Abstract

Background

Many organizations are faced with growing numbers of employees who combine their jobs with informal caregiving responsibilities. To support working caregivers in maintaining a good balance between work, private life and informal care, a workplace participatory approach (PA) intervention was implemented in four Dutch organizations. This study鈥檚 aims were to evaluate the degree of PA implementation, contextual factors influencing implementation, and stakeholder experiences with the PA.

Methods

A mixed methods process evaluation was conducted alongside a randomized controlled trial among three stakeholder groups: caregiving employees, their supervisors, and trained occupational professionals who acted as PA process facilitators. The implementation frameworks of Steckler and Linnan (2002) and Carrol et al. (2007) were applied to evaluate recruitment, reach, dosage, fidelity and context, as well as stakeholders鈥� satisfaction, experiences and perceived intervention outcomes. Data were collected after PA implementation (4鈥�7 months) using questionnaires, semi-structured interviews, checklists and research logs.

Results

Of the 57 caregivers in the intervention group, 48 participated in the stepwise intervention. Among them, 20 (42%) completed all seven steps of the PA, and 30 (63%) involved their supervisors. PA implementation and supervisor involvement varied based on personal factors (e.g. a need for balance-related improvements; preference to keep caregiving private), interpersonal factors (e.g. caregiver-supervisor relationship quality), and organizational factors (high work demands; a supportive workplace culture for caregivers). Caregivers, supervisors, and process facilitators reported positive experiences with the PA, finding it valuable for addressing informal caregiving, receiving support and working on balance-related changes in multiple life domains. Some caregivers, however, needed more than the standard 3 PA meetings to identify key issues and implement solutions.

Conclusions

Stakeholders found the PA helpful in addressing working caregivers鈥� work-life balance, but PA implementation can be further stimulated by creating a supportive organizational culture in which it is encouraged and safe to discuss informal care. Moreover, to better support working caregivers in the long term, the PA should be viewed as an ongoing and iterative process taking into account their evolving balance and circumstances.

Trial registration

Current Controlled Trials ISRCTN15363783 (Registration date 21 November 2022; Retrospectively registered).

Background

Population aging, increased labor participation rates, and rising retirement ages indicate a growing challenge for organizations as more employees have to combine paid work with providing informal care [1, 2]. Currently, in the European Union, one third of people of working age (18鈥�64 years) are estimated to have informal care responsibilities [3]. Informal caregiving involves unpaid care and support provided to persons experiencing health and/or functional challenges within the caregivers鈥� social environment [4]. Support from employers for working caregivers is essential to enable them to fulfill multiple societal roles simultaneously 鈥� whether as a worker, family member or informal caregiver 鈥� all while maintaining one鈥檚 health and wellbeing [5, 6]. Role strain and role conflicts can occur among working caregivers who experience negative overflow when balancing multiple roles across different domains, such as work, informal care, and family / private life [7, 8]. As a result, caregivers may develop health problems, stress and depressive symptoms in their personal lives. They may also face strain in their relationships with the care recipient or other family members, while in the workplace this situation may lead to increased work-related strain, disruptions and absenteeism due to illness [9,10,11,12,13,14]. Conversely, supporting working caregivers in maintaining a good work-life-informal care balance can positively contribute to caregivers鈥� job satisfaction, sustainable employability, and wellbeing [11, 12, 15, 16].

