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Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness
YAPNU-50922; No of Pages 6 Archives of Psychiatric Nursing xxx (2016) xxx–xxx
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Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness Kerime Bademli a,⁎,1, Neslihan Lök b, Ayten Kaya Kılıc c a b c
Akdeniz University Faculty of Nursing, 07050 Antalya, Turkey Selçuk University Faculty of Health Science, Konya, Turkey Antalya Kamu Hastaneleri Birliği Antalya Eğitim Araştırma Hastanesi, Toplum Ruh Sağlığı Merkezi, Turkey
a r t i c l e
i n f o
Article history: Received 21 June 2016 Revised 14 November 2016 Accepted 1 December 2016 Available online xxxx KEYWORDS: Anger Burden Schizophrenia Caregiver
a b s t r a c t OBJECTIVES: The objective of this study was answer to the question: to what extent are the anger of the caregivers of patients diagnosed with schizophrenia and their perceived level of burden are related? METHOD: The study is a descriptive and correlational study. The information form prepared by the researchers which questions the socio-demographic information of the individuals along with the “Caregiving Burden Inventory” which examines the burden of the caregiver as well as “Trait Anger and Anger Expression Style Scale (TAAES)” which determines the anger levels of the caregivers were used. RESULTS: The caregiving burdens of the caregivers according to the score averages were determined as 11.88 ± 9.78 for time and dependency burden, 11.93 ± 8.46 for developmental burden, 8.47 ± 6.63 for physical burden, 5.61 ± 5.26 for social burden, 6.29 ± 5.25 for emotional burden and the total burden score was determined as 44.19 ± 26.75. According to the trait anger and anger expression style scale score averages; trait anger was determined as 15.12 ± 5.95, anger expression as 9.70 ± 3.43, anger-in as 15.22 ± 4.02, anger control as 28.05 ± 5.57 and anger total score average as 68.11 ± 9.97. CONCLUSION: According to the results obtained from this study, caregivers of schizophrenia patients experience developmental, physical, social and emotional burdens in addition to trait anger. The caregivers of schizophrenia patients need knowledge and support in order to control the burden and the anger they experience during the caregiving process. © 2016 Elsevier Inc. All rights reserved.
INTRODUCTION The concept of caregiving has entered the lives of millions of people regardless of their language, culture or country (Sunanda, Ramesh, & Eilean, 2013). In general, it is the immediate family or close relatives of the patient who take on the responsibility of caring for individuals with chronic mental disorders. Individuals with chronic mental disorders generally live with their families (Saunders, 2003). Hence, the care given by the family forms the basis of all caregiving activities (Sunanda et al., 2013). Since primary caregivers are central to patient's daily lives, caregiving relationships can become one-sided, dependent, and intensive; long term obligations that trouble the lives of caregivers as their caregiving responsibilities also increase (Atagün, Balaban, Atagün, et al., 2011). The role of the caregiver is a difficult and unpredictable experience that requires effort and toil, while also causing emotional and economic burdens (McCann, Lubman, & Clark, 2009). The concept of burden can ⁎ Corresponding Author. E-mail address: [email protected] (K. Bademli). 1 Interest in families of schizophrenia patients
be objective or subjective. Objective burden is defined as the observable, concrete costs to the family that result from the disease. Subjective burden includes individual evaluations of the situation and the emotional problems that arise due to patients' disturbing behavior (Awad & Voruganti, 2008). Studies of caregivers of individuals with chronic mental diseases have found that they experience high levels of burden (Geriani, Savithry, Shivakumar, & Kanchan, 2015, Schulze, & Rössler 2006, Hsiao & Tsai, 2015, Martín et al., 2015). Caregiving burden, especially tension, is associated with caregivers' use of maladaptive coping strategies, poor quality of life and higher levels of psychological morbidity (Kate, Grover, Kulhara, & Nehra, 2013). Studies have shown that the psychological and educational training given to caregivers helps them to cope better and reduces their burden (Chen, Liu, Zhang, & Lu, 2016; Martín-Carrasco et al., 2016; Yesufu-Udechuku et al., 2015). Caring for a person with schizophrenia has a significant impact on the lives of caregivers and alleviating caregiver burden is critical for managing its individual and societal costs (Gater et al., 2014). Caregiving burden has been determined to be related to lack of information regarding mental disease, behavioral symptoms and anger (Brady & McCain, 2004). Caring for patients with mental disorders and inability to control patients' behavior can cause anger in caregivers
http://dx.doi.org/10.1016/j.apnu.2016.12.001 0883-9417/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
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K. Bademli et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
(Karp & Tanarugsachock, 2000). Causes of anger in caregivers of schizophrenia patients can be related to mental health disorders, whether they can carry out their role in the family and financial problems with treatment (Avcı, 2001, Saunders, 2003 Caqueo-Urízar, & Gutiérrez-Maldonado). Caregivers may refuse to acknowledge this feeling since they feel ashamed of it. Hence, the feeling of anger can arise as a result of research (MacNeil et al., 2010). The anger experienced by caregivers has been defined in qualitative studies carried out on caregivers of individuals with chronic mental disorders, and caregivers indicated that they experience difficulty and anger because of the patients' behavior (Chang & Horrocks, 2006; Gater et al., 2014). OBJECTIVE Caregivers of schizophrenia patients experience difficulties at every stage of the disease and for the most part have to cope with them on their own (Gülseren, 2002). Nurses continuously interact with patients and caregivers at psychiatric clinics and community mental health centers. Mental health and psychiatric nurses work as consultants, trainers and resource persons and may develop strategies for reducing the burden of caregivers and enabling them to cope with feelings of anger. An understanding of the relationship between anger and burden is needed for such interventions to be developed. This study sought an answer to the question: to what extent are the anger of the caregivers of patients diagnosed with schizophrenia and their perceived level of burden are related? METHOD DESIGN This is a descriptive and correlational study intended to describe the correlation between anger and the perceived burden level of caregivers who care for individuals diagnosed with schizophrenia. SETTING The population of the study consists of primary caregivers of schizophrenia patients at the age of 18 and above registered at the Aşır Aksu Community Mental Health Center of Antalya Training and Research Hospital. The Aşır Aksu Community Mental Health Center provides services to schizophrenia patients and their caregivers every weekday. The patients come to the center by service bus at 9:00 and return by bus to their homes at 16:00. The patients receive service between 9:00–15:30. The patients are treated at the center by healthcare professionals so that they can feel better and better adapt to social life. Individual consultations and training in psychosocial skills are also provided. SAMPLE The population of the study consists of 426 primary caregivers (family member who lives in the same household as the index patient, who spends time with him/her, and/or is directly and actively involved in the care of the patient (supervising medication, bringing him/her to hospital for follow-up) for at least one month) of schizophrenia patients at the age of 18 or above registered at the Aşır Aksu Community Mental Health Center of the Antalya Training and Research Hospital. The sample of the study was determined using the method of sampling with a known (finite) population. The prevalence is not known since there have been no studies conducted to examine the correlation between caregiving burden and anger in caregivers. For this reason, the researcher calculated the prevalence of observing (p) and not observing (q) the event as 50%, and determined 72 individuals to be included in the sample based on 5% standard deviation and a 95% confidence interval. The study's inclusion criteria were voluntary participation, being at least 18 years old, being literate and being the primary caregiver of a
