
2004). Many family caregivers in the UK want to both
work and care for their loved ones (Arksey et al. 2005),
but the pressure of their care responsibilities makes it difficult
for them to reconcile the two roles (Laczko & Noden
1993, Dautzenberg et al. 2000).
Family caregivers were found to be protected from the
harmful effects of care-giving by variables that moderate
interactions between caregivers and care receivers such as
relationship quality and caregiver preparedness (Williamson
& Schulz 1995, Schumacher et al. 2007), but no studies
have explored whether family caregiver outcomes would be
differently influenced by care-giving demand for different
combinations of caregiver’s relationship quality with the
care receiver, preparedness, and/or work-related conditions.
To understand the complex phenomenon of how working
conditions influence family care-giving, thus enabling more
precise identification of families at risk, this study was
undertaken.
Background
The impact of employment on family caregivers has been
well studied. For example, working caregivers of older persons
suffered financial and health costs due to care-giving
and were less productive, resulting in increased cost to business
(Mahoney & Tarlow 2006, Hawranik & Strain 2007,
Heitmueller & Inglis 2007). Conflict between parental care
and employment was reported for 38% of 278 US women
caregivers (Stephens et al. 2001). Greater on-the-job conflict
was related to higher role overload, worry, and strain for
caregivers of cognitively impaired older relatives (Edwards
et al. 2002). Women who care for older family members
suffered work-related disadvantages, including reduced
income, retirement benefits, and health benefits due to
greater involvement with elder care (Zhan 2005, Wakabayashi
& Donato 2006). On the other hand, among mid-life
and older American women caregivers in one study, the
association between informal care and depressive symptoms
was not modified by employment status (Cannuscio et al.
2004).
Among these studies on working caregivers, few
addressed interrelationships between paid employment,
well-being, and informal care, especially in non-white or
Asian family caregivers in Western societies and on the
Asian continent. In particular, no studies have fully clarified
the role of work-related conditions such as having a fulltime
job, work flexibility, and conflict between work and
family care-giving in predicting caregiver outcomes such as
role strain and health outcomes. Furthermore, working conditions
have not been explored in terms of their interactions
with family care-giving dynamics and their influence on
caregiver outcomes.
Family caregivers were found to be protected from the
harmful effects of care-giving by care-giving-interactive
moderating variables such as relationship quality and
caregiver’s preparedness (Williamson & Schulz 1995,
Schumacher et al. 2007). These variables play a role during
interactions between the family caregiver–care receiver dyad
and can provide a more dynamic picture of family care-giving
than contextual variables such as the family caregiver’s
characteristics or care receiver’s functional impairment. For
example, relationship quality was reported to moderate the
association between caregiver burden and depression; with
poorer relationship quality, caregivers’ affect was depressed
at both high and low burden, but with better relationship
quality, affect was depressed only at higher burden
(Williamson & Schulz 1995). Specifically, a three-way interaction
has been reported among care-giving demand, preparedness
for the care-giving role, and mutuality, which
was defined as relationship quality (Schumacher et al.
2007). The joint functions of mutuality and preparedness
protected family caregivers of people with cancer from
adverse outcomes. Moreover, more mutuality and more
preparedness jointly protected family caregivers from the
negative impact of high care-giving demand. Finally, family
caregivers were vulnerable to even low care-giving demand
when both mutuality and preparedness were low (Schumacher
et al. 2007).
However, the mechanisms by which these interactive
family care-giving variables and work-related conditions
jointly or independently moderate family caregiver outcomes
have not been investigated. Specifically, no research
has documented how the conflict between work and caregiving,
relationship quality and caregiver’s preparation
interact to influence the association between care-giving
demand, caregiver health, and caregiver strain.
The study
Aim
The study purpose was to explore the moderating effects of
work-related conditions and interactive family-care-giving
variables, including mutuality and preparedness, on caregiver
mental health and role strain. Caregiver mental health
and role strain were dependent variables and caregiver age,
gender, employment status, work flexibility, care-giving
demand, mutuality, preparedness, and work/care-giving
conflict were independent variables. Conflict between work
and family care-giving was selected as the potential moderating
variable due to its interactive nature between work
and family care-giving. To be specific, we were interested in
whether less work/care-giving conflict, better mutuality, and
better preparedness protected caregivers of elders with
dementia from adverse outcomes when care-giving demand
was high. We hypothesized that: (a) caregivers with little
conflict between work and care-giving, a good dyadic relationship,
and/or well prepared for the caregiver role would
experience low levels of role strain and better mental health
outcomes, even when care-giving demand was high; and (b)
caregivers with more work/care-giving conflict, a poorer
dyadic relationship, and poorer preparedness would experience
greater role strain and poorer mental health outcomes
with increasing care-giving demand.
Design
A cross-sectional, correlational study design was used.
Sample
Family caregivers of patients with dementia were recruited
by convenience sampling from the neurological clinics of
two hospitals, one 3700-bed medical centre and a 555-bed
teaching hospital, which serve urban, suburban, and rural
areas of northern Taiwan. Recruitment from neurological
clinics, where outpatients diagnosed with dementia are
most commonly treated, was similar to previous community-
based studies on Taiwanese family caregivers of
patients with dementia (Ko et al. 2008). Inclusion criteria
for elders with dementia were: (a) age 65 years or older; (b)
diagnosed with dementia by a neurologist or psychiatrist;
and (c) cared for in a home setting, not institutionalized.
Inclusion criteria for family caregivers were: (a) age
18 years or older and (b) primarily responsible for providing
direct care or supervising care of the frail elder. The
minimum estimated sample size was 142 participants for an
alpha of 0•05, 16 predictors including all interactions, a
small effect size of 0•15, and power of 0•8 (Cohen 1992).
Of 250 family caregivers enrolled in the study, 176
(70•4%) completed the questionnaire, with 162 (92%) from
the medical centre and 14 (8%) from the teach
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