Journal of Gerontological Social Work, 58:128–148, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0163-4372 print/1540-4048 online DOI: 10.1080/01634372.2014.925026

Deciding to Institutionalize: Caregiving Crisis, Intergenerational Communication, and Uncertainty Management for Elders and Their Children in Shanghai LIN CHEN Department of Social Welfare, University of California, Los Angeles, Los Angeles, California, USA

This phenomenological study integrated crisis theory, social identity theory, and uncertainty management theory to conceptualize the decision-making process around institutionalization among nursing home residents and their children in Shanghai. I conducted face-to-face, semistructured interviews with 12 dyads of matched elders and their children ( N = 24). The findings suggest that caregiving crises triggered intergenerational communication about caregiving alternatives and new arrangements, although each generation had different stances and motivations. Children finalized the decision by helping their parents to manage the uncertainties pertaining to institutionalization. This study sheds light on caregiving decision-making dynamics for the increasing aging population across cultures. KEYWORDS caregiving crisis, decision-making, family caregiving, filial piety, intergenerational communication, nursing home care, uncertainty management, urban China

Economic reform in urban China has posed unprecedented challenges to its ingrained parent-centered caregiving tradition, rooted in filial piety (Cheung & Kwan, 2009; Lee & Kwok, 2005). Filial piety refers to the idea that Received 20 September 2013; revised 13 May 2014; accepted 13 May 2014. Lin Chen is now at Fudan University as an Assistant Professor in Social Work. Address correspondence to Lin Chen, Department of Social Work, School of Social Development and Public Policy, Fudan University, Humanities and Social Science Building, 220 Handan Road, Shanghai 200433, China. E-mail: [email protected] 128

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the younger generation should fulfill the older generation’s needs for both material and emotional support (Cheung & Kwan, 2009; Chou, 2011; Ikels, 2004). Recently, elders’ needs for formal long-term care in urban China have risen tremendously (Wong & Leung, 2012). For example, a rapidly increasing number of elders in Shanghai have sought social services, in particular nursing home care, to meet their long-term care needs (Social Welfare Department of Shanghai Civil Affairs Bureau, 2013). Nursing home providers in urban China deliver services to elders with considerable variation in their functional capacities and/or cognitive levels. These services include different types of institutional facilities, such as independent residential care, assisted living, and nursing homes, with functions similar to their counterparts in the United States (Feng et al., 2011). From 2006 to 2012, the number of nursing home residents with mixed dependency levels in Shanghai has increased almost 50%, from less than 60,000 to more than 105,000 (Social Welfare Department of Shanghai Civil Affairs Bureau, 2013). This phenomenon calls for exploration of how these elders and their children in Shanghai decide to institutionalize as urban China shifts from its family caregiving tradition. There is a large body of evidence investigating predictors of elders’ nursing home placement. These include advanced age, inability to perform activities of daily living (ADLs) and/or instrumental activities of daily living, living alone, the diagnosis of dementia, and incontinence (e.g. Byrne, Goeree, Hiedemann, & Stern, 2009; Gaugler, Yu, Krichbaum, & Wyman, 2009; Wattmo, Wallin, Londos, & Minthon, 2011). But these quantitative predictors may not convey the nuances of decision-making dynamics, for example, how both generations communicate and negotiate regarding institutionalization. Because of cognitive deterioration of 48.1% of nursing home residents in the United States (Miller, Lima, & Mitchell, 2010), many studies focus only on child caregivers (e.g., McLennon, Habermann, & Davis, 2010). However, investigating a single generation may be inadequate. A dyadic approach can reveal how broad sociocultural shifts may influence communication between members of each generation, who may present a different perspective on institutionalization (Zhang, Harwood, & Hummert, 2005). Indeed, a majority of Chinese nursing home residents maintain their cognitive functioning (Chu & Chi, 2008). Their opinions deserve attention. For example, Chen (2011) investigated 11 cognitively intact nursing home residents’ perspectives on institutionalization in Shanghai. But without their children’s confirmation, the dynamics of negotiations and communication between generations could not be fully understood. Intergenerational communication, including content, frequency, and hierarchy, may reveal the younger generation’s increasing desire for egalitarian status in urban China (Zhang et al., 2005). Another possible reason that intergenerational communication has not been explored in previous qualitative research is that the process is infrequently examined with theoretical constructs, despite an increase in published literature focusing on this phenomenon (e.g., Chen, 2011; Chang

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& Schneider, 2010). However, these studies have not used consistent theories or theoretical constructs, making them potentially vulnerable. Therefore, utilizing a conceptual framework, this study aims to describe what elders and their children in Shanghai experience during the decision-making process around institutionalization.