To support working caregivers in maintaining a good balance across multiple roles, a workplace intervention was developed and implemented in various organizations in the Netherlands as part of the Working on Informal Care study [17]. The study consisted of a randomized controlled trial (RCT) aimed at evaluating the effects of the intervention on work-life balance, combined with a process evaluation focusing on the implementation of the intervention. The intervention, referred to as 鈥榯he participatory approach鈥� (henceforth: PA) is an existing evidence-based stepwise method that has been applied at the individual level (i.e. aimed at individual workers) or organizational level (i.e. aimed at organizational changes) to address health- and functioning-related challenges at work [18, 19]. The PA is based on the Self-Determination Theory [20] and the Positive Health approach [21], and its core principles are: (1) equal and active stakeholder involvement to reach consensus on the most important challenges and solutions (2) stimulation of self-management and adaptation to the physical, emotional and social challenges of one鈥檚 life, and (3) a supportive environment to help act on problems and make changes [22]. The PA used in the Working on Informal Care study builds upon on the individual-level PA as developed by Schaap et al., which considers workers鈥� health problems across multiple life domains, i.e. both inside and outside the workplace [22,23,24]. In the current study, the PA was tailored to the target group of working caregivers by incorporating the care situation as a separate life domain. The aim was to support them in effectively combining informal care, private life and work. For this, caregivers engage in multiple facilitated discussions aimed at fostering agreement on issues and resolutions with their supervisors, under guidance of a trained process facilitator (i.e. an occupational professional) [18].

The current paper presents a process evaluation of the implementation of the PA. Process evaluations are increasingly being regarded as essential to conduct alongside effect evaluations to attain a deeper understanding of aspects such as the acceptability of the intervention, fidelity and contextual factors that influence the implementation and thus, its effectiveness [25,26,27]. This information is important to improve future program implementation. Thus, the aims of the current process evaluation were to gain insight into: (1) the degree and process of implementation of the PA within the participating organizations, and whether it was carried out as intended, (2) the contextual barriers and facilitators that influenced implementation of the PA, and (3) the experiences of process facilitators, caregiving employees and supervisors with the PA.

Methods

Study design

The current process evaluation was conducted alongside a randomized controlled trial (RCT) on the effectiveness of the participatory approach (PA) intervention to support caregiving employees in the workplace. Four Dutch organizations participated in this RCT, in which caregivers were randomly allocated individually to either the intervention group, or the control group. The control group received support as usual, meaning that they could make use of existing support arrangements for caregivers within or outside the organization, such as care leave or individual agreements with the supervisor.

For this process evaluation, a mixed methods evaluation was performed between January 2023 and May 2024 at three levels: the working caregiver level, the supervisor level and the process facilitator level. Following the framework of Steckler and Linnan [28], to evaluate the degree of implementation of the PA intervention, five components were assessed: recruitment, reach, dosage, fidelity and context (Table听1). In this study, the component 鈥榙osage鈥� encompasses both the dose delivered by the process facilitator and the dose received by the caregivers, reflecting the extent to which the steps of the PA were effectively completed in practice. To assess contextual factors in the implementation, intervention-related aspects were examined and the social-ecological framework was applied to identify interpersonal, intrapersonal, and institutional barriers and facilitators [28, 29]. Additionally, following discussions to expand Steckler and Linnan鈥檚 framework [30], participant responsiveness to the PA intervention was evaluated through the components satisfaction, experiences and perceived outcomes [31].

Study population and participants

The study population for this process evaluation consisted of (subsets of) working caregivers and their supervisors from the intervention group in each participating organization of the Working on Informal Care study, as well as the appointed process facilitators. The four participating organizations were: two municipal government organizations, one university of applied sciences and one governmental agency (varying between 3,000 and 10,000 employees). The process facilitators were self-appointed within each organization, and consisted of professionals with knowledge of the occupational (health) policy within the organization (e.g. human resources, social work). Caregiving employees could participate in the study voluntarily and were eligible to participate if they had informal caregiving tasks, and a contract of at least 20 working hours per week. This threshold was set to focus on individuals for whom the combination of work and caregiving was more likely to present substantial challenges, as the demands of balancing both roles may intensify with more working hours spread over multiple days.

