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. Author manuscript; available in PMC: 2019 Apr 1.
Published in final edited form as: J Appl Gerontol. 2016 Apr 1;37(4):464–492. doi: 10.1177/0733464816641391

Double- and triple-duty caregiving men: An examination of subjective stress and perceived schedule control

Nicole DePasquale 1,✉, Steven H Zarit 2, Jacqueline Mogle 3, Phyllis Moen 4, Leslie B Hammer 5, David M Almeida 6
PMCID: PMC5045822  NIHMSID: NIHMS771666  PMID: 27036637

Abstract

Based on the stress process model of family caregiving, this study examined subjective stress appraisals and perceived schedule control among men employed in the long-term care industry (workplace-only caregivers) who concurrently occupy unpaid family caregiving roles for children (double-duty child caregivers), older adults (double-duty elder caregivers), and both children and older adults (triple-duty caregivers). Survey responses from 123 men working in nursing home facilities in the U.S. were analyzed using multiple linear regression models. Results indicated that double- and triple-duty caregivers appraised primary stress similarly to workplace-only caregivers. However, several differences emerged with respect to secondary role strains, specifically work-family conflict, emotional exhaustion, and turnover intentions. Schedule control also constituted a stress buffer for double- and triple-duty caregivers, particularly among double-duty elder caregivers. These findings contribute to the scarce literature on double- and triple-duty caregiving men and provide practical implications for recruitment and retention strategies in the healthcare industry.

Keywords: Men in long-term care, double-duty care, triple-duty care, stress process model of family caregiving, perceived schedule control

Introduction

Men constitute a minority in caregiving professions in the U.S., representing only 11% of certified nursing assistants (CNAs), 10% of registered nurses (RNs), and 8% of licensed practical nurses (LPNs) in 2011 (Landivar, 2013; Paraprofessional Healthcare Institute (PHI), 2013). Societal views mirror this demographical profile, as caregiving professions are typically equated with women (O’Connor, 2015). Collectively, these trends depict men as a major untapped resource for prospective healthcare talent (Sherrod, Sherrod, & Rasch, 2005; Rajacich, Kane, Williston, & Cameron, 2013). With a growing workforce shortage and a rising demand for long-term care services underway, the healthcare industry has increased recruitment and retention efforts targeting this resource (American Association of Colleges of Nursing, 2014; Andrews, Stewart, Morgan, & D’Arcy, 2012; Hart, 2005; Landivar, 2013). Consequently, more men are entering caregiving professions (Andrews et al., 2012; Landivar, 2013). However, gender diversification has been a slow process, gender-related barriers have yet to be successfully addressed, and workplace, recruitment, and retention processes require further modification to effectively target men (Rajacich et al., 2013; Sherrod et al., 2005). For instance, some researchers argue that the homogeneous gender of caregiving professions preserves outdated and sexist notions, obstructs a contemporary portrayal of such professions, and marginalizes men, all of which may undermine recruitment efforts (Christensen & Knight, 2014; Hart, 2005; Jordal & Heggen, 2015). Similarly, differential treatment from colleagues (e.g., expectations to perform more physically strenuous tasks) and patients (e.g., treatment refusal), suspicion regarding intimate touch and the capacity for caring, experiences of isolation or loneliness, felt difficulty in enacting masculine behavior within a female-dominated profession, and a lack of male mentors may impede the effectiveness of retention strategies (MacWilliams, Schmidt, & Bleich, 2013; O’Connor, 2015; Rajacich et al., 2013). Amidst the present workforce shortage and call for gender diversity, a better understanding of the unique challenges experienced by professional caregiving men is essential for facilitating targeted recruitment and retention strategies.

As older adults’ proliferating health and long-term care needs strain an under-resourced system, they are concurrently driving an unprecedented need for family caregivers (Reinhard, Feinberg, Choula, & Houser, 2015). As with caregiving professions, women have dominated unpaid family caregiving roles (Reinhard, Houser, & Choula, 2011). Men are increasingly occupying family caregiving roles, though, and currently represent 40% of adults informally caring for dependent family members in the U.S. (National Alliance for Caregiving (NAC) & the American Association of Retired Persons (AARP) Public Policy Institute, 2015). Recent evidence also indicates that men are investing greater time and becoming more involved in their children’s lives (Gregory & Milner, 2011; Humberd, Ladge, & Harrington, 2014). Further, men’s presence as caregivers of aging relatives is projected to become more prevalent and long-term than ever before (Thompson, 2002). Indeed, prior research suggests that working husbands invest a comparable amount of time to elder care as their employed wives and take on significant elder care responsibilities (Hammer & Neal, 2008). In response to these trends, researchers have begun to highlight the need for organizations to acknowledge and respect men’s work-family interface (Gregory & Milner, 2011; Humberd et al., 2014).

An important, but neglected, aspect of men’s growing presence in both professional and family caregiving is that, compared to men from earlier cohorts, they may have an increased likelihood of partaking in each type of care simultaneously (combined caregiving). Researchers have traditionally studied paid, public and unpaid, private caregiving domains separately, thereby producing limited knowledge regarding combined caregiving (Ward-Griffin et al., 2015). Within this literature, double-duty caregiving refers to professional caregivers who informally care for children (double-duty child caregiving) or older adults (double-duty elder caregiving). Triple-duty caregiving pertains to professional caregivers who informally provide sandwiched care, or care for children and older adults. The few studies considering the convergence of caregiving domains have consistently shown that double- and triple-duty caregivers report various decrements in well-being relative to professional caregivers without family caregiving obligations (referred to as workplace-only caregivers hereafter), including more stress, psychological distress, work-family conflict, physical and mental fatigue, and sleep deprivation (Boumans & Dorant, 2014; DePasquale, Davis, Zarit, Moen, Hammer, & Almeida, 2014; Scott, Hwang, & Rogers, 2006). Nearly all of this research, however, is based solely or predominately on women. To our knowledge, a foundational qualitative examination from Anjos, Ward-Griffin, and Leipert (2012) regarding double-duty elder caregiving men’s caregiving experiences and personal health is the only study that focuses exclusively on men with combined caregiving roles.

