perceptions of family conflict and socioemotional support

Transcription

INT’L. J. AGING AND HUMAN DEVELOPMENT, Vol. 49(1) 1-25, 1999
CAREGIVING AND INSTITUTIONIZATION:
PERCEPTIONS OF FAMILY CONFLICT AND
SOCIOEMOTIONAL SUPPORT*
JOSEPH E. GAUGLER
STEVEN H. ZARIT
The Pennsylvania State University, University Park
LEONARD I. PEARLIN
University of Maryland
ABSTRACT
This study examines the impact of family conflict and socioemotional
support among caregivers who institutionize their relatives. Fifty-two wives,
forty-three husbands, and sixty-seven daughters were interviewed before and
after the placement of a cognitively impaired relative. A repeated measures
ANOVA was performed to examine differences in reports of family conflict
and socioemotional support among caregivers. Husbands reported greater
increases in family conflict than wives or daughters during the
institutionization process. Conversely, wives and daughters indicated higher
levels of socioemotional support than husbands. Hierarchical regression
equations were then calculated to assess the independent contributions of
family conflict and socioemotional support to postplacement adaptation.
Decreases in socioemotional support during institutionalization significantly
predicted postplacement anger among husbands and increases in family
conflict significantly predicted postplacement depression among wives.
Overall, family conflict and socioemotional support have important
implications among caregivers who institutionalize their relatives.
*This study was partially supported by a National Science Foundation Graduate Research
Fellowship to the first author and a National Institute of Mental Health MERIT award (MH-42122) to
the third author.
1
© 1999, Baywood Publishing Co., Inc.
2 / GAUGLER, ZARIT AND PEARLIN
Placing a cognitively impaired relative in a nursing home can have a profound
influence on caregivers’ family relations. Disruptions may occur among the primary caregiver, the care recipient, and other family members who may support
or disagree with the placement decision. Some people may experience a sense of
communal guilt following institutionalization, which lead them to act defensively rather than in a supportive and understanding manner toward the primary
caregiver. The potentially stressful transition of nursing home placement may
leave the organization, support structure, and functioning of the family in disarray (Aneshensel, Pearlin, Mullan, Zarit, & Whitlatch, 1995).
The present study examines perceptions of family conflict and socioemotional
support among family caregivers who institutionalize elderly relatives suffering
from Alzheimer’s disease and related disorders. Family conflict refers to interpersonal struggles or the outright hostility caregivers experience with siblings,
spouses, or other family members outside of the caregiver-care recipient dyad
(Semple, 1992). Socioemotional support represents the caring or concern caregivers receive from friends and family members (Thompson, Futterman,
Gallagher-Thompson, Rose, & Lovett, 1993). Viewed as the cornerstone of
social support, socioemotional support is characterized by understanding,
empathy, trust, and reassurance (Krause, 1987).
This study was designed to answer several research questions. First, do caregivers’ perceptions of family conflict increase and socioemotional support
decrease following the placement of a cognitively impaired relative? Second,
do changes in family conflict and socioemotional support influence caregivers’
postplacement adaptation (i.e., anger and depression)? Prior research has emphasized the relation of family conflict and socioemotional support to negative mental health outcomes (Aneshensel et al., 1995; Pearlin, Mullan, Semple, & Skaff,
1990), but few studies have examined how changes in family conflict
and socioemotional support influence postplacement adaptation. Third, does kin
relationship between caregiver and care recipient (i.e., wives, husbands, and
daughters) affect perceptions of family conflict and socioemotional support during the nursing home transition? Previous research has suggested that wives,
husbands, and daughters approach care situations in intriguing ways
(Anthony-Bergstone, Zarit, & Gatz, 1988; Cantor, 1983). Women tend to have
more socioemotional support than men and may have less difficulty with the
placement decision, while men are more isolated from their network and may
experience a less successful adaptation to placement (Antonucci, 1994; Sarason,
Sarason, & Shearin, 1986).
CONCEPTUAL MODEL
Most caregiving research utilizing community-based samples has drawn
upon models from the study of stress in the family (Pearlin et al., 1990). In
these models, the relation between primary stressors and outcomes are seen as
CAREGIVING AND INSTITUTIONALIZATION / 3
influenced by a number of contextual and intervening variables. Primary
stressors may be objective or subjective in nature. Primary objective stressors
represent the various cognitive, physical, and behavioral deficiencies that are
exhibited by a care recipient during the course of dementia. Primary subjective
stressors refer to the emotional drain of caring for an older relative suffering
from dementia; for example, caregivers may experience emotional fatigue or a
sense of “being trapped” involving their care responsibilities. Primary objective
and subjective stressors have been linked to negative mental health outcomes
among caregivers, such as anger and depression (Aneshensel et al., 1995).
Several intervening and contextual variables have also been shown to play an
important role in the prediction of negative health outcomes among caregivers.
Contextual variables such as income, marital status, length of time providing
care, and gender of the caregiver potentially influence individuals’ adaptation
to the care process (Aneshensel et al., 1995; Cantor, 1983). In addition, socioemotional support and family conflict have been among the intervening variables called to attention in recent caregiving research. In these models,
socioemotional support and family conflict are seen as constructs that may have
direct or moderating effects on various outcomes. Studies of the caregiving process have reported that emotional support moderates the effects of stressors (Li,
Seltzer, & Greenberg, 1997; Thompson et al., 1993). Additional caregiving
research has shown that interpersonal struggles and disagreements with family
members are predictive of anger and depression (Semple, 1992). In sum, conflict
is more than the absence of support; both conflict and support can be present in
the same family and may contribute differently to the caregiver’s adaptation
over time.
