Caregiving: Family Caregiving Systems: Models, Resources and Values

Considerable research has been done on families and caregiving. Unfortunately, the dominant focus on one primary caregiver (PCG) has dominated research and except for gender, has not looked at the role of other siblings. According to Keith (1995), there are several issues with research only focusing on one PCG. The first issue, Keith discusses is not having an accepted definition of the term primary caregiver. For instance, how do researchers differentiate between a sibling who manages their parent’s finances from another who provides the hands-on care? The second issue is collecting data from only a primary caregiver will probably lead to the underestimation of contributions from other siblings. The third problem is by focusing on one primary caregiver, Keith is concerned that this may be viewed as a norm and deter siblings from equitably dividing the care for their parents. Finally, Keith explains while there is often one sibling disproportionately providing the care for their parents, there is growing research that supports adult siblings do work together to care for their aging parents (Keith, 1995).   

Through Keith's qualitative study of thirty-one families, she was hoping to discover new concepts through an exploration of the division of labor by offspring caring for an elderly parent. Each of the families had a mother who had been diagnosed with a cognitive impairment. Ten of the families in the study had one offspring, ten had two and eleven of the families had more. Keith conducted a total of 57 interviews and fifteen of the siblings were not interviewed.

Keith identified three types of family caregiving systems. They are primary caregiver model, the partnership and the team. Each was found to be distinctive in the values that it expresses. The most well-known and researched model is when there is a primary caregiver. In this model there is minimum collaboration among siblings. One person carries all or most of the caregiving responsibilities. In Keith's study, siblings may take turns being the primary caregiver. My mom was the primary caregiver for both of  her parents. Her sister lived six hours away. My aunt did provide my mom with a few weeks of respite care and became their primary caregiver for them when they were at her home. 

The second model is partnership. In this model there is collaboration between two siblings caring for their parents relatively equitably. They are equal in authority and responsibility in making and implementing decisions. Other siblings may be involved in the caregiving but their roles are limited. One of my clients has two son who would fit the model of a partnership. One son does live with the client and provides him with twenty-four hour supervision, but his other son comes by everyday to provide the other son some respite and he also takes care of all of my client's business affairs.

The third model is team. This happens when there is collaboration between multiple siblings. As with the  partnership, the team is distinguished not so much by how tasks are apportioned among the siblings as by the way they perceive their various roles. In this system, siblings perceive themselves to be organized in a planned and integrated manner. I can only think of one of my clients where I see her children working as a team. In her case, I always do a my home visit with at least two of her daughters present. One daughter who is a nurse manages her medications and medical care, her other daughter manages her finances and personal business and her son helps her with shopping and getting to medical appointments since he is retired. Her other daughter is limited in the care she can provide due to disability. They always seem to work really well together and have very effective communication in order to meet their mother's care needs and keep her at home where she wants to be.

There were two factors that affect the caregiving system used by siblings. The first was family composition. Keith found that size of the family and its gender composition contributed to the development of the caregiving system.Obviously an only child can not easily form a partnership or team with another person and none did in this study. Two sibling families could organize as a partnership, but none did in this study. Families with a larger number of siblings could establish any of the three caregiving systems and did. In every one of the sister brother sibling combinations, the sister was the primary caregiver. Gender appears to determine the allocation of caregiving tasks between brothers and sisters. Prior studies have shown that sisters tend to develop a partnership in caring for their parents. However, none did in this study. All of the two sister pairs had developed a primary care system and unfortunately half of these reported bitter resentments over perceived inequities. The only two brother pair established a partnership. Larger families with two or more daughters were more able to develop a  partnership. Only one family in this study exhibited a team system. The authors assume families with a larger number of siblings may use more cooperative style due to less sibling rivalry and less resentment due to the dispersion of responsibility among a number of siblings.

The second factor were values. Four predominant values were identified through analysis of offspring explanations of the caregiving system the families established. These were justice, affiliation, equity and protection of siblings. The author points out that she is not talking about motivations for siblings to provide care to a parent, which she found to be unaffected by family size or composition. She is talking about values that inspire establishment of a particular type of family caregiving system. She found the main motivation was to be considerate towards their other siblings.

The first value that was expressed by the participants was justice.  Keith points out that it should not be confused with fairness. I saw these as societal or family values and beliefs. Justice refers to the allocation of tasks and authority on the basis of such criteria as gender (daughters as the kin keepers are more likely to be the PCG), geographical proximity (siblings who live far away are excused from helping, while the one who lives closer and doesn't help is resented bitterly), and the weight of competing responsibilities (daughters are responsible for the care of their mothers while their brothers are not.). 

The second value as affiliation. When one sibling has a stronger affiliation to the parent it appears to be an influential value in the establishment of the primary caregiver system. Gender appears to explain why daughters assume caregiving responsibilities, while affiliation explains why one daughter rather than another is the primary caregiver.

The third value was equity. Equity was the predominant theme in families characterized by a partnership. There did not need to be an exact division of caregiving work, but reasonably equitable contributions. They were committed to shared, active participation and authority in decision making.

 The fourth value was emotional protection. The predominant motive expressed in the team system was emotional protection of the siblings. They did not want one sibling to carry all or most of the caregiving tasks. The other main theme was to protect other siblings from a parent's excessive demands and criticisms.

I agree with Keith when she states this study can add to understanding of how and why caregiving is distrubuted among family members. However, after rereading Keith's study for this blog I have some new concerns. I'm disappointed that the sample size was so small that only three of the families were defined as having a partnership caregving system and only one as a team caregiving system. Twenty-seven of the families were defined as a primary caregiving system. I don't see how Keith could base all of these factors and values on so few families. I also realized that the siblings were caring for a mother who was diagnosed with a congnitive impairment. Caring for someone with a cognitive impairment is so completely different then caring for someone with a physical impairment that I think you can't begin to look at Keith's findings and apply them to all sibling caregivers. I can also see where the care needs for someone with a cognitive impairment would automatically lead to having a primary caregiving system due to their intense needs.

Keith, C. (1995). Family caregiving systems: Models, resources and values. Journal of Marriage and the

Family, 57, 179-189.