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Currently Arizona is facing a significant caregiver shortage. In response to this the state coordinated a workforce development across agencies. Four managed care organizations partnered with PHI to survey 4,000 caregivers with the aim to understand the factors influencing job retention and areas for improvement. The report recommends supporting caregivers during crisis, promoting diversity, enhancing training, and creating career pathways.

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In the U.S., 62% of caregivers are White, 13% are African-American, 17% are Hispanic, and 6% are Asian-American. Hispanic caregivers have the highest prevalence of caregiving at 21%, followed by African-Americans at 20.3%. White caregivers tend to be older, with an average age of 52.5, while Hispanic caregivers are younger, at 42.7 on average. African-American and Hispanic caregivers report higher burdens, spending around 30 hours per week on caregiving, compared to 20 hours for White caregivers and 16 for Asian-Americans.

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Definitions

A caregiver-sometimes called an informal caregiver-is an unpaid individual (for example, a spouse, partner, family member, friend, or neighbor) involved in assisting others with activities of daily living and/or medical tasks. Formal caregivers are paid care providers providing care in one's home or in a care setting (day care, residential facility, long-term care facility). For the purposes of the present fact sheet, displayed statistics generally refer to caregivers of adults.

The figures below reflect variations in the definitions and criteria used in each cited source. For example, the age of care recipients or relationship of caregiver to care recipient may differ from study to study.

How Many Caregivers in the U.S.?

Approximately 43.5 million caregivers have provided unpaid care to an adult or child in the last 12 months. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

About 34.2 million Americans have provided unpaid care to an adult age 50 or older in the last 12 months. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

The majority of caregivers (82%) care for one other adult, while 15% care for 2 adults, and 3% for 3 or more adults. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Approximately 39.8 million caregivers provide care to adults (aged 18+) with a disability or illness or 16.6% of Americans. [Coughlin, J. (2010). Estimating the Impact of Caregiving and Employment on Well-Being: Outcomes & Insights in Health Management.]

About 15.7 million adult family caregivers care for someone who has Alzheimer's disease or other dementia. [Alzheimer's Association. (2015). 2015 Alzheimer's Disease Facts and Figures.]

Economic Value

The value of services provided by informal caregivers has steadily increased over the last decade, with an estimated economic value of $470 billion in 2013, up from $450 billion in 2009 and $375 billion in 2007. [AARP Public Policy Institute. (2015). Valuing the Invaluable: 2015 Update.]

At $470 billion in 2013, the value of unpaid caregiving exceeded the value of paid home care and total Medicaid spending in the same year, and nearly matched the value of the sales of the world's largest company, Wal-Mart ($477 billion). [AARP Public Policy Institute. (2015). Valuing the Invaluable: 2015 Update.]

The economic value of the care provided by unpaid caregivers of those with Alzheimer's disease or other dementias was $217.7 billion in 2014. [Alzheimer's Association. (2015). 2015 Alzheimer's Disease Facts and Figures.]

Gender

65% of care recipients are female, with an average age of 69.4. The younger the care recipient, the more likely the recipient is to be male. 45% of recipients aged 18-45 are male, while 33% of recipients aged 50 or higher are male. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Upwards of 75% of all caregivers are female, and may spend as much as 50% more time providing care than males. [Institute on Aging. (2016). Read How IOA Views Aging in America.]

Male caregivers are less likely to provide personal care, but 24% helped a loved one get dressed compared to 28% of female caregivers. 16% of male caregivers help with bathing versus 30% of females. 40% of male caregivers use paid assistance for a loved one's personal care. About 14.5 million caregivers are males out of the 43.4% who care for an older family member. [National Alliance for Caregiving and AARP. (2009). Caregiving in the U.S.]

Gender and Care Tasks

Males may be sharing in caregiving tasks more than in the past, but females still shoulder the major burden of care. For example, while some studies show a relatively equitable distribution of caregiving between males and females, female caregivers spend more time providing care than males do (21.9 vs. 17.4 hours per week). [National Alliance for Caregiving and AARP. (2009). Caregiving in the U.S.]

Higher-hour caregivers (21 hours or more weekly) are nearly 4 times more likely to be caring for a spouse/partner. [ National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Among spousal caregivers aged 75+, both sexes provide equal amounts of care. [McCann, J. J., Hebert, L. E., Beckett, L. A., Morris, M. C., Scherr, P. A., & Evans, D. A. (2000). Comparison of Informal Caregiving by Black and White Older Adults in a Community Population.]

Other studies indicate that 36% of female caregivers handle the most difficult caregiving tasks (i.e., bathing, toileting, and dressing) when compared with 24% for their male counterparts, who are more likely to help with finances, arrangement of care, and other less burdensome tasks. [National Alliance for Caregiving and AARP. (2009). Caregiving in the U.S.]

Caregiving in the Lesbian, Gay, Bisexual, and Transgender (LGBTQ+) Communities

9% of caregivers self-identify as LGBTQ+. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

There are at least 3 million LGBTQ+ persons aged 55+ in the U.S. This number is expected to double in the next two decades. [Espinoza, R. (2014). Out and Visible: The Experiences and Attitudes of Lesbian, Gay, Bisexual and Transgender Older Adults, Ages 45-75.]

Male caregivers report providing more hours of care than female caregivers. The average weekly hours of care provided by females from both the LGBTQ+ and general population samples is similar-26 vs. 28 hours-but LGBTQ+ males provide far more hours of care than males from the comparison sample (41 hours vs. 29). This reflects that about 14% of gay males indicate that they are full-time caregivers, spending over 150 hours per week in this capacity, compared to 3% of lesbian and 2% of bisexual respondents. [MetLife. (2010). Still Out, Still Aging: Study of Lesbian, Gay, Bisexual, and Transgender Baby Boomers.]

LGBTQ+ individuals are more likely to be very concerned about having enough money (51% vs. 36%), experiencing loneliness in old age (32% vs. 19%), declining physical health (43% vs. 33%), not being able to take care of themselves (43% vs. 34%) or not having anybody to take care of them (30% vs. 16%) compared to non-LGBT. [Fredriksen-Goldsen, K. I., Kim, H. J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., Goldsen, J., & Petry, H. (2011). The Aging and Health Report: Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults.]

20% of older LGBTQ+ individuals and 44% of older transgender individuals feel their relationship with their healthcare provider would be adversely affected if their health provider knew their sexual orientation/gender. [Fredriksen-Goldsen, K. I., Kim, H.-J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., Goldsen, J., & Petry, H. (2011). The Aging and Health Report: Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults.]

LGBTQ+ older adults are twice as likely to age as a single person, twice as likely to reside alone, and three to four times less likely to have children. [MetLife. (2010). Still Out, Still Aging: The MetLife Study of Lesbian, Gay, Bisexual, and Transgender Baby Boomers.]

Caregiving Tasks

Of family caregivers who provide complex chronic care:

46% perform medical and nursing tasks;

More than 96% provide help with activities of daily living (ADLs) such as personal hygiene, dressing and undressing, getting in and out of bed, or instrumental activities of daily living (IADLs) such as taking prescribed medications, shopping for groceries, transportation, or using technology, or both. [AARP and United Health Hospital Fund. (2012). Home Alone: Family Caregivers Providing Complex Chronic Care.]

On average, caregivers perform 1.7 of 6 ADLs, most commonly getting in and out of beds and chairs (43%). [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

On average, caregivers perform 4.2 of 7 IADLs, most commonly transportation (78%), grocery or other shopping (76%), and housework (72%). [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Age

The number of hours dedicated to caregiving increases with the age of the caregiver.

Higher-hour caregivers are, on average, 51.8 years of age.

Lower-hour caregivers average 48 years of age.

Number of Hours Dedicated to Caregiving by Age of Family Caregiver

[The Partnership for Solutions. (2004). Chronic Conditions: Making the Case for Ongoing Care.]

Older caregivers are more likely to care for a spouse or partner. The average age of spousal caregivers is 62.3. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Many caregivers of older adults are themselves growing older. The average caregiver of a recipient 65 years of age or older is 63 years old. Of these caregivers, one third report being in fair to poor health. [Administration on Aging. (2005). NFCSP: Complete Resource Guide.]

Time Spent Caregiving

4 in 10 (40%) caregivers are in high-burden situations, 18% medium burden, and 41% low burden based on the Level of Care Index (1997). Burden of care increases with hours of care provided. 92% of providers providing 21 or more hours per week are high burden versus 16% of lower hour providers. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Primary family caregivers of people with dementia report spending an average of 9 hours per day providing help to their relatives. [Fisher, G. G., Franks, M. M., Plassman, B. L., Brown, S. L., Potter, G. G., Llewellyn, D., et al. (2011). Caring for Individuals with Dementia and Cognitive Impairment, not Dementia: Findings from the Aging, Demographics, and Memory Study.]

Hours per Week

Family caregivers spend an average of 24.4 hours per week providing care. Nearly 1 in 4 caregivers spends 41 hours or more per week providing care. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Family caregivers who reside with those they provide care for spend 40.5 hours per week caring for this person.

Those caring for a spouse/partner spend 44.6 hours per week performing caregiving tasks.

