The Family Time Squeeze: Perceived Family Time Adequacy Buffers Work Strain in Certified Nursing Assistants With Multiple Caregiving Roles

The Family Time Squeeze: Perceived Family Time Adequacy Buffers Work Strain in Certified Nursing... Abstract Purpose of the Study This study examined how certified nursing assistants (CNAs) with 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”) differed from their nonfamily caregiving counterparts (“workplace-only caregivers”) on four work strain indicators (emotional exhaustion, job satisfaction, turnover intentions, and work climate for family sacrifices). The moderating effects of perceived family time adequacy were also evaluated. Design and Methods Regression analyses were conducted on survey data from 972 CNAs working in U.S.-based nursing homes. Results Compared with workplace-only caregivers, double-and-triple-duty caregivers reported more emotional exhaustion and pressure to make family sacrifices for the sake of work. Triple-duty caregivers also reported less job satisfaction. Perceived family time adequacy buffered double-duty-child and triple-duty caregivers’ emotional exhaustion and turnover intentions, as well as reversed triple-duty caregivers’ negative perceptions of the work climate. Implications Perceived family time adequacy constitutes a salient psychological resource for double-duty-child and triple-duty caregivers’ family time squeezes. Amid an unprecedented demand for long-term care and severe direct-care workforce shortages, future research on workplace factors that increase double-and-triple-duty caregiving CNAs’ perceived family time adequacy is warranted to inform long-term care organizations’ development of targeted recruitment, retention, and engagement strategies. Double-duty caregiving, Triple-duty caregiving, Family time pressures, Work–family interface, Nursing homes The 65 and older population in the United States is projected to nearly double over the next 30 years (He, Goodkind, & Kowal, 2016). Accordingly, their long-term care needs will proliferate (He et al., 2016). The number of certified nursing assistants (CNAs) and other direct-care workers will grow significantly to address these needs, becoming the nation’s largest occupational group by 2020 (Paraprofessional Healthcare Institute [PHI], 2013; Stone, 2012). Concurrently, family members will increasingly provide unpaid help, remaining the country’s largest source of long-term care (He et al., 2016). A surge in direct-care employment, coupled with ongoing reliance on unpaid assistance, will give rise to more adults engaging in paid and unpaid care simultaneously (Boumans & Dorant, 2014). In particular, health care employees are likely to serve as family caregivers because they are usually the only “health professional in the family” and relied on heavily by family members to use their expertise for family care (Ward-Griffin, Brown, Vandervoort, McNair, & Dashnay, 2005, p. 384; Wohlgemuth, Auerbach, & Parker, 2015). Yet direct-care workers with family caregiving roles are grossly understudied (DePasquale, Bangerter, Williams, & Almeida, 2016c). In this article, we focus on work strain among family caregiving CNAs in U.S.-based nursing homes as an initial step toward understanding their work–family interface. The Work Domain CNAs and other direct-care employees constitute the backbone of the country’s formal long-term care system, providing nearly 80% of the hands-on care and emotional support for countless elderly, disabled, and chronically ill Americans (PHI, 2013; Stone, 2012). They also represent one of the nation’s largest, fastest-growing workforces (PHI, 2013). Concerns about projected job growth translating to actual job growth, however, have surfaced amid a worsening shortage of CNAs (Stone, 2012). Researchers attribute these shortages to several characteristics of long-term care employment (Stone, 2012). Long-term care employment is stressful, challenging, and linked to physical and emotional strain (Stone, 2012). CNAs are principal caregivers of older adults with chronic conditions and cognitive or functional impairments, balance heavy workloads, and perform physically strenuous tasks (Bureau of Labor Statistics [BLS], 2015). Relatedly, their nonfatal occupational injury and illness rates are disproportionately high (BLS, 2015). CNAs also experience grief following care recipients’ deaths; these grief experiences contribute to burnout, a stress-related reaction characterized by emotional exhaustion (Anderson, 2008). Moreover, CNAs often endure poor working conditions (Stone, 2012). They feel disregarded and treated unfairly, perceive an imbalance between task control and work demands, and cite contradictions between organizational rhetoric and practices or policies concerning respect, appreciation, and value for their work (Bowers, Esmond, & Jacobson, 2003). They also work demanding schedules that hinder work–family balance (Geiger-Brown, Muntaner, Lipscomb, & Trinkoff, 2004). Further, CNAs are a low-wage, hourly workforce with few advancement opportunities and limited employee benefits (Stone, 2012). Approximately 25% of direct-care workers are without health insurance, 48% live below the poverty threshold, and 49% receive public benefits (PHI, 2013). Prior research suggests that food insufficiency and financial strain, both of which are associated with depressive symptoms, are pervasive among these employees (Okechukwu, El Ayadi, Tamers, Sabbath, & Berkman, 2012). The aforementioned workplace factors have contributed to high turnover rates and job dissatisfaction among CNAs (Bowers et al., 2003; Castle, Engberg, Anderson, & Men, 2007; Karsh, Booske, & Sainfort, 2005; Rosen, Stiehl, Mittal, & Leana, 2011; Stone, 2012; Temple, Dobbs, & Andel, 2009). Such information about these factors is useful for long-term care organizations in that it can inform retention, recruitment, and engagement strategies targeting CNAs. This information may be incomplete, though, without consideration of family domain factors. Care Transcending the Work–Family Divide Literature on the convergence of care in the work and family domains uses “double-and-triple-duty caregiving” terminology to distinguish health care employees with caregiving roles beyond the work domain from their nonfamily caregiving counterparts, or “workplace-only caregivers” (DePasquale et al., 2016a, 2016b; Ward-Griffin et al., 2005). “Double-duty caregivers” are health care employees who informally care for children (“double-duty-child caregivers”) or older adults (“double-duty-elder caregivers”) whereas “triple-duty caregivers” are health care employees who informally care for children and older adults. Traditionally, formal and family caregiving have been studied separately (Ward-Griffin et al., 2005). Consequently, double-and-triple-duty caregiving research is in its infancy (Ward-Griffin et al., 2015) and largely limited to qualitative data, registered nurses (RNs), and non-U.S.-based health care employees (DePasquale et al., 2016c). In this study, we focus on work strain indicators—emotional exhaustion, job satisfaction, turnover intentions, and work climate for family sacrifices—with implications for actual turnover and quality of care in long-term care organizations (Castle et al., 2007; Hyer et al., 2011; Rosen et al., 2011). To our knowledge, these indicators have not been studied exclusively among CNAs in U.S.-based nursing homes. Instead, researchers have compared workplace-only caregivers to U.S.-based double-and-triple-duty caregiving men (DePasquale et al., 2016b), Netherlands-based double-duty caregivers (double-duty-child and double-duty-elder caregivers were aggregated) (Boumans & Dorant, 2014; Dorant & Boumans, 2016), and Canadian-based double-duty caregiving RNs (double-duty-child and double-duty-elder caregivers were aggregated) (Stewart et al., 2011). These efforts have produced mixed evidence regarding differences in workplace-only and double-and-triple-duty caregivers’ emotional exhaustion (Boumans & Dorant, 2014; DePasquale et al., 2016b; Dorant & Boumans, 2016) and turnover intentions (DePasquale et al., 2016b; Stewart et al., 2011). None of these studies detected job satisfaction differences, nor have they considered differences in felt expectations to make family sacrifices because of the work climate (Kossek, Colquitt, & Noe, 2001). Recently, researchers (Boumans & Dorant, 2014) have drawn upon role scarcity and expansion hypotheses, two competing rationales on the consequences of multiple role occupancy within role theory, to elucidate double-and-triple-duty caregivers’ work experiences. The role scarcity hypothesis depicts multiple roles as competitors for individuals’ finite sum of role resources (e.g., time; Goode, 1960). Accordingly, role demands proliferate and resources dwindle as individuals expand their role sets, producing variants of role strain, or felt difficulty addressing role demands. This hypothesis suggests that, given their multiple caregiving roles, double-and-triple-duty caregivers will experience more work strain than workplace-only caregivers. Conversely, the role expansion hypothesis proposes that multiple role occupancy yields more gratification than strain (Marks, 1977; Sieber, 1974). Role resources are considered abundant or flexible, meaning that some roles can be occupied without resource loss (e.g., resource deficits in one role compensate for such deficits in another role) or even generate resources for use in other roles (e.g., positive attributes of one role enhance experiences in another role). These advantageous features of role multiplicity facilitate role management and integration, thereby leading to more positive (and fewer negative) experiences. Based on this hypothesis, double-and-triple-duty caregivers will experience similar or less work strain compared with workplace-only caregivers. Based on competing perspectives within role theory, we pose the following question (RQ1): How does work strain differ between workplace-only and double-and-triple-duty caregivers? In addressing RQ1, we extend double-and-triple-duty caregiving literature on work strain to CNAs in U.S.-based nursing homes. Additionally, we provide a more precise test of role theory by comparing health care employees with the same work role in the same industry. That is, heterogeneity in the work environment is held constant, with family caregiving role occupancy constituting the distinguishing factor between workplace-only and double-and-triple-duty caregivers. Perceived Family Time Adequacy Resources comprise an important component of role theory. In the role scarcity hypothesis (Goode, 1960), resource diminution creates work strain. In the role expansion hypothesis (Marks, 1977; Sieber, 1974), resource accumulation offsets work strain and/or facilitates positive work experiences. Implicit in role theory is the notion that perceived resources would moderate the relationship between double-and-triple-duty caregiving role occupancy and work strain. The role scarcity and expansion hypotheses, however, translate to direct, not moderated, role occupancy-role strain associations. We address this limitation by examining whether perceived family time adequacy acts as a buffer against work strain in CNAs with double-and-triple-duty caregiving roles. Perceived family time adequacy refers to the subjective assessment of family time allocation, or the extent to which individuals feel they have enough time to spend with family members (Hill, Tranby, Kelly, & Moen, 2013; Lee et al., 2015). In accordance with prior research, we view perceived family time adequacy as a psychological resource (ten Brummelhuis & Bakker, 2012). To illustrate, individuals with high perceived family time adequacy sense their time allocation is efficient; they are able to actively manage their competing demands with minimal work strain. Conversely, individuals with low perceived family time adequacy experience family time squeezes, or subjective family time pressures like feeling rushed, stressed, or crunched for time (Hill et al., 2013). Family time squeezes reflect perceived or actual resource depletion (e.g., objective time), both of which have the potential to be psychologically harmful and result in stress and strain (Halbesleben, Neveu, Paustian-Underdahl, & Westman, 2014; ten Brummelhuis & Bakker, 2012). In the double-and-triple-duty caregiving literature, qualitative research has highlighted how double-duty-child caregiving RNs long to obtain unstructured or spontaneous family time (Maher, Lindsay, & Bardoel, 2010). Despite these desires, they report constant temporal tensions between work and family time that necessitate strategic time management, create difficulty in preserving time for family care, and increase their sense of time urgency. Based on interviews with Canadian double-duty-elder caregivers in various health professions, researchers have also concluded that those who feel they have more time for family care are better able to manage their work–family interface (Ward-Griffin et al., 2005). Still, it remains unknown as to whether perceived family time adequacy functions as a psychological resource for work strain experienced by double-and-triple-duty caregiving CNAs. We explore this possibility with our second research question (RQ2): Does work strain differ depending on double-and-triple-duty caregiving CNAs’ subjective perceptions of family time adequacy? Methods We use data from the Work, Family and Health Study (WFHS), a research initiative by the Work, Family and Health Network (WFHN) to examine long-term care employees’ work, family life, and health outcomes (Bray et al., 2013). Study methods were approved by appropriate institutional review boards. Participants The WFHN partnered with a long-term health and specialized care company in New England referred to by the alias of Leef. Leef managed 56 nursing homes, 30 of which were selected for research participation. Facilities were excluded if they were recently acquired and had fewer than 30 direct-care employees; none declined participation. Within each facility, employees were eligible for participation if they provided direct patient care, worked at least 22.5 hours per week, and did not do regular night work. Of 1,783 eligible employees, 1,524 (85%) enrolled in the WFHS, 1,025 of whom were CNAs. We restricted our final sample to 972 CNAs without missing data on study constructs. Procedures Trained field interviewers conducted computer-assisted personal interviews with employees that averaged 60 minutes. Employees answered questions about their work experiences, individual well-being, and family life, for which they received $20. Additional WFHS protocol information is described elsewhere (Bray et al., 