Eldercare: The new frontier of work–family balance

Work–family balance is a popular topic in the media, with the discussion usually focusing on the challenges of having a career and raising a family at the same time. However, there is another issue that should be part of the conversation – eldercare. As lifespans increase around the world and more working adults care for ageing family and friends, eldercare is an emerging issue for organisations and their employees. According to a report by Carers UK (2013), 'by 2017 the UK will reach the tipping point for care when the numbers of older people needing care will outstrip the numbers of working age family members currently available to meet that demand'.

In this article I will discuss the impact of eldercare on the health and well-being of caregivers, explore the relationship between employment and eldercare, explain why working is good for caregivers and describe how employers can play a positive role in helping employees deal with eldercare responsibilities. I will begin with a personal story, because it explains what inspired me to study the intersection of eldercare and work.

An eldercare odyssey

Until she was 85 years old my mother lived on her own and enjoyed good health. I never gave much thought to what would happen if she could not care for herself. As is often the case, my introduction to eldercare began with a phone call that went something like this: 'Hello, Lisa. This is Helen. Your mother passed out at church, the paramedics are here and she refuses to go to the emergency room.' This call began a two-year odyssey that included three hospital stays, major surgery, two stints in a rehabilitation facility, frequent outpatients tests and regular follow-up visits with doctors. In addition to coordinating my mother's medical care, I arranged in-home help and home modifications, worked out health insurance issues and managed her finances and household needs while she was hospitalised. The most difficult role was providing emotional support as my mother struggled with the loss of her independence and, at times, resisted getting the treatment and help she needed.

The call came at a challenging time for me professionally – one week after I had completed the first year of my first tenure-track academic job. Fortunately this happened during the summer when I had more flexibility, but a couple of months later I found myself juggling a demanding job and my mother's care. As an only child, balancing the two roles was particularly challenging even with support from my spouse, extended family and friends.

At a stressful time like this, as only an academic would do, I turned to the literature to try to make sense of my predicament. What I discovered was a compelling topic that was understudied compared to other work–family issues. As a result, I stumbled into a new and unexpected research area. Studying it helped me understand my own experience and launched a new research agenda as I encountered friends and colleagues who said 'Me too'. Here are some highlights of what I learned as both a researcher and a caregiver.

Effect on caregiver health and well-being

One definition of eldercare is informal care of ageing family and friends that may entail addressing a combination of physical, psychological, medical, household and financial needs (Smith, 2004). Care recipients may live with their caregivers, remain in their own homes or live in a residential facility. Examples of typical eldercare responsibilities include: providing direct care such as bathing and feeding; coordinating medical care; managing medication; arranging in-home services; offering emotional support; handling finances; and providing transportation to appointments. Eldercare is psychologically distinct from childcare because the need for care often begins with an unexpected emergency and usually increases over time as the care recipient becomes more dependent. Eldercare can also generate complex emotions because of the role reversal of children caring for parents, and the surfacing of unresolved family issues (Smith, 2004).

Research indicates that all types of caregivers experience more stress than non-caregivers (Lee, 1997), but eldercare seems to produce more psychological strain than childcare (Duxbury et al., 2011). Indeed, eldercare affects the physical, psychological and economic health of caregivers, which is collectively known as 'caregiver burden' (George & Gwyther, 1986). Numerous meta-analyses have revealed how eldercare impacts caregiver health and well-being. Vitaliano et al. (2003) found that caregivers have a slightly greater risk for health problems than non-caregivers. Pinquart and Sörensen (2003) found that four dimensions of psychological health – depression, stress, self-efficacy and well-being – are affected more strongly than physical health. They also found that the characteristics of caregivers and care recipients make a difference. For example, spouses fare worse than adult children who provide care, and caregivers of people with dementia are the most negatively affected of all groups. The daily stress of caring for a dementia patient, especially a spouse, has been associated with increased depressive symptoms, decreased immune function and elevated markers of inflammation (McGuire et al., 2002; Gouin et al., 2012).

