Nurses negotiating professional-familial care boundaries: striving for balance within double duty caregiving.

562645 research-article2014

JFNXXX10.1177/1074840714562645Journal of Family NursingWard-Griffin et al.

Article

Nurses Negotiating Professional–Familial Care Boundaries: Striving for Balance Within Double Duty Caregiving

Journal of Family Nursing 2015, Vol. 21(1) 57–85 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1074840714562645 jfn.sagepub.com

Catherine Ward-Griffin, RN, PhD1, Judith Belle Brown, PhD1, Oona St-Amant, RN, PhD2, Nisha Sutherland, RN, PhD3, Anne Martin-Matthews, PhD4, Janice Keefe, PhD5, and Mickey Kerr, PhD1

Abstract The purpose of this sequential, two-phase mixed-methods study was to examine the health of male and female nurses who provided care to older relatives (i.e., double duty caregivers). We explored the experiences of 32 double duty caregivers, which led to the development of an emergent grounded theory, Negotiating Professional–Familial Care Boundaries with two broad dialectical processes: professionalizing familial care and striving for balance. This article examines striving for balance, which is the process that responds to familial care expectations in the midst of available resources and reflects the health experiences of double duty caregivers. Two subprocesses 1Western

University, London, Ontario, Canada University, Toronto, Ontario, Canada 3Lakehead University, Thunder Bay, Ontario, Canada 4University of British Columbia, Vancouver, Canada 5Mount Saint Vincent University, Halifax, Nova Scotia, Canada 2Ryerson

Corresponding Author: Catherine Ward-Griffin, Professor, Arthur Labatt Family School of Nursing, Western University, Health Sciences Addition, Room H131, London, Ontario, Canada N6A5C1. Email: [email protected]

Downloaded from jfn.sagepub.com at UNIV OF CONNECTICUT on May 11, 2015

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of striving for balance, reaping the benefits and taking a toll, are presented in three composite vignettes, each representing specific double duty caregiving (DDC) prototypes (making it work, working to manage, living on the edge). This emergent theory extends current thinking of family caregiving that will inform the development and refinement of practices and policies relevant to DDC. Keywords caregiving, nurses, family caregiving, nurse-as-family-caregiver, elder care, blurring boundaries, work–family interface

As the proportion of nurses aged 60 years and older continues to increase at a rapid rate relative to other age groups (Canadian Institute for Health Information [CIHI], 2014) so also does that of their elderly relatives, many of whom require support and care (Newson, 2010). How nurses and other health professionals balance their family lives, such as caring for aging parents with their professional responsibilities, has become a priority in human resource planning among health care organizations (Shields & Wilkins, 2005; M.-L. Wang & Tsai, 2014). Although the prevalence of double duty caregiving (DDC), defined here as the provision of care to elderly relatives by practicing health care professionals, is currently unknown, previous research suggests that 30% to 50% of the working population provides care to elderly relatives (Martin-Matthews, 2000; Ward-Griffin et al., 2009). DDC is important for the nursing profession for two key reasons. First, many nurses are also family caregivers and the impact of these dual caregiving roles has serious potential implications for the health of nurses. For instance, work–family conflict among nurses is associated with a variety of negative consequences such as lower job satisfaction (Kovner, Brewer, Wu, Cheng, & Suzuki, 2006; Shiao, Lee, Ho, Hu, & Guo, 2014; M.-L. Wang & Tsai, 2014; Yildirim & Aycan, 2008), burnout (Burke & Greenglass, 2001; Leineweber et al., 2014; Y. Wang, Chang, Fu, & Wang, 2012), fatigue (Demerouti, Bakker, & Bulters, 2004; Jansen, Kant, Kristensen, & Nijhuis, 2003), emotional distress or depressive symptoms (Frone, 2000; Grzywacz, 2000; Killien, 2004), and physical pain (Kim et al., 2013). Furthermore, these negative outcomes have been linked to poor performance by health care providers (Smith et al., 2001; M.-L. Wang & Tsai, 2014) and have been implicated in medical errors (Pani & Chariker, 2004). Therefore, work–family conflict, of which DDC is a particular component, has significant potential to undermine nurses’ ability to provide high quality patient care (Killien, 2004).


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Second, given the aging population (United Nations, Department of Economic and Social Affairs, Population Division, 2013) and an aging nursing workforce in Canada (CIHI, 2014), an understanding of the health experiences among nurses who care for elderly relatives (i.e., double duty caregivers) is particularly urgent. However, one of the challenges in understanding DDC is that much of the theoretical literature addressing the interface between employment and family life conceptualizes these two spheres as distinct and disconnected from one another (Ward-Griffin, 2008). For instance, in the spillover model, which has been used to guide research of the work and family roles of health professionals (Duxbury, Higgins, & Smart, 2011; Fast, 2005), there is a tendency to assume what one does at work is dissimilar to what one does in the family. In a U.S. survey on work–family conflict among 4,000 registered nurses (RNs) in 29 states, it was found that 92% of nurses surveyed had experienced work interference with family obligations, while 63% of nurses reported experiencing family interference with work (Grzywacz, Frone, Brewer, & Kovner, 2006). This indicates that spillover from formal nursing work, in the form of fatigue and stress, is more likely to have a negative impact on family life, rather than family spillover into the workplace. While the spillover model acknowledges that the activities and events in one’s work and family influence one another, the separation of these two domains obscures the meaning of phenomena in both (Ward-Griffin, 2008). Furthermore, the conceptualization of formal caregiving and family caregiving as separate domains makes it difficult to identify those nurses who have difficulties in negotiating the boundary between formal and familial care, and to understand and address social contextual factors that shape these experiences. This type of knowledge is essential for creating individual and organizational strategies for supporting those who are both health care providers and family caregivers and for delivering these resources to those nurse–family caregivers in greatest need. Therefore, the purpose of this study was to examine how nurses experienced DDC and how it affected their health. Building on a program of research in DDC (Ward-Griffin, 2008; Ward-Griffin, Brown, Vandervoort, McNair, & Dashnay, 2005), this article is meant to extend our understanding of how double duty caregivers negotiate the caregiving interface (CI) between these two competing, yet interrelated domains of formal and familial care and to recommend specific policy changes that will promote the health of double duty caregivers.

Literature Review Despite many contributions to our understanding of work–family conflict, including the negative health effects of role stress among family caregivers


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and increasing empirical investigation of employed caregivers (Duxbury, Higgins, & Schroeder, 2009; Duxbury et al., 2011), knowledge about individuals who provide care in both their professional and personal lives is extremely limited. The few published studies in the area have focused largely on the benefits and challenges of being a double duty caregiver and the resulting impact of DDC.

