Accepted: 20 June 2017 DOI: 10.1111/jan.13379

ORIGINAL RESEARCH: EMPIRICAL RESEARCH—QUANTITATIVE

Balancing competing needs mediates the association of caregiving demand with caregiver role strain and depressive symptoms of dementia caregivers: A cross-sectional study Hsin-Yun Liu1 | Ching-Tzu Yang2 | Yu-Nu Wang3

| Wen-Chuin Hsu4,5 |

Tzu-Hsin Huang6 | Yueh-E Lin6 | Chin-Yi Liu2 | Yea-Ing L. Shyu2,7,8 1

Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan 2

School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan 3

Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan 4

Dementia Center, Department of Neurology, Chang Gung Memorial Hospital, Taoyuan, Taiwan 5

School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan 6

Department of Nursing, Chang Gung Memorial Hospital, Taoyuan, Taiwan 7

Traumatological Division, Department of Orthopedics, Chang Gung Memorial Hospital, Taoyuan, Taiwan 8 Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

Correspondence Yea-Ing L. Shyu, School of Nursing, Chang Gung University, Taoyuan, Taiwan. E-mail: [email protected] Funding Information This study was funded by the Chang Gung Medical Foundation (grant no. CMRP1E0161, CMRPD1E0162, BMRP297) and Healthy Aging Research Center, Chang Gung University (grant no. EMRPD1G0211), Taiwan.

Abstract Aims: To examine the role of balancing competing needs in the relationship between caregiving demand and caregiving outcomes (caregivers’ role strain and depressive symptoms). Background: Caregivers who do not balance competing needs are more likely to experience negative caregiving outcomes, suggesting that balance mediates between caregiving demand and caregiving outcomes. Identifying a mediator of negative caregiving effects may help in developing tailored interventions for family caregivers of persons with dementia. Design: A cross-sectional, correlational design. Methods: Data were collected from family caregivers’ self-completed questionnaires between March 2013 - April 2014. A convenience sample of 120 family caregivers and care receivers with dementia was enrolled. We examined whether balance mediated the relationship between caregiving demand and caregiving outcomes (caregivers’ role strain and depressive symptoms) by multiple regression analysis. To evaluate the significance of the indirect effect of caregiver balance, we used the Sobel test and Monte Carlo method, an alternative approach to testing mediation. Results: Balancing competing needs completely mediated the association of caregiving demand with depressive symptoms and partially mediated the association of caregiving demand with role strain. Conclusion: Assessing caregivers’ self-perceived sense of balance may help to identify caregivers at high risk for role strain and depressive symptoms. Interventions to enhance caregivers’ perceived sense of balance between competing needs may provide a strategy for reducing the negative effects of caregiving. KEYWORDS

balance, caregiver role strain, caregiving demand, depressive symptoms, home nursing, mediation

J Adv Nurs. 2017;1–11.

wileyonlinelibrary.com/journal/jan

© 2017 John Wiley & Sons Ltd

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1 | INTRODUCTION Dementia has significant adverse effects not only on those afflicted

Why is this research or review needed?

but also on the people who care for them and other family mem-

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bers. Worldwide, 47.5 million older people suffer from dementia and

caregiving tasks (caregiving demand) and caregiving out-

this number is projected to increase to 75.6 million by 2030 (World Health Organization 2016). Dementia has become a major disease burden for an increasing number of older people in Taiwan, as in

Little is known about mediators between the number of comes (caregivers’ role strain and depressive symptoms).

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Identifying a mediator of negative caregiving outcomes may help in developing tailored interventions for family

many other developed nations. The age-adjusted prevalence of all-

caregivers of persons with dementia.

cause dementia in Taiwan was 8.04% in 2012 (Sun et al., 2014), a number expected to rise as the ageing population increases. Among Taiwan’s population, 12% is over 65 years old (approximately 2 million people in 2014), and this percentage is estimated to more than

What are the key findings?