schizophrenia patient registered at the Aşır Aksu Community Health Center. Secondary caregivers and minors were excluded. MEASUREMENTS The researchers created an information form to collect the participants' socio-demographic data. The researchers also used the Caregiver Burden Inventory to evaluate the burden of the caregivers and the State Trait Anger Scale to determine their anger levels. THE CAREGIVER BURDEN INVENTORY This inventory was developed in 1989 in Canada by Novak and Guest to measure the effects of caregiving on the caregiver relatives of patients (Novak & Guest, 1989). It is a 24-item five-point Likert type inventory with five sub-fields: time-dependency burden, developmental burden, physical burden, social burden and emotional burden. All the subfields have five items except for the physical field, which has four. Each sub-field is scored between 0 and 20. The items are scored as: not defining or 0 points, somewhat defining or 1 point, moderately defining or 2 points, well defining or 3 points and very well defining or 4 points. Physical burden consists of four items for which the answers given to each item is multiplied by 1.25 to calculate the score and a total score of 20 points is attained from this factor. The total score of each individual varies between 0 and 100. High scores indicate high burden levels, and low scores indicate low burden levels. The reliability and validity of the inventory for Turkish society was carried out by Küçük Güçlü et al. in 2009. Its Cronbach alpha value was 0.94. It was 0.93 for the sub-field of time dependency burden, 0.94 for developmental burden, 0.94 for physical burden, 0.82 for social burden and 0.94 for emotional burden. This study found the Cronbach's alpha value to be 0.89 in general, 0.91 for the “Time-dependency Burden” sub-factor, 0.86 for the “Developmental Burden” sub-factor, 0.90 for the “Physical Burden” sub-factor, 0.88 for the “Social Burden” sub-factor and 0.93 for the “Emotional Burden” sub-factor. THE STATE TRAIT ANGER SCALE This scale was developed by Spielberger, Jacobs, Russell, & Crane, 1983 (p. 161). It has two sub-scales: trait anger and anger expression style. The trait anger sub-scale indicates what the individual generally feels or the anger level that the individual experiences. Anger expression style is divided into three sub-scales. The anger-out sub-scale measures how much the individual expresses their anger. The anger-in subscale measures how much the individual suppresses their anger and keeps it inside. The scale consists of 34 items. It is based on a Likert type four-point rating that ranges between almost never (1) and almost always (4). The lowest possible score on the scale is 34, and the highest possible score is 136 (Spielberger et al., 1983; Özer, 1994). Scoring is carried out separately for trait anger and anger expression. The first 10 items on the scale measure trait anger. The remaining 24 items are related to anger expression style: 8 for anger-out, 8 for anger-in and 8 for anger control. Anger-out is measured by items 12, 17, 19, 22, 24, 29, 32 and 33 on the anger expression style sub-scale. Anger-in is measured by items 13, 15, 16, 20, 23, 26, 27 and 31. Anger control is measured by items 11, 14, 18, 21, 25, 28, 30 and 34. The arithmetic average of the scores for each group is calculated to score each sub-scale. Low scores indicate low trait anger or anger expression levels, and high scores indicate high trait anger or anger expression levels. The item total score correlations were determined to vary between 0.14 and 0.56, whereas the Cronbach's alpha internal consistency coefficient was determined to vary between 0.73 and 0.84 during the adaptation and reliability studies of the scale (Özer, 1994). In some studies, the Cronbach's alpha internal consistency coefficient was found to be between 0.76 and 0.82 (Albayrak & Kutlu, 2009), 0.77 and 0.90 (Yöndem & Bıçak, 2008) and 0.79 and 0.91 (Güleç, Sayar, & Özkorumak, 2005). In the present study, the Cronbach's alpha internal consistency coefficient was found to be between 0.79 and 0.88.
Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
K. Bademli et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
DATA COLLECTION The study data were collected from primary caregivers of schizophrenia patients registered at the Aşır Aksu Community Mental Health Center of the Antalya Training and Research Hospital. The study was carried out after obtaining ethical approval and institutional permission. The data were collected by the researcher at the center in face-to-face interviews. DATA ANALYSIS Study data were evaluated using SPSS 17.0 software. Number and percentile distributions were examined, and the Mann-Whitney U test, Anova, t-test and correlation analysis were also used. The results were evaluated at a 95% reliability interval using a p b 0.05 threshold for statistical significance. ETHICAL PROCEDURES The ethical approval required for the study was obtained from the Antalya Training and Research Hospital's Ethics Committee. Required explanations were made to the individuals who participated in the study regarding its title, objective, duration and method, and a consent form was read. Thus, it was ensured that they understood the objective and scope of the study. Written consents were obtained from the participants. RESULTS The sociodemographic data of the caregivers showed that their average age was 55.5 ± 10.98, that 79.2% were female, and that 76.4% were parents. Of them, 54.2% were housewives, 52.8% had completed primary school, and 84.7% were unemployed. Of them, 62.5% were married, and 87.5% had children. They had 3 children on average, and their average caregiving duration was 14.50 ± 9.57 years. Of the patients, 56.9% were male and their age average was 37.59 ± 7.99. The caregivers' time and dependency burden score average was 11.88 ± 9.78. Their average for developmental burden was 11.93 ± 8.46, and 8.47 ± 6.63, 5.61 ± 5.26, 6.29 ± 5.25 for physical, social and emotional burdens, respectively. Their total burden score average was 44.19 ± 26.75. When the sociodemographic properties of the caregivers and the caregiving burden sub-scale score averages were examined, it was determined that the burdens were in the time and dependency burden sub-scale for divorced or widowed women, for those with caregiving periods between 16 and 20 years and for the literate caregivers. Burdens were greater in the developmental burden sub-dimension for female caregivers in addition to those who are divorced or widowed women, those with caregiving periods of 21 years and above and those who are literate. Burdens were determined to be greater in the physical burden sub-dimension for female caregivers, those who are divorced or widowed women, those with caregiving periods that vary between 16 and 20 years and those who are literate. Burdens were greater in the social burden sub-dimension for female caregivers as well as for those who are divorced or widowed women, those with caregiving periods of 21 years and above and those who are literate. Burdens were found to be greater in the emotional burden sub-dimension for female caregivers, for those who are divorced or widowed women those with caregiving periods that vary between 16 and 20 years and those who are literate. When the total score averages of the caregiving burden inventory were examined, it was determined that the average value for female caregivers, divorced or widowed women and those with caregiving periods ranging between 16 and 20 years was 54.75 ± 32.15 (F: 1.697, p: 0.16) whereas it was also determined that literate caregivers have a higher caregiving burden (Table 1). This study determined that the score average for trait anger was 15.12 ± 5.95. For anger-out it was 9.70 ± 3.43, and for anger-in it was