CONCEPTUAL FRAMEWORK Crisis Theory There is no consistent definition of a family caregiving crisis. Some have referred it as a temporary event, having a sudden onset, and evoking emotional and instrumental caregiving tensions that need to be resolved (Sprangers, Tempelaar, van den Heuvel, & de Haes, 2002). Others have emphasized that a caregiving crisis occurs when children care for sick parents. This caregiving crisis may involve not only health or caregiving issues, but also social, emotional, financial, and idiosyncratic considerations (Sims-Gould, Martin-Matthews, & Gignac, 2008). According to crisis theory, changes may induce a potential caregiving crisis, which requires restructuring of family caregiving patterns (LevyStorms, 1996; Schulz, Gallagher-Thompson, Haley, & Czaja, 2000). Crisis theory defines two main types of changes, maturational and situational (Schulz et al., 2000). Maturational changes pertain to people’s normal development stages over the life course, such as childbirth, children leaving home, and retirement. Situational changes pertain to unpredictable crises, for example, the illness of elderly parents. Both types may lead to family caregiving crises. The former is of greater concern for elders with chronic conditions, whereas the latter relates to various sudden onset of illness, which, if grave enough, may lead to family caregiving crises (Biegel, Sales, & Schulz, 1991). These changes may not predict elders’ immediate institutionalization, but rather may strain family caregiving resources and capacities, causing changes in caregiving arrangements and extra stress on caregiving relationships, which may lead to elders’ institutionalization (Levy-Storms, 1996). For this study, a caregiving crisis was defined to include any changes in caregiving resources, caregiving arrangements, and/or caregiving relationships. It may particularly relate to declining family caregivers’ capacities and/or depleting family caregiving resources to respond to elders’ increasing needs. These caregiving crises may trigger the decision-making process around institutionalization.

Social Identity and Intergenerational Communication Social identity theory (SIT) posits that individuals categorize themselves and others as members of groups. By comparing their group position with that

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of others, they try to achieve a sense of positive identity (Barker, Giles, & Harwood, 2004; Tajfel, 1978). According to SIT, attempts to achieve positive social identity often result in discrimination, favoring members within the group but giving a negative identity for members outside the group. During caregiving decision-making, for example, children may perceive themselves as having more positive identities than their elderly parents, because they have more resources and know more about available social services. Furthermore, social identity manifests in communicative behaviors, especially the linguistic strategies distinguishing members from other social groups (Barker et al., 2004). Hajek and Giles (2003) defined intergroup communication as communicative behaviors based on the social categories between individuals’ identification of themselves and others. For this study, intergenerational communication is defined as the ways children and their elderly parents communicate to decide to institutionalize, including their attitudes, feelings, contents, and perceptual, strategic lingual underpinnings.

Uncertainty Management Theory Uncertainty management theory (UMT) offers a way to sort through the relationships between the experience of uncertainty and information exchanges (Hogan & Brashers, 2009). UMT categorizes the uncertainty management process into information seeking, appraisal, adaptation, and reappraisal (Hogan & Brashers, 2009). When making a caregiving decision, if both generations consider institutionalization a potential solution for the family caregiving crisis, they may collect the information about eligible nursing homes, such as staffing, meal services, and exercise routines. Comparing various uncertainties pertaining to each eligible nursing home and to the degree to which they can manage these uncertainties, elders and their children evaluate different alternatives. After elders move into a nursing home, they may reappraise the decision and choose another that would better fit their requirements and expectations. In particular, uncertainty management is closely connected with decision-making (Scholz, 1983). For this study, uncertainty may be internally attributed (e.g., elders are not sure whether they can benefit more from nursing home care than from family caregiving) or externally attributed (e.g., it is not clear whether institutionalization can reduce the caregiving stress for children; Scholz, 1983). Intergenerational communication may help to clarify these uncertainties to reach a decision on nursing home care for both generations. Table 1 summarizes how the three theories help to conceptualize the decision to institutionalize among elders and their children. The three prior propositions provide direction for the study but do not determine outcomes (Gilgun & Abrams, 2002). They will be modified according to

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TABLE 1 Three Preliminary Propositions Proposition

Theory

1

Crisis Theory

2

Intergenerational Communication

3

Uncertainty Management Theory

Before the Study

After the Study

Caregiving crises may initiate the decision-making process around institutionalization between generations. The younger generation may have greater capacity to make the decision. Each generation may conceptualize caregiving uncertainties differently related to the decision to institutionalize, and intergenerational communication influences the management process.