Workplace participatory approach intervention

The evaluated workplace PA intervention aims to assist caregiving employees in balancing informal care, personal life, and work responsibilities. An occupational professional from within the organization who is trained as process facilitator guides the employee and supervisor through a stepwise process (Table听2). To complete the steps, a 3-fold meeting structure is recommended. Facilitators have the flexibility to deviate from this structure if deemed necessary. The PA begins with the process facilitator contacting the caregiving employee and supervisor to establish the purpose, method, and timing of the participatory approach. The initial meeting between facilitator and caregiver (week 1) involves identifying and discussing (the prevention of) current challenges related to work, personal life, and caregiving. Simultaneously, the supervisor performs a task analysis outlining the employee鈥檚 work duties and potential challenges due to caregiving. Subsequently, the second meeting (week 2鈥�3) allows the caregiver and supervisor to jointly prioritize the most relevant areas for improvement and create an action plan to implement solutions. Solutions are sought within the organization鈥檚 existing frameworks for caregiver support or in the caregiving/home environment. Approximately four weeks later, a third meeting takes place with the caregiver and supervisor to assess the effectiveness of the implemented actions and determine if the caregiver鈥檚 situation has sufficiently improved. If necessary, further actions are discussed and planned. In the current study, process facilitators were directed to complete the PA process within a maximum of four months.

Table 1 Framework components evaluated in the process evaluation of the participatory approach (PA) intervention

Table 2 Steps of the Participatory Approach (PA) intervention

Training of process facilitators in the intervention

Process facilitators received two three-hour training sessions equipping them to guide caregiver-supervisor duos through the PA steps as a neutral facilitator. The training was provided by the main researcher (E.V.) and covered theory and evidence about the PA, the most commonly faced challenges and needs of working caregivers, and available support forms for caregivers, both within and beyond the workplace. Role-playing exercises and case studies based on caregiving literature and interviews with working caregivers [32], were used to practice PA steps, and practice creating a safe environment for discussions and stimulating self-management in caregivers. Facilitators received a training manual and the Working on Informal Care toolkit, containing forms and visual materials to aid each step, such as a template to develop the action plan.

Data collection

Data were collected among three participant groups using checklists, questionnaires, interviews and research notes (Table听1).

Checklists (process facilitators)

Process facilitators filled in a checklist for each caregiver that participated in the PA after completion of the PA steps, within the instructed timeframe of 4 months. Checklists were also filled in if the PA was terminated prematurely. In the checklists, they provided information about the degree of implementation, such as the number of consultations and delivered PA steps, and an overview of problems and solutions that were identified and implemented.

Questionnaires (process facilitators, supervisors and caregivers)

Online questionnaires about process variables (Table听1) were developed for the current study and administered: (1) immediately after conclusion of the PA, usually within 1鈥�4 months (supervisors), and (2) at 7 months (caregivers; included in the final follow-up questionnaire for the RCT). Furthermore, process facilitators filled in questions to evaluate the training. For supervisors, only those who had given their informed consent to be directly contacted by the researcher after completion of the PA were sent the questionnaire.

Semi-structured interviews (process facilitators, supervisors and caregivers)

After PA implementation, semi-structured group interviews were held with process facilitators and caregivers, separately, at their organizations鈥� location. Participants who were unable to join a group interview were interviewed individually. Group interviews were conducted by two researchers: one moderator who led the interviews, and one observer who was tasked with process and time keeping. Supervisors were interviewed individually online, via video conferencing application Microsoft Teams (version 4.16). For each participant group, interview guides contained questions on the components of the process evaluation frameworks described above (Additional File 1).

For the process evaluation, process facilitators who had applied the PA with at least one caregiver and supervisors who had expressed willingness in the online questionnaire were invited for individual interviews. Caregivers who attended at least two PA meetings were invited for a group interview. Additionally, a convenience sample consisted of caregivers who attended only the initial PA meeting.

Research logs

During the study period, research logs were recorded by the main researcher (E.V.) regarding the process variables recruitment and reach, as well as background on contextual factors, perceived outcomes and experiences in the PA (Table听1). For example, logs on recruitment barriers were made after having e-mail or telephone contact with study participants. Also, structurally, notes about experiences were recorded during update meetings with process facilitators. Finally, one caregiver and one supervisor did not want to participate in a formal audio-taped interview, but shared their experiences through a (video)call with the researcher, during which notes were made.

Data analysis

Quantitative data from questionnaires and checklists were analyzed in IBM SPSS (version 29) using descriptive statistics, presented as means (SD) and percentages. The number of completed PA intervention steps (dosage) were calculated among caregivers who had actually started the PA.

