INTERNATIONAL PEDIATRIC NURSING

Column Editor: Bonnie Holaday, DNS, RN, FAAN

Caregiver Burden: A Concept Analysis

Kuei-Ru Chou, PhD, RN

The development of the concept of burden for use in research lacks consistent conceptualization and operational definitions.
The purpose of this article is to analyze the concept of burden in an effort to promote conceptual clarity. The technique
advocated by Walker and Avant is used to analyze this concept. Critical attributes of burden include subjective perception,
multidimensional phenomena, dynamic change, and overload. Predisposing factors are caregiver’s characteristics, the demands
of caregivers, and the involvement in caregiving. The consequences of burden generate problems in care-receiver, caregiver,
family, and health care system. Overall, this article enables us to advance this concept, identify the different sources of burden,
and provide directions for nursing intervention.
Copyright r 2000 by W.B. Saunders Company

B URDEN is one of the most commonly used

variables in caregiving research, both as a
predictor and as an outcome. However, the develop-
ment of the concept of burden for use in a research
lacks consistent conceptualization and operational
definitions. The lack of consistency in the results
across studies and the inadequate psychometric
properties of burden measures limit burden’s scien-
tific rigor for generating additional research. The
meaning of burden is further obscured by the
tendency for some researchers to use the term
interchangeably with ‘‘well-being, stress, prob-
lems, adverse effects’’ (Montgomery, Stull, & Bor-
gatta, 1985). The need to clarify the concept and to
understand the relevant attributes of burden would
help explicate it’s usefulness in practice and re-
search. The purpose of this article is to analyze the
concept of burden in an effort to promote concep-
tual clarity. The technique advocated by Walker
and Avant (1988) will be used to analyze the
concept of burden. This report seeks to (1) provide
a review of the conceptual definitions of burden, (2)
delineate the critical attributes of burden, (3) ex-
plore the predisposing factors that may be influenc-
From the School of Nursing, National Defense Medical
Center, Taipei, Taiwan.
Address reprint requests to Kuei-Ru Chou, PhD, RN, Associ-
ate Professor, School of Nursing, National Defense Medical
Center, Taipei, Taiwan ROC.
Copyright r 2000 by W.B. Saunders Company
0882-5963/00/1506-0002$10.00/0
doi:10.1053/jpdn.2000.16709
ing the occurrence of burden, (4) identify the
consequences of this concept, and (5) explore the
empirical referents of burden.
CONCEPT OF BURDEN IN THE HEALTH
PROFESSIONS
The concept of family burden was first intro-
duced into the literature by Grad and Sainsbury
(1966) in an examination of community care for the
mentally ill. They defined burden as any cost
(negative consequences) to the family of which the
patient is a member. In this context, burden is
broadly viewed as a mediating force between the
patient’s impairment and the impact that caregiving
has on the lives of the caregivers and their families.
Since that time, burden has become a commonly
recognized phenomenon in the health care litera-
ture.
Burden as a concept was first explicated by
Hoenig and Hamilton in 1966. They suggested that
events, activities, and specific events need to be
separated from emotions, feelings, and attitudes
associated with caregiving. Thus, these investiga-
tors were the first to dichotomize burden into
subjective and objective dimensions. Objective
burden referred to the events and activities associ-
ated with negative caregiving experiences. Subjec-
tive burden referred to feelings aroused in caregiv-
ers as they fulfilled their caregiving functions
(Hoenig & Hamilton, 1966).
To further clarify this concept, Zarit, Reever, &
Bach-Peterson (1980) defined burden as ‘‘the ex-
tent to which caregivers perceived their emotional,

398 Journal of Pediatric Nursing, Vol 15, No 6 (December), 2000

CAREGIVER BURDEN: A CONCEPT ANALYSIS
physical health, social life, and financial status as a
result of caring for their relative’’ (p. 261). Zarit et
al. (1980) viewed burden as the product of a
specific, subjective, interpretive process. This view
depicts caregiver burden in a way that is not
perceived as an unavoidable, negative consequence
of providing care, but as the subjective perception
of the caregiver of tasks performed by him or her
for the impaired person, or to personal and individu-
alized reactions to the care-receiver’s behavior.