REVIEWING THE LITERATURE:
CAREGIVING AND INSTITUTIONALIZATION
While models of family stress have been applied to community-based samples
of caregivers, fewer studies have examined the stress process among caregivers
who institutionalize their elderly relatives suffering from dementia. Placement is
a major turning point in the lives of caregivers, and while immediate responsibility for care of the elder has been taken away, caregivers experience a variety
of new stressors (Mackenzie & Maclean, 1992; Rosenthal, Sulman, & Marshall,
1992; Zarit, Anthony, & Bouselis, 1987). Individuals gain relief from caring for
the physical needs of the relative, which include toileting, dressing, feeding,
and other such activities. However, “nontechnical,” or emotional and psychosocial care, is often continued by caregivers and other family members after the
institutionalization of a relative (Bowers, 1988; Dobrof, 1981). The persistence
of stress and burden has important and complex implications for caregivers
after placement (Colerick & George, 1986; Zarit, Todd, & Zarit, 1986; Zarit &
Whitlatch, 1992).
Little research has examined patterns of family conflict and socioemotional
support among caregivers who institutionalize their relatives, and these studies
have yielded conflicting results. Studies analyzing the involvement of family
members with nursing home residents have found that family visitation diminishes in quality after placement (York & Calsyn, 1977). In addition, when a
debilitated relative is an acute care hospital waiting for placement in a long-term
care facility, family relationships may experience heightened tension (Rosenthal
et al., 1992). Caregivers who institutionalize elderly relatives also report a loss
of social support after placement (Colerick & George, 1986; Zarit & Whitlatch,
1992). While diminished levels of social support may represent either a dissipation in caregivers’ social networks or a continuation of low levels of support,
caregivers who remain isolated after the institutionalization of a relative constitute an important problem (Zarit & Whitlatch, 1992). Other research, however,
has shown that the impact of institutionalization may help relieve the strains of
physical care placed on family members, leading to enhanced family solidarity
(Bowers, 1988; Smith & Bengtson, 1979). Similar studies have found that nursing home care policies which are oriented toward including the family as a “client” (or, meeting the support needs of the family) as opposed to a “servant”
(neglecting the family’s need for support) are more successful in enhancing family integration (Montgomery, 1982).
Two factors account for the conflicting results found in past research. First,
previous studies have not incorporated the numerous stressors involved in the
caregiving process when examining the influence of family conflict and
socioemotional support during the nursing home transition. The present study
will examine background characteristics, primary objective stressors, and
primary subjective stressors in conjunction with conflict and support variables to
determine the independent contributions of family conflict and socioemotional
support to postplacement adaptation. Another reason for contradictory findings
in past research may be due to examining caregivers as a unitary population.
Adult child and spousal caregivers have different obligations and life course
positions (Anthony-Bergstone et al., 1988; Cantor, 1983; Harper & Lund, 1990).
While wives, husbands, and daughters (i.e., the groups who comprise the largest
number of caregivers) may all experience family conflict surrounding
institutionalization, the family pressure placed on these caregivers may vary. For
example, daughters may experience conflict pertaining to institutionalization if
family members criticize the timing of placement and/or choice of institution, or
if family members believe not enough was done to keep the relative at home.
Spouses, in turn, may have difficulty letting go of their partner and may receive
pressure from children and other family members to hurry the placement
decision along. Furthermore, wives, husbands, and daughters may have different
perceptions of socioemotional support during the institutionalization process.
Husbands may have less support to begin with, while wives would be in an
intermediate position, drawing more support than husbands but less than
daughters who have a fuller support network (Antonucci, 1994; Carstensen,
1992; Sarason et al., 1986). This study will examine the different perceptions of
conflict and support experienced by wives, husbands, and daughters during the
nursing home transition.
METHODS
Procedure
The present study is based on data from the Caregiver Stress and Coping
Study (Aneshensel et al., 1995). Potential participants were identified through
local Alzheimer’s Disease and Related Disorders Associations (ADRDA) in the
San Francisco and greater Los Angeles areas and through the Family Caregiver
Alliance in the San Francisco area. Participants were contacted through telephone screenings to determine whether or not an individual met the criteria of
the study and was willing to participate. Eligibility was defined as individuals
who were considered “primary caregivers” (i.e., the one member of the family
who spends the greatest amount of time caring for his/her relative) of a noninstitutionalized spouse, parent, or parent-in-law suffering from dementia.
Five hundred and fifty-five caregivers, all of whom were caring for their relatives at home, were interviewed at Time 1. In order to study the transition to
institutionalization a “synthetic cohort” was constructed. Wives, husbands, and
daughters who institutionalized their relatives during the first three years of
the study were identified. Interviews conducted immediately prior to and after
the placement of a relative were used to provide comparable pre- and postplacement information on each participant. The resulting sample was comprised
of fifty-two wives, forty-three husbands, and sixty-seven daughters. Figure 1
documents the construction of the synthetic cohort.
