Caregiving appraisal refers to how caregivers evaluate their caregiving situation. However, this concept, first introduced by Lawton et al. in 1989, has been inconsistently defined (e.g., often inaccurately interchanged with caregiving burden) over the past three decades. As the landscape of healthcare advances and caregiver roles evolve, it is crucial to re-evaluate the concept of caregiving appraisal. This concept analysis aimed to achieve conceptual clarity and to understand the multidimensionality of caregiving appraisal. Using Rodgers’ evolutionary model, our analysis systematically searched six databases, identifying 86 relevant studies that revealed various definitions and dimensions of caregiving appraisal. The concept analysis clarifies that caregiving appraisal involves subjective cognitive evaluations and assessments by caregivers, encompassing cognitive and affective responses, and the re-evaluation of potential stressors and one’s coping ability. Caregiving appraisal is a multidimensional construct that can be neutral, positive, or negative. Different dimensions of caregiving appraisal can occur simultaneously. Additionally, caregiving appraisal acts as a mediator between caregivers’ objective stress and their reactions to that stress. In this analysis, we defined the action of appraising unspecified stress in a caregiving situation as the general (or broad) definition of caregiving appraisal and the action of appraising specified stress as the specific (or narrow) definition (e.g., illness severity caregiving appraisal and social support caregiving appraisal). Caregiving appraisal encompasses four key categories: caregivers appraising their own situation, caregivers assessing the care recipient’s situation, caregivers evaluating personal capabilities, and caregivers evaluating the caregiver–care receiver relationship. This conceptual analysis underscores the imperative need to reassess Lawton’s caregiving appraisal model and refine measurement tools in line with evolving healthcare practices. Future studies must clearly define caregiving appraisal, avoid using a single dimension to reflect holistic caregiving appraisal, and provide a valid reason for only focusing on one (or several) domain when using caregiving appraisal as the concept of interest.

1. Introduction

Informal caregivers, who are relatives, partners, friends, or others providing uncompensated care, play a fundamental role in managing symptoms and assisting with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) for those dealing with chronic illness or functional impairments [1]. These caregivers also help navigate the complex healthcare system, including insurance processes, treatment options, and medical procedures [2]. Caregiving can be demanding and stressful, particularly because caregivers may lack the resources necessary to manage the physical and emotional demands of caregiving [3]. Most caregiving is provided at home, where medical support is minimal [4] and respite is rare, especially when caring for highly dependent patients [5]. Besides the physical and emotional toll, caregivers also face the economic impact of caregiving, such as lost wages or job instability, and the financial burden associated with healthcare expenses, medications, and specialized equipment [2]. Consequently, many caregivers are at greater risk of deteriorating physical and mental health [6, 7], including higher rates of depressive symptoms, poorer sleep quality, and decreased quality of life [8].

While challenges can be significant, caregiving can also have positive effects such as increased sensitivity to persons with disabilities, clarity about life priorities, and a greater sense of inner strength, along with caregiving satisfaction and finding meaning through the caregiving experience [9, 10]. Other positive effects include a sense of purpose, feeling useful, gratification when the caregiver completes caregiving tasks, and the development of a closer relationship with the care recipient [11].

An individual’s perception of events and experiences directly and indirectly influences their emotional and behavioral reactions [12]. According to Lazarus and Folkman’s stress theory, stress occurs when the demands of a situation exceed one’s capacity to manage it [13]. The stress theory emphasizes the dynamic interaction between the individual and the stressor, recognizing that stress is not solely determined by the objective characteristics of the stressor, but rather by the individual’s perception and interpretation of the situation. It underscores the importance of individual differences, cognitive appraisal, and coping strategies in shaping the stress experience and its outcomes [13]. Negative perceptions about caregiving may lead to declines in emotional health and problematic behaviors such as anger, confrontation, and defensiveness. In contrast, caregivers with a positive disposition toward their role, and who perceive their caregiving situation as manageable, typically demonstrate more positive emotions [10, 14, 15].

Based on Lazarus and Folkman’s stress theory, caregiving appraisal was initially coined in 1989 and defined as “all cognitive and affective appraisals and reappraisals of the potential stressor and the efficacy of one’s coping efforts” [13, 16]. A caregiver’s appraisal of the experience and the relationship between the caregiver and the care recipient are integral factors influencing the experience and its effect on the caregiver’s sense of self [17]. Continuous appraisal of the caregiving experience may constitute a daily reality for many caregivers [18]. However, inconsistencies exist in how caregiving appraisal is understood [19]. Caregiving appraisal was initially designed to reflect the primary appraisal (the assessment of the stressor’s relevance) and secondary appraisal (the evaluation of coping resources in relation to the demand) in Lazarus and Folkman’s stress theory [20–22]. While Lawton, who developed the widely used Caregiver Appraisal Scale, believed that caregiving appraisal mainly falls under secondary appraisal [16], its interpretation has varied over time [23, 24].

As healthcare practices and policies continue to evolve, the roles of caregivers also continue to change [19, 25]. Caregivers now face different challenges and have modified their caregiving tasks compared to 1989. For example, from 1990 to 2019, the life expectancy of adults aged 65 and older increased significantly by 2.1 years, but their healthy life expectancy only rose by 1.4 years, resulting in a slightly longer period spent in poor health [26]. Not surprisingly, during the same period, the family caregiver burden has been reported to increase as well [27]. Second, there is an increasing number of caregivers who are children of care recipients. Many caregivers juggle caregiving responsibilities with their own careers, family duties, and personal lives, leading to time management challenges and role conflicts. The proportion of primary caregivers have either a full-time or part-time job was 28.2% in 1989 [28] compared to 61% in 2024 [29]. Third, with the rise of telehealth and remote monitoring, caregivers must be adept at using digital tools to track health metrics, communicate with healthcare providers, and access health information online. However, many current caregivers have been reported to have low income and low education levels, both factors associated with less frequent use of technology [30, 31]. As the population of older adults continues to grow, it is projected that the number of caregivers will also increase exponentially, warranting the need to reexamine the concept of caregiving appraisal.

The purpose of this concept analysis is to achieve a clearer and more accurate conceptual understanding of caregiving appraisal. This study aims to disentangle the overlap between related terms and refine the concept’s attributes to enhance understanding of caregiving appraisal and inform nursing research and practice.