Family caregiving context

Caregiving uncertainties management Intergenerational communication to gain positive social identity

Family caregiving crises

Deciding to institutionalize

FIGURE 1 Conceptual framework of deciding to institutionalize.

interpretations of participants’ responses in the interviews. The comparison of these propositions before and after the study will appear in the Discussion. Figure 1 presents the conceptual framework of the study. The decision to institutionalize begins with one or more changes in the original family caregiving context, which may become family caregiving crises and trigger intergenerational communication on caregiving alternatives. However, each generation strives for positive social identity and maintains decisionmaking power, because they belong to different generations. They also begin to manage various uncertainties related to the decision to institutionalize. Intergenerational communication conveys opinions and concerns from each side to help manage these uncertainties.

METHODS This study takes a phenomenological approach. “Phenomenology is concerned with wholeness, with examining entities from many sides, angles,

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and perspectives until a unified vision of the essences of a phenomenon or experience is achieved” (Moustakas 1994, p. 58). Because the study focuses on participants’ subjective experiences, perceptions, and meaning-related issues on deciding to institutionalize, a phenomenological approach is ideal. Given the interacting nature of qualitative studies, in this study, I became the instrument to explore intergenerational communication. As a former gerontological social worker intern in a nursing home in Shanghai, I have been fascinated about intergenerational communication among residents and their children. Since then, I’ve intend to bring more insight on how such communication would reflect the evolving filial piety and influence the development of long-term care in urban China. However, I was cautious about my own self-reflection on the phenomenon of interest (Creswell, 2007). I bracketed my knowledge and experiences from my previous study (Chen, 2011) to perform phenomenological reduction. I appraised my stance throughout the data collection and data analysis procedures.

Participants I purposively sampled 12 elders in a government-sponsored, nonprofit nursing home in Shanghai. Government-sponsored nursing homes attract most elders and their children in urban China because of low fees and dependable quality of care (Chen, 2011). These elders had minimal cognitive impairment symptoms assessed by the physician in the nursing home, and lived with their children before institutionalization. Elders helped to identify and invite their children who were their primary caregivers to participate in the study. So I interviewed 12 dyads of matched elders and their children (N = 24). Table 2 displays the characteristics of the sample. Although qualitative inquiry does not require specific rules for sample size (Patton, 1999), saturation was achieved, that is, the basic pattern of decision-making processes reoccurred in each subsequent case analysis. Thus, the 24 interviews were considered sufficient for this study.

Data Collection Data collection consisted of 24 face-to-face, semistructured, individual interviews with elders and their children. The rationale for separating interviews was to avoid potential data contamination between generations. Interview questions, guided by the conceptual framework, included three topical areas: family caregiving contexts and crises, intergenerational communication, and uncertainties related to institutionalization. The interviews took place in a private conference room in the nursing home, and were audio-recorded with permission.

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TABLE 2 Demographic and Health Characteristics of Participants

Age Average (Range) Gender Men Women Length of residence Average (Range) Number of children alive Average (Range) Marital status Married Widowed Individual elder’s retirement plan 500–999 yuan∗ 1,000–1,499 yuan 1,500–2,000 yuan Elders’ living arrangement before institutionalization Living with sons Living with daughters Elders’ self-perceived health status Relatively healthy Not healthy Chronic diseases for elders who considered themselves unhealthy† Asthma Cataract Coronary heart disease Diabetes Minor stroke Relationship with elder Eldest son Youngest son Eldest daughter Second daughter Youngest daughter

Elders (N = 12)

Children (N = 12)

85.7 (81–92)

55.25 (49–61)

3 9

8 4

3.7 (1–9) 3.9 (3–5) 12 12 1 3 (22.2%) 8 (66.7%) 8 4 5 7 1 3 1 2 1 3 5 1 1 2

Note. ∗ At the current exchange rate, 100 yuan equals roughly $16. † These elders had multiple chronic diseases.