Those caring for a child under age 18 spend 29.7 hours per week performing caregiving tasks. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Older caregivers who are 75+ years old provide 34 hours in an average week on caregiving. Middle aged caregivers report spending 21.7 hours per week on caregiving tasks. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Family and other unpaid caregivers of people with Alzheimer's disease and other dementias provide an estimated 21.9 hours of care per week. [Alzheimer's Association. (2015). 2015 Alzheimer's Disease Facts and Figures.]

Months and Years Providing Care

Regardless of employment status, unpaid caregivers report that positive activities in their respective daily lives are reduced by 27.2% as a result of their caregiving responsibilities. This effect is three times greater in their personal lives than in their professional lives. [Coughlin, J. (2010). Estimating the Impact of Caregiving and Employment on Well-Being: Outcomes & Insights in Health Management.]

Measured by duration of care, Alzheimer's and dementia caregivers provide care on average 1-4 years more than caregivers caring for someone with an illness other than Alzheimer's disease. They are also more likely to be providing care for five years or longer. [Alzheimer's Association. (2015). 2015 Alzheimer's Disease Facts and Figures.]

Race and Ethnicity

Individual adult caregivers in the U.S. identify their race/ethnicity as the following:

White: 62%

African-American: 13%

Hispanic (non-White, non-African-American): 17%

Asian-American: 6% [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Hispanic (non-White, non-African-American) and African-American caregivers experience higher burdens from caregiving and spend more time caregiving on average than their White or Asian-American peers. The percentage of high burden caregivers caregiving time by racial/ethnic groups are as follows:

African-American: 57%, 30 hours per week

Hispanic (non-White, non-African-American): 45%, 30 hours per week

White: 33%, 20 hours per week

Asian-American: 30%, 16 hours per week [Alzheimer's Association. (2015). 2015 Alzheimer's Disease Facts and Figures.]

More than half of African-American caregivers find themselves "sandwiched" between caring for an older person and a younger person under age 18, or caring for more than one older person. African-American caregivers are also more likely to reside with the care recipient and spend an average of 20.6 hours per week providing care. In addition, 66 percent of African-American caregivers are employed full or part-time. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

The needs of care recipients vary by race/ethnicity. African-American caregivers (41%) are more likely to provide help with more than three ADLs than white caregivers (28%) or Asian-Americans (23%). [Alzheimer's Association. (2015). 2015 Alzheimer's Disease Facts and Figures.]

Relationships between Caregivers and Care Recipients

A vast majority of caregivers (85%) care for a relative or other loved one:

42% care for a parent (31% for a mother, 11% for a father);

15% care for a friend, neighbor or another non-relative;

14 % care for a child;

7% care for a parent-in-law;

7% care for a grandparent or grandparent-in-law. [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Parent care continues to be the primary caregiving situation for mid-life caregivers with 70% of the caregivers between the ages of 50 and 64. [Wagner, D. & Takagi, E. (2010). Health Affairs: Informal Caregiving by and for Older Adults.]

Most care recipients reside in their own home (48%), and one in three (35%) reside in their caregiver's home. 3 in 10 care recipients who are not in assisted-living or skilled nursing facilities reside alone (31%).

[National Alliance for Caregiving and AARP. (2009 & 2015). Caregiving in the U.S.]

The Department of Health defines abuse as, "a violation of an individual's human and civil rights by another person or persons." Abuse can take many forms, including physical, psychological, sexual, or financial abuse, discrimination, or neglect.
Under this definition, as many as 25% of elder care recipients report significant levels of abuse. [Cooper, C., Selwood, A., & Livingston, G. (2008). The Prevalence of Elder Abuse and Neglect: A Systematic Review.]

Approximately 1 in 10 Americans aged 60+ have experienced some form of elder abuse. Some estimates range as high as 5 million elders who are abused each year. [National Council on Aging. (2016). Elder Abuse Facts.]

Only 7% of elder abuse cases are ever reported to authorities. [National Research Council. (2003). Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America.]

For every 1 case of elder abuse known to programs and agencies there are 24 unknown cases. [Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of Cornell University & New York City Department for the Aging. (2011). Under the Radar: New York State Elder Abuse Prevalence Study.]

Elder abuse, even modest abuse, increases risk of death by 300% compared to elders who have not been abused. [Dong, X., Simon, M. A., Beck, T., Farran, C., McCann, J., Mendes de Leon, C., et al. (2011). Elder Abuse and Mortality: The Role of Psychological and Social Wellbeing.]

The direct medical costs associated with violent injuries to older adults are estimated to add over $5.3 billion to the nation's annual health expenditures, and the annual financial loss by victims of elder financial exploitation were estimated to be $2.9 billion in 2009, a 12% increase from 2008. [Administration on Aging: National Center on Elder Abuse. (2016). Statistics/Data: Impact of Elder Abuse].

Elder Abuse

The vast majority of caregivers (75%) reside within 20 minutes of their care recipient. 13% of caregivers reside between 20 minutes and an hour away from their care recipient.
The proportion of caregivers reporting they reside fewer than 20 minutes from the home of their care recipient has increased steadily over the past 10 years (44% in 2004, 51% in 2009, and 75% in 2015). [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

48% of care recipients reside in their own home.

Higher-hour care recipients are less likely to reside at home (28%) than lower-hour recipients (57%).

Inversely, higher-hour care recipients are more likely to reside in their caregiver's home (62%) than lower-hour recipients (22%). [National Alliance for Caregiving and AARP. (2015). Caregiving in the U.S.]

Approximately 5-7 million caregivers in the U.S. (about 15% of all caregivers) are long-distance caregivers. This number is projected to double by 2020. [National Council on Aging. (2006). Nearly 7 Million Long-Distance Caregivers Make Work and Personal Sacrifices.]

Long-distance caregivers have the highest annual expenses (about $8,728) compared to co-resident caregivers (about $5,885) or those who care for a loved one nearby (about $4,570). [AARP Public Policy Institute. (2008). Valuing the Invaluable: The Economic Value of Family Caregiving.]

Long-distance caregivers reside an average of 450 miles (724 km) from their care recipients (or approximately 7 hours travel time).
More males (58%) than females (42%) are long-distance caregivers. [National Alliance for Caregiving and the MetLife Mature Market Institute. (2004). Miles Away: The MetLife Study of Long-Distance Caregiving.]

Long-distance caregivers are more likely to report emotional distress (47%) than caregivers either residing with their care recipient (43%) or residing less than one hour away (28%). [National Alliance for Caregiving and AARP. (2004). Caregiving in the U.S.]

Caregivers who do not reside with their care receiver reside the following distances from those for whom they care:

Geographic Distance Between Caregiver and Care Recipient

[Gallup-Healthways. (2011). Gallup-Healthways Well-Being Survey: Caregiving Costs U.S. Economy $25.2 Billion in Lost Productivity.]

More than half of the 65 million Americans living in rural areas are over the age of 50. Elders in rural areas (about a quarter of all elders) are more likely to reside alone, near or at the poverty level, and suffer from a chronic condition or physical disability. They require an average of 46 miles of travel to get to the nearest health professional. [U.S. Department of Health and Human Services Rural Task Force. (2002). HHS Rural Task Force Report.]

3-6 million Americans are distance caregivers who provide care for a family member that resides an average of 450 miles away. [National Alliance for Caregiving & AARP. (2005). Caregiving in the U.S.]

About 51% of caregivers in rural areas use community-based services. [Buckwalter, K. C., & Davis, L. L. (2009). Elder Caregiving in Rural Communities.]

Caregiving in Rural Areas

There are an estimated 641,000 adults aged 60+ with cognitive and other disabilities (e.g., cerebral palsy, autism, epilepsy, traumatic brain injury).
This number is projected to double to 1,242,794 by 2030, coinciding with the aging population of baby boomers born between 1946 and 1964. [Heller, T. (2011). Strength for Caring: Older Adults with Developmental Disabilities and Their Aging Family Caregivers.]

Families are still the primary caregivers for adults with developmental disabilities and are themselves aging. About 76% of individuals with developmental disabilities reside at home.

In 25% of these homes, the family caregiver is over 60 years of age.

The average age of the care recipient with a developmental disability is age 38. [Heller, T. (2011). Strength for Caring: Older Adults with Developmental Disabilities and Their Aging Family Caregivers.]

Older Adults with Developmental Disabilities

There are a total of 5.5 million caregivers caring for former or current military personnel in the U.S. (1.1 million post 9/11). [Ramchand, R., Tanielian, T., Fisher, M., Vaughan, C., Trail, T., Batka, C., Voorhies, P., Robbins, M., Robinson, E., & Ghosh-Dastidar, B. (2014). Key Facts and Statistics from the RAND Military Caregivers Study.]

9 in 10 (96%) caregivers of veterans are female and 70% provide care to their spouse or partner. 30% of veterans' caregivers care for a duration of 10 years or more as compared to 15% of caregivers nationally. 88% report increased stress or anxiety as a result of caregiving, and 77% state sleep deprivation as an issue. [National Alliance for Caregiving and United Health Foundation. (2010). Caregivers of Veterans: Serving on the Home Front.]

