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of Family Nursing

Development of a Caregiver Empowerment Model to Promote

Positive Outcomes
Patricia S. Jones, Betty W. Winslow, Jerry W. Lee, Margaret Burns and Xinwei
Esther Zhang
Journal of Family Nursing 2011 17: 11
DOI: 10.1177/1074840710394854
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394854
854Jones et al.Journal of Family Nursing
The Author(s) 2011

JFN17110.1177/1074840710394

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Articles

Development of
a Caregiver
Empowerment
Model to Promote
Positive Outcomes

Journal of Family Nursing

17(1) 1128
The Author(s) 2011
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1074840710394854
http://jfn.sagepub.com

Patricia S. Jones, PhD, RN, FAAN1,

Betty W. Winslow, PhD, RN1,
Jerry W. Lee, PhD, RN2, Margaret Burns, DNSc, RN1,
and Xinwei Esther Zhang, EdS, MS1

Abstract
Family members caring for aging parents experience both negative and positive outcomes from providing care. Theoretical explanations for negative
outcomes have been developed. There is need for models that explain and
predict positive outcomes. This article describes the evolution of the Caregiver Empowerment Model (CEM) to explain and predict positive outcomes
of family caregiving. Although empirical findings support positive outcomes
of family caregiving, less attention has been given to theoretical rationale for
positive effects. The CEM predicts that, in the presence of filial values and
certain background variables, caregiving demands are appraised as challenges
instead of stressors. Appraising caregiving demands as a challenge, finding
meaning, and using certain types of coping strategies are posited to be associated with growth and well-being. The CEM extends our understanding of
the complexity of the caregiving experience, and can serve as a framework
to guide in developing and testing theory-based interventions to promote
positive outcomes.
1

School of Nursing, Loma Linda University, Loma Linda, CA

School of Public Health, Loma Linda University, Loma Linda, CA

Corresponding Author:
Patricia S. Jones, PhD, RN, FAAN, Professor, School of Nursing, Loma Linda University,
1125A West Hall, Loma Linda, CA 92350
Email: pjones@llu.edu

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Journal of Family Nursing 17(1)

Keywords
family caregivers, aging families, conceptual model, meaning-focused coping,
positive outcomes, health promotion

Introduction
Even though family members caring for elderly relatives experience
stress and negative health outcomes (Aneshensel, Pearlin, Mullan, Zarit,
& Whitlatch, 1995), some family caregivers find rewards in providing care
(Andren & Elmstahl, 2005; Farberman et al., 2003; Pierce, Steiner, Govoni,
Thompson, & Friedemann, 2007). Interviews with Chinese and Filipino
American women filial caregivers (Jones, 1995, 1996; Jones, Zhang,
Jaceldo-Siegl, & Meleis, 2002; Jones, Zhang, & Meleis, 2003) indicated
that although the caregivers faced multiple stressors, they reported more
positive than negative outcomes. The women were challenged by the
demands of multiple roles but rewarded by satisfaction from giving back to
their parents in gratitude for what they had done for them. Their commitment to traditional values of respect and reciprocity influenced the way they
managed their responsibilities, how they coped with the stressors and
ultimately their health.
These findings from the study of Asian American women caring for aging
parents are congruent with other empirical reports of positive outcomes from
family caregiving in diverse cultural groups. More than a decade ago Farran
and colleagues reported that African American and White caregivers of family members with dementia found meaning in the caregiving experience, and
caregivers with higher levels of meaning had lower depression scores (Farran,
Miller, Kaufman, & Davis, 1997; Farran, Miller, Kaufman, Donner, & Fogg,
1999). These observations are congruent with Folkmans (1997) research on
the co-occurrence of positive affect along with negative affect during acute
and chronic stress, and on meaning-focused coping (Moskowitz, Folkman,
Collette, & Vittinghoff, 1996). Although Moskowitz and colleagues studied
AIDS caregivers, subsequent research has supported their observations with
other stressors. For example, Fredricksons (1998) work showing the beneficial role of positive emotions in broadening and replenishing the persons social, intellectual, and physical coping resources is consistent with
Moskovitz et al.s findings. The significance of meaning as a factor influencing coping and coping outcomes warrants attention in investigators efforts to
promote caregiver well-being. Folkmans (1997, 2008) revised stress and
coping model provides for both a mediating and moderating impact of
meaning-focused coping and positive emotions on appraisal and reappraisal

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Jones et al.