Data Analysis I transcribed and translated all interviews into English. All interview data were analyzed together. Data analyses were concurrent with data collection to identify when saturation had been reached. According to Creswell (2007), phenomenological data analysis consists of a series of steps: dividing the original transcriptions into statements, transforming these statements into clusters of meanings, describing concepts relevant to the phenomenon of interest, and linking these statements together to create a general description of the phenomenon.

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I analyzed the data by identifying significant statements, themes, and patterns. Initially, I identified significant statements pertaining directly to participants’ experiences of deciding to institutionalize. Meanings were formulated from these significant statements, through which common themes regarding the decision-making process emerged. I clustered them to identify the basic decision-making pattern. After identifying the pattern, I reread the original transcripts to ensure that no main themes remain unidentified. Furthermore, guided by the dyadic perspective, I compared intradyad characteristics to highlight how they strived to achieve positive social identity in intergenerational communication. I also compared the interdyad experiences throughout the 12 families. I kept field notes, reflexive journals, and memos as audit trails. In addition, an expert in qualitative analysis (my advisor) reviewed data analysis periodically and oversaw all stages of the study.

RESULTS Family Caregiving on the Brink Challenging caregiving for children. First, children did not prioritize their parents in family caregiving when they had other engagements. For example, Ms. Cao-C1 (50 years old) focused more on her daughter, who was going to take the college entrance exam, than on taking care of her father. Mrs. Ye-E (86 years old) felt ignored after her daughter had a granddaughter. Second, it was challenging for children to balance work, their own life, and taking care of elderly parents. Mr. Chen-C (58 years old) said: Taking care of both generations was unbearable for me, especially when both parents fell ill. It was too much. I had to work, as well. But I did not want to ignore my families. So I had to take early retirement to take care of my paralyzed father and my whole family.

Third, children’s health problems prevented them from providing sufficient caregiving for their parents. For example, Ms. Wang-C (50 years old) had a car accident when her father was recovering from a minor stroke, which dramatically decreased family caregiving capacities. Because of her own chronic conditions, Ms. Ye-C (59 years old) was unable to provide adequate caregiving for her mother, who had a broken ankle. Thus, children encountered various difficulties in providing family caregiving, which may have gradually depleted family caregiving resources to respond to their parents’ increasing healthcare needs. Undesirable co-residence for elders. First, different living habits between generations negatively influenced coresidence. For example, Mrs. Zhang-E 1

All participants’ family names are fictitious. E and C indicate elders and their children.

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(86 years old) mentioned that her unique dietary preferences had related to unpleasant coresidence: “Daughters are families. Daughters-in-law are not families, after all. I did not get along well with my youngest daughter-inlaw.” Mrs. Fan-E (88 years old) and her son’s family had different living schedules, which cumulated in various frictions in everyday life. Second, children’s apartment conditions were difficult for elders to live. For example, without elevators, it was impossible for Mrs. Shen-E (93 years old) to go up and down in a six-floor building. Moreover, because of their declining health, elders became increasingly sensitive to their living environment. For example, Mr. Zhou-C (49 years old) said: “Because of his asthma, my father is very alert during night. My apartment is quite old. It is not quite soundproof. My father was very sensitive to the noises. He cannot sleep well and he complained a lot.” Mr. Huang-C (56 years old) reported that the limited space in his apartment prevented him from providing sufficient family caregiving, because he needed extra support to take care of his mother. Third, children’s simplified caregiving––instrumental support only––made their parents feel unwelcome during coresidence. For example, Mrs. Nie-E (87 years old) stated: “I was like an intruder to their life. They care about me, of course, but I couldn’t ask for more because they had already taken me in. I was not happy.” Thus, elders had undesirable coresidence experiences, including environmental difficulties and emotional disturbance, which may have precipitated family caregiving crises. Collapsing family caregiving. Both generations described the critical moment when they realized that family caregiving could not continue. First, elders’ declining health status was beyond their children’s caregiving capacities and resources. Mrs. Lin-E (89 years old) and Mrs. Ye-E (86 years old) had sudden accidents, which left their children unprepared for escalating caregiving burdens. Other elders had chronic conditions over the years, which worsened as they aged, and their children were out of resources to respond. For example, Mr. Huang-C (59 years old) described his frustration: We can take care of my mother’s life, but not her medical conditions. She was always complaining about short breath. What we can do was only to take her to the hospital. We did not know what else we could do to help her.