•

Balancing competing needs completely mediated the

triple by 2060 (Directorate-General of Budget, Accounting and

association of caregiving demand with depressive symp-

Statistics 2014). Most Taiwanese persons with dementia receive care

toms and partially mediated the association of caregiving

at home; indeed, 86.3% of such persons were cared for at home in

demand with role strain.

2011 (Taiwan Alzheimer’s Disease Association 2012). This high inci-

•

Family caregivers experiencing higher levels of caregiving

dence of home care may be due to a cultural emphasis on filial piety

demand reported more role strain and depressive symp-

throughout Asia, with adult children feeling personally and culturally

toms in part because they did poorly in balancing com-

responsible for providing care to their ageing and ill parents (Miya-

peting needs.

waki, 2015). Thus, family caregivers play a critical role in caring for a loved one with dementia in Taiwan.

How should the findings be used to influence policy/practice/research/education?

1.1 | Background

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Assessing caregivers’ self-perceived sense of balance may help to identify caregivers at high risk for role strain

Providing care for a person with dementia causes excessive strain and increased stress on family caregivers due to the progression of patients’

behavioural problems and neuropsychiatric disorders

and depressive symptoms.

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(Richardson, Lee, Berg-Weger, & Grossberg, 2013). Excessive caregiver role strain, or the difficulty perceived in performing the caregiver role (Burns, Archbold, Stewart, & Shelton, 1993), has been associated with enhanced depression and anxiety symptoms (Mausbach, Chattillion, Roepke, Patterson, & Grant, 2013; Phillips, Gallagher, Hunt, Der, & Carroll, 2009). Moreover, caregiving demand or

Interventions to enhance caregivers’ perceived sense of balance between competing needs may provide a strategy for reducing negative caregiving outcomes.

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The results of this study may serve as a reference point for healthcare providers in other countries to design tailored interventions for caregivers of persons with dementia, thus increasing the likelihood of successful caregiving outcomes.

the number of caregiving activities has been found to increase levels of depression and role strain (Brodaty & Donkin, 2009; Givens, Mezzacappa, Heeren, Yaffe, & Fredman, 2014). These negative outcomes have been shown to be important determinants of whether older

Balancing competing needs reflects the effort to maintain equilibrium

people with dementia are admitted to a long-term care institution

between the caregiver’s and care receiver’s competing needs in daily

(Schoenmakers, Buntinx, & Delepeleire, 2010). Thus, decreasing neg-

life (Shyu, Archbold, & Imle, 1998). In the USA, “balancing” was

ative caregiving effects and maintaining family caregivers’ health are

described as a caregiving style where family caregivers of persons

necessary to preserve their essential role in caring for persons with

with dementia tended to make efforts to balance competing needs

dementia. Nevertheless, little is known about factors mediating these

(Corcoran, 2011). For example, caregivers who balanced wisely used

negative effects of caregiving demand. Identifying a mediator in the

environmental controls (e.g. baby monitors) to supervise the care

relationship between caregiver role strain and depressive symptoms

receiver while working in another room. These family caregivers

may provide a foundation for developing effective interventions to

maintained balance by using strategies to prevent problematic situa-

improve caregiving outcomes for family caregivers of persons with

tions with the care receiver while dealing with competing needs

dementia.

(Corcoran, 2011).

Family caregivers of people with dementia must manage not only

In Taiwan, “finding a balance point” is an interactive family care-

care receivers’ needs but also other competing needs. These include

giving process (Shyu et al., 1998). This process includes recognizing

other family needs (e.g. children’s needs), facing inconsistent caregiv-

competing needs, weighing competing needs and making judgements

ing due to multiple caregivers, or caregivers’ own needs regarding

about them, and choosing and implementing balancing strategies.

health, work and/or social activities (Liu et al., 2014; Shyu, 2000).