Platt (1985) pointed out that objective burden
involves ‘‘disruption to family/household life that
is potentially verifiable and observable’’ (p. 386).
‘‘Objective burden differs from subjective burden,
which depends entirely on caregivers sharing their
personal feelings’’ (p. 386). Similarly, Montgom-
ery, Gonyea, & Hooyman (1985) defined subjec-
tive burden as ‘‘the caregivers’ attitude toward or
emotional reactions to the caregiving experience,
while objective burden is the extent of disruptions
or changes in various aspects of the caregiver’s life
and household’’ (p. 21). However, the conceptual
distinction between the experience and the distress
is not clear (Braithwaite, 1992).
Later studies have tried to clarify the differences
between objective and subjective burden. The most
recent trend in the literature has taken an even
broader approach to understanding caregiver bur-
den. Instead of conceptualizing burden as a subjec-
tive/objective dichotomy, caregiver burden is not
viewed as a multidimensional construct, and re-
searchers are trying to understand the variables
involved (Kosberg, Cairl, & Keller, 1990), thus
moving the conceptualization of burden towards
more specificity. The term caregiver burden is now
more widely used to refer to the physical, psycho-
logical or emotional, social, and financial problems
that can be experienced by family members caring
for a chronically ill or impaired family member.
The concept of caregiver burden applies to parents
caring for a child with a chronic illness as well as a
spouse or adult caring for an ill or aging parent.
CRITICAL ATTRIBUTES
Walker and Avant (1988) suggest that the critical
attributes of the concept being analyzed are the
characteristics of the concept that emerge repeat-
edly throughout the literature. Critical attributes of
burden include subjective perception, multidimen-
sional phenomena, dynamic change, and overload.
Subjective Perception
How can burden seriously affect some caregivers
but not others in similar situations? According to
399
Romeis (1989), the evaluation process of burden is
based on how the caregiver interprets the demands
of the ill person and how the caregiver organizes
and uses available resources (p. 193). The concept
of burden should be used to refer to the subjective
perceptions of caregivers related to the degree of
problems experienced in relation to the patient’s
specific impairments. These approaches suggest
that burden is processed through caregivers’ subjec-
tive perception (Schene, 1990).
Multidimensional Phenomena:
Bio-eco-psycho-social
Most recently, researchers have found caregiver
burden to show multidimensional characteristics.
When using selected statistical (factor analyses)
and measurement (multiple measures) strategies to
study the multidimensional phenomenon (bio-eco-
psycho-social), the concept of burden usually cov-
ers four aspects: physical, financial, psychological,
and social. Burden resulting from caregiving can
generate burden in several life domains of the
caregiver: physical, psychological, social, spiritual,
and financial (Woods, Haberman & Packard, 1993).
However, the caregiver may not perceive all of the
dimensions at one time.
Dynamic Change
Burden is believed to change as demands and the
extent of caregiving involvement change. Care-
giver burden changes over time because of increas-
ing disability of the impaired care-receiver and
changes in the family’s expectations of the patient.
Thus, what might be considered burdensome at one
time may change as the caregiver adapts and finds
new ways to cope with the patient’s impairment, or
are replaced with new problems or crisis situations
(Perlick, Clarkin, & Sirey, 1995).
Overload
Burden results from an imbalance of perceived
demands and resources. These primary and associ-
ated demands may come from the care-receiver,
other family members, work, or society. The re-
sources may come from an individual himself or
herself or other informal or formal supports. Once
the individual’s resources are not adequate to meet
the demands, the individual may experience over-
load in dealing with the specific demands. The
caregiver will feel burdened to the extent that he or
she perceives the care-receiver’s demands or other
associated demands as outstripping the available
resources. The most frequent emotional reactions
400
reported by the caregivers were feelings of being
overloaded (Corbin & Strauss, 1988).
