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THE RELATIONSHIP BEIWEE‘N IMPACI‘ ON SCHEDULE AND *
DEPRESSION IN CAREGIVER DAUGHTERS, OF ELDERLY NDIHERS,
WITH DIFFERING EMPLOYMENT STATUS

presented by

Patricia M. Kemner De Vries

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THE RELATIONSHIP BETWEEN IMPACT ON SCHEDULE AND
DEPRESSION IN CAREGIVER DAUGHTERS, OF ELDERLY MOTHERS,
WITH DIFFERING EMPLOYMENT STATUS

By

Patricia M. Kemmer DeVries

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1995

ABSTRACT

THE RELATIONSHIP BETWEEN IMPACT ON SCHEDULE AND
DEPRESSION IN CAREGIVER DAUGHTERS, OF ELDERLY MOTHERS,
WITH DIFFERING EMPLOYMENT STATUS
By

Patn'cia M. Kemmer DeVries

This study examined the impact on schedule of 120 caregiver
daughters, of elderly mothers, who were employed, unemployed, or
had terminated employment during the first 2 through 4 weeks of
caregiving and the relationship between impact on schedule and
depression. No significant differences on impact on schedule were
found in the three different employment groups by using analysis.
Significant Pearson correlation were found between impact on
schedule and depression in employed and unemployed caregiver
daughters. However, there was no significant relationship between
impact on schedule and depression in daughters who terminated
employment. Implications for adVanced practice nurses were based
on role theory and include adequate preparation of the new
caregiver regarding expected tasks, time involvement, and

community resources.

Acknowledgments
The completion of this thesis would not have been

possible without the support and encouragement of many people.
Thank you to Carla Barnes, Ph.D., for chairing my committee and
providing guidance and encouragement. Thank you also to Barbara
Given, Ph.D. and Rachel Schiffman, Ph.D. for their patience and
insight.

A special thanks to my mother Martha Kemmer and my
husband Phil DeVries whose support sustained me in my efforts

toward completion of this thesis.

iii

Table of Contents

List of Tables
list of Figures .
The Problem
Introduction .
Research Question.
Definition of Concepts .
Impact on Schedule .
Depression.
Literature Review .
Impact of Caregiving on Schedule .
Caregiver Daughters.
Caregiver Spouses
Employment Status of Caregivers .
Summary .
Caregiver Depression .
Caregiver Daughters .
Depressive Symptomatology .
Clinical Criteria .
Spouse Caregivers .
Depressive Symptomatology .

iv

Page
vii

viii

\ICDCDOWi—ir—t

10
10
11
12
13
13
14
14
14
16
17
17

Clinical Criteria .
Summary.

Caregiver Daughters and Employment . .

Employment as a Buffer.
Role Overload .

Summary..

Theoretical Framework.
Methods.

Sample

Operational Definitions . . .
Employment Status.

Impact on Schedule .
Depression .

Instruments .

Hypotheses .

Protection of Human Rights .
Assumptions and Limitations.
Data Analysis .

Results.

Discussion .

Interpretation of Findings .
Demographic Variables .
Dependent Variables .

Result of Hypothesis Testing .
Hypothesis #1 .

Hypothesis #2 .

19
19
20
20
21
23
24
29
3o
30
30
31
31
32
33
33
33
34
34
38
38
38
39
40
4o
42

Implications for Role Theory .
Implications for the Advanced Practice Nurse.
Limitations of the Study .
Recommendations for Future Research.
Summary .

Appendix A Caregiver Reaction Assessment (CRA)

Appendix B Center for Epidemiologic Studies of Depression
Scale(CES-D). . . . . . . . . . .

Appendix C University Committee on Research Involving
Human Subjects (UCRIHS) Approval for the Original Study

Appendix D UCRIHS Approval for the Current Study .

List of References .

vi

43
44
47
so
51
52

54

S6
58
S9

List of Tables

Table Page
1. Sociodemographic Characteristics of Caregiver

Daughters by Employment Status . . . . . . . 36
2. The Correlation of Impact on Schedule and
Depression in Caregiver Daughters by Category

ofEmployment.............. 38

vii

List of Figures
Figure Page

1. Potential Deleterious Effects of Role Strain . . 26

2. .Women with Multiple Roles may Experience

Impact on Schedule and Depression . . . . . . 27

viii

The Problem
Introduction

In contemporary society, it is common for women to have
multiple roles including wife, mother, career woman, and caregiver
of elderly parents. Sometimes referred to as the "sandwich
generation", middle-aged women are finding themselves caring for
' both their children and their parents. Daughters are more frequently
involved in caregiving activities for elderly disabled family members
comprising 29% of family caregivers, compared to sons who make up
less than 10% of family caregivers (Gallagher, Rose, Rivera, Lovett, &
Thompson, 1989).

As a result of advanced technology in health care, people are
living longer but the quality of life is not equally extended.
Presently, persons 85 years and older constitute the age group that is
experiencing the most rapid growth rate in America (Longino, 1988).
In 1963, 25% of people over the age of 45 had a surviving parent
and by 1980, 40% of people in their late fifties had at least one
surviving parent (National Retired Teachers Association - American
Association of Retired Persons, 1984). It is estimated that by the
year 2000, the population over 85 years will reach 5.4 million
compared to 2.3 million in 1980 (Longino, 1988).

Hence, society must make provisions to maintain the

1

fundamental requirements of the elderly who are unable to perform
independent activities of daily living. An estimated 70% of
individuals 85 years and older require assistance with one or more
activities of daily living (Johnson & Hoover, 1982; Soldo & Longino,
1989; Suzman & Riley, 1985). It was predicted that many elderly
people will be women who are disabled and in need of caregivers
(Iamphere-Thorpe & Blendon, 1991; Manton & Soldo, 1985). An
estimated 70% of the oldest Americans are female (Longino, 1988)
and widowed females account for the majority of persons 85 years
and older (Serow & Sly, 1987). Since women are surviving longer
than their spouses, the responsibility of caregiving generally falls
upon their daughters. The Census Bureau estimates that by the year
2030, 7 of 10 baby boom women will outlive their husbands to live
approximately 15 years alone (Beck, 1990), generating a cycle of
perpetual need for caregiver daughters. More elderly widows will
depend on their daughters as a result of advanced technology
prolonging their lives; caregiver daughters can expect to spend more
years caring for an aging parent than for a dependent child
(Wisensale, 1993).

Thus, caregiver daughters will persistently experience the
demands of role accumulation and new Stressors as they combine the
modern role of employment with the traditional role of caregiving. A
considerable number of daughters provide care for their elderly
parents, particularly their mothers, while employed (Brody &
Schoonover, 1986; Pohl, Given, & Given, 1991; Stoller, 1983;
Wisensale, 1993). Approximately 75% of all women 18 to 44 years

of age are in the labor force, as are 62% of all women between 45
and 54, and 42% of those between the age of 53 and 64 (Wisensale,
1993). The Family and Medical Leave Act of 1993 provides unpaid
leave for caregivers who are employed by private companies with 50
or more employees. Many workers and particularly low income
individuals cannot afford time Off work without pay. Caregiver
daughters who work for companies with less than 50 employees may
be forced to terminate employment to care for their elderly parents.
Caregiver daughters who continue to work may experience role
Strain including emotional distress and schedule disruptions (Walker,
Martin, & Jones, 1992). In general, female caregivers report higher
levels of strain than do male caregivers (Cantor, 1983; Fitting, Rabins,
Lucas, & Eastham, 1986; Horowitz, 1985). This susceptibility may be
attributed to the finding that female caregivers are typically younger
than male caregivers (Fitting & Rabins, 1985). At a younger age,
women may be in the work force and raising children, in addition to
providing care to an elderly mother. Moreover, caregiver daughters
with multiple roles may experience emotional strain when they
protect their families and work, but not their personal interests
(Cantor, 1983). Hence, working women with multiple roles may find
that caregiving decreases time for meeting personal needs, engaging
in other relationships, and focusing on career goals (Archbold, 1982).
Particularly, a lack of personal time to concentrate on one's
own physical and emotional needs may lead to a loss of sense of self
and eventually to depression (Barusch & Spaid, 1989). An estimated

50% of all caregivers suffer from depression (Cohen & Eisdorfer,

1988; Shields, 1992). Caregiver depression may be due to a lack of
support, respite, and confidence in performing care activities. As a
result, caregivers may experience loneliness, anger, guilt, and longing
for a lost lifestyle (Sommers & Shields, 1987). Furthermore,
depression has been found to interfere with daily functioning and to
impede the ability to provide care (Clayton, 1982). Also, it has been
shown that high levels of depression cause vulnerability to physical
health problems over time (Given, Given, & Stommel, 1991). It is
typical for modern women to have multiple roles; however, the
addition of parent caregiver to these roles may result in a significant
impact on schedule and have possible deleterious psychological
effects.

In the primary care setting, it iS not uncommon for individuals
to seek medical attention for vague and ill-defmed symptoms.
Caregiver daughters may seek medical attention for symptoms
triggered by role strain associated with the transition to caregiving.
It is also likely that caregiver daughters will accompany their parent
to health care visits, so advanced practice nurses (APN) need to
attend not only to the patient but also to the caregiver. As primary
care providers, APNS often must determine the origin of presenting
symptoms and conuibuting factors, such as multiple roles. In order
to detect a potentially health threatening situation and provide early
intervention the APN must be aware of caregiving-related stressors,
impact on schedule, and potential depression.

Much of the current literature examines seasoned caregivers

who have been involved in caregiving activities on average 3 to 5

years (Brody, litvin, Hoffman, & Kleban, 1992; Dellasega, 1990; Pohl,
Given, Collins, & Given, 1991). Relatively few studies have looked at
the effect of caregiving during the transition phase or in first 3
months of caregiving. Franklin, Ames, and King (1994) studied
employed female caregivers (N = 1 19) who responded to telephone
interviews and self-report questionnaires after 3 months of
caregiving. They found that women employed full-time or part-time
before caregiving used short-term work adjustments during the first
3 months of caregiving. These work adjustments did not influence
the probability of the caregiver taking a leave of absence or
terminating employment in the next 3 months.