Sample
At the preplacement interviews, mean ages were 69.23 (SD = 7.91), 72.49
(SD = 9.15), and 50.21 (SD = 9.56) years for wives, husbands, and daughters,
respectively. Before institutionalization, the average age of relatives suffering
from dementia was 75.08 years (n = 162, SD = 8.40). Of the 162 cognitively
impaired relatives, there were 102 women (43 wives, 59 mothers) and sixty men
(52 husbands, 8 fathers). All husbands and wives were married to their spouses
during the study. Among daughters, forty-three were married, eleven were
divorced or separated, nine were widowed, and four had never married. Also, as
shown in Table 1, the overall sample of caregivers was predominately white
(n = 138). However, several other ethnic groups were represented in the sample,
including thirteen African Americans, seven Hispanics, and four caregivers who
classified themselves as “Asian-American” or “Other.” At preplacement, wives
reported that their relatives had exhibited dementia symptoms for an average of
Figure 1. Constructing the synthetic cohort.
6.28 years (SD = 4.20), while husbands and daughters indicated an average of
5.96 (SD = 5.02) and 5.64 (SD = 3.66) years, respectively. Wives, husbands, and
daughters first began caring for their relatives an average of 3.06 (SD = 1.80),
3.38 (SD = 2.02), and 3.44 (SD = 2.22) years before the preplacement interview,
respectively. Relatives had been residing in nursing homes an average of 5.74
(SD = 3.83) months at the time of postplacement interviews. Table 1 displays
other preplacement characteristics of caregivers which may potentially impact
postplacement adaptation.
Measures
In addition to background characteristics, participants were assessed on measures of family conflict, socioemotional support, primary objective stressors, primary subjective stressors, and negative mental health outcomes.
Family Conflict
Family conflict refers to tension, interpersonal struggles, or outright hostility
among caregivers and other family members outside of the caregiver-care
Table 1. Caregiver Characteristics at Preplacement (N = 162)
Relationship to Care Recipient
Caregiver Characteristics
Wives
Husbands
Daughters
Race of caregiver
Non-Hispanic white
African American
Hispanic
Asian American and other
46 (88%)
1 (2%)
4 (8%)
1 (2%)
35 (81%)
5 (12%)
1 (2%)
2 (5%)
57 (85%)
7 (11%)
2 (3%)
1 (1%)
Education of caregiver
Less than high school
High school
Some college
College or more
8 (15%)
11 (19%)
17 (35%)
16 (31%)
8 (19%)
8 (19%)
11 (25%)
16 (37%)
5 (7%)
11 (17%)
27 (40%)
24 (36%)
Religion of caregiver
Protestant
Roman Catholic
Jewish
Other
None
21 (40%)
9 (17%)
14 (27%)
4 (8%)
4 (8%)
17 (41%)
11 (25%)
7 (15%)
4 (12%)
3 (7%)
31 (46%)
15 (23%)
5 (7%)
8 (12%)
8 (12%)
Income of caregiver
Less than $20,000 a year
$20,000 to $50,000 a year
More than $50,000 a year
Not available
17 (33%)
23 (44%)
8 (15%)
4 (8%)
12 (28%)
22 (51%)
7 (16%)
2 (5%)
14 (21%)
28 (42%)
23 (34%)
2 (3%)
Employment status
Employed
Not employed
6 (12%)
46 (88%)
5 (12%)
38 (88%)
25 (37%)
42 (63%)
Health of caregiver
Poor
Fair
Good
Excellent
Not available
1 (2%)
14 (27%)
25 (48%)
11 (21%)
1 (2%)
0 (0%)
8 (19%)
25 (58%)
10 (23%)
0 (0%)
3 (5%)
7 (10%)
36 (54%)
20 (30%)
1 (1%)
recipient dyad (Semple, 1992). An eight-item scale was used to measure family
conflict among caregivers who institutionalize their relatives. Caregivers were
asked how much disagreement they had with other family members over
particular care issues. Caregivers responded to these items according to a 4-point
scale, with responses ranging from “no disagreement” (0) to “quite a bit” (3). A
family conflict score was obtained by summing the responses and taking the
mean item score. The family conflict scale showed good reliability when an
alpha coefficient was calculated for the entire sample (preplacement a = .90).
Socioemotional Support
Socioemotional support is defined as affective assistance provided by relatives or friends of the caregiver. For this study, socioemotional support was measured by a six-point scale which gauges the amount of connection caregivers
feel toward their social networks. Participants responded on a 4-point scale, with
responses ranging from “strongly agree” (4) to “strongly disagree” (1). For one
item (“there is no one who understands what you are going through”) the scoring was reversed to match the other items in the scale. A socioemotional support
score was created by summing the responses and taking the mean item score.
The reliability for this scale was good when an alpha coefficient was calculated
for the entire sample (preplacement a = .81).
Primary Objective Stressors
As dementia progresses, elderly relatives may exhibit a number of physical,
emotional, and behavioral problems which require assistance from family caregivers. Consequently, these increased demands for help may result in caregiver
stress. Three primary objective stressors were measured in this study. Problematic behavior represents the troublesome and disruptive behavior that may occur
as a result of the relative’s dementia (Teri et al., 1992). A fourteen-item scale
gauging how often care recipients exhibit behavior problems in the past week
was used for the current analysis (preplacement a = .81). Responses ranged
from “no days” (1) to “5 or more days” (4). Cognitive impairment refers to the
range and difficulty of relatives’ memory loss, communication deficits, and recognition failures (Aneshensel et al., 1995). A seven item-scale which measures
the severity of impairment among relatives was included (preplacement a =
.82). Responses ranged from “not at all difficult” (0) to “can’t do at all” (5).