Military caregivers after 9/11 are more likely to be employed (63% vs. 47%), less likely to have a support network (47% vs. 71%), younger (37% under 30 years old vs. 11%), more likely to be caring for a recipient with a behavioral health condition (64% vs. 36%) or a VA disability rating (58% vs. 30%). [Ramchand, R., Tanielian, T., Fisher, M., Vaughan, C., Trail, T., Batka, C., Voorhies, P., Robbins, M., Robinson, E., & Ghosh-Dastidar, B. (2014). Key Facts and Statistics from the RAND Military Caregivers Study.]

Veteran care recipients (post 9/11) are more likely to have no health insurance (32% vs. 23%) or regular source of health care (28% vs. 14%), have a mobility limiting disability (80% vs. 66%) or mental health/substance abuse condition (64% vs. 33%), and meet criteria for probable depression (38% vs. 20%) compared to civilians. [Ramchand, R., Tanielian, T., Fisher, M., Vaughan, C., Trail, T., Batka, C., Voorhies, P., Robbins, M., Robinson, E., & Ghosh-Dastidar, B. (2014). Key Facts and Statistics from the RAND Military Caregivers Study.]

Veterans suffer more frequently from Traumatic Brain Injury (29%), Post-traumatic Stress Disorder, Diabetes (28%), and paralysis or Spinal Cord Injury (20%). [National Alliance for Caregiving and United Health Foundation. (2010). Caregivers of Veterans: Serving on the Home Front.]

Veterans

Family Caregiver Alliance
National Center on Caregiving
(415) 434-3388 | (800) 445-8106
Website: www.caregiver.org
Email: info@caregiver.org
FCA CareNav: https://fca.cacrc.org/login
Services by State: www.caregiver.org/connecting-caregivers/services-by-state/.
The present fact sheet was prepared by Family Caregiver Alliance. © 2016 Family Caregiver Alliance. All rights reserved.
Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. Through its National Center on Caregiving, FCA offers information on current social, public policy, and caregiving issues and provides assistance in the development of public and private programs for caregivers. For residents of the greater San Francisco Bay Area, FCA provides direct support services for caregivers of those with Alzheimerʼs disease, stroke, traumatic brain injury, Parkinsonʼs, and other debilitating disorders that strike adults.

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Caregiver Statistics: Demographics - Family Caregiver Alliance

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A caregiver-sometimes called an informal caregiver -is an unpaid individual (for example, a spouse, partner, family member, friend, or neighbor) involved in assisting others with activities of daily living and/or medical tasks. Formal caregivers are paid care providers providing care in one's home or in a care setting (day care, residential facility, long-term care facility).

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A survey by the National Opinion Research Center (2014) found that 83% of caregivers view caregiving as a positive experience. Many reported benefits such as giving back to a loved one, personal growth, finding purpose, and passing on caregiving traditions.

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Finding a positive form of coping with stressful circumstances and situations can involve finding meaning through positive reappraisals, spiritual beliefs or other adaptive coping mechanisms in the face of stress.

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Fifteen studies from nine countries analyzed the impact of assistive technology on paid caregivers working with older adults. Technologies studied included grab bars, bidet seats, bed transfer devices, sensors, communication systems, and robots. Benefits included reduced stress and workload, though caregivers reported both positive and negative effects. The article suggests the need for more research to evaluate the specific impacts of these technologies on caregiver turnover.

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Reducing the Burdens of Paid Caregivers of Older Adults by Using Assistive Technology: A Scoping Review

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Paid caregivers are needed to support older adults, but caregiver burden contributes to high turnover rates. Assistive technologies help perform activities of daily living (ADLs) and can reduce caregiver burden, but little is known about how they impact…

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Caregiver burnout can be avoided by feeling empowered and focusing on what you can control. Practicing acceptance, embracing your caregiving choice, staying organized, and finding the positive aspects of caregiving can help reduce stress. Seek help from friends, family, or respite services, and be open to delegating tasks. Take breaks to recharge, prioritize your own health, and use relaxation techniques. Join a caregiver support group or talk to a therapist that will provide emotional support and valuable insights.

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Caregiver Stress and Burnout - HelpGuide.org

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Caregiving stress can lead to burnout if you don’t take care of yourself. These tips will help you avoid caregiver burnout and regain control over your life.

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Paid caregivers of hospitalized patients in China often experience a high caregiving burden and a high prevalence of depression symptoms. Several factors contributing to this were identified, suggesting potential areas for future interventions to reduce stress and improve caregiver well-being.

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BMC Public Health 18, Article number: 53 (2018) Cite this article

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An Erratum to this article was published on 22 September 2017

Abstract

Background

Caregiving burden and depression in family caregivers have been investigated, but little is known about how they affect paid caregivers. The aim of this study was to investigate caregiving burden and depression in paid caregivers of hospitalized patients.

Methods

A cross-sectional survey study was conducted in a tertiary referral hospital (Chengdu, China) that enrolled 108 paid caregivers who worked in the inpatient department. The Caregiver Burden Inventory (CBI) and the Center for Epidemiologic Studies Depression (CES-D) scale were incorporated into a self-developed questionnaire to gather demographic information on the following four aspects: general, work, income, and family.

Results

The mean total CBI score was 29.7 ± 12.5. The time-dependence burden had the highest score of 15.3 ± 4.0, which was followed by the physical burden score of 6.5 ± 4.6, developmental burden score of 3.7 ± 4.0, social burden score of 3.2 ± 4.0, and emotional burden score of 2.4 ± 3.1. Multiple linear regression analysis showed that a higher CBI was associated with a longer time as a paid caregiver [β=7.041, 95% Confidence Interval (CI):1.935 to 12.974, p = 0.009], lower income satisfaction (β= − 6.573, 95% CI: -11.248 to −3.020, p = 0.001), and higher frequency of meeting with their relatives (β=7.125, 95% CI: 2.019 to 12.456, p = 0.006). The mean CES-D score was 11.9 ± 8.7, and significant depression was found in 28 (25.9%) paid caregivers according to the CES-D score ≥ 16 cut-off. There was a moderate positive correlation between the CBI and CES-D scores (Pearson's r = 0.452, p < 0.001).

Conclusions

A high caregiving burden was commonly observed in paid caregivers of hospitalized patients in China, as was a high prevalence of depression symptoms. Several associated factors were identified that could be areas for future interventions.

Peer Review reports

Background

Caregivers have been shown to suffer from high caregiving burden and depression; therefore, they are a group of vulnerable people or "invisible patients" who need attention or interventions from medical staff and social workers. [ 7, 8] However, most previous studies [ 1, 7, 8] have focused on the caregiving burden of family caregivers for patients who stayed at home and not on the growing population of paid caregivers who work in hospitals. According to published studies in Chinese journals, most paid caregivers are middle-aged women who were previously farmers from a rural area or laid-off workers from a city. [ 9, 10] Although psychological health and work pressure were investigated in paid caregivers in China, which were related to sleep disturbances, unstable income, and a lack of social respect and support, [ 11, 12] data are very limited on the caregiving burden in this population, especially by the use of designated inventories. Therefore, to provide information for developing practical interventions, a survey study was conducted to identify the prevalence of caregiving burden and depression symptoms as well as their associated factors from four categories, including general, work, income, and family characteristics.

Methods

Study design

This was a cross-sectional survey study in a tertiary referral hospital (Chengdu, China) performed with a self-developed questionnaire that is described in the "Instruments" section. Nurses participated in the design, distribution and return of the questionnaire.

Participants

Considering that caregiving burden could be affected by the working environment and patients of paid caregivers, the subjects were all paid caregivers who worked in four medical and four surgical wards (i.e., cardiology vs. cardiac surgery, respiratory medicine vs. thoracic surgery, gastrointestinal medicine vs. gastrointestinal surgery, and neurology vs. neurosurgery). The subjects were enrolled if they met the following criteria: (1) agreed to participate and signed the informed consent form and (2) could read and complete the questionnaire. Consequently, 120 of the 124 (96.8%) registered paid caregivers from the aforementioned wards were enrolled; four people did not fulfil the inclusion criteria as they refused to participate.

Instruments

The questionnaire was written in Chinese and consisted of three parts. In the first part, the baseline characteristics of the study subjects were collected; this included proposed factors associated with the caregiving burden or depression that were categorized into general, work, income, and family information. General information included the age, gender, education, and marital status. Work information included the ward in which they worked, number of years as a paid caregiver, and number of vacation days per month. For the income information, "income satisfaction" was a required field, while "income per month before and after becoming a paid caregiver" was optional. The number of dependents, frequency of meeting his/her own family, and housing status in Chengdu (owned or rental) were categorized as family information.