Archbold, Stewart, Greenlick, and Harvath (1990) interviewed
caregivers (N = 78) after 6 weeks using the Family Caregiving
Inventory (Archbold & Stewart, 1986). They found caregiver
competence may have been a Stronger predictor of role strain at the
end of 6 weeks rather than during periods of more stability. The
transition period is a critical time when caregivers may experience
the most diffiuclty adjusting to the role. Moreover, Barusch and
Spaid (1989) interviewed caregivers (N = 131) after 3 months using
a coping inventory, Milardo's Social Support Inventory (1983), and a
caregiver burden scale (Zarit, Reever, & Back-Peterson, 1980). They
found that the care recipient's cognitive and behavioral difficulties
predicted burden. Other factors may predict burden prior to the 3
month mark, such as employment status.

Overall, the current caregiver literature has focused on

individuals who have been caregivers for an extended period of time.

little attention has been given to daughters as caregivers. In
addition to further research on caregiver daughters, more studies are
necessary to determine the effect of caregiving during transition to
the role. New caregivers in transition have been overlooked as a
sample and may produce different data regarding the effect of
caregiving than seasoned caregivers. This study is unique because it
examines an inception cohort during the first month of caregiving
rather than after long term adaptation.
Research Questions

Two questions were posed by this study: (a) what is the
impact on schedule in caregiver daughters who are unemployed,
employed, or have terminated employment during the early part of
caregiving? and (b) is there a relationship between impact on
schedule and level of depression in caregiver daughters bylevel of
employment? ,

Definition of Concepts

In this section the concepts of impact on schedule and
depression will be defined.
Impact on Schedule

In this study, impact on schedule was defined as a lack of
personal time which affects an individual's sense of self and freedom
as a result of caregiving. This definition includes not having enough
time for self, family/ friends, or leisure. The Impact on Schedule
subscale of the Caregiver Reaction Assessment (CRA) (Given,
Given, Stommel, Collins, King, & Franklin, 1992) was used to measure

impact on schedule. This study defined impact on schedule according

to the CRA, as a lack of personal time, elimination of scheduled
activities, and/ or constant interruptions. Examples of caregiving
tasks that may interfere with personal activities include: providing
transportation, helping with household tasks, assisting with personal
finances, running errands, and providing emotional support
(Robinson & Thumer, 1979).

A decrease in personal time may be reflected by a lack of time
for leisure activities, vacation, socialization with friends, and
management of one's own home (Cantor, 1983). Moreover, impact on
schedule is evident in the amount of privacy, personal Space,
freedom, and family time available and may subsequently lead to
sleep disturbances and exhaustion (Archbold, 1982). The changes
that are imposed on one's lifestyle are reflected in activities, income,
relationships, and habits (Archbold, 1982).

As involvement in caregiving tasks of communication, food
preparation, administration of medication, mobility, hygiene,
dressing, and feeding occurs, impact on schedule may become more
noticeable (Barusch & Spaid, 1989; Dwyer & Coward, 1991). The
amount of time necessary to complete numerous caregiving tasks
may leave an individual who has additional responsibilities, little
time for family, career, and self. Long term effects may include
depression, guilt, and anger toward the care recipient.

mm

Depression may be measured and categorized many different

ways. It may be defined according to clinical criteria, mood, or

depressive symptomatology. For the purpose of this Study,

depressive symptomatology is defined as an emotional condition
which may be a cumulative response to life processes, such as
caregiving. It may be characterized by feeling blue, depressed,
lonely, tearful, sad, disliked, bothered, unable to concentrate,
unrnotivated, that people are unfriendly, lacking appetite, and/ or
sleeping restlessly.

A common approach for defining depression focuses on the
diagnosis of clinical depression as defined by the DSM-IV (American
Psychiatric Association, 1994). The DSM-IV defines major
depression as depressed mood or loss of interest or pleasure lasting
for at least 2 weeks. At least 5 Of the following symptoms must be
experienced most of the day, nearly every day to conclude major
depression: (a) depressed mood, (b) diminished interest or pleasure
in almost all activities, (c) significant weight loss without dieting or
weight gain of 5% of body weight or increase/ decrease in appetite,
(d) insomnia or hypersomnia, (e) observable psychomotor agitation
or retardation (not merely subjective feelings of restlessness or being
slowed down), (f) fatigue or loss of energy, (g) feelings of ,
worthlessness or excessive/ inappropriate guilt, (h) diminished
ability to think/ concentrate or indecisiveness, or (i) recurrent
thoughts of death, recurrent suicidal ideation without a specific plan,
suicide attempt, or specific plan for committing suicide. These
symptoms must cause significant distress or impairment in social,
occupational, or other important areas of functioning to be
considered major depression and do not result from a

substance/ medication or general medical condition, such as

hypothyroidism.

Mood states may also be used in defining depression. For
example, the Profile of Mood States (POMS) (McNair, Iorr, &
Droppleman, 1971) describes depression as including feelings of
hopelessness and discouragement. Depression may be depicted as a
trait or mood, such as pessimism, loss of social interest, work
difficulty, fatigue or somatic preoccupation.

Another approach to defining depression is based on
depressive symptomatology. The Beck Depression Inventory (BDI)
(Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), Center for
Epidemiologic Studies - Depression Scale (CBS-D) (Radloff, 1977), and
lung self-rating Depression Scale (Zung, 1965) are examples of tools
that define depression according to symptoms. For example, the BDI
considers specific cognitive, behavioral, or vegetative symptoms and
attitudes to be manifestations of depression.

Rather than diagnosing depression according to clinical criteria,
the CBS-D identifies depression as evidenced by depressive
symptoms (Barnes & Prosen, 1984). The CBS-D is based on similar
symptomatology as the DSM—IV. Barnes and Prosen (1984) Stated
that depressive symptoms depend on the time available to
sleep/ read, the ability to be efficient, to have fun/ laugh, or to have a
meaningful life. According to the Radloff (1977), depressed affect
manifests itself as the blues, depression, loneliness, crying and/ or
sadness. The author of the CBS-D states that depression may include
depressed mood, feelings of guilt, worthlessness, helplessness,

hopelessness, and psychomotor retardation as perceived by the

10

individual. As a result, depression may adversely effect physical
health by causing a poor appetite, restless sleep, irritability, inability
to concentrate, lack of motivation, and/ or not being talkative.
Moreover, Radloff defines depression as psychological distress as
evidenced by the helplessness and hopelessness that often
accompanies depression. This study used the CES-D to measure
depression in caregiver daughters Since it incorporated mood, affect,
and depressive symptomatology. For the purpose of this study,
depression was defined as depressive symptomatology because
clinical depression was an unlikely manifestation during the 2
through 4 week transition period to caregiving.
Literature Review
The literature reviewed on caregiver daughters focused on the
impact of caregiving on schedule, caregiver depression, and
caregiving and employment. Depression and burden have been
investigated, but few people have looked at the relationship between
impact on schedule and depression.
Impact of Caregiving on Schedule
This section compared the literature on impact on schedule in
caregiver daughters with that in spouses and other caregivers. It
also looked at employment status and impact on schedule. For many
people, caregiving means they must sacrifice something in
order to provide time to socialize with or care for a homebound
elderly person. Unfortunately, sacrifices are usually made in the
area of personal time. The following studies reviewed caregivers

who were caregivers from a few weeks to over 5 years.

11

Caregiver Daughters
The literature found that caregiver daughters experienced a

considerable impact on schedule. Cantor (1983) studied impact on
schedule in a sample of caregivers, including daughters, using a
questionnaire (N = 1 1 1). Caregivers provided care following an acute
medical episode and were assessed before and after 12 weeks of
care. Cantor reported two-thirds of her sample of caregiver children
lived in separate households from their parents and lost personal
time by duplicating household responsibilities. In addition to
providing assistance to a dependent parent, caregiver children had to
carry out their own activities of daily living. Impact on schedule was
indicated by a lack of personal time. Cantor's study showed that
children lost more personal time than other relatives or friends.
Cantor did not specifically examine caregiver daughters.

Franan et al. (1994) found that caregiver daughters with full
- and part time employment made substantial adjustments during the
initial 3 months of caregiving. Time for caregiving, work, and family
had to be carequy balanced in order to avoid role overload. The
authors found that the time of role acquisition was the time most
caregiver daughters needed help. Franklin et al. (1994) found that
caregiver daughters who were employed particularly experienced
impact on schedule. Franklin et al. (1994) focused on the transition
period of caregiving rather than long term impact on schedule.

Archbold (1982) looked at the changes in lifestyle that
parentcaring daughters (N = 30) made as a result of caregiving.

Archbold (1984) found that caregiver daughters experienced impact

12

on schedule on a daily basis by a loss of freedom and inability to
make long range life plans. Two thirds of her sample had provided
care for five years or longer. Her data were based on interviews,
participant observation, and the OARS Multidimensional Functional
Assessment (Pfeiffer, 1976). Some caregivers postponed plans of
traveling or relocating in order to be near the care recipient, while
other caregivers rearranged their daily schedules to provide care,
especially if they were employed. Archbold's sample was small and
completely Caucasian; therefore, her findings may not apply to the
general population. Nevertheless, these studies showed impact on
schedule is a common experience among caregiver daughters.
Caregiver Spouses

In comparison, the literature on other caregivers Showed that
spouses experienced more impact on schedule than daughters.
Cantor (1983) studied a sample of caregiver spouses, children, other
relatives and friends/ neighbors (N = 1 1 1) using a questionnaire to
assess worry, strain and impact of caregiving on private life during
the first 12 weeks of care. She found that after spouses, the lives of
children were next most severely affected by caregiving. Cantor's
study showed the most severe impact was in the areas of free time
for oneself and opportunities to socialize with friends, take vacations,
have leisure time pursuits, and run one's own house. Furthermore,
Cantor (1983) found the impact of caregiving was most severe for

spouses, all of whom lived in the same house as the care recipient.