Activities of daily living dependencies (ADLs) represent the amount of assistance
elderly relatives require for basic tasks (Aneshensel et al., 1995). Caregivers
were asked how much care recipients relied on them to complete fifteen basic
tasks. Responses ranged from “not at all” (0) to “completely” (4). Reliability for
the ADL scale was good when an alpha coefficient was calculated for the entire
sample (preplacement a = .87). Scale scores for primary objective stressors were
created by summing the responses and taking the mean item scores.
Primary Subjective Stressors
Two dimensions which represent subjective caregiving stress were included in
the present study. Role captivity focuses on the involuntary aspects of caregiving:
individuals are obliged to do one thing (care for a debilitated relative) when they
would rather do something else (Aneshensel et al., 1995). A four-item scale
assessing the unwanted aspects of the caregiving role was included (preplacement
a = .79). Ratings were made on a 4-point scale that ranged from “not at all” (1) to
“very much” (4). Role overload occurs when individuals feel overwhelmed and
worn-out by caregiving responsibilities. A three-item scale was utilized to measure caregivers’ feeling of emotional and physical fatigue (preplacement a = .74).
The response categories ranged from “not at all” (1) to “completely” (4). Scores
for the role captivity and role overload scales were created by summing responses
and taking the mean item scores.
Negative Mental Health Outcomes
The burdens associated with the care of a cognitively impaired older adult may
result in several negative mental health outcomes (Pearlin et al., 1990). Two negative mental health outcomes were measured in the current study. Depression items
cover feelings of hopelessness, loss of appetite and energy, boredom, depressed
mood, loneliness, and other indicators of depressive symptomatology. Depression
was measured on a seven-item scale derived from the Hopkins Symptom Checklist (Derogatis, Covi, Lipman, & Rickels, 1971). Caregivers were asked how often
symptoms of depression have occurred in the last week and responded on a
4-point scale, with four representing “5 or more days,” three referring to “3 or 4
days,” two representing “1 or 2 days,” and one referring to “no days”
(preplacement a = .85). Anger was derived from the Hopkins Symptoms Checklist as a four-item scale (Derogatis et al., 1971). Items cover feelings of irritability,
annoyance, and impatience (preplacement a = .76). Caregivers were asked how
often these feelings have occurred in the last week, with responses ranging from
“not at all” (1) to “very much” (4). Scores for depression and anger were created
by summing the responses and taking the mean item scores.
Analysis
Data analysis proceeded in four steps. First, exploratory factor analyses were
performed on the family conflict and the socioemotional support scales to determine the underlying structure of the measures. Second, means were calculated
for primary stressors, negative mental health outcomes, and conflict and support
variables. Third, repeated measures ANOVAs were performed to examine the
changes in family conflict and socioemotional support reported by wives, husbands, and daughters prior to and following institutionalization. Finally, hierarchical regressions were calculated to determine the contributions of family conflict and socioemotional support to postplacement anger and depression.
In the following hierarchical regressions, family conflict, socioemotional support, primary objective stressors, primary subjective stressors, and background
characteristics served as the independent variables. The dependent variables
were posplacement reports of anger and depression. The order of variable entry
was as follows. All of the demographic variables outlined in the Sample section
and in Table 1 were taken into account in subsequent analyses. Specifically, the
demographic variables’ relationship with anger and depression were assessed. If
any of the demographic variables were found to correlate significantly with
postplacement anger and/or depression, they were included as the first “block”
of variables in the hierarchical regression analyses. Preplacement covariates
(anger/depression, family conflict, and socioemotional support) were entered
second, preplacement primary objective stressors were entered in the third
block, and preplacement primary subjective stressors were entered fourth.
Residualized gain scores for socioemotional support and family conflict comprised the final block entered. Residualized gain scores test the stability, or “rank
order” of variables as time progresses. This is done by regressing the time 2
variable onto the time 1 variable for each individual. The subsequent “residuals”
from these regression equations are then used as predictors in their own right.
Even though they are used frequently, residualized gain scores have been shown
to be ineffective when high-rank order stability over time is accompanied by
change (Stoolmiller & Bank, 1996). However, when individual differences in
change are small, residualized gain scores can be useful in the interpretation of
change (Stoolmiller & Bank, 1996). As shown below, preplacement conflict and
support differed slightly from postplacement measures. Therefore, residualized
gain scores were appropriate for inclusion in the regression equations.
RESULTS
Factor Analyses of Family Conflict and
Socioemotional Support Measures
Family Conflict
An exploratory factor analysis was conducted on the family conflict scale
and the principal axes factor method was used to extract the factors. The
results pointed to only one factor. The eigenvalue for factor 1 was 5.32, the
eigenvalue for factor 2 was .40, and the remaining eigenvalues were similarly
low. The proportion of variance accounted for by the first factor was 93 percent,
while the next closest factor accounted for 7 percent of the variance. The
unrotated factor loadings for the family conflict scale are shown in Table 2. All
items had factor loadings above .30 and were retained for subsequent analyses
(Gorsuch, 1983).