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15.22 ± 4.02. For anger control it was 28.05 ± 5.57, and the total score average was 68.11 ± 9.97. Comparing the sociodemographic properties of caregivers and their trait anger and anger expression style score averages revealed that the trait anger levels were higher for males, single caregivers, literate caregivers and those who had been caregiving between 1 and 5 years. It was determined that the anger-out sub-scale score averages were greater for males, single caregivers, literate caregivers, and those who had been caregiving between 1 and 5 years. High anger-in score averages were found for males, single caregivers, literate caregivers, and those who had been caregiving between 1 and 5 years. It was determined that the anger control sub-dimension score averages were higher for females, married caregivers, those who had been caregiving for 21 years or more and caregivers who completed elementary school. Total score averages on the anger scale were higher for males, single caregivers, literate caregivers and those who had been caregiving between 1 and 5 years (Table 2). The relationship between the caregiving burden inventory of caregivers and the score averages for trait anger and anger expression style scale was examined via correlation analysis as a result of which statistically significant relationships were determined. Accordingly; there was a positive medium level relationship between time and dependency burden and trait anger level (r: 0.544, p: 0.02), a positive and weak relationship between developmental burden and trait anger level (r: 0.401, p: 0.00) and a positive and weak relationship between developmental burden and anger-out (r: 0.435, p: 0.00). It also found a positive and weak relationship between developmental burden and anger-in (r: 0.335, p: 0.00), a negative and high level relationship between developmental burden and anger control (r: − 0.772, p: 0.02) and a positive and weak relationship between developmental burden and anger total score (r: 0.372, p: 0.00). A positive and high level relationship was determined between physical burden and trait anger (r: 0.763, p: 0.00). A positive and strong relationship was determined between physical burden and anger-in (r: 0.766, p: 0.00), and a positive and weak relationship was determined between social burden and trait anger (r: 0.273, p: 0.02). A positive and weak relationship was determined between social burden and anger-in (r: 0.259, p: 0.02). A negative and strong relationship was determined between emotional burden and anger control (r: − 0.869, p: 0.01), and a positive and weak relationship was determined between burden total score and trait anger level (r: 0.319, p: 0.00). A positive and weak relationship was determined between burden total score and anger-out (r: 0.248, p: 0.03), and a positive and weak relationship was determined between burden total score and anger total score (r: 0.245, p: 0.03) (Table 3). DISCUSSION This study found that caregivers of schizophrenia patients experience developmental, physical, social and emotional burdens and trait anger. Its results show that there is a relationship between caregiving burden and trait anger. The personal factors related with the burden perception of caregivers are age, ethnic origin, gender, relationship with the patient, whether they have volunteered for caregiving or not, education, economic status, health condition, coping skills, beliefs, social support and culture (Atagün et al., 2011). Hsiao and Tsai (2015) found that the burdens of female caregivers are greater than those of men at a statistically significant level. Perceived burden varies with family support in, the patient symptoms, gender, occupational status, marital status, cultural beliefs and coping strategies (Talwar & Matheiken, 2010, Roick, et al. 2007). Adeosun (2013) found that caregivers of schizophrenia patients experience economic and emotional burdens, patient dependency and fail to spare time for themselves. It has also been found that the burden experienced by caregivers is related with long disease durations, being female, uncertain prognoses and emotional difficulties. Similarly, this study found that female caregivers
Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
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K. Bademli et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
Table 1 Comparison of the sociodemographic properties of caregivers and their caregiving burden inventory score averages.
Gender Female Male Test value, p Marital status Married Single Divorced/widow Test value, p Caregiving period 1–5 years 6–10 years 11–15 years 16–20 years 21 years and above Test value, p Education status Literate Primary school Test value, p
Time and dependency burden
Developmental burden
Physical burden
Social burden
Emotional burden
Burden total score
12.03 ± 10.65 11.33 ± 5.55 U:418.00 P:0.89
12.49 ± 8.88 9.8 ± 6.43 U:350.50 P:0.28
9.01 ± 6.42 6.40 ± 7.23 U:306.50 P:0.09
5.64 ± 4.84 5.46 ± 6.83 U:363.00 P:0.36
6.40 ± 5.08 6.26 ± 5.34 U:414.50 P:0.85
45.45 ± 27.76 39.40 ± 22.69 U:369.00 P:0.41
11.04 ± 6.27 8.28 ± 6.60 15.05 ± 9.35 F:1.721 P:0.18
12.44 ± 9.60 6.28 ± 3.35 12.75 ± 6.12 F:1.771 P:0.17
8.26 ± 5.91 2.85 ± 4.05 10.90 ± 7.77 F:4.211 P:0.01
5.46 ± 5.50 3.28 ± 2.87 6.75 ± 6.41 F:1.171 P:0.31
5.33 ± 4.71 4.85 ± 4.56 8.95 ± 5.89 F:3.85 P:0.02
42.55 ± 24.31 25.57 ± 15.61 54.40 ± 31.37 F:3.46 P:0.03
11.75 ± 11.67 9.23 ± 7.51 9.83 ± 5.23 16.33 ± 12.03 12.31 ± 7.06 F:1.002 P:0.41
9.93 ± 7.15 10.07 ± 7.13 9.91 ± 6.45 13.33 ± 5.36 15.26 ± 11.87 F:1.397 P:0.24
6.31 ± 6.32 7.69 ± 5.51 6.25 ± 5.32 15.31 ± 4.51 13.08 ± 5.01 F:2.528 P:0.04⁎
4.68 ± 5.27 5.92 ± 6.00 5.16 ± 5.60 5.83 ± 4.52 6.31 ± 5.38 F:0.235 P:0.91
5.75 ± 4.49 3.53 ± 4.70 5.33 ± 4.97 9.31 ± 6.08 6.16 ± 3.88 F:2.88 P:0.00⁎
38.43 ± 36.46 ± 36.50 ± 54.75 ± 52.52 ± F:1.697 P:0.16
12.31 ± 10.38 10.14 ± 6.72 U:376.00 P:0.66
12.51 ± 8.82 9.50 ± 6.50 U:321.00 P:0.22
8.86 ± 6.92 6.85 ± 5.21 U:336.00 P:0.31
6.12 ± 5.53 3.50 ± 3.36 U:298.50 P:0.04⁎
6.43 ± 5.25 5.71 ± 5.41 U:368.50 P:0.59
46.24 ± 27.65 35.71 ± 21.46 U:324.00 P:0.24
28.79 23.38 21.85 32.15 24.16
⁎ p b 0.05, U: Mann Whitney U, F: ANOWA.
experience greater burden than male caregivers (Table 1). Kate et al. (2013) found that the age, marital status, education and occupational status all affect the caregiving burden of caregivers of schizophrenia patients. They determined that single caregivers experience greater burdens than other caregivers at a statistically significant level (Kate et al., 2013). This study also found that single caregivers experience greater burden levels than other caregivers. This can be explained by the fact that single caregivers perceive themselves as having less social support. Various studies have shown that social support is related with the perceived burden of caregivers (Talwar & Matheiken, 2010; Möller-Leimkühler & Wiesheu, 2012; Jagannathan, Thirthalli, Hamza, Nagendra, & Gangadhar, 2014). It has been determined that the close family ties of the caregiver and having a wide social network are related
more closely with the burden perceived by the caregiver than the properties of the disease itself (Möller-Leimkühler & Wiesheu, 2012). Similarly, Jagannathan et al. (2014) found that the burden levels of caregivers are related to the psychopathology of the disease, the dependency of the patient on the caregiver, the education level of the caregiver and the social support received by the caregiver. The dependency of the patient and long caregiving periods are factors that increase the burden of the caregiver (Hsiao & Tsai, 2015). This study also found that the burdens of those who had been caregiving period for 16 years or more were greater (Table 1). This study found that anger levels were high for male caregivers, single caregivers and those whose duration of caregiving had lasted between one to five years. Gater et al. (2014) carried out a qualitative study and found that caregivers of schizophrenia patients experience
Table 2 Comparison of the sociodemographic properties of caregivers and the trait anger and anger expression style scale score averages.