13

Employment Status Of Caregivers
Stone and Short (1990) compared employed and unemployed

caregivers (N = 1003) in a caregiver survey that estimated the
personal characteristics and use of health—related services by
disabled non-institutionalized elderly persons in the United States.
They found that primary caregivers (individuals with major care
responsibility) were about 19% more likely to alter their schedules
than secondary caregivers, regardless of employment status.
However, Stone and Short (1990) also Showed that employed
caregivers devoted less time to free time, household and leisure
activities. Hence, employed caregivers may experience greater
impact on schedule because they do not give up any responsibilities.
Stone and Short (1990) focused on caregivers in general, rather than
on daughters, and did not explore the effect of caregiving on long
range plans.
Summary

Impact on schedule was defined similarly across the studies
reviewed. Most of the literature defines impact on schedule as a loss
of personal time and freedom as evidenced by alterations in short
and long term plans. Although the literature on caregiver impact on
schedule does not emphasize daughters, it does Show that they are
the second most vulnerable group after spouses.

The majority of research has not differentiated daughters aSa
population that is especially vulnerable to a loss of personal time as a
result of caregiving. The literature shows that caregiver daughters

experience the second highest impact on schedule after spouses. In a

14

society where it is virtually required of women to manage many
aspects of family care, in addition to providing an income, it is
necessary to examine the relationship between multiple roles and
impact on schedule. Caregiver daughters may experience impact on
schedule because they do not eliminate activities from their
schedules as they acquire new responsibilities. As a result, they may
lose personal time. An individual subjected to the unrelenting
demands of life without reprieve may develop physical symptoms in
response to role overload.
Caregiver Depression

Depression has been defined differently throughout the
literature according to clinical criteria, mood states, and depressive
symptomatology. The studies reviewed were based on depressive
symptomatology and clinical criteria since they were the most
common approaches to measuring depression in caregivers. In this
section, the literature on depression in caregiver daughters was
compared with that in spouses and other caregivers.
Caregiver Daughters

Depressive Supptomatology. Some authors of the literature on
depression in caregiver daughters based their definition of '
depression on depressive symptomatology (Brody, Litvin, Hoffman, &
Kleban, 1992; Young & Kahana, 1989). Brody et al. (1992)
interviewed 492 caregiver daughters of elderly parents using the
Center for Epidemiologic Studies Depression Scale (CBS-D) (Radloff,
1977). The CBS-D focuses on depressive symptoms and psychological
distress to signify depression. Brody et al. (1992) found that marital

15

status of caregiver daughters was associated with differences in the
caregiving experience. The study reported married caregiver
daughters tended to receive more socioemotional and instrumental
support, have less financial strain due to higher incomes, and be less
depressed. Married daughters experienced more family conflict due
to caregiving, but the positive aspects of marriage outweighed the
negative aspects of caregiving. Brody et al. (1992) found that more
depression in caregiver daughters who were widowed or divorced
may have been related to a recent change in marital status.
Therefore, marital status may influence the risk of depresSion in
caregiver daughters. Brody et al. (1992) did not report the severity
of depression.

Young and Kahana (1989) conducted another study that looked
at depressive symptomatology in caregiver daughters. They held in-
home interviews using the Symptom Checklist (Derogatis, lipman &
Covi, 1973) to assess depression in 183 caregivers of post-myocardial
infarction patients. The authors found more symptoms reported by
daughters than wives, but did not report the prevalence of
depression. Caregiver daughters tended to adapt over time but
experienced more depressive symptoms than other caregivers.
Moreover, female caregivers reported higher levels of depression
than males, with a significantly greater mental distress reported by
daughters (Young & Kahana, 1989). Wives and daughters provided
similar amounts of care and both experienced negative outcomes, but
they did not suffer the same uniform effects. Young and Kahana

(1989) found that spouses provided a different range of services

16

than child providers and reported very different caregiver outcomes
related to burden and role conflict. They also found that caring for
an ill spouse may be a normative expectation for Older couples who
may perceive less burden. Hence, marital status and types of
services provided may influence whether a caregiver daughter
experiences depressive symptoms.

Clinical Criteria. Rivera et al. (1991) looked at depression in
caregiver daughters according to clinical criteria. They used the
Research Diagnostic Criteria (RDC) (Spitzer, Endicott, & Robins, 1978)
to assess depression in 165 women caring for frail family members
with similar levels of disability. The RDC were designed to identify
and classify individuals with psychiatric disorders. Based on the
diagnostic categories of major and minor depressive disorder, the
RDC may aid in the diagnosis of clinical depression. Rivera et al.
(1991) reported 44.8% (p = 39) of caregiver daughters was depressed
compared to 52.8% (p = 46) wives. The authors found caregivers
with more frequent general social contact were not depressed
because they adapted more readily to Stressors. Both depressed and
nondepressed caregivers had equal access to social support, but
nondepressed caregivers used resources more. Whereas, depressed
caregivers reported more negative interactions with others. The
Study by Rivera et al. (1991) was limited to a sample of Caucasians
with relatively high income and education. Clinical depression in

caregiver daughters seemed to be dependent on social support.

17

Spouse Caregivers
Depressive Symptomatology. In comparison to caregiver

daughters, studies on spousal caregivers determined depression
according to depressive symptomatology. Boss et al. (1990) studied
dementia patients and their caregivers (N = 70) using a semi-
Structured 2 hour interview and the lung Depression Scale (Zung,
1965) to measure depressive symptoms in the caregivers. The lung
Depression Scale determines depression according to the frequency
of 20 depressive symptoms in the past week. Their study showed a
sense of control and mastery in managing stressful caregiving
situations was associated with less depression. Whereas, patient
behavioral problems caused caregiver uncertainty about their
relationship with the patient and subsequent depression. Boss et al.
(1990) found that ambiguity and preoccupation created more burden
than the severity of the patient's illness. Caregiver perception of an
event determined whether caregiving had a negative impact. The
number of symptoms and severity of depression were not reported.
Robinson (1989) interviewed spousal caregivers (N = 78) using
the CBS—D. Robinson found caregiver health was the best predictor of
depression with caregiver attitude being the second most reliable
predictor. Her study Showed that caregiver spouses in better health
and with positive attitudes had less depression. Robinson (1989)
found that caregiver spouses generally believe caregiving is their
own responsibility and that they should be able to take care of their
spouses independently. She also found that an unmet desire for

support results in more stress and depression.

18

Stommel et al. (1990) used the CBS-D to measure caregiver
depression in 307 patient-caregiver dyads. Stommel et al. (1990)
found that depression may be the cumulative outcome of caregiving
processes. Stommel et al. (1990) found that their sample was
depressed, but felt that depression may have existed prior to
caregiving.

Given et al. (1993) studied 196 caregivers of cancer patients, of
whom 80% were spouses, using the CBS-D. It was found that patient
dependencies in activities of daily living (ADL) were directly related
to depressive symptomatology in the caregiver. Moreover, patient
dependencies in ADLs, symptom distress, and immobility were
directly related to impact of caring on caregiver schedule. Given et
al. (1993) found that the level of caregiver optimism was an
important predictor of variations in caregiver depression and
perceived impact of caregiving on health. Caregiver optimism
predicted impact of caregiving on daily schedule. Once again, a
relationship between depression and impact on schedule was cited in
the literature.

Macera, Baker, Jannarone, Davis, and Stoskopf (1993)
interviewed 82 family caregivers with 53% being Spouses. Using the
CBS—D, Macera et al. (1993) found that depressive symptomatology
was inversely related to having enough time to Sleep, read, etc.,
being efficient, having fun and laughing, and having meaningful
lives. The most important factor was getting enough rest or Sleep.
In summary, spouses experienced depressive symptoms when they

were unable to master stressful caregiving situations, had poor

19

health and negative attitudes, had little personal time, and their
partners had many dependencies. The severity and extent of
depression were not reported.

Clinical Criteria. Other studies used clinical criteria to define
depression in spousal caregivers. Drinka, Smith, and Drinka (1987)
found that 83% of 1 17 spousal caregivers of Alzheimer patients met
DSM-III-R criteria for major depression. Furthermore, Coppel et al.
(1985) reported that 41% of spousal caregivers (N = 68) met
Research Diagnostic Criteria (Spitzer et al., 1978) for depression. It
was also found in a sample of Alzheimer patients that 46% of related
caregivers seeking help met criteria for depression according to the
BDI (Gallagher, Wrabetz, Lovett, Del Maestro, & Rose, 1989).
Summary

In the current literature, the finding of depression varies
widely according to the conceptual definition of depression, including
clinical depression, depressed mood, and depressive
symptomatology. Much of the existing literature on caregiver
depression, with the exception of Brody et al. (1992) and Young and
Kahana (1989), fails to differentiate daughters from other caregivers.

Spouses are generally older and in poorer health at the
inception of caregiving which may increase their risk of depression. .
However, a caregiver daughter may have more outside obligations
and roles to fulfill than a caregiver spouse because of the differences
in age and developmental life stages at the time of caregiving. Thus,
caregiver daughters may be at greater risk for depression than

spouses. Caregiver daughters are also more likely to be employed

20

than caregiver spouses, since spouses are usually older.

Caregiver Daughters and Employment
The American Association of Retired Persons (1989) conducted

 

telephone interviews (N = 754) nationally and found almost one-
third of full and part time workers spend 2 1 or more hours per week
providing care. Therefore, caregivers spent a significant amount of
time providing care while employed. Hence, there were two themes
in the current literature: employment as a buffer and as a precursor
to role overload.
Employment as a Buffer

One perspective suggests that employment may act as a buffer
on caregivers (Baruch & Barnett, 1986; Barusch & Spaid, 1989;
Froberg, Gjerdingen, & Preston, 1986; Pohl, Given, Collins, &
Given, 1991; Scharlach, 1989; Stoller & Pugliesi, 1989; Tiedje,
Wortman, Downey, Emmons, Biernat, & lang, 1990; Waldron &
Jacobs, 1989). As a buffer, employment provides the caregiver with
outside social contacts and the opportunity to be productive. Studies
including caregiver daughters have demonstrated that roles outside
of the family are associated with improved caregiver well-being by
providing the opportunity for social interaction and respite from the
pressures of caregiving (Baruch & Barnett, 1986; Pohl et al., 1991;
Scharlach, 1989; Stoller & Pugliesi, 1989). Supporting research has
determined that employment also provides caregiver daughters
with a sense of competence at work which enhances self-esteem
(Baruch & Barnett, 1986; Froberg et al., 1986; Stoller & Pugliesi,
1989; Tiedje et al., 1990; Waldron & Jacobs, 1989).