Furthermore, children were mentally and physically drained by their parents’ needs for healthcare. For example, Ms. Wang-C (50 years old) realized that she could not continue family caregiving even if she had not had the accident, because she had already turned 50 years old and provided care for her father for over 10 years. In particular, several children worried that they might not be able to provide sufficient or timely caregiving for their parents. For example, Ms. Nie-C (55 years old) expressed her concerns: “It is not safe for my mother to stay with me anymore. After all, she is

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getting older and older. You do not know what is going to happen to her at any time.” Because of their parents’ old age, children considered family caregiving became insufficient, regardless of their parents’ health conditions. Therefore, family caregiving was gradually collapsing because of undesirable coresidence conditions for elders and/or challenging caregiving responsibilities for their children. These cumulating factors intertwined with elders’ declining health to create intergenerational tension. Both generations began to reconsider coresidence, realizing that family caregiving may have become inadequate and alternatives were needed.

Seeking Caregiving Alternatives Institutionalization as a viable caregiving alternative. First, all children agreed that nursing home care provided professional healthcare. Mr. Zhou-C (49 years old) admitted that professional healthcare was the most attractive aspect of institutionalizing his father with the hope to improve his father’s health condition. Mr. Fan-C (59 years old) and his siblings agreed with their mother’s proposal: [My siblings and I] agreed with our mother to turn to a nursing home for professional healthcare. We had a couple of meetings about which nursing home to send our mother to. We considered all kinds of service categories, such as food, staff, and administration.

Some elders were also knowledgeable about the services in the nursing homes. For example, Mr. Wang-E (87 years old) agreed to placement because of the professional healthcare in the nursing home. Mr. Cao-E (83 years old) recalled: Other patients told us [Mr. Cao and his late wife], “You two are too old to take care yourselves. It is not realistic to live with children now. Nursing home care is a better choice. You do not need to cook or do any housework. They have doctors and nurses. You can be taken good care of.”

Furthermore, given the limited long-term care options in urban China, both generations favored nursing home care. For example, Mr. Lin-C (61 years old) described: I did not think paid caregivers could have those medical skills to help my mother. Then it only left nursing homes for me to consider.

Thus, both generations preferred nursing home care for its professional healthcare.

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Proposing to institutionalize. Some children directly told their parents to go into a nursing home, explaining that family caregiving could not continue and nursing home care was the only alternative. For example, Mr. Yang-C (57 years old) described how he persuaded his mother: I told my mother that we had no choice. She had nowhere else to go. Moving to a nursing home is the only way for her to have proper care. . . . She is getting older and older. God forbid, if anything happens to her when she’s alone at home, I cannot handle the situation.

Other children indirectly suggested institutionalization for their parents to consider. For example, Mr. Lin-C (61 years old) listed the advantages of institutionalization to prepare his mother in advance. Mr. Zhou-C (49 years old) asked his father to try institutionalization for a month: I asked him to try one month to see if he likes [the] nursing home. I told him that he’s not well and the staff in the nursing home has the medical skills can help him. I also told him that he could go home at any time if he didn’t feel [like] living here anymore.

As such, children directly and indirectly conveyed their ideas to their parents. They controlled the decision-making and emphasized their own caregiving constraints. However, several elders stressed that they proposed to enter a nursing home in the first place. For example, Mrs. Fan-E (88 years old) decided to enter the home because she was too lonely at home. Mrs. Huang-E (86 years old) decided to institutionalize to find her own caregiving solutions. These elders sought caregiving alternatives to maintain their decision-making autonomy. Thus, children decided to institutionalize their parents because of family caregiving crises; elders proposed to go into homes to maintain their independence and autonomy.

Au Revoir Family Caregiving Divergent uncertainties between generations. Elders were concerned about adjusting to life in the new environment. For example, Mrs. Lin-E (89 years old) feared that her limited mobility would make it very difficult for her to adjust to institutional life. Mrs. Yang-E (85 years old) shared her thoughts: I worried about so many things before moving here. I did not know if I was capable of adapting to the life in the nursing home. I was not sure if my children would still come to see me. These two things were my major, major concerns.

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Furthermore, the decision-making was emotionally disturbing for elders. Elders felt violated because of their lack of autonomy and disappointed by their children, who were not honoring filial piety. For example, Mrs. Zhang-E (86 years old) expressed her feelings: The nursing home was a mysterious place to me. I did not know what to expect. I cannot picture myself at such a place with other childless elders. I thought my children just wanted to dump me here.