2013). Measures Predictors Consistent with prior research (DePasquale et al., 2016a, 2016b, 2016c; Scott, Hwang, & Rogers, 2006), we categorized CNAs into mutually exclusive workplace-only and double-and-triple-duty caregiving groups. Double-duty-child caregivers lived with children aged 18 or younger for at least 4 days per week. Double-duty-elder caregivers provided care (i.e., help with shopping, medical care, or financial/budget planning) for at least 3 hours per week in the past 6 months to an adult relative, regardless of residential proximity. Triple-duty caregivers satisfied each double-duty caregiving criterion whereas workplace-only caregivers did not fulfill either criterion. Overall, 35% (n = 342) of CNAs were workplace-only; 34% (n = 330), double-duty-child; 17% (n = 160), double-duty-elder; and 14% (n = 140), triple-duty caregivers. Double-duty-child and triple-duty caregivers lived with children aged 6.49 (SD = 5.22) and 7.69 (SD = 5.01), respectively, on average. Although family caregivers’ relation to adult care recipients was unspecified, qualitative data from the WFHS suggest that long-term care employees frequently cared for aging parents with poor or declining health (DePasquale et al., 2016a). Moderator Perceived family time adequacy was measured with seven items adapted from the larger Family Resource Scale-Revised (Van Horn, Bellis, & Snyder, 2001). Using a 5-point Likert scale (1 = never, 5 = all of the time), participants rated the extent to which they felt they had spent enough time with their children (e.g., time to take your children to school and medical appointments), partner/spouse (e.g., time to be with your partner/spouse), and/or family (e.g., time to care for other family members’ needs) on a regular basis in the past year. Participants only responded to items that were applicable to their respective family configuration. For instance, married, childfree participants skipped questions about time spent with children and instead reflected on time spent with their spouse and family. The mean score was 3.41 (SD = 0.68), with higher scores translating to higher levels of perceived family time adequacy (α = .66). Work Strain Emotional exhaustion (M = 4.50, SD = 1.66, α = .86) was measured with the three-item emotional exhaustion subscale from The Maslach Burnout Inventory (Maslach & Jackson, 1986), which assessed feelings of being emotionally overextended by one’s work (e.g., feeling emotionally drained from work). Responses ranged from 1 (never) to 7 (every day), with higher scores reflecting more emotional exhaustion. For the remaining work strain measures, response options ranged from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating a higher degree of the outcome being examined. Job satisfaction (M = 4.20, SD = 0.66, α = .81) was examined with a three-item subscale from the Michigan Organizational Assessment Questionnaire reflecting global, affective job satisfaction (e.g., generally like this job, Cammann, Fichman, Jenkins, & Klesh, 1983). Turnover intentions (M = 2.11, SD = 1.00, α = .80) were evaluated with a two-item scale reflecting intentions to vacate the work role (e.g., seriously considering quitting company for an alternative employer, Boroff & Lewin, 1997). Work climate for family sacrifices (M = 2.90, SD = 1.09) was examined with one item, “In your workplace, employees are expected to put their families or personal lives second to their jobs” (Kossek et al., 2001). Covariates We considered several covariates based on their potential to affect study constructs. We selected age, race, marital status, and child disability (i.e., developmental disabilities or health problems) given their link to double-and-triple-duty caregivers’ work–family interface (DePasquale et al., 2016a). Additionally, workplace-only and double-and-triple-duty caregivers’ gender, company tenure, and hours worked per week have differed in past studies (Boumans & Dorant, 2014; DePasquale et al., 2016c); we examined these variables to minimize potential confounding effects. We also included educational attainment and annual household income, as these may be related to resource possession. Statistical Analyses We first used analysis of variance methods to examine sample characteristics and identify any variables on which workplace-only and double-and-triple-duty caregivers differed for inclusion as covariates in later analyses. Next, because CNAs were nested within nursing homes, we calculated intraclass correlations to determine whether analytic models should account for between-facility variance. These calculations indicated that variance in work strain measures was almost entirely attributable to between-person differences. Under the reasonable assumption of statistical independence between facilities, we then estimated two separate multiple linear regression models for each outcome. Model 1 included dichotomous indicators for each double-and-triple-duty caregiving role (with workplace-only caregivers as the reference group), perceived family time adequacy, and relevant covariates from bivariate analyses. Model 2 entailed a moderation analysis in which each double-and-triple-duty caregiving role was interacted with perceived family time adequacy and added to Model 1. Significant interaction terms were followed by a simple slopes analysis to enhance understanding of these effects. All analyses were conducted using SAS software version 9.4. Results Descriptive Analyses Table 1 presents the characteristics for the total sample and by double-and-triple-duty caregiving role occupancy. Compared with the workplace-only caregiving group, the double-duty-child and triple-duty caregiving groups were younger, included proportionately more women, and some lived with disabled children. Additionally, the double-duty-child caregiving group had proportionately more partnered CNAs and shorter average company tenure. Therefore, age, gender, child disability, marital status, and company tenure were selected as covariates. Table 1. Certified Nursing Assistants’ Characteristics by Double-and-Triple-Duty Caregiving Role Occupancy Total sample Workplace-only caregivers Double-duty-child caregivers Double-duty-elder caregivers Triple-duty caregivers n = 972 n = 342 (35%) n = 330 (34%) n = 160 (17%) n = 140 (14%) Characteristics, n (%) M (SD) or % M (SD) or % M (SD) or % M (SD) or % M (SD) or % F test Age (in years) 36.72 (12) 39.02 (15) 33.70 (9)*** 40.24 (14) 34.19 (8)*** 17.54*** Female 0.91 0.87 0.95** 0.91 0.94* 5.55** White 0.62 0.64 0.62 0.65 0.56 1.01 Some college education or more 0.47 0.50 0.44 0.49 0.44 1.07 Annual household income 8.26 (3) 8.51 (3) 8.00 (3) 8.50 (3) 8.00 (3) 2.36† Partnered or married 0.59 0.54 0.67** 0.51 0.66† 6.62*** Disabled child 0.10 0.00 0.18*** 0.00 0.28*** 48.84*** Hours worked per week 36.28 (7) 36.51 (7) 35.85 (7) 36.81 (6) 36.13 (8) 0.91 Company tenure 5.97 (6) 6.83 (7) 5.17 (5)** 6.39 (7) 5.25 (5)† 4.80** Total sample Workplace-only caregivers Double-duty-child caregivers Double-duty-elder caregivers Triple-duty caregivers n = 972 n = 342 (35%) n = 330 (34%) n = 160 (17%) n = 140 (14%) Characteristics, n (%) M (SD) or % M (SD) or % M (SD) or % M (SD) or % M (SD) or % F test Age (in years) 36.72 (12) 39.02 (15) 33.70 (9)*** 40.24 (14) 34.19 (8)*** 17.54*** Female 0.91 0.87 0.95** 0.91 0.94* 5.55** White 0.62 0.64 0.62 0.65 0.56 1.01 Some college education or more 0.47 0.50 0.44 0.49 0.44 1.07 Annual household income 8.26 (3) 8.51 (3) 8.00 (3) 8.50 (3) 8.00 (3) 2.36† Partnered or married 0.59 0.54 0.67** 0.51 0.66† 6.62*** Disabled child 0.10 0.00 0.18*** 0.00 0.28*** 48.84*** Hours worked per week 36.28 (7) 36.51 (7) 35.85 (7) 36.81 (6) 36.13 (8) 0.91 Company tenure 5.97 (6) 6.83 (7) 5.17 (5)** 6.39 (7) 5.25 (5)† 4.80** Note: Means (and standard deviations) or proportions are shown. Analysis of variance (ANOVAs) tests with Tukey post hoc comparisons were conducted to identify mean differences across groups with workplace-only caregivers designated as the reference group. Annual household income is a continuous variable with categories that range from less than $4,999 (1) to more than $60,000 (13). Income was equivalent to $35,000–39,999 (8) or neared $40,000–44,999 (9) across groups. †p < .10. *p < .05. **p < .01. ***p < .001. View Large Table 1. Certified Nursing Assistants’ Characteristics by Double-and-Triple-Duty Caregiving Role Occupancy Total sample Workplace-only caregivers Double-duty-child caregivers Double-duty-elder caregivers Triple-duty caregivers n = 972 n = 342 (35%) n = 330 (34%) n = 160 (17%) n = 140 (14%) Characteristics, n (%) M (SD) or % M (SD) or % M (SD) or % M (SD) or % M (SD) or % F test Age (in years) 36.72 (12) 39.02 (15) 33.70 (9)*** 40.24 (14) 34.19 (8)*** 17.54*** Female 0.91 0.87 0.95** 0.91 0.94* 5.55** White 0.62 0.64 0.62 0.65 0.56 1.01 Some college education or more 0.47 0.50 0.44 0.49 0.44 1.07 Annual household income 8.26 (3) 8.51 (3) 8.00 (3) 8.50 (3) 8.00 (3) 2.36† Partnered or married 0.59 0.54 0.67** 0.51 0.66† 6.62*** Disabled child 0.10 0.00 0.18*** 0.00 0.28*** 48.84*** Hours worked per week 36.28 (7) 36.51 (7) 35.85 (7) 36.81 (6) 36.13 (8) 0.91 Company tenure 5.97 (6) 6.83 (7) 5.17 (5)** 6.39 (7) 5.25 (5)† 4.80** Total sample Workplace-only caregivers Double-duty-child caregivers Double-duty-elder caregivers Triple-duty caregivers n = 972 n = 342 (35%) n = 330 (34%) n = 160 (17%) n = 140 (14%) Characteristics, n (%) M (SD) or % M (SD) or % M (SD) or % M (SD) or % M (SD) or % F test Age (in years) 36.72 (12) 39.02 (15) 33.70 (9)*** 40.24 (14) 34.19 (8)*** 17.54*** Female 0.91 0.87 0.95** 0.91 0.94* 5.55** White 0.62 0.64 0.62 0.65 0.56 1.01 Some college education or more 0.47 0.50 0.44 0.49 0.44 1.07 Annual household income 8.26 (3) 8.51 (3) 8.00 (3) 8.50 (3) 8.00 (3) 2.36† Partnered or married 0.59 0.54 0.67** 0.51 0.66† 6.62*** Disabled child 0.10 0.00 0.18*** 0.00 0.28*** 48.84*** Hours worked per week 36.28 (7) 36.51 (7) 35.85 (7) 36.81 (6) 36.13 (8) 0.91 Company tenure 5.97 (6) 6.83 (7) 5.17 (5)** 6.39 (7) 5.25 (5)† 4.80** Note: Means (and standard deviations) or proportions are shown. Analysis of variance (ANOVAs) tests with Tukey post hoc comparisons were conducted to identify mean differences across groups with workplace-only caregivers designated as the reference group. Annual household income is a continuous variable with categories that range from less than $4,999 (1) to more than $60,000 (13). Income was equivalent to $35,000–39,999 (8) or neared $40,000–44,999 (9) across groups. †p < .10. *p < .05. **p < .01. ***p < .001. View Large Primary Analyses Direct Associations In Model 1 (Table 2), a 1-year increase in age was negatively related to emotional exhaustion and turnover intentions and positively associated with job satisfaction. Additionally, women perceived the work climate as more encouraging of family sacrifices than men, and longer company tenure was linked to greater emotional exhaustion. Turning to the central focus of this study, all double-and-triple-duty caregivers reported higher levels of emotional exhaustion and felt more obligated to make family sacrifices for the sake of work than workplace-only caregivers. Triple-duty caregivers also reported less job satisfaction. Higher levels of perceived family time adequacy were associated with less emotional exhaustion, greater job satisfaction, lower turnover intentions, and less felt obligation to make family sacrifices for the sake of work. With the exception of the job satisfaction model, these main effects for perceived family time adequacy were qualified by significant interactions with double-and-triple-duty caregiving role occupancies in Model 2 (discussed below). Table 2. Multiple Linear Regression Analysis Results Emotional exhaustion Job satisfaction Turnover intentions Work climate for family sacrifices Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Intercept 4.02 (0.18)*** 4.05 (0.18)*** 4.19 (0.08)*** 4.18 (0.08)*** 2.15 (0.12)*** 2.16 (0.11)*** 2.40 (0.13)*** 2.46 (0.12)*** Age −0.03 (0.01)*** −0.03 (0.01)*** 0.01 (0.002)*** 0.01 (0.002)*** −0.01 (0.003)** −0.01 (0.003)** 0.001 (0.003) 0.001 (0.003) Female 0.27 (0.18) 0.29 (0.18) 0.03 (0.07) 0.02 (0.07) −0.05 (0.11) −0.04 (0.11) 0.36 (0.12)** 0.38 (0.12)** Child disability 0.03 (0.18) −0.002 (0.18) 0.07 (0.07) 0.08 (0.07) 0.04 (0.11) 0.02 (0.11) 0.14 (0.12) 0.13 (0.12) Partnered/Married −0.11 (0.10) −0.11 (0.10) 0.07 (0.04) 0.07 (0.04) −0.07 (0.06) −0.07 (0.06) −0.11 (0.07) −0.11 (0.07) Company tenure 0.03 (0.01)** 0.02 (0.01)** −0.003 (0.004) −0.003 (0.004) −0.01 (0.01) −0.01 (0.01) 0.01 (0.01) 0.01 (0.01) DDCC 0.32 (0.13)* 0.32 (0.13)* −0.09 (0.05)† −0.09 (0.05)† −0.01 (0.08) 0.001 (0.08) 0.21 (0.09)* 0.20 (0.09)* DDEC 0.58 (0.15)** 0.55 (0.15)** −0.02 (0.06) −0.02 (0.06) 0.09 (0.09) 0.09 (0.09) 0.25 (0.10)* 0.26 (0.10)* TDC 0.66 (0.17)*** 0.70 (0.17)*** −0.19 (0.07)** −0.20 (0.07)** 0.18 (0.11)† 0.21 (0.11)† 0.35 (0.11)** 0.40 (0.12)** Perceived family time adequacy −0.66 (0.08)*** −0.40 (0.11)** 0.15 (0.03)*** 0.10 (0.05)* −0.20 (0.05)*** −0.11 (0.07) −0.37 (0.05)*** −0.31 (0.07)*** DDCC × Perceived family time adequacy −0.57 (0.19)** 0.14 (0.08)† −0.27 (0.12)* −0.13 (0.13) DDEC × Perceived family time adequacy −0.17 (0.20) 0.01 (0.08) 0.06 (0.13) 0.11 (0.14) TDC × Perceived family time adequacy −0.75 (0.25)** 0.17 (0.10)† −0.36 (0.16)* −0.45 (0.17)** R2 .14 .15 .07 .07 .05 .06 .07 .08 ΔR2a .083*** .013** .026*** .005 .023*** .010* .057*** .009* Emotional exhaustion Job satisfaction Turnover intentions Work climate for family sacrifices Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Intercept 4.02 (0.18)*** 4.05 (0.18)*** 4.19 (0.08)*** 4.18 (0.08)*** 2.15 (0.12)*** 2.16 (0.11)*** 2.40 (0.13)*** 2.46 (0.12)*** Age −0.03 (0.01)*** −0.03 (0.01)*** 0.01 (0.002)*** 0.01 (0.002)*** −0.01 (0.003)** −0.01 (0.003)** 0.001 (0.003) 0.001 (0.003) Female 0.27 (0.18) 0.29 (0.18) 0.03 (0.07) 0.02 (0.07) −0.05 (0.11) −0.04 (0.11) 0.36 (0.12)** 0.38 (0.12)** Child disability 0.03 (0.18) −0.002 (0.18) 0.07 (0.07) 0.08 (0.07) 0.04 (0.11) 0.02 (0.11) 0.14 (0.12) 0.13 (0.12) Partnered/Married −0.11 (0.10) −0.11 (0.10) 0.07 (0.04) 0.07 (0.04) −0.07 (0.06) −0.07 (0.06) −0.11 (0.07) −0.11 (0.07) Company tenure 0.03 (0.01)** 0.02 (0.01)** −0.003 (0.004) −0.003 (0.004) −0.01 (0.01) −0.01 (0.01) 0.01 (0.01) 0.01 (0.01) DDCC 0.32 (0.13)* 0.32 (0.13)* −0.09 (0.05)† −0.09 (0.05)† −0.01 (0.08) 0.001 (0.08) 0.21 (0.09)* 0.20 (0.09)* DDEC 0.58 (0.15)** 0.55 (0.15)** −0.02 (0.06) −0.02 (0.06) 0.09 (0.09) 0.09 (0.09) 0.25 (0.10)* 0.26 (0.10)* TDC 0.66 (0.17)*** 0.70 (0.17)*** −0.19 (0.07)** −0.20 (0.07)** 0.18 (0.11)† 0.21 (0.11)† 0.35 (0.11)** 0.40 (0.12)** Perceived family time adequacy −0.66 (0.08)*** −0.40 (0.11)** 0.15 (0.03)*** 0.10 (0.05)* −0.20 (0.05)*** −0.11 (0.07) −0.37 (0.05)*** −0.31 (0.07)*** DDCC × Perceived family time adequacy −0.57 (0.19)** 0.14 (0.08)† −0.27 (0.12)* −0.13 (0.13) DDEC × Perceived family time adequacy −0.17 (0.20) 0.01 (0.08) 0.06 (0.13) 0.11 (0.14) TDC × Perceived family time adequacy −0.75 (0.25)** 0.17 (0.10)† −0.36 (0.16)* −0.45 (0.17)** R2 .14 .15 .07 .07 .05 .06 .07 .08 ΔR2a .083*** .013** .026*** .005 .023*** .010* .057*** .009* Note: DDCC = double-duty-child caregiver; DDEC = double-duty-elder caregiver; TDC = triple-duty caregiver. Unstandardized regression coefficients (and standard errors) are displayed for all models. All continuous variables are mean centered. aThe change in R2 for Model 1 represents the change from a covariates-only model (i.e., age, gender, child disability, marital status, and company tenure) to a model with both covariates and substantive predictors (i.e., double-and-triple-duty caregiving role occupancies and perceived family time adequacy). †p < .10. *p < .05. **p < .01. ***p < .001. View Large Table 2. Multiple Linear Regression Analysis Results Emotional exhaustion Job satisfaction Turnover intentions Work climate for family sacrifices Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Intercept 4.02 (0.18)*** 4.05 (0.18)*** 4.19 (0.08)*** 4.18 (0.08)*** 2.15 (0.12)*** 2.16 (0.11)*** 2.40 (0.13)*** 2.46 (0.12)*** Age −0.03 (0.01)*** −0.03 (0.01)*** 0.01 (0.002)*** 0.01 (0.002)*** −0.01 (0.003)** −0.01 (0.003)** 0.001 (0.003) 0.001 (0.003) Female 0.27 (0.18) 0.29 (0.18) 0.03 (0.07) 0.02 (0.07) −0.05 (0.11) −0.04 (0.11) 0.36 (0.12)** 0.38 (0.12)** Child disability 0.03 (0.18) −0.002 (0.18) 0.07 (0.07) 0.08 (0.07) 0.04 (0.11) 0.02 (0.11) 0.14 (0.12) 0.13 (0.12) Partnered/Married −0.11 (0.10) −0.11 (0.10) 0.07 (0.04) 0.07 (0.04) −0.07 (0.06) −0.07 (0.06) −0.11 (0.07) −0.11 (0.07) Company tenure 0.03 (0.01)** 0.02 (0.01)** −0.003 (0.004) −0.003 (0.004) −0.01 (0.01) −0.01 (0.01) 0.01 (0.01) 0.01 (0.01) DDCC 0.32 (0.13)* 0.32 (0.13)* −0.09 (0.05)† −0.09 (0.05)† −0.01 (0.08) 0.001 (0.08) 0.21 (0.09)* 0.20 (0.09)* DDEC 0.58 (0.15)** 0.55 (0.15)** −0.02 (0.06) −0.02 (0.06) 0.09 (0.09) 0.09 (0.09) 0.25 (0.10)* 0.26 (0.10)* TDC 0.66 (0.17)*** 0.70 (0.17)*** −0.19 (0.07)** −0.20 (0.07)** 0.18 (0.11)† 0.21 (0.11)† 0.35 (0.11)** 0.40 (0.12)** Perceived family time adequacy −0.66 (0.08)*** −0.40 (0.11)** 0.15 (0.03)*** 0.10 (0.05)* −0.20 (0.05)*** −0.11 (0.07) −0.37 (0.05)*** −0.31 (0.07)*** DDCC × Perceived family time adequacy −0.57 (0.19)** 0.14 (0.08)† −0.27 (0.12)* −0.13 (0.13) DDEC × Perceived family time adequacy −0.17 (0.20) 0.01 (0.08) 0.06 (0.13) 0.11 (0.14) TDC × Perceived family time adequacy −0.75 (0.25)** 0.17 (0.10)† −0.36 (0.16)* −0.45 (0.17)** R2 .14 .15 .07 .07 .05 .06 .07 .08 ΔR2a .083*** .013** .026*** .005 .023*** .010* .057*** .009* Emotional exhaustion Job satisfaction Turnover intentions Work climate for family sacrifices Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Intercept 4.02 (0.18)*** 4.05 (0.18)*** 4.19 (0.08)*** 4.18 (0.08)*** 2.15 (0.12)*** 2.16 (0.11)*** 2.40 (0.13)*** 2.46 (0.12)*** Age −0.03 (0.01)*** −0.03 (0.01)*** 0.01 (0.002)*** 0.01 (0.002)*** −0.01 (0.003)** −0.01 (0.003)** 0.001 (0.003) 0.001 (0.003) Female 0.27 (0.18) 0.29 (0.18) 0.03 (0.07) 0.02 (0.07) −0.05 (0.11) −0.04 (0.11) 0.36 (0.12)** 0.38 (0.12)** Child disability 0.03 (0.18) −0.002 (0.18) 0.07 (0.07) 0.08 (0.07) 0.04 (0.11) 0.02 (0.11) 0.14 (0.12) 0.13 (0.12) Partnered/Married −0.11 (0.10) −0.11 (0.10) 0.07 (0.04) 0.07 (0.04) −0.07 (0.06) −0.07 (0.06) −0.11 (0.07) −0.11 (0.07) Company tenure 0.03 (0.01)** 0.02 (0.01)** −0.003 (0.004) −0.003 (0.004) −0.01 (0.01) −0.01 (0.01) 0.01 (0.01) 0.01 (0.01) DDCC 0.32 (0.13)* 0.32 (0.13)* −0.09 (0.05)† −0.09 (0.05)† −0.01 (0.08) 0.001 (0.08) 0.21 (0.09)* 0.20 (0.09)* DDEC 0.58 (0.15)** 0.55 (0.15)** −0.02 (0.06) −0.02 (0.06) 0.09 (0.09) 0.09 (0.09) 0.25 (0.10)* 0.26 (0.10)* TDC 0.66 (0.17)*** 0.70 (0.17)*** −0.19 (0.07)** −0.20 (0.07)** 0.18 (0.11)† 0.21 (0.11)† 0.35 (0.11)** 0.40 (0.12)** Perceived family time adequacy −0.66 (0.08)*** −0.40 (0.11)** 0.15 (0.03)*** 0.10 (0.05)* −0.20 (0.05)*** −0.11 (0.07) −0.37 (0.05)*** −0.31 (0.07)*** DDCC × Perceived family time adequacy −0.57 (0.19)** 0.14 (0.08)† −0.27 (0.12)* −0.13 (0.13) DDEC × Perceived family time adequacy −0.17 (0.20) 0.01 (0.08) 0.06 (0.13) 0.11 (0.14) TDC × Perceived family time adequacy −0.75 (0.25)** 0.17 (0.10)† −0.36 (0.16)* −0.45 (0.17)** R2 .14 .15 .07 .07 .05 .06 .07 .08 ΔR2a .083*** .013** .026*** .005 .023*** .010* .057*** .009* Note: DDCC = double-duty-child caregiver; DDEC = double-duty-elder caregiver; TDC = triple-duty caregiver. Unstandardized regression coefficients (and standard errors) are displayed for all models. All continuous variables are mean centered. aThe change in R2 for Model 1 represents the change from a covariates-only model (i.e., age, gender, child disability, marital status, and company tenure) to a model with both covariates and substantive predictors (i.e., double-and-triple-duty caregiving role occupancies and perceived family time adequacy). †p < .10. *p < .05. **p < .01. ***p < .001. View Large Moderation Analyses Model 2 (Table 2) addressed RQ2 by examining the moderating effects of perceived family time adequacy. The addition of interaction terms in Model 2 led to a significant increase in the proportion of explained variance for emotional exhaustion, turnover intentions, and work climate for family sacrifices. In these models, perceived family time adequacy interacted significantly with double-duty-child caregiving to predict emotional exhaustion and turnover intentions; perceived family time adequacy also conditioned associations between triple-duty caregiving and emotional exhaustion, turnover intentions, and work climate for family sacrifices. Follow-up simple slopes tests indicated that, for every one-unit increase in perceived family time adequacy, double-duty-child and triple-duty caregivers reported less emotional exhaustion (B = −0.98, SE = 0.15, p < .001 and B = −1.16, SE = 0.22, p < .001, respectively) and lower turnover intentions (B = −0.38, SE = 0.10, p < .001 and B = −0.47, SE = 0.14, p = .001, respectively). Triple-duty caregivers also felt less obligated to make family sacrifices for the sake of work (B = −0.76, SE = 0.15, p < .001). We further probed significant interactive effects by computing model-estimated means for each outcome at high (1 SD above the mean) and low (1 SD below the mean) values of perceived family time adequacy. Double-duty-child and triple-duty caregivers had lower emotional exhaustion (M = 3.70, SE = 0.22 and M = 3.96, SE = 0.26, respectively; Figure 1) and turnover intentions (M = 1.90, SE = 0.14 and M = 2.05, SE = 0.16, respectively; Figure 2) scores in the context of high perceived family time adequacy than in the context of low perceived family time adequacy (emotional exhaustion: M = 5.04, SE = 0.24 for double-duty-child caregivers and M = 5.54, SE = 0.29 for triple-duty caregivers; turnover intentions: M = 2.43, SE = 0.15 for double-duty-child caregivers and M = 2.69, SE = 0.18 for triple-duty caregivers). Triple-duty caregivers also had lower (M = 2.34, SE = 0.18) and higher (M = 3.38, SE = 0.20) work climate for family sacrifices scores in high and low perceived family time adequacy contexts, respectively (Figure 3). Figure 1. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on emotional exhaustion at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect more emotional exhaustion. Figure 1. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on emotional exhaustion at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect more emotional exhaustion. Figure 2. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on turnover intentions at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect greater turnover intentions. Figure 2. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on turnover intentions at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect greater turnover intentions. Figure 3. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on work climate for family sacrifices at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect a work climate in which employees feel more obligated to make family sacrifices for the sake of work. Figure 3. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on work climate for family sacrifices at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect a work climate in which employees feel more obligated to make family sacrifices for the sake of work. Discussion The objectives of this study were twofold. First, we compared workplace-only and double-and-triple-duty caregivers’ work strain. Drawing on a sample of 972 CNAs in U.S.-based nursing homes, we found that the role scarcity hypothesis (Goode, 1960) was generally more applicable to triple-duty caregivers than the role expansion hypothesis (Marks, 1977; Sieber, 1974). Triple-duty caregivers reported more emotional exhaustion, less job satisfaction, and greater felt obligation to make family sacrifices for the sake of work relative to workplace-only caregivers. Conversely, neither hypothesis was more applicable for double-duty caregivers. Compared with workplace-only caregivers, double-duty caregivers reported more emotional exhaustion and obligation to make family sacrifices for the sake of work (consistent with the role scarcity hypothesis), but did not differ with respect to job satisfaction and turnover intentions (consistent with the role expansion hypothesis). Some of our findings were also dissimilar to those from prior research—for example, researchers had not detected lower job satisfaction among triple-duty caregivers (DePasquale et al., 2016b). Previous investigations, though, have focused on different types of double-and-triple-duty caregivers in varying work settings. These findings thus suggest that such work strain indicators operate differently for double-and-triple-duty caregiving CNAs in U.S.-based nursing homes, and lend support to the notion that not all double-and-triple-duty caregivers are the same (Ward-Griffin et al., 2005). Second, we expanded on past research by examining whether perceived family time adequacy functioned as a moderator of associations between double-and-triple-duty caregiving occupancy and work strain. The results showed that greater perceived family time adequacy attenuated double-duty-child and triple-duty caregivers’ emotional exhaustion and turnover intentions as well as reversed triple-duty caregivers’ perceptions regarding the work climate for family sacrifices. Subsequent model-estimated means revealed that high and low family time adequacy buffered and exacerbated these work strain indicators, respectively. This evidence suggests that double-duty-child and triple-duty caregiving CNAs’ work strain differs depending on the perceived inadequacy or adequacy of family time. It also implies that perceived family time adequacy constitutes a salient psychological resource for these particular caregivers and they are motivated to obtain, retain, and protect family time (Hobfoll, 1989). Limitations and Future Research Directions This study has some limitations. First, although this study covered new ground, analyses were cross-sectional. Researchers should use longitudinal designs to study the long-term dynamics of the associations examined here. Second, nonprobability sampling of nursing homes limits generalizability of study findings. A representative sample of U.S.-based CNAs would be particularly informative as double-and-triple-duty caregiving studies typically focus on health care employees in other countries that might vary with respect to work–family balance norms. Third, we conducted a secondary analysis of existing data not specifically designed to study family caregiving. We therefore lacked family caregiving intensity measures and constructed family caregiving role occupancy measures using available child cohabitation, child age, and elder care information in accordance with prior studies (DePasquale et al., 2016a, 2016b; Scott et al., 2006). Still, this role occupancy approach was advantageous relative to family caregiving measures in past double-and-triple-duty caregiving research (Boumans & Dorant, 2014; Stewart et al., 2011; Ward-Griffin et al., 2005, 2015; Wohlgemuth et al., 2015) because it differentiated family care recipients; enabled consideration of triple-duty caregivers; and included a criterion for weekly hours of elder care. Nevertheless, researchers should build on this study by using more nuanced measures that account for care hours; caregiving duration; number, type, and intensity of caregiving demands or activities; and adult care recipients’ age, health status, behavior problems, and relation to double-and-triple-duty caregivers, for instance, as these may yield other insights. Fourth, the overall variance explained by our regression models was relatively low across work strain indicators. Unmeasured constructs, such as the previously suggested family caregiving measures, may explain more variance than models that only include family caregiving role occupancy predictors. In light of these limitations, it will be important to see whether other researchers who replicate our study arrive at similar conclusions. Replication is critical if we are to advance understanding of why perceived family time adequacy did not emerge as a psychological resource for double-duty-elder caregivers. Currently, it is unclear if their resource needs differ from those of double-duty-child and triple-duty caregivers or if such results can be attributed to the aforementioned measurement limitations, for example. Moreover, not all work strain indicators were conditioned by perceived family time adequacy for double-duty-child and triple-duty caregivers. Accordingly, further evidence is needed to determine if perceived family time adequacy is more pertinent for certain work strain indicators (e.g., turnover intentions). Aside from replication, this study also points to future research directions. One such direction is to examine the moderating effects of other psychological (e.g., mental resilience) resources as well as work (e.g., task control) and family (e.g., partner support) resources on work strain. An additional possibility is the concurrent use of subjective and objective family time measures to assess which is more strongly related to work strain. Another promising avenue entails qualitative investigations in which double-and-triple-duty caregiving CNAs identify workplace factors that exacerbate family time squeezes and facilitate perceived family time adequacy. Evidence yielded from such investigations may inform the development of targeted work-life strategies, scheduling practices, and family-friendly policies in