2. Methods

We used Rodgers’ evolutionary model for this concept analysis, as the model addresses contemporary concerns by valuing the dynamic and evolutionary characteristics of concepts [32]. Since the term “appraisal” was first introduced in the stress model in 1984 [13], exported into the nursing and caregiving context in 1989 [16], and has continued to be used in caregiver research, we believe that an in-depth understanding of the concept requires an examination of its evolutionary development. Rodgers argues that concepts develop over time and are shaped by the context in which they are used [33]. This is evident in our concept of interest. For example, when the focus is on a caregiver’s overall evaluation of their caregiving experience, the definition of caregiving appraisal typically aligns with Lawton’s framework. However, when the context involves specific stressors (e.g., illness, pain, lack of social support), the definition of caregiving appraisal diverges from Lawton’s model, which focuses on general caregiving experience appraisal rather than specific stressor appraisal.

Using Rodgers’ step-by-step inductive analysis [34] and its clearly defined phases ensures the unambiguous use of concepts and facilitates the analysis of potential differences between disciplines [33]. We applied the seven phases of Rodgers’ model, namely: (1) identify and name the concept of interest; (2) identify the surrogate terms and relevant uses of the concept; (3) select an appropriate realm (sample) for data collection; (4) recognize attributes of the concept; (5) ascertain the references, antecedents, and consequences of the concept, if possible; (6) identify concepts related to the concept of interest; and (7) generate a model case of the concept [32].

For this study, all selected articles were carefully reviewed to extract data on definitions, defining attributes, antecedents, consequences, empirical referents, dimensionality of caregiving appraisal, and conceptual framework. In addition, alternative and related terms were summarized. Rodgers’ analysis emphasizes the centrality of three influences on the meaning attached to a concept: significance, usage, and application [34]. Accordingly, we used thematic analysis to distinguish attributes, antecedents, and consequences of caregiving appraisal through coding and categories process. After achieving data saturation, extracted data were categorized and labeled.

3. Results

The results of this concept analysis are structured into seven distinct phases, each aimed at systematically dissecting and enhancing our understanding of the concept of caregiving appraisal. This approach improves clarity in identifying, defining, and operationalizing caregiving appraisal within the broader context of healthcare and caregiving research.

3.1. Phase 1: Identify and Name the Concept of Interest

The name of the concept of interest in this concept analysis is caregiving appraisal.

3.2. Phase 2: Identify the Surrogate Terms and Relevant Uses of the Concept

“Caregiving appraisal” consists of two parts, “caregiving” and “appraisal.” A caregiver is defined as a person who provides direct care to children, elderly individuals, or those with chronic illnesses [35]. Broadly, caregiving refers to the activity performed by caregivers [36]. More specifically, as defined by a qualitative concept analysis, caregiving is the process of assisting someone who is unable to care for themselves in a holistic manner—physically, mentally, emotionally, and socially [37]. Informal caregivers are those who provide unpaid, ongoing assistance with ADLs or IADLs to individuals who may have chronic illnesses or functional limitations [38, 39]. Surrogate terms of “caregiver” include “carer,” “caretaker,” “family caregiver,” “unpaid caregiver,” and “informal caregiver” [40–43].

Appraisal is a term used across multiple disciplines. According to Merriam-Webster, appraisal is defined as an act or instance of appraising or assessing something or someone; appraising means to set a value on, estimate the amount of, or evaluate the worth, significance, or status of something [35]. The Oxford Advanced Learner’s Dictionary defines an appraisal as a judgment of the value, performance, or nature of somebody or something [44]. In the field of business, an appraisal refers to the evaluation of property, such as real estate, a business, a collectible, or an antique, by an authorized person [45]. In psychology, appraisal is a subjective process used to assess whether an external situation is a stressor or nonstressor and to evaluate one’s capability for coping with the threat [13]. In other words, appraisal is an evaluation of the equilibrium between demands and resources [20]. Surrogate terms of appraisal include appraisement, assessment, evaluation, estimation, interpretation, judgment, and value judgment [35]. Related terms include perception, perspective, attitude, affect, and emotion [46, 47]. Appraisal is also defined as a set of cognitive actions, an evaluative judgment about situations, and a cognitive process performed by an individual who may or may not be consciously aware of doing it [21]. Appraisal influences an individual’s adjustment, adaptation, emotional status, and the process of attributing personal meaning to a situation [48]. Appraisal occurs when individuals evaluate circumstances based on their unique configuration of needs, goals, values, and abilities [49]. In addition to the initial evaluation of threats and coping resources, the appraisal also involves assessing a potentially stressful person–environment encounter in terms of its personal meaning or significance to the individual’s well-being [50].

Lazarus et al. often serve as the foundation of Lawton’s caregiving appraisal model [16]. Lawton realized the uniqueness of the cognitive process in caregivers compared to the general population and exported the concept of cognitive appraisal from the stress model into the caregiving context, termed caregiving appraisal [13, 16]. “Caregiving appraisal” was initially coined to replace “caregiver burden” to reflect a broader and holistic conceptualization [16]. Caregiving is a mixture of positive and negative experiences, but its most investigated aspect in research is the subjective burden [20]. Caregiver burden only describes the negative aspects of the caregiving experience; therefore, it should only be considered a related term, not a surrogate term. Besides the caregiving burden, the other major dimensions of caregiving appraisal based on Lawton’s framework include “caregiving satisfaction,” “perceived caregiving impact,” “caregiving mastery,” and “caregiving ideology” [16]. The subdomains of caregiving appraisal are not limited to Lawton’s caregiving appraisal model; multiple caregiving appraisal theories exist across the literature, which will be further explained in Phase 4. Since each of these subdomains does not capture the comprehensive aspects of caregiving appraisal, they are also considered as related terms instead of surrogate terms. Before the term “caregiving appraisal” was coined in 1989, studies had been using “cognitive appraisal of the caregiving situation” to characterize this concept, which was measured by the Burden Interview [51]. Other surrogate terms that can be used interchangeably include “caregiver appraisal” [49, 52], “caregiver’s cognitive appraisal” [53, 54], “caregiver’s stress appraisal” [55–57], “caregiver’s cognitive stress appraisal,” “caregiver’s psychological appraisal” [17], “caregiver’s perceived stress appraisal” [58], and “caregivers’ threat appraisal and benefit appraisal” [59].

