Joumal of Admnced Nursmg, 1990,15, 788-795
The relationships between social skills, social support, self-esteem and burden in adult caregivers Karen Robinson DNS RN Assoaaie Professor, School of Nursing, Umverstiy of Loutsvtlle, Kenhtcky, USA
Accepted for pubhcahon 3 October 1989
ROBINSON K (1990) Journal of Advanced Nursmg 15, 788-795
The relationships between social skills, social support, self-esteem and burden in adult caregivers The purpose of this study was to explore the relationships between social skills, self-esteem, soaal support and burden in a sample of adult caregivers The Gambnll and Richey Assertion Inventory, Rosenberg's Self-Esteem Scale, Montgomery's Objective and Subjective Burden Scale, Norbeck's Social Support Queshormaire and Sarason's Soaal Support Questiormaire were administered to a convenience sample of 31 caregivers Unassertive caregivers had less available social support Those caregivers who felt more discomfort m situations also had less available social support Caregivers who had sigmficantly more affechon, affirmation and aid from within their soaal network were foimd to have higher self-esteem Those with lower self-esteem reported losing a greater number of important relationships m the past year Nonassertive caregivers were more likely to expenence lower subjective burden
CRITICAL HEALTH POLICY ISSUE
mcreased visits to the earegiver by family members and fnends Fengler & Coodnch (1979) reported that children. One of the most cnhcal health policy issues to be relatives and fnends who visited became important social addressed m the next decade is long-term care for the supports for high-morale caregivmg wives Thus, the soaal elderly (Montgomery ei al 1985) The issue of altematives network has been found to play a significant role in shess to hospitalizahon for the elderly demented viehm is of reduetion among earegivers (George & Gwyther 1986, ever-mcreasmg importance Home care has become an Gilhooly 1984, Snyder & Keefe 1985) important altemative to mshtuhonahzahon Research has Recent social support literature has focused on the eondemonstrated that when older persons need eare, family hnbuhon that individuals make to determme their own members are the pnmary earegivers Oones & Vetter 1984) social support levels (Rook 1984) Personahty characterWith growmg reeognihon of the stressful nature of eare- jstics of earegivers must be eonsidered m relahon to soaal giving, a growmg researeh arena has foeused on how best support One independent vanable that has received mueh to support the lay earegiver attenhon is soaal skills (Sarason ei al 1985) Gotbeb (1981) Soaal support is a eoneept of great importanee m the suggested that soaal sblls and personal eharactenstics mveshgahon of lay caregivmg This concept refers to inter- which predispose one to develop a soaal network are personally supportive behaviours and mdudes the givmg needed m order to develop both ties to others and form and receivmg of soaal support throughout the life course new conneehons that result m more soeial support CareZant ei al (1980) found earegivmg burden deereased with givers with better soaal skills wiU be able to enhance their Correspondence DrKaren Rohnson Assocu^te Professor School of Numng, Umverstiy
of Lomsmlk Kentucky 40192 USA 788
° ^ ^ " " ^ ^ ^ P P O ^ >" "'^"^
their caregivmg situahon
* ° " ^ ^ ^ ^ ^ " adjUShnent tO
Adult caregtvers
t
Social ^ • 1 Mobilization of skills ~ ^ 1 1 social network
Sociai support
•1
Caregiving burden
+
t Figure 1 Theorehcai conceptualization of soaal support Self-esteem
THE STUDY The present study investigated the relationships between soeial skills, self-esteem, soaal support and burden m adult caregivers The eoneepts of soeial skills, soaal support, selfesteem and burden were selected because of the study's theorehcai framework This framework, illustrated in Figure 1, IS based on Tolsdorf's (1976) conception of social support Tolsdorf theonzed that mdividuals mobilize their social networic when they can no longer deal with stress
alone If successful, these increased supportive transactions with network members result m mcreased self-esteem Individuals with mcreased sociai skills mobilize more persons in their soaal network As a result the individual receives more supportive transachons, resultmg in increased selfesteem The outcome of this mcreased social support hopefully IS decreased caregivmg burden This same framework theonzmg that scxnal skills were an important antecedent of soaal support was used to develop a social shlls trammg programme which was found to signiftcantly reduce earegivmg burden (Robinson 1988)