Caregiving Demands
Care-receiver Impairment
Caregiving Activities
Competing Role Demands

Background
Acculturation
Demographics
Prior Relationships

Filial Values
Responsibility
Respect
Care

Appraisal
Challenge or
Stressor

Caregiver Outcomes
Perceived Health
Personal Growth
Existential Well-being

Resources
Personal: Coherence,
Spirituality, Meaningfocused Coping
Family: Connectedness,
Family Assistance
Community: Use of
Community Resources

Figure 1. The Caregiver Empowerment Model

of stressors and resources. These insights provide theoretical support for the
creation of a model that can explain and predict outcomes of well-being in
family caregivers.
Based on our own conceptual and empirical work, and its congruence
with that of other scholars, we have developed the Caregiver Empowerment
Model (CEM, see Figure 1) to guide practice and research with a goal of
promoting positive outcomes in family caregivers. In this article we
describe the theoretical and empirical foundations of the CEM, along with
its potential to predict well-being in family caregivers. The model takes
into account the background variables that influence the caregiving situation, cultural beliefs about responsibility for family caregiving, caregiving
demands, the caregivers appraisal of the demands they are facing, and specific resources that can facilitate positive outcomes. Implications of the
CEM for research and practice are discussed and directions for future studies are suggested.

Theoretical Foundations of the

Caregiver Empowerment Model
The CEM is based primarily on two existing frameworks: (a) Jones and Meleis
(1993) health empowerment model, which incorporates both Antonovskys

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Journal of Family Nursing 17(1)

(1979) salutogenic theory of stress and Pearlin, Mullan, Semple, and

Skaffs (1990) caregiving stress process model, and (b) Folkman and
Mosokvitzs (2000a) theory of meaning-focused coping. Each of these frameworks adds insights to explain and predict positive outcomes from family
caregiving. In the CEM, empowerment is defined as an increase in ones
ability to appraise, influence, and manage a situation using contextual and
personal resources to achieve desired outcomes.

The Health Empowerment Model

The Health Empowerment Model (Jones & Meleis, 1993) evolved from
several theoretical and interdisciplinary views of health for the purpose of
promoting health in individuals who are exposed to ongoing stressful stimuli.
This model influenced the CEM by contributing the proposition and theoretical support that, when stressors are present, personal, family, and community resources can empower the caregiver to manage the situation effectively
and achieve positive health outcomes.
Regardless of ones definition of health, it is acknowledged that some individuals emerge from an illness or stressful situation stronger and healthier
than before rather than more vulnerable as might be expected. Some of the
theories which have contributed to this view include Youngers (1991) theory
of mastery, Mochs (1989) idea of the possibility of health-within-illness, and
Jones and colleagues (2003) report of caregivers transforming vulnerability
into well-being. Thus the CEM proposes that caregivers who are challenged to
meet competing demands can be empowered for action and for health when
personal and contextual (family and community) resources are available.
Antonovskys (1979) theory of a salutogenic (health generating) response
to stress contributed to the development of the health empowerment model.
The core construct of his theory, sense of coherence (SOC), is a pervasive
and enduring feeling of confidence that ones internal and external environments are predictable and that things will work out as well as can reasonably
be expected. A variety of factors contribute to the development of a SOC.
One factor is adaptability, which Antonovsky (1979) described as physiological, psychological, social, and cultural in nature. Others are meaningfulness, comprehensibility, and manageability (Antonovsky, 1987). Antonovsky
explained that, where there is a strong sense of meaningfulness in a difficult
situation it is likely the individual will see the experience as one that can be
coped with, and challenges that can be met (p. 17).
Support for Antonovskys work includes studies by Kobasa (1979) and
Maddi (2008) who addressed psychological hardiness; Dubos (1965) and Lerner

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Jones et al.