Gender Female Male Test value, p Marital status Married Single Divorced/widow Test value, p Caregiving period 1–5 years 6–10 years 11–15 years 16–20 years 21 years and above Test value, p Education status Literate Primary school Test value, p
Trait anger
Anger-out
Anger-in
Anger control
Anger total score
15.07 ± 6.27 15.33 ± 4.76 t: 0.151 p: 0.88
9.54 ± 3.47 10.33 ± 3.30 t: 0.789 p:0.43
15.12 ± 4.06 15.60 ± 3.96 t:0.406 p:0.68
29.26 ± 2.43 27.73 ± 4.83 t: 0.945 p: 0.34
67.47 ± 10.34 70.53 ± 8.28 t: 1.058 p: 0.02⁎
15.30 ± 6.77 17.75 ± 5.25 14.32 ± 4.47 F:0.385 P:0.85
9.82 ± 3.91 12.85 ± 5.29 8.85 ± 2.11 F:0.532 P:0.75
14.12 ± 3.46 17.25 ± 2.75 11.00 ± 2.64 F:2.381 P:0.04
30.25 ± 1.06 27.71 ± 5.87 28.18 ± 2.18 F:1.283 P:0.02⁎
67.97 ± 10.05 73.25 ± 6.50 57.37 ± 10.64 F:1.063 P:0.03
17.62 ± 6.25 12.92 ± 4.25 13.58 ± 4.03 14.50 ± 5.79 15.89 ± 7.30 F:1.502 P:0.01⁎
10.62 ± 3.07 9.30 ± 3.30 8.58 ± 2.31 9.75 ± 2.26 9.89 ± 4.82 F:0.651 P:0.21
16.00 ± 15.23 ± 14.50 ± 15.33 ± 14.94 ± F:0.260 P:0.90
22.00 ± 23.07 ± 27.91 ± 26.83 ± 28.52 ± F:1.227 P:0.02⁎
4.98 2.23 3.25 3.13 2.68
71.26 ± 6.70 63.25 ± 11.82 64.58 ± 8.61 68.41 ± 6.58 65.53 ± 9.97 F:1.056 P:0.02⁎
15.68 ± 6.39 12.78 ± 2.75 t: 1.656 p: 0.00
9.74 ± 3.57 9.57 ± 2.90 t: 0.165 p:0.99
15.63 ± 4.16 13.50 ± 2.90 t:1.814 p:0.13
27.86 ± 5.83 28.85 ± 4.41 t: 597 p: 0.33
68.93 ± 10.41 64.71 ± 7.26 t: 1.430 p: 0.21
4.51 3.81 3.50 4.09 4.28
⁎ p b 0.05 t: t-test F: ANOWA.
Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
K. Bademli et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
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Table 3 Relationship between the caregiving burden inventory of caregivers and trait anger and anger style scale score averages (r, p). Caregiving burden inventory
Trait ager and anger styles scale
Trait anger Anger-out Anger-in Anger control Anger total
Time and dependency burden 0.544 0.02⁎ 0.049 0.68 0.055 0.64 −0.104 0.38 0.066 0.58
Developmental burden 0.401 0.00⁎ 0.435 0.00⁎ 0.335 0.00⁎
Physical burden 0.763 0.00⁎ 0.112 0.35 0.766 0.00⁎
Social burden 0.273 0.02⁎ 0.113 0.34 0.259 0.02⁎
−0.772 0.02⁎ 0.372 0.00⁎
−0.045 0.70 0.137 0.25
−0.224 0.05 0.182 0.12
Emotional burden 0.230 0.05 0.215 0.06 0.124 0.29 −0.869 0.01⁎ 0.167 0.16
Burden total score 0.319 0.00⁎ 0.248 0.03⁎ 0.218 0.06 −0.213 0.07 0.245 0.03⁎
⁎ p b 0.05.
difficulties and anger as a result of patients' behaviors. Another study found that caregivers experience difficulties and anger due to patients' mood swings, which make it impossible for caregivers to control patients' daily activities (Chang & Horrocks, 2006). The caregivers who participated in our study may experience anger because they do not know the reasons for their patients' behaviors and how to cope with them. Caregivers of schizophrenia patients experience complex emotions during the disease, including anger. Caregivers may experience stress disorders, anger and depression as a result of chronic sadness. Effective coping methods should be taught to the caregivers so that they can cope with such emotions (Olwit, Musisi, Leshabari, & Sanyu, 2015). Males, single individuals and caregivers who have been caregiving for 1–5 years may experience trait anger because they do not know about effective coping methods, lack social support or fail to adapt to the disease (Table 2). This study found statistically significant relationships between the caregivers' caregiving burden inventory and their state trait anger scale score averages (p = 0.03; Table 3). Lauber, Eichenberger, Luginbühl, Keller, and Rössler (2003) reported that caregivers of schizophrenia patients experience objective and subjective burden, and that more than half of them try to cope with anger. This study found that the time and dependency burden, emotional burden, social burden and physical burden of caregivers are related with the anger levels. Caregivers of schizophrenia patients may have different emotional reactions to the disease. Hence, caregivers should develop a variety of coping strategies to deal with feelings of burden, loss, mourning and anger emotions (Teschinsky, 2000). Magliano et al. (1999) found in their studies that the burden experienced by caregivers of schizophrenia patients is related with the coping methods they use. Psychiatric nurses support caregivers by developing training programs for them and helping them to preserve their mental health (Teschinsky, 2000). LIMITATIONS This study is limited to the primary caregivers of schizophrenia patients registered at the Antalya Training and Research Hospital's Aşır Aksu Community Mental Health Center who were open to communication, had no trouble speaking and agreed to participate in it. IMPLICATIONS FOR PRACTICE The findings acquired from this study can guide nurses' interactions with caregivers. Nurses continuously interact with patients and their caregivers at psychiatry clinics during the treatment of schizophrenia patients. Psychiatric-mental health nurses should examine the caring practices in the families and their impact on the fulfillment of the needs of each family member. Psychiatric-mental health nurses can develop strategies and interventions for coping with anger and for reducing caregiving burdens by carrying out their roles as consultants, educators and resource persons. It is important to understand the
relationship between anger and burden of caregivers to do so effectively. Improvement in communication among family members and development of problem-solving abilities may help family members to find a balance between their individual needs and those of the family as a whole. Psychiatric-mental health nurses should plan psychoeducational interventions on “anger and coping with anger” for the caregivers of schizophrenic patients.
CONCLUSION This study's findings indicate that caregivers of schizophrenia patients experience continuous anger, express anger, repress anger, fail to control anger and have developmental, physical, social and emotional burdens. Caregivers need knowledge and support to cope with caregiving burden and anger. Psychiatric nurses can develop coping strategies for caregivers in order to reduce their caregiving burdens and anger. This study's results suggest that psychiatric nurses should provide support, training and consultancy to the caregivers of psychiatric patients, and that doing so may help caregivers manage anger and express themselves better.
