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Risk of burnout increases as pandemic adds extra layer of burden

By Sunmeet Kaur
August 15, 2022

Caregiving is a role that we will all require or fulfil in our lifetime. As the former first lady Rosalynn Carter (2011) once said, “There are only four kinds of people in the world: those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need caregivers.”

Statistics from 2018 show that a quarter of Canadians (7.8 million people) are caregivers, almost half (47 per cent) of them caring for their parents or parents-in-law and the majority (64 per cent) spending less than 10 hours per week on caregiving duties (Statistics Canada, 2020). Given the strain on health-care resources and increased reliance on family caregivers (Kent et al., 2020) since the beginning of the COVID-19 pandemic, the number of caregivers and intensity and time spent caregiving have increased. In Canada, caregivers spent an average of 4.7 more hours per week caregiving during the peak of the pandemic than they did before the pandemic began (EMD Serono, 2021). In Ontario, the percentage of caregivers who felt isolated, anxious, overwhelmed, unappreciated, or said that they are not coping well or their mental health worsened, increased in the second year of the pandemic compared to the first year (Ontario Caregiver Organization, 2021).

As a result of the additional stressors and challenges posed by the pandemic, family caregivers are at risk for increased caregiver burden (Archer et al., 2021) and may therefore require additional support (Dang et al., 2020). The issue of caregiver burden will have long-lasting effects on both caregivers and care recipients (Irani et al., 2021).

Pandemic’s impact on family caregivers

The COVID-19 pandemic posed — and continues to pose — various challenges for family caregivers. There are many lessons that we have learned. Fear of infecting the care recipient and the additional task of protecting them from COVID-19 infection was a major source of burden for caregivers (Archer et al., 2021). Caregivers were hesitant to request assistance from friends and family for fear of exposure to the virus (Kent et al., 2020), further contributing to the loss of social support. Caregivers experienced economic stressors as many of them risked losing their jobs or faced a reduction in income (Kent et al., 2020). In addition to presenting new challenges, the COVID-19 pandemic intensified many of the challenges that family caregivers already faced, such as social isolation (Dang et al., 2020; Kent et al., 2020) and difficulty navigating the health-care system (Archer et al., 2021). Factors that influenced the impact of the pandemic on caregivers include age, gender, culture, family structure, length of caregiving, relationship to the care recipient, socio-economic status, caregiving intensity, caregiver characteristics such as resilience, and religious beliefs (Archer et al., 2021; Cohen et al., 2021; Sherman, 2019).

Caregivers can become consumed by their caregiving role.

In 2018, despite 70 per cent of caregivers receiving some form of social or financial assistance, one-third of them said that their needs remained unmet and that they desired additional support in terms of finances, assistance in the home, information or advice, and support from health-care professionals (Statistics Canada, 2020). Nurses can intervene and meet some of these needs by providing information and support to family caregivers. Additional pandemic-induced demands and stressors, coupled with inadequate support, increase the risk of caregivers experiencing burnout, “a multidimensional bio-psycho-social reaction that results from an imbalance of care demands that are relative to caregivers’ personal time, social roles, physical and emotional states, and financial resources, and other role responsibilities” (Cohen et al., 2011, as cited in Sherman, 2019, p. 6). Family caregivers play an essential role in care recipients’ lives and in society by protecting an already strained health-care system. Thus, it is imperative that caregivers receive timely support and that action is taken to reduce caregiver burnout, particularly during stressful events like the COVID-19 pandemic. Nurses can do this by incorporating the interventions discussed below into their practice.

Nursing interventions

Address the caregiver and assess for caregiver burden

Nurses are in an ideal position to screen for caregiver burnout across a variety of settings, such as inpatient units and outpatient clinics. When caregivers accompany the care recipient, it presents a convenient window for nurses to assess for burnout. Acknowledging the caregiver aligns with viewing the client as a whole. It also recognizes the intricate relationship between caregivers and care recipients and the impact that the well-being of one has on the other (Kent et al., 2020).

Family caregivers are often considered a “shadow workforce” (Archer et al., 2021); thus, acknowledging and addressing them by making eye contact and greeting them (Sherman, 2019) highlight their importance. Simply asking the question “How are you?” with intention and appropriate use of body language can set the stage for meaningful interaction with the caregiver. Creating a comfortable environment that opens the lines of communication can encourage caregivers who require support to open up and seek assistance. It also facilitates further assessment using probing questions, checklists and validated tools if needed (see the resource list at the end of this article). Nurses can use their judgment and emotional intelligence, taking cues such as the caregiver’s body language, to determine the timing and depth of an assessment for caregiver burnout. Nurses should recognize that levels of burnout may be greater for caregivers who belong to marginalized groups, although pandemic-related research in this area is limited (Cohen et al., 2021).