Thus, additional information regarding double- and triple-duty caregiving men’s well-being is needed. This information, in turn, will illuminate the potential work-family pressures experienced by double- and triple-duty caregiving men, which can then be integrated into the healthcare industry’s recruitment and retention strategies. Thus, the objective of the present study was to examine subjective stress and perceived schedule control among men employed as CNAs, RNs, and LPNs working in nursing homes in the U.S., half of whom occupy family caregiving roles. This study will also partially replicate a previous investigation on double- and triple-duty caregiving women’s psychosocial stress from the same population described herein (DePasquale et al., 2014) to descriptively compare the stress of double- and triple-duty caregiving on men and women.

Conceptual Framework

Our investigation is guided by an adaptation of the stress process model of family caregiving (SPM; Pearlin, Mullan, Semple, & Skaff, 1990). The SPM defines stress as the conditions, experiences, and activities that are problematic for family caregivers and distinguishes between primary and secondary stress. Primary stress is directly rooted in caregiving hardships and can be objective (i.e., based on care recipient conditions) or subjective (i.e., based on caregiver experiences). Secondary stress, specifically subjective role strains, originates from caregiving demands but spreads to multiple life domains (e.g., work). In this paper, we focus on men’s double- and triple-duty caregiving role occupancy as predictors of subjective primary and secondary stress, or subjective stress appraisals.

Primary Stress

We consider one indicator of primary stress, perceived stress. Although workplace-only and double- and triple-duty caregivers are all exposed to professional caregiving stress, the Anjos et al. (2012) investigation highlighted stress specific to family caregiving. For example, double-duty elder caregiving men described familial pressure to have “the right answers” and provide support for a range of health problems, regardless of their expertise, because they were deemed the “health go-to person in the family” (pp. 113, 117). One double-duty elder caregiver likened his experience to “stepping in a minefield" in which he dealt with “a lot more emotional hooks” than at work (pp. 117). Others discussed their felt obligation and familial expectations to continue providing family care despite the stress they experienced. Therefore, double- and triple-duty caregiving may increase men’s stress exposure beyond that encountered at work.

Alternatively, workplace-only and double- and triple-duty caregiving men’s primary stress appraisals may not differ. Dissimilar to caregiving women, men often employ a managerial approach to family caregiving (Thompson, 2002). This caregiving style blends masculine, traditional workplace values such as task-orientation, leadership, authority, control, and self-efficacy with emotional, nurturing care provision (e.g., Calasanti, & King, 2007; Russell, 2001; Thomas, 2002). Men emulating a managerial caregiving style typically compartmentalize their family caregiver identity and do not allow it to permeate other roles, thereby reducing caregiving burden (Thompson, 2002). Given that professional caregiving men also use this approach (Cottingham, 2015), it is plausible that this caregiving style is more prevalent among double- and triple-duty caregiving men. Indeed, the Anjos et al. (2012) study found that men typically assumed a managerial position within their familial care network. Double- and triple-duty caregiving men, then, may use caregiving styles that shield them from primary stress.

Secondary Stress

Researchers have only recently begun to consider the work-family interface for men with combined caregiving roles (Anjos et al., 2012). The designated secondary stress indicators of the present study therefore focus on role strains within the major institutions of work and family. Specifically, we examine work-family conflict, work-to-family positive spillover (WFPS), turnover intentions, emotional exhaustion, and job satisfaction. Work-family conflict reflects a bidirectional process in which any role characteristic that affects time, involvement, strain or behavior within the work domain is capable of producing conflict with the family domain (work-to-family conflict or WFC) and vice versa (family-to-work conflict or FWC; Greenhaus & Beutell, 1985; ten Brummelhuis & Bakker, 2012). Conversely, WFPS occurs when experiences in the work domain improve role performance in the family domain (Hanson, Hammer, & Colton, 2004). Consistent with previous research (DePasquale et al., 2014), we consider WFPS and job satisfaction indicators of strain with respect to the degree in which satisfaction is lacking.

In their qualitative study, Anjos et al. (2012) highlighted how men’s combined caregiving created secondary role strains. Family members often expected men to capitalize on their professional status to access workplace resources to benefit family care (e.g., timely appointments), which sometimes led men to act inappropriately at work (e.g., overstepping boundaries). Other unique cross-pressures, dilemmas, and role strains included tension between professional caregiving (e.g., deciding when to provide professional versus emotional support) and family member (e.g., husband) roles, discomfort providing family care, changes in family relationship dynamics, difficulty managing competing demands, and compromised emotional health. Secondary stress appraisals could therefore reflect double- and triple-duty caregiving men’s subjective responses to role strains as well as their dissatisfaction with how their workplace addresses their unique work-family needs and alleviates role strains. However, double-duty elder caregiving men also noted that, although family caregiving is sometimes “a frustrating experience, as it can be at work,” it is also a “rewarding” endeavor (pp. 117). Rewarding caregiving experiences across work and family domains, then, could offset strains produced from their convergence and generate WFPS and job satisfaction, as hypothesized in the role enhancement literature (Marks, 1977).