Children, however, were concerned about the quality of care. In particular, children were uncertain whether relationships between their parents and nursing home staff would adversely affect the quality of care. For example, Mr. Lin-C (61 years old) said, “Staff in the nursing home were not families.” Mr. Zhou-C (49 years old) shared a similar view: I worried about my father’s relationship with staff and fellow residents. My father had become more and more stubborn and paranoid, because he was bed-bound for too long. I just hoped that my father would not fight with the staff.

This concern may have reflected children’s own experiences of family caregiving, in which they had experienced misunderstanding and miscommunication with sick parents. Mystery disentangled. Children helped their parents to manage the uncertainties of institutionalization primarily by searching for qualified nursing homes. Close proximity was one of the most important factors for children in deciding on an eligible nursing home. For example, Ms. WangC (50 years old) described her search process: “My husband and I visited about 10 nursing homes after I was discharged from the hospital. We narrowed down to two nursing homes. This one is closer to my home, so we decided on this one.” Besides proximity, children specifically attended to the quality of care. For example, Ms. Nie-C (55 years old) checked the room, the service, the food, and the healthcare several times before deciding to send her mother to the current nursing home. Children also chose the nursing home because it fit their parents’ preferences. For example, Ms. Cao-C (54 years old) identified this nursing home met her father’s hygiene requirement. Mr. Fan-C (53 years old) chose this nursing home for his mother’s interests: “Besides the good healthcare services, this nursing home offers interest groups, among which there is a Shanghai opera group. My mother loves listening to Shanghai opera. I thought she could continue her hobby in the nursing home.” Once they decided on a nursing home, some children brought their parents to check out the services, themselves, before the placement. Mr. Wang-E (87 years old) recalled his visit:

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My daughter and son-in-law brought me here to check it out. I remember my first impression was clean. I watched several staff working. I even tried the lunch on that day. I liked the food. I was very satisfied with my daughter’s decision. So I moved in here not long after my visit.

Thus, children took various factors into consideration in choosing the current nursing home for their parents, including distance, service quality, and their parents’ preferences, to reduce their parents’ uncertainties about institutionalization.

DISCUSSION Age-Distinctive Decision-Making Dynamics In this study, each generation held a distinct stance related to the decision, suggesting that age differences inevitably emerge in caregiving decisionmaking (Meisner, 2012). Elders decided to enter facilities primarily for more peer support and less loneliness in the nursing home. This may relate to their experiences of discordant caregiving arrangements during coresidence, which contributed to disappointment with and distrust of their children’s practice of filial piety. These elders decided to enter nursing homes because they were familiar with nursing home care. So they may be more open to other types of caregiving alternatives (Wang, Laidlaw, Power, & Shen, 2009). Their positive expectations suggest that engaging with peer groups may give elders a greater sense of psychological comfort and social identification than staying at home alone (Cheng, 2009; Knight, Haslam, & Haslam, 2010). Their recognition of China’s shifting family caregiving tradition lowered elders’ expectations of their children. This finding suggests that Chinese elders acknowledge a discrepancy between filial piety ideal and caregiving reality, and they adjust their expectations accordingly (Li, Long, Essex, Sui, & Gao, 2012). Compared with their parents, children decided to institutionalize mainly for the extra instrumental assistance. Children responded to the increasing family caregiving pressure by seeking professional healthcare in the nursing home. Regardless of their parents’ health conditions, children excised decision-making power to decide for their parents. Ignoring their parents’ autonomy, children’s decision may have evoked their parents’ resentment and disappointment. In addition, children emphasized their siblings’, instead of their parents’, opinions. For example, several children had family conferences with their siblings to discuss the decision. Possibly, they shared mutual understandings of the increasing caregiving pressure, so they jointly decided for their parents (Zhan, Liu, & Guan, 2006).

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Theoretical Implications The conceptual framework, integrating crisis theory, SIT, and UMT, captured the experiences of deciding to institutionalize between generations. Table 3 compares the three propositions before and after the study. The discussion of each theory follows. Crisis theory. First, each generation conceptualized and approached caregiving crises differently. Children reported that their needs for extra assistance with instrumental and medical support fueled caregiving crises. Elders, however, felt their children’s declining willingness to provide care and their emotional distance culminated in undesirable coresidence for them. Emphases on different aspects of caregiving between generations indicate that elders have higher caregiving expectations than their children. Future research should pursue how these discrepancies in conceptualizing caregiving crises between generations influence caregiving decision-making.