It is worth noting that large volumes of the literature have used the term “caregiving appraisal” outside of Lawton’s framework and definition (Table 1). Instead of appraising unspecified stimuli or stress (general experience) in caregiving, caregiving appraisal is also the evaluation of specified types of stimuli or stress, including symptom appraisal, pain appraisal, appraisal of social support, appraisal of medication side effects, and appraisal of technology. In this concept analysis, we define the action of appraising unspecified stimuli or stress in caregiving situations as the general (or broad) definition of caregiving appraisal; we define the action of appraising specified stimuli or stress as the specific (or narrow) definition of caregiving appraisal. Caregivers’ appraisals of the general caregiving experience and specific stress targets (e.g., illness severity) are distinct concepts [60], which will be further clarified in Phases 4 and 6.

Table 1. Caregiving appraisal of context-specific experiences or situations (nontraditional caregiving appraisals).

Caregiver appraisal of illness [60, 61]

Caregiver appraisal of symptoms [62]

Caregiver appraisal of functional capacity [63, 64]

Caregiver appraisal of behavioral problems [17, 53, 65]

Caregiver appraisal of social support [66–68]

Caregiver appraisal of interpersonal communication strategy [69]

Caregiver appraisal of emotion expression [70]

Caregiver appraisal of family environment [12]

Caregiver appraisal of ability to cope [71]

Caregiver appraisal of self-efficacy [72]

Caregiver appraisal of pain management [62]

Caregiver appraisal of medication side effects [62]

Caregiver appraisal of technological support [73]

Caregiver appraisal of caregiving roles [74]

Caregiver appraisal of sleep quality [75]

Caregiver appraisal of loss [76]

3.3. Phase 3: Select an Appropriate Realm (Sample) for Data Collection

A review of nursing and health-related literature covering the years 1989–2023 was conducted. The Medline (Ovid), CINAHL Plus with Full Text (EBSCOhost), Embase (Elsevier), APA PsycINFO (EBSCOhost), Sociology Source Ultimate (EBSCOhost), and ProQuest Dissertations and Theses Global were systematically searched to identify relevant studies. An example of the MEDLINE search is as follows: (exp Caregivers/) OR ((carer^∗ OR caregiver^∗ OR caretaker^∗).ti,ab.) OR ((Care Adj2 (giver^∗ or giving or taker^∗ or partner^∗)).ti,ab.) AND ((apprais^∗ or reapprais^∗).ti,ab.). The database search was developed and conducted by two medical librarians with input from the other authors and included a mix of keywords representing caregiving and appraisal. Other sources included Merriam Webster, Oxford Advanced Learner’s Dictionary [35, 44], encyclopedias, and Investopedia. The terms “caregiver appraisal,” “caregiving appraisal,” or “carer appraisal” were identified as the appropriate search terms as they are the most common terms used to describe the concept of interest.

We included studies that met one of the following criteria: (1) offered definitions, antecedents, and consequences of caregiving appraisal; (2) delved into conceptual models of caregiving appraisal; and (3) employed qualitative methodology to investigate the nature or the process of caregiving appraisal. Studies solely utilizing the Caregiving Appraisal Scale (CAS) without providing information on conceptual clarity were excluded. Additionally, studies focusing on interventions, such as feasibility and effectiveness, were excluded. The present concept analysis covers articles from each decade spanning the 1980s to the 2020s. The articles were selected through purposive sampling to capture theoretical richness in the utilization, application, or exploration of the concepts over the 35 years since their inception [77]. Specifically, articles with theoretical discussions on the nature of the concepts, conceptual definitions, explorations of their use, or characteristics were abstracted and organized by concept [78]. After the search, 6403 articles were uploaded into Covidence Systematic Review Software [79], with 2700 duplicates automatically removed. A total of 3703 citations underwent title and abstract screening. After the title and abstract review, 314 articles were subject to full-text review, resulting in the inclusion of 86 final articles.

3.4. Phase 4: Recognize Attributes of the Concept

Defining attributes are critical characteristics that differentiate one concept from other related concepts and clarify its meaning [80]. Essential attributes of “caregiving appraisal” are as follows.

3.4.1. Multidimensionality

Caregiving appraisal is fundamentally a multidimensional construct. The multidimensional nature is exemplified in Lawton’s framework, which included subjective burden, satisfaction, the impact of caregiving, caregiving mastery, and reappraisal (caregiving ideology) [16, 22]. In his framework, Lawton characterized the multidimensionality of caregiving appraisal as “the cognitive and affective responses or evaluation and re-evaluation that caregivers have in reaction to the demands of caregiving” [16] or “an evaluation of any part of the caregiving process” or “a caregiver’s subjective perception of objective demands” [22]. Beyond Lawton’s framework, various definitions (Table 2) and models in the literature have also highlighted different dimensions of caregiving appraisal. Over time, the concept evolved, and multiple caregiving appraisal frameworks and models were proposed; all of them have more than one dimension:

•
Oberst’s caregiving appraisal theory (4 subdomains): Harm (or loss), threat, challenge, and benign [94].
•
Szmukler’s caregiving appraisal theory (10 subdomains): Difficult behaviors, negative symptoms, stigma, problems with services, effects on the family, the need to provide backup, dependency, loss, rewarding personal experiences, and good aspects of the relationship with the patient [95].
•
Braithwaite’s caregiving appraisal theory (six subdomains): Task load caregiving, dysfunctional caregiving, inner strength and efficacy, social captivity, intimacy and love, and social distance [84].
•
Oumtanee’s family appraisal theory (three subdomains): Stressor appraisal, situational appraisal, and global appraisal [96].
•
Gitlin’s caregiving appraisal theory (three subdomains): Somatic appraisal, affect appraisal, and management appraisal [97].

Table 2. Definitions of caregiving appraisal (chronological order).