Benefits and Challenges of Being a Double Duty Caregiver Because nurses are positioned within their families with specific “inside knowledge” that is derived from their professional roles, they are often selected by the family to be “in charge” of care (Salmond, 2011). As a result, they are expected to interact with the health care team, to keep the family informed of what is happening, to interpret meaning for them, to assure that “proper” care is administered, and to sustain their hope (Salmond, 2011). For instance, in a descriptive qualitative study of eight female nurses providing care to their parents or in-laws, participants used their authority as nurses that informed decisions about care and assumed critical roles in providing care to parents (Hurliman, 2004). Furthermore, “knowing the ropes” (Lee, 2009) enabled nurses to be involved in caring for their own family with a deep appreciation of the meaning of illness and suffering (Mills & Aubeeluck, 2006) and to effect positive change for their ill family members (Mills & Aubeeluck, 2006; Phillips, Bernard, & Chittenden, 2002; Ward-Griffin, 2004). For example, participants in Ward Griffin’s study of 15 community health care nurses in Ontario reported that they used their nursing knowledge and skills to assess their family members’ health status and make decisions for further care requirements. Similarly, in another study (Mills & Aubeeluck, 2006), participants indicated that their nursing knowledge and skills not only enabled them to provide a positive contribution to practical and emotional aspects of care to their ill family member, but they were also more reflective in their professional practice as a result of the experience as a family caregiver. In several studies, nurses also reported that their knowledge of the health care system was extremely beneficial to them as family caregivers. For example, Ward-Griffin (2004) found that nurses were able to access information, resources, and expertise not normally available to other family caregivers. Similarly, nurse participants in Mills and Aubeeluck’s (2006) study reported that their familiarity with the health care system enabled them to influence and facilitate the care required at the time of their relative’s death. Therefore, having connections with the health care system facilitated access to privileged medical information and services.


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While some nurses have voiced confidence in providing physical and emotional care to their family members (Salmond, 2011), others have indicated that having health care and nursing knowledge was at times problematic, especially in end-of life situations. Lee (2009) found that knowing the diagnosis and subsequent prognosis ahead of their relatives and other family members placed nurses in dilemmas of whether or when they should disclose the information to others. Indeed, nurses were at times unable to separate their identity as a nurse from that as a family member (Mills & Aubeeluck, 2006); they were “caught in the middle” (Lee, 2009) or were located “betwixt and between” their familial care and formal care responsibilities (WardGriffin, 2004; Ward-Griffin et al., 2005). Although viewed as beneficial, possessing medical knowledge also placed expectations on nurses to provide high quality of care to meet the needs of their relatives and other family members. Because they were expected to be the expert, nurses reported that they needed to be vigilant in ensuring their family member received appropriate care (Laylan, 2006; Lee, 2009; WardGriffin, 2004; Ward-Griffin et al., 2005). For instance, “walking a fine line” was identified as the basic social process in Layland’s study of nurses. When the safety of their family member was jeopardized, nurse participants became angry, protective, and intervened to prevent a potentially poor outcome, while trying to maintain a positive relationship with staff nurses, as well as other family members.

Impact of Caregiving There is growing evidence that nurses who provide care in both work and personal life experience negative health impacts, including mental and physical fatigue, increased levels of stress (Mills & Aubeeluck, 2006; Scott, Hwang, & Rogers, 2006), feelings of guilt and inadequacy when they lacked the knowledge to provide aspects of care (Lee, 2009; Ward-Griffin et al., 2005; Ward-Griffin, St-Amant, & Brown, 2011), and emotional difficulties following the death of their family members (Lee, 2009). In a study measuring the impact of multiple caregiving roles on nurses’ work performance, stress, and fatigue were significantly higher among nurses who simultaneously cared for both children and elderly family members at home and patients at work (Scott et al., 2006). Furthermore, nurses who provided care to elderly relatives reported greater levels of physical and mental fatigue on paid work time compared with nurses who had no caregiving responsibility at home (Scott et al., 2006). In addition, the researchers found that nurses who provided care to elderly relatives were more than twice as likely to make medication-related errors, and procedural and transcription mistakes, postulating that work


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performance is related to sleep loss with nurses who cared for elderly family members at greater risk of being more sleep deprived. Work–family conflict can lead to medication errors or other mistakes in the workplace (Scott et al., 2006), a decrease in work productivity (Grzywacz et al., 2006), a decrease in work satisfaction (Grzywacz et al., 2006; Hopkins & Monahan, 2002; Rosenfeld, 2007; Scott et al., 2006), and the inability to provide high quality patient care (Killien, 2004). These outcomes stem from the burden of care associated with each role and the tensions associated with negotiating the boundaries between the roles. Furthermore, nurses expressed feelings of guilt about “cheating the system” or letting other colleagues down when they took time off to care for relatives because often they were leaving their colleagues to cope with understaffed and busy units (Mills & Aubeeluck, 2006; WardGriffin et al., 2005). In summary, although there is an increasing recognition on the importance of work–home life balance among health care providers, little attention has been given to the health effects of DDC or to the factors that shape this experience. This knowledge is critical if healthy workplaces are to be achieved for nurses; ultimately, this information is necessary to inform the development and refinement of practices and polices relevant to DDC.

Method This sequential, mixed-methods study had two phases and was conducted in 2009-2011 to examine how and to what extent DDC among male and female Canadian nurses affects health. Approval for the study was obtained from the Ethics Review Board at The University of Western of Ontario for both Phase 1 and Phase 2 of this study. A stratified sample of 3,700 male and female RNs was randomly selected from the membership lists of the Colleges of Nurses of British Columbia, Ontario, and Nova Scotia. The inclusion criteria for Phase 1 of the study were male and female nurses 35 years of age or older who provided direct patient care and worked a minimum of 30 hr in a health care facility. Our sample of double duty caregivers also excluded those who were caring for children with special needs because such individuals would potentially have different experiences than those caring for older relatives. Because a small percentage of Canadian nurses are men (5.8%), we also purposefully oversampled male RNs across the three provinces to ensure that we had adequate statistical power to explore the relationship between gender and DDC. In Phase 1 of this study, nurses (n = 1,424) completed either a mailed or online survey used to assess health status, caregiver well-being, caregiver burnout, and DDC. A total of 37.9% (n = 529) of the sample was double duty


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caregivers, of whom 55.6% (n = 294) were male and 44.4% (n = 235) were female. At the end of the survey, those respondents who self-identified as double duty caregivers were invited to participate in two telephone interviews, providing them with the opportunity to discuss their distinct health experiences over time as double duty caregivers and suggest strategies and other possible solutions for addressing resulting health effects of DDC. This article focuses on the second phase of this study, the development of a constructivist grounded theory (Charmaz, 2006).