A Potential Moderating Resource

According to the SPM (Pearlin et al., 1990), the negative consequences of stress are conditional, in part, on access to resources that modify the effects of stress. In this study, we consider the potential moderating effects of perceived schedule control (referred to as schedule control henceforth). Schedule control is a psychological, time-based work resource that reflects employees’ felt ability to determine when they work (Kelly & Moen, 2007) to accommodate their personal needs and capacities (Krausz, Sagie, & Bidermann, 2000). The construct of schedule control has conceptual ties to the job demands-control model, which proposes that work strain and dissatisfaction are more likely in the context of high demands and low control; increasing employees’ autonomy and discretion over the work environment is thus considered key for work performance, health and well-being, and coping with job demands (Karasek, 1979). Schedule control constitutes a complementary extension of this model by focusing on when, rather than how, work is done (Kelly & Moen, 2007). Researchers have theorized that schedule control may counteract time pressures as well as enhance health, well-being, and productivity (Kelly & Moen, 2007) through time-regulation and recovery-regulation processes (Nijp, Beckers, Geurts, Tucker, & Kompier, 2012). The time-regulation mechanism implies that schedule control permits employees to manage conflicting work and family time demands, thereby reducing work-family conflict. The recovery-regulation mechanism views schedule control as a key factor in preventing work overload, preserving a favorable effort-recovery balance, and stimulating work performance by allowing employees to modify work time to facilitate recovery opportunities.

Among professional caregivers, schedule control is positively associated with organizational commitment and job satisfaction, and negatively related to exhaustion, turnover intentions, and risk of psychological distress (Choi, Jameson, Brekke, Anderson, & Podratz, 1989; Hurtado, Glymour, Berkman, Hashimoto, Reme, & Sorensen, 2015; Krausz et al., 2000). Schedule control may be particularly relevant for men working in nursing homes given that these facilities offer 24-hour care that is dependent on shift work, meaning that they may work outside traditional morning-to-afternoon hours. Although there are benefits and some employees prefer shift work, this non-standard work schedule can adversely affect physical, mental, and social well-being and presents challenges such as constant changes in lifestyle habits (Blachowiz & Letizia, 2006; Vogel, Braungardt, Meyer, & Schneider, 2012). Shift work also creates additional challenges for double-duty child and triple-duty caregivers, like negotiating and allocating work and family time on a tight schedule and managing conflicts with children’s schedules or needs (Maher, Lindsay, & Bardoel, 2010). Prior research suggests, however, that schedule control is a critical factor in determining whether shift work is disruptive or harmful for employees (Fenwick & Tausig, 2001). Further, researchers have found that schedule control matters a great deal for employees’ family and health outcomes, regardless of schedule type, and is more salient for employees’ psychological responses to work than objective work conditions, such as actual work schedule and workload (Fenwick & Tausig, 2001; Krausz et al., 2000; Seashore & Taber, 1975). Additionally, previous qualitative findings imply that schedule control would be beneficial for professional caregivers with family caregiving obligations (Maher et al., 2010). Therefore, schedule control may constitute a valuable resource in double- and triple-duty caregiving men’s stress process.

Research Questions

Research on double- and triple-duty caregiving men remains a largely uncharted territory. By examining subjective stress and schedule control exclusively among professional caregiving men, we aim to address a critical gap in existing research and advance understanding of the stress experienced by double- and triple-duty caregiving men relative to their workplace-only caregiving counterparts. Specifically, we pose the following research questions: RQ1) How do double- and triple-duty caregivers differ from workplace-only caregivers in their subjective stress appraisals? RQ2) Does schedule control constitute a workplace resource for double- and triple-duty caregivers?

Methods

This study is based on data from the Work, Family and Health Study (WFHS). The WFHS is part of a large research network effort to understand how workplace practices and policies affect work, family, and health outcomes among employees working in the long-term care industry. The WFHS was approved by several internal review boards, and a detailed description of its protocol and design can be found in Bray et al. (2013).

Sample

Employees were recruited from 30 nursing home facilities throughout New England that were owned by the same long-term health and specialized care company. Eligible employees worked at least 22.5 hours per week in direct care on day or evening shifts. Of 1,783 eligible employees, 1,524 (85%) participated, 125 of whom were men and comprise the focus of the present study. The gender distribution of WFHS participants (8% male) is consistent with national data on the gender distribution of nursing occupations in 2011 (9% male; Landivar, 2013). However, WFHS participants reported a lower median annual household income (WFHS: $45,000–49,999; U.S.: $53,482), lower level of educational attainment (WFHS: 24% of persons age 25 or over have a Bachelor’s degree or higher, U.S.: 29%), and more racial diversity (WFHS: 51% White, includes persons reporting more than one race, U.S.: 64%) when compared to U.S. census data from 2010 to 2014 (U.S. Census Bureau, 2014).

Procedures

Trained field interviewers administered computer-assisted personal interviews at a private location in the workplace on a rolling basis from September of 2009 to July of 2011. Employees provided information about sociodemographics, work experiences, and well-being. Interviews averaged 60 minutes and employees received $20 for their time.

Concepts and Their Measurement

Double- and triple-duty caregiving role occupancy

Consistent with prior research (DePasquale et al., 2014; DePasquale, Bangerter, Williams, & Almeida, 2015; Scott et al., 2006), we categorized employees into mutually exclusive workplace-only and double- and triple-duty caregiving groups. Double-duty child caregivers had children 18 years of age or younger living with them for at least four days per week. Double-duty elder caregivers provided care (i.e., assistance with shopping, medical care, or financial/budget planning) at least three hours per week in the past six months to an adult relative, regardless of residential proximity. Triple-duty caregivers fulfilled child and elder care criteria. The remaining men were classified as workplace-only caregivers.