[16] 1989	The largest category that includes all cognitive and affective appraisals and reappraisals of the potential stressor and the efficacy of one’s coping efforts. The major dimensions of caregiving appraisal are caregiving satisfaction, perceived caregiving impact, caregiving mastery, caregiving ideology, and subjective caregiving burden.
[22] 1991	The evaluation of any part of the caregiving process, an outcome of caregiving and a central mediator between the stressor and psychological well-being of caregivers.
[81] 1996	A cognitive process of caregivers based on self-defined stress within his or her personal meaning system, rather than according to a universal standard.
[82] 1998	Caregiving appraisal is [16] definition + caregiver’s action to integrate environmental realities and personal interests.
[83] 1999	A process of self-talk, the set of evaluating thoughts caregivers give to facts and events that happen to them that determine their emotions and reactions
[84] 2000	Caregiving appraisal is [16] definition + a comprehensive term including the following aspects: (1) task load caregiving, (2) a dysfunctional caregiver–care receiver relationship, (3) threat of social captivity, (4) intimacy and love, (5) caregiver resiliency, and (6) social distance caregiving.
[85] 2002	A subjective interpretation of impact, burden, satisfaction, and mastery.
[86] 2003	The process by which a caregiver estimates the amount of significance of caregiving; the caregiver’s assessment of both the nature of the stressor and his or her resources for coping with it.
[48] 2003	An evaluative process (instead of an informative process) one that focused on meaning or significance of caregiving.
[17] 2005	A way of caregivers making sense of their experience.
[87] 2007	Caregiving appraisal is [16] definition + caregiving appraisal and also includes reappraisal, which is a neutral appraisal of the caregivers’ cognitive interpretation of their feelings about caregiving and caregiving behavior.
[49] 2012	The process by which an individual estimates the amount or significance of caregiving.
[88] 2012	The salience of both threatening and positive aspects of the caregiving role.
[89] 2013	The subjective perception of distress and loss consistent with burden and impact as well as the subjectively perceived positive aspects and gains from the experience.
[52] 2013	The process by which a caregiver estimates the amount or significance of caregiving taking into consideration both the nature of the stressor and the resources to cope with it.
[90] 2017	Caregiver burden and self-efficacy.
[91] 2018	Caregiver burden and self-esteem.
[18] 2018	How caregivers view or perceive the positive and negative aspects of the caregiving experience.
[19] 2020	Caregiving appraisal is [16] definition + the cognitive evaluation of the caregiving situation (whether and to what extent the transaction between the person and the environment is stressful or not).
[92] 2020	The way caregivers perceive or appraise context-specific experiences.
[93] 2022	The ways that caregivers view their roles.

3.4.2. Subjectivity

A key attribute of caregiving appraisal is that it consists of subjective cognitive evaluations based on the caregiver’s perceptions. These evaluations are not merely reactions to objective demands but are influenced by the caregiver’s personal meaning systems, self-talk, and assessment of stressors and coping resources within the caregiving context (Table 2). Caregiving appraisal is firmly based on actual caregiving demand but encompasses more than the actual demand alone: “It’s not the external demand, it’s the person’s perception of the demand” [22]. Evidence supporting this defining attribute includes terms such as subjective perception [89], self-defined stress [81], subjective evaluating thoughts caregivers give to facts and events [83], subjective interpretation [85], a caregiver estimates the amount of significance [86], evaluative process focused on meaning [48], and cognitive interpretation of feelings [87].

3.4.3. Flexibility: Context-Dependent and Dynamic Nature

Caregiving appraisal is a dynamic cognitive process that evolves based on the context in which it occurs. Different contexts or stressors can lead to varying definitions and understandings of caregiving appraisal. This dynamic characteristic is what Rodgers emphasizes in her evolutionary model, where concepts develop over time and are influenced by the context in which they are used. Lawton’s initial model was revised and expanded by various researchers over time. The initial version of Lawton’s framework included subjective burden, satisfaction, the impact of caregiving, caregiving mastery, and reappraisal (caregiving ideology) [16]. It is important to note that, due to its psychometric limitations [16, 22], the first version of Lawton’s framework is less used compared to the revised 4-domain framework (subjective burden, satisfaction, impact of caregiving, and caregiving mastery) [23, 98, 99] and the revised 3-domain framework (subjective burden, satisfaction, and impact of caregiving) [89]. The binary framework (subjective burden and satisfaction) has also been found to be occasionally used [22]. Crabb and colleagues also proposed a 3-subdomain model, which overlapped with Lawton’s model to some extent, suggesting that caregiving appraisal consisted of caregiving satisfaction, caregiving burden, and caregiving self-efficacy [100]. Other studies have also indicated that caregiving appraisal consists of caregiver burden and self-efficacy [90] or burden and self-esteem [91].

3.4.4. Valence: Neutral, Positive, and Negative Dimensions

Caregiving appraisal can have neutral, positive, or negative dimensions. These dimensions can occur simultaneously and are critical in understanding the full scope of caregiving appraisal. Among the five subdomains, subjective burden and caregiving impact are considered negative domains, whereas caregiving satisfaction is a positive domain. Caregiving mastery and reappraisal (caregiving ideology) are considered neutral domains. Specifically, caregiving satisfaction represents perceived gains from desirable aspects of, or positive affective returns from, caregiving and was defined as the realization that what one does or feels as a caregiver is a source of personal satisfaction [22]. Other components of caregiving satisfaction include cumulative daily uplifts, experiences that provide pleasure, joy, or affirmation [85, 101], and caregiver esteem [49, 91]. Caregiving burden was defined as the perception of anxiety, depression, demoralization, generalized loss of freedom, or other forms of psychological distress as a result of caregiving activities [22]. Other aspects of caregiving burden include worry, anxiety, frustration, fatigue, poor health, guilt, resentment [85], isolation, loss of control, and feeling trapped [101]. Caregiving mastery, a concept closely associated with caregiver self-efficacy, is the self-appraised ability to deal with caregiving tasks and demands [101], and the perception or evaluation that a caregiver is capable of coping with stressors in caregiving as they arise [102, 103]. In addition, caregiving mastery is considered a relatively stable view of self that includes the expectation of behavioral competence [85]. Caregiving impact refers to the degree to which caring for a family member disrupts life patterns [102] or the perception that caregiving has intruded upon social life, activities, work, and other areas [85]. Examples of caregiving impact could include hampered lifestyle, negative family relationships, loss of privacy, less socialization, and diminished personal space [101]. Finally, caregiving ideology was defined as the “meaning” that family members attribute to caring for their family member at home [102], the moral or traditional ideas about caregiving obligations, or the perceived social pressures that promote caregiving behaviors [101]. Caregiving ideology is closely tied to the cultural background of a caregiver [83].