Table 2. Unrotated Factor Loadings for Family Conflict and
Socioemotional Support Scales
Items
Factor
Loading
Family Conflict
They don’t give you enough help
They don’t do their share in caring for your relative
They don’t spend enough time with your relative
They don’t show enough appreciation for your work as a caregiver
They don’t show enough respect for your relative
They don’t visit or telephone you (caregiver) enough
They lack patience with your relative
They give you unwanted advice
.93
.89
.87
.84
.78
.78
.71
.65
You have people around you that help keep your spirits up
There are people in your life that make you feel good about yourself
You have a friend or relative in whose opinions you have confidence
You have someone you feel that you can trust
The people close to you let you know that they care about you
There is really no one who understands what you are going through
.76
.73
.63
.63
.61
.32
The six-item socioemotional support scale was also subjected to an exploratory factor analysis. The principal axes factor method suggested only one meaningful factor. Factor 1 had an eigenvalue of 2.38. The eigenvalue for factor 2
was .25, and the remaining eigenvalues were similarly low. The first factor had a
proportion value of 1.13, while the next largest factor recorded a .11 proportion
value. As the factor pattern in Table 2 indicates, all items loaded onto a single
factor.
Levels of Conflict and Support Prior To
and Following Placement
Means and standard deviations were calculated for conflict and support variables, preplacement stressors, and negative mental health outcomes. Means and
standard deviations for all scales are reported in Table 3. In general, wives and
husbands reported relatively little family conflict at preplacement (M = .63 and
M = .47 respectively) and postplacement (M = .79 and M = .89, respectively).
Daughters experienced slightly higher levels of family conflict prior to and
after the placement of a relative (M = 1.02 and M = 1.06, respectively). Wives,
Table 3. Means and Standard Deviations for Scales
Wives
Husbands
Daughters
M
SD
M
SD
M
SD
Preplacement
Family conflict
Socioemotional support
Anger
Depression
Cognitive impairment
Problematic behavior
ADL dependencies
Role overload
Role captivity
.63
3.31
1.64
2.08
2.37
2.04
3.08
2.87
2.81
.78
.49
.67
.79
.77
.62
.61
.82
.90
.47
3.24
1.59
1.79
2.44
1.96
3.22
2.40
2.50
.82
.42
.57
.71
.87
.59
.74
.94
.99
1.02
3.42
1.65
1.95
2.34
2.03
2.89
2.80
3.00
1.00
.46
.59
.75
.77
.58
.89
.90
.88
Postplacement
Family conflict
Anger
Depression
.79
3.44
1.39
2.12
.83
.50
.61
.82
.89
3.17
1.36
1.81
.89
.47
.53
.68
1.06
3.44
1.55
1.86
.89
.44
.60
.74
Variables
husbands, and daughters all reported high levels of socioemotional support at
preplacement (M = 3.31, M = 3.24, and M = 3.42, respectively) and
postplacement (M = 3.44, M = 3.17, and M = 3.44, respectively.)
Wives, husbands, and daughters experienced moderate levels of anger and
depression during the nursing home transition. Wives indicated slightly higher
feelings of depression at preplacement (M = 2.08) than either husbands or
daughters (M = 1.79, M = 1.95, respectively). The same trend occurred for
postplacement reports of depression (M = 2.12, M = 1.81, M = 1.86 for wives,
husbands, and daughters, respectively). Levels of anger were similar for caregivers at preplacement (M = 1.64, M = 1.59, M = 1.65, for wives, husbands, and
daughters, respectively) and declined by postplacement (M = 1.39, M = 1.36, M
= 1.55 for wives, husbands, and daughters, respectively).
Wives, husbands, and daughters all experienced noticeable amounts of
preplacement stress. Reports of care recipients’ cognitive impairment (M = 2.37,
M = 2.44, M = 2.34 for wives, husbands, and daughters, respectively), behavior
problems (M = 2.04, M = 1.96, M = 2.03 for wives, husbands, and daughters,
respectively) and ADL dependencies (M = 3.08, M = 3.22, M = 2.89 for wives,
husbands, and daughters, respectively) were relatively similar. Daughters
experienced slightly more role captivity (M = 3.00) than wives or husbands
Figure 2. Family conflict means plotted prior to and after placement.
(M = 2.81, M = 2.50, respectively), while wives and daughters indicated greater
role overload (M = 2.87, M = 2.80) than husbands (M = 2.40).
Due to the positive and negative skewness of the conflict and support variables, transformations were performed to normalize the data for subsequent
analyses. A square root transformation was used for the family conflict variable,
and the socioemotional support variable was squared.
Family Conflict, Socioemotional Support, and
Kin Relationships Over Time
Differences among wives, husbands, and daughters on perceptions of family
conflict were analyzed using a two-way ANOVA with repeated measures on one
factor. The TIME (preplacement-postplacement) main effect and the GROUP
(wives, husbands, and daughters) ö TIME interaction were significant, F(1,159)
= 12.17, p < .001; F(2,158) = 3.37, p < .05, respectively. Post-hoc contrasts
showed that husbands’ increase in family conflict across preplacement and
postplacement was significant, F(1,159) = 6.14, p < .05. Post-hoc comparisons
also indicated that daughters reported higher preplacement family conflict than
wives or husbands, and husbands indicated significantly lower conflict than
daughters or wives, F(1,159) = 14.58, p < .001; F(1,159) = 8.28, p < .01, respectively. Figure 2 plots the means for husbands’, wives’, and daughters’ reports of
conflict prior to and following institutionalization.