Sampling and Sample The main purpose of Phase 2 of this study was to extend our understanding of the social processes of DDC and how boundary blurring changes over time (oscillation) within the three DDC prototypical experiences (making it work, working to manage, and living on the edge) identified in our previous study (Ward-Griffin et al., 2005). Each prototype depicted varying degrees of boundary blurring between formal and familial caregiving (i.e., CI). The extent to which this CI was influenced by the degree of familial care expectations and the resources available to manage these caregiving demands. For instance, making it work, with its higher level of resources combined with lower expectations, depicted the smallest amount of blurring (i.e., small CI), while the boundaries in living on the edge were almost totally eroded (i.e., extensive CI). To better understand the DDC construct, our goal was to further explore these variations in the blurring of boundaries between formal and familial caregiving, the movement between these DDC prototypes and to understand how health risks may vary by our DDC prototypes. Although 24% (n = 117) of Phase 1 respondents who self-identified as double duty caregivers agreed to be contacted for Phase 2 of the study, the research team devised a theoretical sampling strategy that informed the purposeful selection of 32 Phase 2 participants. First, we established theoreticalinformed CI scores that represented each prototypical experience. For example, respondents who scored between 7 and 18 (out of 35) on the CI subscale were assigned to the making it work typology; scores between 19 and 24 were assigned to working to manage and those who scored 25 to 35 were assigned to living on the edge. Based on our previous work, the higher the CI score, the greater the degree of blurring, or overlap, of the boundaries. Next, once we felt that there was saturation of the prototypical DDC experience categories, we refined the theoretical sampling strategy to include other theoretically informed factors. These included gender, the number of care recipients for whom the double duty caregiver provided care, geographical proximity to their relative, sibling involvement in care, socioeconomic status,


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number of employed hours per week, and a general health score. Data collection continued until saturation of the theoretical categories was achieved. Therefore, as theoretical sampling is strategic and systematic (Charmaz, 2006), specific factors relevant to DDC were used to guide theoretical sampling. On this basis, we contacted 78 of the 117 potential participants using the theoretical sampling strategy described above, allowing for three contact attempts. We were not successful in reaching all of the potential participants when contact information provided in the survey was incomplete, thereby making it impossible to contact them, or when they did not return the initial email correspondence and/or phone messages. No one declined to participate if the research assistant was successful in reaching a potential participant by email or phone; however, due to the lapse of time between the completion of Phase 1 and Phase 2 recruitment (2-4 months), some participants (n = 28) no longer qualified to participate in phase two of the study. For those who met the inclusion criteria (i.e., currently caring for an older relative and employed in a direct nursing practice position), the research team successfully enrolled 50 participants for Time 1 (T1) interviews and 32 participants for Time 2 (T2) interviews. The discrepancy/attrition between the sample sizes for T1 and T2 (50 vs. 32) was attributable to loss of care recipient, change of employment status and/ or the research assistant was unable to follow-up with the participant. The majority of Phase 2 participants cared for one relative (58%), while 42% cared for two or more older relatives. Most were born in Canada (88%) and lived in Ontario (60%, n = 19); others lived in Nova Scotia (27%, n = 9) and British Columbia (12%, n = 4). Sixteen (50%) were male and 16 were female (50%). The majority of participants were married (72%); 12% were single and 16% were separated or divorced. Many were diploma prepared (58%) while 24% were baccalaureate, and the remainder of the sample held graduate degrees. The average income was between $75K and $90K (Canadian) per year and most participants worked greater than 30 hr per week (82%) in an urban location (82%).

Data Collection Two in-depth, semistructured, telephone interviews were scheduled approximately 6 to 12 months apart. In total, we conducted 82 in-depth, semistructured, telephone interviews. The decision to have two sets of qualitative interviews with each participant was largely based on the experience of the research team that attention to the process of DDC is as important as the outcome. In addition, theoretical sampling requires repeat interviews (Charmaz, 2006), which helped to uncover the social and structural processes of DDC


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and to check for emergent fit with our earlier conceptualization of the three prototypes of DDC (Ward-Griffin et al., 2005). This sample size was sufficient for a grounded theory study (Charmaz, 2006); recruitment and sampling of participants ceased when the data were saturated, that is, no new information on constructs, such as familial care expectations and resources, was uncovered. Furthermore, participants were asked to describe the impact of policies on their health as double duty caregivers and to recommend any changes that may address their issues or concerns. Questions that focused on their suggestions for change are consistent with critical research approaches interested in empowerment and social change (Acker, 2012; Carroll, 2004). At the completion of each interview, field notes were recorded, capturing specific details such as interviewer perceptions and nuances of communication. In addition, we held focus group interviews in British Columbia, Ontario, and Nova Scotia after the second set of interviews were completed with the aim to refine the grounded theory analysis.

Analysis Concurrent with data collection, data were analyzed using the constant comparison methods of constructivist grounded theory (Charmaz, 2006) modifying and building the emergent theory such that it fit both the new data and the relevant constructs of the proposed prototypes of DDC. Immediately after each interview, all interviews and field notes were transcribed. Early analysis focused on initial codes that emerged from the data. Focused coding was the second major phase of coding in which initial codes were discarded or refined if they were not supported by the data (Charmaz, 2006; Lofland, Snow, Anderson, & Lofland, 2005). We created an initial coding system, whereby focused codes were inserted onto the text by hand and then entered onto Nvivo 9.0, a Qualitative software program (QSR International, 2010). The third phase of coding involved the identification of the properties and dimensions of subcategories and categories. Using a data matrix (Miles & Huberman, 1994), a visual summary of common emerging themes (i.e., familial care expectations, resources, strategies, health experiences, DDC prototypical experiences) was constructed for each of the participants, which helped facilitate constant comparisons between and among the participants over time. To establish credibility of the data, strategies such as member checking in subsequent Time 2 interviews and in focus groups provided the opportunity for participants to respond to the interpretation and applicability of the preliminary analysis, and subsequently to refine current concepts within the proposed typologies of DDC. The final phase of analysis was the refinement of the emergent grounded theory (see Figure 1), which was shared at three focus groups in each


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Figure 1. Negotiating professional and familial care boundaries.

participating province (British Columbia, Ontario, and Nova Scotia). After the second set of interviews was completed, the participants were invited to join one of the provincial focus groups. All participants expressed an interest to attend a focus group but due to logistics, such as scheduling and travel distance, approximately one third of the sample (n = 11) actually participated. Facilitated by the principal investigator (PI) and one of the co-investigators, each focus group included three to six male and female participants and lasted 2 to 3 hr. During the first 30 min of the focus group, we shared a power point presentation of the emergent grounded theory of DDC, which included a description of the three prototypical experiences (making it work, working to manage, living on the edge). Next, participants were invited to introduce themselves and to describe their DDC experiences and to comment if the emergent theory reflected these experiences. In particular, we asked two major questions with follow-up probes: (a) Where would you situate yourselves (if at all) across the three identified prototypes of DDC? If so, has your situation or location changed over the last few months (i.e., since your last telephone interview)? and (b) How has your health been affected by DDC? Finally, the participants were invited to make suggestions as to how double duty caregivers could be better supported in their workplace and communities. The discussion that ensued at each focus group confirmed our emergent theory as well as refined the subprocesses of striving for balance and professionalizing familial care. Although grounded theory is both a process and a product (Charmaz, 2006), we describe the “product” of grounded theory in this article; further detail of the grounded theory process can be found elsewhere (St-Amant et al., 2014).