SPM

Our analysis is based on an adaptation of the SPM (Pearlin et al., 1990), as shown in Figure 1. We incorporate the following three domains of this model: 1) background characteristics and situational context, 2) subjective primary and secondary stress, and 3) moderating resources.

Figure 1.

Figure 1

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Concepts and measures for the analysis of double- and triple-duty caregiving men’s subjective stress appraisals.

Background characteristics and situational context

According to the SPM, caregivers’ background characteristics and situational context can potentially affect the extent to which they are exposed to stress. In particular, caregivers’ ascribed statuses, including age (in years) and race (1=White, 0=other) as well as educational (1=Bachelor’s degree or higher, 0=less than Bachelor’s degree), occupational (1=CNA, 0=RN or LPN), and economic attainments (annual household income of $39,999 or less, $40,000–54,999, or $55,000 or more per year) are embedded throughout the stress process. We therefore examine these attributes as potential covariates.

Additionally, we assess several work context features accounted for in previous double- and triple-duty caregiving studies (Boumans & Dorant, 2014; DePasquale et al., 2014), including average number of hours worked per week, company tenure (in years), and work-related injuries in the past six months (1=yes, 0=no). Given its positive associations with perceived stress and WFC among long-term care workers (DePasquale et al., 2014), we also consider psychological job demands with a three-item measure (e.g., job requires very hard work) from Karasek, Brisson, Kawakami, Houtman, Bongers, & Amick (1998); higher scores reflect more demands (α=.72).

Moreover, we examine family context features such as marital status (1=cohabiting or married, 0=single) because partners may provide support at home. We also assess men’s dual-earner couple status and the average number of hours partners work per week; unemployed partners may substantially contribute to family caregiving (Hertz, 1997), thereby lessening men’s family caregiving duties. Further, we account for the presence of residential children with a range of health conditions and disabilities (e.g., developmental disabilities; 1=yes, 0=no), as fathers with disabled children report increased stress (Darling, Senatore, & Strachan, 2012). We also examine whether men have non-residential children as a proxy for care or support to these children (DePasquale, Polenick, Davis, Moen, Hammer, & Almeida, 2015b).

Subjective stress

Unless stated otherwise, men indicated the extent to which they disagreed or agreed with statements using a five-point response scale ranging from 1 (strongly disagree) to 5 (strongly agree) for all subjective stress measures. Scale scores were computed by calculating the mean of items, with higher values signifying higher mean scores.

We measured primary stress with a global, four-item measure of perceived stress (e.g., confident about ability to handle personal problems) pertaining to the last 30 days (Cohen, Kamarck, & Mermelstein (1983). Responses ranged from very often (1) to never (5). We reverse-coded two items (a=.68).

We examined secondary role strains with six measures. We used the WFC and FWC scales from Netemeyer, Boles, and McMurrian (1996). Five items pertained to WFC (e.g., work demands interfere with family/personal time, a=.91) and five items assessed FWC (e.g., family-related strain interferes with job-related duties, α=.84) in the past six months. WFPS was assessed with the four-item affective spillover subscale (e.g., being happy at work facilitates happiness at home, α=.85) from Hanson et al. (2004). Turnover intentions were measured with a two-item scale (e.g., seriously considering quitting company for an alternative employer, α=.80) from Boroff and Lewin (1997). Emotional exhaustion was examined with the three-item (e.g., feel emotionally drained from your work, α=.84) emotional exhaustion subscale from The Maslach Burnout Inventory (Maslach & Jackson, 1986); responses ranged from never (1) to every day (7). Job satisfaction was measured with a three-item (e.g., like working at your job; α =.78) scale reflecting global job satisfaction (Cammann, Fichman, Jenkins, & Klesh, 1983).

Moderating resource

We examined the potential moderating resource of schedule control with a modified measure from Thomas and Ganster (1995). Employees rated the extent to which eight statements (e.g., control over when vacation or days off are taken) accurately depicted their perceived control over their work hours using a response scale ranging from very little (1) to very much (5). The mean score was 2.71 (SD=.77, range=1–5; α=.61), with higher scores reflecting higher mean schedule control.

Analytic Strategy

The analyses presented here focus on a reduced analytic sample of 123 men. Reasons for exclusion included holding an administrative position (n=1) and missing schedule control data (n=1). We first examined background and context characteristics by conducting ANOVAs to identify mean differences between men with and without combined caregiving roles. We used Games-Howell post-hoc tests to account for unequal and small group sizes. We then examined any variables on which the groups differed, as well as child disability, in correlational analyses to detect potential multicollinearity issues and finalize covariate selection. Next, given that men were nested within facilities, we calculated an intraclass correlation (ICC) for each dependent variable by fitting empty models that decomposed variance into individual-level (men) and facility-level components. WFC (.11), emotional exhaustion (.21), and turnover intentions (.07) had ICCs above 5% whereas the remaining dependent variables had ICCs below 3%. We subsequently performed separate multiple linear regression models to predict subjective stress appraisals. We accounted for shared variance by obtaining robust standard errors (Huber-White correction) for the WFC, emotional exhaustion, and turnover intentions models. We did not modify the remaining models based on the reasonable assumption of statistical independence across facilities. Model 1 included binary indicators for each combined caregiving role (with workplace-only caregivers as the reference group), schedule control, and covariates. In Model 2, we added interaction terms for each combined caregiving role with schedule control to examine the extent to which schedule control conditioned double- and triple-duty caregivers’ stress appraisals. When a combined caregiving role by schedule control interaction was significant, estimate commands were used to calculate the simple slope for each role.

