Emotional Labor of Caregivers of Elderly Patients with Dementia and Disabilities in a Psychiatric Hospital in China

Introduction

There were 1 billion people aged 60 years and above worldwide in 2020, and it is estimated that the population aged 60 years and above will increase to 1.4 billion by 2030 [1]. In the United Kingdom, there are more than 944 000 people who have dementia, with 1 in 11 people over the age of 65 being in that group [2]. In the United States, 1 in 10 people over the age of 65 had dementia [3]. By the end of 2022, there were 280 million Chinese people over the age of 60, and among them, there were 44 million elderly people with dementia and disabilities [4]. With an aging population worldwide, the number of elderly people with dementia and disabilities is increasing. In facing such a large number of elderly people with those conditions, there are increasing demands for caregivers, not only in quantity, but also in the quality of caregiving skills. Elderly people with dementia and disabilities generally have declining physical functions and gradually impaired cognition. When serving them, caregivers are extremely prone to fatigue and burnout [5]. This fatigue is not only physical but also psychological.

Hochschild [6] suggested that emotional labor refers to an individual’s facial expressions or body movements that can be observed, and that it is a process of psychological adjustment and control. Hochschild emphasized that emotional labor is a process of managing one’s emotions. Emotional labor, like mental labor and physical labor, is also a state that organizations expect to be shown. Emotional labor itself is considered to be a kind of “management” in itself. An individual’s surface and deep acting is the “management” of their own emotional labor. Hochschild [7] proposed that the public expect more from women’s emotional expression than that of men. It is believed that sex has an impact on “acting” in emotional labor, and women are more likely to engage in surface acting than men [8,9]. An employee’s age is positively correlated with their effort in emotional labor and emotional dysregulation. The older the employee is, the more likely they are to have emotional dysregulation. Men require more effort than women in emotional labor [10,11].

The World Health Organization is working on improving the lives of the caregivers of the people with dementia [12]. The results of Grabher [13] have shown that caregivers of people with Alzheimer disease have physical and emotional stress. The results of Cheng et al [14] have shown the effectiveness of psychological interventions for dementia caregivers in reducing their distress. However, studies on the emotional labor of caregivers are rare. This study aimed to investigate the emotional labor of caregivers of elderly patients with dementia and disabilities in a psychiatric hospital in China and to propose measures to make things better. The emotional labor management described in this study was explained from the organizational level, which refers to a behavior and process of an organization’s coordination, support, control, and management of individuals’ emotional labor. The significance of our study lies in the following 3 aspects: (1) increase the positive driving force of individuals’ emotional labor; (2) reduce individuals’ negative emotions; and (3) optimize the emotional labor’s impact within the organization.

Material and Methods

ETHICS APPROVAL:

Ethics approval of this study was obtained from the Medical Ethics Committee of Chengdu Dekang Hospital ([2021] Ethics Assessment (01)). Verbal informed consent was obtained from all participants.

STUDY SETTING:

Chengdu Psychiatric Hospital, also known as Chengdu Dekang Hospital, is a secondary grade A hospital in China. The hospital has 800 beds. The Department of Geriatrics has 315 beds. There were 73 caregivers for the elderly patients with dementia and disabilities and 8 caregiver managers during the course of the investigation. The Department of Geriatrics was established in the 1990s and provides a rich caregiving experience for elderly patients with dementia and disabilities.

STUDY DESIGN:

This was a cross-sectional study. Convenience sampling was used in this study. A questionnaire survey was conducted with the caregivers from the Department of Geriatrics, Chengdu Psychiatric Hospital in May 2021. The questionnaire consisted of 2 parts: (1) demographic information of the respondent; and (2) an emotional labor scale.

Demographic information in the study questionnaire included sex, age, marital status, educational attainment, working years, number of elderly patients the respondent was taking care of, monthly income, form of contract, and job position [5].