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Findings From female and male nurses’ descriptions of their DDC experiences, we constructed an emergent theory of Negotiating Professional and Familial Care Boundaries. In Figure 1, we have presented this theory as a dynamic process where nurses negotiate the professional and familial care boundaries in their lives. For each participant, negotiating professional and familial care boundaries is an individual experience that over time involves expectations to provide familial care and the availability of resources to provide this care. This theory refines our previous knowledge on how double duty caregivers experience an array of expectations, occurring intrinsically (from self), familial expectations and norms (from family members), or systemic expectations (from other health care professionals). They also rely on resources to provide this care and are located in the familial and formal care domains such as, supportive relationships, the availability of services, and a flexible work environment. In response to these expectations and availability of resources, a central finding of this study is that female and male nurses who provide care to older relatives set limits and make connections, which ultimately shapes the degree of boundary blurring between the family and professional domains of care. This CI is negotiated through two broad dialectical processes: professionalizing familial care and striving for balance. While these two processes constitute the emergent theory of Negotiating Professional and Familial Care Boundaries, striving for balance is the focus of this article. Professionalizing familial care or the ways in which health professionals transfer and use their knowledge and skills to enact their family caregiver role are summarized here, but a more detailed description of this process is available elsewhere (St-Amant et al., 2014). In examining the participants’ responses to familial care expectations, six interrelated strategies were used. Assessing reflects how double duty caregivers examine the care situation and arrive at an “objective and professional” judgment. Advising involves educating others, providing information about illnesses and treatments, whereas in a crisis or urgent situation, advocating focuses on being assertive and taking action on behalf of their relative; it involves knowing and working the system that is often difficult to navigate. Collaborating is the purposeful alignment and cooperation with other unpaid and paid caregivers to ensure quality care. Coordinating focuses on organizing family care by delegating tasks to others with the aim to mobilize knowledge into action. Finally, consulting occurs when the double duty caregiver does not have the knowledge or expertise to provide the care and seeks out other health providers to fill those knowledge gaps and/or reaffirm information. Despite the proactive use of these professionalizing strategies, double duty caregivers


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typically have fewer or more limited resources in providing family care than in their professional care setting. This discrepancy often places them in an untenable position. In this article, we present the process of striving for balance, and its two subprocesses, reaping benefits and taking a toll, as three composite vignettes, each representing the specific DDC prototypes of making it work, working to manage, and living on the edge. Striving for balance involves responding to familial care expectations in the midst of available resources and depicts the health experiences of double duty caregivers. Within this process, there are two interrelated subprocesses (see Figure 1). The first, reaping benefits, involves positive health experiences about being a double duty caregiver— feeling competent and confident that they are able to access knowledge and services for their relative due to their professional status. Reaping benefits is usually experienced in making it work when there is minimal boundary blurring between professional and familial care. In contrast, taking a toll, the second subprocess of striving for balance, involves a state of negative and ambivalent feelings of stress, exhaustion, and self-doubt, and occurs when the care boundaries are significantly blurred, such as in living on the edge. Furthermore, our emergent grounded theory depicted in Figure 1 extends our understanding of boundary blurring over time (oscillation) within the three prototypes of DDC: making it work, working to manage, and living on the edge. This oscillation is shaped by contextual factors such as a change in care needs, expectations, and resources (Ward-Griffin, 2004, 2008). For instance, the blurring of boundaries in prototype, making it work, is fairly limited because familial care expectations are low while the supports or resources are strong. In comparison, those who are working to manage experience more blurring of professional and personal caregiving roles while for those who are living on the edge, the level of expectations are exceedingly high and resources have weakened considerably, resulting in the erosion of boundaries between the two domains of care work. In general, our qualitative data analysis revealed that the health experiences of double duty caregivers were generally better for those who were making it work, followed by working to manage and living on the edge, and that double duty caregivers can move from one prototype to another. In this article, we present our findings as three composite vignettes, each representing specific DDC prototypes of making it work, working to manage, and living on the edge. Vignettes are composites that encapsulate what the researcher finds through the fieldwork (Spalding & Phillips, 2007). Based on the wide range of examples from the interviews, we wrote three composite vignettes (Ely, Vinz, Downing, & Anzul, 1997) that are an eclectic mix of double duty caregivers. Although the use of vignettes in research has been


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documented for more than 25 years, this approach is usually used to collect data rather than highlight common study findings among the participants. However, we chose this approach for presenting our findings because creating a composite of our analytic DDC prototypes and the inherent grounded theory categories of expectations, resources, and negotiating strategies could enhance grounded theory criteria of credibility, originality, resonance, and usefulness (Charmaz, 2006). By drawing upon multiple participants’ experiences and developing the following composite vignettes, our written account of how DDC affects the everyday lives of nurses is inventive and interpretive, and not merely a reporting of the processes and subprocesses of the studied experience (Charmaz, 2006). The first vignette stories one man’s DDC experience, although his “experience” was commonly shared among many of our male participants: the need to set boundaries between professional and personal caregiving roles while using professional connections to make it work.

Andrew: Making It Work I’m a nurse and I help out with my mother-in-law’s care. I work in the ER at the hospital. I entered nursing a bit late compared to other nurses: I was 32, but I have been at this game for about 18 years now. My mother-in-law has end stage COPD and type II diabetes with a recent onset of renal failure; her serum creatinine levels were through the roof the other day. She has gout and neuropathies related to her diabetes that leave in her pain a lot of the time. And most recently she’s been diagnosed with melanoma. So you could say she’s got a laundry list of ailments. I have a pretty stereotypical relationship with my mother-in-law. We can exchange pleasantries and share a holiday meal together, but if my wife offers to leave me at home to do yard work while she takes the kids over to her mom’s, I’d rather spend an afternoon with my rake rather than my mother-inlaw. But I’m happy that she and my wife get along so well—my wife is her only daughter, and they’ve always been close. And more than that, I’m happy I’m able to support my wife when her mom is so sick: my family knows that I understand medical decision-making, you know, medical terminology, and so they look to me to translate whatever it is that the doctors tell them about my mother-in-law’s health care. In terms of her actual care, she has a personal support worker who comes in twice a week. I’ll work on some rehab therapy type stuff with her once and awhile, but I draw the line at peri-care: no peri-care. She’d like to have someone come in more often but she isn’t all that financially independent. I guess you could say that she can take care of her basic needs, but anything above that, she


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requires assistance. This is usually okay because I can work around my wife’s availability, like taking my mother-in-law to the doctor’s office, but I feel guilty for asking for time off, especially right now. We are so short staffed and my absence results in more work for my colleagues. So, I guess you could say that my main role is that I’m the liaison. I am the interpreter. I advise the family on how to be objective, on how to be realistic. And, as a nurse I have some professional connections. Like last year when my mother-in-law needed cataract surgery I spoke with Dr. Green and got her in right away . . . it’s like a professional courtesy, you know? It feels good to help out, but I think as a professional, I tend to keep an emotional distance from my patients for my own safety: I try to stand far enough back so that I can make decisions with my mind, not my heart. And so even as a son-in-law, I expect my decisions to be objective. It’s the best way for me to make this work.