Quality of delivery (fidelity) was assessed with questionnaire items about satisfaction with the process facilitator (caregivers and supervisors) using a rating scale between 1 (lowest satisfaction) and 10 (highest satisfaction). For process facilitators, satisfaction with the PA guidance was assessed in each checklist, using a 5-point scale (very unsatisfied, unsatisfied, neutral, satisfied, and very satisfied). The component satisfaction was assessed by using questions on satisfaction with the PA in general (caregivers and supervisors) and satisfaction with PA training (process facilitators); all on a rating scale between 1 (low satisfaction) and 10 (high satisfaction). Process facilitators鈥� readiness to conduct the PA after training was assessed using the question 鈥楧o you feel able to conduct the participatory approach with caregivers and supervisors after this training?鈥� with answer options on a 5-point scale (strongly disagree, quite disagree, neutral, quite agree, and strongly agree). Finally, supervisors鈥� likelihood to participate in the PA with other employees in the future was also rated between 1 (not likely at all) and 10 (most likely).

Qualitative data were audio-taped, transcribed verbatim, and together with the research notes, analyzed using the software program MAXQDA (2022). To get a sense of the data, transcripts were first read in their entirety by the main researcher (E.V.) and then deductively coded based on the relevant components of the evaluation frameworks of Steckler and Linnan [28] and Carroll [31]. To analyze contextual factors, additionally, the social-ecological framework was used to code interpersonal, intrapersonal and institutional contextual barriers and facilitators [29]. Assigned codes were checked and supplemented by another researcher (D.S.) and any discrepancies were resolved together. Findings for each of the framework components were then discussed and refined with all co-authors. Data were analyzed and presented on the level of the participant group (i.e. facilitators, caregivers and supervisors). In cases where large organizational differences existed in components, these were highlighted in the results.

Ethics

All participants (caregivers, supervisors and process facilitators) received an information letter about the study, and provided informed consent. The Center for Clinical Expertise of the Dutch National Institute for Public Health and the Environment determined that the Medical Research Involving Human Subjects Act did not apply to this study (VPZ-515), and that the study therefore did not require further ethical review.

Results

Participants

Process facilitators consisted of occupational social workers (n鈥�=鈥�9), human resources (HR) professionals (n鈥�=鈥�4), and one sickness absenteeism consultant (n鈥�=鈥�1); 12 out of these 14 were female. The mean age of the 57 working caregivers in the intervention group was 48.9(卤鈥�9.7) years, with an average of 34.1(卤鈥�5.9) working hours and 21.2(卤鈥�25.2) caregiving hours per week; 79% were female. 41 caregivers indicated that their supervisor was already aware of their caregiving situation; 22 caregivers agreed to be interviewed (Table听3). The 23 supervisors who filled in the questionnaire had a mean age of 49.1(卤鈥�6.6) years, and an average number of team members of 28 (卤鈥�17.4), range 12鈥�90. 74% were female. Only six supervisors agreed to be additionally interviewed (Table听3). Limited information was provided by participants about specific reasons for declining post-PA interviews.

Table 3 Data collection in the process evaluation

Degree of implementation

Recruitment

None of the participating organizations had a clear overview of all caregiving-employees. In each organization, therefore, a tailor-made plan was made to inform all employees and supervisors about the study, with help of HR and/or the organization鈥檚 occupational health service. Examples of channels that were used were employee meetings, company-wide e-mails, blog posts, newsletters, visiting different locations to distribute flyers and researcher presentations to the management. Reasons for caregiver non-participation were only sporadically communicated to the researcher, including perceived time constraints, a lack of need to improve work-life balance, or reservations about discussing their caregiving situation with their supervisor.

Reach

In total, 57 caregivers were randomized in the intervention group, of whom nine did not start the PA at all (Table听4). Reasons for not starting the PA were: changing their minds about participation (n鈥�=鈥�3), unexpected sickness absence (n鈥�=鈥�2), passing away of the care recipient (n鈥�=鈥�1), leaving the employer (n鈥�=鈥�1), having no supervisor in the organization (n鈥�=鈥�1), and unknown reasons (n鈥�=鈥�1). The supervisor was involved in 30 of the started PA trajectories (62.5%), varying per organization (organization 1: 50%; organization 2: 94%; organization 3: 56%; organization 4: 31%). Reasons for lack of involvement were, amongst others, insufficient need for work-related improvements or further support from work, and hesitance to discuss their informal care situation with their supervisor. In one case, the supervisor refused to participate.