21

Pohl et al. (1991) Studied a sample of caregiver daughters (N =
159) who were interviewed using the Social Provisions Scale (Russel,
Altrnaier, and VanVelzen, 1984) and the Caregiver Reaction
Assessment Scale (Given et al., 1992; Stommel, Given, & Given, 1990).
Pohl et al. (1990) found that employment buffered the effects of
more difficult roles and possibly enhanced well-being during the
transition to caregiving by providing social support and increasing
self-esteem. This is of principal importance when considering that
women may choose to terminate employment, and lose the
associated benefits, in order to perform caregiving duties.
Furthermore, women who forego employment and personally
sacrifice to provide care to elderly mothers may become isolated,
depressed, and resentful (Brody, 1981). Despite their findings, Pohl
et al. (1991) did not explore the prevalence of depression in their
sample of caregivers.

Scharlach (1989) used questionnaires regarding impact of
caregiving on work to study employed caregivers (N = 332).
Twenty-seven percent of his sample reported that their overall
caregiving situation was less stressful as a result of their working.
Barusch and Spaid (1989) interviewed 131 caregivers using a coping
inventory and found employment offered the most effective
protection against engulfment by the caregiving role.

Role Overload

Several studies have reported negative effects of caregiving on
employment, such as role overload (Barr et al., 1992; Brody, 1981;
Brody, Kleban, Johnson, Hoffman, & Schoonover, 1987; Brody et al.,

22

1992; Gibeau & Anastas, 1989; Green, 1991; Orodenker, 1990;
Scharlach & Boyd, 1989). Employed daughters who become
caregivers of elderly parents lose leisure and personal time (Brody et
al., 1987). Moreover, many caregivers take leaves of absence from
work, leave work early, or are so tired on the job that they cannot
work effectively (Scharlach & Boyd, 1989; Stone & Short, 1990).
Stone and Short (1990) found that females were about 12% more
likely to take time off without pay. They also reported 29% of their
sample of caregivers (N = 1003) either quit their jobs or had to
accommodate their work schedules to assume care responsibilities
and considered employment "just a job" instead of a career. No
personal rewards were associated with their work. Other studies
found that daughters experienced more job conflicts related to
caregiving than sons (Stoller, 1983). Stoller (1983) found that unlike
daughters, sons reduced hours of caregiving when employed.
Barnes, Given, and Given (1995) looked at a sample of
caregiver daughters (N = 1 18) from a longitudinal study which used
interviews and questionnaires to compare employed and
unemployed caregiver daughters. They found caregiver daughters
who terminated employment reported a greater impact on schedule
due to caregiving activities than those who were unemployed.
Furthermore, Brody (198 1) found that women who forego
employment and sacrifice personally to provide care to elderly
parents often feel resentful and become depressed and isolated.
Gibeau and Anastas (1989) found that most caregiver
daughters with full-time employment experienced role conflict

23

between work and caregiving responsibilities. Therefore, some
caregiver daughters choose to continue employment and purchase
care while others limit or terminate work in order to provide more
care. Orodenker (1990) interviewed a sample of female caregivers
(N = 1 168) and found that employed caregiver daughters
experienced significantly more Stress when they were unable to
balance the demands of two roles and were forced to adjust work
schedules in order to perform caregiving duties. Orodenker's Study
is limited by the cross-sectional data which may cause attitudes to be
misinterpreted as ongoing when they may actually be temporary.

Another study showed 22% of caregiver daughters terminated
employment due to family care obligations (Enright, 1991). Boyd
and Treck (1989) found that women who quit working were placed
in jeopardy by losing salary, benefits, social networks, and a sense of
job satisfaction that employment offered. Others found that
unemployed caregivers were economically vulnerable due to
inadequate social security and pension benefits (Atchley, 1990; Doty,
1986; Holden, 1989; Stone, 1989).
Summm

Eight of the studies found that employment was a buffer, while
eight found employment contributed to role overload. Positive social
interaction and personal rewards seemed to suggest employment
would be a buffer rather than cause overload in the studies cited. As
a buffer, employment offers the opportunity for social interaction
and respite from caregiving. It also promotes competence, enhances

self-esteem, and provides financial security. On the other hand,

24

individuals may experience role overload when combining
- employment with caregiving. For example, employment may
exacerbate job-family conflict and distress in the context of
caregiving. Frequently, women occupy more roles than men since
they tend to be the primary caregivers of both children
and elderly parents.

little attention has been given to the effect of role
accumulation on daughters in the current caregiver literature. While
the literature concerning employment as a buffer is compelling, the
data regarding employment leading to role overload is more
substantive. Therefore, this study focused on employment and role
overload data to support the hypotheses.

Theoretical Framework

Role theory is the conceptual framework which guided this
study. The term role is defined as expected and actual behaviors
associated with a position (Hardy & Conway, 1988). As a result of
social expectations, individuals may experience role Stress and strain.
Role stress occurs when persons are subjeCt to conflicting, very
difficult, or impossible demands. For example, caregiver daughters
who are employed must balance a career with caregiving and
domestic duties. Robinson (1983) has identified several caregiving
Stressors: inconvenience, confinement, family adjustment, changes in
personal plans, competing demands on time, emotional adjustments,
work adjustments, and feelings of being completely overwhelmed.
Thus, role Stress may lead to a state of distress, or role strain. Role

strain is defined as hardship, challenge, and conflict experienced by

25

persons as they engage in their normal social roles (Kaplan, 1983).
Role strain is more likely to occur when an individual occupies
multiple roles.

According to Ward (1986), there are several antecedents to
role Strain; however, there are two that are particularly relevant to
employed caregiver daughters. First, role accumulation creates role
Strain when an individual participates in many different roles with
many different obligations (Ward, 1986). Second, role conflict may
occur as a result of multiple roles, especially when a person occupies
two positions with completely separate sets of role expectations
(Hardy & Conway, 1988). This type of conflict may be experienced
by caregiver daughters who are pressured to meet the competing
demands of both a mother who requires care and an employer.

In Figure 1, Ward (1986) lists the antecedents of role strain as
they lead to role stress. The intervening conditions either lead to
role gratification or to role strain. This model includes the
properties, attributes, and empirical referents of role strain.
Basically, the properties describe the degree of role strain while the
attributes of role Strain measure the difficulty experienced with
multiple roles, and the empirical referents (observable properties)
are manifestations of role strain or indicators of role overload.
Finally, the consequences of role Strain are identified.

An adaptation of Ward's model was the theoretical framework
for this study. Figure 2 identifies the multiple roles of women who
are caregiver daughters with varying employment status. In this

study, impact on schedule and depression are the attributes of

26

Antecedents of role strain
Role conflict Role overqualification
Role accumulation Role incongruity
Role rigidities Role uncertainty
Role intensity Role disparity
Role ambiguity Role incompatibility
Role incompetence Tedium

Role stress

Intervening conditions

Amount of role pressure
Role location

Status

Audience

Lack of reciprocity

Self-esteem

Role mastery

Cultural factors

1‘. >Role gratification

Role strain

Properties Attributes
Necessary: Fatigue
Perceptive, subjective State Exhaustion
Pressure of an etiological Depression
stimulus Cognitive Strain
Undesirable/negative state Insecurity
Negative relevant: Embarrassment
Lacks verb properties Tension
Positive relevant: Anger
Possesses noun properties Hostility
I Guilt
Indecision
Failure

Job dissatisfaction
Physiological stress
Physical damage
Anxiety
Threat
Discomfort
Consequences ‘

Role restructure "

Role resignation

Increased role distance

Decreased level of involvement

Role bargaining

Negotiation of meaning of the stimulus

Concealing Stressors

Converting Stressors to social prestige

Coping with Stressors

Suicide

Drug Abuse

Empirical referents
Subjective report:
Fatigue
Exhaustion
Depression
Anxiety

Job related
tension index
Absenteeism
Turnover
Accident rate
Blood pressure
Catecholamine
excretion
Galvanic skin
response

Fatty acid levels

Adapted from Ward, C. R. (1986). The meaning of role strain. Advances in

Nursing Science, §(2), 43.
Figure 1.

Potential deleterious effects of role strain.

 

27

Role
Daughter
Caregiver
Career woman
(Employed, unemployed,
or terminated employment

during first 2-4 weeks of

caregiving)

Antecedents of role strain
Role conflict
Role accumulation

i

Role Stress
i
Intervening conditions
Amount of role pressure
Self-esteem
Role mastery

Role gratification Role strain
Attributes Empirical referents
Impact on schedule Impact on schedule
Depression Depression

Figure 2. Women with multiple roles may experience impact on

schedule and depression.

28

role strain. This framework emphasizes role conflict and role
accumulation as antecedents to caregiver role strain in the daughter,
relieved or exacerbated by the intervening conditions (i.e.,
employment) associated with role pressure, self-esteem, and role as
caregiver and career woman. The subsequent role stress may be
related to the mastery of the caregiver daughter role. This model
does not demonstrate causality, but rather depicts a relationship
between role stress/Strain, impact on schedule, and depression in
caregiver daughters.

Lebowitz (1977) found that most employed women, whatever
their occupation, continue to Struggle with conflicts between "'family
obligations, personal desires and ambitions, and the demands and
limitations of their wor " (p. i). Therefore, the demands of multiple
roles may create role strain and present as a negative impact on
schedule or depression. Multiple roles including wife, mother, and
career woman will likely consume more energy and time than may
be available (Hardy & Conway, 1988; Vaughn & Wittig, 1980). By
adding parent caregiver to her repertoire of roles, a daughter may
find herself compromised and depressed. The prevalence of
depression and impact on schedule in the caregiver daughter may
vary according to employment status and the associated strain.
Caregiver daughters with a balance of roles and subsequent role
gratification may not experience role overload and strain.

Some studies have shown that multiple roles are not
necessarily detrimental, but may actually reap cumulative rewards
(Meneghan, 1989; Moen, Dempster-McClain, & William's, 1991;

29

Waldron & Jacobs, 1989). Enhanced role performance and role
gratification may be welcome recompense provided by a combination
of roles. Hardy and Conway (1988) state that role accumulation is
associated with a positive sense of self for many women who
maintain traditional roles with contemporary roles. Moreover,
modern career women may choose alternative methods of care
provision (i.e., home care or a retirement home) in order to meet
their mother's needs, as well as satisfying their own lifestyle.