(1984) who focused on concepts of plasticity and adaptability; Crafts (1999)

study on feminine hardiness; and McCrae and Costas (1988) work on egoresilience and psychological resilience. These constructs reflect similar understandings of how some individuals are able to endure prolonged stress without
negative effects on their health. Hardiness, resilience, and SOCall feature the
human ability to manage difficult demands in ways that maintain and promote
health. Hence they are a core part of the theoretical foundation of the health
empowerment model. While these are not the only personal resources that contribute to positive outcomes and mediate the negative effects of stress but also
they empower individuals to manage tension and engage effectively in problem
solving, thus providing strong support for the CEM.
Pearlin and Schoolers (1978) stress and coping process also contributed
to the health empowerment model. Of particular importance is the significant
role that background and contextual factors play in influencing which life
experiences are stressful. All of these authors agree that given certain personal characteristics and resources, it is possible for human beings to do more
than survive crises, and to actually grow stronger as a result of encountering
stressors and demands. Antonovskys concept of SOC is consistent with the
work of other scholars in this area: for example, Tedeschi and Calhoun (1995);
Tedeschi, Park, and Calhoun, (1998); Rutter (1985); Strumpfer (1995); and
Harvey (1996) all describe the remarkable ability of the human spirit to recover
from insult and grow in ways that reflect healing, wisdom, and strength
(Almedom, 2005). As the health empowerment model was built on these
insights and integrates constructs that have the potential to explain and predict empowerment for health in individuals who are at risk, it provides a
strong theoretical foundation for the CEM.

Meaning-Focused Coping
Lazarus and Folkman (1984) described coping with stress as beginning with
appraisal (primary and secondary) and ending with reappraisal. Primary
appraisal of an encounter leads to interpreting an experience as irrelevant,
benign-positive, or stressful and, if stressful, involving harm/loss, threat, or
challenge. Secondary appraisal involves assessment of the resources available
for coping. Encounters that require resources beyond the individuals ability
to manage are considered as stressors. Reappraisal of both stressors and
resources is very important; when reappraisal of one or both is positive,
positive outcomes are facilitated (Lazarus & Folkman, 1984). The processes
of appraisal and reappraisal allow for interpretation of the meaning and
significance of the demands and challenges the caregiver is facing. When

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Journal of Family Nursing 17(1)

appraised as deeply meaningful and important to an individuals values and

purposes, energy for coping expands empowering individuals to persist,
survive, and grow. This is supported by the observations of other scholars
who have found meaning to be an important variable influencing caregiving
outcomes (Ayres, 2000; Farran et al., 1997; Hunt, 2003).
Current work by Folkman and colleagues (Folkman, 2008; Folkman &
Moskowitz, 2004, 2007) acknowledge that coping is more complex than first
thought. These authors and others suggest that there is a strong adaptive function in the use of positive psychological states to cope with stressors and
manage distress. For example, finding meaning in an ongoing stressful encounter contributes to positive reappraisal and ultimately to positive outcomes.
Similarly, revising ones goals facilitates a sense of control and also helps
restore psychological resources for coping.
An important piece of this complex interplay among concepts is the fit
between the coping strategies used and the demands of the situation or
coping-environment fit (Folkman & Moskowitz, 2004). This fit implies
that the individual is able to modify his or her coping if necessary, and that
there can be coping flexibility. Coping flexibility is congruent with the concept of adaptability (Antonovsky, 1979, 1987; Jones, 1991) and with the construct of psychological resilience (Tugade, Fredrickson, & Barrett, 2004).
Another piece of the complexity is the finding that positive and negative
emotions co-occur (Folkman, 1997, 2008; Folkman & Greer, 2000; Folkman
& Moskowitz, 2000a, 2004). In fact, studies support the possibility that positive affect in the midst of enduring stress serves as a buffer against adverse
physiological consequences of stress and contributes to adaptation (Folkman
& Moskowitz, 2000b). Fredrickson (1998) showed that positive emotions
broaden the individuals behavioral repertoire and replenish or build the
persons social, intellectual, and physical resources. Thus, it is now recognized that positive emotions and psychological resilience (Tugade et al.,
2004) contribute to coping strength and health. These personal resources,
along with access to family and community resources, empower the individual to manage the caregiving demands in a way that can be health generating
(Mittelman, Roth, Haley, & Zarit, 2004).