Taiwanese caregivers facing competing needs were found to have

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three patterns of finding a balance: maintaining a balance point,

Lower levels of role strain or depressive symptoms have been

regaining a balance point and establishing a balance point (Shyu,

strongly associated with many factors, such as mutuality (Yang, Liu, &

2000). Maintaining a balance point occurs when the family caregiv-

Shyu, 2014), coping strategies (Hilgeman et al., 2009) or self-efficacy

ing situation is stable. Family caregivers tend to use strategies con-

(Gallagher et al., 2011). These factors are potential mediators

tinuously to prevent problematic situations. Regaining a balance

between caregiving demand and role strain. However, the process of

point occurs when problematic situations arise due to the beha-

balancing competing needs is a culturally sensitive model in family

vioural and psychological symptoms of dementia. Family caregivers

care (Daire & Mitcham-Smith, 2006; Shyu, 2002), based on the Chi-

need to respond swiftly by using strategies to restore balance.

nese cultural value of filial piety, which influences not only how family

Establishing a balance point occurs when a care receiver is hospital-

caregivers of persons with dementia perceive stress and psychological

ized and later discharged with a serious decline in functional status.

morbidity but also how they cope (Che, Yeh, & Wu, 2006; Sun, Ong,

Family caregivers need to learn new strategies and rearrange their

& Burnette, 2012). Therefore, to explore how Taiwanese caregivers

living activities to establish a new balance. Therefore, the process of

of persons with dementia manage the caregiving experience, we

finding a balance point reflects how family caregivers adjust their

focused on balance as a mediator between caregiving demand and

coping strategies to face changes in competing needs.

caregiving outcomes (i.e. role strain and depressive symptoms).

Such a caregiving process was shown to be advantageous for overall caregiving consequences (Shyu, 2002) and caregiver wellbeing (Corcoran, 2011). Conversely, caregivers with a poor sense of balance between competing needs might suffer from a higher level of role strain and depressive symptoms. Therefore, the ability to bal-

2 | THE STUDY 2.1 | Aims

ance competing needs may be a vital resource for mediating the

The aim of this study was to investigate whether balance mediates

effects of competing needs on family caregivers’ perceived stress.

the relationship between caregiving demand and caregiving out-

For family caregivers, understanding how to balance competing

comes (i.e. role strain and depressive symptoms). More specifically,

needs can decrease conflicts so that they can continue in the care-

we examined the extent to which the impact of caregiving demand

giving role. For healthcare providers, this understanding can guide

on caregiver role strain/depressive symptoms is mediated by balance

the design of more effective and tailored interventions.

among competing needs in family caregivers of persons with demen-

Stress in family caregiving has been conceptualized in a stress

tia. We hypothesized that caregivers with greater caregiving demand

model (Pearlin, Menaghan, Lieberman, & Mullan, 1981; Pearlin, Mul-

would have a poorer sense of balance, resulting in higher levels of

lan, Semple, & Skaff, 1990) featuring four domains: caregiving con-

caregiver role strain and depressive symptoms.

text, stressors, mediators of stress and caregiving outcomes. Stressors are either primary or secondary. Primary stressors reflect patient-related illness factors (e.g. cognitive status, comorbidities and

2.2 | Design

dependence in activities of daily living [ADL]) and the demands of

For this cross-sectional survey study, a convenience sample of family

daily caregiving (Montgomery, Rowe, & Kosloski, 2007; Pearlin et al.,

caregiver person with dementia dyads was recruited from the neuro-

1990). Secondary stressors, such as family conflicts, the quality of

logical clinics of a 3,700-bed medical centre, neurological ward and

the dyadic relationship or social activities, are a direct result of car-

day care centre affiliated with a regional hospital in northern Taiwan.

ing for a person with dementia (Carradice, Shankland, & Beail, 2002). Facing multiple secondary stressors (i.e. competing needs) places family caregivers at greatest risk for excessive role strain. Therefore,

2.3 | Participants

caring for a person with dementia often challenges family caregivers’

