Effects of caregiving demand, mutuality, and preparedness on family caregiver outcomes during cancer treatment

Oncology Nursing Forum, Jan, 2008 by Karen L. Schumacher, Barbara J. Stewart, Patricia G. Archbold, Mildred Caparro, Faith Mutale, Sangeeta Agrawal

Although much research has explored family caregiving in the cancer population, relatively little has focused directly on implementation of the caregiving role. Given the increasing complexity of family caregiving during cancer treatment (Given, Given, & Kozachik, 2001; Houts, Nezu, Nezu, & Bucher, 1996), the development and testing of theoretical models focusing on role implementation and the identification of outcomes sensitive to role implementation variables are essential directions for research. The purpose of this study was to test in the cancer population a model of family caregiving derived from the interactionist approach to role theory (Archbold, Stewart, Greenlick, & Harvath, 1990; Burr, Leigh, Day, & Constantine, 1979; Schumacher, 1995). The interactionist approach to role theory emphasizes concepts related to role implementation, including the tasks and behaviors that comprise the role, the way in which interactions between role partners shape role implementation, and anticipatory preparation for the role.

Conceptual Framework

The interactionist approach to role theory is a broad area of scholarship that provides a complementary perspective to theories of stress and coping. Theories of stress and coping predominate in family caregiving research and have stimulated important gains in knowledge about how caregiver, patient, and disease characteristics affect responses to caregiving stressors (Given et al., 1993; Haley, Lamonde, Han, Burton, & Schonwetter, 2003; Northouse, Mood, Templin, Mellon, & George, 2000; Oberst, Thomas, Gass, & Ward, 1989). However, stress and coping theories provide fewer insights into role implementation or how family members actually carry out the caregiving role. Typically, theories of stress and coping view the family caregiving role simply as a source of stress, rather than as a complex and interesting phenomenon in its own right.

In contrast, the interactionist approach to role theory provides a lens through which to focus on the caregiving role itself and suggests numerous concepts that may provide new insights about how to assist family caregivers with effective role implementation (Archbold et al., 1990; Burr et al., 1979; Schumacher, 1995). Roles are defined as goal-oriented patterns of behavior (Turner, 1990), and interaction between role partners is emphasized (Turner, 1962). Anticipatory preparation for new roles is a key concept (Burr et al.).

Applying these broad concepts to family caregiving during cancer treatment, the authors defined patterns of behavior as caregiving demand (time spent in the tasks and behaviors that comprise the caregiving role), interaction between role partners as mutuality (the quality of the relationship between caregiver and patient), and anticipatory preparation as preparedness (caregivers' perceived readiness to provide care). The authors created a model in which demand, mutuality, and preparedness are the predictor variables (see Figure 1). Outcomes were conceptualized as multidimensional indicators of role strain and mood. Indicators of role strain are specific to caregiving, whereas the multiple dimensions of mood represent more generic outcomes. The model controls for caregiver gender and age because previous research (cited in the literature review) has shown those variables to be related to caregiver outcomes.

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The model expands a line of research initiated by Archbold et al. (1990), who examined mutuality and preparedness as predictors of role strain among caregivers of frail older adults following hospitalization. Subsequent studies have explored mutuality and preparedness in other clinical populations, including family caregivers of individuals with Parkinson disease (Carter et al., 1998) or coronary artery disease (Kneeshaw, Considine, & Jennings, 1999). One study explored preparedness and caregiver burden among caregivers of inpatients with cancer (Scherbring, 2002). The authors of the current article sought to expand on previous research by testing a model with three predictor variables and a broader range of caregiver outcomes. The hypotheses were that (a) demand, mutuality, and preparedness will explain significant variance in caregiver outcomes, controlling for caregiver gender and age; (b) higher levels of demand and lower levels of mutuality and preparedness will be associated with more negative outcomes; (c) demand, mutuality, and preparedness will have different patterns of association across outcomes; (d) demand and preparedness will be stronger predictors of role strain than mood; and (e) mutuality will have a pervasive effect across outcomes.

Literature Review

Caregiving Demand

Of the three predictor variables, caregiving demand has received the most attention in the cancer population. Caregiving demand has been defined in numerous ways, including the time spent in caregiving tasks (Carey, Oberst, McCubbin, & Hughes, 1991; Nijboer, Triemstra, Tempelaar, Sanderman, & van den Bos, 1999; Oberst et al., 1989; Schott-Baer, 1993), the number of care tasks performed (Nijboer, Tempelaar, Triemstra, van den Bos, & Sanderman, 2001), and the amount of assistance provided (Cameron, Franche, Cheung, & Stewart, 2002). Research has demonstrated that higher levels of demand are associated with higher levels of threat and loss appraisals (Oberst et al.), disrupted schedules and loss of physical strength (Nijboer et al., 1999), and role overload, role captivity, and loss of intimate exchange (Gaugler et al., 2005). To expand on previous research, the current authors explored demand in relation to outcomes that have received less attention, such as tension and fatigue.