The focus of this study was the mother- daughter relationship
because it is a unique bond. The role of daughter incorporates a
certain closeness toward a mother. For example, daughters
outnumber sons as primary caregivers in a ratio of about 4:1 (Brody,
litvin, Hoffman, & Kleban, 1992) and wives are more likely than
husbands to be the primary caregiver of their spouses. Women have
acquired the nurturing role regardless of their relationship to a
significant other. Therefore, this study explored the relationship of
caregiver daughters and their mothers.

Methods

This correlational study was a secondary analysis of data from
research supported by grant #ROl AG065 84, "Caregivers Response to
Managing Elderly Patients at Home", funded by HHS National
Institute on Aging. The Principal Investigator was Charles W. Given,
Ph.D. from the Department of Family Practice in the College of Human
Medicine at Michigan State University, East Lansing, MI. A
descriptive survey was used in the original study and data for the

current study was analyzed using the SPSS/ PC software package.

Salim:

First-time family caregivers (N = 628) of patients with a broad
range of diagnoses were recruited upon the patient's discharge from
27 hospitals in Michigan and surveyed 2 through 4 weeks (M = 21
days) after beginning caregiving responsibilities (Given & Given,
1989). Data for the original study were obtained through telephone
interviews and self-report questionnaires. From the original sample,
a total of 190 daughters were identified. For the current study, a
sample of daughters (N = 120) was selected based on the following
criteria: (a) the daughter was a first time primary caregiver for her
mother, (b) the mother was 55 or older, (c) the daughter was
assisting with at least one activity of daily living (ADL) or 2
instrumental ADLS or one health care activity (i.e., wound care,
catheter care, intravenous feedings, nasogastric feedings, etc.), ((1) the
mother resided in a home in the community (either her own or a
family member's or friend's), (e) the daughter was not a paid
caregiver, (f) the daughter was not caring for more than one disabled
family member when she entered the study, and (g) the daughter
spoke and read English.

Operational definitions

Emploment Status
Two to 4 weeks after the start of caregiving, daughters were

asked to report their previous and current employment status.
Current employment status was divided into three categories. The
category of "employed" caregiver daughters (p = 63) was created by

combining full-time (p = 45) and part-time (p = 18) workers. The

31

" terminated employment" category (I; = 5) was made up of caregiver
daughters who took a leave of absence (:1 = 2) or quit work to care (p
= 3) during the first 2 through 4 weeks of caregiving. Lastly,
daughters who were retired (p = 17) and unemployed or laid off (p
= 35) composed the third category of those who were "not employed"
(:1 = 52). The three employment groups were the independent
variables in this study.
lrnpact on schedule

One dependent variable measured was impact on schedule in
the caregiver daughters. lrnpact on schedule was operationally
defined as the score on the Impact on Schedule subscale of the
Caregiver Reaction Assessment (Given et al., 1992). A high score
reflected a high level of impact on schedule, whereas a low score
meant little or no impact on schedule. Scores ranged from 1.0 to 5.0.
Depression

Depression was the second dependent variable operationally
defined as the score caregiver daughters obtained on the CBS-D
(Radloff,1977). The four subscales within the CBS-D were depressed
affect (feeling blue, depressed, lonely, tearful, sad), happy subscale
(feeling as good as other people, hopeful, happy, enjoying life),
somatic/psychomotor retarded activity (feeling bothered, unable to
concentrate, unmotivated, lacking appetite, sleeping restlessly) and
interpersonal subscale (feeling people are unfriendly, people diser
me). Scores were summed across 20 items, with a potential range of
0-60. Scores 0-16 indicated no depressive symptomatology,

whereas scores 16 or greater indicate depressive symptomatology.

32

Insmments
The tool used to measure impact on schedule is from the

Caregiver Reaction Assessment (CRA) (Given, Given, Stommel, Collins,
King, & Franklin, 1992). The Impact on Schedule subscale contained
five items with each scored using a 5-point Likert scale ranging from
1 (strongly disagree) to 5 (strongly agree) (see Appendix A). Data on
the psychometric properties and construct validity of the instrument
are published and Show reliability (Given et al., 1992). Given et al.
(1992) reported the Cronbach's alpha coefficient was .82 for the
Impact on Schedule subscale. The Impact on Schedule subscale has
been confirmed as an independent factor in the CRA across caregiver
samples (Given et al., 1992). Pohl et al. (1991) reported CrOnbach's
alpha coefficient was .8 1 for her sample of caregiver daughters.

Depression was measured using the Center for Epidemiologic
Studies Depression Scale (CES-D) (Radloff, 1977). This instrument
consisted of 20 items measured individually on a likert scale ranging
from 0 (rarely or none of the time) to 3 (most or all of the time) to
identify psychological distress by the presence of depressive
symptoms in the past month (see Appendix B). Overall reliability
and validity was consistent for this instrument across samples
(Stommel et al., 1990; Stommel et al., 1993). Stommel et al. (1990)
conducted a Study of family caregivers (N = 307) of elderly,
dependent relatives and reported Cronbach's alpha was .89. In the
second study, Stommel et al. (1993) studied caregivers of chronically
ill elderly (N = 504) and reported Cronbach's alpha

coefficient was .89.

33

Hypptheses
Two hypotheses governed this Study: (a) There is a greater

impact on schedule for employed caregiver daughters than for
unemployed caregiver daughters and for those who have terminated
employment during the first 2 through 4 weeks of care, and (b)
There is a relationship between impact on schedule and level of
depression in caregiver daughters by category of employment.
Protection of Human Rights
Consent forms were obtained from caregivers and care
recipients during the original study. Human subjects remained
anonymous. The original study received approval from the
University Committee on Research Involving Human Subjects
(UCRIHS). Approval for the original and current studies was
obtained from UCRIHS (see Appendices C and D).
Assumptions and limitations
Assumptions of this study included: (a) The caregiver
daughters completed the instruments accurately, and (b) The data
were coded accurately. The limitations of this study include: (a) the
study used a convenience sample of Caucasian, middle class women;
therefore, results may not generalize to the general population, (b)
the current study is confined to tools/ data of the original study
reflecting the limitations of the original study, and (c) concepts other
than impact on schedule and depression were not included;
therefore, other factors that may affect caregiver daughters were not
Studied.

34

Data analysis
Data for the three employment categories were summarized

using descriptive statistics appropriate for age, income, living
arrangements, education level, and marital status. A one-way
analysis of variance (ANOVA) was used to test the first hypothesis:
There impact on schedule in caregiver daughters who are
unemployed, employed, or have terminated employment during the
early part of caregiving. The ANOVA compared scores on the Impact
on Schedule subscale of the CRA in the three different employment
groups. An ANOVA was selected to test the impact on schedule in
the three employment groups by comparing the variability between
and within groups.

Pearson Product Moment Correlations were used to test the
second hypothesis: There is a relationship between impact on
schedule and level of depression in caregiver daughters by category
of employment. Correlation coefficients were performed to assess
the relationship between impact on schedule and depression. Data
were correlated for each employment group.

Results

Selected sociodemographic characteristics of the caregiver
daughters by employment Status are described in Table 1. Of the
total sample, 53% (p = 63) was employed either full or part time, 4%
(Meneghan, 1989; Moen, Dempster-McClain, & William's, 1991;
Waldron & Jacobs, 1989). Enhanced role performance and role (p
= 5) terminated employment (p = 3) or took a leave of absence (p

= 2) during the first 2 through 4 weeks of caregiving, and 43%

35

(p = 52) were not employed as a result of choice, retirement, or
layoff. living arrangements of the caregiver daughters and their
mothers were fairly evenly distributed between separate (p =54)
and shared (p =66) households. The majority of mothers were
widowed (p = 94) and ranged in age from 56 to 96 (M = 76.83, SD =
8.2). Ten percent of mothers were married, but their daughters were
still primary caregivers. Ages were similar among mothers of
caregiver daughters who were employed (M = 75.9, E = 8.0),
unemployed (M = 78.2, SI; = 8.5), and those who terminated
employment (M = 74.0, .S_D = 5.7). Mothers had an annual household
income ranging from $1000 to $62,500 with and average income of
$26,700 (fl = $20,317) per year. In the 55% of caregiver daughters
who lived with their mothers, the daughters' annual salaries were
included in their mothers' total annual household incomes.

Most of the caregiver daughters were married (p =78) and
ranged in age from 22 to 72 years of age (M = 48.66, SD = 9.92). The
unemployed caregiver daughters were the oldest of the three groups.
The unemployed group also accounted for caregiver daughters who
were retired (p = 17) and may explain why this category was older.
Overall, 85% of the caregiver daughters were Caucasian (p = 102) and
received a current annual household income ranging from $3000 to
$62,500 (M = 37,680, SD = 18,044). Employed caregiver daughters
earned an annual household income with a mean of approximately
$10,000. more per year than the unemployed and terminated work
since 68.3% of the employed daughters were married. Income of the

terminated employment group indicated that the reported income

36

Table 1

Comparispn of Cgegiver Daughters by Employment Status and
Selected Characteristics (N = 120)

 

Emplpyment status

 

 

Employed Unemployed Terminated
(.n.= 63) (n= 52) (I_1= 5)
Char cteristic number % number % number %
Education
Less than high school 5 (7.9) 17 (32.7) --
High school graduate 20 (31.7) 15 (28.8) 2 (40.0)
Some college 26 (41.3) 15 (28.8) 3 (60.0)
College graduate 5 (19.0) 5 (9.6) --
Marital status
Married 43 (68.3) 33 (63.5) 2 (40.0)
Not married 20 (31.7) 19 (36.5) 3 (60.0)
Race
White 56 (88.9) 42 (80.8) 4 (80.0)
African American 7 (11.1) 10 (19.2) 1 (20.0)
living arrangements
With mother 33 (52.4) 30 (57.7) 3 (60.0)
Separate 30 (47.6) 22 (42.3) fiZ (40.0)
M SD M. E M E
Age (years) 46.7 8.5 5 1.3 1 1.1 46.4

Income (dollars) 42.681 16.323

31.418 18.682

32.500 16.015

37

was received before termination of employment or that money may
have come from sources other than employment, such as disability or
husband's salary.