3.4.5. Mediation: Mediating Role of Caregiving Appraisal

Caregiving appraisal serves as a mediator between caregivers’ objective stressor and their stress reaction. Lazarus and Folkman’s general stress theory considers appraisal as a cognitive mediational process [13]. Similarly, caregiving appraisal is an outcome of caregiving but, in turn, as the central mediator between the stressor (e.g., the demand of caregiving) and psychological well-being in Lawton’s model [22]. Various studies have supported the mediating role of caregiving appraisal. For example, a study has shown that caregiving stressors did not affect well-being through direct paths, but it was mediated by effects for subjective appraisal [66]. Similarly, another study has demonstrated that cognitive appraisal plays a mediating role between severity of patient condition (as a source of stress) and caregiver depression [54]. Additionally, Pot et al. showed that caregiving appraisal, as measured by perceived pressure from caregiving, mediated three out of four associations between stressors and caregivers’ psychological distress [55]. However, the mediation role can be convoluted, as caregiving appraisal could be separated into primary and secondary appraisal, and primary or secondary appraisal alone cannot explain the relationship between stressors and psychological outcomes [104]. This mediating role is crucial as it highlights how the caregiver’s subjective evaluation of their situation influences their overall experience and well-being. The multidimensional and dynamic nature of caregiving appraisal allows it to function as a critical intermediary that shapes how caregivers respond to the challenges and rewards of their role.

Finally, to obtain a richer and more informative definition of caregiving appraisal that aligns with contemporary usage, we used Lawton’s definition as a foundation, enhancing it with its defining characteristics obtained from our literature review. In the following three sentences, we define caregiving appraisal as: Caregiving appraisal is the subjective cognitive and affective evaluations of caregivers regarding the potential stressors and the effectiveness of coping efforts within the caregiving process, considering positive, negative, and neutral aspects of the caregiving experience. This dynamic, context-dependent process serves as a mediator between caregiver objective stressors and stress reactions. Caregiving appraisal is a multidimensional concept that includes, but is not limited to, subjective burden, caregiving satisfaction, perceived impact, caregiving mastery, and caregiving ideology. In essence, caregiving appraisal can be succinctly defined as how caregivers evaluate their caregiving situation and roles.

3.5. Phase 5: Ascertain the References, Antecedents, and Consequences of the Concept

3.5.1. Empirical Referent

Empirical referent refers to the measurable aspect that represents a concept of interest. As discussed in Phase 2, there are two major groups of caregiving appraisal: caregiving appraisal related to Lawton’s model (the general definition: caregiving appraisal of the overall caregiving experience or caregiving appraisal about unspecified stimuli or stress) and caregiving appraisal irrelevant to Lawton’s model (the specific definition: caregiving appraisal about specific stimuli or stress, including symptom appraisal, pain appraisal, appraisal of social support, appraisal of medication side effect, and appraisal of technology).

When caregiving appraisal is used in the context of the general definition, Lawton’s CAS, or its variations, was most often used as the empirical referents [22, 23, 85, 89, 98, 99, 101–103, 105]. Besides Lawton’s CAS, two other commonly used measures that assess holistic caregiving appraisal are Appraisal of Caregiving Scale (ACS) [94] and Experience of Caregiving Inventory (ECI) [95]. Other less commonly used tools that measure caregiving appraisal are listed in Table 3.

Table 3. Empirical referents of caregiving appraisal (assessing both positive and negative aspects of caregiving appraisal).

ECI: Experience of Caregiving Inventory [95]

ACS: Appraisal of Caregiving Scale [94]

RCAS: The 2-Factor Revised Caregiving Appraisal Scale (based on CAS) [92];

CRA: Caregiver reaction assessment [106]

Caregiver Appraisal Scale [107, 108]

Carer Appraisal Scale (1st and 2nd Edition) [109, 110]

CCA: Cognitive caregiving appraisal [111]

EOLCAS: End-of-Life Caregiving Experience Appraisal Scale [112];

FACQ-PC: Family Appraisal of Caregiving Questionnaire for Palliative Care [113, 114]

CGQ: Caregiver Questionnaire [103, 115]

PCI: Perceived Change Index [97]

Three-dimension appraisal measurement [116]

Six-dimension appraisal measurement [84]

Revised Caregiver Appraisal Scale and the Brief Family Distress Scale [107, 117]

However, when caregiving appraisal was used in the context of the specific definitions, measurement tools vary based on the specific target that caregivers appraise. For example, the caregiver’s appraisal of family environment is measured by the 27-item Family Relationship Index, which was used to measure caregivers’ perceptions of the family environment and their interactions with their care recipients [12]; caregiving appraisal of illness is measured by Carers Beliefs about Illness Questionnaire (CBIQ), which assesses whether caregivers perceive the patient’s illness as having a negative impact on the patient’s future goals and outlook [118]; and caregiver’s appraisal on impression of the patient’s overall progress is measured by Carer Appraisal Scale, which shares a similar name with CAS but measures completely distinctive concept other than Lawton’s caregiving appraisal [109, 110]. It is worth noting that there were occasions when different domains under caregiving appraisal were measured using different instruments, and sometimes, items of one subdomain within CAS were used in combination with other measurement tools. For example, a study used separate measures for caregiving satisfaction, burden, and self-efficacy and integrated them together as a measure of caregiving appraisal [89].

Based on the questionnaire items that have been used to assess caregiving appraisal (Table 3), caregiving appraisal mostly occurs in 4 distinct but related ways: (1) Caregivers appraise their own situation; (2) caregivers appraise the care receiver’s situation; (3) caregivers appraise what they can do or if they are able to do; and (4) caregivers appraise the relationship with the care receiver/family. We have provided ten questionnaire item examples under each category (Table 4).