Checklists and screening tools for assessing the risk for caregiver burnout (Kent et al., 2020) make it easier and quicker for nurses to ask the necessary questions using appropriate or standardized language. The shortened 12-item Zarit Burden Interview is an easy-to-use tool with strong internal validity and reliability that nurses can use to assess for burnout among different types of caregivers (Zarit, 2014). After establishing rapport with the caregiver, the nurse can use the Zarit tool as a screening measure to assess for caregiver burnout and intervene accordingly (see resource list). Awareness of subjective burden influences a caregiver’s decision to seek support (Zarit, 2014); therefore, simply completing this interview with the caregiver can help them recognize the impact caregiving is having on their life. Shorter and simpler screening tools can also be used (see resource list). Caregivers may not ask for support immediately, but the interaction may serve as the impetus for the caregiver seeking assistance at a later time. Nurse educators can provide the tools and training necessary to assist nurses in communicating with caregivers and assessing their burnout.

Validate, support and encourage help-seeking

Caregiving is a rewarding experience, but in times of substantial stress, it can also be a burden. Caregivers are often underappreciated and unsupported (Archer et al., 2021); therefore, acknowledging them and validating their role are simple yet effective ways to offer support. This can be done by affirming that these are unprecedented times and reassuring caregivers that they are doing their best (Kent et al., 2020). Nurses can employ emotional intelligence and effective communication skills to actively engage with caregivers. To understand the caregiver’s perspective, nurses should educate themselves on the issues caregivers face (see resource list). This will ensure that dialogue with caregivers is genuine. Although the focus of the encounter is the care recipient, it is also an opportunity to address the needs of the caregiver, who should be considered a second-order patient (Sherman, 2019).

Caregivers may be juggling several roles (Conway, 2019, as cited in Archer et al., 2021), all of which are being affected by the pandemic, impacting their ability to withstand the stresses of caregiving. Nurses can intervene by normalizing the experience and encouraging help-seeking (Kent et al., 2020; Young et al., 2021). Caregivers can become consumed by their caregiving role, which can lead them to become physically and emotionally drained (Sherman, 2019). Activities the caregiver normally participated in to cope or seek respite from caregiving may have been impacted by the pandemic (Irani et al., 2021), putting the caregiver at risk for negative outcomes. Nurses can emphasize the importance of self-care (Young et al., 2021) and recommend stress-reducing activities (Irani et al., 2021), such as practising mindfulness and gratitude. Many caregivers also have co-morbidities of their own, which may have been exacerbated by the pandemic (Schmaderer et al., 2020, as cited in Archer et al., 2021).

Encouraging caregivers to take care of their physical health and overall well-being is important. Family caregivers need to recharge for their own well-being and the care recipient’s.

Many family caregivers were pushed to a breaking point by the additional stressors of the COVID-19 pandemic. Caregivers often find it difficult to ask for help and may have been even more reluctant to do so during the pandemic due to the risk of COVID-19 exposure (Kent et al., 2020). Support from social networks can help reduce caregiver burnout (Archer et al., 2021); however, access to established support systems may also be impacted by the pandemic (Dang et al., 2020; Irani et al., 2021). Nurses can empower caregivers to seek help in ways they are comfortable with and make use of their social support network as needed (Kent et al., 2020).

Connect caregivers with appropriate resources

Ensuring that caregivers are supported throughout stressful events is essential as burnout can negatively impact both the caregiver and the care recipient (Irani et al., 2021). Family caregivers are often considered, whether they want to be or not, members of the health-care team, and this may lead to their own needs being overlooked by health-care professionals (Sherman, 2019). Health-care workers should understand that family caregivers are not a substitute for formal care services. The caregiver is often already overwhelmed before they ask for any assistance; therefore, timely intervention can fill gaps in their support system (Dang et al., 2020) and prevent negative outcomes, such as caregiver crisis (Young et al., 2021).

The pandemic impacted the type and availability of services available to caregivers due to factors such as staffing and social distancing. Another pandemic wave or other calamity is always a possibility. Resources and services vary by region and province, so nurses should be familiar with what is available in their area. An awareness of community organizations that provide services, such as meal preparation and delivery, is helpful to be able to refer caregivers appropriately (Dang et al., 2020; Kent et al., 2020). Although many formal services may be reduced during the pandemic (Dang et al., 2020), telehealth alternatives are available and can provide professional support (Archer et al., 2021). Many 24/7 helplines exist, so caregivers can seek help when needed (Dang et al., 2020). Nurses can develop pamphlets with information on caregiver burnout and available resources that can be given to caregivers at the point of care, ensuring that members of the team have the tools to support caregivers even when they are limited on time.

After screening for caregiver burnout, referrals to other members of the health-care team, such as home care or patient care coordinators, can be made as necessary to ensure the well-being of the caregiver (Sherman, 2019). This also safeguards the care recipient, who may receive safer and more adequate levels of care once the caregiver is supported in their role. Many caregivers have had little to no training or preparation for their role (Sherman, 2019). Education sessions and web-based interventions can be offered to caregivers (Sherman, 2019) to improve coping, increase resilience and reduce burnout, especially during pandemics. Screening for caregiver burnout may also lead to the detection of situations in which abuse is a risk or already taking place, further highlighting the importance of assessment.