PREDISPOSING FACTORS
Predisposing factors are those factors that occur
before a care-receiver’s perception of feeling bur-
den (Walker & Avant, 1988). These factors increase
the risk or vulnerability for perceiving burden.
Several predisposing factors have been identified
with caregiver burden. These are caregiver’s char-
acteristics, the demands of caregivers, and the
involvement in caregiving (Table 1).
Caregiver’s Characteristics
Social Locations
Pearlin (1989) points out that many stressful
experiences can be traced back to surrounding
social structures and peoples’ locations within the
structure. Hence, the origin and analysis of the
burden concept should begin with examining ‘‘the
social arrangements of society and the structuring
of experience within these arrangements’’ (p. 242).
The most encompassing of these social structures
are the various systems of stratification that cut
across societies, such as those based on social and
economic class, race and ethnicity, and gender. The
social positions viewed as lower locations include
being female, older, unemployed, and having lower
socioeconomic status.
Gender. The gender of the caregiver is an
important consideration because it appears that
burden is differentially experienced by men and
women in the caregiving role. Because of persistent
sex role differences and greater female life expec-
Table 1. List of Elements in the Concept of Burden
Critical Attributes Predisposing Factors
Subjective perception Caregiver’s characteristics
Multidimensional phenomena Social locations
Dynamic change Gender
Age
Socioeconomic status
Race/culture
Overload Health
Psychological factors
The sense of obligation and responsibility
Affection, reciprocity, and familism
Ego development
Personality factors
The demands of caregivers
Primary demands
Secondary demands
Involvement in caregiving
Time involvement
Number of tasks involved
Types of caregiving
KUEI-RU CHOU
tancy, women are much more likely than men to
assume responsibility for providing direct care.
This relationship between gender and burden has
persisted across a number of studies. The greater
burden on female caregivers has been explained as
‘‘women in the middle’’ and ‘‘the sandwich genera-
tion’’ (Glazer, 1990; Loomis & Booth, 1995; Corbin
& Strauss, 1988) which refers to the multiple roles
such as mother, wage earner, household manager,
and primary emotional supporter. Gender differ-
ences in approach to caregiver burden can be traced
to the result of role socialization (Montgomery &
Datwyler, 1990). Men may focus more on task
accomplishments and experience less stress (Robin-
son, 1990a). Several studies also contained usable
data about gender differences in caregiver burden
(Dowler, Jordan-Simpson, & Adams, 1992; Parks
& Pilisuk, 1991). Consistent findings are that the
majority of family caregivers are women (range,
47% to 80%) and female caregivers perceived their
burden to be greater than men. However, the
sample bias from overreliance on small and clini-
cally drawn samples and lack of consistent mea-
sures of key concepts might limit this interpreta-
tion.
Socioeconomic status. Economic resources play
an important role in a family’s perception of
well-being. Income also has been found to be the
primary determinant of whether and how many
services to alleviate the burden of caregiving can be
purchased (Loomis & Booth, 1995). It has been
shown that insufficient income reduces the access
to resources that might make caregiving more
bearable. Financial expense of caregiving is one of
Mediating and/or Consequences/
Moderating Factors Outcomes
Coping strategies Caregiver
Social support Deterioration in health status
Occurrence of psychological problems
Restrictions in social activities
Care-receiver
Poor health outcomes
Family
Conflict
Financial costs
Health care system
Increasing care expenditures
CAREGIVER BURDEN: A CONCEPT ANALYSIS
the best predictors of caregiver burden (Fink,
1995). However, there are some burden studies that
have failed to find the relationship between family
income and burden (Cuijpers, 1999; Noh & Avison,
1996).