This vignette suggests that Andrew has the best of both worlds—because of his connections he is able to assist with his mother-in-law’s care, but only within the parameters of his “comfort zone.” He is making it work because he has the freedom to choose the frequency, type, and timing of the care that he provides to his mother-in-law, as well as the role he plays in the family—an objective liaison. Andrew reports that he is pleased to access professional services for his mother-in-law, but fails to see how his professional position affords him this privilege. His story illustrates how he is reaping the benefits as a double duty caregiver and he attributes this outcome to his ability to set limits on familial care expectations. Is this the key to successful navigation between formal and familial care boundaries—to have the right connections and to take a peripheral, objective position as a double duty caregiver? In the next vignette, it is apparent that DDC may be a bit more complex. Based on a number of interviews we conducted with daughters who were working to manage the care of their ill mothers, Ingrid’s story illustrates how contextual factors such as gender relations, the health of the family member, and availability of familial and formal care resources shape the health experience of striving to balance.

Ingrid: Working to Manage I am a 54-year-old divorcee and a nurse manager of a cardiology ward at our 400-bed hospital. But my story is really about my mother and me. My 84-yearold mother has had many health challenges in the past several years including congestive heart failure. She lost her husband of 55 years, four years ago. It has been hard, for both of us. I’ve tried to help her out the best I can. Initially, I was taking her to doctors’ appointments where I would assist by translating the medical jargon that confused her. Oh, and of course, I do the banking, groceries,


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drug store and all those daily things. But recently, Mother has needed more help with personal care such as bathing, quite a change in our roles as mother and daughter. Nonetheless, this is what is expected of me as a daughter and as a nurse. The expectation as a nurse is that you know what and who to ask and what to do. Others expect this of me and I expect this of myself. But the boundaries between that of daughter and nurse are beginning to become very blurred. I am finding it increasingly difficult to know who I am in relation to my mother. I find the responsibility of caring for my mother as her nurse very wearing. I put on a very professional front while I bathe her but as soon as I leave her room, I feel the tears coming . . . but I am quick to wipe them away before I go back to help her. I know my health is being affected—I am not sleeping well—I just toss and turn at night worrying about work—worrying about Mother—trying my best to manage it all! I almost quit my job—but who would I be without my work? Besides I really can’t afford to quit work before I turn at least 60—I’m not sure how it would affect my pension. I’ve been nursing for over 30 years and worked my way up to be a manager. I love my job but now the stress of work and caring for Mother is becoming a challenge. Somehow, I’m still working to manage it all. However, it is a fragile balancing act. I am constantly using my nursing skills to assess, advise, and advocate for Mother. Yet, there are moments when it all seems far too much to manage.

In this vignette, it is apparent that Ingrid’s situation is different than Andrew’s. Although they are both expected to assess, advocate, and coordinate their relatives’ care because they are the “nurse in the family,” Ingrid’s relationship with her mother coupled with the gendered nature of care influences her DDC experience, which ultimately affects both her health and her professional career. Ingrid talks about DDC being a balancing act, but not just in the usual sense of balancing the demands of work and family life. Ingrid must also attempt to balance the constant expectations as both her mother’s nurse and daughter. Similar to Andrew, she attempts to set boundaries by “putting on a professional front” when she provides personal care to her mother, but this negotiating strategy is much less effective for Ingrid. She says that the blurring of professional and familial care boundaries is at times very difficult to manage and is having an impact on her health. Therefore, this vignette illustrates how the two subprocesses reaping benefits and taking a toll play out in the prototype working to manage. The next vignette captures a glimpse into the lives of those double duty caregivers who described themselves as living on the edge where the familial expectations to provide complex, daily care were exceedingly high with few resources. Consequently, the boundaries between formal and familial care are eroded to the point that the nurses’ health is taking a toll, often experiencing


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adverse health outcomes, such as physical and mental exhaustion. Furthermore, female nurses were more likely than male nurses over time to experience living on the edge.

Jennifer: Living on the Edge For the past 16 months, I have nursed my mom and dad. Mom was diagnosed with fourth stage ovarian cancer six months ago and Dad has mild dementia. They were fine on their own for awhile, but for the past three months Mom’s condition has deteriorated. So I arranged to have palliative care services in the home. Right from the start, my family expected me to make sure that she had the right care. They figured I knew the “right” people to call but oncology is not my specialty. I provided a lot of care myself because Mom needed a lot more care than what is provided by home care. I also got the feeling that much of the care was left to me because I was a nurse—not only do I provide personal care to my mother, but I monitor her meds, assess her pain control and nutritional status, and take her to appointments. So after I work a shift at the hospital, I do another one at my parent’s house. But this shift is usually longer because I stay late into the night or early morning. Dad can’t handle the demands of this kind of care—he is 80 years old—and besides he isn’t able to competently monitor Mom’s medical status. I heard that home care has been cut back, but expecting family members to do the lion’s share of the work is not only unrealistic, it is just unfair! I also feel at times that Mom is getting less home care because they know I am a nurse. But there is no one else—home care tells us that we are getting the maximum hours allowed and my parents do not have the money to pay for private duty nurses. Besides, they say with a nurse in the family, they are grateful that they do not need to hire nurses. I agreed with them initially, but I was not prepared for this! I didn’t realize how intense or how long I would have to provide my mother’s care. Sure I am a nurse, but I am a cardiac nurse—nobody took the time to teach me the nuances of the palliative care, like pain control—they just assumed I knew how to do it—but let’s face it, this is my mother, not just my patient. I need some support and help, but I feel very much alone. I don’t even talk to my friends and colleagues at work—our patient load keeps us so busy who has time to talk? Besides this isn’t something you feel comfortable talking about—we are nurses and we take care of sick people so what’s the problem? But I finally went to my manager two weeks ago and asked about flexing my time or to take a short-term leave but do you know what she said to me?? And I quote—“we are sympathetic to your situation Jennifer, but if we make exceptions for your case, everyone will ask for special treatment.” Can you believe it?? So I have no choice but to use my sick time to provide care to Mom or take her to appointments. She is getting so frail, and Dad can’t do it himself. Although I feel guilty calling in sick when I am not ill because it leaves my


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colleagues in a bind with us being so short staffed, I don’t feel I have any choice! What would you do in my situation?