Empirical Foundations of the Caregiver

Empowerment Model
In addition to the theoretical foundations described above, our own empirical
work along with that of other investigators led to development of the model
(Figure 1). Each construct in the model functions as a significant variable

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Jones et al.

organized in a deliberate and meaningful pattern of interaction. Each has the

potential to contribute to the process of empowerment.

Background
Potential background variables in the CEM include, but are not limited to,
acculturation, demographics, and prior relationships. These variables are
posited to directly influence caregiving demands, filial values, and use of
resources. Research supports these proposed relationships. Acculturation is
described in various ways, one of which is number of years in the U.S.
Acculturation influences beliefs and values related to filial responsibility, as
well as coping strategies and resources used to manage the caregiving (Hsueh,
Hu, & Clarke-Ekong, 2008). A Swedish study of 156 family caregivers
revealed that older caregivers expressed more satisfaction in caregiving than
their younger counterparts (Andren & Elmstahl, 2005). African American
caregivers have been found to express more positive aspects of caregiving
than Caucasians (Hilgeman, Allen, DeCoster, & Burgio, 2007). The influence
of demographic variables such as race or ethnicity have been found to be
associated with resources (Hilgeman et al., 2009), while caregiver gender has
been associated with attitudes and beliefs regarding filial values (Chappell &
Kusch, 2007; Yoo & Kim, 2010). The nature of prior relationships may also
influence the caregivers interaction with the care receiver and the type of care
he or she will provide (Williamson & Shaffer, 2001; Yamashita & Amagai,
2008). Caregivers who are more distantly related to the care receiver have
also been shown to express less satisfaction from caregiving than those who
are more closely related (Andren & Elmstahl, 2005).

Filial Values
Filial values are attitudes and beliefs about responsibility for ones aging
parents. Beliefs and commitments to maintaining traditional values have
been shown to influence caregiver motivation to provide care for aging
parents. Such commitment has been examined and reported under different
labels including filial obligations and responsibility, filial norms, filial piety,
and others. There is beginning evidence across cultures that ones filial beliefs
and values not only influence caregivers motivation to provide care but also
influence caregiver actions and outcomes as well (Cheng & Chan, 2006; Kao
& Travis, 2005; Pang et al., 2002; Pierce, 2001).
In Chinese culture, filial values are based on beliefs about filial piety,
called Hsiao, which are rooted in Confucianism and recognized as nearly

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Journal of Family Nursing 17(1)

sacred. Although perceived partly as an obligation, caregiving is also regarded

as an opportunity to show appreciation for the gift of life and to pay back
the love and generosity received during childhood. This represents reciprocity between generations. Reciprocity is a core virtue in Chinese culture, but is
not unique or limited to Asian culture. It is a core concept in Western social
science theories that explain responsibility of adult children for aging parents.
Social exchange theory and equity theory are examples (Adams, Berkowitz, &
Hatfield, 1976; Homans, 1961). In the context of families, whether it be
social exchange or equity, reciprocity is central.
Jones, Lee, and Zhang (2007) developed and tested a scale to measure
filial values. Exploratory factor analysis identified three dimensions to the
scale: (a) a sense of responsibility for parents, (b) respect and admiration for
parents, and (c) a desire to care for parents. This was validated through confirmatory analysis. In the CEM it is proposed that filial values may (a) change
how the individual appraises caregiving demandsthat is, as challenges
instead of stressors, (b) contribute to the resources available for coping
through the strong sense of purpose and meaning associated with giving back
to ones parents, (c) influence access to family resources and use of community resources, and (d) indirectly influence outcomes through resources and
appraisal.