Race and Culture. Race can affect the intensity
of the experience of caregiver burden (Picot, 1995;
Starn, 1996). Normal levels of intergenerational
contact and filial responsibility affect the meaning a
culture attaches to family care. Varying cultural
values also affect caregiving decisions about the
care of children with special health care needs
(McCubbin, 1993). Who cares for the child in the
home and who makes decisions about care varies
by culture.
The relationship between race/culture and bur-
den may be affected by other intervening factors
such as socioeconomic status or the sense of
obligation and responsibility. However, the com-
plex interaction of these factors is still not fully
understood in the literature and little research has
been conducted in this area.
Health
Caregivers in poor health were consistently
found to have significantly higher burden levels
than those in good health (Bull, 1990; Corbin &
Strauss, 1988; Monahan, Greene, & Coleman,
1992; Sisk, 2000). According to Bull (1990),
relationships between burden and health can change
over time as the situation becomes more burden-
some.
Psychologic Factors
Some studies suggest that a few people may
actually benefit from the caregiver experience
(Chen, 1999). This indicates the importance of the
interindividual discrepancy in the subjective percep-
tion of burden. Caregiver burden may be better
known by psychological variables and characteris-
tics of the caregiving context than by factors such
as the illness characteristics (Turner-Henson, Hola-
day, Corser, Ogletree, & Swan, 1994). These fac-
tors might influence a parent to perceive a situation
as burdensome and unpleasant while another parent
values the responsibilities of caregiving as an
opportunity for growth. Findings such as these may
imply the presence of certain factors in the psycho-
logical makeup of the caregiver which have gone
undetected.
Sense of obligation and responsibility. Obliga-
tion may be one of the potential motivating factors
in the caregiving relationship. Caregivers’ sense of
responsibility for an ill child may discourage them
401
from taking vacations and may curtail social activi-
ties, and worrying about the child’s welfare may
restrict their enjoyment of activities they choose to
pursue (Biegel, Song, & Chakravarthy, 1994). An
attribution of responsibility is the result of a
process involving the evaluation of five dimen-
sions; causal dimension, knowledge of the conse-
quences, intentionality, coercion, and appreciation
of the moral wrongfulness of the event. Helene
(1993) reported that there was a significant correla-
tion between responsibility attribution for relative’s
impairment and burden (r ⫽ .37, p ⬍ .01).
Affection, reciprocity, and familism. Knafl
(1993) identified some variables that are believed
to be related to the caregiver–care-receiver (parent–
ill child) relationship as affection, reciprocity, and
normalization. Family caregiving takes on an his-
toric context because bonds of affection, reciproc-
ity, and familism that sustain caregiving took root
in past relationships. Both child and caregiver
(parent) bring a history of interaction that may
enhance the complicated caregiving process. These
factors may positively affect the quality of the
caregiver (parent)–care-receiver (child) relation-
ship. They also will affect the motivation and level
of burden experienced by the parent. Several
studies have found that parents who reported
positive relationships with the child who was ill
were less likely to perceive a high degree of burden
(Deatrick, Knafl, & Walsh, 1988; Kazak, 1989).
Therefore, caregiving may be perceived as less
burdensome when the caregiver and care-receiver
relationship is characterized by strong bonds of
affection.
Ego development. The caregiver’s level of ego
development may mediate the stress-inducing re-
sponsibilities of the caregiving role and directly
influence the perception of burden level of the
caregiver. Horowitz and Dobroff (1982) proposed
that an individual’s level of ego development
directly influenced his or her own subjective expe-
rience of caregiver burden. However, Bililies (1989)
found ego development did not account for a
significant portion of the variance in the regression
equation (r ⫽ .08). Research in the area of ego
development and burden towards a family mem-
ber’s impairment has been limited.
Personality factors. Few studies have recog-
nized personality factors, such as locus of control,
self-efficacy, and hardiness, as an influence in how
the caregiver perceives the caregiving situation.
Most of the research has been focused on the
buffering effect of hardiness on stressful life events
and illness (Tartasky, 1993). According to an
402
exploratory study by Carey, Oberst, McCubbin,
and Hughes (1991), family hardiness is an impor-
tant resource that diminishes caregiver burden and
increases the use of social support. These results
suggest that hardy people may become more in-
volved in caregiving and treat it as an effective way
for dealing with burden events.