Results

Background Characteristics and Situational Context

Table 1 presents men’s background characteristics and situational context. Overall, 50% of men occupied double- and triple-duty caregiving roles. There were 62 (50%) workplace-only, 27 (22%) double-duty child, 22 (18%) double-duty elder, and 12 (10%) triple-duty caregivers. ANOVA analyses indicated that workplace-only and double- and triple-duty caregiving groups differed on psychological job demands, marital and dual-earner couple statuses, and child disability. Specifically, triple-duty caregivers reported more psychological job demands and had a higher proportion of dual-earner couples than workplace-only caregivers. Double-duty child and triple-duty caregivers had higher proportions of cohabiting or married men.

Table 1.

Professional caregiving men’s characteristics by combined caregiving role occupancy

Characteristics, n(%) Overall (n=123) WP-only care n=62 (50%) Double-duty child care n=27 (22%) Double-duty elder care n=22 (18%) Triple-duty care n=12 (10%)
Background and context
 Age (in years) 36.67 (9.38) 35.95 (10.53) 40.07 (7.68) 34.32 (8.45) 37.00 (6.65)
 White .51 .56 .48 .50 .33
 Bachelor’s degree or higher .23 .23 .22 .32 .08
 Certified nursing assistant .76 .77 .74 .77 .67
 $39,999 or less per year .39 .41 .35 .38 .36
 $40,000 to 54,999 per year .21 .18 .23 .29 .18
 $55,000 or more per year .40 .41 .42 .33 .46
Work context
 Hours worked per week 38.12 (5.48) 37.65 (5.67) 39.06 (5.69) 38.75 (5.62) 37.29 (3.65)
 Company tenure 5.55 (5.14) 5.30 (5.56) 6.93 (5.38) 4.41 (3.82) 5.84 (4.15)
 Work-related injury .12 .10 .08 .18 .25
 Psychological job demands 3.72 (.83) 3.54 (.91) 3.77 (.62) 3.94 (.81) 4.11 (.61)*
Family context
 Cohabiting or married .53 .39 .89*** .23 1.00***
 Dual-earner couple .41 .32 .59† .18 .83**
 Hours partner works 39.65 (10.92) 41.47 (12.25) 38.67 (10.00) 38.00 (4.00) 38.30 (12.26)
 Disabled child .06 --- .22 --- .08
 Non-residential children .35 .36 .37 .24 .42
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Notes: WP-only care= Workplace-only care. Means (and standard deviations) or proportions are shown. ANOVAs with Games-Howell significant difference comparison tests were conducted to identify mean differences across groups. Annual household income was assessed in $5,000 increments up to $60,000. Income categories shown in this table are based on the median annual household income for workplace-only and double- and triple-duty caregivers, which ranged from $40,000–44,999 per year for double-duty elder caregivers to $50,000–54,999 per year for triple-duty caregivers. The dual-earner couple measure is based on all participants, including those who are single.

†

p<.10,

*

p<.05,

**

p <.01,

***

p <.001

Based on ANOVA results, we examined correlations among psychological job demands, marital and dual-earner couple statuses, and child disability. Marital and dual-earner couple statuses were highly correlated (r=.78, p<.001) and could not be considered in the same model. However, only dual-earner couple status was correlated with stress appraisals and therefore retained. Additionally, child disability was not correlated with stress appraisals and subsequently excluded from model testing in favor of parsimony. Final models included psychological job demands and dual-earner couple status as covariates.

RQ1: Subjective Stress Appraisals

Table 2 displays multiple regression results. Workplace-only and double- and triple-duty caregivers’ primary stress appraisals did not differ. As for secondary role strains, triple-duty caregiving was positively associated with WFC and all three combined caregiving roles predicted greater FWC. Additionally, triple-duty caregiving was associated with greater emotional exhaustion whereas double-duty child caregiving was related to lower turnover intentions. Workplace-only and double- and triple-duty caregivers’ WFPS and job satisfaction appraisals did not differ.

Table 2.

Multiple Linear Regression Analysis: Men’s Combined Caregiving Role Occupancy in Relation to Subjective Stress Appraisals

Primary Stress Secondary Stress
Perceived
Stress
(n=121)		 Work-to-Family
Conflict
(n=123)		 Family-to-
Work Conflict
(n=123)		 Work-to-Family
Positive Spillover
(n=123)		 Emotional
Exhaustion
(n=120)		 Turnover
Intentions
(n=122)		 Job
Satisfaction
(n=122)
B (SE) B (SE) B (SE) B (SE) B (SE) B (SE) B (SE)
Intercept 9.19 (.40)*** 2.54 (.12)*** 1.85 (.09)*** 4.03 (.09)*** 4.56 (.28)*** 2.31 (.13)*** 4.23 (.09)***
Double-duty child care .71 (.67) .19 (.21) .46 (.14)** .12 (.16) −.04 (.22) −.47 (.22)* −.003 (.15)
Double-duty elder care .68 (.70) .16 (.20) .50 (.15)** −.06 (.16) −.67 (.38)† −.08 (.19) .01 (.15)
Triple-duty care .43 (.93) .75 (.29)* .91 (.20)*** .28 (.22) .96 (.39)* −.19 (.34) −.10 (.20)
Psychological job demands .25 (.31) .24 (.10)* .01 (.07) .21 (.07)** .75 (.17)*** .26 (.10)* −.08 (.07)
Dual-earner couple −.98 (.55)† −.02 (.17) −.19 (.12) −.09 (.13) −.44 (.30) .06 (.17) −.14 (.12)
Schedule control −.66 (.33)* −.29 (.10)** −.01 (.07) .18 (.08)* −.28 (.23) −.22 (.11)* .19 (.07)**
R2 .09 .18 .21 .13 .23 .11 .09
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Notes: Unstandardized regression coefficients are shown. Sample size varies by outcome variable due to missing data. All continuous variables are mean-centered.