87% were White females (only 4 were males), and 68% were either the spouse or adult ehild of the lU older person The remaining earegivers were sisters or other relatives The majonty of earegivers were mamtammg the elder in the eommunity outside an institution Even though the elder was m a nursing home, six of the 31 earegivers were meluded m the study beeause they met the 'spendmg a sigrufteant amount of time' entenon They reported spending the greater part of eaeh day at the nursmg home and also reported earegiving tasks of bathing and feeding their loved ones Four of the earegivers (two with and two without formal trainmg) were hired earegivers who were formally unrelated to the ill person but beeame 'like family' to the patient cifter being hired as earegivers Nearly half of the earegivers (n = 13) reported having 'a very adequate ineome' (were able to pay bills regularly, having money left over), only four reported having 'difftculty paying monthly bills' The majonty (M = 20) rated their health as 'good', only two reported 'poor' health Caregivers reported spending a range of from I to 16 hours (M— 3 3) per day giving eare to their loved one and had been doing this for 2 to 7 years ( M = 2 6) This wide rcinge of hours meluded supervision of the ill f>erson as well as earegivmg tasks The majonty of earegivers reported that their patient expeneneed eonfusion, forgetfulness and wandenng Nine reported harmful behaviour
INSTRUMENTS Hypotheses In the present researeh, the following four hypotheses were tested 1
2 3 4
The eorrelations between subseales on the Norbeek Soeial Support Questionnaire (NSSQ) and the Sarason Soaal Support Questionnaire (SSSQ) will be less than r = 0 70 Soeial sblls will be positively assoeiated with social support Social support will be posihvely associated with self-esteem Social skills will be mversely assoaated with burden
Sample Thirty-one adult caregivers who were carmg for an impaired elder (age 53 to 85 years) sufifenng from an irreversible dementia were recruited The caregiver had to be spending a 'significant amoimt of time' with the impaired elder Of the 31 earegivers, 77% were age 50 and older.
Social skills The 40-item self-report assertion inventory, developed by GambnU & Riehey (1975), includes items that sample a range of situations believed to be important to family caregivers Examples of factors identifted by factor analysis mcluded mitiatmg mteractions, eonfronhng others, giving negahve feedback, responding to crihcism, turning dovm requests, and assertiveness m serviee situations For eaeh item, the earegiver was requested to mdieate (a) degree of discomfort m regcird to eaeh speeiftc situation on a 5-pomt scale ranging from (I) none to (5) very much, and (b) their likelihood of engagmg m speaftc behaviours if actually presented with the situation on a 5-point scale rangmg fi'om (1) always to (5) never The mventory has been found to have high stability of scores over time (Gambnll & Richey 1975) Validity was supported when the mventory differenhated between a clinical group seekmg asserhveness trainmg and a normal populahon The inventory also reflected signiftcant differences withm the clmical group itself before and after trammg (Gambnll & Richey 1975) 789
K Robinson
intermittent ties that play a significant part m mamtammg physical and psychological health over time The 27-item This instrument, developed by Montgomery et al (1985), SSSQ IS mtended to quantify the dimensions of perceived separates concrete events, happenings and activities of availabihty of and satisfaction with social support Subjects caregiving (l e objective measures of burden) from feel- are asked (a) to list the people to whom they can tum and ings, attitudes and emotions related to caregiving (l e sub- on whom they can rely m each given set of circumstances jective measures of burden) Objective burden is defined as cind (b) to indicate how satisfied they are with these social the extent of disruptions or changes in vanous aspects of supports Availability is computed as the number of persons the caregiver's life and household because of caregiving listed