TABLE 3 Three Modified Propositions Proposition

Theory

Before the Study

1

Crisis Theory

Caregiving crises may initiate the decisionmaking process around institutionalization between generations.

2

Intergenerational Communication

Children may have greater capacity to make the decision.

3

Uncertainty Management Theory

Each generation may conceptualize caregiving uncertainties differently related to the decision to institutionalize, and intergenerational communication influences the management process.

After the Study When children face depleting caregiving resources, caregiving crises directly initiate intergenerational communication about the decision to institutionalize. When elders and their children take precautions about family caregiving, potential caregiving crises motivate the decision. In general, children lead the decision-making even though elders may maintain decision-making capacities. Both generations share some uncertainties, but different perceptions of nursing home care also exist. Children help their parents to manage uncertainties not only by intergenerational communication, but some also include their parents in the actual selection process.

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Second, both generations recognized that caregiving crises did not necessarily arise suddenly. In this study, children admitted that steady deterioration of their parents’ health, rather than sudden accidents, seriously challenged their abilities to provide sufficient family caregiving. Children’s own constraints also contributed to caregiving crises; their declining stamina prevented them from providing adequate care to their parents and as a result, they were motivated to seek caregiving alternatives. Thus, tremendous caregiving pressure may have triggered children’s decision to institutionalize, especially when they began to appraise family caregiving in relation to their adaptive abilities. Intergenerational communication. Aging is socially constructed (Williams & Nussbaum, 2001). Consequently, when communicating with each other, elders and their children become two distant social groups, which reflects that each generation negotiates identity in the context of age relations (Williams & Harwood, 2004). Children seemed superior to their parents in the decision-making process, because they assumed they were more knowledgeable about nursing home care than their parents. That is, children justified their decision to institutionalize based on the fact that professional healthcare was urgently needed, and purporting that their parents had limited knowledge of available types of formal long-term care. Furthermore, children in this study were more vigilant about responding to family caregiving crises than their parents. They proposed institutionalization to prevent potential caregiving crises. Compared with their children, elders in this study seemed to have less power in the decision-making process. This was particularly true for elders with unstable health conditions. Declining functional abilities increased their dependence on their children and their feelings of obligation, which, in turn, decreased their decision-making autonomy. Although they were disappointed and resented about their children’s decisions, given their frailty, these elders felt powerless to overturn the decisions and the resultant changes in caregiving arrangements. Their mixed attitudes may relate to the fact that Chinese elders sometimes try to avoid intergenerational conflicts to keep harmonious relationships with their children (Li et al., 2012). Future research should explore how elders’ health conditions may affect their identity in intergenerational communication and their autonomy in decisions regarding caregiving. Uncertainty management. Before finalizing the decision to institutionalize, all participants expressed uncertainties related to moving into the nursing home—the social uncertainties categorized by UMT (Hogan & Brashers, 2009). Elders were distressed and anxious about adjustment. Children worried about their parents’ relationships with staff, and the resulting impacts on quality of care. Children engaged in information seeking, appraisal, adaptation, and reappraisal (Hogan & Brashers, 2009). First, they took geographical distance, quality of care, food, and roommate issues into consideration and

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searched for qualified nursing homes. Then they checked services in different nursing homes several times. Finally, children evaluated each eligible nursing home and finalized the decision with their siblings and/or their parents. However, in contrast to UMT, children did not reevaluate the decisions after their parents moved. Because of their health conditions, participating elders did not go through these uncertainty management processes. They did not reevaluate the decision, either. Although several elders had the opportunity to check the nursing home before actually moving, all of them still accepted the decision regardless. Children communicated with their parents to manage uncertainties related to institutionalization by emotionally preparing elders for this lifechanging event. Almost all the participating children listed the advantages of nursing home care to persuade their parents during the decision-making process. Children tried to match the nursing home with their parents’ detailed criteria, such as distance from children’s home and living conditions of the nursing home, which helped to reduce elders’ uncertainties. However, neither generation described intergenerational communication after they finalized the decision. Future research should explore whether and how children continue to address their parents’ feelings of uncertainty and being abandoned after institutionalization.