†

p<.10,

*

p<.05,

**

p <.01,

***

p <.001

RQ2: The Potential Moderating Resource of Schedule Control

In Model 2, evidence for the moderating effects of schedule control emerged only for double-duty elder caregivers. Specifically, schedule control moderated double-duty elder caregivers’ appraisals of perceived stress (B=−2.09, SE=.89, p<.05), WFPS (B=.45, SE=.21, p<.05), turnover intentions (B=−.54, SE=.26, p<.05), and job satisfaction (B=.40, SE=.20, p<.05). We conducted follow-up analyses using a simple slopes test to determine for which group (i.e., workplace-only versus double-duty elder caregivers) schedule control was significantly associated with each outcome. These analyses indicated that, for every one unit increase in schedule control, double-duty elder caregivers reported less perceived stress (B=−2.17, SE=.72, p<.01) and lower turnover intentions (B=−.60, SE=.17, p<.01) as well as more WFPS (B=.52, SE=.17, p<.01) and job satisfaction (B=.46, SE=.16, p<.01). Figures 2–5 present visual representations of these effects by displaying model estimated means for each outcome at low (one standard deviation below the mean) and high (one standard deviation above the mean) values of schedule control. In the context of low schedule control, double-duty elder caregivers indicated greater perceived stress (Figure 2) and turnover intentions (Figure 3) as well as less WFPS (Figure 4) and job satisfaction (Figure 5) relative to mean scores on the same variables in the presence of high schedule control. These same patterns were also evident among double-duty child and triple-duty caregivers, but not workplace-only caregivers.

Figure 2.

Figure 2

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Model estimated means for the conditional effects of double- and triple-duty caregiving on perceived stress, an indicator of primary stress.

*p<.05, ** p <.01, *** p <.001

Figure 5.

Figure 5

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Model estimated means for the conditional effects of double- and triple-duty caregiving on job satisfaction, an indicator of secondary stress.

*p<.05, ** p <.01, *** p <.001

Figure 3.

Figure 3

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Model estimated means for the conditional effects of double- and triple-duty caregiving on turnover intentions, an indicator of secondary stress.

*p<.05, ** p <.01, *** p <.001

Figure 4.

Figure 4

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Model estimated means for the conditional effects of double- and triple-duty caregiving on work-to-family positive spillover, an indicator of secondary stress.

*p<.05, ** p <.01, *** p <.001

Discussion

This investigation partially replicates a recent study based on women from the same sample described in this paper (DePasquale et al., 2014). Guided by the SPM, the current and earlier investigations examine double- and triple-duty caregivers’ perceived stress, work-family conflict, and WFPS relative to workplace-only caregivers. Whereas the earlier investigation includes partner relationship role strains, this study emphasizes additional work role strains and considers the moderating effects of schedule control. When applicable, findings from RQ1 are descriptively compared to the previous investigation to further contextualize how double- and triple-duty caregiving affects stress subjectively experienced by men.

Results suggest that workplace-only and double- and triple-duty caregiving men appraise primary stress (conceptualized as perceived stress) similarly. These findings are in contrast to DePasquale et al. (2014), in which double-duty elder and triple-duty caregiving women reported more perceived stress. There are several potential explanations for the lack of effects in the current study. First, the male subsample drawn on here is substantially smaller than the female subsample from DePasquale et al. (n=123 versus n=1,399 respectively). Therefore, this study may lack statistical power to detect smaller differences between workplace-only and double- and triple-duty caregivers relative to the earlier investigation. Second, double- and triple-duty caregiving men may emulate a managerial caregiving style. The protective nature of this caregiving approach could enable men to occupy multiple caregiving roles with minimal primary stress (Anjos et al., 2012; Cottingham, 2015; Thompson, 2002). Third, this finding is based on a single indicator of subjective primary stress. Other indicators (e.g., overload) may produce different results or be more applicable for double- and triple-duty caregiving men. Fourth, both applications of the SPM focus on caregivers’ subjective experiences rather than care recipient conditions. Future applications of the SPM should integrate objective primary stress indicators that focus on care recipients’ health, behavior, and functional capabilities as well as the surveillance, work, and time required by family caregivers as these may be more relevant for double- and triple-duty caregiving men.

Several differences emerged, however, with respect to secondary stress appraisals. Consistent with DePasquale et al. (2014), triple-duty caregivers reported more WFC, double- and triple-duty caregivers indicated greater FWC, and there were no differences in WFPS appraisals. Comparable to prior research linking dependent children to nurses’ lower turnover intentions (Stewart et al., 2011), double-duty child caregivers also reported lower turnover intentions. Although adult relatives are also linked to lower turnover intentions, workplace-only caregivers’ and double-duty elder and triple-duty caregivers’ turnover intentions were similar. Additionally, triple-duty caregivers indicated more emotional exhaustion. This finding complements previous evidence suggesting that professional caregiving men informally caring for older adults are at risk of emotional burnout (Anjos et al., 2012). Given that triple-duty caregivers also perceived more work-family conflict, this particular group may be struggling to maintain professional and family caregiving role boundaries (Ward-Griffin, 2004). Emotion regulation, or the strategic management and experience of feelings to create desired, observable facial expressions in accordance with contextual expectations and norms (Ekman, 1992; Wharton & Erickson, 1993), represents one mechanism that may facilitate the erosion of such boundaries. In the SPM, emotion regulation constitutes a secondary role strain as emotion regulation performance in one role may affect emotion regulation and outcomes in other roles (Wharton & Erickson, 1993). Both professional and family caregiving entail emotion regulation, likely constituting a substantial portion of caregiving responsibilities in both domains and pitting triple-duty caregivers’ three caregiving roles against one another for scarce energy (Goode, 1960). That is, the expenditure of energy for managing emotions in both family caregiving roles may limit triple-duty caregivers’ emotional resources or energy for professional caregiving and vice versa, thus facilitating emotional exhaustion.