the long-term care industry. Implications for Long-Term Care Organizations Our findings suggest that providing family-friendly workplace supports may constitute an opportunity for long-term care organizations to attract, retain, and engage employees. For instance, double-duty-child and triple-duty caregiving CNAs’ lower turnover intentions in the context of greater family time adequacy indicate that workplace initiatives or resources alleviating family time squeezes may yield a positive return-on-investment. Given that turnover intentions are indicative of actual turnover (e.g., Rosen et al., 2011), long-term care organizations may experience more workforce stability and continuity of care, decreased turnover-related costs, and improved well-being among residents and employees by enhancing double-duty-child and triple-duty caregivers’ perceived family time adequacy. One workplace resource that may boost perceived family time adequacy is schedule control or flexibility. Hill and colleagues (2013) recently highlighted how a white-collar organization’s initiative to integrate flexibility within the organizational culture increased perceived family time adequacy. Mothers experienced more schedule control following the initiative and, subsequently, greater perceived family time adequacy. However, neither mothers’ nor fathers’ actual family time allocation changed. The authors thus concluded that perceived family time adequacy, rather than family time allocation, was more malleable through flexibility. Obviously, long-term care and white-collar industries differ in the resources they can feasibly offer to employees. Nonetheless, the amenability of perceived family time adequacy to flexibility may bode well for the long-term care industry. Initiatives such as a shift swapping system, for example, may not increase family time allocation but might enhance perceived family time adequacy. Enhanced perceived family time adequacy, in turn, could catalyze resource gains in double-and-triple-duty caregiving CNAs. Relatedly, because CNAs often desire to have more control in the workplace, flexibility initiatives may be a particularly effective retention strategy. Further, although greater schedule control did not affect fathers’ family time adequacy in the Hill and colleagues’ study, a family-supportive company culture was positively related to their perceived family time adequacy. This finding underscores the notion that in order to have a broader impact on employees’ work–family interface, support must be demonstrated for employees’ families or personal lives at all levels within an organization (Hammer & Neal, 2008). An unsupportive organizational work–family climate will likely undermine the utilization of work resources intended to increase family time adequacy and the uptake of family-supportive initiatives in general. Conclusion We found that double-and-triple-duty caregiving CNAs report more work strain than their workplace-only caregiving counterparts. We also identified perceived family time adequacy as a salient psychological resource that buffered double-duty-child and triple-duty caregivers’ emotional exhaustion and turnover intentions as well as reversed triple-duty caregivers’ negative perceptions of the work climate for family sacrifices. Amid direct-care workforce shortages and an unprecedented demand for long-term care services, additional research about double-and-triple-duty caregiving CNAs’ work–family interface is urgently needed to inform the long-term care industry’s recruitment, retention, and engagement strategies. Funding This work was supported by the National Institute On Aging of the National Institutes of Health under Award Number F31AG050385 to N. DePasquale. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Acknowledgments 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 (Grants U01HD051217, U01HD051218, U01HD051256, and U01HD051276), National Institute on Aging (Grant U01AG027669), Office of Behavioral and Social Sciences Research, and National Institute for Occupational Safety and Health (Grants U01OH008788 and U01HD059773). This study was also supported by grants from the William T. Grant Foundation, Alfred P Sloan Foundation, and the Administration for Children and Families have provided additional funding. 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. Special acknowledgment goes to Extramural Staff Science Collaborator, Rosalind Berkowitz King, PhD, and Lynne Casper, PhD, for design of the original Workplace, Family, Health and Well-Being Network Initiative. We also wish to express our gratitude to the worksites, employers, and employees who participated in this research. References Anderson K. A . ( 2008 ). Grief experiences of CNAs: Relationships with burnout and turnover . Journal of Gerontological Nursing , 34 , 42 – 49 . Google Scholar CrossRef Search ADS PubMed Boroff K. E. , & Lewin D . ( 1997 ). Loyalty, voice, and intent to exit a union firm: A conceptual and empirical analysis . ILR Review , 51 , 50 – 63 . doi: 10.1177/001979399705100104 Google Scholar CrossRef Search ADS Boumans N. P. Dorant E . ( 2014 ). Double-duty caregivers: Healthcare professionals juggling employment and informal caregiving. A survey on personal health and work experiences . Journal of Advanced Nursing , 70 , 1604 – 1615 . doi: 10.1111/jan.12320 Google Scholar CrossRef Search ADS PubMed Bowers B. J. Esmond S. , & Jacobson N . ( 2003 ). Turnover reinterpreted: CNAs talk about why they leave . Journal of Gerontological Nursing , 29 , 36 – 43 . doi: 10.3928/0098-9134-20030301-09 Google Scholar CrossRef Search ADS PubMed Bray J. W. Kelly E. L. Hammer L. B. Almeida D. M. Dearing J. W. King R. B. , & Buxton O. M . ( 2013 ). An integrative, multilevel, and transdisciplinary research approach to challenges of work, family, and health . RTI Press publication No. MR-0024-1303. Research Triangle Park, NC : RTI Press . doi: 10.3768/rtipress.2013.mr.0024.1303 Bureau of Labor Statistics . ( 2015 ). Nursing assistants and orderlies: Occupational outlook handbook, 2016–17 Edition . Retrieved from http://www.bls.gov/ooh/healthcare/nursing-assistants.htm. Cammann C. Fichman M. Jenkins G. D. , & Klesh J . ( 1983 ). Michigan Organizational Assessment Questionnaire . In S. E. Seashore E. E. Lawler P. H. Mirvis , & C. Cammann (Eds.), Assessing organizational change: A guide to methods, measures, and practices (pp. 71 – 138 ). New York : Wiley-Interscience . Castle N. G. Engberg J. Anderson R. , & Men A . ( 2007 ). Job satisfaction of nurse aides in nursing homes: Intent to leave and turnover . The Gerontologist , 47 , 193 – 204 . doi: 10.1093/geront/47.2.193 Google Scholar CrossRef Search ADS PubMed DePasquale N. Davis K. D. Zarit S. H. Moen P. Hammer L. B. , & Almeida D. M . ( 2016 a). Combining formal and informal caregiving roles: The psychosocial implications of double-and triple-duty care . The Journals of Gerontology, Series B: Physiological Sciences and Social Sciences , 71 , 201 – 211 . doi: 10.1093/geronb/gbu139 Google Scholar CrossRef Search ADS DePasquale N. Zarit S. H. Mogle J. Moen P. Hammer L. B. , & Almeida D. M . ( 2016 b). Double-and triple-duty caregiving men: An examination of subjective stress and perceived schedule control . Journal of Applied Gerontology . Advance online publication. doi: 10.1177/0733464816641391 DePasquale N. Bangerter L. Williams J. , & Almeida D.M. ( 2016 c). Certified nursing assistants balancing family caregiving roles: Healthcare utilization among double- and triple-duty caregivers . The Gerontologist , 56 , 1114 – 1123 . doi:10.1093/geront/gnv081 Google Scholar CrossRef Search ADS PubMed Dorant E. , & Boumans N. P . ( 2016 ). Positive and negative consequences of balancing paid work and informal family care: A survey in two different sectors . International Journal of Health and Psychology Research , 4 , 16 – 33 Geiger-Brown J. Muntaner C. Lipscomb J. , & Trinkoff A . ( 2004 ). Demanding work schedules and mental health in nursing assistants working in nursing homes . Work & Stress , 18 , 292 – 304 . doi: 10.1080/02678370412331320044 Google Scholar CrossRef Search ADS Goode W. J . ( 1960 ). A theory of role strain . American Sociological Review , 25 , 483 – 496 . doi: 10.2307/2092933 Google Scholar CrossRef Search ADS Halbesleben J. R. Neveu J. P. Paustian-Underdahl S. C. , & Westman M . ( 2014 ). Getting to the “COR” understanding the role of resources in Conservation of Resources theory . Journal of Management , 40 , 1334 – 1364 . doi: 10.1177/0149206314527130 Google Scholar CrossRef Search ADS Hammer L. B. , & Neal M. B . ( 2008 ). Working sandwiched-generation caregivers: Prevalence, characteristics, and outcomes . The Psychologist-Manager Journal , 11 , 93 – 112 . doi: 10.1080/10887150801967324 Google Scholar CrossRef Search ADS He W. Goodkind D. , & Kowal P . ( 2016 ). An aging world: 2015: International population reports . Washington, DC : U.S. Census Bureau . Hill R. Tranby E. Kelly E. , & Moen P . ( 2013 ). Relieving the time squeeze? Effects of a white-collar workplace change on parents . Journal of Marriage and Family , 75 , 1014 – 1029 . doi: 10.1111/jomf.12047 Google Scholar CrossRef Search ADS PubMed Hobfoll S. E . ( 1989 ). Conservation of resources: A new attempt at conceptualizing stress . American Psychologist , 44 , 513 – 524 . doi: 10.1037//0003-066x.44.3.513 Google Scholar CrossRef Search ADS PubMed Hyer K. Thomas K. S. Branch L. G. Harman J. S. Johnson C. E. Weech-Maldonado R . ( 2011 ). The influence of nurse staffing levels on quality of care in nursing homes . The Gerontologist , 51 , 610 – 616 . doi: 10.1093/geront/gnr050 Google Scholar CrossRef Search ADS PubMed Karsh B. Booske B. C. Sainfort F . ( 2005 ). Job and organizational determinants of nursing home employee commitment, job satisfaction and intent to turnover . Ergonomics , 48 , 1260 – 1281 . doi: 10.1080/00140130500197195 Google Scholar CrossRef Search ADS PubMed Kossek E. E. Colquitt J. A. , & Noe R. A . ( 2001 ). Caregiving decisions, well-being, and performance: The effects of place and provider as a function of dependent type and work-family climates . Academy of Management Journal , 44 , 29 – 44 . doi: 10.2307/3069335 Lee S. Almeida D. M. Davis K. D. King R. B. Hammer L. B. Kelly E. L . ( 2015 ). Latent profiles of perceived time adequacy for paid work, parenting, and partner roles . Journal of Family Psychology , 29 , 788 – 798 . doi: 10.1037/a0039433 Google Scholar CrossRef Search ADS PubMed Maher J. M. Lindsay J. Bardoel E. A. ( 2010 ). Freeing time? The ‘family time economies’ of nurses . Sociology , 44 , 269 – 287 . doi: 10.1177/0038038509357205 Google Scholar CrossRef Search ADS Marks S. R . ( 1977 ). Multiple roles and role strain: Some notes on human energy, time and commitment . American Sociological Review , 42 , 921 – 936 . doi: 10.2307/2094577 Google Scholar CrossRef Search ADS Maslach C. , & Jackson S . ( 1986 ). Maslach Burnout Inventory Manual ( 2nd ed .). Palo Alto, CA : Consulting Psychologists Press . Okechukwu C. A. El Ayadi A. M. Tamers S. L. Sabbath E. L. Berkman L . ( 2012 ). Household food insufficiency, financial strain, work-family spillover, and depressive symptoms in the working class: The Work, Family, and Health Network study . American Journal of Public Health , 102 , 126 – 133 . doi: 10.2105/AJPH.2011.300323 Google Scholar CrossRef Search ADS PubMed Paraprofessional Healthcare Institute . ( 2013 ). America’s direct-care workforce . PubMed PubMed Rosen J. Stiehl E. M. Mittal V. Leana C. R . ( 2011 ). Stayers, leavers, and switchers among certified nursing assistants in nursing homes: A longitudinal investigation of turnover intent, staff retention, and turnover . The Gerontologist , 51 , 597 – 609 . doi: 10.1093/geront/gnr025 Google Scholar CrossRef Search ADS PubMed Scott L. D. Hwang W.-T. , & Rogers A. E . ( 2006 ). The impact of multiple care giving roles on fatigue, stress, and work performance among hospital staff nurses . Journal of Nursing Administration , 36 , 86 – 95 . doi: 10.1097/00005110-200602000-00007 Google Scholar CrossRef Search ADS PubMed Sieber S. D . ( 1974 ). Toward a theory of role accumulation . American Sociological Review , 39 , 556 – 578 . doi: 10.2307/2094422 Google Scholar CrossRef Search ADS Stewart N. J. D’Arcy C. Kosteniuk J. Andrews M. E. Morgan D. Forbes D. , … Pitblado J. R . ( 2011 ). Moving on? Predictors of intent to leave among rural and remote RNs in Canada . The Journal of Rural Health , 27 , 103 – 113 . doi: 10.1111/j.1748-0361.2010.00308.x Google Scholar CrossRef Search ADS PubMed Stone R. I . ( 2012 ). The long-term care workforce: From accidental to valued profession . In D. Wolf and N. Folbre (Eds.), Universal coverage of long-term care in the United States: Can we get there from here? (pp. 155 – 178 ). Russell Sage Foundation e-book. Retrieved from https://www.russellsage.org/publications/universal-coverage-long-term-care-united-states. Temple A. Dobbs D. Andel R . ( 2009 ). Exploring correlates of turnover among nursing assistants in the National Nursing Home Survey . Health Care Management Review , 34 , 182 – 190 . doi: 10.1097/HMR.0b013e31819c8b11 Google Scholar CrossRef Search ADS PubMed ten Brummelhuis L. L. Bakker A. B . ( 2012 ). A resource perspective on the work-home interface: The work-home resources model . The American Psychologist , 67 , 545 – 556 . doi: 10.1037/a0027974 Google Scholar CrossRef Search ADS PubMed Van Horn M. L. Bellis J. M. , & Snyder S. W . ( 2001 ). Family Resource Scale-Revised: Psychometrics and validation of a measure of family resources in a sample of low-income families . Journal of Psychoeducational Assessment , 19 , 54 – 68 . doi: 10.1177/073428290101900104 Google Scholar CrossRef Search ADS Ward-Griffin C. Brown J. B. Vandervoort A. McNair S. , & Dashnay I . ( 2005 ). Double-duty caregiving: Women in the health professions . Canadian Journal on Aging , 24 , 379 – 394 . doi: 10.1353/cja.2006.0015 Google Scholar CrossRef Search ADS Ward-Griffin C. Brown J. B. St-Amant O. Sutherland N. Martin-Matthews A. Keefe J. Kerr M . ( 2015 ). Nurses negotiating professional-familial care boundaries: Striving for balance within double duty caregiving . Journal of Family Nursing , 21 , 57 – 85 . doi: 10.1177/1074840714562645 Google Scholar CrossRef Search ADS PubMed Wohlgemuth C. M. Auerbach H. P. Parker V. A . ( 2015 ). Advantages and Challenges: The Experience of Geriatrics Health Care Providers as Family Caregivers . The Gerontologist , 55 , 595 – 604 . doi: 10.1093/geront/gnt168 Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Gerontologist Oxford University Press

The Family Time Squeeze: Perceived Family Time Adequacy Buffers Work Strain in Certified Nursing Assistants With Multiple Caregiving Roles

Loading next page...