Five CBI factors and their scores. CBI, Caregiving Burden Inventory. The bar chart represents the means ± standard deviation, and the adjusted physical burden is the original score multiplied by 1.25 to give an equivalent score out of 20 for comparison. † p < 0.001 vs. the time-dependence burden and § p < 0.001 vs. the physical burden

The third part of the questionnaire assessed the depression symptoms of paid caregivers with the Chinese version of the Center for Epidemiologic Studies Depression Scale (CES-D), which has been validated and showed good reliability in a Chinese population. [ 17, 18, 19] The CES-D includes 20 items that cover affective, cognitive, behavioural, and somatic symptoms associated with depression. The subjects were asked to indicate the frequency of symptoms on the following 4-point scale from 0 (rarely or none of the time) to 3 (most or all of the time). The 4 positively formulated items (items 4, 8, 12, and 16) were recorded in reverse. Therefore, the total score of the CES-D ranged from 0 to 60, and a score of 16 or higher indicates the likely presence of clinically significant depression. [ 18, 20].

According to the study design, the copies of the questionnaire with inadequate quality were not entered into the final analysis, including those with an incomplete CBI or CES-D section, and a consistent lowest score (i.e. "0" score) or highest score (i.e. "4" score in the CBI section and "3" score in the CES-D section) for each item in either section. This extreme and unchangeable scoring situation was considered to indicate that the participant had not understood the survey or had not seriously considered it.

Statistics

The statistical analysis was performed using SPSS software, version 20.0 (SPSS, Chicago, IL, USA). A Kolmogorov-Smirnov test was performed to determine whether continuous parameters were normally distributed. T-tests, chi-square tests and Fisher's exact tests were used for univariate analyses. One-way ANOVA was used to test differences among the 5 factors of the CBI. Multiple linear regression was performed to identify factors associated with the CBI and CES-D scores. A Pearson correlation coefficient was used to analyse the correlations between the CBI and CES-D scores. A p-value <0.05 was considered statistically significant.

Results

During the study period, 120 copies of the survey were sent out and returned (100% response rate) by assigned ward nurses. However, several surveys were unsuitable for analysis (12/120, 10%), including nine that had an incomplete CBI or CES-D section and another three that had a consistent "0" score for each item in the CBI section.

Baseline characteristics

Data for the 4 domains are presented in Table 1. All paid caregivers were middle-aged, and most were female. The majority of the subjects achieved an educational level below high school. The number of years that each participant worked as a paid caregiver was categorized into five groups in the questionnaire (i.e., less than 1 year, 1 ~ 3 years, 3 ~ 5 years, 5 ~ 10 years, and more than 10 years); however, 73 (66.7%) paid caregivers worked in this field for more than 10 years.

Table 1 Baseline characteristics of the paid caregivers

Caregiving burden and depression scores in paid caregivers

The total CBI score was normally distributed among the study population with a mean value of 29.7 ± 12.5. There were some differences among the 5 factors of the CBI that were detected by the ANOVA (F ₍₄₅₃₅₎ = 194.207, P < 0.001) and post hoc analysis. The time-dependence burden factor had the highest score of 15.3 among the 5 factors; it was significantly higher than those of the remaining factors (all P < 0.001). It was followed by the physical burden score of 6.5, which was significantly higher than the emotional, developmental, and social burden scores (all P < 0.001). The scores of the last 3 factors were similar. (Fig. 1).

The CES-D score of the study participants also had a normal distribution with a mean value of 11.9 ± 8.7. Using the CES-D score ≥ 16 cut-off, depression was found in 28 (25.9%) paid caregivers. Moreover, the CBI score of the depression group (CES-D score ≥ 16) was significantly higher than that of the non-depression group (36.3 ± 14.3 vs. 27.4 ± 11.0, P = 0.001). The CBI score was positively correlated with the CES-D score ( r = 0.452, P < 0.001). (Fig. 2).

Correlation between the CES-D and CBI scores. CES-D, Center for Epidemiologic Studies Depression Scale. CBI, Caregiving Burden Inventory. The Pearson correlation coefficient is 0.452 ( P value <0.001)

Factors associated with a higher caregiving burden and depression

A multiple linear regression analysis was used to identify the factors that were related to higher CBI (Table 2) and CES-D (Table 3) scores. The parameters in Table 1 were all included as covariates in the model, where either the CBI or CES-D score was the dependent variable. Three independent variables were associated with a higher CBI score, which included a longer time as a paid caregiver ( P = 0.009), lower income satisfaction ( P = 0.001), and more frequent meeting with his/her own family ( P = 0.006). (Table 2) Similarly, a lower income satisfaction was found to be associated with a higher CES-D score ( P = 0.008). (Table 3).

Table 2 Variables associated with the likelihood of a higher CBI score

Table 3 Variables associated with the likelihood of a higher CES-D score

Discussion

In this survey, the majority of paid caregivers were married, middle-aged women with a low educational level. They suffered from a high caregiving burden that was related to the amount of time as a caregiver, income satisfaction and frequency of meeting with their own family. The depression rate of this group was higher than that of the general population, but it was lower than that of family caregivers; it was also positively correlated with caregiving burden.

High caregiving burden in paid caregivers

Factors associated with a higher caregiving burden

Previous studies showed that the risk factors for caregiving burden included female gender, [ 30] a low education, [ 31, 32] sleep deprivation, financial stress, [ 33] depression, [ 34] social isolation, [ 35] and time restrictions [ 36]. Because the paid caregivers in the current study worked on a 24-h schedule, we gathered the number of years they spent as paid caregivers rather than the number of hours per day spent performing their job and found the former to be associated with the CBI score. This association might be attributed to the self-perceived long-term time restrictions and deteriorating physical health of the paid caregivers. As previously reported, financial stress was a risk factor for caregiving burden [ 33], and poor payment for paid caregivers was a common issue. [ 37, 38] In China, most tertiary referral hospitals (as the study site) provide high-quality, specialized medical health care services to a number of districts that are located in urban areas; however, these areas also have the largest demand for paid caregivers. [ 39] In contrast, most paid caregivers are from the countryside and have moved to a city for a better living. Not surprisingly, lower income satisfaction was significantly associated with a higher caregiving burden, indicating a conflict among their actual payment, self-expectations and financial circumstances. However, this conflict cannot be resolved only by raising their salaries. It is possible that organized lectures and regular meetings could identify what paid caregivers need and think. More interestingly, it was observed in the study that paid caregivers who met with their own families more frequently had a higher CBI score. This phenomenon has not been previously identified, and its cause remains unexplored in the current study.

Correlation between depression and caregiving burden

Study limitations

The major limitations of this study include its cross-sectional nature and the absence of health consequence data, i.e. the result of coupling between the caregiving burden and the physical/emotional health of paid caregivers. Although some practical interventions to reduce the caregiving burden could be developed based on the results of the current study, their impact on the professional health of paid caregivers remains unclear. The relatively small sample size is another limitation.

Conclusions

Caregiving burden is high in paid caregivers of hospitalized patients in China, most of whom are middle-aged women from rural areas. It is associated with a prolonged working time, low income satisfaction and unexplained impact from their own families. In addition, the caregiver burden and depression are correlated, which is more prevalent in paid caregivers than in the general population.

Change history

22 September 2017

An erratum to this article has been published.

Abbreviations

CBI:

Caregiver Burden Inventory

CES-D:

Center for Epidemiologic Studies Depression Scale

References

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Acknowledgements

We appreciate Professor Rui Zhang (Department of Medical Administration, National Health and Family Planning Commission, P.R.C.) for providing us with the validated Chinese version of the CBI.

Funding

No funding supported this study.

Availability of data and materials

Data will be available upon request from the corresponding author.

Author information

Authors and Affiliations

1. Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China

Yao-Dan Liang, Ya-Li Wang, Zhi Li, Li He, Ying Xu, Qing Zhang & Gui-Ying You

2. Department of Nephrology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China

Xu-Hua Mi

Contributions

MXH designed this study and wrote the study protocol. LYD conducted the study and drafted the manuscript. YGY designed the questionnaire. WYL and LZ helped to finalize the questionnaire and recruited the paid caregivers in each ward. HL and XY were responsible for giving out and receiving the questionnaires, organizing the data, and performing the literature review. ZQ was responsible for performing the statistical analysis and revising the manuscript. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Xu-Hua Mi.

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Ethics approval and consent to participate

The current study was an observational study that was approved by the ethics committee of the West China Hospital of Sichuan University. Written informed consent was obtained from each study participant.

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Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Additional information

An erratum to this article is available at https://doi.org/10.1186/s12889-017-4709-6.

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Liang, YD., Wang, YL., Li, Z. et al. Caregiving burden and depression in paid caregivers of hospitalized patients: a pilot study in China. BMC Public Health 18, 53 (2018). https://doi.org/10.1186/s12889-017-4563-6
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Caregiving burden and depression in paid caregivers of hospitalized patients: a pilot study in China - BMC Public Health

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Background Caregiving burden and depression in family caregivers have been investigated, but little is known about how they affect paid caregivers. The aim of this study was to investigate caregiving burden and depression in paid caregivers of hospitalized patients.

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The Acceptance Theory of Family Caregiving explains how family caregivers' acceptance of their role in caring for older adults is influenced by commitment to familial relationships, cultural expectations, and a sense of gratitude. The theory suggests that successful caregiving is shaped by the caregiver’s acceptance of the physical, emotional, and economic consequences of this role.