Table 4. The meaning of caregiving appraisal under four categories (questionnaire item examples).

Caregivers appraise their own situation	Caregivers appraise the care receiver’s situation	Caregivers appraise what they can do or if they are able to do	Caregivers appraise the relationship with the care receiver/family
The situation doesn’t affect my lifestyle [94].	The patient is unpredictable [95].	I feel difficulty getting information about the patient’s illness [95].	The illness causing a family breakup [95].
This situation isn’t especially stressful for me [94].	The patient is behaving in a strange way [95].	I know how to make complaints about the care [95].	The patient is good company [95].
I am healthy enough to care [106].	The patient lacks interest in things [95].	I feel unable to do the things I want [95].	My relationship with the person needing my care has suffered a lot [94].
I resent having to care [106].	The patient is uncommunicative [95].	I worry that I won’t be able to do enough [95].	I’ve lost the support of friends and/or family [94].
I have become more confident dealing with others [95].	The patient thinks a lot about death [95].	I worry that I’ll have to give up more and more things in the future [94].	How often do you feel that helping care recipient has made you feel closer to him/her [119]?
Taking care of the care recipient gives me a trapped feeling [119].	The patient attempts to harm himself [95].	I feel able to handle most problems in care of the care recipient [119].	I visit family/friends less [106].
Caring for someone increases my sense of self-worth [111].	I am aware of the individual being aggressive [109, 110].	How often do you feel uncertain about what to do about the care recipient [119]?	My family left me alone [106].
Caregiving has helped me grow as a human being [111].	I believe the treatment is going well [109, 110].	I feel confident I can handle most problems in caring for the patient [113, 114].	I feel happy when I am with my care recipient [111].
I feel frustrated by caregiving [116].	I feel the individual is a danger to him/herself or others [109, 110].	I worry that I won’t be able to do enough to care for the patient [113, 114].	Caregiving interferes with my interactions with relatives, friends, and neighbors [111].
As a caregiver, I feel I am losing control over my life [113, 114].	I am concerned about the individual’s anxiety [109, 110].	I am able to comfort the patient when he/she needs it [113, 114]	I feel our family is closer because of caring for the patient [113, 114].

3.5.2. Antecedents

Antecedents refer to the events that occur before the concept appears and the prerequisites for analyzing a concept [120]. For caregiving appraisal to occur, the following entities must exist: (1) patients or care recipients, (2) caregivers, (3) the caregiving context or demand of caregiving, and (4) the general experience of caregiving or newly occurring circumstances that need to be addressed by caregivers (e.g., stressors).

The caregiving appraisal process must begin with some degree of illness or disability of the other person that creates a need for assistance from others [121]. Additionally, caregivers must perform caregiving activities in a caregiver–care recipient relationship with a subjective interpretation of the stressor [122]. The presence of objective external stressors without a subjective interpretation will not lead to caregiving appraisal [13, 122]. Objective stressors could include the patient’s level of functional disability, presence of cognitive impairment, and presence of behavioral problems [19, 104], family conflict (e.g., disagreement on treatment options), job-caregiving conflict, economic problems, etc. [24]. To allow the assessment of the caregiving situation to occur, the personal and social resources of the caregiver as antecedents must be present [122]. The lasting impact of the stressor must be present to elicit caregiving reappraisal, and caregivers need to see the needs and meaning to appraise the emotional situation from a new angle for reappraisal to occur [122]. Caregiving appraisal is a neutral concept. The antecedents of caregiving do not necessarily have to be negative events, challenging situations, or stimuli.

Various factors can impact caregiving appraisal, generally including caregiver variables and patient variables (patient characteristics or illness characteristics) [23, 81, 123]. Specifically, caregiver variables include the caregiver’s age, race, ethnicity, gender, education level, employment status, marital status, duration of caregiving [19, 23, 98], socioeconomic status, geographic location, generational status, caregiver past life experiences, cultural values and beliefs [18, 83], religiosity [49, 124], role involvement (e.g., parents, adult children, or spouse) [18], and caregiver health and well-being [22, 97, 125]. Modifiable caregiver characteristics include hardness attributes, unmet needs and concerns, perception and beliefs about caregiving, self-efficacy, coping strategies, and perceived quality of life [19]. Patient variables include the patient’s personal and illness characteristics (e.g., symptom severity, behavioral problems, diagnosis, duration of illness, functional status, and dependency) [19, 125], the patient’s relationship with the caregiver [126], the demand of caregiving (e.g., hours of help provided by the caregiver) [22], support system (e.g., informal assistance provided by friends and family) [23, 92], and resources for coping [48]. Other factors that impact caregiving appraisal include social pressure, caregiving obligation, and filial piety [19].

3.5.3. Consequences

Consequences of caregiving appraisal include various reactions and adaptations that result from the role [90, 98, 127, 128]. When caregiving appraisal is discussed within the realm of Lazarus’s stress model, where primary appraisal follows external stressors and is followed by secondary appraisal, which is then followed by reappraisal, the latter step will always be the consequence of the previous step, although the process does not always occur in a linear manner [13, 47]. A caregiver’s appraisal informs what type of coping they will engage in [129], which may affect the type, quality, intensity, and duration of the subsequent emotional response to a stressful situation [81, 130], and lead to reappraisal [48, 131].

Physical and psychological well-being, as well as the quality of life of caregivers, are important consequences of caregiving appraisal [18, 88, 122, 132, 133]. For example, caregiving appraisal determines depression, emotional stability, sleep disturbance, and self-esteem [84, 104, 134]. Negative caregiving appraisals typically lead to psychological distress [21, 22, 88, 135]. Higher levels of distress are associated with more unhelpful appraisals of the illness and more dysfunctional coping behavior [129]. In contrast, positive caregiving appraisal can lead to psychological well-being (e.g., positive affect and obtaining cultural meaning of caregiving) [22, 83, 135].