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Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
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Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu
Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness Kerime Bademli a,⁎,1, Neslihan Lök b, Ayten Kaya Kılıc c a b c
Akdeniz University Faculty of Nursing, 07050 Antalya, Turkey Selçuk University Faculty of Health Science, Konya, Turkey Antalya Kamu Hastaneleri Birliği Antalya Eğitim Araştırma Hastanesi, Toplum Ruh Sağlığı Merkezi, Turkey
a r t i c l e
i n f o
Article history: Received 21 June 2016 Revised 14 November 2016 Accepted 1 December 2016 Available online xxxx KEYWORDS: Anger Burden Schizophrenia Caregiver
a b s t r a c t OBJECTIVES: The objective of this study was answer to the question: to what extent are the anger of the caregivers of patients diagnosed with schizophrenia and their perceived level of burden are related? METHOD: The study is a descriptive and correlational study. The information form prepared by the researchers which questions the socio-demographic information of the individuals along with the “Caregiving Burden Inventory” which examines the burden of the caregiver as well as “Trait Anger and Anger Expression Style Scale (TAAES)” which determines the anger levels of the caregivers were used. RESULTS: The caregiving burdens of the caregivers according to the score averages were determined as 11.88 ± 9.78 for time and dependency burden, 11.93 ± 8.46 for developmental burden, 8.47 ± 6.63 for physical burden, 5.61 ± 5.26 for social burden, 6.29 ± 5.25 for emotional burden and the total burden score was determined as 44.19 ± 26.75. According to the trait anger and anger expression style scale score averages; trait anger was determined as 15.12 ± 5.95, anger expression as 9.70 ± 3.43, anger-in as 15.22 ± 4.02, anger control as 28.05 ± 5.57 and anger total score average as 68.11 ± 9.97. CONCLUSION: According to the results obtained from this study, caregivers of schizophrenia patients experience developmental, physical, social and emotional burdens in addition to trait anger. The caregivers of schizophrenia patients need knowledge and support in order to control the burden and the anger they experience during the caregiving process. © 2016 Elsevier Inc. All rights reserved.
INTRODUCTION The concept of caregiving has entered the lives of millions of people regardless of their language, culture or country (Sunanda, Ramesh, & Eilean, 2013). In general, it is the immediate family or close relatives of the patient who take on the responsibility of caring for individuals with chronic mental disorders. Individuals with chronic mental disorders generally live with their families (Saunders, 2003). Hence, the care given by the family forms the basis of all caregiving activities (Sunanda et al., 2013). Since primary caregivers are central to patient's daily lives, caregiving relationships can become one-sided, dependent, and intensive; long term obligations that trouble the lives of caregivers as their caregiving responsibilities also increase (Atagün, Balaban, Atagün, et al., 2011). The role of the caregiver is a difficult and unpredictable experience that requires effort and toil, while also causing emotional and economic burdens (McCann, Lubman, & Clark, 2009). The concept of burden can ⁎ Corresponding Author. E-mail address: [email protected] (K. Bademli). 1 Interest in families of schizophrenia patients
be objective or subjective. Objective burden is defined as the observable, concrete costs to the family that result from the disease. Subjective burden includes individual evaluations of the situation and the emotional problems that arise due to patients' disturbing behavior (Awad & Voruganti, 2008). Studies of caregivers of individuals with chronic mental diseases have found that they experience high levels of burden (Geriani, Savithry, Shivakumar, & Kanchan, 2015, Schulze, & Rössler 2006, Hsiao & Tsai, 2015, Martín et al., 2015). Caregiving burden, especially tension, is associated with caregivers' use of maladaptive coping strategies, poor quality of life and higher levels of psychological morbidity (Kate, Grover, Kulhara, & Nehra, 2013). Studies have shown that the psychological and educational training given to caregivers helps them to cope better and reduces their burden (Chen, Liu, Zhang, & Lu, 2016; Martín-Carrasco et al., 2016; Yesufu-Udechuku et al., 2015). Caring for a person with schizophrenia has a significant impact on the lives of caregivers and alleviating caregiver burden is critical for managing its individual and societal costs (Gater et al., 2014). Caregiving burden has been determined to be related to lack of information regarding mental disease, behavioral symptoms and anger (Brady & McCain, 2004). Caring for patients with mental disorders and inability to control patients' behavior can cause anger in caregivers
http://dx.doi.org/10.1016/j.apnu.2016.12.001 0883-9417/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
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(Karp & Tanarugsachock, 2000). Causes of anger in caregivers of schizophrenia patients can be related to mental health disorders, whether they can carry out their role in the family and financial problems with treatment (Avcı, 2001, Saunders, 2003 Caqueo-Urízar, & Gutiérrez-Maldonado). Caregivers may refuse to acknowledge this feeling since they feel ashamed of it. Hence, the feeling of anger can arise as a result of research (MacNeil et al., 2010). The anger experienced by caregivers has been defined in qualitative studies carried out on caregivers of individuals with chronic mental disorders, and caregivers indicated that they experience difficulty and anger because of the patients' behavior (Chang & Horrocks, 2006; Gater et al., 2014). OBJECTIVE Caregivers of schizophrenia patients experience difficulties at every stage of the disease and for the most part have to cope with them on their own (Gülseren, 2002). Nurses continuously interact with patients and caregivers at psychiatric clinics and community mental health centers. Mental health and psychiatric nurses work as consultants, trainers and resource persons and may develop strategies for reducing the burden of caregivers and enabling them to cope with feelings of anger. An understanding of the relationship between anger and burden is needed for such interventions to be developed. This study sought an answer to the question: to what extent are the anger of the caregivers of patients diagnosed with schizophrenia and their perceived level of burden are related? METHOD DESIGN This is a descriptive and correlational study intended to describe the correlation between anger and the perceived burden level of caregivers who care for individuals diagnosed with schizophrenia. SETTING The population of the study consists of primary caregivers of schizophrenia patients at the age of 18 and above registered at the Aşır Aksu Community Mental Health Center of Antalya Training and Research Hospital. The Aşır Aksu Community Mental Health Center provides services to schizophrenia patients and their caregivers every weekday. The patients come to the center by service bus at 9:00 and return by bus to their homes at 16:00. The patients receive service between 9:00–15:30. The patients are treated at the center by healthcare professionals so that they can feel better and better adapt to social life. Individual consultations and training in psychosocial skills are also provided. SAMPLE The population of the study consists of 426 primary caregivers (family member who lives in the same household as the index patient, who spends time with him/her, and/or is directly and actively involved in the care of the patient (supervising medication, bringing him/her to hospital for follow-up) for at least one month) of schizophrenia patients at the age of 18 or above registered at the Aşır Aksu Community Mental Health Center of the Antalya Training and Research Hospital. The sample of the study was determined using the method of sampling with a known (finite) population. The prevalence is not known since there have been no studies conducted to examine the correlation between caregiving burden and anger in caregivers. For this reason, the researcher calculated the prevalence of observing (p) and not observing (q) the event as 50%, and determined 72 individuals to be included in the sample based on 5% standard deviation and a 95% confidence interval. The study's inclusion criteria were voluntary participation, being at least 18 years old, being literate and being the primary caregiver of a