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Abstract

Acceptance of roles in the care of older adults by a family caregiver depends on factors emanating from commitment to familial relationships, widespread cultural expectation, and debt of gratitude. This study aims to develop a theory that explains the acceptance of the role of caregiving of the older adults by the family caregiver necessary to predict behavioral adaptation and control caring phenomenon that favors successful meeting of caring expectation across trajectory phases and transitions. A deductive axiomatic approach to theory generation was utilized, resulting in four axioms that served as bases for four propositions. Acceptance Theory of Family Caregiving implies that older adults who expect their children to take care of them as they age have cultural influence and that the acceptance of the role will determine the caregiver's acceptance of consequences in the form of physical, economical, psychological, and spiritual aspects. In terms of preparedness, family members who accept the possibility of the decline of their older adults are more likely to be assume caregiving roles efficaciously. In the process that family members face in this so-called trajectory caregiving process, resources play a significant role. The developed theory suggests that the care of the older adult in the family caregiving process is determined by the acceptance of role assumption by the family caregiver across trajectory phases. This study highlights the vital implication of acceptance of role assumption to the outcomes of the caregiving process with respect to older adult care, prevention of family caregiver burden, and establishment of strong familial and social relationships.

Keywords: acceptance, adaptation, aged, caregiver burden, family caregiving, nursing

Introduction

The rapidly aging population has become an urgent global health concern (Sakakibara et al., 2015) because the long-term process of older adult care is faced with limited family and professional caregivers (Harvath et al., 2020). The widespread expectation on families, along with its ubiquity of practice to watch over their older adults, has been aligned with strong intergenerational family solidarity (Paguirigan, 2019). More so, the conception of debt of gratitude has both influenced the responsibility a significant burden. The widespread expectation in terms of family caregiving reveals that 85 to 95% of all older adults receive care from their family members on a global scale (Gaugler et al., 2018). Likewise, the need to balance personal and social roles amidst increasing pressure to provide care to an older adult becomes the caregiver's predicament (Donovan et al., 2011; Thomas et al., 2017). Meanwhile, it gives some an opportunity to reward and fulfill role assumptions (Luichies et al., 2021; Reinhard et al., 2011).

Acceptance of caregiving roles assumption in the care for an older adult can be as sudden or carefully planned to depend on several factors. Despite the many shared experiences of family caregiving, this process varies in terms of family dynamics, nature of timing, duration, transitions of care, and end of life. Common to this journey is the acceptance of the family members to be able to enter the adjustment process of becoming their "self" in caregiving (Nguyen & Levkoff, 2020). Acceptance of change that requires family decision-making is vital to initiate action (Kristanti et al., 2021; Potter et al., 2017). Caregiving trajectory is the term used to denote the process that family caregivers undergo specifically in phases that generally include role awareness, emerging responsibilities, increasing demands for care, and finally, end of life (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016). In the process of caregiving, acceptance and commitment as central aspects of this emerging evidence-based practice are crucial in stress levels and the quality of life of caregivers (Han et al., 2021).

Assignment of the primary caregiver for an older adult in the family is based on several factors that encompass existing relationships, gender, societal norms and expectations, geographical proximity, and moral and expected familial obligation (Luichies et al., 2021; Nguyen et al., 2021). Evidence suggests that family caregivers do not receive adequate preparation in the assumption of caregiving roles in matters related to problem-solving and communication skills (Robinson et al., 2020). Inadequate preparation and execution caused by an interplay of factors related to poor acceptance of the current condition, inadequate resources, conflict with familial and employment responsibilities and financial difficulties, and new circumstances result in inadequate adaptation to the caregiving role (Ainamani et al., 2020; Hashemi-Ghasemabadi et al., 2016; Nguyen et al., 2021). Moreover, increasing dependence on the caregiver emanates from the older adult's functional decline over time (Ainamani et al., 2020; Pinto et al., 2021), and the caregiving role becomes more intense in the advanced and end-of-life phase (Robinson et al., 2020).

Relevant to understanding the beginning role of caregiving is acceptance of expectation. The Acceptance Theory of Family Caregiving is based on societal and familial expectations endured through several generations (Luichies et al., 2021). In simpler terms, the family caregiver is aware of such a responsibility of looking after the older adult when the time of physical and cognitive decline and dependency emerge while it is also an expectation of the older adult to have someone to look after them when the time comes amidst the possibility of embarrassment or perceived burden on family caregivers (Bekhet & Garnier-Villarreal, 2020; Hickman et al., 2020; Kellner et al., 2017). Therefore, a successful view on adaptation to family caregiving roles prerequisites acceptance.

While cultural expectations on family caregiving hold true, it is vital to determine the degree of family members' acceptance as it is integrated within them. Therefore, this study aims to develop a theory that explains the acceptance of caregiving roles by the family caregiver for the older adults necessary to predict behavioral adaptation and control caring phenomenon that favors successful meeting of caring expectation across trajectory phases and transitions. Developing a working knowledge of acceptance as it vitally influences caring behaviors among family caregivers contributes to older adults' health and well-being. Imperative to this understanding shall be beneficial in relating it with family caregivers' preparedness, self-efficacy, and quality of life secondary to planned behavior of caring.

Methods

The Acceptance Theory of Family Caregiving utilized a deductive approach. Starting with broad concepts and determining which concepts apply to populations, the top-down approach leads to the formulation of conclusions, known as deductions. For a sound deduction to occur, generalizations must be true because this is where logical consequences can be drawn (Utley et al., 2017). As a premise for deductive argument, an axiom is a logical principle assumed to be true and chosen carefully to avoid inconsistency. Axioms demonstrate consistency, plausibility, and richness to provide a system of logic in the creation of a theory. From a generalized statement that contains abstractions, a theory explains and predicts the interrelationship of variables through its ideas, concepts, and themes (Kivunja, 2018).

With the use of a deductive method to theory development, generalizations about the caregiving process, family psychology, cultural influence of older adult care, and gerontology nursing were determined through rigorous literature reviews. The definition of a family caregiver applies to any relative, partner, friend, or neighbor of the older adult that is based on a significant relationship. Following a literature review, the iterative yet sequential process of searching, screening, and assessing related works proceeded with data extraction and analysis (Paré & Kitsiou, 2017). Data extraction and analysis resulted in the identification of trends and patterns to systematically view the statements that were generally accepted to be true. These non-debatable facts known as axioms were identified, which subsequently became the basis for propositions. An axiomatic approach paved the way for preserving and furthering the growth of the discipline that tackles older adult care through family caregiving. Building the theory through logic and axiomatic systems of the behavior (Levy, 2017) of family caregiving, identification of propositions from the theory, and establishing testable hypotheses are placed at the process.

The proposed Acceptance Theory of Family Caregiving is an example of a mid-range theory that describes, explains, and predicts phenomena of caregiving of older adults by the family members in the practice of gerontology nursing. It also describes how the variables, namely acceptance, the trajectory of caregiving, resources, and cultural influence, relate with each other.

Results

Consistent with the deductive axiomatic approach to theory generation, literature reviews play a crucial role in the identification and support of the identified axioms and propositions in the buildup of the theory. Table 1 illustrates the extracted four axioms that were derived from literature reviews, and these served as the reference in the formulation of four propositions necessary in the framework of the developed acceptance theory of family caregiving.

Table 1

Axioms

Propositions

Theory

Axiom 1
Family relationships are founded based on commitment derived from various forms.

Proposition 1
Older adults who expect their children to take care of them as they age have cultural influence.

Care of the older adult in the family caregiving process is determined by the acceptance of role assumption by the family caregiver across trajectory phases (Acceptance Theory of Family Caregiving)

Axiom 2
Acceptance pre-requisites successful adaptation to one's environment.

Proposition 2
Acceptance of the role will determine the caregiver's acceptance of consequences in the form of physical, economical, psychological, and spiritual aspects.

Axiom 3
Acceptance of the caregiving role is a process.

Proposition 3
Family members who accept the possibility of the decline of their older adults are more likely to be prepared to assume caregiving roles.

Axiom 4
The family, as a unit, strives for balance and requires resources to sustain it.

Proposition 4
The trajectory family caregiving process is influenced by factors such as resources.

The role of a significant relationship between older adults and that of the family caregiver extends beyond influences of blood and marriage through the commitment of various forms explicitly referred on the definition of family caregiver that refers to any relative, partner, friend, or neighbor who provides a broad range of assistance-related activities with a basis of significant relationship to an older adult with chronic and disabling conditions. Therefore, family relationships are founded based on commitment derived from various forms (Axiom 1), which implicates those older adults who expect their children to take care of them as they age have cultural influence (Proposition 1).

Acceptance of the change is crucial to successfully adapt to family dynamics, atmosphere, and role assignments in the presence of older adults that require family caregiving. While it explains that acceptance pre-requisites successful adaptation to one's environment (Axiom 2), the beginning and unfolding responsibilities demand careful family discussion in addressing the older adults' needs along with the caregiver responsibilities that accompany them along with all phases of family caregiving trajectory, thereby suggests that acceptance of the caregiving role is a process (Axiom 3). The widespread expectation of pursuing caregiving of the older adults supports the idea that acceptance of the role will determine the caregiver's acceptance of consequences in the form of physical, economical, psychological, and spiritual aspects (Proposition 2). Furthermore, the acceptance of role is challenged as responsibilities of family caregiving unfold that may present role ambiguity, future uncertainty, and self-efficacy concerns during care provision. This implies that whatever change the older adults present during the term of care provision, the family caregiver is ready to accept the consequences that may accompany role assumption supporting the idea that family members who accept the possibility of the decline of their older adults are likely to be prepared to assume caregiving roles (Proposition 3).