It was hypothesized that there would be a greater impact on
schedule for employed daughters than for unemployed daughters
employment categories. Results of the ANOVA indicated no
statistically significant differences among the groups for impact on
schedule [F (2,1 17) = 1.74, NS]. The terminated employment group
received similar scores on the Impact on Schedule subscale with a
range of 2.6 to 5.0 (M = 4.08, SD = .98) as caregiver daughters who
were employed with a range of 1.4 to 5.0 (M = 3.54, E = 1.04) and
unemployed with a range of 1.6 to 5.0 (M = 3.84, M) = .89). The
means indicated that all three groups of caregiver daughters
experienced similar impact on schedule during the first 2 through 4
weeks of caregiving.

It was also hypothesized that a relationship between impact on
schedule and level of depression existed by category of employment.
Overall, the caregiver daughters reported depressive
symptomatology. The depression scores on the CES-D were very
similar between caregiver daughters who were employed with scores
ranging from 0.0 to 48.0 (M = 16.14, SD = 10.13) and unemployed
with scores ranging from 2.0 to 42.0 (M= 16.76, SD = 9.16). '
Daughters who terminated employment had the highest mean scores
on the CES—D (M = 19.4, $2 = 9.23) with scores ranging from 5.0 to
30.0. As shown in Table 2, a moderately strong and significant

relationship between impact on schedule and depression was found

38

in the employed caregiver daughters group and the not employed

group indicating partial support for the second hypothesis.

Table 2

The Correlation of Impact on Schedule and Depression in Caregiver

Daughters by Categogy of Employment

 

Employed Unemployed Terminated employment
(11 = 63) (n= 52) (n = 5)
.5 8* .43** .56

 

*p < .000. **p < .002.

However, no significant relationship was found between impact on
schedule and depression in the caregiver daughters who terminated
employment.
Discussion
Inteppretation of Findings

Demographic variables
Education levels were of Statistical significance ( 1(7— : .02).

However, no statistical differences were found between the 3 groups
of caregiver daughters. According to reports of income, it is not
determined whether caregiver daughters received money from
disability, retirement, or shared income with their husbands.

Furthermore, these incomes reflected the last year prior to

39

caregiving and not current household income.

The unemployed group included retired caregiver daughters
which may have made this group older and more vulnerable to
factors associated with aging. Unemployed daughters may have
experienced more stress related to aging than to employment or
caregiving. This sample did not reflect the findings of previous
research that have shown daughters who terminate employment to
care for elderly parents tend to be older, have lower education, and
lower incomes than employed caregivers (Barnes et al., 1993; Brody,
Kleban, Hoffman, & Schoonover, 1987; Pohl et al., 1991).

Dependent variables

In this study, the findings of depression on caregiver daughters
who terminated employment did not support findings in the
literature, nor did the findings of impact on schedule support
findings in the literature. Due to the small sample size (p = 5) of the
terminated employment group, the results of this Study may not
apply to the general population. It is difficult to assess whether
caregiving contributes to the decision to terminate employment with
only 4% of the sample in this employment category, particularly
when 2 of 5 caregiver daughters in the terminated employment
group were on leave of absence. Although all of the caregivers had
depressive symptomatology in this study, it is not known whether
impact on schedule or depression vary according to employment
status after the 2 through 4 week transition to caregiving. One
month may not be enough time to determine whether new

caregivers are depressed or experience impact on schedule,

40

especially if it is not known whether the caregivers are depressed
before caregiving. Caregiver daughters may experience the greatest
impact on schedule and depression during the transition to care or
they may notice a greater impact over time.
Result pf Hypothesis Testing .
In this section, each hypothesis will be considered separately

with a discussion of the interpretation of data.

Hypothesis #1
There is a greater impact on schedule for employed daughters

than for unemployed daughters and for those who hav_e_ terminated
employppent during the first 2 through 4 weeks of care. This

 

hypothesis was not supported. Mean scores on the Impact

on Schedule subscale had little variation between employment
groups. Scores of the overall sample indicated moderate impact on
schedule, which means that all groups experienced similar impact on
schedule. Impact on schedule may have been similar across
employment categories because all caregiver daughters may have
sacrificed personal time to provide care. Employed caregiver
daughters had Slightly lower mean scores on the Impact on Schedule
subscale than the unemployed and terminated employment groups,
while the terminated employment group had the highest mean
scores. Despite the variation in scores among employment groups,
impact on schedule had the same magnitude and no statistically
significant differences were found among groups. Barnes et al.
(1995) reported that caregiver daughters who terminated

employment reported more impact on schedule than their

41

unemployed counterpart. Barnes et al. finding was not supported in
this study, but her sample was not an inception cohort. In this study,
the small size of the terminated employment group was too small to
draw conclusions since only a few caregiver daughters quit work
during the early transition period. The small size of the terminated
employment group may mean that 2 to 4 weeks after starting care is
too early in caregiving for the caregiver to quit work.

Other research reports that employed caregiver daughters
make substantial adjustments during the first 3 months of caregiving
compared to unemployed and terminated employment groups
(Franan et al., 1994). Franklin et al. (1994) looked at daughters
during the first 2 through 4 weeks of caregiving and did not find a
Significant difference in impact on schedule among employment
categories. Perhaps, in the second or third months of caring a
significant difference occurs among employment categories. After 2
or 3 months, the caregiver daughter may feel either more
comfortable with the caregiver role or She might experience
increased frustration. A daughter's comfort level with caregiving
may depend on her mother's degree of illness and whether her
mother's health improves or declines over time. Long term impact
on schedule may cause the caregiver daughter to terminate
employment after 3 months. It is likely that the caregiver daughter
will have less available help as friends and family members who
helped initially return to their usual schedules. Financial resources
may dwindle as caregiving expenSes continue and leaves of absence

run out after 2 to 3 months. Most jobs will not allow much time off

42

work, and even fewer positions provide time off with salary.
Therefore, a caregiver daughter might have to choose between losing
her job, taking a family medical leave without pay, or quitting work
to care.
Hypothesis #2

There is a relationship between impact on schedule and level of

depression in caregiver daughters by level pf employr_nent. This
hypothesis was accepted in part because there was a statistically

significant positive correlation between impact on schedule and
depression in employed and unemployed caregiver daughters. There
was no statistical significance in the relationship between impact on
schedule and depression in the terminated employment group, which
may be due to the small number of caregiver daughters who
terminated employment.

While all 3 employment categories report depressive
symptoms, the prevalence of depression was not reported in the
current study. Despite statistical insignificance, it was found that
mean scores on the CBS-D indicated depressive symptoms in the
sample as a whole (M = 16.55, E = 9.63), since the mean score is
greater than 16. The terminated employment group received the
highest mean scores on the CBS-D compared to the employed and
unemployed caregiver daughters. Daughters who quit work to care
may have had higher depression scores because their mothers were
sicker and required more skilled care or because they were already
depressed.

Few studies were found that look at the relationship between

43

impact on schedule and depression in caregivers with different

employment status. However, the literature does Show that a lack of

rest time was correlated with depressive symptoms in the

family caregiver (Macera et al., 1993). Differences among

employment groups may be related to differences in patient

diagnoses, amount of care needed, and type of care required.
Implications for Role Theog

In partially supporting the hypothesis based on the
relationship between impact on schedule and depression, this study
lends partial support for role theory. Nevertheless, it is not known
what implications of other possible roles exist for the daughters in
this study, beside caregiver and career woman. Caregiver daughters
who are not employed may have other roles that employed caregiver
daughters do not have (i.e., mother, wife) and vice versa. Also, the
magnitude of caregiving is not known because the mother's degree of
illness is not clear.

Employed caregiver daughters may experience impact on
schedule and depression due to role Stress and strain from social
expectations that they care for their elderly mothers, as well as earn
an income. According to role theory, many different roles with
different obligations may lead to role strain. Multiple roles may
account for the impact on schedule and depression that employed
caregiver daughters experienced in this study. However, role theory
does not explain why caregiver daughters who are unemployed and
those who terminated employment also experience the same level of

impact on schedule. If the number of roles occupied, as well as

44

the intensity of the roles and tasks of the caregiver daughters was
known, this study may have reaped more conclusive data.

Role theory is a model that can be used when looking at
caregiver daughters. All of the caregiver daughters in this study
experience impact on schedule and depression which may be
attributed to multiple roles and the associated role strain. Different
types of employment produce various levels of stress and strain.
Therefore, the type of job may also influence whether a caregiver
daughter experiences impact on schedule and depression, but this is
not assessed in this study.

Caregiver daughters who terminated employment had the
highest mean scores on the Impact on Schedule subscale and CES-D.
According to role theory, they may base the decision to terminate
work on excessive role strain and conflict from the completely
separate role expectations of caregiving and employment. This Study
did not explore the reasons for termination of employment. Role
theory may be used for'future research because it raises further
questions for study regarding the implications of role gratification
and strain, number of roles occupied, and reasons for terminating
employment.

Implications for the Advanced Practice Nurse (APN )

The findings of a Significant positive correlation between
impact on schedule and depression in employed and unemployed
caregiver daughters indicate that assistance and support is required
during the transition to caregiving. Although there is no statistically

significant relationship between impact on schedule and depression

45

in caregiver daughters who quit work, it is evident by their scores
that they still experience moderate impact even though it was early
in caregiving. Since this study shows that caregiver daughters are
vulnerable to impact on schedule and depression, APNS are in the
ideal position to prepare and educate caregiver daughters regarding
the caregiver role. It is important to address caregiver needs early
in order to possibly prevent negative impact on schedule and
depressive symptomatology from occurring as well as worsening.
Caregiver daughters should be involved in their parent's plan of care
from the beginning. They should be supported not to neglect their
own health and reminded to set aside time for personal needs and
respite. APNS should counsel caregivers regarding the typical strains
to expect during the transition to care. Although this study shows
that all employment groups experience similar depression and
impact on schedule, APN S Should assess each caregiver daughter and
provide an individualized plan of care.