divided by the number of items The satisfaction scale (e g money, vacations, freedom, etc) Subjective burden is ranged from (1) 'very dissatisfied' to (6) 'very satisfied' defined as the respondent's attitudes toward or emotional Satisfaction is computed as the satisfaction sum divided by reactions to the caregiving expenence Objective burden is the number of items on the SSQ Past research mdicated measured by eight items and subjective burden five items that the SSSQ is a reliable instrument (Sarason et al 1983) on 5-point scales ranging from 'a lot less' to 'a lot more' Previous research has indicated reliabihty coefficients of 0 85 for both scales (Montgomery et al 1985) Subjective Self-esteem and objective burden were correlated ( r = 0 34), but shared Rosenberg's (1968) Self-Esteem Scale consists of 10 items only 12% common vanance (Montgomery et al 1985) answered on a 4-point Guttman scale from 'strongly agree' Objechve and subjective burden
Social support Two different instruments were chosen to measure social support because the hterature emphasizes the need to measure diverse vanables The NSSQ is designed to measure multiple dimensions of soaal support The Norbecketfl/ (1981,1983)concept of soaal supportis based on Kahn & Antonucci's (1982) definitions of social support and definitions from network theory The NSSQ measures perceived support available to the individual rather than reciprocal support discussed m Kahn's definition It is a global measure of soaal support and is not aimed at specific populations Subscales of affect, affirmation and aid are added together to denve a total/MndiOTw/ score Subscales of types of relationships, stability and availability are added together to equal a total network score Total loss is the combmed quantity and quality of recent losses expienenced by the mdividual Norbeck etal (1981) reported that high levels of mtemal consistency were established for the NSSQ m its first phase of testing on graduate nursing students (« = 75) (1981) A second phase of testmg focused on validity of the NSSQ (Norbeck et al 1983) Satisfactory concurrent validity was estabhshed wth the Personal Resource Questionnaire (PRQ) developed by Brandt & Weinert (1981) Predictive validity of the NSSQ was also supported (Norbeck et al 1983) The NSSQ was found to represent moderately high stabihty over a 7-month interval Sarason's Soaal Support Questionnaire (SSSQ) was also used m this study This instrument on soaal support (Sarason et al 1983) is designed accordmg to Caplan's (1974) definition of an endunng pattem of contmuous or 790
to 'strongly disagree' All the items of the scale revolve around likmg of the self, therefore, the scale probably measures the self-acceptance aspect of self-esteem more than it does other factors A reproduability coefficient of 0 92 and a test-retest reliabihty over a 2-week penod of 0 85 have been reported (Rosenberg 1968) Convergent vahdity has been found to be satisfactory when the scale was correlated with simiW measures and clinical assessment (Rosenberg 1968)
PROCEDURE Subjects were recruited from a chapter of the Alzheimer's Disease and Related Disorders Assoaation and from the client population of a university department of family practice in a large midwestem city Informed consent was obtamed from all subjects Subjects were either personally interviewed by the researcher or they filled out the questionnaire in small groups with structured mstructions from the researcher Interviews took place m the subjects' homes, the family practice clinic, a local church and a nearby restaurant
Data analysis Data analysis was camed out in order to descnbe the sample, and descnbe rehability plus validity of instruments All multiple-item scales were added together to form total scale scores Despite nonindependence, therefore, accordmg to the Central Limit Theorem it seems reasonable to assume the distnbution of data is approximately nomial (Kerlmger 1973) Pearson Correlation was used to test the hypotheses
Adult caregtvers Table 1 Alpha coefficients (« = 31)
Instrument Assertion Inventory Discomfort Response Burden Scale Objective burden Subjective burden Norbeck SSQ Affect Affirmation Aid Function Sarason SSQ Number available Satisfaction
Table 2 Pearson correlation coefficients between the NSSQ and the SSSQ No of items
Alpha coefficients
40 40
0 96 0 93
SSQ Available SSQ Satisfaction