Caregiving appraisal not only affects the caregivers’ own well-being but also may impact the health and well-being of those they care for [127]. Consequences of caregiving appraisal can be categorized into proximal and distal outcomes. For example, expressed emotion by caregivers could be a more proximal consequence of the caregiving appraisal process [136], compared to the caregiver’s quality of life [90] and the eventual health outcomes of people they care for (e.g., patient mortality) [137, 138]. Finally, it is important to note that consequences of caregiving appraisal, such as negative reactions to stress and its resultant emotions and behaviors, could ultimately become an additional layer of stress, which can also be considered as the antecedent that reinforces the next round of caregiving appraisal [22]. For example, a caregiver’s appraisal of the extent to which the caregiving role is burdensome can place additional stressors on the patient–caregiver dyad as a unit, which may lead to negative implications for the caregiver’s personal and family well-being [67, 139].

3.6. Phase 6: Identify Concepts Related to the Concept of Interest

Various subdomains of caregiving appraisal are considered related terms. These subdomains are not necessarily limited to those identified by Lawton’s model (see Phase 4). Caregiving appraisal is a concept built upon the appraisal theory in psychology. Therefore, “cognitive appraisal,” defined as the subjective and evaluative cognitive process focuses on the meaning or significance of events and plays a role in mediating emotional reactions, is also an important related term of caregiving appraisal [13]. Cognitive appraisal is a more immediate and short-term reaction to stress [13], whereas caregiving appraisal is a more long-term and stable process [16, 122]. How caregivers evaluate their caregiving situation, react to, and respond to changes in their environment cannot be solely explained by Lazarus’s stress model [13]. Caregiving appraisal is more than just the cognitive appraisal of caregiving.

Family appraisal, which refers to a family’s perception of the gravity of a situation [96], is also a concept interconnected with caregiving appraisal. It involves the family’s subjective understanding of the stressor, the challenges it brings, and its impact on the family unit [96]. This subjective interpretation is influenced by the family’s values and past experiences in coping with change and confronting crises [96]. Unlike caregiving appraisal, which focuses on the caregiver’s evaluation of stressors, family appraisal emphasizes the caregiver and the care recipient as part of a family unit, and the context may not necessarily relate to illness caregiving. While the concepts of caregiving appraisal and family appraisal are distinct, they share some commonalities. When the focus is on the caregiver–patient dyad, rather than the entire family, the term dyadic appraisal has been used in the literature [140]. Again, dyadic appraisal does not necessarily have to be related to illness caregiving.

Parental caregiving appraisal refers to the cognitive and affective assessments parents make about caregiving for their children, including their perceived efficacy in handling caregiving stressors [107, 108, 117]. The uniqueness of parental caregiving appraisal lies in the dual responsibility of parents who take on both the role of caregiving for a child (e.g., teaching life skills and assisting with cognitive development) and a patient (e.g., administering medication and managing symptoms). This compound caregiving may contribute to increased stress and burden [141]. Parental caregiving appraisal is a subcategory of caregiving appraisal.

The definitions of caregiving appraisal vary significantly depending on the context and whether it is discussed within the framework of Lawton’s caregiving appraisal model, as mentioned in Phase 2. Specifically, when the caregiver’s appraisal focuses on specific stimuli (or stressors), such as the appraisal of illness severity, social support, or the patient’s medication side effects, it falls into the category of “nontraditional (or non-Lawton) definitions of caregiving appraisal.” Nontraditional caregiving appraisal is defined as a caregiver’s assessment of context-specific experiences or situations [17, 92]. A list of nontraditional caregiving appraisal types is provided in Table 1. These terms are considered related terms, not surrogate terms, because they cannot be used interchangeably with the core concept of interest.

Additionally, studies have claimed that caregiving appraisal is closely tied to the caregiver’s coping process, as it serves as a cognitive strategy employed throughout the coping process [83, 102, 126]. Caregiving appraisal occurs whenever the caregiver receives new information or feedback from others, which enables them to expand or refine the meaning of their caregiving experiences over time [83]. In summary, related terms of caregiving appraisal include (1) cognitive appraisal (and its surrogate terms), (2) family appraisal, (3) dyadic appraisal, (4) parental caregiving appraisal, (5) caregiver coping, and (6) various subdomains of caregiving appraisal (e.g., caregiving burden).

3.7. Phase 7: Generate a Model Case of the Concept

Ms. Yang is a caregiver who takes care of her mother, who is living with progressive dementia. This is her second year providing care to her mother. About 6 months ago, Ms. Yang moved in with her mother, so she could help as needed and avoid the need for institutionalized care. Recently, her mother has begun to display combativeness when prompted to eat and bathe, and she frequently becomes confused and agitated at night. Ms. Yang gradually started to feel that her mother no longer recognized her and had become a “totally different person” (dysfunctional relationship). Ms. Yang is an accountant and has limited knowledge about dementia, except for information she obtains from healthcare providers and the Internet. She relies mainly on her mother’s primary care provider for support in managing her mother’s care. Ms. Yang has reported experiencing sleep disturbances due to anxiety (subjective caregiving burden), an inability to visit friends (impact of caregiving), and occasional uncertainty about how to handle her mother’s agitation (caregiving mastery). Ms. Yang occasionally thinks about sending her mother to a nursing home due to the burden associated with nighttime caregiving. However, she has chosen to take on all caregiving responsibilities due to her belief in filial piety (the cultural aspect of caregiving appraisal). On some days, her mother has long lucid intervals, allowing Ms. Yang to enjoy talks and walks with her (caregiving satisfaction). In addition to the positive aspects of caregiving, Ms. Yang believes that a significant reason for caring for her mother is to set a good example for her children to follow (caregiving ideology).