schizophrenia patient registered at the Aşır Aksu Community Health Center. Secondary caregivers and minors were excluded. MEASUREMENTS The researchers created an information form to collect the participants' socio-demographic data. The researchers also used the Caregiver Burden Inventory to evaluate the burden of the caregivers and the State Trait Anger Scale to determine their anger levels. THE CAREGIVER BURDEN INVENTORY This inventory was developed in 1989 in Canada by Novak and Guest to measure the effects of caregiving on the caregiver relatives of patients (Novak & Guest, 1989). It is a 24-item five-point Likert type inventory with five sub-fields: time-dependency burden, developmental burden, physical burden, social burden and emotional burden. All the subfields have five items except for the physical field, which has four. Each sub-field is scored between 0 and 20. The items are scored as: not defining or 0 points, somewhat defining or 1 point, moderately defining or 2 points, well defining or 3 points and very well defining or 4 points. Physical burden consists of four items for which the answers given to each item is multiplied by 1.25 to calculate the score and a total score of 20 points is attained from this factor. The total score of each individual varies between 0 and 100. High scores indicate high burden levels, and low scores indicate low burden levels. The reliability and validity of the inventory for Turkish society was carried out by Küçük Güçlü et al. in 2009. Its Cronbach alpha value was 0.94. It was 0.93 for the sub-field of time dependency burden, 0.94 for developmental burden, 0.94 for physical burden, 0.82 for social burden and 0.94 for emotional burden. This study found the Cronbach's alpha value to be 0.89 in general, 0.91 for the “Time-dependency Burden” sub-factor, 0.86 for the “Developmental Burden” sub-factor, 0.90 for the “Physical Burden” sub-factor, 0.88 for the “Social Burden” sub-factor and 0.93 for the “Emotional Burden” sub-factor. THE STATE TRAIT ANGER SCALE This scale was developed by Spielberger, Jacobs, Russell, & Crane, 1983 (p. 161). It has two sub-scales: trait anger and anger expression style. The trait anger sub-scale indicates what the individual generally feels or the anger level that the individual experiences. Anger expression style is divided into three sub-scales. The anger-out sub-scale measures how much the individual expresses their anger. The anger-in subscale measures how much the individual suppresses their anger and keeps it inside. The scale consists of 34 items. It is based on a Likert type four-point rating that ranges between almost never (1) and almost always (4). The lowest possible score on the scale is 34, and the highest possible score is 136 (Spielberger et al., 1983; Özer, 1994). Scoring is carried out separately for trait anger and anger expression. The first 10 items on the scale measure trait anger. The remaining 24 items are related to anger expression style: 8 for anger-out, 8 for anger-in and 8 for anger control. Anger-out is measured by items 12, 17, 19, 22, 24, 29, 32 and 33 on the anger expression style sub-scale. Anger-in is measured by items 13, 15, 16, 20, 23, 26, 27 and 31. Anger control is measured by items 11, 14, 18, 21, 25, 28, 30 and 34. The arithmetic average of the scores for each group is calculated to score each sub-scale. Low scores indicate low trait anger or anger expression levels, and high scores indicate high trait anger or anger expression levels. The item total score correlations were determined to vary between 0.14 and 0.56, whereas the Cronbach's alpha internal consistency coefficient was determined to vary between 0.73 and 0.84 during the adaptation and reliability studies of the scale (Özer, 1994). In some studies, the Cronbach's alpha internal consistency coefficient was found to be between 0.76 and 0.82 (Albayrak & Kutlu, 2009), 0.77 and 0.90 (Yöndem & Bıçak, 2008) and 0.79 and 0.91 (Güleç, Sayar, & Özkorumak, 2005). In the present study, the Cronbach's alpha internal consistency coefficient was found to be between 0.79 and 0.88.
Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
K. Bademli et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
DATA COLLECTION The study data were collected from primary caregivers of schizophrenia patients registered at the Aşır Aksu Community Mental Health Center of the Antalya Training and Research Hospital. The study was carried out after obtaining ethical approval and institutional permission. The data were collected by the researcher at the center in face-to-face interviews. DATA ANALYSIS Study data were evaluated using SPSS 17.0 software. Number and percentile distributions were examined, and the Mann-Whitney U test, Anova, t-test and correlation analysis were also used. The results were evaluated at a 95% reliability interval using a p b 0.05 threshold for statistical significance. ETHICAL PROCEDURES The ethical approval required for the study was obtained from the Antalya Training and Research Hospital's Ethics Committee. Required explanations were made to the individuals who participated in the study regarding its title, objective, duration and method, and a consent form was read. Thus, it was ensured that they understood the objective and scope of the study. Written consents were obtained from the participants. RESULTS The sociodemographic data of the caregivers showed that their average age was 55.5 ± 10.98, that 79.2% were female, and that 76.4% were parents. Of them, 54.2% were housewives, 52.8% had completed primary school, and 84.7% were unemployed. Of them, 62.5% were married, and 87.5% had children. They had 3 children on average, and their average caregiving duration was 14.50 ± 9.57 years. Of the patients, 56.9% were male and their age average was 37.59 ± 7.99. The caregivers' time and dependency burden score average was 11.88 ± 9.78. Their average for developmental burden was 11.93 ± 8.46, and 8.47 ± 6.63, 5.61 ± 5.26, 6.29 ± 5.25 for physical, social and emotional burdens, respectively. Their total burden score average was 44.19 ± 26.75. When the sociodemographic properties of the caregivers and the caregiving burden sub-scale score averages were examined, it was determined that the burdens were in the time and dependency burden sub-scale for divorced or widowed women, for those with caregiving periods between 16 and 20 years and for the literate caregivers. Burdens were greater in the developmental burden sub-dimension for female caregivers in addition to those who are divorced or widowed women, those with caregiving periods of 21 years and above and those who are literate. Burdens were determined to be greater in the physical burden sub-dimension for female caregivers, those who are divorced or widowed women, those with caregiving periods that vary between 16 and 20 years and those who are literate. Burdens were greater in the social burden sub-dimension for female caregivers as well as for those who are divorced or widowed women, those with caregiving periods of 21 years and above and those who are literate. Burdens were found to be greater in the emotional burden sub-dimension for female caregivers, for those who are divorced or widowed women those with caregiving periods that vary between 16 and 20 years and those who are literate. When the total score averages of the caregiving burden inventory were examined, it was determined that the average value for female caregivers, divorced or widowed women and those with caregiving periods ranging between 16 and 20 years was 54.75 ± 32.15 (F: 1.697, p: 0.16) whereas it was also determined that literate caregivers have a higher caregiving burden (Table 1). This study determined that the score average for trait anger was 15.12 ± 5.95. For anger-out it was 9.70 ± 3.43, and for anger-in it was