8 5
0 86 0 77
•p
The relationships between social skills, social support, self-esteem and burden in adult caregivers Karen Robinson DNS RN Assoaaie Professor, School of Nursing, Umverstiy of Loutsvtlle, Kenhtcky, USA
Accepted for pubhcahon 3 October 1989
ROBINSON K (1990) Journal of Advanced Nursmg 15, 788-795
The relationships between social skills, social support, self-esteem and burden in adult caregivers The purpose of this study was to explore the relationships between social skills, self-esteem, soaal support and burden in a sample of adult caregivers The Gambnll and Richey Assertion Inventory, Rosenberg's Self-Esteem Scale, Montgomery's Objective and Subjective Burden Scale, Norbeck's Social Support Queshormaire and Sarason's Soaal Support Questiormaire were administered to a convenience sample of 31 caregivers Unassertive caregivers had less available social support Those caregivers who felt more discomfort m situations also had less available social support Caregivers who had sigmficantly more affechon, affirmation and aid from within their soaal network were foimd to have higher self-esteem Those with lower self-esteem reported losing a greater number of important relationships m the past year Nonassertive caregivers were more likely to expenence lower subjective burden
CRITICAL HEALTH POLICY ISSUE
mcreased visits to the earegiver by family members and fnends Fengler & Coodnch (1979) reported that children. One of the most cnhcal health policy issues to be relatives and fnends who visited became important social addressed m the next decade is long-term care for the supports for high-morale caregivmg wives Thus, the soaal elderly (Montgomery ei al 1985) The issue of altematives network has been found to play a significant role in shess to hospitalizahon for the elderly demented viehm is of reduetion among earegivers (George & Gwyther 1986, ever-mcreasmg importance Home care has become an Gilhooly 1984, Snyder & Keefe 1985) important altemative to mshtuhonahzahon Research has Recent social support literature has focused on the eondemonstrated that when older persons need eare, family hnbuhon that individuals make to determme their own members are the pnmary earegivers Oones & Vetter 1984) social support levels (Rook 1984) Personahty characterWith growmg reeognihon of the stressful nature of eare- jstics of earegivers must be eonsidered m relahon to soaal giving, a growmg researeh arena has foeused on how best support One independent vanable that has received mueh to support the lay earegiver attenhon is soaal skills (Sarason ei al 1985) Gotbeb (1981) Soaal support is a eoneept of great importanee m the suggested that soaal sblls and personal eharactenstics mveshgahon of lay caregivmg This concept refers to inter- which predispose one to develop a soaal network are personally supportive behaviours and mdudes the givmg needed m order to develop both ties to others and form and receivmg of soaal support throughout the life course new conneehons that result m more soeial support CareZant ei al (1980) found earegivmg burden deereased with givers with better soaal skills wiU be able to enhance their Correspondence DrKaren Rohnson Assocu^te Professor School of Numng, Umverstiy
of Lomsmlk Kentucky 40192 USA 788
° ^ ^ " " ^ ^ ^ P P O ^ >" "'^"^
their caregivmg situahon
* ° " ^ ^ ^ ^ ^ " adjUShnent tO
Adult caregtvers
t
Social ^ • 1 Mobilization of skills ~ ^ 1 1 social network
Sociai support
•1
Caregiving burden
+
t Figure 1 Theorehcai conceptualization of soaal support Self-esteem
THE STUDY The present study investigated the relationships between soeial skills, self-esteem, soaal support and burden m adult caregivers The eoneepts of soeial skills, soaal support, selfesteem and burden were selected because of the study's theorehcai framework This framework, illustrated in Figure 1, IS based on Tolsdorf's (1976) conception of social support Tolsdorf theonzed that mdividuals mobilize their social networic when they can no longer deal with stress
alone If successful, these increased supportive transactions with network members result m mcreased self-esteem Individuals with mcreased sociai skills mobilize more persons in their soaal network As a result the individual receives more supportive transachons, resultmg in increased selfesteem The outcome of this mcreased social support hopefully IS decreased caregivmg burden This same framework theonzmg that scxnal skills were an important antecedent of soaal support was used to develop a social shlls trammg programme which was found to signiftcantly reduce earegivmg burden (Robinson 1988)