Caregiving Demands
Examples of caregiving demands include care-receiver impairment, the caregiving activities, and competing role demands. There is ample evidence of
the negative impact of caregiving demands on the life and health of caregivers (Aneshensel et al., 1995; Faison, Faria, & Frank, 1999; Stephens,
Townsend, Martire, & Druley, 2001). For some caregivers such demands are
clearly experienced as stressors with all the consequences of exposure to
prolonged stress. In contrast when caregivers identify uplifts in caregiving,
these uplifts are associated with caregiver subjective well-being (Pinquart &
Sorensen, 2004). In the CEM it is suggested that when filial values are present, and when certain resources are available, the caregiver is likely to
appraise the demands as meaningful challenges (Kobasa, 1979), as salutogenic instead of pathogenic (Antonovsky, 1987), and as a stimulus for personal growth. The consequences of such appraisal are likely to be positive
rather than negative, which is a conceptual difference between Pearlins
(Pearlin, 1989; Pearlin et al., 1990; Pearlin, Lieberman, Menaghan, & Mullan,
1981) caregiver stress process model and the CEM.

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Jones et al.

Resources
Resources are factors that help support positive appraisal of caregiving
demands and facilitate effective coping and management of care. Some are
interpersonal resources such as coherence and spirituality, and some are external or contextual, such as family support or community resources. In the
CEM resources can have a direct effect on outcomes and an indirect effect
through the influence of appraisal on outcomes (Baron & Kenny, 1986;
Kraemer, Wilson, Fairburn, & Agras, 2002). Although much of the research
evaluating the effectiveness of community resources in reducing caregiving
burden has shown minimal effects, studies in which clients and/or their
families received timely and adequate amounts of help have shown more
positive outcomes (Santo, Scharlach, Nielsen, & Fox, 2007; Zarit, Gaugler,
& Jarrott, 1999). In addition to timeliness and adequacy of community services, studies also suggest that these services must be culturally appropriate
(Li, 2004). When services are accessible, timely, and appropriate, it is suggested that they will positively influence outcomes. Similarly, when personal
resources of coherence and spirituality are present and when family connectedness exists, appraisal of caregiving demands as challenges may actually
enhance perceived health, stimulate personal growth, and promote existential
well-being (Jones et al., 2003). On the other hand, when such resources are
lacking, caregiving demands may be perceived as stressors, and detrimental
to health, growth, and well-being (Aneshensel et al., 1995). Depending on
cultural values, particularly filial values, use of community resources will
vary greatly because in some cultural groups accepting assistance from outside the family is seen as an insult to their parents and to be done only as a
last resort (Jones et al., 2002).
Based on the relationships between the constructs in the CEM it could be
hypothesized that caregivers who are committed to caregiving, who view
their caregiving responsibility as a meaningful challenge, and are psychologically resilient are likely to manage caregiving demands effectively leading to
positive health outcomes.

Appraisal
Appraisal is subjective assessment of the presence and level of threat to wellbeing, or of the challenges faced, and of the resources available to manage
the challenge. It is posited to be directly influenced by caregiving demands,
filial values, and personal, family and community resources. These proposed

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Journal of Family Nursing 17(1)

relationships are supported by the findings in Jones et al.s (2002, 2003)