Dyads were included by these criteria: the family caregiver assumed

sense of balance between competing needs and threatens their

primary responsibility for the care of a person with dementia; the

physical and mental health (Glozman, 2004). Thus, how well family

caregiver was ≥18 years old; and the care receiver was diagnosed

caregivers maintain balance between competing needs may mediate

with dementia by a neurologist or psychiatrist, ≥65 years old and

between caregiving demands and overall caregiving outcomes.

cared for in a home setting. Care receivers with terminal illness such

Family caregivers generally experience different levels of caregiv-

as end-stage cancer or renal diseases were excluded. Of the 176

ing role strain. High-strain caregivers of a family member with a

caregivers recruited from March 2013 - April 2014, 120 (68%) com-

chronic illness or disability were more likely than moderate- or no-

pleted the study questionnaire.

strain caregivers to report poorer quality of life and more depressive symptoms (Roth, Perkins, Wadley, Temple, & Haley, 2009). Family caregivers of persons with dementia are more severely affected by role strain or mental problems than caregivers of care receivers with other conditions (Ory, Hoffman, Yee, Tennstedt, & Schulz, 1999).

2.4 | Data collection 2.4.1 | Demographic data

Thus, ways to reduce caregiver role strain and psychological morbidity

Demographic data of caregivers and care receivers were self-

are critical issues for family caregivers of persons with dementia.

reported. Care receivers’ clinical variables, including cognitive

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function and comorbidities (i.e. cancer, stroke, heart problems, dia-

and dividing by the number of caregiving tasks the family caregiver

betes mellitus, Parkinson’s disease, arthritis and hypertension), were

needs to administer.

obtained from their medical records.

2.4.2 | Caregiver balance

2.4.6 | Care receivers’ dependence in ADL and dementia severity

Caregivers’ balance, or the degree to which they can simultaneously

Care receivers’ dependence in ADL was measured using the Chi-

handle competing caregiving needs, was assessed using the 18-item

nese Barthel Index (CBI; Chen, Dai, Yang, Wang, & Teng, 1995).

Chinese-version Finding a Balance Scale (Liu et al., 2014; Shyu,

The items include eating, transferring, grooming, toileting, bathing,

2002). Caregivers report how well they are currently addressing each

walking, climbing stairs and dressing, along with bowel and bladder

of 17 competing scale items (e.g. “While taking care of this family

control. The score ranges from 0 (total dependence) to 100 (total

member, you also need to host guests”), with responses on a scale

independence). Care receivers’ dementia severity was assessed

from: 0 (unable to handle either); 1 (able to handle only one); 2 (able

using the Clinical Dementia Rating (CDR; Lin & Liu, 2003). The

to handle both, but not well) - 3 (usually able to handle both well).

CDR score contains six domains: memory, orientation, judgement

The average degree of balance is calculated by summing item scores

and problem-solving, community affairs, home and hobbies and per-

and dividing by the number of items reported as competing caregiv-

sonal care. Responses to these items are combined to produce a

ing needs. Item 18 is an open-ended question that is not used to

composite score ranging from 0 (no cognitive impairment) - 3 (sev-

determine the overall score. Scores range from 0-3; higher scores

ere dementia).

indicate a better sense of balance.

2.5 | Ethical considerations 2.4.3 | Caregiving demand

Research Ethics Committee approval for conducting the study was

Caregiving demand, that is, the tasks performed by the family care-

given by the Institutional Review Board of the Medical Centre Study

giver in assisting the care receiver, was assessed using the 87-item

Site (101-3702C). Patients and caregivers who met the inclusion cri-

Chinese-version Caregiving Activities Scale of the Family Caregiving

teria were contacted by research assistants who obtained their

Inventory (FCI, Archbold, Stewart, Greenlick, & Harvath, 1992; Ste-

signed consent. Before signing the consent form, dyads were

wart, Archbold, Harvath, & Nkongho, 1993). Caregivers rate scale

informed about study goal and of their rights to leave the study at

items (tasks) by indicating whether they perform each task (0 = no,

any time and to refrain from answering any questions. Caregivers

1 = yes); scores are calculated by summing all item scores. Total

were asked to fill out the questionnaire at home. The research assis-

scores range from 0-87, with higher scores indicating higher levels

tants then contacted caregivers via telephone to increase the ques-

of caregiving demand.

tionnaire response rate; they also arranged home visits to assist those who had trouble completing the questionnaire.