Following unfolding responsibility in the family caregiving trajectory, increasing care demands lead to surrogacy in terms of healthcare decisions and physical care. This is congruent with the idea that the family, as a unit, strives for balance and requires resources to sustain it (Axiom 4). Therefore, the trajectory family caregiving process is influenced by factors such as resources (Proposition 4). Acceptance of the caregiving role also means that end-of-life care terminates the family caregiving trajectory. This requires more intensive caregiving demands, which supports that acceptance of the role will determine the caregiver's acceptance of consequences in the form of physical, economical, psychological, and spiritual aspects (Proposition 2). This idea is applied not only in the final phase of the family caregiving trajectory but is also evident during unfolding responsibilities and increasing care demands.

Discussion

Literature postulates the dynamism of family relationships as crucial to understanding the behavior of its members. Children and parents, for instance, remain closely related across the course of life, and the well-being of these individuals is guaranteed by the quality of intergenerational relationships that they have. These relationships are enduring and consequential, and their behavior is a result of the years they have been together (Schulz et al., 2020; Thomas et al., 2017). The quality of family relationships in the form of support and supervision determines the favorable influence and consequently acceptance among growing children of the responsibility that they hold as their older adults age. Children of the older adults, for instance, assume roles from a personal perspective with the basis of obtaining profound meaning and reward and as a means of giving back the love and care they were given as children along with the idea that central to their well-being is the commitment to favor connection of generations (Reinhard et al., 2011; Thomas et al., 2017).

Shared within the context of familial relationships and rearing, beliefs that underpin the family members' behavior in the care of their older adults encompass culture (Revenson et al., 2016). Who ends up as becoming the primary caregiver is shaped by existing relationships to the older adult in need of care, gender expectations, cultural background, and geographic proximity (Scheibl et al., 2019; Solomon et al., 2018). Primary caregivers may range from a spouse or any other family members, and this decision is determined by cultural factors (Donovan et al., 2011). Family caregivers often serve as advocates and coordinators of care, and their roles are unfolded within transitions of caregiving trajectory. Assumption of caregiving roles by the family member is directed towards achieving a satisfactory level of acceptance regarding this crucial decision-making process which is highly influenced by widespread cultural expectation (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016; Reinhard et al., 2011). The cultural influence of both the older adults and the caregivers likewise provides direction in the choice of culturally appropriate care that the recipient requires. This likewise connotes that caregiving services become highly individualized for the older adults to receive compared to when they are delivered by service agencies, implicating the cultural relevance of family caregiving societal acceptance (Donovan et al., 2011; Revenson et al., 2016). Endured by generations, the witnessed caring practices have somehow shaped the family members' views of anticipating the care of the older adults in the future. It is also grounded from the influences of internalized debt of gratitude and desire to give back the care they once received, thereby enhancing their motivation to accept family caregiving roles.

Equally important in exploring the cultural and relationship-based nature of the concept of family caregiving is the understanding of the process to denote when it begins, pursues, and terminates. The trajectory of family caregiving begins with the awareness of the family members towards the older adults' behavioral indication or changes in health that may warrant a certain degree of caregiving (Gilbert et al., 2018). Functional impairment, when gradually observed, provides subtle assumption of acceptance of family caregiving as compared with sudden older adult's health decline that proves challenging (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016). The Roy Adaptation Model explains the interaction of a person in a changing environment (Ursavas et al., 2014). Given the complexity of family caregiving, preparedness for the responsibility is crucial. Inadequate preparation of the caregivers is what constitutes burnout (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016). This denotes the relative importance of acceptance as a requirement for being prepared to assume caregiving roles. While the intensity of required assistance may not be as exhausting in the initial phase of the caregiving trajectory, accepting the role prepares the caregiver for more challenging roles in the future. The psychological well-being of the family caregiver relates to acceptance of the role that positively influences the outcomes of the caregiving (OMalley & Qualls, 2020). Studies pointed out higher anxiety levels and burden caused by longer duration of caregiving, which can be attributed to required duties that range from provision of assistance to direct administration of services to the care recipient, assistance with household activities, self-care measures, ambulation or mobility, emotional and social support provision, advocacy, coordination of required health care and surrogacy (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016; Lou et al., 2015). The need to balance personal and social roles in these trying times can prove to be challenging, specifically with respect to competing pressures of employment, watching over their own children, and older adult care (Donovan et al., 2011; Thomas et al., 2017). The widespread expectation of pursuing caregiving of the older adults provides clear implications that informal caregiving is what families must take as a primary responsibility (Revenson et al., 2016).

The unpredictability of the older adult's condition and poor acceptance of role compromise the process of caregiving, leading to disadvantaged positions for both parties (Camak, 2015; Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016). Over time, the older adult's dependency contributes to increasing reliance on the family caregiver to perform required functions (Schulz et al., 2020). Consequently, the caregiver is expected to provide more assistance than usual which compromises resources and work-life balance. Change in caring status and demands results in strengthening coping secondary to required adaptation. While increasing physical dependence leads to more caregiving demands, there is not always a negative consequence as some family caregivers find fulfillment in the accepted caring roles. Domains of care may include monitoring older adults' condition, medication administration, communication with healthcare professionals, and transition from home to hospital or facility management. This implicates that family caregivers are introduced as partners with healthcare professionals in the integration of a collaborative approach of care with an emphasis on caregiver-friendly policies and flexible arrangements (Bell et al., 2019). On a similar note, better transitional care calls for effective and quality care as the transition from one setting to another proves to be the most vulnerable and traumatic experience of the family caregiving process (Reinhard et al., 2011).

Caregiving roles may change over time and may be highly individualized as older adults tend to go into the transition from one health care setting to the other, changes in the familial, social, and geographical context of care provision. While transitions can be planned as in the case of scheduled older adult's follow up in the hospital or unplanned such as emergency room visit or required re-admission, that certain degree of unpredictability of family caregiving proves that the family members' needs and dynamics must be assessed periodically so that their needs are addressed during transitional periods (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016; Gitlin, 2019). Caregiving responsibilities are considered acute for families if older adults suffer from abruptly appearing conditions such as stroke, dementia, or even mental illness (Gitlin, 2019). These often become troublesome as the older adult's condition becomes complex and their behaviors become severe (Liu et al., 2018; Reinhard et al., 2011). Acceptance of the nature of predictability of the older adult's condition over time makes caregiving roles well-tolerated alongside the idea that family members are more likely equipped to respond to demands when prompted.

The increasing complexity and intensity of older adults' conditions prove to be challenging as they are burdened by their decisions to determine what would be best for their older adults (Jehangir et al., 2019; Reinhard et al., 2011). With respect to the beginning and sustaining family caregiving process, caregivers relied on siblings and other support services to communicate older adults' intensified needs (Gilbert et al., 2018). Monetary resources to pave the way for medication procurement, check-up, and required to follow up are crucial to both the health of the family caregiver and older adult (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016). The amount and type of care the family caregivers provide heavily depends on economic resources and the demand for the family caregiver's time and energy (Kaplan & Berkman, 2021; Schulz et al., 2020). Despite challenges, caregivers find meaning and purpose at the end-of-life care phase of family caregiving (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016; OMalley & Qualls, 2020). The cultural beliefs that underlie the older adults and the family caregivers are crucial to care provision in this process (Revenson et al., 2016).

With an unprecedented demographic imperative of the global population of older adults, specific family caregiving implications arise (Gitlin, 2019). The concepts related to family caregiving encompass the phenomenon as a process influenced by resources, cultural expectation, and degree of acceptance by caregivers who provide care to an older family member. The development of a theory to fully understand this process is beneficial to certain degrees as it explains the occurrence of practice, predicts based on future empirical evidence, and controls the process that favors both the older adult and the caregiver. This theory can greatly contribute to the practice of gerontology nursing in matters relating to older adults' health and well-being, family structures and relationships, and caregiver self-efficacy and fulfillment. As the family caregivers represent the health care system's partners to ensure older adults' maximal health, understanding this theory from the perspective of both the older adults and their caregivers is essential.

The Acceptance Theory of Family Caregiving aims to explain acceptance as vital in the trajectory phases of caregiving, not only on the older adult but also on the family caregiver to initiate needed actions (Potter et al., 2017). It also aims to predict that inadequate preparation to caregiving role assumption due to poor acceptance of the demanded situation often leads to caregiver burden (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016). Therefore, mitigation strategies to address caregiver burden is to allow the family caregivers to realize the change that demands adaptation, and only through acceptance of family caregiving role should adjustment set in (Nguyen & Levkoff, 2020).