study of immigrant Chinese and Filipino American women caregivers of
aging parents. Using a grounded theory approach (Strauss & Corbin, 1990),
this qualitative study of 41 Asian American women revealed two substantive
social processes. These processes were (a) transforming vulnerability (Jones
et al., 2003) and (b) caregiving between two cultures (Jones et al., 2002).
Transforming vulnerability refers to the experience of increased risk that the
caregivers described, and the coping strategies developed that led to positive
outcomes. Limited availability and use of community support contributed to
their vulnerability. Cultural beliefs about family versus community responsibility interfered with accessing such assistance. For some, the stress of caregiving
resulted in difficulty sleeping, hypertension, and other indications of compromised well-being. However, a sincere sense of gratitude toward their parents
and a desire to give back were intricately intertwined with feelings of obligation
and responsibility. Most participants became more determined to do whatever
it takes because it was so important to them. The meaning derived from fulfilling their obligation brought great satisfaction. The strategies they developed to
overcome increased risk included (a) connecting with their deeply held values,
(b) integrating the caregiving role into the fullest meaning of who they are, and
(c) mobilizing resourcesparticularly personal and family resources. While the
caregiving demands and stressors encountered will vary according to cultural
group, the coping strategies developed by these caregivers are not unique to
Asian culture. Caregivers from other groups also report personal and spiritual
growth from the caregiving experience (Andren & Elmstahl, 2005; Hilgeman
et al., 2007; Picot, Debanne, Namazi, & Wykle, 1997).
Caregiving between two cultures reflects the challenge the caregivers
experienced as they struggled to integrate two sets of cultural values. The
women had strong beliefs of filial responsibility, were deeply committed to
caring for their aging parents and to maintaining traditional values. They perceived their caregiving responsibility as a challenge rather than a stressor,
and as a way to give back to their parents. Therefore, their experience was
infused with meaning. The women developed personal resources (coherence,
endurance, and spirituality) and drew on family resources (family connectedness and assistance from family members) to manage the challenge and preserve well-being. Thus in spite of the lack of culturally appropriate support
services and limited or no use of community resources, the caregivers persisted
in the caregiving role and ultimately described outcomes of personal growth,
meaning, and integration. Although caregivers in other cultural groups may
not be struggling with being in two cultures, traditional and contemporary
values are present in any group with tension between the two.

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Jones et al.

Outcomes
Outcomes are defined as changes in caregiver health and well-being as a
consequence of participating in the caregiver role. A unique element of the
CEM is its focus on positive outcomes of the caregiving process. Although
there will be variability in the consequences of how one manages the caregiving demands, in the CEM there is a possibility of positive outcomes. The
model suggests that in the presence of filial values, demands are perceived
as challenges, and when personal, family, and community resources are
accessed the caregiver has the potential to experience enhanced well-being
in both physical and mental health, personal growth, and existential wellbeing. Literature has shown that appraising stress as a challenge, being able
to create meaning for it, and using certain types of coping appear to be associated with growth (Park, 1998).

Implications for Nursing Research and Practice

Although there have been empirical findings supporting positive outcomes
of family caregiving, less attention has been given to theoretical or conceptual frameworks in providing rationale for positive effects. The quality of the
prior childadult relationship has been suggested as a predictor of how caregiving responsibility is perceived and accepted (Williamson & Shaffer, 2001).
Theories such as role attainment and attachment have been used to explain
caregiver reward (Lee, 2007). Acculturation and social exchange variables
have been tested as predictors of parental expectations for filial piety (Kao &
Travis, 2005). Conceptualization of social exchange that includes aspects of
reciprocity, repaying, obligation, and implicit cultural exchange has also
been supported through qualitative research (Hsu & Shyu, 2003). Testing of
a theoretical model by Carruth and colleagues was reported to show that
family satisfaction in elder caregiving was predicted by a sense of reciprocity, emotional well-being, and positive family functioning (Carruth, Tate,
Moffett, & Hill, 1997).
Despite these studies that have included theoretical underpinnings, most
of the literature explaining positive caregiver outcomes does not have the
same depth of theoretical consideration that can be found when looking at the
negative outcomes. Models such as the Stress Process (Pearlin, 1989; Pearlin
et al., 1981, 1990) and Stress and Coping (Lazarus & Folkman, 1984) have
provided convincing rationale for understanding the stressful outcomes of
caregiving. If we are to understand the family caregiving experience in its
many facets, theoretical understandings of positive outcomes are also needed.