In primary care, APNS are prepared to assess and evaluate
caregiver daughters for depressive symptoms and explore
psychosocial issues and family dynamics that may be contributing to
depression. The APN can assess caregiver needs in numerous ways.
For example, the APN can ask the patient during an appointment or a
phone call how the caregiver is doing. The caregiver can be
encouraged to attend appointments with her parent to primary care
and be involved in the ongoing plan of care. The APN can explore
living arrangements, hours of employment, number and intensity of

roles, and use of formal services during assessment of the caregiver

46

daughter. After care has been initiated, the APN can monitor the
caregiver situation by making periodic phone calls to assess
continuing care needs of both the patient and caregiver. The APN in
primary care can assist caregiver daughters in locating the necessary
resources and support during the transition to caregiving. APNS are
ready to implement appropriate interventions, such as counseling,
referrals to social work or other disciplines, and/ or chemical
intervention if severe depression is indicated.

Early respite care and counseling should be instituted before
impact on schedule and depression begin. This is of foremost
importance when many caregivers fail to seek respite care or
assistance until they are under immense Stress (Lawton, Brody &
Saperstein, 1989). Nursing home placement may not reduce impact
on schedule and depression since it is costly and caregivers would
still need to fit nursing home visits into their schedules. Therefore,
the responsibility of caring for elderly parents is becoming more
prominent as patients spend less time in hospitals and nursing
homes and more time at home. APNS can ease the transition to
caregiving by anticipating both the patient's and caregiver's needs,
and by preventing the occurence of burden. Helpful interventions
may include referrals to visiting nurse services, Hospice, support
groups, and employment assistance programs. APNS can also
increase caregiver access to care by providing support group
meetings at job sites before or after working hours.

Nurses in advanced practice are the ideal educators, counselors,

and researchers of caregiver daughters. As educators, APNS in

47

primary care can inform caregivers of the patient's course of illness
and disease management strategies. APNS can also counsel
caregivers in order to manage feelings of depression, guilt,
resentment, and anger. Stommel et al. (1990) found that caregivers
may be depressed before they become caregivers of elderly parents.
The APN must monitor for signs and symptoms of depression
possibly related to family situations in order to provide early
intervention to caregiver daughters. Finally, nurse researchers must
continue to study caregiver daughters, since this group reports the
most deleterious effects on their quality of life from caring for
elderly dependents, compared to spouses and other relatives (Jones
& Peters, 1992).

With limited options available for caregiving of the elderly, it
would be ideal to maintain caregiving at home. By making
caregiving more convenient for employed caregivers, the impact on
schedule and level of depression may be reduced. APN S in primary
care can assess financial capacity and refer caregivers and patients to
available resources. The APN can also follow up by assessing
continuing needs via a telephone call or office visit at regular
intervals after initiating care.

limitations of the Study

Limitations of the current study reflect the data that have not
been examined. In this section, several variables are identified that
would have added more meaning if included in this study, such as
number of patient dependencies, living arrangement, hours of

employment, number of roles, intensity and magnitude Of role

48

responsibilities, and use of formal services.

A very important area to examine is the number and kinds of
dependencies of the care recipient and how they might effect impact
on schedule and depression. Dellasega (1990) found that the
expectations and dependency of the care recipient caused more
Stress in unemployed caregivers who were generally older and less
healthy than employed caregivers. Factors which may effect the
amount of time Spent caregiving must be considered, such as how
sick the mother was and the type of care needed, whether Skilled or
custodial. The patients' diagnoses would have added insight
regarding what kind and how much care was needed. It is necessary
to examine the patient's number of dependencies and kinds of needs,
because many dependencies may decrease the caregiver's personal
time and increase the likelihood of becoming depressed by
demanding more time for caregiving tasks. Patients with more
dependencies probably require more hours of care. It is not known
how many hours were spent providing care in each employment
category.

Another variable that was not explored was whether employed
and unemployed caregiver daughters who are living with their
mothers experienced more impact on schedule and depression than
those who lived separately. The sample in this Study was almost
equally divided in living arrangements, with half of the caregiver
daughters living with their mothers and half living separately.
Possibly, a difference in impact on schedule and/ or depression exists

between these groups. Caregiver daughters may experience more

49

depression and impact on schedule with greater amounts of time
spent caregiving as a result of living together.

In addition, this study did not specify if caregiver daughters
were employed full or part time and how much time was spent at
work and providing care. Daughters who worked full time may have
had help providing care from other family members or outside
agencies. Whereas, caregiver daughters who spent equal amounts of
time between providing care and working may have had less
personal time and more impact on schedule and depression.

Another limitation of this study was not knowing how many
roles the caregiver daughters had. It is assumed that the caregiver
daughters had multiple roles; however, it is not known which
employment group had more roles. Furthermore, it is not known if
the caregiver with more roles experienced greater impact on
schedule and depression.

This study is also limited by not examining whether formal
services were used to assist with care or if other caregivers were
involved. Caregiver daughters who had respite from caring may
have reported less impact on schedule and depression. Caregiver
daughters with more financial resources may have used formal
caregiving services more often and experienced less impact on
schedule and depression than those who had fewer financial
resources. Furthermore, the use of informal social support, such as
support groups, may have helped prevent or alleviate the deleterious
effect of impact on schedule and depression and Should be explored.

These factors may explain more about why there is a relationship

50

between impact on schedule and depression in employed and
unemployed caregiver daughters.
Recommendations for Future Research

Recommendations for further study include the limitations in
the earlier section and the following:

A longitudinal study of caregiver daughters with differing
employment Status would be beneficial to see if impact on schedule
and depression are higher during transition or if they increase over
time. This study found that only a small percentage of caregiver
daughters terminated employment during the early transition to
care. It may be evident in a Study of 6 months to a year that more
caregiver daughters quit work to care than during the first 2-4
weeks of caregiving. In a longitudinal study, it would be easier to
pinpoint when caregivers are most likely to terminate employment.
Caregiver daughters who take a leave of absence should also be
studied over time and compared to those who quit work.

It would also be beneficial to explore whether caregiver
daughters were depressed before initiating care. Depression may
exist before caregiving and depression scores obtained after care ‘
began would not reflect the caregiver daughter's response to
caregiving if she was depressed before initiating care. On the other
hand, it may be too early to see depression 2 to 4 weeks after
initiating care. It would be helpful to assess depression in caregiver
daughters prior to providing care and after a period of caregiving.

Another area that Should be investigated is whether daughters

terminated employment because of caregiving or for other reasons.

51

Furthermore, it Should be explored if daughters were unemployed
because they received financial support elsewhere (i.e., spouse,
disability, retirement). The reasons for terminating employment and
being unemployed are not known and may be relevant. Daughters
who may have quit work for personal reasons, such as declining
health rather than to provide care, may be depressed before
caregiving.

Finally, financial resources and the use of formal caregiving
services should be compared in the different employment groups. It
would be beneficial to determine if financial security effects impact
on schedule and depression. Also, the involvement of a social worker
or home care provider may positively influence the daughter's
perception of caring. Caregiver daughters with more resources may
experience less impact on schedule and depression.

Summafl

The findings of this study have expanded the literature base by
comparing impact on schedule and depression in caregiver daughters
who are employed, unemployed, and those who terminated
employment during the first 2 through 4 weeks of caregiving. A
major finding of this study indicates that caregiver daughters may
not quit work during the early transition to caregiving. Therefore,
continued research is necessary to determine when termination of

employment actually occurs.

Appendices

Appendix A

52

Appendix A

Caregiver Reaction Assessment (CRA)
(1) Strongly disagree (2) Disagree (3) Do not disagree or agree
(4) Agree (5) Strongly agree
In my relationship with my mother:

1. We're dependent on each other. 1 2 3 4 5
2. We anticipate each other's moods. 1 2 3 4 5
3. We nurture each other. 1 2 3 4 5
4. I feel like I want to support her. 1 2 3 4 5
5. She is closer to me than others. 1 2 3 4 5
6. My mother is too involved in my life. 1 2 3 4 5
7. We're emotionally dependent on each other. 1 2 3 4 5
8. When we anticipate being apart our

relationship intensifies. 1 2 3 4 5
9. We anticipate each other's needs. 1 2 3 4 5
10. My mother and I often argue. 1 2 3 4 5
1 1. Our best times are with each other. 1 2 3 4 5
12. We want to spend time together. 1 2 3 4 5
13. She shows that she loves me. 1 2 3 4 5
14. We're honest with each other. 1 2 3 4 5
15. We can accept each other's criticism

of our faults and mistakes. 1 2 3 4 5
16. I often feel angry with my mother. 1 2 3 4 5
17. We like each other. 1 2 3 4 5
18. We respect each other. 1 2 3 4 5

S3

(1) Strongly disagree (2) Disagree (3) Do not disagree or agree
(4) Agree (5) Strongly agree
In my relationship with my mother:

19. Our lives are better because of each other. 1 2 3
20. We enjoy the relationship. 1 2 3
21. She cares about the way I feel. 1 2 3
22. We feel like we're a unit. 1 2 3
23. There's a great amount of unselfishness

in our relationship. 1 2 3
24. I do not like my mother's behavior. 1 2 3
25. She always thinks of my best interests. 1 2 3
26. I'm lucky to have her in my life. 1 2 3
27. She always makes me feel better. 1 2 3
28. She is important to me. 1 2 3
29. We love each other. 1 2 3
30. I'm sure of this relationship. 1 2 3
3 1. My mother sees things from my point

of view. 1 2 3
32. I feel that my mother often tries to

change me. 1 2 3
33. We are able to share private things

face to face. 1 2 3

34. Our relationship is somewhat strained. 1 2 3

48484848
UlUIU‘lU]

AAA-AAA-b-h
mmmmmmmm

Appendix B

54

Appendix B

Center for Epidemiologic Studies Depression Scale (CES - D)

(0) Rarely or none of the time (1) Some of the time

(2) Most of the time (3) Almost all of the time

During the past month, how much of the time...