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15.22 ± 4.02. For anger control it was 28.05 ± 5.57, and the total score average was 68.11 ± 9.97. Comparing the sociodemographic properties of caregivers and their trait anger and anger expression style score averages revealed that the trait anger levels were higher for males, single caregivers, literate caregivers and those who had been caregiving between 1 and 5 years. It was determined that the anger-out sub-scale score averages were greater for males, single caregivers, literate caregivers, and those who had been caregiving between 1 and 5 years. High anger-in score averages were found for males, single caregivers, literate caregivers, and those who had been caregiving between 1 and 5 years. It was determined that the anger control sub-dimension score averages were higher for females, married caregivers, those who had been caregiving for 21 years or more and caregivers who completed elementary school. Total score averages on the anger scale were higher for males, single caregivers, literate caregivers and those who had been caregiving between 1 and 5 years (Table 2). The relationship between the caregiving burden inventory of caregivers and the score averages for trait anger and anger expression style scale was examined via correlation analysis as a result of which statistically significant relationships were determined. Accordingly; there was a positive medium level relationship between time and dependency burden and trait anger level (r: 0.544, p: 0.02), a positive and weak relationship between developmental burden and trait anger level (r: 0.401, p: 0.00) and a positive and weak relationship between developmental burden and anger-out (r: 0.435, p: 0.00). It also found a positive and weak relationship between developmental burden and anger-in (r: 0.335, p: 0.00), a negative and high level relationship between developmental burden and anger control (r: − 0.772, p: 0.02) and a positive and weak relationship between developmental burden and anger total score (r: 0.372, p: 0.00). A positive and high level relationship was determined between physical burden and trait anger (r: 0.763, p: 0.00). A positive and strong relationship was determined between physical burden and anger-in (r: 0.766, p: 0.00), and a positive and weak relationship was determined between social burden and trait anger (r: 0.273, p: 0.02). A positive and weak relationship was determined between social burden and anger-in (r: 0.259, p: 0.02). A negative and strong relationship was determined between emotional burden and anger control (r: − 0.869, p: 0.01), and a positive and weak relationship was determined between burden total score and trait anger level (r: 0.319, p: 0.00). A positive and weak relationship was determined between burden total score and anger-out (r: 0.248, p: 0.03), and a positive and weak relationship was determined between burden total score and anger total score (r: 0.245, p: 0.03) (Table 3). DISCUSSION This study found that caregivers of schizophrenia patients experience developmental, physical, social and emotional burdens and trait anger. Its results show that there is a relationship between caregiving burden and trait anger. The personal factors related with the burden perception of caregivers are age, ethnic origin, gender, relationship with the patient, whether they have volunteered for caregiving or not, education, economic status, health condition, coping skills, beliefs, social support and culture (Atagün et al., 2011). Hsiao and Tsai (2015) found that the burdens of female caregivers are greater than those of men at a statistically significant level. Perceived burden varies with family support in, the patient symptoms, gender, occupational status, marital status, cultural beliefs and coping strategies (Talwar & Matheiken, 2010, Roick, et al. 2007). Adeosun (2013) found that caregivers of schizophrenia patients experience economic and emotional burdens, patient dependency and fail to spare time for themselves. It has also been found that the burden experienced by caregivers is related with long disease durations, being female, uncertain prognoses and emotional difficulties. Similarly, this study found that female caregivers
Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
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Table 1 Comparison of the sociodemographic properties of caregivers and their caregiving burden inventory score averages.
Gender Female Male Test value, p Marital status Married Single Divorced/widow Test value, p Caregiving period 1–5 years 6–10 years 11–15 years 16–20 years 21 years and above Test value, p Education status Literate Primary school Test value, p
Time and dependency burden
Developmental burden
Physical burden
Social burden
Emotional burden
Burden total score
12.03 ± 10.65 11.33 ± 5.55 U:418.00 P:0.89
12.49 ± 8.88 9.8 ± 6.43 U:350.50 P:0.28
9.01 ± 6.42 6.40 ± 7.23 U:306.50 P:0.09
5.64 ± 4.84 5.46 ± 6.83 U:363.00 P:0.36
6.40 ± 5.08 6.26 ± 5.34 U:414.50 P:0.85
45.45 ± 27.76 39.40 ± 22.69 U:369.00 P:0.41
11.04 ± 6.27 8.28 ± 6.60 15.05 ± 9.35 F:1.721 P:0.18
12.44 ± 9.60 6.28 ± 3.35 12.75 ± 6.12 F:1.771 P:0.17
8.26 ± 5.91 2.85 ± 4.05 10.90 ± 7.77 F:4.211 P:0.01
5.46 ± 5.50 3.28 ± 2.87 6.75 ± 6.41 F:1.171 P:0.31
5.33 ± 4.71 4.85 ± 4.56 8.95 ± 5.89 F:3.85 P:0.02
42.55 ± 24.31 25.57 ± 15.61 54.40 ± 31.37 F:3.46 P:0.03
11.75 ± 11.67 9.23 ± 7.51 9.83 ± 5.23 16.33 ± 12.03 12.31 ± 7.06 F:1.002 P:0.41
9.93 ± 7.15 10.07 ± 7.13 9.91 ± 6.45 13.33 ± 5.36 15.26 ± 11.87 F:1.397 P:0.24
6.31 ± 6.32 7.69 ± 5.51 6.25 ± 5.32 15.31 ± 4.51 13.08 ± 5.01 F:2.528 P:0.04⁎
4.68 ± 5.27 5.92 ± 6.00 5.16 ± 5.60 5.83 ± 4.52 6.31 ± 5.38 F:0.235 P:0.91
5.75 ± 4.49 3.53 ± 4.70 5.33 ± 4.97 9.31 ± 6.08 6.16 ± 3.88 F:2.88 P:0.00⁎
38.43 ± 36.46 ± 36.50 ± 54.75 ± 52.52 ± F:1.697 P:0.16
12.31 ± 10.38 10.14 ± 6.72 U:376.00 P:0.66
12.51 ± 8.82 9.50 ± 6.50 U:321.00 P:0.22
8.86 ± 6.92 6.85 ± 5.21 U:336.00 P:0.31
6.12 ± 5.53 3.50 ± 3.36 U:298.50 P:0.04⁎
6.43 ± 5.25 5.71 ± 5.41 U:368.50 P:0.59
46.24 ± 27.65 35.71 ± 21.46 U:324.00 P:0.24
28.79 23.38 21.85 32.15 24.16
⁎ p b 0.05, U: Mann Whitney U, F: ANOWA.
experience greater burden than male caregivers (Table 1). Kate et al. (2013) found that the age, marital status, education and occupational status all affect the caregiving burden of caregivers of schizophrenia patients. They determined that single caregivers experience greater burdens than other caregivers at a statistically significant level (Kate et al., 2013). This study also found that single caregivers experience greater burden levels than other caregivers. This can be explained by the fact that single caregivers perceive themselves as having less social support. Various studies have shown that social support is related with the perceived burden of caregivers (Talwar & Matheiken, 2010; Möller-Leimkühler & Wiesheu, 2012; Jagannathan, Thirthalli, Hamza, Nagendra, & Gangadhar, 2014). It has been determined that the close family ties of the caregiver and having a wide social network are related
more closely with the burden perceived by the caregiver than the properties of the disease itself (Möller-Leimkühler & Wiesheu, 2012). Similarly, Jagannathan et al. (2014) found that the burden levels of caregivers are related to the psychopathology of the disease, the dependency of the patient on the caregiver, the education level of the caregiver and the social support received by the caregiver. The dependency of the patient and long caregiving periods are factors that increase the burden of the caregiver (Hsiao & Tsai, 2015). This study also found that the burdens of those who had been caregiving period for 16 years or more were greater (Table 1). This study found that anger levels were high for male caregivers, single caregivers and those whose duration of caregiving had lasted between one to five years. Gater et al. (2014) carried out a qualitative study and found that caregivers of schizophrenia patients experience
Table 2 Comparison of the sociodemographic properties of caregivers and the trait anger and anger expression style scale score averages.