Although Jennifer and Ingrid are both daughters who are expected to provide professional care outside of their expertise, this vignette reveals a number of other factors that shape the blurring of boundaries between professional and familial care boundaries. Jennifer’s story highlights how a number of structural issues such as the availability of home care services, health human resources, and nursing shortages influence the process of striving for balance. Jennifer is torn between being the daughter and being the health professional. She questions not only her competence in caring for her mother, but she also questions the policies and practices of the health care system that rely so heavily on family caregivers. Double duty caregivers like Jennifer with exceedingly high familial expectations to provide complex, daily care in conjunction with weak or nonexistent supports or resources experienced an erosion of their professional and familial caregiving boundaries (CI), which led to reports of ill health. These three vignettes reflect the three prototypes of DDC, making it work, working to manage and living on the edge. However, DDC is not static, it is in constant flux and double duty caregivers tend to oscillate between the three prototypes, depending on the interplay among expectations, resources, and negotiating strategies. Furthermore, study findings also revealed that the availability of workplace and community resources is particularly significant to the process of striving for balance. Six months later, Andrew is no longer making it work, but rather, he is working to manage. The failing health of his mother-in-law, lack of available resources, and the demands of being a husband and a nurse have contributed to the oscillation from one DDC prototype to another. My mother-in-law passed away shortly after our last interview. We couldn’t control her renal failure anymore, she eventually went into a coma and died a couple of weeks later. Thinking back, there was a lot that I could have done differently. When her health was better it was obviously not a big deal to help out, but as her health failed, it became a bigger role. You know, it’s hard to say, what is an acceptable amount of pressure and responsibility for one person? And I’m the son-in-law, not the son, you know. On one hand, I was trying to be a supportive husband while also being a caregiver. But there were added roles, especially when she became so medically fragile. I guess the price that I paid was personal—my wife and I are now separated. My wife wasn’t looking for a professional, she was looking for emotional support and that was the bat that I sort of swung and missed. My wife was


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frustrated that I took on the role of being the family advisor and not her support. I was absolutely more of a nurse than I was a husband for sure. I just couldn’t switch roles that well. I’m actually pretty surprised at how reliant other professionals became of me—I mean, it was like because I was there, they didn’t need to do their job. And that was just added pressure for me. Everyone would turn to me for answers. I was pretty stressed. I guess you could say that I’m still experiencing some residual stress. I haven’t been sleeping or eating well. I’m actually down four pant-sizes. I put that managerial position on hold in order to deal with all this. I just need to get things under control before moving forward, you know?

The blurring of boundaries and the difficulty of maintaining some distinction between professional–familial roles was a common concern among double duty caregivers. For instance, Ingrid’s continuing story revealed how the blurring of these roles was extremely stressful, and led to a number of health issues. Furthermore, she identified a number of factors such as dwindling supports and unrealistic expectations that contributed to feeling overwhelmed and out of control. The last few months have been devastating—for both of us. Mother’s health has deteriorated significantly. First of all she fell and fractured her hip, postoperatively. She then suffered a stroke and now she is located in a chronic care facility. When I am not at work I am at her bedside. I am her protector. I want to ensure she has a good death but there are times when I am unsure if I can achieve this expectation. As a nurse, this is my value, my mission. As a daughter, I also want the best outcome, the perfect death for Mother—but at what cost to me? Oh dear, once again I have gone from speaking about Mother’s problems to focusing on mine. They just seem so overlapping, so blended together, as if there are no longer any boundaries between mother/daughter, care recipient/caregiver, family member/professional caregiver. I don’t know how much longer I can continue on this way. I am so overwhelmed. I’m usually in such control—at home and at work. But I am I am very distracted at work and I know my performance is suboptimal. I have used all my vacation time, to be with Mother. I realized more than ever that taking care of Mother is taking a toll. I am not eating well, my sleep is dreadful, and my blood pressure is not under control even with medication. My house is in disarray—what a mess— so I have canceled family gatherings—such as last Easter—an event I have always enjoyed as a hallmark of spring—a time of a renewal. But now I feel no sense of renewal—only despair and loneliness.

Feelings of powerlessness and despair were common health experiences in those double duty caregivers who were living on the edge—they felt they had no choice but to provide care, and usually did so on their own, at least


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until other solutions or supports were found. In these situations, they felt very stressed and isolated in their attempts to provide familial care as health professionals. A cycle that is often never ending as illustrated in Jennifer’s case. Mom passed three months ago. I hate to say this but I was bit relieved because I really couldn’t go on for much longer. It was hard on me and hard on Mom— it definitely changed our relationship and not always for the best. I really regret that I was forced to be her nurse, not her daughter—even the health professionals who were involved in her care treated me that way—that was hard. As well, the situation really started taking a toll on my own health and not just my mental health. My blood pressure was really elevated so I started taking antihypertensives. So I thought—wow, I need to do something to decrease my stress. I decided to drop down to part-time work which helped for awhile I think, but as a result, I spent more time caring for my mother. It felt like a vicious cycle—I wasn’t doing any less nursing care, just not at the hospital. Now that I didn’t have a full-time job, I was at their beck and call. Even my husband, who is normally supportive, was getting upset with me for spending so much time at my parent’s house. So when mom died I thought okay, things can go back to normal. But shortly after mom died, I noticed that Dad’s memory was getting worse and his hygiene was slipping. So I started dropping in on my way to and after work to check on him. I now realize that perhaps he had exhibited some of these signs and symptoms of dementia for awhile now but I was so focused on mom’s care, I guess I didn’t notice. As a nurse, I feel guilty for not detecting this earlier because I could have connected him with a geriatrician earlier than we did— now we have to wait another couple of months. I am still working part-time, but I would like to return to full-time. But I am so afraid—my health, my marriage—they really took a beating when I was caring for Mom. I can see that now. but at the time, I didn’t see any alternatives to what I did—so much was expected of me and I had so few supports. In my situation with Mom, I guess I got off easy—it only lasted about 6 months, but what about those who have long term conditions, like Alzheimer’s disease— perhaps like my Dad. I have to tell you —that really scares me—not that he has the disease, which is bad enough, but that I may find myself in this situation again. I feel like I am living on the edge without anyone out there that even notices, let alone can help me. Isn’t there something we can do to ensure nurses, as well as the ones they care for, aren’t placed in these types of situations?