87% were White females (only 4 were males), and 68% were either the spouse or adult ehild of the lU older person The remaining earegivers were sisters or other relatives The majonty of earegivers were mamtammg the elder in the eommunity outside an institution Even though the elder was m a nursing home, six of the 31 earegivers were meluded m the study beeause they met the 'spendmg a sigrufteant amount of time' entenon They reported spending the greater part of eaeh day at the nursmg home and also reported earegiving tasks of bathing and feeding their loved ones Four of the earegivers (two with and two without formal trainmg) were hired earegivers who were formally unrelated to the ill person but beeame 'like family' to the patient cifter being hired as earegivers Nearly half of the earegivers (n = 13) reported having 'a very adequate ineome' (were able to pay bills regularly, having money left over), only four reported having 'difftculty paying monthly bills' The majonty (M = 20) rated their health as 'good', only two reported 'poor' health Caregivers reported spending a range of from I to 16 hours (M— 3 3) per day giving eare to their loved one and had been doing this for 2 to 7 years ( M = 2 6) This wide rcinge of hours meluded supervision of the ill f>erson as well as earegivmg tasks The majonty of earegivers reported that their patient expeneneed eonfusion, forgetfulness and wandenng Nine reported harmful behaviour
INSTRUMENTS Hypotheses In the present researeh, the following four hypotheses were tested 1
2 3 4
The eorrelations between subseales on the Norbeek Soeial Support Questionnaire (NSSQ) and the Sarason Soaal Support Questionnaire (SSSQ) will be less than r = 0 70 Soeial sblls will be positively assoeiated with social support Social support will be posihvely associated with self-esteem Social skills will be mversely assoaated with burden
Sample Thirty-one adult caregivers who were carmg for an impaired elder (age 53 to 85 years) sufifenng from an irreversible dementia were recruited The caregiver had to be spending a 'significant amoimt of time' with the impaired elder Of the 31 earegivers, 77% were age 50 and older.
Social skills The 40-item self-report assertion inventory, developed by GambnU & Riehey (1975), includes items that sample a range of situations believed to be important to family caregivers Examples of factors identifted by factor analysis mcluded mitiatmg mteractions, eonfronhng others, giving negahve feedback, responding to crihcism, turning dovm requests, and assertiveness m serviee situations For eaeh item, the earegiver was requested to mdieate (a) degree of discomfort m regcird to eaeh speeiftc situation on a 5-pomt scale ranging from (I) none to (5) very much, and (b) their likelihood of engagmg m speaftc behaviours if actually presented with the situation on a 5-point scale rangmg fi'om (1) always to (5) never The mventory has been found to have high stability of scores over time (Gambnll & Richey 1975) Validity was supported when the mventory differenhated between a clinical group seekmg asserhveness trainmg and a normal populahon The inventory also reflected signiftcant differences withm the clmical group itself before and after trammg (Gambnll & Richey 1975) 789
K Robinson
intermittent ties that play a significant part m mamtammg physical and psychological health over time The 27-item This instrument, developed by Montgomery et al (1985), SSSQ IS mtended to quantify the dimensions of perceived separates concrete events, happenings and activities of availabihty of and satisfaction with social support Subjects caregiving (l e objective measures of burden) from feel- are asked (a) to list the people to whom they can tum and ings, attitudes and emotions related to caregiving (l e sub- on whom they can rely m each given set of circumstances jective measures of burden) Objective burden is defined as cind (b) to indicate how satisfied they are with these social the extent of disruptions or changes in vanous aspects of supports Availability is computed as the number of persons the caregiver's life and household because of caregiving listed divided by the number of