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In this article we have drawn together theoretical and research findings and
have posited a heuristic model that suggests potential pathways for predicting
caregiver empowerment. The CEM was developed to help explain and predict positive outcomes of filial caregiving. It is presented here as a framework
to guide in developing and testing interventions to promote these outcomes.
Such interventions may focus on one or more of the variables in the model.
For example, interventions focused on finding meaning through fulfillment
of filial values, promotion of positive appraisal and positive coping, development of personal resources and accessing family, and community resources
could facilitate positive outcomes. Given current changes in the health care
environment and an aging society, there will undoubtedly be greater demand
for filial caregiving in the future and for promotion of positive caregiver
health outcomes.
We suggest that researchers move beyond describing the relationships
between predictor variables and caregiving outcomes to testing and refining theoretical models to extend our understanding of the complexity of
the caregiving experience. Studies could be designed to test portions of the
model presented in this article. For example, researchers might choose to
test whether filial values mediate the influence of background variables
on caregiver appraisal and/or use of resources (Baron & Kenny, 1986;
Kraemer et al., 2002). Studies could also examine the potential direct
relationship of resources on appraisal and whether the effects of resources
on outcomes are also mediated through appraisal. Additional research
could be directed at whether the influence of caregiving demands is wholly
mediated through appraisal, as suggested in the CEM, or whether caregiver demands also have direct effects on caregiver outcomes. Ultimately,
with an adequate sample, structural equation modeling could be used to
test the multiple direct and indirect pathways suggested by the model. It is
anticipated that, with adequate research, this model would be revised and
provide a more complete explanation of variables that influence caregiver
well-being.
By focusing research efforts on understanding why some families experience positive outcomes from caregiving we will have evidence for the development of supportive interventions. It is our conviction that interventions
targeted toward empowering the family caregiver will result in reduced caregiver stress and lead to more positive outcomes for caregivers and their
family members. Revisioning family caregiving through an empowerment
framework will guide health professionals in promoting caregiver well-being
and lead to new opportunities to partner with families in meeting the challenges of community-based elder care.

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Jones et al.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the authorship
and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this
article.

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Bios
Patricia S. Jones, PhD, RN, FAAN, is a professor at Loma Linda University School of
Nursing, and Director of International Nursing. Her research focuses on filial caregiving
including cultural differences in caregiving values and practice. Recent publications
include A Bold Adventure in Innovation: An International Off-Campus Masters Degree
Program appearing in Journal of Nursing Education (2010, with Van Cleve, King,
Bossert, & Herrmann) and Assessing Cross-Cultural Differences Through Use of

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Multiple-Group Invariance Analyses appearing in Journal of Personality Assessment

(2006, with Stein & Lee).
Betty W. Winslow, PhD, RN, is a professor at Loma Linda University School of
Nursing. Her research focuses on family caregiving for relatives with dementia. As a
community health nurse her clinical focus is in community based care of elders. Recent
publications include Vulnerable Populations and Ultimate Responsibility appearing in Issues in Mental Health Nursing (2010, with Flaskerud) and Deciding to Place
a Relative in Long-Term Care: We Really Dont Do That. appearing in Issues in
Mental Health Nursing (2009, with Flaskerud).
Jerry W. Lee, PhD, RN, is a professor in the School of Public Health at Loma Linda
University. His research interests include religion and health, filial values and caregiving, cross-cultural research methodology, and the theory of planned behavior and
health behavior. He is currently PI on a 5-year NIH-NIA funded study of the connection between religion and health called the biopsychosocial religion and health study.
Recent publications include Effect of Early Skin-to-Skin Mother-Infant Contact
During the First 3 Hours Following Birth on Exclusive Breastfeeding During the
Maternity Hospital Stay appearing in Journal of Human Lactation (2010, with
Bramson, Moore, Montgomery, Neish, Bahjri, & Melcher) and Cohort profile: The
biopsychosocial religion and health study (BRHS) appearing in International Journal
of Epidemiology (2009, with Morton, Walters, Bellinger, Butler, Wilson, . . . Fraser).
Margaret Burns, DNSc, RN, is an associate professor at Loma Linda University
School of Nursing. Her scholarly interests include conceptual development; educational evaluation and RN-BS student outcomes related to critical thinking, professional values, and cultural awareness; application of nursing theory; and development
of online courses for RN-BS students. Recent publications include the chapter Nursing
Education at Loma Linda University in The Neuman Systems Model (2010).
Xinwei Esther Zhang, EdS, MS, is a research associate at Loma Linda University
School of Nursing. She is involved in filial caregiving research. Recent publications
include Transforming Vulnerability appearing in Western Journal of Nursing
Research (2003, with Jones and Meleis).

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