In summary, the relationship between psychologi-
cal factors and caregiver burden has not been
explored extensively in the literature. Only a few
studies (Helene, 1993; Robinson, 1990b; Sisk,
2000) have investigated the relationship of psycho-
logic factors and burden. The sense of obligation
and responsibility has been found to be moderately
correlated (r ⫽ .37) with burden (Helene, 1993).
Affection has been found to be moderately associ-
ated with caregiver burden (r ⫽ .30; r ⫽ .15) (Rob-
inson, 1990b). The study of the relationship of ego
development, reciprocity, familism, and personal-
ity factors to burden has been widely neglected.
The Demands of Caregivers
Primary Demands
Primary demands are determined by the func-
tional limitation and degree of disturbance behav-
ior of the impaired family member. Functional
limitations are related to the care-receiver’s func-
tional capabilities which are measured by the
activities of daily living and instrumental activities
of daily living.
Degree of functional limitation. The degree of
functional limitation in the care-receiver (child) has
been shown in some studies to be a significant
variable with respect to the degree of burden
experience by the caregiver (Chou, LaMontagne, &
Hepworth, 1999; Noyes, Hartman, & Samuels,
1999). Functional limitation may prevent the child
from independently conducting activities of daily
living (e.g., bathing, eating, dressing, walking,
going to school, preparing snacks, taking medicine,
and using the telephone). Chakraberti, Kulhara, and
Verma (1992) assessed the strength and direction of
assorted variables taken together in determining
burden. Functional limitation of the impaired care-
receiver was a meaningful variable and explained
38% of the variance ( p ⬍ .01). Similarly, a number
of studies also have shown that the dysfunctions of
children were significantly correlated with care-
giver burden (Monsen, 1999; Ostwold, 1997).
Presence of disturbance behavior. The relation-
ship between the child’s disturbance or disruptive
behavior and caregiver burden is noteworthy. The
child’s constant need for care or attention can lead
to parental fatigue and anxiety (Moser, Dracup, &
KUEI-RU CHOU
Doering, 1999; Williams, Press, & Williams, 1999).
Disturbance behavior can be related to four aspects
of caregiver burden; negative family relationships,
restrictions in caregiver activity, decrease in care-
giver health, and caregiver depression (Kurnat &
Moore, 1999; Mastrain, Ritter, & Deimling, 1996).
Reinhard (1994) also found that behavioral distur-
bance was a predictor of burden accounting for
23% of the variance ( p ⬍ .001). However, some
researchers found that caregiver burden is not
directly influenced by the behavior problems in the
care-receiver (Baronet, 1999). These latter findings
contradict the results cited above and may be
caused by (1) the variability in assessment of the
person’s physical and behavioral problems, (2) the
relationship of particular types of problems with
specific types of burden, (3) the inconsistent opera-
tional definitions of burden, and (4) the differentia-
tion in the conceptualization of burden. These
reasons probably contributed to the discrepancies
in the empirical findings and also made compari-
sons difficult across studies.
Secondary Demands
Secondary demands on the caregiver may come
from family, work, or society (Davidhizar, 1994).
The burden on the caregiver appears to be specifi-
cally related to the presence of young children in
the household and to single-parent families headed
by a woman. Noh and Avison (1996) reported that
being in households with young children was a
significant predictor of burden among female care-
givers (B ⫽ .35, p ⬍ .05).
Involvement in Caregiving
Involvement in caregiving is defined as the
number of caregiving tasks performed and the
amount of time the caregiver spends performing
them (Schott-Baer, 1993). Focusing on the number
of tasks of caregiving will divert attention from the
work these caregivers are engaged in. It may be
more important to distinguish the caregiving in-
volvement by purpose (quality) as well as by time
or tasks (quantity).