Conclusion

An analysis of the issue reveals that additional stressors brought on by the pandemic put family caregivers at risk of burnout, and taking action through supporting caregivers is vital to mitigating the negative effects the pandemic had. As nurses, we are in an ideal position to assess caregivers for risk of burnout, support family caregivers, and help connect them to the appropriate resources. Small actions taken by nurses can have a meaningful impact on the lives of caregivers and their care recipients. However, support for caregivers does not begin or end at the point of care. Nurses must advocate for policies that protect and support family caregivers.

An exploration into the impact of the COVID-19 pandemic on caregivers and differences in caregiver burnout is necessary. Such a study, which could focus on factors such as gender, socio-economic status and ethnicity, would be beneficial to further inform strategies to support caregivers and even help in the development of a pandemic-specific burnout assessment tool. By taking steps to assess and reduce the burnout of family caregivers, nurses can acknowledge the invaluable role that family caregivers play in health-care systems and support the family caregiver workforce that works alongside them in caring for Canadians.

Resource list

• At-a-Glance: Resources for Care Providers to Support and Include Caregivers (one-page table published by the Ontario Caregiver Organization)
• How to Identify a Family and Friend Caregiver (four-page resource published by Family Caregivers of British Columbia)
• Ontario Caregiver Organization’s courses for health-care providers
• Zarit Burden Interview
• Burden Scale for Family Caregivers (“short” 10-question version)
• Caregiver Burden Scale (one-page survey by Zarit)
• Self-Rated Burden Scale (best practice guideline)
• Screening for Stress and Burden in Caregivers of Seniors (toolkit of screening assessments)

References

Archer, J., Reiboldt, W., Claver, M., & Fay, J. (2021). Caregiving in quarantine: Evaluating the impact of the COVID-19 pandemic on adult child informal caregivers of a parent. Gerontology and Geriatric Medicine, 7. doi:10.1177/2333721421990150

Carter, R. (2011, May 26). Written testimony of Former First Lady Rosalynn Carter before the Senate Special Committee on Aging. The Carter Center. Retrieved from https://www.cartercenter.org/news/editorials_speeches/rosalynn-carter-committee-on-aging-testimony.html

Cohen, S. A., Kunicki, Z. J., Drohan, M. M., & Greaney, M. L. (2021). Exploring changes in caregiver burden and caregiving intensity due to COVID-19. Gerontology and Geriatric Medicine, 7. doi:10.1177/2333721421999279

Dang, S., Penney, L. S., Trivedi, R., Noel, P. H., Pugh, M. J., Finley, E., … Leykum, L. (2020). Caring for caregivers during COVID‐19. Journal of the American Geriatrics Society, 68(10), 2197-2201. doi:10.1111/jgs.16726

EMD Serono. (2021). The global carer well-being index. Carers Canada. https://www.carerscanada.ca/wp-content/uploads/2021/03/Global-Carer-Well-Being-Index-Report_FINAL-2021-NA.pdf

Irani, E., Niyomyart, A., & Hickman, R. L., Jr. (2021). Family caregivers’ experiences and changes in caregiving tasks during the COVID-19 pandemic. Clinical Nursing Research, 30(7), 1088-1097. doi:10.1177/10547738211014211

Kent, E. E., Ornstein, K. A., & Dionne-Odom, J. N. (2020). The family caregiving crisis meets an actual pandemic. Journal of Pain and Symptom Management, 60(1), e66-e69. doi:10.1016/j.jpainsymman.2020.04.006

Ontario Caregiver Organization. (2021). Spotlight report – The impact of COVID-19 on caregivers: Year two. Retrieved from https://ontariocaregiver.ca/wp-content/uploads/2021/11/OCO-Spotlight-report-English-2021-NOV22-240PM.pdf

Sherman, D. W. (2019). A review of the complex role of family caregivers as health team members and second-order patients. Healthcare, 7(2), 63. doi:10.3390/healthcare7020063

Statistics Canada. (2020, January 10). Caregivers in Canada, 2018. Catalogue no. 11-001-X. Retrieved from https://www150.statcan.gc.ca/n1/daily-quotidien/200108/dq200108a-eng.htm

Young, E., Milligan, K., Henze, M., Johnson, S., & Weyman, K. (2021). Caregiver burnout, gaps in care, and COVID-19: Effects on families of youth with autism and intellectual disability. Canadian Family Physician, 67(7), 506-508. Retrieved from https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC8279676/

Zarit, S. H. (2014). Zarit Burden Interview. MAPI Research Trust. Retrieved from https://eprovide.mapi-trust.org/instruments/zarit-burden-interview

Sunmeet Kaur, RN, MN, recently graduated with her master’s degree from Athabasca University and is a family caregiver.