Discussion The emergent theory of Negotiating Professional–Familial Care Boundaries offers a useful framework for interpreting men’s and women’s experiences as


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double duty caregivers, and provides new understanding of the transitions and trajectories of the complex process of striving for balance. There are two major implications from this theory. First, the health of nurses and other health professionals caring for relatives may be at risk if we do not acknowledge the social significance of the blurring of professional and familial care boundaries. Second, failure to provide adequate resources that support the caring work of double duty caregivers will have a potentially negative effect on health human resources, which could place those for whom they care, both at home and at work, at risk. Because there is a need to support all family caregivers regardless of their occupation, the findings from this grounded theory may be transferable to other employed family caregivers; however, more research is necessary to determine the relevance of this grounded theory with different caregiving groups. A strength of this grounded theory is its rich and comprehensive description of how boundary blurring corresponds with the health experiences of male and female double duty caregivers. Similar to other studies (Anjos, Ward-Griffin, & Leipert, 2012; Lee, 2009; Ward-Griffin, 2004), participants in this study experienced conflict from being “torn between two worlds” as they negotiated their dual roles of professional nurse and family caregiver. Furthermore, these roles were not dichotomous, but rather intertwined. This emergent theory helps illuminate the positive and negative health effects of DDC (reaping benefits, taking a toll) and how the health experiences vary across the three prototypes of DDC, and over time: making it work, working to manage, and living on the edge. For instance, Andrew’s vignette in making it work reflects how boundary blurring does not necessarily lead to negative health experiences for the double duty caregiver or his relative. Because of Andrew’s connections as a nurse, he was able to access services without delay, resulting in positive health outcomes for both Andrew and his motherin-law. In contrast, double duty caregivers living on the edge, such as Jennifer, described feeling guilt, powerlessness, and exhaustion due to high caregiving demands without adequate resources. Our study findings also suggest that lack of resources and support from the formal health care system contributes to the stress of caregiving, and over time, the health of double duty caregivers is compromised. Moreover, the challenges and opportunities encountered by men and women in our study were shaped by gender norms, practices, and relations of power. For instance, it is noteworthy that more women than men fell within the prototype of living on the edge, especially over time. Furthermore, although male and female nurses tended to use similar negotiating strategies, such as setting limits, the ways in which men and women responded to DDC and their resulting health experiences varied. Thus, the refinement and extension of our


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theoretical DDC model helps explain the complex experiential and temporal nature of DDC for men and women. Moreover, a knowledge base that takes gender into account will help us to address any health inequities within caregiving (Morris, 2004). Although we are a long way from putting this gender based knowledge into health promotion practice (Armstrong, 2007), this emergent theory is a step in the right direction. As the health of the nursing workforce is of vital importance to the health of the public (Advisory Committee on Health Human Resources, 2004; Villeneuve & MacDonald, 2006), efforts to maintain and promote the health of double duty caregivers should become a priority. Previous research has demonstrated that double duty caregivers who have limited resources to meet their caregiving demands have a direct impact on health and well-being (Phillips et al., 2002; Ward-Griffin, 2004), suggesting the need for long-term solutions in the form of professional, workplace, and government policies. If we are committed to promoting, retaining, and recruiting health care professionals, it is important to shift our attention from individualistic health promotion approaches to include strategies that address the social-political context of care within DDC. For instance, our study findings suggest that increasing resources such as flexible work arrangements and enhanced community/home supports may decrease boundary blurring and therefore improve the health of double duty caregivers. Nurses often cite flexibility in scheduling as a major quality of work-life issue (College of Registered Nurses of Nova Scotia, 2006; O’Brien-Pallas, Alksnis, & Wang, 2003). However, future research needs to evaluate whether the provision of flexible work arrangements actually decreases work–family conflict among double duty caregivers and if so, to what extent. This type of research would be invaluable to inform health promotion policy and practice in hospitals and other organizations employing nurses and other health professionals (Grzywacz, 2000). As other studies and reports have noted (O’Brien-Pallas et al., 2003; Villeneuve & MacDonald, 2006), there is also an urgent need to accommodate an aging nursing workforce. However, our study findings illustrate that workplace, professional, and government resources to assist middle-aged nurses caring for their older relatives were minimal at best. Inflexible work schedules and a lack of understanding from managers and colleagues (Hurliman, 2004) about the demands of family caregiving responsibilities is a primary reason for nurses leaving their employment (Gould & Fontenla, 2006; Leon, Altholz, & Dziegielewski, 1999; Reineck & Furino, 2005). According to Baumann and colleagues (2001), flexibility in scheduling and organized child and elder care would allow for better balance of work and home life, particularly if caring for an ill family member. Our analysis also


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suggests that availability of hospital, home, and community care supports is essential if the retention of mid and late career nurses and other health professionals is to be realized. Thus, the provision of flexible, family-friendly scheduling is critical if nursing and other female dominated health professions are to be able to “balance” their health care and family care demands in the future. Finally, based on the evidence from this study and others in our program of research on DDC, 23 stakeholders from across Canada (Nova Scotia, Prince Edward Island, Ontario, Saskatchewan, and British Columbia) representing nursing associations, unions, and workplaces attended a transformative knowledge transfer (KT) workshop in June 2012 in Vancouver, British Columbia. The purpose of this KT workshop was to create an opportunity for dialogue, reflection and action on this important health human resources issue. In particular, we aimed to facilitate the uptake of gender and health services research evidence into practice, policy, and other areas to address caregiving challenges. As was the case during the generation of practicebased evidence about DDC, socially interactive, inclusive, and action-oriented dialogue between and among health care practitioner, researchers, administrators, and policy makers enabled the creation of successful research and community partnerships that integrated DDC evidence into policy and practice. In the months following the workshop, a policy brief, Supporting Double Duty Caregivers: A Policy Brief (n.d.), comprising nine specific recommendations related to workplace and community care supports was drafted, refined, and disseminated electronically among our stakeholders across Canada (see http://www.uwo.ca/nursing/cwg/index.html). The interest and commitment among our collaborative partners and workshop participants in using this policy brief was essential to its success, and ultimately, to advance further theoretical, empirical, and policy work in health human resources and DDC.

Conclusion This study extends our knowledge about the impact of family caregiving on health from the perspective of those who provide care in their professional lives. In particular, this work sheds light on the unique experiences of nurses providing care to their own relatives. As double duty caregivers continue to engage in family care work, it is important to acknowledge the contributions they make and to develop strategies that will reduce the negative health effects of DDC. Family nurses are well positioned to identify double duty caregivers at risk of living on the edge. Future research is required to understand what factors affect the health of double duty caregivers such as the type


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of occupation and how policies help and/or hinder family care work. Furthermore, we need to explore how double duty caregivers manage home and paid work simultaneously and what policies shape this work. Finally, it is important to recognize double duty caregivers’ knowledge base as both an asset and hindrance in their care work. For example, double duty caregivers making it work provide high quality care to their relatives while also feeling reciprocated, whereas double duty caregivers living on edge lack choice in their care work when they are expected to provide care and endure the health consequences. Therefore not all double duty caregivers are the same. Family nurses need to be attuned to the specific needs of each type of double duty caregiver and identify health-promoting strategies that address their unique experiences. Now and in the future, family nurses will be instrumental to promote the health for all double duty caregivers and their family members, especially those at risk of living on edge. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Canadian Institutes of Health Research (IGH, IHSR) Grant MOP89362.