Time Involvement
A study by Breslau (1983) showed the parent
spent an average of 6 hours 28 minutes per day
assisting with medication, personal hygiene, house-
hold chores, transportation, and general physical
care. It also showed that the majority of parents had
provided care 7 days a week for an average of 4
hours a day in assisting the ill child (Holaday &
Turner-Henson, 1991). Some studies showed that
CAREGIVER BURDEN: A CONCEPT ANALYSIS
time involvement was positively correlated with
caregiver burden (range, r ⫽ .17 to .37) (Chou et
al., 1999; Whitley, Kristjanson, & Denger, 1999).
Number of Tasks Involved
Holaday and Turner-Henson (1991) found that
the tasks most frequently performed by caregivers
included household and financial management,
mobility, and personal care. Research conducted by
Schott-Baer (1993) found that the number of tasks
performed by caregivers were positively correlated
with burden (range, r ⫽ .19 to .37).
Types of Caregiving
Considering the involvement in caregiving, the
focus on time and number of tasks involved may
limit our understanding of the endeavors of caregiv-
ers. Most researchers do not address the type of
caregiving. Time involvement and number of tasks
involved only explain the quantity of caregiving
(Turner-Henson et al., 1994). Despite the impor-
tance of this caregiving experience, little is known
about the relationship between the types of caregiv-
ing and caregiver burden (Corbin & Strauss, 1988).
MEDIATING AND/OR MODERATING FACTORS
Coping and Burden
The burden experienced by a caregiver is in part
determined by the caregiver’s choice of coping
strategies (Singer & Irvin, 1989). Some researchers
pointed out that a chosen coping strategy may be
affected by both personality variables and the
situation itself (Lazarus & Folkman, 1984). Studies
have addressed the specific coping strategies used
by caregivers to mediate burden. The empirical
findings show that higher levels of interaction with
family members, social and spiritual support-
seeking behaviors, and receiving help from family
members decrease caregiver burden (Brickman,
Rabinowitz & Karuza, 1982). Singer & Irvin
(1989) found that three internal coping strategies
(confidence in problem-solving, reframing the prob-
lem, and passivity) and two external coping strate-
gies (use of spiritual support and extended family)
were significantly related to less caregiver burden.
Information seeking and affective regulation also
have been found to be correlated with decreased
burden. However, some coping strategies may
increase caregiver burden (Tilden & Galyen, 1987).
Social Support and Burden
The potential of social support as a mediator
and/or moderator to burden might appear to be of
value in families who experience the burden associ-
403
ated with an impaired family member. Burden
associated with caregiving tasks may be avoided or
reduced by sharing or delegating specific tasks to
others (Chen, 1999). For example, the perspectives
of hierarchical substitution, functional, and social
convoys suggest that larger networks with greater
diversity in composition will emerge over time in
response to this type of burden. Research about the
social costs of providing care suggests that interper-
sonal sources of burden may be less affected by
specific types of help (Fink, 1995).
Holaday and Turner-Henson (1991) found that
parents tended to provide care alone or with
assistance from family members because formal
care from community and social service seems to
be viewed as a last resort by the parents. Most of
the literature on caregiver burden emphasized the
importance of informal support to caregivers. Feel-
ings of burden may be lessened when informal
helpers share in the caregiving responsibilities
(Cuijpers, 1999). Several researchers found that the
availability of formal or informal supports received
by the caregivers were negatively correlated with
caregiver burden (range, r ⫽ ⫺.26 to ⫺.48) (Bull,
1990; Robinson, 1990a). This finding suggests that
the more supports received, the less the burden
perceived by the caregiver. Also, the degree of
available formal and informal support has been
shown to significantly moderate caregiver burden
and to have a positive impact on lessening the
burdensome aspects of the caregiving role (Biegel
et al., 1994). It is important to distinguish between
the availability of a social resource and the actual
use of that resource. This distinction was not made
in these studies (Bull, 1990).