Overall, a descriptive comparison of findings from the present study and the DePasquale et al. (2014) investigation suggests that subjective stress appraisals among double- and triple-duty caregiving men and women do not vastly differ. Findings from the present study, however, warrant additional research examining how double- and triple-duty caregiving men negotiate workplace and family caregiving role boundaries, utilize the managerial caregiving approach or employ other caregiving styles at work and at home, and regulate emotions when transitioning in and out of workplace and family caregiving roles. From a practice standpoint, the stress experienced by double- and triple-duty caregiving men will only become a greater concern for the healthcare industry as it strives to recruit and retain men with an increased likelihood of family caregiving. Given the gendered barriers, discrimination, and stigma experienced by professional caregiving men (MacWilliams et al., 2013; O’Connor, 2015; Rajacich et al., 2013), the inclusion of family caregiving men in work-family programs, practices, and policies is imperative and may signify a pivotal step toward discarding the healthcare industry’s gendered image. Indeed, a lack of understanding for or oversight of double- and triple-duty caregiving men’s work-family challenges may exacerbate or reinforce preexisting notions about the homogenous gender of caregiving professions and subsequently deter potential talent or increase turnover.

Perceived Schedule Control

Schedule control emerged as a resource for double- and triple-duty caregiving men’s stress process (RQ2). Specifically, moderation results revealed that double-duty elder caregivers reported less primary stress and lower turnover intentions as well as more WFPS and job satisfaction with increased schedule control. Model estimated means for the conditional effects of double-duty child and triple-duty caregiving also mirrored these findings but may not have achieved statistical significance due to insufficient power. Descriptively, differences calculated between primary and secondary stress appraisal scores in the context of lower and higher schedule control were greater for all combined caregiving configurations compared to workplace-only caregivers, thereby illustrating the significance of schedule control for double- and triple-duty caregiving men. At a time in which the healthcare industry is actively targeting men in recruitment and retention efforts, these findings are particularly noteworthy. According to a recent report on employer strategies to attract, retain, and engage workers amidst a workforce shortage, organizations that offer or provide benefits that employees find useful or valuable will retain talent (AARP, 2015). In applying this logic to the present study, double- and triple-duty caregiving men’s lower turnover intentions in the presence of greater schedule control reinforces the notion that they benefit from and/or value schedule control. Further, our findings suggest that schedule control will not only help recruit and retain family caregiving men, but it may yield a positive return-on-investment. Namely, turnover in the healthcare sector has serious, wide-ranging implications ranging from system costs to resident outcomes (Hayes et al., 2012; Trinkoff, Han, Storr, Lerner, Johantgen, & Gartrell, 2013). If lower turnover intentions associated with increased schedule control translate to actual behavior, the healthcare industry may experience a reduction in turnover-related costs, more stability and continuity of care in its workforce, and better health outcomes among residents and employees. Schedule control, then, may constitute a resource beyond the employee-level.

Moreover, these findings reflect and extend prior research regarding professional caregiving men’s satisfaction with their work role and traditional constructions of masculinity. Previous studies suggest that professional caregiving men express concerns about and experience stress because of the gendered organizational climate engulfing caregiving professions; nonetheless, men still convey passion, enthusiasm, and optimism for their work role (e.g., Hart, 2005; Sherrod et al., 2005). It is feasible that the challenges associated with family caregiving make double- and triple-duty caregiving men more susceptible or reactive to workplace stress, ultimately detracting from their job satisfaction. In that case, potential benefits derived from schedule control (e.g., addressing work-family needs) may help these men reconnect with the desires, preferences, or selling points of the profession that initially attracted them to their work role and increase WFPS and job satisfaction. Additionally, schedule control may be a particularly appealing work resource for double- and triple-duty caregiving men given that control is characteristic of traditional masculinity ideology (Fournier & Smith, 2006). Double- and triple-duty caregiving men may be exposed to more gender-based discrimination, barriers, or stigma as well as conflicting masculinity norms encountered at both work (e.g., lack of support for work-family balance) and home (e.g., engaging in care traditionally provided by women) because of their family caregiving roles (Anjos et al., 2012). Therefore, schedule control may enable double- and triple-duty caregiving men to maintain their masculine identity by exercising more control over when they work and partake in the family domain, thus attenuating stress appraisals. Conversely, low schedule control may exacerbate men’s perceived loss of masculinity.

With a lack of prior research, we can only speculate as to how or why schedule control favorably conditions double- and triple-duty caregiving men’s perceived stress, WFPS, turnover intentions, and job satisfaction. These findings suggest, though, that a key factor in recruiting and retaining double- and triple-duty caregiving men is accommodating their work-family interface. Thus, the availability, utilization patterns, and relevance of as well as organizational climate surrounding workplace practices (such as and in addition to schedule control), programs, and policies for double- and triple-duty caregiving men represent pivotal future research directions that will yield pertinent information for the development of appropriate and targeted work-life initiatives. Further, these timely findings are novel and provide initial evidence regarding the potential benefits of schedule control for double- and triple-duty caregiving men as well as the healthcare sector. We believe they provide essential baseline information for family caregiving men considering or currently in caregiving professions, long-term care employees, and healthcare providers who counsel professional caregiving men.