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Author Biographies Catherine Ward-Griffin, RN, PhD, is a professor, Arthur Labatt Family School of Nursing, Faculty of Health Sciences, University of Western Ontario, and scientist, Lawson Health Research Institute in London, Ontario, Canada. Her research interests include gender and health, health promotion, home care, dementia care, and health and social policy. Using both qualitative and quantitative methods, her program of research focuses on the boundaries of care work. Specifically, she critically examines caregiving relationships between and among health care providers, older adults, and


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their families in both home care and long-term care settings. Her recent publications include the following: “Understanding Gendered Expectations and Exemptions Experienced by Male Double-Duty Caregivers: A Qualitative Secondary Analysis” in Canadian Journal of Nursing Research (2012, with A. P. Anjos & B. Leipert) and “Supportive Care to Family Caregivers Is Not Supportive Enough: Moving Towards an Equitable Approach to Dementia Home Care” in Neurodegenerative Disease Management (2012). Judith Belle Brown, PhD, is a professor in the Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, and professor, School of Social Work, King’s College, London, Ontario, Canada. She conducts research in the areas of patient-centered care, interprofessional teamwork and teambuilding, physician well-being, physician practice behavior, and double duty caregiving. Her recent publications include the following: “Primary Health Care Models: Medical Students’ Knowledge and Perceptions” in Canadian Family Physician (2012, with R. French, A. McCulloch, & E. Clendinning) and “Conflict on Interprofessional Primary Health Care Teams—Can It Be Resolved?” in Journal of Interprofessional Care (2011, with L. Lewis, K. Ellis, M. Stewart, T. R. Freeman, & M. J. Kasperski). Oona St-Amant, RN, PhD, is an assistant professor in the Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada. She holds a Canadian Institutes of Health Research Doctoral Award in Health Services and Population Health in HIV/AIDS Research. Her program of research focuses on unpaid care work, including family caregiving and volunteer work. Through her doctoral study, which utilized an ethnographic approach to explore non-government organization (NGO) volunteer HIV/AIDS health work in Tanzania, she developed a particular interest in how power is enacted in the context of volunteer work. Her recent publications include the following: “Professionalizing Family Care: Examining Nurses’ Unpaid Family Care Work” in Advances in Nursing Science (2014, with C. Ward-Griffin, J. B. Brown, A. Martin-Matthews, N. Sutherland, J. Keefe, & M. Kerr) and “Compassion Fatigue Within Double Duty Caregiving: Nurse-Daughters Caring for Elderly Parents” in OJIN: The Online Journal of Issues in Nursing (2011, with C. WardGriffin & J. Brown). Nisha Sutherland, RN, PhD, recently commenced a position as lecturer at Lakehead University in Thunder Bay, Ontario, Canada. Her research interests include health promotion, social determinants of health (e.g., gender, race, age, class), and equity in health care policy and practice. With a focus in the areas of end-of-life, gerontology, and community-based care, her doctoral research critically analyzed gender relations in hospice palliative home care. Her recent publications include the following: “The Meaning of Being in Transition to End-of-Life Care for Female Partners of Spouses With Cancer” in Palliative & Supportive Care (2009). Anne Martin-Matthews, PhD, is a professor of sociology at the University of British Columbia in Vancouver, Canada. Her research focus is in social gerontology and her


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current research examines issues of home and community care for older people, and also widowhood in cultural contexts. Her recent publications include the following: “Workers’ Experiences of Crises in the Delivery of Home Support Services to Older Clients: A Qualitative Study” in Journal of Applied Gerontology (2013, with J. SimsGould, K. Byrne, & C. Beck) and “Ethno-Cultural Diversity in the Experience of Widowhood in Later Life: Chinese Widows in Canada” in Journal of Aging Studies (2013, with C. E. Tong, C. J. Rosenthal, & L. McDonald). Janice Keefe, PhD, is a professor, Department of Family Studies and Gerontology, Mount Saint Vincent University, and director of the Nova Scotia Centre on Aging and Lena Isabel Jodrey Chair in Gerontology, Halifax, Nova Scotia, Canada. Her research interests include family/friend caregiving, health human resources, and continuing care policy. Her recent publications include the following: “Trends and Characteristics Affecting Disability Among Older Canadians Living in Private Households” in Canadian Studies in Population (2013, with G. Lefrançois, S. Vézina, & J. Légaré) and “The Influence of Intrinsic and Extrinsic Job Values on Turnover Intention Among Continuing Care Assistants in Nova Scotia” in Home Health Care Services Quarterly (2012, with D. M. Dill & D. S. McGrath). Mickey Kerr, PhD, is an associate professor, Arthur Labatt Family School of Nursing, Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada. His research interests include the workplace psychosocial environment, stress research, and workplace interventions in health services. Much of his recent work has been focused on exploring the relationship between the work environment and the health of nurses, including an evaluation of the introduction of a new clinical practice models for nursing care at a large teaching hospital. His recent publications include the following: “The Development and Validation of the Double-Duty Caregiving (DDC) Scale” in Canadian Journal of Nursing Research (2009, with C. Ward-Griffin, J. Keefe, A. Martin-Matthews, J. Brown, & A. Oudshoorn) and “Identifying Factors That Predict Women’s Inability to Maintain Separation From an Abusive Partner” in Issues in Mental Health Nursing (2012, with E. Abdulmohsen Alhalal, M. Ford-Gilboe, & L. Davies).


Double- and Triple-Duty Caregiving Men.

Certified Nursing Assistants Balancing Family Caregiving Roles: Health Care Utilization Among Double- and Triple-Duty Caregivers.

Combining Formal and Informal Caregiving Roles: The Psychosocial Implications of Double- and Triple-Duty Care.

Striving for good nursing care: nurses' experiences of do not resuscitate orders within oncology and hematology care.

Negotiating boundaries: Accessing donor gametes in India.

Negotiating learner-teacher boundaries in medical education.

Negotiating a professional nurses contract.

Cell signalling: Double duty for Dishevelled.

RIG-I works double duty.

Outcomes evaluation: striving for excellence in ambulatory care pharmacy practice.

Enhancing Nurses' Ability to Care Within the Culture of Incarceration.

Mgm101: A double-duty Rad52-like protein.

Negotiating self-care in rehabilitation nursing.

Striving for comprehensiveness.

Striving for effective communication.

Negotiating technology-mediated interaction in health care.

Nurses receive inadequate training in duty of candour.

Barriers to work-life balance for hospital nurses.

Balance Across Boundaries: Service-Learning from an International Perspective.

Person-centred dementia care: moving beyond caregiving.

Patient-centered care or cultural competence: negotiating palliative care at home for Chinese Canadian immigrants.

Health care prioritization: a clinician's duty.

Student life - duty of care or carefree?

Duty of care to a quasi patient.