Implications for Research and Social Work Practice First, this study establishes a conceptual framework to capture the decisionmaking process around institutionalization among elders and their children. This framework helps to analyze how, when, and under what circumstances this decision may occur. This process involves the original family caregiving context, family caregiving crises, intergenerational communication, uncertainty management, and finalizing the decision. Examining these elements may help the younger generation know when they need to take actions to face crises and seek alternatives before family caregiving reaches its limits. It is also meaningful to the older generation to emotionally prepare to receive instrumental support from people other than their children. However, this framework needs further testing in in the world facing aging trends. Second, this study shows participants’ unexpected strong confidence in government-sponsored nursing homes. This may relate to the missing reevaluation stage of both generations’ uncertainty management process, which may be because they trusted the government-monitored professional healthcare. Without many other choices, participating elders unconditionally accepted their children’s decisions. Meanwhile, their children reported that monitored nursing home care compensated for inadequate family caregiving. Children continued to focus on instrumental support, rather than emotional attachment with their parents, because they decisively prioritized the former. This finding suggests that although children consider various interpersonal

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and pragmatic factors when making caregiving decisions, the final decision may still emphasize feasibility (Caron & Bowers, 2003). Finally, this study provides insight into health assessments, coordination of and support for decision-making, adjustment to long-term care, and family communication as essential components to social workers’ roles in long-term care (Berkman, Gardner, Zodikoff, & Harootyan, 2006; Koenig, Lee, Fields, & Macmillan, 2011). Given the mixed needs for long-term care of elders in urban China (Feng, Liu, Guan, & Mor, 2012), detailed needs assessment can help target specific needs and link them with suitable services (e.g., tailored community-based services vs. simple institutionalization). Furthermore, children’s regular, effective communication can prompt the mental health of elders during the transition period of institutionalization (Koenig et al., 2011). In addition, understanding intergenerational communication can ease the tension between families and staff, who often have negative stereotypes of one another (Pillemer et al., 2003) and reduce anxiety and stress caregiving for elders.

Study Limitations Several limitations of this study should be noted. First, because elders and their children were interviewed retrospectively, some inaccurate descriptions may have occurred due to participants’ naturally diminished memories. Furthermore, participants may have remembered relatively more intensive conversations and forgotten less outstanding ones that took place much earlier. The conceptual framework may have missed earlier conversations about caregiving arrangements between generations. Second, some participants may have hidden their true feelings; others may have tried overly hard to cooperate by offering responses that they perceived as helpful. Third, a purposive sample may be too limited. The sample in this study was limited to participants with similar income levels and within a particular geographic area. Fourth, all elders lived with their children prior to institutionalization. Regardless of their difficult relationship during coresidence, these elders may have held rather traditional views on family caregiving, as their children followed the filial piety. Their perceptions of nursing home care may be different from elders who lived alone before institutionalization. Finally, excluding other family members might have missed a holistic understanding of children’s perspectives in the caregiving decision-making. Future study may integrate the experiences from all siblings and probably, children-in-law as well.

Conclusion In sum, this study recognizes the shifting family caregiving tradition in urban China and its implications for elders’ caregiving arrangements. Integrating

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crisis theory, SIT, and UMT, this study conceptualizes the experiences of institutionalizing among elders and their children in Shanghai. The findings suggest that caregiving crises may have triggered intergenerational communication on caregiving decision-making and, eventually, institutionalizing elderly parents. Children retained a positive social identity in the intergenerational communication and a superior position in the decision-making, compared with their elderly parents. Elders’ declining health conditions prevented them from striving for positive social identity and obtaining more decision-making autonomy. By communicating about their concerns, children helped their parents to manage the uncertainties about institutionalization along the process. However, the implications of these three theories need further examination in other caregiving contexts. In relation to gerontological social work practice, this study informs needs assessments for more specialized long-term care services and intergenerational communication with family members and staff members in the nursing home to improve direct care for elders.

ACKNOWLEDGMENTS I thank all the elders and their children for graciously agreeing to participate in this study. I am very grateful to my dissertation committee chair, Dr. Lené Levy-Storms, for her advice, suggestions, and comments throughout this study. I also appreciate valuable input from my committee members: Dr. Laura Abrams, Professor A. E. Benjamin, and Professor Marjorie Kagawa-Singer.

FUNDING The author received the Dissertation Year Fellowship from the Graduate Division, University of California, Los Angeles to conduct this study.

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