Differences in reports of socioemotional support were also examined using a
two-way ANOVA with repeated measures on one-factor. Main effects showed
that wives, husbands, and daughters varied in their reports of socioemotional
support at postplacement, F(2,159) = 4.72, p < .05. Neither the TIME main
effect nor the GROUP ö TIME interaction were significant, F(1,160) = .82, p =
.37; F(2,159) = 1.58, p = .21, respectively. Post-hoc comparisons indicated that
husbands reported significantly lower socioemotional support at postplacement
than wives or daughters, F(1,160) = 9.38, p < .001. Also, wives indicated significant increases in socioemotional support during institutionalization, F(1,160) =
3.11, p = .05. Figure 3 plots wives’, husbands’, and daughters’ mean levels of
socioemotional support prior to and after placement.
Figure 3. Socioemotional support means plotted prior to and after placement.
Predictors of Postplacement Adaptation
The method of variable entry used for the regression equations was a conservative approach; we examined family conflict and socioemotional
support after the effect of other important variables had been considered.
Because the previous analyses found differences among caregivers on reports
of family conflict and socioemotional support, regression equations were
calculated sequentially for wives, husbands, and daughters on each dependent
variable.
Wives
As shown in Table 4, no background variable accounted for postplacement
anger among wives. The addition of preplacement covariates accounted for
39 percent of the variance in postplacement anger, F(3,48) = 10.18, p < .001.
The entry of primary objective stressors accounted for an additional 1 percent
of the variance, F(6,45) = 4.99, p < .001. Primary subjective stressors increased
the variance accounted for to 42 percent, F(8,43) = 3.84, p < .01. Residualized
gain scores for family conflict and socioemotional support accounted for an
additional 2 percent of the variance in postplacement anger, F(10,41) = 3.22,
p < .01. Changes in family conflict and socioemotional support during the
institutionalization process did not reliably predict postplacement anger among
wives.
Turning to postplacement depression, duration of symptomatology accounted
for 8 percent of the variance, F(1,49) = 4.13, p < .05. Wives who indicated a
shorter duration of dementia symptomatology in their spouses reported higher
levels of postplacement depression (B = –.06), SE = .03, p < .05). Preplacement
covariates increased the variance accounted for to 43 percent, F(4,46) = 8.73,
p < .001. The entry of primary subjective stressors accounted for an additional 10 percent of the variance, F(7,43) = 4.78, p < .001. Wives who
reported fewer behavior problems in their spouses at preplacement experienced higher levels of postplacement depression (B = –.35, SE = .15, p < .05).
Primary subjective stressors did not increase the variance accounted for in
postplacement depression, F(9,41) = 5.05, p < .001. The residualized gain scores
for family conflict and socioemotional support accounted for an additional
9 percent of the variance, F(11,39) = 5.83, p < .001. Change in family
conflict was found to significantly predict postplacement depression (B = .70,
SE = .22, p < .005). Wives were more likely to report postplacement depression
if they experienced an increase in family conflict during the
institutionalization process.
Husbands
In examining postplacement anger, education accounted for 12 percent of the
variance, F(1,39) = 5.08, p < .05. Husbands who were less educated reported
Table 4. Predictors of Postplacement Adaptation for Wives
Predictor
Anger
Step 1 (preplacement covariates)
Anger
Family conflict
R2
F
df
.39
10.18***
3, 48
Step 2 (preplacement objective stressors)
ADL dependencies
.40
Step 3 (preplacement subjective stressors)
Role overload
Role captivity
.42
Step 4 (residualized gain scores)
Family conflict
.44
Depression
Step 1 (background characteristics)
Duration of symptomatology
4.99***
B
SE
.57**
*
–.02
–.01
.12
.14
.02
6, 45
.06
–.10
–.05
3.84**
8, 43
.05
–.10
3.22**
4.13*
.09
.09
10, 41
–.20
–.02
.08
.13
.12
.16
.19
.02
1, 49
.03
–.06*
Depression
Family conflict
.43
ADL dependencies
.53
Role overload
Role captivity
.53
Family conflict
.62
8.73***
4, 46
.58**
4.78***
5.05***
*
–.08
7, 43 –.05
–.14
–.35*
9, 41 –.07
.16
.15
.20
.12
.12
.03
5.83*** 11, 39 –.01
.22
.03
.70**
–.04
*p < .05
**p < .01
***p < .001
.13
.19
.03
Table 5. Predictors of Postplacement Adaptation for Husbands
Predictor
R2
F
df
Anger
.12
5.09*
1, 39
Anger
Family conflict
.42
ADL dependencies
.43
Role overload
Role captivity
.51
Family conflict
.57
Depression
Depression
Family conflict
6.49***
B
SE
–.09*
.04
4, 36
.48**
*
.09
–.02
3.62**
7, 33
–.03
–.09
.08
3.58**
12.72***
.53
Role overload
Role captivity
.55
Family conflict
.57
6.29***
4.81***
*
–.01
6, 34 –.01
–.10
–.10
8, 32 –.05
.11
.15
.03
.12
.15
.13
.12
.10
4.01**
–.01
10, 30 –.12
.16
.03
.01
–.04
*p < .05
**p < .01
***p < .001
.13
.03
3, 37
.66**
ADL dependencies
.09
.09
11, 29
–.02
–.05
.50
.10
.14
.12
9, 31
–.12
.16
3.54**
.13
.14
.02
higher postplacement anger (B = –.09, SE = .04, p < .05) (Table 5).