1. were you bothered by things that usually
don't bother you? 0 1 2 3

2. have you not felt like eating; had a poor
appetite? - 0 1 2 3

3. have you felt that you could not shake
off the blues even with the help from
family or friends? 0 1 2 3

4. have you felt that you were just as good

as other people? 0 I 2 3
5. have you had trouble keeping your mind

on what you were doing? 0 1 2 3

have you felt depressed? 0 1 2 3

have you felt that everything you did
was an effort? 0 1 2 3
have you felt hopeful about the future? 0 1 2 3
9. have you thought your life has been
a failure?
10. have you felt tearful?

11. has your sleep been restless?

OOOO
I—tI—AI—tr—I
NNNN
WWWUJ

12. were you happy? -

(0) Rarely or none of the time (1) Some of the time

55

(2) Most of the time (3) Almost all of the time
During the past month, how much of the time...

13.
14.
15.
16.
17.
18.
19.
20.

have you talked less than usual?

have you felt lonely?

were people unfriendly?

have you enjoyed life?

have you had crying spells?

have you felt sad?

have you felt that peOple disliked you?

could you not get "going"?

OOOOOOOO

t—iHHt-th-‘HH

NNNNNNNN

WWWWWWWW

Appendix C

 

OFHCEOF
RESEARCH
AND
GRADUATE
STUUHES

lvmlty Committee on
Research Involving
Home: Subjects
(UCRIH!)

Michigan State University
2 Administration Building
East Lansing, Michigan
flflfiJNfi

517A355~2180
FAX: 517/432-1171

mumwmsmunwmv
i054 is Wises! Dimity,
Emilee: in Action

Mwuenfimmwamn
emi-c: 22.-an!» lawman

56
MICHIGAN STATE

lJ hi I \’ E I! S I 1' Y

October 6, 1995

Appendix C

TO: Charles G van
3108 Clin cal Center

Barbara A. Given
A230 Life Sciences

RB: Instr 92-280
TITLr: gaggfix Hon: CARS rOR ORNcrn--a COHHUNITY-BASED
RSVISION RSOUSSTSD: 08 10 95 '
carroonv: :0 L Asvrsw

APPROVAL DATE: 06/05/95

The University Committee on Research Involving Human Subjects'
(UCRIHS) review of this project is complete. I am pleased to.advise
that the rights and welfare of the human subjects appear to be
adequately protected and methods to obtain informed consent are

eppro tie a. Therefore, the UCRIHS approved this project including any
revis on listed above.

CONSENT FORMS Ion THE FOLLOWING SITES HAVE BEEN Rrvrswrn & APPROVED BY
UCRIHS: HOLAREN, SAGINAW COOPERATIVE HOSPITALS ST. JOSEPH HERO!
HOSPTIRL. wrST HICHIOAN CANCER CSNTSR FOOTE HOSPITAL, NORTHERN
HICHIORN HOSPITAL BURNS CLINIC FOUNDATION ST. HARY'S HEALTH SERVICES,
MERCY MEMORIAL HE ICAL CENTER, HID-HICHIGAN REGIONAL KEDICAL CENTER,
8?. LAWRENCE HOSPITAL a HEATLHOAR: SERVICES SPARROW HOSPITAL,
MICHIGAN STATE UNIVERSITY e BUTTIRWORTR HOSPITAL.

IBNBHIL: UCRIHS approval is valid for one calender year, begining with
the approval date shown above. Investigators planning to
continue a project be and one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek u ate certification. There is a
maximum of four sucn expedite renewals ssible. Investigators
wishing to continue a reject beyond the time need to submit it
again or complete rev ew.

REVISIONS: UCRIHS must review any changes in rocedures involving human
subjects, rior to in tiation or t e change. If this is done at
the time o renewal, please use the teen renewal form. To
revise an approved protocol at any 0 her time during the year
send your written request to the c3138 Chair, requesting revised
approval and referencing the'project's IRE i and title. Include
in our request a descr ption ot the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PROBLIII/

OIAIOBI: Should either of the following arise during the course or the
work, investigators must noti y UCRIHS promptly: (1) problems
(unexpected side effects comp aints, e o.) involving human
Subjects or 12) changes in the research environment or new
information ndicating greeted risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help lease do not hesitate to contact us
at (517)355-2180 or FAX (517)4 5- 171. testing 123

e

"litigio-

David 8. Wright, Ph.D.
UCRIHS chair
DIR 3 bed

cc: Donna Neumark

 

OFFICE OF
nesenncn
AND
GRADUATE
STUDIES

Matty Committee on
. Research involving
' ~ Human Subjects
(UCRIHS)

mmmMwaumhnm
ImmWHHMMfimmm
ERUMMgMMMwI
4%NHNO

5177355~2180
FAX: 517/432-1171

WMHWMSMHWHWU
OUBMMMmfimnma
Emmanmamm

wwnmum~mnmwi
mmflflanhmwm

   
 
 
  
   

57'

MICHIGAN STATE

U IQ I‘V

June 6, 199

E R.!5 I'T Y

5

TO: Barbara A. Given

A230

Life Sciences

RB: IRB#: 92-280
TITLE: §3§§EY 30H! CARE FOR CANCER--A COHNUNITY-BASED
REVISION REQUESTED: 05 25 95
CATEGORY: FU L VIEW
APPROVAL DATE: 06/05/95

The University Committee-on Research Involving Human Subjects'(UCRIHS)

review or this project is complete. I am pleased to adv

as that the

rights and welfare of the human subjects eppgar to be adequately
rotected and methods to obtain informed consent are appropriate.
V

Therefore,
above.

RENIHALI

REVISIONS!

PROBLEMS]
CEANGBS:

If we can b
at (517)355

sincerel

UCRIHS Chai
DEW:kaa/lcp

the UCRIHS approved this project and any re sions listed

UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project be end one year must use the green renewal
torm (enclosed with t e original approval letter or when a

pro act is renewed) to seek u date certification. There is a
max mum of tour such expedite renewals cssrble. Investigators
wishing to continue a reject beyond the time need to submit it
again or complete rev ew.

UCRIHS must review any changes in procedures involving human
subjects, rior to in tiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an ap roved prOtocol at any O her time during the year
send your wr tten request to the. CRIHS Chair, requesting revised
approval and referencing the prOJOCt'C IRB # and title. Include
in our request a descr ptiOn of the.change and any revised

ins ruments, consent forms or advertisements that are applicable.

Should either of the followin arise during the course of the
work, investi ators must noti UCRIHS romptly: {1) problems
(unexpected e de effects comp eints, e c.) involv ng uman
subjects or 12) changes in the research environment or new
information ndicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

e of any future help lease do not hesitate to contact us
-2180 or FAX (517)4 i- 171.

, \r

ight, Ph.D.
r

Appendix D

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

niversity Committee on
Research Involving
Human Subjects
(UCRIHS)

Mlchtgan State University
‘25 Admlnlstratlon Building
East Lansing, Michigan
48824-1046

517/355-2180
FAX 517/432-1171

l'r I) ‘_ , .
' a - :In.Itt!!/r7.1I/-,naigrxnn

I 1.?!!"}{I‘D(}rv"i/.'!!L" 'II’c’it't'Jv'lv' r;

 

MICHIGAN STATE 58

UNIVERSITY

February 22, 1995 Appendlx D
To: Tricia M. Kemmer
429 Colle e Avenue
Holland, I 49423
RE: IRB#: ~ 95-048
TITLE: THE RELATIONSHIP BETWEEN DEPRESSION AND IMPACT

ON SCHEDULE IN CAREGIVER DAUGHTERS, OF ELDERLY
MOTHERS, WITH DIFFERING EMPLOYMENT STATUS

REVISION REQUESTED: M/A

CATEGORY: 1-E

APPROVAL DATE: 02/22/95

The University Committee on Research Involving Human Subjects'(UCRIHS)
review Of this project is complete. I am pleased to advise that the
rights and welfare of the human subjects appear to be adequately
protected and methods to obtain informed consent are appropriate.
lheiegorg, the UCRIHS approved this project including any revision

is e a ove.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project be ond one year must use the green renewal
form (enclosed with t e original approval letter or when a
project is renewed) to seek u date certification. There is a
maximum of four such expedite renewals ossible. Investigators
wishing to continue a project beyond the time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any O her time during the year,
send your written request to the CRIBS Chair, requesting revised
approval and referencing the project's IRB # and title. Include

in your request a description of the change and any revised

ins ruments, consent forms or advertisements that are applicable.

PROBLEMS]

CHANGES: Should either of the followin arise during the course of the
work, investigators must noti y UCRIHS promptly: (1) problems
(unexpected side effects, comp ainte, e c.) involving uman
subjects or (2) changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help, lease do nOt hesitate to contact us
at (517)355-2180 or FAX (Sl7)3 6- 171.

   

avid E. Wright, Ph.
UCRIHS Chair'

DEW:pjm

cc: Carla L. Barnes

list of References

List of References

American Association of Retired Persons. (1989). Working
caregivers report: A national survey of caregivers. Washington, DC.:
Author.

American Psychiatric Association. (1994). Diagnostic and
statistical manual of mental disorders (4th Edition). Washington, DC.:
Author.

Archbold, P. G. (1982). An analysis of parentcaring by women.
Home Health Care Services QuarterlyLS (2), 5-26.

Archbold, P. G., & Stewart, B. J. (1986). Family caregiving
inventory. (Available from Patricia G. Archbold, Department of
Family Nursing, School of Nursing, Oregon Health Sciences University,
Portland, OR 97201-3098).

Archbold, P. G., Stewart, B. J ., Greenlick, M. R., & Harvath, T.
(1990). Mutuality and preparedness as predictors of caregiver role
strain. Research in Nursing & Health, 13 (6), 375-3 84.

Atchley, R. C. (1990). Defining the vulnerable older population.
In 2. Harel, P. Ehrlich, & R. Hubbard (Eds), The vulnerable aged (pp.
18-31). New York: Springer. _

\ Barnes, C. L., Given, B. A., & Given, C. W. (1992). Caregivers of
elderly relatives: Spouses and adult children. Health and Social
59

60

Work 17 (4), 282-289.

\ Barnes, C. L., Given, B. A., & Given C. W. (1994). Parent
caregivers: A comparison of employed and not employed daughters.
Soci W rk 4 (3), 375-381.

Barnes, G., & Prosen, H. (1984). Depression in Canadian general
practice attenders. Canadian loumal 9f Psychiag'y, 22 (1), 2-10.

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