Within the bounds of familial relationships and widespread cultural expectation, the care of the older adults translates as a responsibility of the family members endured by several generations (Gaugler et al., 2018). The strong inter-generational solidarity emphasizes that family caregiving, as the name implies, is based on a commitment derived from cultural and familial factors (Paguirigan, 2019). Varying from these influences, the family caregiving process, known as trajectory, involves a series of phases that present several challenges to both older adults and family caregivers (Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, 2016). Requisites to meeting each phase of the process is a degree of acceptance of role assumption by the caregiver that equates to the anticipation of the requirement of resources, role changes, and demands with respect to awareness, unfolding responsibilities, increasing demands, and end of life phases of family caregiving.

Acceptance Theory of Family Caregiving

Understanding acceptance also intends to communicate it as inherent in family relationships within the context of older adult care (Schulz et al., 2020; Thomas et al., 2017). While it is an expectation for older adults to have someone to care for them when dependency calls for caregiving roles, the crucial role it plays determines the success of the family caregiving process (Luichies et al., 2021). At some point in their lives, older adults require someone to perform for them the activities of daily living owing to increasing physical dependency and cognitive decline. The acceptance of a family member's caregiving role, while a process, is situated in every phase of the family caregiving trajectory. Associated with motivation, acceptance is a driving mechanism that influences the behavior of the family caregiver in performing roles that are unique in every step of caregiving.

Figure 1 shows the theory's framework as it relates to the essential concepts of family caregiving. Central to the framework is acceptance infused within the overlapping trajectory phases: awareness, unfolding responsibilities, increasing care demands, and end of life. The diagram attempts to communicate that as the phase/s (represented by green circles) move away from acceptance (represented by a yellow circle), it decreases infusion not only with acceptance but successful family caregiving (represented as a large red circle) as well.

The overlapping trajectory phases imply the stages that every family caregiver goes through with respect to the needed assistance of the older adult. As the care can be highly individualized, the demands vary along with other determinants, including resources and self-efficacy. Similarly, there is a variation in terms of the duration by which the family caregiver undergoes, along with the gradual or sudden emergence of care demands. The care of the older adult in the family caregiving process is determined by the acceptance of role assumption by the family caregiver across trajectory phases, crucial in the understanding of successful family caregiving.

The theory is applied among families whose care of older adults is within their domain. It may not be fully applied to families that delegate the care of their older adults in nursing facilities. In addition, the underlying cultural acceptance of family caregiving influences the theory's applicability. Lastly, the definition of the family caregiver in the context of this theory extends beyond the influence of blood and marriage, consistent with related literature and studies. Going through the provided definition minimizes confusion relating to the population scoped within the theory.

Conclusion

While several challenges await the family caregiver in the assumption of societal and culture-based measures alongside the expectation of older adult care, much concern is concentrated on their health status over the caregiver's situation. The discrepancy of the care recipient and provider focus paved the way for a developed theory that targets acceptance of these challenging roles of the provider as it greatly determines the outcomes of favorable healthcare outcomes of the recipient. The developed theory suggests that the care of the older adult in the family caregiving process is determined by the acceptance of role assumption by the family caregiver across trajectory phases. This study highlights the vital implication of acceptance of role assumption to the outcomes of the caregiving process with respect to older adult care, prevention of family caregiver burden, and establishment of strong familial and social relationships.

Acknowledgment

All authors would like to thank Cebu Normal University and Angeles University Foundation for the support and encouragement in this academic scholar study.

Declaration of Conflicting Interest

All authors declare no potential conflict of interest.

Funding

No specific grant from any funding institution is received for this research.

Authors' Contributions

AF conceptualized, designed, analyzed, literature searched, and drafted the study. EF contributed to conceptualization, edited, formatted, and prepared the final manuscript draft. DP likewise contributed to conceptualization and analysis, reviewed, and supported concepts with intellectual content and literature search. FG additionally analyzed data with intellectual content and literature search. All authors substantially contributed with equal efforts until approval of the final article and acknowledged that all those entitled to authorship are listed as authors until publication.

Authors' Biographies

Alfredo Feliciano, PhD, RN is an Assistant Professor IV at the College of Nursing, Angeles University Foundation, Angeles City, Philippines and a DScN Gerontology Nursing student at the College of Nursing, Cebu Normal University, Cebu City, 6000, Philippines.

Evelyn Feliciano, PhD, RN is an Assistant Professor VI at the College of Nursing, Angeles University Foundation, Angeles City, Philippines and a DScN Gerontology Nursing student at the College of Nursing, Cebu Normal University, Cebu City, 6000, Philippines.

Daisy Palompon, DScN, PhD, RN is a Professor VI and Vice-President for Academic Affairs at the College of Nursing, Cebu Normal University, Cebu City, 6000, Philippines.

Dr. Ferdinand Gonzales is an Assistant professor at the Medical-Surgical and Pediatric Nursing Department, College of Nursing, University of Hail, Saudi Arabia.

Data Availability

Not applicable.

References

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Articles from Belitung Nursing Journal are provided here courtesy of Belitung Raya Foundation

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Acceptance of roles in the care of older adults by a family caregiver depends on factors emanating from commitment to familial relationships, widespread cultural expectation, and debt of gratitude. This study aims to develop a theory that explains the ...

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This articles includes many stories about the effects of a caregiver worker and how their experience has made an impact in their life.

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The following stories have been shared by NDWA supporters who have been impacted by domestic workers.

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While caregiving can be rewarding and strengthen relationships, it often leads to high levels of stress and emotional or physical strain. Signs of caregiver stress include constant worry, fatigue, mood swings, and neglecting personal health.

Managing stress involves asking for help, focusing on achievable tasks, staying connected to support systems, and maintaining personal health. Caregivers should use resources like support groups, respite care, and local caregiving services.

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Practical solutions for caregiver stress

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Fight caregiver stress and prevent burnout by taking time to take care of yourself.

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Caring for others at work can be tough and stressful, which affects both your health and the quality of care you provide. It’s important for managers to recognize signs of stress and adjust workplace policies to help reduce it. Additionally, both managers and employees should learn ways to cope with stress and know where to find support.

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Providing care and services to the public can be demanding and stressful. Work-related stress can affect your well-being, the care and services you give to others while doing your job, and the well-being of the people you care about outside of work.

It is critical for managers and supervisors to recognize what stress looks like, and to change organizational policies and practices to reduce job-related stress. It is also helpful for managers and workers alike to learn how to cope with stress and know where to go for help.

Feeling irritated, angry, or in denial

Feeling uncertain, nervous, or anxious

Feeling helpless or powerless

Lacking motivation

Feeling tired, overwhelmed, or burned out

Feeling sad or depressed

Having trouble sleeping

Having trouble concentrating

Know about burnout:
Workers experiencing burnout often feel exhausted and cynical. Working in a distressing environment can strain a person's physical, emotional, and psychological well-being. Workers with burnout are more likely to experience mental health conditions like anxiety and depression. Burnout can also impact employee retention. Workers experiencing burnout may be less engaged at work and choose to leave their job or their profession altogether.

Managers and supervisors can play a big role in reducing and preventing job-related stress. Burnout can develop when workers have too many demands that require effort and not enough resources to meet those demands. While individual-level solutions like self-care and resilience training can help, changing workplace policies and practices the best way to address burnout.

CDC has an online training for public health supervisors and managers: learn strategies to prioritize employee health and well-being and prevent burnout .

Managers and supervisors can use a Total Worker Health ® approach to implement policies, practices , and programs . A program to reduce work-related stress might include:

1. Implement organizational and management policies that eliminate the root causes of stress, such as excess demands or workplace bullying . Also implement policies that provide workers with increased flexibility and control over their work and schedules.

2. Provide training for supervisors on strategies to reduce stressful working conditions.

3. Provide training and interventions to build resiliency for stress management and reduction for all workers. Provide access to Employee Assistance Programs.

Communicate with your coworkers, supervisors, and employees about job stress.

Talk openly about how job stress is affecting your well-being.

Identify factors that cause stress and work together to identify solutions.

Ask about how to access mental health resources in your workplace.

Identify and accept those things which you do not have control over.

Take breaks during your shift to rest, stretch, or check in with supportive colleagues, coworkers, friends and family.

When away from work, get exercise when you can. Spend time outdoors either being physically activity or relaxing. Do things you enjoy during non-work hours.

Learn healthy ways to cope with stress.

If you're concerned that you or someone in your household may harm themselves or someone else:

If you need to find treatment or mental health providers in your area:

If you want more information on coping with stress and building resilience:

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Support for Public Health Workers and Health Professionals﻿

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CDC's mental health website provides basic public health information about mental health including surveillance, disorders, myths and facts, and prevention.

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Veronica has dedicated over 30 years to working as a nurse's aide and patient care assistant, providing compassionate care to patients who often had no family. Due to health issues, she stopped working in 2006 and now relies on a limited disability income. Facing financial struggles and the risk of losing her home, she’s trying to re-enter the workforce but is hindered by costly certification requirements.