Dosage

On average, caregivers who started the PA participated in 2.3 (1.0) meetings over a time frame of 64 days (range 1-175 days). 28 caregivers (58.3%) partially completed the PA (completing between 1 and 6 intervention steps), while 20 caregivers (41.7%) completed all seven steps. The lower completion rates of steps 6 and 7 (Table听4) were primarily attributed to the PA not producing new or concrete solutions to implement or evaluate. Additionally, planning issues and changes in team leadership also played a role. Thirteen caregivers did not continue beyond the first PA meeting, in which they looked at potential areas for improvement in their work-care-life situation. Their satisfaction with their current balance and arrangements, and lack of (further) need for assistance from their supervisor were the main reasons.

Table 4 Key quantitative process variables

Fidelity

Adherence

In a few cases, PA intervention steps were delivered with adaptations from how the intervention was originally prescribed. This concerned: continuing the PA after the first meeting but without one鈥檚 supervisor (n鈥�=鈥�5) and skipping one or two steps (n鈥�=鈥�10 and n鈥�=鈥�5, respectively).

The PA鈥檚 main goal was to identify improvements and solutions across multiple domains (Fig.听1). In 73% of the PA cases, improvements were identified in the work domain, 54% in the informal care domain, and 54% in the caregiver鈥檚 personal domain. In 29 PA cases, actions were recorded in the action plan, averaging 3 actions per case with a range of 1鈥�7. Of the 91 proposed actions that were recorded, 59 were implemented, 16 were not (yet) implemented, and 16 unknown at the time of the evaluation meeting. For instance, although care leave was sometimes seen as a solution, it was not always implemented due to financial repercussions for the caregiver.

Quality of delivery

Caregivers and supervisors were very positive about the quality of the PA intervention delivery by process facilitators (Table听4). One core principle of good PA facilitation is stimulating employees鈥� self-determination in identifying relevant issues and solutions tailored to their own situation. Facilitators acknowledged being mostly successful in enabling caregivers to take the lead, despite challenges arising from their traditional role as experts who provide more directive advice. They observed a shift among caregivers from recognizing challenges to actively making changes in their circumstances. However, they also noted that not all caregivers were equally prepared for this transition and could find this process difficult.

Fig. 1

Actions to improve work-life balance in the participatory approach (PA)

鈥淣辞飞, I think the employee finds it [self-management] quite challenging, and that鈥檚 where our learning process lies, you know, because I also find it difficult not to start dictating, so to speak. Because the employee has been involved in that situation for so long that they themselves no longer see that there are other possibilities.鈥� [Process facilitator, org.4].

Another important principle of PA facilitation is creating a safe and supportive environment for discussions where all stakeholders feel heard. Caregivers and supervisors noted that the conversations usually took place in a constructive manner, with a confidential space for open dialogue, but caregivers also emphasized the importance of feeling a personal connection in order to open up. Some caregivers mentioned feeling uneasy discussing their personal caregiving matters at work and wanted to avoid their caregiving tasks being perceived as a disadvantage. In this regard, they often found the presence of the process facilitator a valuable resource: 鈥淸What I found most helpful] that was that you can inform your supervisor with someone who already knows something about the situation. That you don鈥檛 just go to your supervisor alone. For me, that was just a little more pleasant.鈥� [Caregiver, org.2].

Context

We identified various intrapersonal, interpersonal, institutional and intervention-related barriers and facilitators for PA implementation (Table听5).