While there are various methodological limitations in the academic research, and some contradictory results, it is clear that certain groups – such as women, ethnic minorities and people with lower socio-economic status – experience more negative outcomes (Pinquart & Sörenson, 2003, 2005, 2006). Public policy research in the United Kingdom, United States and Canada reaches the same conclusion (Carers UK, 2013; Feinberg & Choula, 2012; Schroeder et al., 2012). Another finding is that having greater financial resources and stronger informal support systems positively affects physical and psychological outcomes (Pinquart & Sörenson, 2007). Thus, inequality of outcomes is evidence of a social equity dimension to burdens of eldercare, although the issue is seldom discussed in these terms.

Balancing caregiving and employment

Because caregiving responsibilities and careers tend to peak around the same time – between the ages of 45 and 64 – another important area of inquiry is the effect of eldercare on work (Carers UK, 2013). Although employed caregivers report higher levels of work-family conflict (Zuba & Schneider, 2013) and experience more stress than non-caregivers (Keene & Prokos, 2007), there is no conclusive evidence that the stress of eldercare translates into negative work outcomes (Zacher et al., 2012).

Although research results are ambiguous about the extent to which eldercare disrupts work, anyone who juggles both roles knows that spillover is inevitable. The most extreme reaction to an increase in caregiving responsibilities is to reduce work hours permanently or drop out of the workforce entirely, leading to a phenomenon known as the 'caregiver penalty'. This refers to the long-term financial impact of lost earnings, employment-related benefits and pension contributions (Feinberg & Choula, 2012). Again, both academic and public policy research agree that women, especially those in low-skilled and low-status jobs, as well as low-income workers and ethnic minorities, are most likely to reduce their hours or leave the workforce (e.g. Austen & Ong, 2014; Feinberg & Choula, 2012).

For caregivers who stay in the workforce, being absent from work is also unavoidable. Boise and Neal (1996) define absenteeism as days missed, lateness, leaving work early or during the workday and other interruptions resulting from caregiving responsibilities. Absenteeism is an interesting variable to study because employees with children tend to miss more work than those caring for elders, even though managers perceive eldercare to be particularly disruptive (Katz et al., 2011). This may be because parents experience regular interruptions, whereas eldercare frequently entails brief but intense periods of care (Boise & Neal, 1996). Boise and Neal also found that women caring for elders experienced more absenteeism than men, again demonstrating the inequality of outcomes.

Although combining work and eldercare does not result in more absenteeism, it may impact productivity when employees focus their time and attention on care issues during the workday. This phenomenon is known as 'presenteeism' (Smith, 2004). For example, caregivers may worry about the care recipient, plan what needs to be done at night or spend time on the phone coordinating care (Zuba & Schneider, 2013). Since most healthcare providers and other services are primarily open during business hours, caregivers often have no choice but to make calls during the day. While they may try to do this during lunchtime or breaks, it is likely that calls will be returned at other times. In my own experience, I would make calls during a long train commute, only to have them returned while I was in class or during office hours.  

You're better off if you work

While there are challenges to balancing work and eldercare, employed caregivers receive psychological benefits from working. Within the work–family literature, there are two schools of thought on the dual roles of caregiver and employee (McMillan et al., 2011). According to scarcity theory (Marks, 1977), the demands of eldercare and work compete for a person's time and energy, ending in a zero-sum game where one role impinges on the other. In contrast, enhancement or enrichment theory says that people with dual roles are better off because the benefits of each role positively spill over into the other (Greenhaus & Powell, 2006). For example, work may provide financial resources to arrange outside care, increase self-esteem, foster a sense of personal accomplishment, provide access to social support systems outside of family and friends and offer respite from caregiving duties (Utz et al., 2012; Zuba & Schneider, 2013). At the same time, successfully navigating the challenges of caregiving and finding benefit in the experience can lead to personal growth, enhanced relationships and clarification of goals (Davis et al., 1998; Parkenham, 2005).