However, Tilden and Galyen (1987) provide
some opposite views that did not support the idea
that social support moderates stress. Social support
may not always be benevolent and sometimes it
may be a source of stress. Cuijpers (1999) found
that caregivers occasionally viewed visits by other
relatives as intrusive rather than helpful. Thus, we
may need to carefully explore to what extent the
moderated or mediated effect of social support
influence caregiver burden in the future.
CONSEQUENCES/OUTCOMES
The literature on burden limits the conclusions
that can be made about the consequences/outcomes
of burden because the majority of burden studies
are correlational. Therefore, no predictions can be
made about burden’s impact on various outcomes.
Overall, the burden resulting from caregiving can
generate problems in several life domains of the
404
care-receiver, caregiver, family, and health care
system.
Caregiver
The deterioration in health status. Generalized
somatic complaints are well-known within the
burden literature such as chronic fatigue, sleepless-
ness, stomach problems, and weight change (Corbin
& Strauss, 1988). One of the potentially negative
consequences of caregiving found by Mastrian et
al., (1996) was an overwhelming significant in-
crease in the illness rate among caregivers as a
result of their new responsibilities. Similarly,
Kiecolt-Glaser et al. (1991) found that spouse
caregivers had reductions on three measures of
cellular immunity when compared with socioeco-
nomic status matched controls.
The occurrence of psychologic problems. Ac-
cording to Coppel, Burton, Becker, and Fiore
(1985), the top six psychologic problems of caregiv-
ers were depression, anger, worry, discouragement,
guilt, and anxiety. A number of studies (Perlick et
al., 1995) showed highly significant discrepancies
between caregivers and non-caregivers in their
mental health indicators. Caregivers reported al-
most three times as many depressive symptoms as
their age-matched non-caregivers (Monsen, 1991;
Ostwold, 1997).
Skaff and Pearlin (1992) noted that caregivers
were at risk for loss of self. This resulted from an
engulfment in the caring role. The limited time for
socialization and the reduction of the caregiver’s
social roles may have contributed to the loss. Skaff
and Pearlin (1992) stated that the notion of ‘‘loss of
self’’ helps to understand the very personal cost of
the caregiving experience.
Restrictions in social activities. Caregivers have
been portrayed as facing social isolation and inter-
ruptions of careers (Maurin & Boyd, 1990). This
reduction is usually caused by an inability to leave
the child with a babysitter. Within the caregiving
role, things like social pastimes and recreation that
tend to be more flexible in nature are usually given
up first in an effort to cope with the demands of
providing care (Corbin & Strauss, 1988).
Care-receiver (Child)
The physical or psychologic state of the care-
giver (parent) as well as the caregiver’s perception
about the child’s problems can also affect the
physical or psychologic state of the child. Corbin
and Strauss (1988) show that personal distress in
the caregiver correlates with an increase in with-
drawn and apathetic behavior in the care-receiver.
KUEI-RU CHOU
Negative feelings held by the parent may correlate
with the degree of mood disturbance or depression
by the child (Bennett, 1994). Heightened feelings
of sadness, helplessness, and worthlessness in the
child may contribute to the burden of the parent.
Family
Conflict. Conflicts can occur in fulfilling differ-
ent roles because of the number of roles and role
obligations. The negative consequences of caregiv-
ing stem not simply from feeling compelled to
provide care, but from the conflict between feeling
obligated to provide care versus feeling anger at
having to provide care. Family/marital conflict is
common when examining caregiver burden. It has
been reported that 30% to 56% of caregivers
experience family or marital conflict as a result of
burden created by providing care to a chronically ill
child (Knafl, 1993; Sabbeth & Leventhal, 1984).
Financial costs. People with a special-needs
child face unique financial problems (Rowland,
1989). Because of the demanding nature of the
caregiving experience, caregivers may have to stop
working or work part-time to provide care. Other
researchers also report that financial problems
occur within the family in the care of the chroni-
cally ill family member (range, 11% to 42%)
(Kurnat & Moore, 1999).