Gender Female Male Test value, p Marital status Married Single Divorced/widow Test value, p Caregiving period 1–5 years 6–10 years 11–15 years 16–20 years 21 years and above Test value, p Education status Literate Primary school Test value, p
Trait anger
Anger-out
Anger-in
Anger control
Anger total score
15.07 ± 6.27 15.33 ± 4.76 t: 0.151 p: 0.88
9.54 ± 3.47 10.33 ± 3.30 t: 0.789 p:0.43
15.12 ± 4.06 15.60 ± 3.96 t:0.406 p:0.68
29.26 ± 2.43 27.73 ± 4.83 t: 0.945 p: 0.34
67.47 ± 10.34 70.53 ± 8.28 t: 1.058 p: 0.02⁎
15.30 ± 6.77 17.75 ± 5.25 14.32 ± 4.47 F:0.385 P:0.85
9.82 ± 3.91 12.85 ± 5.29 8.85 ± 2.11 F:0.532 P:0.75
14.12 ± 3.46 17.25 ± 2.75 11.00 ± 2.64 F:2.381 P:0.04
30.25 ± 1.06 27.71 ± 5.87 28.18 ± 2.18 F:1.283 P:0.02⁎
67.97 ± 10.05 73.25 ± 6.50 57.37 ± 10.64 F:1.063 P:0.03
17.62 ± 6.25 12.92 ± 4.25 13.58 ± 4.03 14.50 ± 5.79 15.89 ± 7.30 F:1.502 P:0.01⁎
10.62 ± 3.07 9.30 ± 3.30 8.58 ± 2.31 9.75 ± 2.26 9.89 ± 4.82 F:0.651 P:0.21
16.00 ± 15.23 ± 14.50 ± 15.33 ± 14.94 ± F:0.260 P:0.90
22.00 ± 23.07 ± 27.91 ± 26.83 ± 28.52 ± F:1.227 P:0.02⁎
4.98 2.23 3.25 3.13 2.68
71.26 ± 6.70 63.25 ± 11.82 64.58 ± 8.61 68.41 ± 6.58 65.53 ± 9.97 F:1.056 P:0.02⁎
15.68 ± 6.39 12.78 ± 2.75 t: 1.656 p: 0.00
9.74 ± 3.57 9.57 ± 2.90 t: 0.165 p:0.99
15.63 ± 4.16 13.50 ± 2.90 t:1.814 p:0.13
27.86 ± 5.83 28.85 ± 4.41 t: 597 p: 0.33
68.93 ± 10.41 64.71 ± 7.26 t: 1.430 p: 0.21
4.51 3.81 3.50 4.09 4.28
⁎ p b 0.05 t: t-test F: ANOWA.
Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001
K. Bademli et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
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Table 3 Relationship between the caregiving burden inventory of caregivers and trait anger and anger style scale score averages (r, p). Caregiving burden inventory
Trait ager and anger styles scale
Trait anger Anger-out Anger-in Anger control Anger total
Time and dependency burden 0.544 0.02⁎ 0.049 0.68 0.055 0.64 −0.104 0.38 0.066 0.58
Developmental burden 0.401 0.00⁎ 0.435 0.00⁎ 0.335 0.00⁎
Physical burden 0.763 0.00⁎ 0.112 0.35 0.766 0.00⁎
Social burden 0.273 0.02⁎ 0.113 0.34 0.259 0.02⁎
−0.772 0.02⁎ 0.372 0.00⁎
−0.045 0.70 0.137 0.25
−0.224 0.05 0.182 0.12
Emotional burden 0.230 0.05 0.215 0.06 0.124 0.29 −0.869 0.01⁎ 0.167 0.16
Burden total score 0.319 0.00⁎ 0.248 0.03⁎ 0.218 0.06 −0.213 0.07 0.245 0.03⁎
⁎ p b 0.05.
difficulties and anger as a result of patients' behaviors. Another study found that caregivers experience difficulties and anger due to patients' mood swings, which make it impossible for caregivers to control patients' daily activities (Chang & Horrocks, 2006). The caregivers who participated in our study may experience anger because they do not know the reasons for their patients' behaviors and how to cope with them. Caregivers of schizophrenia patients experience complex emotions during the disease, including anger. Caregivers may experience stress disorders, anger and depression as a result of chronic sadness. Effective coping methods should be taught to the caregivers so that they can cope with such emotions (Olwit, Musisi, Leshabari, & Sanyu, 2015). Males, single individuals and caregivers who have been caregiving for 1–5 years may experience trait anger because they do not know about effective coping methods, lack social support or fail to adapt to the disease (Table 2). This study found statistically significant relationships between the caregivers' caregiving burden inventory and their state trait anger scale score averages (p = 0.03; Table 3). Lauber, Eichenberger, Luginbühl, Keller, and Rössler (2003) reported that caregivers of schizophrenia patients experience objective and subjective burden, and that more than half of them try to cope with anger. This study found that the time and dependency burden, emotional burden, social burden and physical burden of caregivers are related with the anger levels. Caregivers of schizophrenia patients may have different emotional reactions to the disease. Hence, caregivers should develop a variety of coping strategies to deal with feelings of burden, loss, mourning and anger emotions (Teschinsky, 2000). Magliano et al. (1999) found in their studies that the burden experienced by caregivers of schizophrenia patients is related with the coping methods they use. Psychiatric nurses support caregivers by developing training programs for them and helping them to preserve their mental health (Teschinsky, 2000). LIMITATIONS This study is limited to the primary caregivers of schizophrenia patients registered at the Antalya Training and Research Hospital's Aşır Aksu Community Mental Health Center who were open to communication, had no trouble speaking and agreed to participate in it. IMPLICATIONS FOR PRACTICE The findings acquired from this study can guide nurses' interactions with caregivers. Nurses continuously interact with patients and their caregivers at psychiatry clinics during the treatment of schizophrenia patients. Psychiatric-mental health nurses should examine the caring practices in the families and their impact on the fulfillment of the needs of each family member. Psychiatric-mental health nurses can develop strategies and interventions for coping with anger and for reducing caregiving burdens by carrying out their roles as consultants, educators and resource persons. It is important to understand the
relationship between anger and burden of caregivers to do so effectively. Improvement in communication among family members and development of problem-solving abilities may help family members to find a balance between their individual needs and those of the family as a whole. Psychiatric-mental health nurses should plan psychoeducational interventions on “anger and coping with anger” for the caregivers of schizophrenic patients.
CONCLUSION This study's findings indicate that caregivers of schizophrenia patients experience continuous anger, express anger, repress anger, fail to control anger and have developmental, physical, social and emotional burdens. Caregivers need knowledge and support to cope with caregiving burden and anger. Psychiatric nurses can develop coping strategies for caregivers in order to reduce their caregiving burdens and anger. This study's results suggest that psychiatric nurses should provide support, training and consultancy to the caregivers of psychiatric patients, and that doing so may help caregivers manage anger and express themselves better.
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Please cite this article as: Bademli, K., et al., Relationship Between Caregiving Burden and Anger Level in Primary Caregivers of Individuals With Chronic Mental Illness, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.12.001