4. Discussion and Conclusion

The purpose of this analysis is to gain a clearer understanding of the concept of “caregiving appraisal.” The evolution of the term reflects its expanding conceptualization over time, especially as research has shifted from focusing solely on caregiver burden to a more holistic understanding of the caregiving experience. Initially, caregiving appraisal emerged from Lazarus and Folkman’s stress model, emphasizing caregivers’ cognitive and affective responses to caregiving demands. The term was first introduced by Lawton as a broader and more holistic alternative to “caregiver burden,” encompassing both the positive and negative aspects of caregiving. As the concept evolved, various frameworks and models were introduced, each adding its own dimensions. Lawton’s original model has undergone numerous revisions and expansions by different researchers over the years. Beyond Lawton’s framework, caregiving appraisal has also been adapted to more specific contexts, resulting in what is known as nontraditional or context-specific caregiving appraisals. This broader usage highlights the flexibility of the caregiving appraisal concept in addressing various stressors and challenges faced by caregivers across different situations. In summary, the term “caregiving appraisal” has evolved from a focus on negative experiences to a comprehensive, multidimensional concept that includes both positive and negative aspects, as well as general and context-specific evaluations. This evolution reflects a growing recognition of the complex and varied nature of the caregiving experience, allowing for a more nuanced understanding of how caregivers perceive and cope with their roles. Caregiving appraisal can be broadly categorized into four key areas: (1) caregivers appraise their own situation, (2) caregivers appraise the care receiver’s situation, (3) caregivers assess their own abilities to manage caregiving responsibilities, and (4) caregivers evaluate their relationship with the care receiver.

There is no clear boundary between the definition and measurement of caregiving appraisal [142]. Some studies use one or more subdomains of caregiver appraisal (e.g., caregiving satisfaction, perceived caregiving impact) to define caregiving appraisal [67, 132]. This becomes problematic when a measurement instrument is considered a holistic caregiving appraisal measure, but only assesses a single domain of caregiving appraisal [143]. For example, caregiving burden is sometimes used interchangeably to represent the entire caregiving experience [144]. Overlooking the multidimensional nature of caregiving appraisal suggests that some researchers may assume the caregiving experience is entirely negative.

Notably, some studies used Lawton’s framework or caregiving appraisal as their main concept of interest. However, these studies often employed a combination of different scales, such as the Caregiving Gratification Scale and the Zarit Burden Index, to measure caregiving appraisal, rather than directly using Lawton’s CAS [67, 132, 144, 145]. When studies are conceptualized based on Lawton’s model but do not utilize the CAS, it may suggest that (1) Lawton’s conceptualization resonates with researchers, but (2) Lawton’s operationalization poses barriers that discourage the use of the CAS. This could also be due to researchers’ unfamiliarity with the CAS (compared to the Zarit Burden Index) or the limited validity and reliability of some domains within the CAS [16]. These issues highlight the need to (1) reexamine Lawton’s caregiving model and (2) revise and retest the caregiving appraisal instrument to align with changes in healthcare practices and caregiving expectations. Furthermore, some studies included caregiving appraisal as a primary variable but either failed to define it [66, 89, 105, 129, 130, 146] or simply used the definition of appraisal or stress appraisal [83, 137], without considering the caregiving context.

There are a few limitations to this study. First, concept analysis involves interpretation and subjective judgment, which can introduce bias into the process. Second, as the population of focus included only unpaid informal caregivers, the findings cannot be generalized to professional caregivers. Third, only articles in English were included. Since caregiving appraisal and its meanings can vary across languages and cultures, this concept analysis may not fully account for these variations. However, this limitation is somewhat mitigated by the inclusion of caregiver research experts from diverse cultural backgrounds on the study team.

In conclusion, caregiving appraisal is the subjective cognitive and affective evaluation of the caregiving experience, encompassing stressors, and coping effectiveness. The implications of this concept analysis for future studies include (1) incorporating a clear definition of caregiving appraisal into their research; (2) avoiding reliance on a single dimension (e.g., burden), which does not fully reflect the holistic nature of caregiving appraisal; and (3) providing valid reasons for considering only specific domains when using caregiving appraisal as the concept of interest. Additionally, this concept analysis lays the foundation for (1) the development of interview guides for future qualitative studies that explore the caregiving appraisal process in depth, (2) the item generation phase for the revision and updates of the CAS, and (3) the development of interventions targeting different domains of caregiving appraisal (e.g., psychosocial education). With a clearer definition of caregiving appraisal, the CAS could be enhanced to provide a more accurate measurement of this concept. Continued research in this area is crucial for developing evidence-based practices that better support caregivers, improving caregiver well-being, optimizing caregiver–patient dyadic interventions, informing policy decisions, and promoting the sustainability of caregiving in the face of evolving societal and healthcare dynamics.

Conflicts of Interest

The authors declare no conflicts of interest.

Author Contributions

Dingyue Wang: conceptualization; methodology; title, abstract, and full-text article screening; data abstraction; formal analysis; writing – original draft; writing – review and editing; and project administration. Sharron Rushton: methodology; abstract, title, and abstract screening; and writing – review and editing. Leila Ledbetter: search strategy curation; review methodology; software; and writing – review and editing. Margaret Graton: search strategy curation; review methodology; software; and writing – review and editing. Kimberly Ramos: abstract, title, and abstract screening; data abstraction; and writing – review and editing. Michael P. Cary: writing – review and editing. Tamryn F. Gray: writing – review and editing. Cristina C. Hendrix: conceptualization; methodology; full-text article screening; data abstraction; formal analysis; writing – review and editing; and supervision.

Funding

No funding was received for this research.

Acknowledgments

We would like to express our sincere gratitude to Duke University School of Nursing for the invaluable support throughout the duration of this research project.

Open Research

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

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All articles

Understanding the Multidimensionality of Caregiving Appraisal: A Concept Analysis

Abstract

1. Introduction

2. Methods

3. Results

3.1. Phase 1: Identify and Name the Concept of Interest

3.2. Phase 2: Identify the Surrogate Terms and Relevant Uses of the Concept

3.3. Phase 3: Select an Appropriate Realm (Sample) for Data Collection

3.4. Phase 4: Recognize Attributes of the Concept

3.4.1. Multidimensionality

3.4.2. Subjectivity

3.4.3. Flexibility: Context-Dependent and Dynamic Nature

3.4.4. Valence: Neutral, Positive, and Negative Dimensions

3.4.5. Mediation: Mediating Role of Caregiving Appraisal

3.5. Phase 5: Ascertain the References, Antecedents, and Consequences of the Concept

3.5.1. Empirical Referent

3.5.2. Antecedents

3.5.3. Consequences

3.6. Phase 6: Identify Concepts Related to the Concept of Interest

3.7. Phase 7: Generate a Model Case of the Concept

4. Discussion and Conclusion

Conflicts of Interest

Author Contributions

Funding

Acknowledgments

Open Research

Data Availability Statement

References

References

Information

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