Limitations and Strengths

The present study has several limitations. First, the cross-sectional design precludes causal ordering, a common limitation of previous studies on caregiving men (Bookwala, Newman, & Schulz, 2002). Second, although heterogeneity in men’s working conditions is inherently controlled for in the WFHS sample, non-probability sampling of nursing home facilities from a company in one region (New England) of one country (the U.S.) limits generalizability of our study findings to the population of men working in the long-term care industry. A third limitation of this study is its sample size. Sensitivity power analyses revealed that data used in the current study were powered to detect approximately medium effect sizes. A much larger sample may be required to detect smaller differences between workplace-only and double- and triple-duty caregiving men. Therefore, future research in this area should intentionally oversample men, when possible, to ensure sufficient sample size, increase statistical power, and enable a precise evaluation of double- and triple-duty caregiving men. It should be noted, though, that professional caregiving men are considered a “difficult-to-obtain” workforce segment and the size of our analytic sample is consistent with previous studies (e.g., Rochlen, Good, & Carver, 2009, p.53; Wallen, Mor, & Devine, 2014; Zamanzadeh, Valizadeh, Negarandeh, Monadi, & Azadi, 2013). Further, much smaller significant differences between workplace-only and double- and triple-duty caregiving men may not be practically meaningful.

Finally, we conducted a secondary analysis of existing data not specifically designed to study caregiving. The data lacked ideal information regarding caregiving intensity, but it enabled us to construct combined caregiving role occupancy measures consistent with prior research (e.g., DePasquale et al., 2014, 2015a; Scott et al., 2006). Still, it should be acknowledged that this approach operationalizes child and elder care differently. Specifically, the child care measure does not assess care provision. Instead, dependency is implied by age and cohabitation. The average age of residential children (double-duty child caregivers: M=5.67, SD=4.57; triple-duty caregivers: M=3.83, SD=3.95), however, affirms dependency. Conversely, the elder care measure specifies criteria for care provision and includes a more stringent time commitment than required in prior double-duty care research (e.g., Ward-Griffin, 2004). It should also be noted that this measure may encompass care for adult relatives other than aging parents (e.g., spouses). Nonetheless, one advantage of a caregiving role occupancy approach is that, given the diversity of family caregiving situations yielded by our measures, our sample may be more representative of double- and triple-duty caregivers than a sample selected for a certain threshold of care or care recipient diagnosis (DePasquale et al., 2014).

To be sure, our findings are suggestive; it is important that they are viewed as an initial step toward developing a more complete understanding of double- and triple-duty caregiving men. We encourage other researchers to replicate and extend our study using larger, representative samples; longitudinal research designs; more sensitive family caregiving measures; and previously described expansions of the SPM (Pearlin et al., 1990). The aforementioned limitations, however, should not outweigh the contributions and knowledge gained from the present study. Previous double- and triple-duty caregiving studies comprise a small, limited body of work primarily based on qualitative evidence, RNs, health professionals working outside of the U.S., informal elder care, and women (Boumans & Dorant, 2014; DePasquale et al., 2014; Giles & Hall, 2014; Scott et al., 2006; Ward-Griffin, 2004; Ward-Griffin, Brown, Vandervoort, McNair, & Dashnay, 2005; Ward-Griffin et al., 2015). We address these gaps and contribute to existing literature by exclusively focusing on men working in nursing homes in the U.S., the majority of whom are CNAs; considering different workplace and family caregiving configurations; and providing new evidence regarding double- and triple-duty caregiving men’s subjective stress and schedule control. Additionally, the inclusion of workplace-only caregiving men as a reference group, rather than women, is beneficial in that it enables an assessment of within-group variables and provides a more accurate context for understanding the stress of family caregiving on men (Bookwala et al., 2002; Rochlen et al., 2009). Finally, our preliminary study lays the groundwork for future research on double- and triple-duty caregiving men. It is our hope that the issues discussed here will motivate other researchers to further investigate and expand this important line of empirical inquiry.

Acknowledgments

Funding

This research was conducted as part of the Work, Family and Health Network (www.WorkFamilyHealthNetwork.org), which is funded by a cooperative agreement through the National Institutes of Health and the Centers for Disease Control and Prevention: Eunice Kennedy Shriver National Institute of Child Health and Human Development (Grant # U01HD051217, U01HD051218, U01HD051256, U01HD051276), National Institute on Aging (Grant # U01AG027669), Office of Behavioral and Social Sciences Research, and National Institute for Occupational Safety and Health (Grant # U01OH008788, U01HD059773). Grants from the William T. Grant Foundation, Alfred P Sloan Foundation, and the Administration for Children and Families have provided additional funding. This work was also supported by the National Institute On Aging of the National Institutes of Health under [Award Number F31AG050385] to Nicole DePasquale. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of these institutes and offices.

Contributor Information

Nicole DePasquale, National Institute on Aging Pre-doctoral Fellow, Doctoral Candidate, Center for Healthy Aging and Department of Human Development & Family Studies, The Pennsylvania State University, 422 Biobehavioral Health Building, University Park, PA 16802.

Steven H. Zarit, Distinguished Professor and Head, Human Development & Family Studies, The Pennsylvania State University, 305 Health & Human Development East, University Park, PA United States 16802

Jacqueline Mogle, Assistant Professor, College of Nursing, Pennsylvania State University, 307D Nursing Sciences Building, University Park, PA 16802

Phyllis Moen, McKnight Presidential Endowed Chair, Sociology Department, University of Minnesota, 1123 Social Science Building, 267 19th Avenue South, Minneapolis, MN United States 55455

Leslie B. Hammer, Professor of Psychology, Portland State University, 1721 SW Broadway, 317 Cramer Hall, Portland, OR United States 97207-0751

David M. Almeida, Professor of Human Development, The Pennsylvania State University, 420 Biobehavioral Health Building, University Park, PA United States 16802

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