For items concerning demographic information, sex had 2 response choices: male and female. Age had 4 response choices: under 40 years old, 40–49 years old, 50–59 years old, and 60 years old and over. Marital status had 2 response choices: unmarried, and married and had child. Educational attainment had 4 response choices: primary school and below, junior high school, technical secondary school, and senior high school. Working years had 4 response choices: 4 years and less, 5–9 years, 10–19 years, and more than 20 years. Number of elderly patients the respondent was taking care of had 3 response choices: 2 patients, 3–4 patients, and 5 patients and more. Monthly income (Chinese Yuan) had 4 response choices: 2999 and less, 3000–3999, 4000–4999, and 5000 and more. Form of contract had 2 response choices: employment contract and contract for service. Job position had 2 response choices: caregiving worker and caregiving team leader.

The emotional labor scale used in our study was the Chinese version translated by Luo et al, based on the scale developed by Grandey et al [15]. The scale contained 14 items involving 3 components: surface acting (items 1–7), emotional expression (items 8–11), and deep acting (items 12–14). A 6-point Likert scale was used. A score from 1 to 6 was assigned to the response options ranging from “strongly disagree” to “strongly agree”. The higher the score, the higher the degree of agreement. The average scores for the 3 components of the emotional labor scale were in order of ≤2, 2–4, and ≥4, respectively. The Cronbach alpha coefficients of surface acting, emotional expression, and deep acting of the scale in the Chinese version were 0.763, 0.694, and 0.830, respectively. The reliability and validity analysis of the scale showed that the standardized Cronbach alpha was 0.857, the Kaiser-Meyer-Olkin value was 0.678, and a P<0.05 was identified in the Bartlett test, indicating good reliability and validity. The emotional labor scale used was suitable for our study (Tables 1, 2).

DATA COLLECTION:

A previous investigation found that these caregivers had a low level of educational attainment. Therefore, the researchers trained the investigators uniformly, explained the purpose and method of this study in detail, and explained the exact meaning of each item in the questionnaire. They also randomly checked whether each investigator could accurately explain the meaning of the items. After their competence to provide proper explanations was achieved, the investigators distributed the paper questionnaires to the caregivers, which were filled by the caregivers and collected on the spot.

STATISTICAL ANALYSIS:

SPSS 26.0 was used for data analysis. Descriptive analysis was performed on the frequency and intensity of emotional labor using minimum value, maximum value, mean value, standard deviation, median value, and interquartile range. One-way analysis of variance was performed to analyze and compare the frequency and intensity of emotional labor between different individuals and groups [16,17].

Results

DESCRIPTIVE ANALYSIS OF EMOTIONAL LABOR:

The maximum, minimum, mean and median values, standard deviations, and interquartile ranges of surface acting, deep acting, and emotional expression are presented in Table 3.

DIFFERENTIAL ANALYSIS OF EMOTIONAL LABOR:

In this study, statistically significant differences (P<0.05) were identified in surface acting by sex, age, educational attainment, and monthly income. A statistically significant difference (P<0.05) was identified between deep acting and emotional expression by marital status. A statistically significant difference (P<0.05) was identified between surface acting and deep acting by the number of elderly patients the respondent was taking care of. No statistically significant differences were identified in the form of contract and job position (P>0.05) (Table 4).

Discussion

LIMITATIONS:

This study was a single-center study. A sample size of 73 cases was small for research and therefore could cause deviations in the research results. Convenience sampling was used, which might not be conducive to the accuracy of the research results. A future study with a larger sample size or using supplementary research methods will need to be conducted to verify the reliability of the results.

Conclusions

This investigation on emotional labor can be used to understand the working status of caregivers who take care of elderly patients with dementia and disabilities. Heavy emotional labor and negative emotions widely existed among caregivers of the elderly patients with dementia and disabilities in the psychiatric hospital. This can affect the operational efficiency and quality of service of the hospital. More training on emotional labor should be provided for the caregivers, and the management system of the hospital should be improved. The recommended improvement measures can be used to help hospitals and nursing homes better manage caregivers and help caregivers to provide better care services for the elderly, thereby helping the aging society.