Important personal obstacles for caregivers to participate in the PA and discuss informal care were a preference to keep their caregiving role private / separate from work, and finding it difficult to ask for help and articulate what they needed. Fear of burdening the supervisor because of their situation, and being seen as a 鈥榙ifficult鈥� employee with possible repercussions at work, also played a role. Some supervisors seemed more aware of this tension than others. Therefore, a good interpersonal relationship with mutual trust, understanding and communication between caregiver and supervisor, was considered essential for successfully engaging in the PA.

鈥淲别濒濒, trust and the relationship with the supervisor was also, in my opinion, a point where a number [of caregivers] thought: well, then I won鈥檛 participate. There have been so many changes of supervisors in certain departments that they鈥檙e like, well, I barely know that person鈥� And it doesn鈥檛 always have to be a bad relationship, but also having trust in, like, okay, does it have added value or not. And also there were people I spoke to, who said, yeah, I see informal care really as my own problem.鈥� [Process facilitator, org.1].

Important institutional barriers for all three stakeholder groups were high experienced work pressure, which could result in a perceived lack of time to get familiar with and engage in the PA. In some organizations, participants felt that the realization of solutions was limited by a lack of or inadequate organizational support policies for caregivers. In this regard, supervisors frequently highlighted the necessity for clearer information and guidelines about available support options.

Table 5 Barriers (B) and facilitators (F) for participatory approach (PA) implementation

Participant responsiveness

Satisfaction

Process facilitators, expressed high satisfaction with the training they received to prepare them for the PA (average rating of 8.1 (0.9) out of ten), and all indicated feeling capable of applying it in practice (Table听4). Caregivers and supervisors rated their satisfaction with the PA 7.6 (1.4) and 7.4 (1.3) out of ten, respectively. Process facilitators differed in the extent to which they actively used the materials from the intervention Toolkit. When the Toolkit was used, both caregivers and supervisors mentioned that the forms provided structure to the conversations, and they found the materials useful to document challenges and agreements. In particular, the visual discussion aid used in the first meeting, which helped the caregiver to evaluate and score their wellbeing in each life domain, was positively received.

Positive and negative experiences with PA method

The three stakeholder groups had largely positive experiences working with the PA method. A commonly highlighted beneficial aspect by process facilitators was the step-by-step model provided by the PA for addressing issues and solutions across multiple life domains: 鈥淣辞飞 that people had to write it down themselves and think about it, and then it was followed-up in the next conversation, well, then it becomes more tangible for people or something, resulting in quicker action being taken than in my previous conversations, without a guiding model.鈥� [Process facilitator, org.1].

Meanwhile, the process also demanded quite a bit from caregivers. Some caregivers suggested that the PA could be more flexible or extended to better align with their personal process of identifying challenges and achieving changes: 鈥淔or me, the transition between the first and second conversation felt quite fast. Because the first conversation is, I think, an hour, and then you鈥檝e only discussed, well, the tip of the iceberg, so to speak, and there鈥檚 still a lot that lies beneath the surface, which you simply don鈥檛 get to. But you already have to start identifying bottlenecks, even though you鈥檙e not there yet.鈥� [Caregiver org.4]. Furthermore, they emphasized how achieving balance is an ongoing process: I think some additional evaluation moments as needed would be nice, because it鈥檚 a long-term thing. [Your balance] it fluctuates a lot, it could be going well for a month and then you could have two bad months.鈥� [Caregiver org.4].

Supervisors found that communication about the PA process and expectations could be more effective, yet they valued the PA for facilitating in-depth discussions about informal care. Despite occasionally feeling capable of conducting these discussions independently, they also recognized the value of involving another professional in the PA: 鈥淔or myself as a supervisor, I found it very comforting to notice that [name caregiver] could actually turn to someone else with the issues she was dealing with, besides me. [鈥�] This gave me the feeling that I could also let go of it a little.鈥� [Supervisor org.4].