 
/lp/ou_press/the-family-time-squeeze-perceived-family-time-adequacy-buffers-work-JQ40g6GZzM
Publisher
Oxford University Press
Copyright
© The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN
0016-9013
eISSN
1758-5341
D.O.I.
10.1093/geront/gnw191
Publisher site
See Article on Publisher Site

Abstract

Abstract Purpose of the Study This study examined how certified nursing assistants (CNAs) with 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”) differed from their nonfamily caregiving counterparts (“workplace-only caregivers”) on four work strain indicators (emotional exhaustion, job satisfaction, turnover intentions, and work climate for family sacrifices). The moderating effects of perceived family time adequacy were also evaluated. Design and Methods Regression analyses were conducted on survey data from 972 CNAs working in U.S.-based nursing homes. Results Compared with workplace-only caregivers, double-and-triple-duty caregivers reported more emotional exhaustion and pressure to make family sacrifices for the sake of work. Triple-duty caregivers also reported less job satisfaction. Perceived family time adequacy buffered double-duty-child and triple-duty caregivers’ emotional exhaustion and turnover intentions, as well as reversed triple-duty caregivers’ negative perceptions of the work climate. Implications Perceived family time adequacy constitutes a salient psychological resource for double-duty-child and triple-duty caregivers’ family time squeezes. Amid an unprecedented demand for long-term care and severe direct-care workforce shortages, future research on workplace factors that increase double-and-triple-duty caregiving CNAs’ perceived family time adequacy is warranted to inform long-term care organizations’ development of targeted recruitment, retention, and engagement strategies. Double-duty caregiving, Triple-duty caregiving, Family time pressures, Work–family interface, Nursing homes The 65 and older population in the United States is projected to nearly double over the next 30 years (He, Goodkind, & Kowal, 2016). Accordingly, their long-term care needs will proliferate (He et al., 2016). The number of certified nursing assistants (CNAs) and other direct-care workers will grow significantly to address these needs, becoming the nation’s largest occupational group by 2020 (Paraprofessional Healthcare Institute [PHI], 2013; Stone, 2012). Concurrently, family members will increasingly provide unpaid help, remaining the country’s largest source of long-term care (He et al., 2016). A surge in direct-care employment, coupled with ongoing reliance on unpaid assistance, will give rise to more adults engaging in paid and unpaid care simultaneously (Boumans & Dorant, 2014). In particular, health care employees are likely to serve as family caregivers because they are usually the only “health professional in the family” and relied on heavily by family members to use their expertise for family care (Ward-Griffin, Brown, Vandervoort, McNair, & Dashnay, 2005, p. 384; Wohlgemuth, Auerbach, & Parker, 2015). Yet direct-care workers with family caregiving roles are grossly understudied (DePasquale, Bangerter, Williams, & Almeida, 2016c). In this article, we focus on work strain among family caregiving CNAs in U.S.-based nursing homes as an initial step toward understanding their work–family interface. The Work Domain CNAs and other direct-care employees constitute the backbone of the country’s formal long-term care system, providing nearly 80% of the hands-on care and emotional support for countless elderly, disabled, and chronically ill Americans (PHI, 2013; Stone, 2012). They also represent one of the nation’s largest, fastest-growing workforces (PHI, 2013). Concerns about projected job growth translating to actual job growth, however, have surfaced amid a worsening shortage of CNAs (Stone, 2012). Researchers attribute these shortages to several characteristics of long-term care employment (Stone, 2012). Long-term care employment is stressful, challenging, and linked to physical and emotional strain (Stone, 2012). CNAs are principal caregivers of older adults with chronic conditions and cognitive or functional impairments, balance heavy workloads, and perform physically strenuous tasks (Bureau of Labor Statistics [BLS], 2015). Relatedly, their nonfatal occupational injury and illness rates are disproportionately high (BLS, 2015). CNAs also experience grief following care recipients’ deaths; these grief experiences contribute to burnout, a stress-related reaction characterized by emotional exhaustion (Anderson, 2008). Moreover, CNAs often endure poor working conditions (Stone, 2012). They feel disregarded and treated unfairly, perceive an imbalance between task control and work demands, and cite contradictions between organizational rhetoric and practices or policies concerning respect, appreciation, and value for their work (Bowers, Esmond, & Jacobson, 2003). They also work demanding schedules that hinder work–family balance (Geiger-Brown, Muntaner, Lipscomb, & Trinkoff, 2004). Further, CNAs are a low-wage, hourly workforce with few advancement opportunities and limited employee benefits (Stone, 2012). Approximately 25% of direct-care workers are without health insurance, 48% live below the poverty threshold, and 49% receive public benefits (PHI, 2013). Prior research suggests that food insufficiency and financial strain, both of which are associated with depressive symptoms, are pervasive among these employees (Okechukwu, El Ayadi, Tamers, Sabbath, & Berkman, 2012). The aforementioned workplace factors have contributed to high turnover rates and job dissatisfaction among CNAs (Bowers et al., 2003; Castle, Engberg, Anderson, & Men, 2007; Karsh, Booske, & Sainfort, 2005; Rosen, Stiehl, Mittal, & Leana, 2011; Stone, 2012; Temple, Dobbs, & Andel, 2009). Such information about these factors is useful for long-term care organizations in that it can inform retention, recruitment, and engagement strategies targeting CNAs. This information may be incomplete, though, without consideration of family domain factors. Care Transcending the Work–Family Divide Literature on the convergence of care in the work and family domains uses “double-and-triple-duty caregiving” terminology to distinguish health care employees with caregiving roles beyond the work domain from their nonfamily caregiving counterparts, or “workplace-only caregivers” (DePasquale et al., 2016a, 2016b; Ward-Griffin et al., 2005). “Double-duty caregivers” are health care employees who informally care for children (“double-duty-child caregivers”) or older adults (“double-duty-elder caregivers”) whereas “triple-duty caregivers” are health care employees who informally care for children and older adults. Traditionally, formal and family caregiving have been studied separately (Ward-Griffin et al., 2005). Consequently, double-and-triple-duty caregiving research is in its infancy (Ward-Griffin et al., 2015) and largely limited to qualitative data, registered nurses (RNs), and non-U.S.-based health care employees (DePasquale et al., 2016c). In this study, we focus on work strain indicators—emotional exhaustion, job satisfaction, turnover intentions, and work climate for family sacrifices—with implications for actual turnover and quality of care in long-term care organizations (Castle et al., 2007; Hyer et al., 2011; Rosen et al., 2011). To our knowledge, these indicators have not been studied exclusively among CNAs in U.S.-based nursing homes. Instead, researchers have compared workplace-only caregivers to U.S.-based double-and-triple-duty caregiving men (DePasquale et al., 2016b), Netherlands-based double-duty caregivers (double-duty-child and double-duty-elder caregivers were aggregated) (Boumans & Dorant, 2014; Dorant & Boumans, 2016), and Canadian-based double-duty caregiving RNs (double-duty-child and double-duty-elder caregivers were aggregated) (Stewart et al., 2011). These efforts have produced mixed evidence regarding differences in workplace-only and double-and-triple-duty caregivers’ emotional exhaustion (Boumans & Dorant, 2014; DePasquale et al., 2016b; Dorant & Boumans, 2016) and turnover intentions (DePasquale et al., 2016b; Stewart et al., 2011). None of these studies detected job satisfaction differences, nor have they considered differences in felt expectations to make family sacrifices because of the work climate (Kossek, Colquitt, & Noe, 2001). Recently, researchers (Boumans & Dorant, 2014) have drawn upon role scarcity and expansion hypotheses, two competing rationales on the consequences of multiple role occupancy within role theory, to elucidate double-and-triple-duty caregivers’ work experiences. The role scarcity hypothesis depicts multiple roles as competitors for individuals’ finite sum of role resources (e.g., time; Goode, 1960). Accordingly, role demands proliferate and resources dwindle as individuals expand their role sets, producing variants of role strain, or felt difficulty addressing role demands. This hypothesis suggests that, given their multiple caregiving roles, double-and-triple-duty caregivers will experience more work strain than workplace-only caregivers. Conversely, the role expansion hypothesis proposes that multiple role occupancy yields more gratification than strain (Marks, 1977; Sieber, 1974). Role resources are considered abundant or flexible, meaning that some roles can be occupied without resource loss (e.g., resource deficits in one role compensate for such deficits in another role) or even generate resources for use in other roles (e.g., positive attributes of one role enhance experiences in another role). These advantageous features of role multiplicity facilitate role management and integration, thereby leading to more positive (and fewer negative) experiences. Based on this hypothesis, double-and-triple-duty caregivers will experience similar or less work strain compared with workplace-only caregivers. Based on competing perspectives within role theory, we pose the following question (RQ1): How does work strain differ between workplace-only and double-and-triple-duty caregivers? In addressing RQ1, we extend double-and-triple-duty caregiving literature on work strain to CNAs in U.S.-based nursing homes. Additionally, we provide a more precise test of role theory by comparing health care employees with the same work role in the same industry. That is, heterogeneity in the work environment is held constant, with family caregiving role occupancy constituting the distinguishing factor between workplace-only and double-and-triple-duty caregivers. Perceived Family Time Adequacy Resources comprise an important component of role theory. In the role scarcity hypothesis (Goode, 1960), resource diminution creates work strain. In the role expansion hypothesis (Marks, 1977; Sieber, 1974), resource accumulation offsets work strain and/or facilitates positive work experiences. Implicit in role theory is the notion that perceived resources would moderate the relationship between double-and-triple-duty caregiving role occupancy and work strain. The role scarcity and expansion hypotheses, however, translate to direct, not moderated, role occupancy-role strain associations. We address this limitation by examining whether perceived family time adequacy acts as a buffer against work strain in CNAs with double-and-triple-duty caregiving roles. Perceived family time adequacy refers to the subjective assessment of family time allocation, or the extent to which individuals feel they have enough time to spend with family members (Hill, Tranby, Kelly, & Moen, 2013; Lee et al., 2015). In accordance with prior research, we view perceived family time adequacy as a psychological resource (ten Brummelhuis & Bakker, 2012). To illustrate, individuals with high perceived family time adequacy sense their time allocation is efficient; they are able to actively manage their competing demands with minimal work strain. Conversely, individuals with low perceived family time adequacy experience family time squeezes, or subjective family time pressures like feeling rushed, stressed, or crunched for time (Hill et al., 2013). Family time squeezes reflect perceived or actual resource depletion (e.g., objective time), both of which have the potential to be psychologically harmful and result in stress and strain (Halbesleben, Neveu, Paustian-Underdahl, & Westman, 2014; ten Brummelhuis & Bakker, 2012). In the double-and-triple-duty caregiving literature, qualitative research has highlighted how double-duty-child caregiving RNs long to obtain unstructured or spontaneous family time (Maher, Lindsay, & Bardoel, 2010). Despite these desires, they report constant temporal tensions between work and family time that necessitate strategic time management, create difficulty in preserving time for family care, and increase their sense of time urgency. Based on interviews with Canadian double-duty-elder caregivers in various health professions, researchers have also concluded that those who feel they have more time for family care are better able to manage their work–family interface (Ward-Griffin et al., 2005). Still, it remains unknown as to whether perceived family time adequacy functions as a psychological resource for work strain experienced by double-and-triple-duty caregiving CNAs. We explore this possibility with our second research question (RQ2): Does work strain differ depending on double-and-triple-duty caregiving CNAs’ subjective perceptions of family time adequacy? Methods We use data from the Work, Family and Health Study (WFHS), a research initiative by the Work, Family and Health Network (WFHN) to examine long-term care employees’ work, family life, and health outcomes (Bray et al., 2013). Study methods were approved by appropriate institutional review boards. Participants The WFHN partnered with a long-term health and specialized care company in New England referred to by the alias of Leef. Leef managed 56 nursing homes, 30 of which were selected for research participation. Facilities were excluded if they were recently acquired and had fewer than 30 direct-care employees; none declined participation. Within each facility, employees were eligible for participation if they provided direct patient care, worked at least 22.5 hours per week, and did not do regular night work. Of 1,783 eligible employees, 1,524 (85%) enrolled in the WFHS, 1,025 of whom were CNAs. We restricted our final sample to 972 CNAs without missing data on study constructs. Procedures Trained field interviewers conducted computer-assisted personal interviews with employees that averaged 60 minutes. Employees answered questions about their work experiences, individual well-being, and family life, for which they received $20. Additional WFHS protocol information is described