2.4.4 | Caregiver depression Caregivers’ depressive symptoms were assessed using the 20-item,

2.6 | Data analysis

self-report Chinese-version Centre for Epidemiologic Studies Depres-

Characteristics of caregivers and care receivers were analysed by

sion Scale (CES-D; Fu, Lee, & Chen, 2003). CES-D items (symptoms)

descriptive statistics (means, standard deviations, frequency and per-

are rated for frequency over the previous 7 days from 0 (less than 1

cent). Correlations among variables were analysed by Pearson’s cor-

day), 1 (1–2 days), 2 (3–4 days), to 3 (5–7 days). The summed scores

relation coefficient. To determine whether balance mediated the

range from 0-60, with higher scores indicating more depressive

relationship between caregiving demand and caregiving outcomes

symptoms.

(caregivers’ role strain and depressive symptoms), we used multiple regression analysis (Baron & Kenny, 1986) with the following covari-

2.4.5 | Caregiver role strain

ates: caregivers’ age and gender, care receivers’ age and gender, comorbidities, dementia severity and dependence in ADL.

Caregivers’ perceived role strain was measured using the 87-item

We analysed relationships among variables based on the model

Chinese-version Role Strain Scale of the Family Caregiving Inventory

proposed in Figure 1. The first step in the analysis was to examine

(Shyu, Yang, et al., 2010). This scale measures the degree of per-

whether caregiving demand was a significant predictor of caregiving

ceived difficulty in administering different caregiving tasks, including

outcomes (Figure 1, path c). The second step was to ask whether

personal care, mobility and protection, illness related to caregiving,

caregiving demand was also a significant predictor of balance (Fig-

banking and legal issues, transportation, housekeeping, emotional

ure 1, path a). The third step was to ask whether balance was a sig-

support, managing symptoms of dementia and arranging for caregiv-

nificant predictor of caregiving outcomes (Figure 1, path b), after

ing. For each item (task), the score ranges from 0 (easy) to 4 (very

controlling for caregiving demand (Figure 1, path c’). Complete medi-

difficult). The overall score is calculated by summing all item scores

ation was determined if path c’ did not differ significantly from zero,

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0.87. The Chinese-version caregiving demand scale and role strain

(a)

Balance

scale were demonstrated to have good internal consistency (Cron-

a. –0·007 (–0·203)

b. –0·799 (–0·583)

givers of older people with dementia (Shyu, Yang, et al., 2010). In this study, Cronbach’s alphas for the Chinese-version caregiving

c. 0·016 (0·339) Role strain

Caregiving demand

bach’s alphas = 0.91 and 0.97, respectively) among Taiwanese care-

c’. 0·011 (0·231)

demand scale and role strain scale were 0.94 and 0.98, respectively. The psychometric properties of the Chinese-version CES-D have been validated in Taiwanese populations (Fu et al., 2003). Cronbach’s alpha for the CES-D in this study was 0.94. The reliability of data collection was ensured by training research nurses to telephone and

(b)

Balance

conduct home visits with caregivers if needed, to collect chart data, to code data and to protect the anonymity of participant informa-

a. –0·007 (–0·203)

b. –10·927 (–0·529)

tion. To control systematic error and bias in data collection, research assistants made follow-up telephone calls and home visits to care-

c. 0·196 (0·281) Depressive symptoms

Caregiving demand

c’. 0·123 (0·176)

givers who had difficulty with the questionnaire and used a protocol to record answers from family caregivers and answer questions about problems providing care.