Preplacement covariates accounted for an additional 30 percent of the variance
in postplacement anger among husbands, F(4,36) = 6.49, p < .001. The entry
of primary objective and subjective stressors accounted for an additional
1 percent and 8 percent of the variance, F(7,33) = 3.62, p < .01; F(9,31) = 3.58,
p < .01, respectively. Residualized gain scores for socioemotional support
and family conflict increased the variance accounted for to 57 percent,
F(11,29) = 3.54, p < .01. The residualized gain score for socioemotional support
was found to significantly predict postplacement anger (B = –.05, SE = .03,
p < .05). Husbands were more likely to report postplacement anger if they
received decreasing amounts of socioemotional support during the nursing
home transition.
No background variables correlated with postplacement depression among
husbands. The addition of preplacement covariates accounted for 50 percent of
the variance in postplacement depression, F(3,37) = 12.72, p < .001. The entry
of primary objective stressors accounted for an additional 3 percent of the variance, F(6,34) = 6.29, p < .001. Primary subjective stressors increased the variance accounted for to 55 percent, F(8,32) = 4.81, p < .001. Residualized gain
scores for socioemotional support and family conflict accounted for an additional 2 percent of the variance in postplacement depression, F(10,30) = 4.01, p
< .01. The residualized gain scores for family conflict and socioemotional support did not reliably predict postplacement depression among husbands.
Daughters
Of the three background characteristics which significantly correlated with
postplacement anger, duration of care was the only variable which reliably predicted postplacement anger, F(3,63) = 3.79, p < .05, (R2 = .15, see Table 6).
Daughters who spent less time in the caregiving role were more likely to experience postplacement anger (B = –.06, SE = .03, p < .05). Preplacement covariates
accounted for an additional 22 percent of the variance in postplacement anger
among daughters, F(6,60) = 5.77, p < .001. Primary objective stressors increased
the variance accounted for to 40 percent, F(9,57) = 4.25, p < .001. The entry
of primary subjective stressors accounted for an additional 1 percent of the variance, F(11,55) = 3.51, p < .001. Residualized gain scores for socioemotional
support and family conflict did not increase the variance accounted for in
postplacement anger, F(13,53) = 2.87, p < .01.
Among the background variables associated with depression, age of the relative, employment status, and duration of symptomatology were found to reliably
predict postplacement depression among daughters, and accounted for 26 percent of the variance, F(4,60) = 5.25, p < .001). Daughters who cared for younger
relatives, were unemployed, and reported a shorter duration of dementia
symptomatology in their relatives were more likely to experience postplacement
Table 6. Predictors of Postplacement Adaptation for Daughters
Predictor
R2
Anger
.15
Age of relative
Duration of care
Race (0 = Caucasian, 1 = non-Caucasian)
Anger
Family conflict
.37
ADL dependencies
.40
Role overload
Role captivity
.41
Family conflict
.41
Depression
Age of relative
Employment status
(0 = unemployed, 1 = employed)
Duration of symptomatology
.26
Depression
Family conflict
.40
ADL dependencies
.41
Role overload
Role captivity
.45
Family conflict
.46
*p < .05
**p < .01
***p < .001
F
3.79*
5.77***
4.25***
3.51***
2.87**
5.25***
5.46***
3.70***
3.61***
2.98**
df
B
SE
–.02
– .06*
.13
.01
.03
.12
.52***
–.01
–.01
.12
.12
.02
–.01
.05
–.12
.10
.12
.08
.04
–.08
.09
.08
–.01
–.01
.16
.02
–.04**
–.03
–.43*
.01
.05
.17
–.04*
.02
.41**
.12
–.01
.12
.15
.03
.05
–.06
–.05
.13
.15
10
.25*
–.05
.12
.11
.03
.01
.20
.03
3, 63
6, 60
9, 57
11, 55
13, 53
4, 50
7, 57
10, 54
12, 52
14, 50
depression (B = –.04, SE = .01, p < .001; B = –.43, SE = .17, p < .05; B = –.04,
SE = .02, p = .06, respectively). Preplacement covariates increased the variance
accounted for in postplacement depression to 40 percent, F(7,57) = 5.40,
p < .001. The entry of primary objective stressors accounted for an additional
1 percent of the variance, F(10,54) = 3.70, p < .001. Primary subjective stressors
increased the variance accounted for to 45 percent, F(12,52) = 3.61, p < .001.
Daughters who reported higher levels of role overload at preplacement experienced greater feelings of postplacement depression (B = .25, SE = .12, p < .05).
Residualized gain scores for socioemotional support and family conflict
increased the variance accounted for in postplacement depression by 1 percent,
F(14,50) = 2.98, p < .001. Family conflict and socioemotional support did not
reliably predict postplacement depression for daughters.
DISCUSSION
The purpose of this study was to examine family conflict and socioemotional
support among wives, husbands, and daughters who institutionalize their relatives. This study found, overall, that rate of conflict was low and perceived support high. Nonetheless, conflict and support played a significant role in the nursing home transition, with wives, husbands, and daughters reporting varying
patterns of change in family conflict and socioemotional support as well as different predictors of postplacement adaptation.
The finding of low family conflict and high socioemotional support is consistent with previous caregiving research (Malonebeach & Zarit, 1995; Suitor &
Pillemer, 1988). More interesting were the differences in conflict and support
due to relationship throughout the placement transition. Daughters reported
the highest amount of conflict at preplacement but only a slight increase
following institutionalization. Wives reported lower levels of preplacement
conflict than daughters and, like daughters, experienced only a slight increase in
family conflict after institutionalization. Husbands, however, experienced a
significant increase in family conflict during the nursing home transition. Also,
while wives and daughters had high levels of socioemotional support throughout
the institutionalization process, husbands reported consistently lower levels of
support.