elsewhere (Bray et al., 2013). Measures Predictors Consistent with prior research (DePasquale et al., 2016a, 2016b, 2016c; Scott, Hwang, & Rogers, 2006), we categorized CNAs into mutually exclusive workplace-only and double-and-triple-duty caregiving groups. Double-duty-child caregivers lived with children aged 18 or younger for at least 4 days per week. Double-duty-elder caregivers provided care (i.e., help with shopping, medical care, or financial/budget planning) for at least 3 hours per week in the past 6 months to an adult relative, regardless of residential proximity. Triple-duty caregivers satisfied each double-duty caregiving criterion whereas workplace-only caregivers did not fulfill either criterion. Overall, 35% (n = 342) of CNAs were workplace-only; 34% (n = 330), double-duty-child; 17% (n = 160), double-duty-elder; and 14% (n = 140), triple-duty caregivers. Double-duty-child and triple-duty caregivers lived with children aged 6.49 (SD = 5.22) and 7.69 (SD = 5.01), respectively, on average. Although family caregivers’ relation to adult care recipients was unspecified, qualitative data from the WFHS suggest that long-term care employees frequently cared for aging parents with poor or declining health (DePasquale et al., 2016a). Moderator Perceived family time adequacy was measured with seven items adapted from the larger Family Resource Scale-Revised (Van Horn, Bellis, & Snyder, 2001). Using a 5-point Likert scale (1 = never, 5 = all of the time), participants rated the extent to which they felt they had spent enough time with their children (e.g., time to take your children to school and medical appointments), partner/spouse (e.g., time to be with your partner/spouse), and/or family (e.g., time to care for other family members’ needs) on a regular basis in the past year. Participants only responded to items that were applicable to their respective family configuration. For instance, married, childfree participants skipped questions about time spent with children and instead reflected on time spent with their spouse and family. The mean score was 3.41 (SD = 0.68), with higher scores translating to higher levels of perceived family time adequacy (α = .66). Work Strain Emotional exhaustion (M = 4.50, SD = 1.66, α = .86) was measured with the three-item emotional exhaustion subscale from The Maslach Burnout Inventory (Maslach & Jackson, 1986), which assessed feelings of being emotionally overextended by one’s work (e.g., feeling emotionally drained from work). Responses ranged from 1 (never) to 7 (every day), with higher scores reflecting more emotional exhaustion. For the remaining work strain measures, response options ranged from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating a higher degree of the outcome being examined. Job satisfaction (M = 4.20, SD = 0.66, α = .81) was examined with a three-item subscale from the Michigan Organizational Assessment Questionnaire reflecting global, affective job satisfaction (e.g., generally like this job, Cammann, Fichman, Jenkins, & Klesh, 1983). Turnover intentions (M = 2.11, SD = 1.00, α = .80) were evaluated with a two-item scale reflecting intentions to vacate the work role (e.g., seriously considering quitting company for an alternative employer, Boroff & Lewin, 1997). Work climate for family sacrifices (M = 2.90, SD = 1.09) was examined with one item, “In your workplace, employees are expected to put their families or personal lives second to their jobs” (Kossek et al., 2001). Covariates We considered several covariates based on their potential to affect study constructs. We selected age, race, marital status, and child disability (i.e., developmental disabilities or health problems) given their link to double-and-triple-duty caregivers’ work–family interface (DePasquale et al., 2016a). Additionally, workplace-only and double-and-triple-duty caregivers’ gender, company tenure, and hours worked per week have differed in past studies (Boumans & Dorant, 2014; DePasquale et al., 2016c); we examined these variables to minimize potential confounding effects. We also included educational attainment and annual household income, as these may be related to resource possession. Statistical Analyses We first used analysis of variance methods to examine sample characteristics and identify any variables on which workplace-only and double-and-triple-duty caregivers differed for inclusion as covariates in later analyses. Next, because CNAs were nested within nursing homes, we calculated intraclass correlations to determine whether analytic models should account for between-facility variance. These calculations indicated that variance in work strain measures was almost entirely attributable to between-person differences. Under the reasonable assumption of statistical independence between facilities, we then estimated two separate multiple linear regression models for each outcome. Model 1 included dichotomous indicators for each double-and-triple-duty caregiving role (with workplace-only caregivers as the reference group), perceived family time adequacy, and relevant covariates from bivariate analyses. Model 2 entailed a moderation analysis in which each double-and-triple-duty caregiving role was interacted with perceived family time adequacy and added to Model 1. Significant interaction terms were followed by a simple slopes analysis to enhance understanding of these effects. All analyses were conducted using SAS software version 9.4. Results Descriptive Analyses Table 1 presents the characteristics for the total sample and by double-and-triple-duty caregiving role occupancy. Compared with the workplace-only caregiving group, the double-duty-child and triple-duty caregiving groups were younger, included proportionately more women, and some lived with disabled children. Additionally, the double-duty-child caregiving group had proportionately more partnered CNAs and shorter average company tenure. Therefore, age, gender, child disability, marital status, and company tenure were selected as covariates. Table 1. Certified Nursing Assistants’ Characteristics by Double-and-Triple-Duty Caregiving Role Occupancy Total sample Workplace-only caregivers Double-duty-child caregivers Double-duty-elder caregivers Triple-duty caregivers n = 972 n = 342 (35%) n = 330 (34%) n = 160 (17%) n = 140 (14%) Characteristics, n (%) M (SD) or % M (SD) or % M (SD) or % M (SD) or % M (SD) or % F test Age (in years) 36.72 (12) 39.02 (15) 33.70 (9)*** 40.24 (14) 34.19 (8)*** 17.54*** Female 0.91 0.87 0.95** 0.91 0.94* 5.55** White 0.62 0.64 0.62 0.65 0.56 1.01 Some college education or more 0.47 0.50 0.44 0.49 0.44 1.07 Annual household income 8.26 (3) 8.51 (3) 8.00 (3) 8.50 (3) 8.00 (3) 2.36† Partnered or married 0.59 0.54 0.67** 0.51 0.66† 6.62*** Disabled child 0.10 0.00 0.18*** 0.00 0.28*** 48.84*** Hours worked per week 36.28 (7) 36.51 (7) 35.85 (7) 36.81 (6) 36.13 (8) 0.91 Company tenure 5.97 (6) 6.83 (7) 5.17 (5)** 6.39 (7) 5.25 (5)† 4.80** Total sample Workplace-only caregivers Double-duty-child caregivers Double-duty-elder caregivers Triple-duty caregivers n = 972 n = 342 (35%) n = 330 (34%) n = 160 (17%) n = 140 (14%) Characteristics, n (%) M (SD) or % M (SD) or % M (SD) or % M (SD) or % M (SD) or % F test Age (in years) 36.72 (12) 39.02 (15) 33.70 (9)*** 40.24 (14) 34.19 (8)*** 17.54*** Female 0.91 0.87 0.95** 0.91 0.94* 5.55** White 0.62 0.64 0.62 0.65 0.56 1.01 Some college education or more 0.47 0.50 0.44 0.49 0.44 1.07 Annual household income 8.26 (3) 8.51 (3) 8.00 (3) 8.50 (3) 8.00 (3) 2.36† Partnered or married 0.59 0.54 0.67** 0.51 0.66† 6.62*** Disabled child 0.10 0.00 0.18*** 0.00 0.28*** 48.84*** Hours worked per week 36.28 (7) 36.51 (7) 35.85 (7) 36.81 (6) 36.13 (8) 0.91 Company tenure 5.97 (6) 6.83 (7) 5.17 (5)** 6.39 (7) 5.25 (5)† 4.80** Note: Means (and standard deviations) or proportions are shown. Analysis of variance (ANOVAs) tests with Tukey post hoc comparisons were conducted to identify mean differences across groups with workplace-only caregivers designated as the reference group. Annual household income is a continuous variable with categories that range from less than $4,999 (1) to more than $60,000 (13). Income was equivalent to $35,000–39,999 (8) or neared $40,000–44,999 (9) across groups. †p < .10. *p < .05. **p < .01. ***p < .001. View Large Table 1. Certified Nursing Assistants’ Characteristics by Double-and-Triple-Duty Caregiving Role Occupancy Total sample Workplace-only caregivers Double-duty-child caregivers Double-duty-elder caregivers Triple-duty caregivers n = 972 n = 342 (35%) n = 330 (34%) n = 160 (17%) n = 140 (14%) Characteristics, n (%) M (SD) or % M (SD) or % M (SD) or % M (SD) or % M (SD) or % F test Age (in years) 36.72 (12) 39.02 (15) 33.70 (9)*** 40.24 (14) 34.19 (8)*** 17.54*** Female 0.91 0.87 0.95** 0.91 0.94* 5.55** White 0.62 0.64 0.62 0.65 0.56 1.01 Some college education or more 0.47 0.50 0.44 0.49 0.44 1.07 Annual household income 8.26 (3) 8.51 (3) 8.00 (3) 8.50 (3) 8.00 (3) 2.36† Partnered or married 0.59 0.54 0.67** 0.51 0.66† 6.62*** Disabled child 0.10 0.00 0.18*** 0.00 0.28*** 48.84*** Hours worked per week 36.28 (7) 36.51 (7) 35.85 (7) 36.81 (6) 36.13 (8) 0.91 Company tenure 5.97 (6) 6.83 (7) 5.17 (5)** 6.39 (7) 5.25 (5)† 4.80** Total sample Workplace-only caregivers Double-duty-child caregivers Double-duty-elder caregivers Triple-duty caregivers n = 972 n = 342 (35%) n = 330 (34%) n = 160 (17%) n = 140 (14%) Characteristics, n (%) M (SD) or % M (SD) or % M (SD) or % M (SD) or % M (SD) or % F test Age (in years) 36.72 (12) 39.02 (15) 33.70 (9)*** 40.24 (14) 34.19 (8)*** 17.54*** Female 0.91 0.87 0.95** 0.91 0.94* 5.55** White 0.62 0.64 0.62 0.65 0.56 1.01 Some college education or more 0.47 0.50 0.44 0.49 0.44 1.07 Annual household income 8.26 (3) 8.51 (3) 8.00 (3) 8.50 (3) 8.00 (3) 2.36† Partnered or married 0.59 0.54 0.67** 0.51 0.66† 6.62*** Disabled child 0.10 0.00 0.18*** 0.00 0.28*** 48.84*** Hours worked per week 36.28 (7) 36.51 (7) 35.85 (7) 36.81 (6) 36.13 (8) 0.91 Company tenure 5.97 (6) 6.83 (7) 5.17 (5)** 6.39 (7) 5.25 (5)† 4.80** Note: Means (and standard deviations) or proportions are shown. Analysis of variance (ANOVAs) tests with Tukey post hoc comparisons were conducted to identify mean differences across groups with workplace-only caregivers designated as the reference group. Annual household income is a continuous variable with categories that range from less than $4,999 (1) to more than $60,000 (13). Income was equivalent to $35,000–39,999 (8) or neared $40,000–44,999 (9) across groups. †p < .10. *p < .05. **p < .01. ***p < .001. View Large Primary Analyses Direct Associations In Model 1 (Table 2), a 1-year increase in age was negatively related to emotional exhaustion and turnover intentions and positively associated with job satisfaction. Additionally, women perceived the work climate as more encouraging of family sacrifices than men, and longer company tenure was linked to greater emotional exhaustion. Turning to the central focus of this study, all double-and-triple-duty caregivers reported higher levels of emotional exhaustion and felt more obligated to make family sacrifices for the sake of work than workplace-only caregivers. Triple-duty caregivers also reported less job satisfaction. Higher levels of perceived family time adequacy were associated with less emotional exhaustion, greater job satisfaction, lower turnover intentions, and less felt obligation to make family sacrifices for the sake of work. With the exception of the job satisfaction model, these main effects for perceived family time adequacy were qualified by significant interactions with double-and-triple-duty caregiving role occupancies in Model 2 (discussed below). Table 2. Multiple Linear Regression Analysis Results Emotional exhaustion Job satisfaction Turnover intentions Work climate for family sacrifices Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Intercept 4.02 (0.18)*** 4.05 (0.18)*** 4.19 (0.08)*** 4.18 (0.08)*** 2.15 (0.12)*** 2.16 (0.11)*** 2.40 (0.13)*** 2.46 (0.12)*** Age −0.03 (0.01)*** −0.03 (0.01)*** 0.01 (0.002)*** 0.01 (0.002)*** −0.01 (0.003)** −0.01 (0.003)** 0.001 (0.003) 0.001 (0.003) Female 0.27 (0.18) 0.29 (0.18) 0.03 (0.07) 0.02 (0.07) −0.05 (0.11) −0.04 (0.11) 0.36 (0.12)** 0.38 (0.12)** Child disability 0.03 (0.18) −0.002 (0.18) 0.07 (0.07) 0.08 (0.07) 0.04 (0.11) 0.02 (0.11) 0.14 (0.12) 0.13 (0.12) Partnered/Married −0.11 (0.10) −0.11 (0.10) 0.07 (0.04) 0.07 (0.04) −0.07 (0.06) −0.07 (0.06) −0.11 (0.07) −0.11 (0.07) Company tenure 0.03 (0.01)** 0.02 (0.01)** −0.003 (0.004) −0.003 (0.004) −0.01 (0.01) −0.01 (0.01) 0.01 (0.01) 0.01 (0.01) DDCC 0.32 (0.13)* 0.32 (0.13)* −0.09 (0.05)† −0.09 (0.05)† −0.01 (0.08) 0.001 (0.08) 0.21 (0.09)* 0.20 (0.09)* DDEC 0.58 (0.15)** 0.55 (0.15)** −0.02 (0.06) −0.02 (0.06) 0.09 (0.09) 0.09 (0.09) 0.25 (0.10)* 0.26 (0.10)* TDC 0.66 (0.17)*** 0.70 (0.17)*** −0.19 (0.07)** −0.20 (0.07)** 0.18 (0.11)† 0.21 (0.11)† 0.35 (0.11)** 0.40 (0.12)** Perceived family time adequacy −0.66 (0.08)*** −0.40 (0.11)** 0.15 (0.03)*** 0.10 (0.05)* −0.20 (0.05)*** −0.11 (0.07) −0.37 (0.05)*** −0.31 (0.07)*** DDCC × Perceived family time adequacy −0.57 (0.19)** 0.14 (0.08)† −0.27 (0.12)* −0.13 (0.13) DDEC × Perceived family time adequacy −0.17 (0.20) 0.01 (0.08) 0.06 (0.13) 0.11 (0.14) TDC × Perceived family time adequacy −0.75 (0.25)** 0.17 (0.10)† −0.36 (0.16)* −0.45 (0.17)** R2 .14 .15 .07 .07 .05 .06 .07 .08 ΔR2a .083*** .013** .026*** .005 .023*** .010* .057*** .009* Emotional exhaustion Job satisfaction Turnover intentions Work climate for family sacrifices Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Intercept 4.02 (0.18)*** 4.05 (0.18)*** 4.19 (0.08)*** 4.18 (0.08)*** 2.15 (0.12)*** 2.16 (0.11)*** 2.40 (0.13)*** 2.46 (0.12)*** Age −0.03 (0.01)*** −0.03 (0.01)*** 0.01 (0.002)*** 0.01 (0.002)*** −0.01 (0.003)** −0.01 (0.003)** 0.001 (0.003) 0.001 (0.003) Female 0.27 (0.18) 0.29 (0.18) 0.03 (0.07) 0.02 (0.07) −0.05 (0.11) −0.04 (0.11) 0.36 (0.12)** 0.38 (0.12)** Child disability 0.03 (0.18) −0.002 (0.18) 0.07 (0.07) 0.08 (0.07) 0.04 (0.11) 0.02 (0.11) 0.14 (0.12) 0.13 (0.12) Partnered/Married −0.11 (0.10) −0.11 (0.10) 0.07 (0.04) 0.07 (0.04) −0.07 (0.06) −0.07 (0.06) −0.11 (0.07) −0.11 (0.07) Company tenure 0.03 (0.01)** 0.02 (0.01)** −0.003 (0.004) −0.003 (0.004) −0.01 (0.01) −0.01 (0.01) 0.01 (0.01) 0.01 (0.01) DDCC 0.32 (0.13)* 0.32 (0.13)* −0.09 (0.05)† −0.09 (0.05)† −0.01 (0.08) 0.001 (0.08) 0.21 (0.09)* 0.20 (0.09)* DDEC 0.58 (0.15)** 0.55 (0.15)** −0.02 (0.06) −0.02 (0.06) 0.09 (0.09) 0.09 (0.09) 0.25 (0.10)* 0.26 (0.10)* TDC 0.66 (0.17)*** 0.70 (0.17)*** −0.19 (0.07)** −0.20 (0.07)** 0.18 (0.11)† 0.21 (0.11)† 0.35 (0.11)** 0.40 (0.12)** Perceived family time adequacy −0.66 (0.08)*** −0.40 (0.11)** 0.15 (0.03)*** 0.10 (0.05)* −0.20 (0.05)*** −0.11 (0.07) −0.37 (0.05)*** −0.31 (0.07)*** DDCC × Perceived family time adequacy −0.57 (0.19)** 0.14 (0.08)† −0.27 (0.12)* −0.13 (0.13) DDEC × Perceived family time adequacy −0.17 (0.20) 0.01 (0.08) 0.06 (0.13) 0.11 (0.14) TDC × Perceived family time adequacy −0.75 (0.25)** 0.17 (0.10)† −0.36 (0.16)* −0.45 (0.17)** R2 .14 .15 .07 .07 .05 .06 .07 .08 ΔR2a .083*** .013** .026*** .005 .023*** .010* .057*** .009* Note: DDCC = double-duty-child caregiver; DDEC = double-duty-elder caregiver; TDC = triple-duty caregiver. Unstandardized regression coefficients (and standard errors) are displayed for all models. All continuous variables are mean centered. aThe change in R2 for Model 1 represents the change from a covariates-only model (i.e., age, gender, child disability, marital status, and company tenure) to a model with both covariates and substantive predictors (i.e., double-and-triple-duty caregiving role occupancies and perceived family time adequacy). †p < .10. *p < .05. **p < .01. ***p < .001. View Large Table 2. Multiple Linear Regression Analysis Results Emotional exhaustion Job satisfaction Turnover intentions Work climate for family sacrifices Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Intercept 4.02 (0.18)*** 4.05 (0.18)*** 4.19 (0.08)*** 4.18 (0.08)*** 2.15 (0.12)*** 2.16 (0.11)*** 2.40 (0.13)*** 2.46 (0.12)*** Age −0.03 (0.01)*** −0.03 (0.01)*** 0.01 (0.002)*** 0.01 (0.002)*** −0.01 (0.003)** −0.01 (0.003)** 0.001 (0.003) 0.001 (0.003) Female 0.27 (0.18) 0.29 (0.18) 0.03 (0.07) 0.02 (0.07) −0.05 (0.11) −0.04 (0.11) 0.36 (0.12)** 0.38 (0.12)** Child disability 0.03 (0.18) −0.002 (0.18) 0.07 (0.07) 0.08 (0.07) 0.04 (0.11) 0.02 (0.11) 0.14 (0.12) 0.13 (0.12) Partnered/Married −0.11 (0.10) −0.11 (0.10) 0.07 (0.04) 0.07 (0.04) −0.07 (0.06) −0.07 (0.06) −0.11 (0.07) −0.11 (0.07) Company tenure 0.03 (0.01)** 0.02 (0.01)** −0.003 (0.004) −0.003 (0.004) −0.01 (0.01) −0.01 (0.01) 0.01 (0.01) 0.01 (0.01) DDCC 0.32 (0.13)* 0.32 (0.13)* −0.09 (0.05)† −0.09 (0.05)† −0.01 (0.08) 0.001 (0.08) 0.21 (0.09)* 0.20 (0.09)* DDEC 0.58 (0.15)** 0.55 (0.15)** −0.02 (0.06) −0.02 (0.06) 0.09 (0.09) 0.09 (0.09) 0.25 (0.10)* 0.26 (0.10)* TDC 0.66 (0.17)*** 0.70 (0.17)*** −0.19 (0.07)** −0.20 (0.07)** 0.18 (0.11)† 0.21 (0.11)† 0.35 (0.11)** 0.40 (0.12)** Perceived family time adequacy −0.66 (0.08)*** −0.40 (0.11)** 0.15 (0.03)*** 0.10 (0.05)* −0.20 (0.05)*** −0.11 (0.07) −0.37 (0.05)*** −0.31 (0.07)*** DDCC × Perceived family time adequacy −0.57 (0.19)** 0.14 (0.08)† −0.27 (0.12)* −0.13 (0.13) DDEC × Perceived family time adequacy −0.17 (0.20) 0.01 (0.08) 0.06 (0.13) 0.11 (0.14) TDC × Perceived family time adequacy −0.75 (0.25)** 0.17 (0.10)† −0.36 (0.16)* −0.45 (0.17)** R2 .14 .15 .07 .07 .05 .06 .07 .08 ΔR2a .083*** .013** .026*** .005 .023*** .010* .057*** .009* Emotional exhaustion Job satisfaction Turnover intentions Work climate for family sacrifices Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Intercept 4.02 (0.18)*** 4.05 (0.18)*** 4.19 (0.08)*** 4.18 (0.08)*** 2.15 (0.12)*** 2.16 (0.11)*** 2.40 (0.13)*** 2.46 (0.12)*** Age −0.03 (0.01)*** −0.03 (0.01)*** 0.01 (0.002)*** 0.01 (0.002)*** −0.01 (0.003)** −0.01 (0.003)** 0.001 (0.003) 0.001 (0.003) Female 0.27 (0.18) 0.29 (0.18) 0.03 (0.07) 0.02 (0.07) −0.05 (0.11) −0.04 (0.11) 0.36 (0.12)** 0.38 (0.12)** Child disability 0.03 (0.18) −0.002 (0.18) 0.07 (0.07) 0.08 (0.07) 0.04 (0.11) 0.02 (0.11) 0.14 (0.12) 0.13 (0.12) Partnered/Married −0.11 (0.10) −0.11 (0.10) 0.07 (0.04) 0.07 (0.04) −0.07 (0.06) −0.07 (0.06) −0.11 (0.07) −0.11 (0.07) Company tenure 0.03 (0.01)** 0.02 (0.01)** −0.003 (0.004) −0.003 (0.004) −0.01 (0.01) −0.01 (0.01) 0.01 (0.01) 0.01 (0.01) DDCC 0.32 (0.13)* 0.32 (0.13)* −0.09 (0.05)† −0.09 (0.05)† −0.01 (0.08) 0.001 (0.08) 0.21 (0.09)* 0.20 (0.09)* DDEC 0.58 (0.15)** 0.55 (0.15)** −0.02 (0.06) −0.02 (0.06) 0.09 (0.09) 0.09 (0.09) 0.25 (0.10)* 0.26 (0.10)* TDC 0.66 (0.17)*** 0.70 (0.17)*** −0.19 (0.07)** −0.20 (0.07)** 0.18 (0.11)† 0.21 (0.11)† 0.35 (0.11)** 0.40 (0.12)** Perceived family time adequacy −0.66 (0.08)*** −0.40 (0.11)** 0.15 (0.03)*** 0.10 (0.05)* −0.20 (0.05)*** −0.11 (0.07) −0.37 (0.05)*** −0.31 (0.07)*** DDCC × Perceived family time adequacy −0.57 (0.19)** 0.14 (0.08)† −0.27 (0.12)* −0.13 (0.13) DDEC × Perceived family time adequacy −0.17 (0.20) 0.01 (0.08) 0.06 (0.13) 0.11 (0.14) TDC × Perceived family time adequacy −0.75 (0.25)** 0.17 (0.10)† −0.36 (0.16)* −0.45 (0.17)** R2 .14 .15 .07 .07 .05 .06 .07 .08 ΔR2a .083*** .013** .026*** .005 .023*** .010* .057*** .009* Note: DDCC = double-duty-child caregiver; DDEC = double-duty-elder caregiver; TDC = triple-duty caregiver. Unstandardized regression coefficients (and standard errors) are displayed for all models. All continuous variables are mean centered. aThe change in R2 for Model 1 represents the change from a covariates-only model (i.e., age, gender, child disability, marital status, and company tenure) to a model with both covariates and substantive predictors (i.e., double-and-triple-duty caregiving role occupancies and perceived family time adequacy). †p < .10. *p < .05. **p < .01. ***p < .001. View Large Moderation Analyses Model 2 (Table 2) addressed RQ2 by examining the moderating effects of perceived family time adequacy. The addition of interaction terms in Model 2 led to a significant increase in the proportion of explained variance for emotional exhaustion, turnover intentions, and work climate for family sacrifices. In these models, perceived family time adequacy interacted significantly with double-duty-child caregiving to predict emotional exhaustion and turnover intentions; perceived family time adequacy also conditioned associations between triple-duty caregiving and emotional exhaustion, turnover intentions, and work climate for family sacrifices. Follow-up simple slopes tests indicated that, for every one-unit increase in perceived family time adequacy, double-duty-child and triple-duty caregivers reported less emotional exhaustion (B = −0.98, SE = 0.15, p < .001 and B = −1.16, SE = 0.22, p < .001, respectively) and lower turnover intentions (B = −0.38, SE = 0.10, p < .001 and B = −0.47, SE = 0.14, p = .001, respectively). Triple-duty caregivers also felt less obligated to make family sacrifices for the sake of work (B = −0.76, SE = 0.15, p < .001). We further probed significant interactive effects by computing model-estimated means for each outcome at high (1 SD above the mean) and low (1 SD below the mean) values of perceived family time adequacy. Double-duty-child and triple-duty caregivers had lower emotional exhaustion (M = 3.70, SE = 0.22 and M = 3.96, SE = 0.26, respectively; Figure 1) and turnover intentions (M = 1.90, SE = 0.14 and M = 2.05, SE = 0.16, respectively; Figure 2) scores in the context of high perceived family time adequacy than in the context of low perceived family time adequacy (emotional exhaustion: M = 5.04, SE = 0.24 for double-duty-child caregivers and M = 5.54, SE = 0.29 for triple-duty caregivers; turnover intentions: M = 2.43, SE = 0.15 for double-duty-child caregivers and M = 2.69, SE = 0.18 for triple-duty caregivers). Triple-duty caregivers also had lower (M = 2.34, SE = 0.18) and higher (M = 3.38, SE = 0.20) work climate for family sacrifices scores in high and low perceived family time adequacy contexts, respectively (Figure 3). Figure 1. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on emotional exhaustion at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect more emotional exhaustion. Figure 1. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on emotional exhaustion at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect more emotional exhaustion. Figure 2. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on turnover intentions at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect greater turnover intentions. Figure 2. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on turnover intentions at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect greater turnover intentions. Figure 3. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on work climate for family sacrifices at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect a work climate in which employees feel more obligated to make family sacrifices for the sake of work. Figure 3. View largeDownload slide Model-estimated means for the conditional effects of double-and-triple-duty caregiving role occupancy on work climate for family sacrifices at 1 SD above (high perceived family time adequacy) and below (low perceived family time adequacy) the mean of perceived family time adequacy are displayed. Higher scores reflect a work climate in which employees feel more obligated to make family sacrifices for the sake of work. Discussion The objectives of this study were twofold. First, we compared workplace-only and double-and-triple-duty caregivers’ work strain. Drawing on a sample of 972 CNAs in U.S.-based nursing homes, we found that the role scarcity hypothesis (Goode, 1960) was generally more applicable to triple-duty caregivers than the role expansion hypothesis (Marks, 1977; Sieber, 1974). Triple-duty caregivers reported more emotional exhaustion, less job satisfaction, and greater felt obligation to make family sacrifices for the sake of work relative to workplace-only caregivers. Conversely, neither hypothesis was more applicable for double-duty caregivers. Compared with workplace-only caregivers, double-duty caregivers reported more emotional exhaustion and obligation to make family sacrifices for the sake of work (consistent with the role scarcity hypothesis), but did not differ with respect to job satisfaction and turnover intentions (consistent with the role expansion hypothesis). Some of our findings were also dissimilar to those from prior research—for example, researchers had not detected lower job satisfaction among triple-duty caregivers (DePasquale et al., 2016b). Previous investigations, though, have focused on different types of double-and-triple-duty caregivers in varying work settings. These findings thus suggest that such work strain indicators operate differently for double-and-triple-duty caregiving CNAs in U.S.-based nursing homes, and lend support to the notion that not all double-and-triple-duty caregivers are the same (Ward-Griffin et al., 2005). Second, we expanded on past research by examining whether perceived family time adequacy functioned as a moderator of associations between double-and-triple-duty caregiving occupancy and work strain. The results showed that greater perceived family time adequacy attenuated double-duty-child and triple-duty caregivers’ emotional exhaustion and turnover intentions as well as reversed triple-duty caregivers’ perceptions regarding the work climate for family sacrifices. Subsequent model-estimated means revealed that high and low family time adequacy buffered and exacerbated these work strain indicators, respectively. This evidence suggests that double-duty-child and triple-duty caregiving CNAs’ work strain differs depending on the perceived inadequacy or adequacy of family time. It also implies that perceived family time adequacy constitutes a salient psychological resource for these particular caregivers and they are motivated to obtain, retain, and protect family time (Hobfoll, 1989). Limitations and Future Research Directions This study has some limitations. First, although this study covered new ground, analyses were cross-sectional. Researchers should use longitudinal designs to study the long-term dynamics of the associations examined here. Second, nonprobability sampling of nursing homes limits generalizability of study findings. A representative sample of U.S.-based CNAs would be particularly informative as double-and-triple-duty caregiving studies typically focus on health care employees in other countries that might vary with respect to work–family balance norms. Third, we conducted a secondary analysis of existing data not specifically designed to study family caregiving. We therefore lacked family caregiving intensity measures and constructed family caregiving role occupancy measures using available child cohabitation, child age, and elder care information in accordance with prior studies (DePasquale et al., 2016a, 2016b; Scott et al., 2006). Still, this role occupancy approach was advantageous relative to family caregiving measures in past double-and-triple-duty caregiving research (Boumans & Dorant, 2014; Stewart et al., 2011; Ward-Griffin et al., 2005, 2015; Wohlgemuth et al., 2015) because it differentiated family care recipients; enabled consideration of triple-duty caregivers; and included a criterion for weekly hours of elder care. Nevertheless, researchers should build on this study by using more nuanced measures that account for care hours; caregiving duration; number, type, and intensity of caregiving demands or activities; and adult care recipients’ age, health status, behavior problems, and relation to double-and-triple-duty caregivers, for instance, as these may yield other insights. Fourth, the overall variance explained by our regression models was relatively low across work strain indicators. Unmeasured constructs, such as the previously suggested family caregiving measures, may explain more variance than models that only include family caregiving role occupancy predictors. In light of these limitations, it will be important to see whether other researchers who replicate our study arrive at similar conclusions. Replication is critical if we are to advance understanding of why perceived family time adequacy did not emerge as a psychological resource for double-duty-elder caregivers. Currently, it is unclear if their resource needs differ from those of double-duty-child and triple-duty caregivers or if such results can be attributed to the aforementioned measurement limitations, for example. Moreover, not all work strain indicators were conditioned by perceived family time adequacy for double-duty-child and triple-duty caregivers. Accordingly, further evidence is needed to determine if perceived family time adequacy is more pertinent for certain work strain indicators (e.g., turnover intentions). Aside from replication, this study also points to future research directions. One such direction is to examine the moderating effects of other psychological (e.g., mental resilience) resources as well as work (e.g., task control) and family (e.g., partner support) resources on work strain. An additional possibility is the concurrent use of subjective and objective family time measures to assess which is more strongly related to work strain. Another promising avenue entails qualitative investigations in which double-and-triple-duty caregiving CNAs identify workplace factors that exacerbate family time squeezes and facilitate perceived family time adequacy. Evidence yielded from such