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A job at $8 or $9 hourly without benefits - Family Caregiver Alliance

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I have been working as a nurses aide and patient care assistant for aver 30 years, in various healthcare agencies, and nursing homes. I always tried my best to make my patients happy, by giving them best care. I did it as a mission because I like to help people. I know that it’s the last love and care that they are receiving; most of them do not have anyone left in their family. I took care of them the same way I would do for my parents.

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The study looked at how paid caregivers support people with dementia. It found that these caregivers kept the same roles even when care needs changed. Both paid caregivers and family members said that families play a key role in caregiving.

The caregivers provided not just basic help but also care that focused on the individual needs of the person with dementia and their family. The research suggests that this kind of personalized approach can lead to better outcomes for everyone involved. Overall, strong teamwork and emotional connections are important in caring for people with dementia.

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Paid Caregiving in Dementia Care Over Time: Paid Caregiver, Family Caregiver, and Geriatrician Perspectives - 24 Hours access

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Paid Caregiving in Dementia Care Over Time: Paid Caregiver, Family Caregiver, and Geriatrician Perspectives

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AbstractBackground and Objectives. As long-term care increasingly moves from facilities to the community, paid caregivers (e.g., home health aides, other h

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" Key Points:

There needs to be greater awareness in America about the tremendous stress of caregiving.

Adult caregiving is a huge societal burden that will only grow (the silver tsunami).

Major grief and losses are associated with the caregiving role for family members " (Kim, 2023).

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America’s Caregiving Crisis: A Growing Disaster

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As a country, we generally lack user-friendly, systematic resources and policies to address the growing adult caregiving crisis, which can lead to caregiver stress and insolvency.

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Jean Watson’s Theory of Caring, which emphasizes that caring is central to the nursing role. This approach promotes a holistic view of healing, integrating mind, body, and spirit. Nurses are encouraged to be fully present with patients, fostering authentic relationships that enhance healing.

To maintain emotional sensitivity in a demanding work environment, nurses must also prioritize their self-care. Watson's theory highlights that caring benefits both patients and nurses, improving health outcomes and fostering deeper connections.

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Jean Watson’s Theory of Human Caring | Redlands Community Hospital

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For more than 100 years, we have been providing quality, compassionate medical care for the people of Southern CA. Learn more about Jean Watson’s Theory of Human Caring.

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A review looked at the self-care needs of older adult caregivers and found that they need things like exercise, ways to manage stress, and social support. The caregivers used strategies like speaking up for themselves, coping skills, and making their own well-being a priority. The results suggest that more research is needed to help older caregivers stay healthy while they care for others.

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This article explains caregiver burnout, which happens when employees caring for loved ones feel very stressed and exhausted. To help, companies can spot early signs of burnout, adjust workloads, and create a supportive environment. Offering wellness programs and resources for stress management can improve employee well-being and productivity.

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Your employees have been dealing with a lot. A pandemic, changes in work situations, financial uncertainty, social unrest ... but at least they have after-work time and weekends to relax and re-center, right?

Not if they're caregivers, they don't.

Being a caregiver to another person in need, whether it's an aging parent, a child with special needs, or a spouse suffering from health issues, can strain even the most energetic, resilient employees.

In this blog, we'll take a look at caregiver burnout and what you can do to help mitigate the effects on your employees through your wellness program offerings.

What Is Caregiver Burnout?

Caregiver burnout is unique in that it involves more than the physical, emotional, and mental exhaustion that are common with "traditional" employee burnout. An employee can always walk away from a job that's burning them out. But with caregiver burnout, the exhaustion and frustration may be coming from caring for the person the employee loves most in the world. The result? A massive cocktail of affection, resentment, stress and guilt, to name but a few of the many conflicting emotions that come with caregiving. Caregivers often lose their sense of selves, finding themselves taking care of everybody and everything but their own well-being.

How Does Caregiver Burnout Happen?

In addition to neglecting their own needs, employees who struggle with caregiver burnout usually deal with a common set of factors:

Lack of Boundaries: People who become caregivers often have difficulty setting boundaries between their role as a caregiver and their own needs. The other person's dependence on them and their own sense of love or obligation makes it incredibly difficult to carve out "me" time.

Resignation: Many caregivers have unrealistic expectations about the impact they will have on the person in their life. When their loved one suffers from a progressive disease, such as Parkinson's or Alzheimer's, they may become resigned and even experience depression.

Lack of control: Many caregivers become frustrated by the financial impacts of caring for loved ones, as well as not having the skills or support to implement the best care plan.

Overwhelm: In some cases, caregivers become completely overwhelmed by the demands involved in taking care of their loved ones.

What Does Caregiver Burnout Look Like?

Your employees will exhibit certain behaviors when they are experiencing caregiver burnout, including:

Withdrawal from other friends or family members

No longer being interested in hobbies or pastimes

Irritability, hopelessness or pessimism, and sadness

Appetite and weight changes

Fatigue and low energy

Increased illness and use of sick days

Signs of increased alcohol or drug use

How Does Caregiver Burnout Impact Your Organization?

More than likely, you have employees in your company who are in a caregiver role-some of them may have been in that role for years, while others are newly immersed in it. Either way, waiting until employees are already in the tailspin of caregiver burnout can be quite costly for your organization.

The Harvard Business Review estimated a health care spending cost of $125 billion to $190 billion due to caregiver burnout. From a productivity perspective, any type of burnout hampers how well employees perform their jobs and relate to coworkers.

This is especially true for the 73% of women who have found themselves in the "Sandwich Generation," where they care for their children and their aging parents.

Women Are More Likely to Experience Caregiver Burnout

Women are more likely to experience caregiver burnout because they are often burdened with handling the household tasks in addition to working and caring for loved ones. In fact, according to a December 2020 Spring Health report, 80% of employed women say they experience burnout.

Marital status and family size are significant factors in levels of caregiver burnout. About 6% of unmarried American employees say they experience complete burnout compared to 12% of those who are married. When we look at working parents, 12% say they are burned out-almost double that of their counterparts without children.

How You Can Support Caregivers in Your Organization

So how can your organization help employees struggling with caregiver burnout, or better yet, help them prevent it in the first place?

Obviously, you can't do the caretaking for them, nor can you intervene in family dynamics. But there are actions your organization can take to support employees, whether it's through your HR policies, mental health benefits, management training, and/or corporate wellness challenges.

Identify Caregiver Burnout Early

Make sure your supervisors and managers are well trained to recognize burnout, specifically, caregiver burnout in the earliest stages. When it comes to addressing mental illness, having a support system in the workplace that intervenes early can help prevent the depression and anxiety that often accompanies caregiver burnout.

Adjust Employee Workload

Your supervisors should be empowered to adjust employee workloads when they spot the early signs of burnout in an employee. They can alleviate some responsibilities or shift deadlines to provide the employee with a less demanding work environment.

In some cases, reassignment to other teams or responsibilities may be necessary, especially for employees in high-stress positions. However, it's vital to reassure employees that the change is meant to assist them in managing all of their responsibilities and is not a sign of eventual termination. Any employees who see a burned-out co-worker being shown the door will take notes. And they'll avoid reaching out for support ... until it's far too late.

It is highly likely that employees experiencing caregiver burnout will be hard on themselves and have to be encouraged to accept any type of help from their supervisors and senior management.

Develop a Culture of Listening

When employees feel that their managers are willing to listen to work-related problems, they are 62% less likely to burn out.

When employees feel that their managers are willing to listen to work-related problems, they are 62% less likely to burn out. By creating an environment where employees feel heard, supervisors and managers can support employees, keep them engaged, and help alleviate the stressors for caring for loved ones.

Coaching services is another way employees can be supported. If your corporate wellness program includes a coaching component, employees who display the early or late-stage signs of caregiver burnout are excellent candidates for this offering.

Adapt Your Corporate Wellness Program

Not only is your corporate wellness program designed to help employees achieve their health goals, but it can also be extremely useful in addressing issues like caregiver burnout. Specifically, you can incorporate any number of challenges and programs to help employees, including:

Wellness challenges that encourage healthy exercise and nutrition habits

Designated stress-free time and space for employees to unplug

Guided meditation, yoga and other stress-reduction techniques

Challenges related to taking scheduled breaks for a walk outside (or around the building)

Lunch-and-learns or online training regarding Medicare/Medicaid rules for caretakers

Scheduled support groups for "sandwich generation" employees

Access to support resources and guest speakers

These are just a few of the types of activities you can put in place to support employees experiencing caregiver burnout. The key is to keep employees informed, encouraging them to use these resources as soon as they need them. Managers can provide an early detection system, keeping watch for any employees who appear to display signs of burnout and providing them with help and support.

At WellRight, our team of corporate wellness experts have a wealth of knowledge to assist you in creating a supportive space for your employees to thrive. For help setting up challenges and strategies specific to caregiver burnout, contact us. We can help.

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How to Help Your Employees Deal With Caregiver Burnout

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Your employees are more susceptible to caregiver burnout than ever. Learn how to help them cope.

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This article gives many examples for the benefits of caregiving. Some of these include finding purpose, gaining a sense of fulfillment, a flexible schedule, and feeling like you are making a difference.

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The Many Benefits of Becoming a Caregiver – Express Healthcare Professionals