In an analysis of the scarcity versus enhancement debate, Reid et al. (2012) conclude that psychological outcomes are highly individualised in that 'some caregivers may find their employment adds to their stress, whereas others do not; indeed some may find that it provides respite from caregiving and enhances their well-being'. They also conclude that someone can feel stressed and be productive at the same time, and what seems to make the most difference is caregivers' 'subjective assessment of the effect that caregiving is having on work performances'. Therefore, how someone views her ability to juggle eldercare and work may be a more important determinant of role conflict than more objective measures of interference.

Employers can help

Research shows that having a supportive employer may help reduce work–family conflict generally (Kelly et al., 2014) and lessen the psychological strain of eldercare in particular (Zacher & Winter, 2010). However, most employer work-life integration programs still focus on childcare (Kim et al., 2011). Thus there is scope for employers to play a meaningful role in helping employees deal with their eldercare needs, especially at a time when governments are reducing expenditures on health care and social services (Schroeder et al., 2012).

Employer eldercare assistance takes three basic forms: compliance with family leave laws; formal programmes and services; and informal support from managers and supervisors. Although family leave laws vary greatly from country to country, careful adherence to these policies is the minimum that organisations can do to support employees with eldercare needs (Pearce & Kuhn, 2009). In countries with weaker social safety nets, private employers may be more likely to offer formal eldercare benefits such as information and referrals, insurance and financing for care, services such as onsite daycare and respite care, paid leave that exceeds the legal mandates and work schedule modifications (Yang & Gimm, 2013). However, recent research in both the United Kingdom and United States indicates that formal employer eldercare services are not widely available (Carers UK, 2013; Feinberg & Choula, 2012).

Of all the formal employer services mentioned above, employees seem to desire and benefit the most from work schedule modifications, such as flexible hours (Dembe et al., 2012). Similar to family leave laws, flexible work arrangements differ from country to country, and also by industry and type of job. For example, control over work hours is available primarily to professional and managerial employees in the United States (Sweet et al., 2014).

Some of the most interesting findings about employer eldercare support centre on employee perception. Employees who perceive their employer to be supportive are less likely to experience stress regardless of whether they actually take advantage of programmes and services (Zacher & Schulz, in press). However, even when formal organisational eldercare services are available employees tend not to use them (Dembe et al., 2012). This may be due to employers not publicising the services and/or encouraging employees to use them or employees not knowing or thinking to ask about them. Another explanation is that employees, especially women, may perceive a stigma attached to disclosing eldercare issues at work and fear negative career repercussions (Kim et al., 2011). Thus, employers who cultivate a work culture the supports work–family balance are more likely to have employees who feel comfortable disclosing care needs at work (Zuba & Schneider, 2013).

Conclusion

Several conclusions about the relationship between eldercare and work can be drawn from the research presented in this article. First, certain groups experience a greater caregiver burden, resulting in inequality of health, well-being and economic outcomes. To remedy this, policy makers should recognise and address the social equity dimension of eldercare. Second, perceptions impact the degree to which eldercare affects work outcomes. If people perceive that they are able to cope with the demands of both roles, or if they have personal resources and social support, or if their employers are supportive, then they may experience less stress, strain and work–family conflict. Thus, building individual resiliency is key to positive outcomes. Third, for formal employer support programmes to be effective, employees need to know about them, feel comfortable asking about them and be assured that there will be no penalty for using them. Thus, education and training of supervisors and manager is critical to increasing employee awareness and use of eldercare programmes.

With the engagement of all stakeholders, including governments, private employers, the voluntary sector and families, eldercare can be addressed proactively before emergencies happen. Just as parents have 'the talk' with their teenage children about life and the future, perhaps the time is right for adult children to institute 'the talk' when their parents and other elders reach a certain age. This talk would encompass what is needed to ensure both the health and safety of the elder and the well-being of the caregiver. As populations age and more people balance caregiving and work, eldercare must become part of a critical conversation at home, at work an in the media.

Lisa Calvano is Assistant Professor of Management at West Chester University, USA
[email protected]

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