investigations may inform the development of targeted work-life strategies, scheduling practices, and family-friendly policies in the long-term care industry. Implications for Long-Term Care Organizations Our findings suggest that providing family-friendly workplace supports may constitute an opportunity for long-term care organizations to attract, retain, and engage employees. For instance, double-duty-child and triple-duty caregiving CNAs’ lower turnover intentions in the context of greater family time adequacy indicate that workplace initiatives or resources alleviating family time squeezes may yield a positive return-on-investment. Given that turnover intentions are indicative of actual turnover (e.g., Rosen et al., 2011), long-term care organizations may experience more workforce stability and continuity of care, decreased turnover-related costs, and improved well-being among residents and employees by enhancing double-duty-child and triple-duty caregivers’ perceived family time adequacy. One workplace resource that may boost perceived family time adequacy is schedule control or flexibility. Hill and colleagues (2013) recently highlighted how a white-collar organization’s initiative to integrate flexibility within the organizational culture increased perceived family time adequacy. Mothers experienced more schedule control following the initiative and, subsequently, greater perceived family time adequacy. However, neither mothers’ nor fathers’ actual family time allocation changed. The authors thus concluded that perceived family time adequacy, rather than family time allocation, was more malleable through flexibility. Obviously, long-term care and white-collar industries differ in the resources they can feasibly offer to employees. Nonetheless, the amenability of perceived family time adequacy to flexibility may bode well for the long-term care industry. Initiatives such as a shift swapping system, for example, may not increase family time allocation but might enhance perceived family time adequacy. Enhanced perceived family time adequacy, in turn, could catalyze resource gains in double-and-triple-duty caregiving CNAs. Relatedly, because CNAs often desire to have more control in the workplace, flexibility initiatives may be a particularly effective retention strategy. Further, although greater schedule control did not affect fathers’ family time adequacy in the Hill and colleagues’ study, a family-supportive company culture was positively related to their perceived family time adequacy. This finding underscores the notion that in order to have a broader impact on employees’ work–family interface, support must be demonstrated for employees’ families or personal lives at all levels within an organization (Hammer & Neal, 2008). An unsupportive organizational work–family climate will likely undermine the utilization of work resources intended to increase family time adequacy and the uptake of family-supportive initiatives in general. Conclusion We found that double-and-triple-duty caregiving CNAs report more work strain than their workplace-only caregiving counterparts. We also identified perceived family time adequacy as a salient psychological resource that buffered double-duty-child and triple-duty caregivers’ emotional exhaustion and turnover intentions as well as reversed triple-duty caregivers’ negative perceptions of the work climate for family sacrifices. Amid direct-care workforce shortages and an unprecedented demand for long-term care services, additional research about double-and-triple-duty caregiving CNAs’ work–family interface is urgently needed to inform the long-term care industry’s recruitment, retention, and engagement strategies. Funding This work was supported by the National Institute On Aging of the National Institutes of Health under Award Number F31AG050385 to N. DePasquale. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Acknowledgments 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 (Grants U01HD051217, U01HD051218, U01HD051256, and U01HD051276), National Institute on Aging (Grant U01AG027669), Office of Behavioral and Social Sciences Research, and National Institute for Occupational Safety and Health (Grants U01OH008788 and U01HD059773). This study was also supported by grants from the William T. Grant Foundation, Alfred P Sloan Foundation, and the Administration for Children and Families have provided additional funding. 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. Special acknowledgment goes to Extramural Staff Science Collaborator, Rosalind Berkowitz King, PhD, and Lynne Casper, PhD, for design of the original Workplace, Family, Health and Well-Being Network Initiative. We also wish to express our gratitude to the worksites, employers, and employees who participated in this research. References Anderson K. A . ( 2008 ). Grief experiences of CNAs: Relationships with burnout and turnover . Journal of Gerontological Nursing , 34 , 42 – 49 . Google Scholar CrossRef Search ADS PubMed Boroff K. E. , & Lewin D . ( 1997 ). Loyalty, voice, and intent to exit a union firm: A conceptual and empirical analysis . ILR Review , 51 , 50 – 63 . doi: 10.1177/001979399705100104 Google Scholar CrossRef Search ADS Boumans N. P. Dorant E . ( 2014 ). Double-duty caregivers: Healthcare professionals juggling employment and informal caregiving. A survey on personal health and work experiences . Journal of Advanced Nursing , 70 , 1604 – 1615 . doi: 10.1111/jan.12320 Google Scholar CrossRef Search ADS PubMed Bowers B. J. Esmond S. , & Jacobson N . ( 2003 ). Turnover reinterpreted: CNAs talk about why they leave . Journal of Gerontological Nursing , 29 , 36 – 43 . doi: 10.3928/0098-9134-20030301-09 Google Scholar CrossRef Search ADS PubMed Bray J. W. Kelly E. L. Hammer L. B. Almeida D. M. Dearing J. W. King R. B. , & Buxton O. M . ( 2013 ). An integrative, multilevel, and transdisciplinary research approach to challenges of work, family, and health . RTI Press publication No. MR-0024-1303. Research Triangle Park, NC : RTI Press . doi: 10.3768/rtipress.2013.mr.0024.1303 Bureau of Labor Statistics . ( 2015 ). Nursing assistants and orderlies: Occupational outlook handbook, 2016–17 Edition . Retrieved from http://www.bls.gov/ooh/healthcare/nursing-assistants.htm. Cammann C. Fichman M. Jenkins G. D. , & Klesh J . ( 1983 ). Michigan Organizational Assessment Questionnaire . In S. E. Seashore E. E. Lawler P. H. Mirvis , & C. Cammann (Eds.), Assessing organizational change: A guide to methods, measures, and practices (pp. 71 – 138 ). New York : Wiley-Interscience . Castle N. G. Engberg J. Anderson R. , & Men A . ( 2007 ). Job satisfaction of nurse aides in nursing homes: Intent to leave and turnover . The Gerontologist , 47 , 193 – 204 . doi: 10.1093/geront/47.2.193 Google Scholar CrossRef Search ADS PubMed DePasquale N. Davis K. D. Zarit S. H. Moen P. Hammer L. B. , & Almeida D. M . ( 2016 a). Combining formal and informal caregiving roles: The psychosocial implications of double-and triple-duty care . The Journals of Gerontology, Series B: Physiological Sciences and Social Sciences , 71 , 201 – 211 . doi: 10.1093/geronb/gbu139 Google Scholar CrossRef Search ADS DePasquale N. Zarit S. H. Mogle J. Moen P. Hammer L. B. , & Almeida D. M . ( 2016 b). Double-and triple-duty caregiving men: An examination of subjective stress and perceived schedule control . Journal of Applied Gerontology . Advance online publication. doi: 10.1177/0733464816641391 DePasquale N. Bangerter L. Williams J. , & Almeida D.M. ( 2016 c). Certified nursing assistants balancing family caregiving roles: Healthcare utilization among double- and triple-duty caregivers . The Gerontologist , 56 , 1114 – 1123 . doi:10.1093/geront/gnv081 Google Scholar CrossRef Search ADS PubMed Dorant E. , & Boumans N. P . ( 2016 ). Positive and negative consequences of balancing paid work and informal family care: A survey in two different sectors . International Journal of Health and Psychology Research , 4 , 16 – 33 Geiger-Brown J. Muntaner C. Lipscomb J. , & Trinkoff A . ( 2004 ). Demanding work schedules and mental health in nursing assistants working in nursing homes . Work & Stress , 18 , 292 – 304 . doi: 10.1080/02678370412331320044 Google Scholar CrossRef Search ADS Goode W. J . ( 1960 ). A theory of role strain . American Sociological Review , 25 , 483 – 496 . doi: 10.2307/2092933 Google Scholar CrossRef Search ADS Halbesleben J. R. Neveu J. P. Paustian-Underdahl S. C. , & Westman M . ( 2014 ). Getting to the “COR” understanding the role of resources in Conservation of Resources theory . Journal of Management , 40 , 1334 – 1364 . doi: 10.1177/0149206314527130 Google Scholar CrossRef Search ADS Hammer L. B. , & Neal M. B . ( 2008 ). Working sandwiched-generation caregivers: Prevalence, characteristics, and outcomes . The Psychologist-Manager Journal , 11 , 93 – 112 . doi: 10.1080/10887150801967324 Google Scholar CrossRef Search ADS He W. Goodkind D. , & Kowal P . ( 2016 ). An aging world: 2015: International population reports . Washington, DC : U.S. Census Bureau . Hill R. Tranby E. Kelly E. , & Moen P . ( 2013 ). Relieving the time squeeze? Effects of a white-collar workplace change on parents . Journal of Marriage and Family , 75 , 1014 – 1029 . doi: 10.1111/jomf.12047 Google Scholar CrossRef Search ADS PubMed Hobfoll S. E . ( 1989 ). Conservation of resources: A new attempt at conceptualizing stress . American Psychologist , 44 , 513 – 524 . doi: 10.1037//0003-066x.44.3.513 Google Scholar CrossRef Search ADS PubMed Hyer K. Thomas K. S. Branch L. G. Harman J. S. Johnson C. E. Weech-Maldonado R . ( 2011 ). The influence of nurse staffing levels on quality of care in nursing homes . The Gerontologist , 51 , 610 – 616 . doi: 10.1093/geront/gnr050 Google Scholar CrossRef Search ADS PubMed Karsh B. Booske B. C. Sainfort F . ( 2005 ). Job and organizational determinants of nursing home employee commitment, job satisfaction and intent to turnover . Ergonomics , 48 , 1260 – 1281 . doi: 10.1080/00140130500197195 Google Scholar CrossRef Search ADS PubMed Kossek E. E. Colquitt J. A. , & Noe R. A . ( 2001 ). Caregiving decisions, well-being, and performance: The effects of place and provider as a function of dependent type and work-family climates . Academy of Management Journal , 44 , 29 – 44 . doi: 10.2307/3069335 Lee S. Almeida D. M. Davis K. D. King R. B. Hammer L. B. Kelly E. L . ( 2015 ). Latent profiles of perceived time adequacy for paid work, parenting, and partner roles . Journal of Family Psychology , 29 , 788 – 798 . doi: 10.1037/a0039433 Google Scholar CrossRef Search ADS PubMed Maher J. M. Lindsay J. Bardoel E. A. ( 2010 ). Freeing time? The ‘family time economies’ of nurses . Sociology , 44 , 269 – 287 . doi: 10.1177/0038038509357205 Google Scholar CrossRef Search ADS Marks S. R . ( 1977 ). Multiple roles and role strain: Some notes on human energy, time and commitment . American Sociological Review , 42 , 921 – 936 . doi: 10.2307/2094577 Google Scholar CrossRef Search ADS Maslach C. , & Jackson S . ( 1986 ). Maslach Burnout Inventory Manual ( 2nd ed .). Palo Alto, CA : Consulting Psychologists Press . Okechukwu C. A. El Ayadi A. M. Tamers S. L. Sabbath E. L. Berkman L . ( 2012 ). Household food insufficiency, financial strain, work-family spillover, and depressive symptoms in the working class: The Work, Family, and Health Network study . American Journal of Public Health , 102 , 126 – 133 . doi: 10.2105/AJPH.2011.300323 Google Scholar CrossRef Search ADS PubMed Paraprofessional Healthcare Institute . ( 2013 ). America’s direct-care workforce . PubMed PubMed Rosen J. Stiehl E. M. Mittal V. Leana C. R . ( 2011 ). Stayers, leavers, and switchers among certified nursing assistants in nursing homes: A longitudinal investigation of turnover intent, staff retention, and turnover . The Gerontologist , 51 , 597 – 609 . doi: 10.1093/geront/gnr025 Google Scholar CrossRef Search ADS PubMed Scott L. D. Hwang W.-T. , & Rogers A. E . ( 2006 ). The impact of multiple care giving roles on fatigue, stress, and work performance among hospital staff nurses . Journal of Nursing Administration , 36 , 86 – 95 . doi: 10.1097/00005110-200602000-00007 Google Scholar CrossRef Search ADS PubMed Sieber S. D . ( 1974 ). Toward a theory of role accumulation . American Sociological Review , 39 , 556 – 578 . doi: 10.2307/2094422 Google Scholar CrossRef Search ADS Stewart N. J. D’Arcy C. Kosteniuk J. Andrews M. E. Morgan D. Forbes D. , … Pitblado J. R . ( 2011 ). Moving on? Predictors of intent to leave among rural and remote RNs in Canada . The Journal of Rural Health , 27 , 103 – 113 . doi: 10.1111/j.1748-0361.2010.00308.x Google Scholar CrossRef Search ADS PubMed Stone R. I . ( 2012 ). The long-term care workforce: From accidental to valued profession . In D. Wolf and N. Folbre (Eds.), Universal coverage of long-term care in the United States: Can we get there from here? (pp. 155 – 178 ). Russell Sage Foundation e-book. Retrieved from https://www.russellsage.org/publications/universal-coverage-long-term-care-united-states. Temple A. Dobbs D. Andel R . ( 2009 ). Exploring correlates of turnover among nursing assistants in the National Nursing Home Survey . Health Care Management Review , 34 , 182 – 190 . doi: 10.1097/HMR.0b013e31819c8b11 Google Scholar CrossRef Search ADS PubMed ten Brummelhuis L. L. Bakker A. B . ( 2012 ). A resource perspective on the work-home interface: The work-home resources model . The American Psychologist , 67 , 545 – 556 . doi: 10.1037/a0027974 Google Scholar CrossRef Search ADS PubMed Van Horn M. L. Bellis J. M. , & Snyder S. W . ( 2001 ). Family Resource Scale-Revised: Psychometrics and validation of a measure of family resources in a sample of low-income families . Journal of Psychoeducational Assessment , 19 , 54 – 68 . doi: 10.1177/073428290101900104 Google Scholar CrossRef Search ADS Ward-Griffin C. Brown J. B. Vandervoort A. McNair S. , & Dashnay I . ( 2005 ). Double-duty caregiving: Women in the health professions . Canadian Journal on Aging , 24 , 379 – 394 . doi: 10.1353/cja.2006.0015 Google Scholar CrossRef Search ADS Ward-Griffin C. Brown J. B. St-Amant O. Sutherland N. Martin-Matthews A. Keefe J. Kerr M . ( 2015 ). Nurses negotiating professional-familial care boundaries: Striving for balance within double duty caregiving . Journal of Family Nursing , 21 , 57 – 85 . doi: 10.1177/1074840714562645 Google Scholar CrossRef Search ADS PubMed Wohlgemuth C. M. Auerbach H. P. Parker V. A . ( 2015 ). Advantages and Challenges: The Experience of Geriatrics Health Care Providers as Family Caregivers . The Gerontologist , 55 , 595 – 604 . doi: 10.1093/geront/gnt168 Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

The GerontologistOxford University Press

Published: Jan 10, 2017

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off