items The satisfaction scale (e g money, vacations, freedom, etc) Subjective burden is ranged from (1) 'very dissatisfied' to (6) 'very satisfied' defined as the respondent's attitudes toward or emotional Satisfaction is computed as the satisfaction sum divided by reactions to the caregiving expenence Objective burden is the number of items on the SSQ Past research mdicated measured by eight items and subjective burden five items that the SSSQ is a reliable instrument (Sarason et al 1983) on 5-point scales ranging from 'a lot less' to 'a lot more' Previous research has indicated reliabihty coefficients of 0 85 for both scales (Montgomery et al 1985) Subjective Self-esteem and objective burden were correlated ( r = 0 34), but shared Rosenberg's (1968) Self-Esteem Scale consists of 10 items only 12% common vanance (Montgomery et al 1985) answered on a 4-point Guttman scale from 'strongly agree' Objechve and subjective burden
Social support Two different instruments were chosen to measure social support because the hterature emphasizes the need to measure diverse vanables The NSSQ is designed to measure multiple dimensions of soaal support The Norbecketfl/ (1981,1983)concept of soaal supportis based on Kahn & Antonucci's (1982) definitions of social support and definitions from network theory The NSSQ measures perceived support available to the individual rather than reciprocal support discussed m Kahn's definition It is a global measure of soaal support and is not aimed at specific populations Subscales of affect, affirmation and aid are added together to denve a total/MndiOTw/ score Subscales of types of relationships, stability and availability are added together to equal a total network score Total loss is the combmed quantity and quality of recent losses expienenced by the mdividual Norbeck etal (1981) reported that high levels of mtemal consistency were established for the NSSQ m its first phase of testing on graduate nursing students (« = 75) (1981) A second phase of testmg focused on validity of the NSSQ (Norbeck et al 1983) Satisfactory concurrent validity was estabhshed wth the Personal Resource Questionnaire (PRQ) developed by Brandt & Weinert (1981) Predictive validity of the NSSQ was also supported (Norbeck et al 1983) The NSSQ was found to represent moderately high stabihty over a 7-month interval Sarason's Soaal Support Questionnaire (SSSQ) was also used m this study This instrument on soaal support (Sarason et al 1983) is designed accordmg to Caplan's (1974) definition of an endunng pattem of contmuous or 790
to 'strongly disagree' All the items of the scale revolve around likmg of the self, therefore, the scale probably measures the self-acceptance aspect of self-esteem more than it does other factors A reproduability coefficient of 0 92 and a test-retest reliabihty over a 2-week penod of 0 85 have been reported (Rosenberg 1968) Convergent vahdity has been found to be satisfactory when the scale was correlated with simiW measures and clinical assessment (Rosenberg 1968)
PROCEDURE Subjects were recruited from a chapter of the Alzheimer's Disease and Related Disorders Assoaation and from the client population of a university department of family practice in a large midwestem city Informed consent was obtamed from all subjects Subjects were either personally interviewed by the researcher or they filled out the questionnaire in small groups with structured mstructions from the researcher Interviews took place m the subjects' homes, the family practice clinic, a local church and a nearby restaurant
Data analysis Data analysis was camed out in order to descnbe the sample, and descnbe rehability plus validity of instruments All multiple-item scales were added together to form total scale scores Despite nonindependence, therefore, accordmg to the Central Limit Theorem it seems reasonable to assume the distnbution of data is approximately nomial (Kerlmger 1973) Pearson Correlation was used to test the hypotheses
Adult caregtvers Table 1 Alpha coefficients (« = 31)
Instrument Assertion Inventory Discomfort Response Burden Scale Objective burden Subjective burden Norbeck SSQ Affect Affirmation Aid Function Sarason SSQ Number available Satisfaction
Table 2 Pearson correlation coefficients between the NSSQ and the SSSQ No of items
Alpha coefficients
40 40
0 96 0 93
SSQ Available SSQ Satisfaction
8 5
0 86 0 77
•p