Health Care System
Family caregiving can save billions of dollars
that would otherwise be required for long-term
hospitalization and care. Without the involvement
of family caregivers, current public long-term care
expenditures would at least double (Rowland,
1989).
In summary, the evaluation of multiple conse-
quences is highly desirable because individuals
have different social locations, psychologic charac-
teristics, caregiving situations, and mediating pro-
cesses resulting in the manifestations of burden.
Overall, the process of burden is a continuing
process that typically starts with a specific trigger
event. The event may or may not cause burden.
This depends on the individual’s subjective percep-
tion. This perception may be affected by the
individual’s characteristics, psychological factors,
other mediators, and the interaction between the
individual and the event. The consequences result-
ing from caregiver burden are multifaceted and
these consequences may also cause burden indi-
rectly by altering adversely or positively our life
situations. If the situation is viewed adversely,
more complicated antecedents will negatively af-
CAREGIVER BURDEN: A CONCEPT ANALYSIS
fect the entire process. On the contrary, when the
situation becomes tolerable, it helps to positively
restructure the entire situation. Thus, the perceived
burden by the individual is not caused by any one
of the domains but by the interaction among them.
Figure 1 represents the conceptual model of burden
and depicts the relationship among predisposing
factors, mediators or moderators, and conse-
quences.
EMPIRICAL REFERENTS
The final step in this analysis is to identify the
empirical referents that show how the concept is
measured in the real world. In an effort to capture
subjective perception of burden, several research-
ers have generated various measures (Novack &
Guest, 1989; Whiteley et al., 1999; Zarit et al.,
1980).
CONCLUSION
Three major theoretical developments were iden-
tified in this concept analysis of burden. First,
Hoenig, and Hamilton (1966) distinguished objec-
tive from subjective burden, and Platt (1985),
Montgomery et al. (1985), and Vitaliano et al.
(1991) further differentiated the distinction be-
tween subjective and objective burdens. The sec-
ond theoretical contribution was Zarit et al’s.
(1980) identification of the importance of percep-
tion and the idea that burden was a product of a
Figure 1. Structural model of the caregiver burden model.
405
specific, interpretative process. Poulshock and
Deimling (1984) proposed that the caregiver’s
degree of impairment be segregated from burden
and placed into a domain of impairment. However,
it should be noted that this model does not take into
account the caregiver’s feelings about the chronic
illness. Thus, as a concept in research, burden is a
term that can take on different meanings. From the
review of literature, it is justifiable to use the
burden concept to examine both personal reactions
to caregiving and the effects of caregiving.
If this concept of burden is to be useful in
nursing research, its meaning needs to be restricted
in such a way as to give the concept clear theoreti-
cal relevance. I have proposed a model (see figure
1) and a definition of burden as an individual’s
subjective perception of overload in one or more of
four perspectives: physical, psychological, social,
and financial through the caregiving process that
will address these issues. The goal of this concep-
tual model is to provide a means of systematically
and comprehensively describing the processes and
characteristics of the caregiving systems specifi-
cally, with respect to how these components relate
to the perception of burden. Only the major compo-
nents of the proposed model are identified. This
model can be used not only in pediatrics, but also in
gerontology and by those working with adults
caring for an ill spouse.
406
What is proposed is a new conceptual framework
for the concept of burden. The conceptual frame-
work that evolved from the analysis of the concept
of burden unifies the research conducted by those
using different definitions of burden. The proposed
framework begins at a higher level of abstraction
than previous research, but it also makes provisions
for narrower classifications under each category.
Thus, there is hope that more generalizable and
integrated results will be obtained from research
studies. Finally, the framework focuses on caregiv-
ing as it relates to burden as a set of interrelated
functions and it is comprehensive in scope. Thus,
there is hope that the conceptual framework will
provide a better understanding of burden as it
relates to caregiving and will provide directions for
nursing interventions.
Studies related to burden have been largely
exploratory and theoretical. The weakness of this
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