These differences in family conflict and socioemotional support among wives,
husbands, and daughters are somewhat paradoxical. While caregivers who are
women are expected to provide care within the family and might therefore
encounter more resistance to placement (Cantor, 1994; Jutras & Veilleux, 1991),
they receive high levels of emotional support and report little conflict during the
placement transition. Conversely, intensive family care is non-normative among
husbands, yet they experience increased conflict and decreased socioemotional
support during institutionalization. There are several explanations for these
findings. Prior to the nursing home transition, women may see themselves or be
perceived by their family as having fulfilled their normative obligation to provide family care. At this point, family members and friends may support the
decision to place and offer increased amounts of affective assistance to wives
and daughters throughout the institutionalization process. However, because
family caregiving is non-normative and not socially prescribed for men, they
experience heightened scrutiny and greater disapproval from family members
and friends when they place their wives. In addition, husbands may be more
unsure of their capability as caregivers and feel that institutionalizing their
wives is akin to “giving up.” If institutionalization is seen as a failure
among husbands, they may be more likely to perceive criticism from family
members. Whatever the reason, what seems timely and appropriate to families
and friends of women caregivers (i.e., institutionalization) does not appear so
for husbands.
We also sought to determine the contributions of family conflict and socioemotional support to postplacement adaptation while controlling for the potential effects of background variables, primary objective stressors, and primary
subjective stressors. An analysis of significant background variables and primary stressors (e.g., indicating a shorter duration of symptomatology in care
recipients, helping a relative for a shorter period of time, caring for a younger
relative, and reporting fewer problematic behaviors) found that, in general, caregivers who did not have time to cope with a relative’s illness and were forced to
make an early placement decision were less likely to adapt to institutionalization. In addition, daughters who were not employed were more likely to
report higher levels of postplacement depression. While working caregivers
may be expected to suffer a greater deal of stress while employed (Cantor,
1994), work could also offer daughters a better opportunity to adapt to life after
placement.
After background characteristics and primary stressors were taken into
account, increases in family conflict reliably predicted higher postplacement
depression among wives and decreases in socioemotional support significantly
predicted higher postplacement anger among husbands. However, feelings of
exhaustion regarding care responsibilities (i.e., role overload) played a larger
role than conflict or support in predicting postplacement adaptation among
daughters. Previous research has emphasized variability in how caregivers react
and adapt to stressful situations (Zarit, 1994). Many wives and husbands who
place a relative may fare well during the nursing home transition; however,
some spousal caregivers have particular difficulty with their social networks
throughout the institutionalization process. Specifically, spousal caregivers
may rely more heavily on close family members and friends during the
nursing home transition than adult child caregivers; although older adults’ social
networks have been shown to diminish in later life when compared to younger
individuals, the emotional salience in older adults’ social relationships actually
increases (Carstensen, 1992). An analysis of the predictors of adaptation among
caregivers supports this hypothesis; if social networks fail to provide support
and contribute to tension and stress during the institutionalization process,
spousal caregivers (who are generally older than adult child caregivers) are more
likely to suffer from feelings of depression and anger following placement
than daughters.
Limitations of the present study should be noted. First, the participants in this
study were predominately white, making it difficult to generalize the current
findings to the entire population of caregivers. Also, the family conflict measure
assessed conflict in a broad manner. Items which directly assess family tensions
surrounding the institutionalization of a relative would provide a more specific
focus on conflict during the placement process. In addition, information on
who the caregiver is experiencing conflict with and receiving support from in
the family would be beneficial. While the current study highlights the importance of family conflict and socioemotional support among caregivers who
institutionalize their relatives, the complex dynamics inherent in family relationships call for a multiple and more in-depth assessment of these constructs.
Finally, future research must take into account other family members involved in
the caregiving process. Other family members’ reports of conflict and support
will significantly increase our understanding of these variables during the nursing home transition.
The varying impact of family conflict and socioemotional support among
different types of caregivers highlight important issues in the development of
caregiver interventions. Interventions designed to promote adjustment to the
nursing home transition must account for strain and conflict in caregivers’ family and social networks. In addition, interventions must recognize the important
role the caregiver’s relationship with the care recipient plays. Family conflict
and tension in social networks appear to be more predictive of negative
well-being among spousal caregivers. In particular, the results above suggest
that husbands are likely to experience increases in conflict and decreases in support with the placement of a relative. Instead of conceptualizing family caregivers as a unitary population, the unique needs posed by wives, husbands, and
daughters who institutionalize their cognitively impaired elderly relatives should
be recognized by researchers and practitioners alike. In sum, the present study
highlights the importance of family conflict and socioemotional support during
the nursing home transition and extends our understanding of how particular
types of caregivers adapt to the institutionalization process.
ACKNOWLEDGMENTS
The authors would like to thank Karen Fingerman, Carol Whitlatch, Richard
Martin, Linda Collins, and Mike Rovine for their insightful comments on the
earlier drafts of this manuscript.
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Direct reprint requests to:
Joseph E. Gaugler, MS
National Institute on Aging Postdoctoral Fellow
Center on Aging
The University of Minnesota
D351 Mayo Building
Minneapolis, MN 55455

perceptions of family conflict and socioemotional support

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