F I G U R E 1 Balance as a mediator of the relationship of caregiving demand with caregiver role strain (a) and depressive symptoms (b). Unstandardized path coefficients are shown with standardized coefficients in parentheses

3 | RESULTS 3.1 | Participants’ characteristics

indicating that balance completely mediated the relationship

Caregivers’ mean age was 55.52 years (SD 9.87) and care receivers’

between caregiving demand and caregiving outcomes. Partial media-

mean age was 81.88 years (SD 6.83) (Table 1). Care receivers had

tion was determined if the difference between path c and path c’

been suffering from dementia for 66.5 months on average and had

(i.e. c–c’) differed significantly from zero, indicating that balance

mostly a primary school education (71.7%). Most caregivers had at

partly explained the relationship between caregiving demand and

least a high school education (78.3%) and were the care receivers’

caregiving outcomes. In a simple mediation model, an alternative and

adult children (45 sons, 29 daughters and 26 daughters-in-law).

more powerful strategy for testing mediation is to test for an indi-

Slightly more than half of the caregivers were female (n = 63,

rect effect using the product of the path coefficients a and b (Krause

52.5%). Most caregivers lived with their care receivers (n = 92,

et al., 2010). The indirect effect was evaluated by the Sobel test and

76.7%). Caregivers cared for care receivers for a mean of 8.41 (SD

Monte Carlo method, which can be employed even when samples

7.71) hr/day and had been caregiving on average for 68.33 (SD

sizes are small (Preacher & Selig, 2012). The Monte Carlo method

46.65) months.

for assessing the indirect effect was performed with 20,000 repetitions to construct the 95% confidence interval (CI) using an online calculator (Selig & Preacher, 2008).

3.2 | Mediation effect testing

significance

To ensure that no covariates influenced the relationships among

level = 0.05, medium effect size (f2) = 0.15 and power = 0.8. With 9

variables in the proposed model, we analysed correlations among all

The

sample

size

was

estimated

based

on

independent variables and 120 degrees of freedom for the error

study variables. We found that most covariates (caregivers’ age and

variance, the non-centrality parameter (k) = 16.7 (Cohen, 1988, p.

gender, care receivers’ age and gender, comorbidities, dementia

452). The necessary sample size is k/f2 = 16.7/0.15 = 112 (Cohen,

severity [CDR score], dependence in ADL [CBI score]) and caregiving

1988). Accordingly, the sample size should be greater than 112 for a

demand, balance, or caregiving outcomes (caregivers’ role strain and

power of 0.8. The significance level for all tests was set at p < .05.

depressive symptoms) were not significantly correlated (Table 2).

All analyses were performed using SPSS 19.0.

However, we found a small correlation (.1) between caregiving demand and care receivers’ age/dementia severity and a medium

2.7 | Validity and reliability

correlation (.3) between balance and caregivers’ age (Cohen, 1988). To test the hypothesized relationships among study variables, we

The mediating effect of balance on the association between caregiv-

used a series of regression analyses (Table 3). The hypothesis of

ing demand and caregivers’ role strain/depressive symptoms was

interest was that balance would be a significant mediator between

examined using well-established instruments. The Finding a Balance

caregiving demand and role strain/depressive symptoms. As shown

Scale’s psychometric properties were shown to be adequate for fam-

in Figure 1a, path c, before entering balance as a mediator in the

ily caregivers of older people with dementia in Taiwan (Liu et al.,

hypothesized model, the regression coefficient for caregiving

2014). In this study, Cronbach’s alpha for the balance scale was

demand on role strain was 0.016 (p < .01), indicating a significant

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55.52 (9.87)

Female

88 (73.3)

63 (52.5)

Male

32 (26.7)

57 (47.5)

Illiterate

13 (10.8)

0 (0.0)

Primary school

1

10.82

11.21

CES-D

Gender (n, %)

.60 (