Positive and negative outcomes of the PA

Solutions related to work-life balance

Caregivers mentioned that the diverse array of concrete agreements, solutions, and shifts in mindset achieved through the PA across various life domains (Fig.听1), helped them to take steps towards achieving a better work-life balance, and enhancing their control. On one hand, the PA encouraged caregivers鈥� self-awareness and prompted them to take action regarding their own role, including recognizing and adjusting their behavioral patterns or current task division within the caregiving situation. As one caregiver pointed out: 鈥淵ou鈥檙e forced to critically examine: how is it actually going? What am I doing? Because really, you鈥檙e just putting out fires everywhere. And you start to get a bit of an idea for yourself: how do I even achieve balance in all of this?鈥� [Org.2]. On the other hand, the PA facilitated increased functional support from supervisors, leading to the identification and utilization of various support options within the work environment, such as work flexibility, adjustments to work schedules, and additional task support. However, it was noted that not all issues, such as some related to their care situation, could always be resolved through the PA: 鈥�Indeed, for some things, you do not immediately have a solution, or perhaps there is no solution at all [鈥�] For example that mental burden, that always stays with you.鈥� [Caregiver, org.4].

For those caregivers who already had a good grasp on their balance, the PA did not bring about direct changes, but it did confirm that things are currently well arranged. Process facilitators noted that both a more preventive and restorative PA application were valuable, but that commitment and outcomes were more noticeable when the caregiver was in need of improving their balance and there were, thus, actually challenges to solve.

Other outcomes of the PA

Both caregivers and supervisors highlighted the improved ability to openly discuss informal care matters, emphasizing its potential to prevent future issues. Some caregivers involved their supervisor despite not currently experiencing work-care balance issues: 鈥淲别濒濒, I think making it discussable has helped me the most because I鈥檓 not sure if I would have done that on my own very quickly. [鈥�] Whereas, actually, it鈥檚 really good that they just know it already. Because then there鈥檚 also more understanding if something does come up.鈥� [Caregiver Org.3].

Furthermore, the PA conversations also heightened caregivers鈥� piece of mind and perceived social support. By increasing awareness and fostering recognition and mutual understanding, the PA often resulted in the (further) development of relationships between caregivers and supervisors. As one supervisor mentioned: 鈥淚t turned into a more profound conversation about what it means to be a caregiver and all that it entails. So, for me, it provided more insight into just how heavy it really is.鈥� [Org.2]. Similarly, a caregiver expressed: 鈥淭he fact that you feel trusted [by the supervisor] not to slack off when you鈥檙e not there at the moment, and that you complete your work at another time, is so comforting. And that鈥檚 what alleviates the guilt; it just doesn鈥檛 weigh so heavily on you.鈥� [Org.1]. However, there were a few exceptions where the conversations did not lead to adequate recognition or improved relationships, particularly when criticism targeted the employee鈥檚 performance or when caregivers felt their situation was not understood.

Discussion

This study evaluated the implementation and experiences of a workplace problem-solving intervention, the participatory approach (PA), which aims to support caregiving employees in achieving and maintaining a better balance between work, personal life, and informal care. Not all caregivers completed all intervention steps, or engaged their supervisor in the PA. Barriers experienced at the personal and organizational levels, as well as in the mutual relationship between the caregiver and supervisor, contributed to this. Still, intervention stakeholders, i.e. working caregivers, supervisors and process facilitators, were generally positive about the stepwise intervention and outcomes. Through participation, caregivers actively reflected on their well-being and behavioral patterns and were stimulated to start implementing concrete actions to better balance responsibilities across multiple life domains. Concurrently, the PA facilitated caregivers in receiving functional and social support from their supervisors, while it also contributed to enhanced awareness and acknowledgment of informal caregiving within the workplace.

Most caregivers who participated in the intervention identified challenges in their work-life-care balance during the first PA step, followed by a 鈥榳atershed鈥� moment. Caregivers with satisfactory balance and supervisor support often did not continue with the PA or action plan, indicating a more preventive application aimed at averting potential future issues, rather than rectifying existing work-life imbalances. The actual implementation of actions in the PA (in 28 out of 48 PA cases), was therefore rather moderate. Process facilitators noted the higher commitment of caregivers who were actively grappling with balance-related issues, aligning with prior research demonstrating the challenges employers face in implementing and reaching individuals with preventive health interventions [33, 34]. Moreover, many caregivers shared their personal journey of starting to recognize themselves as caregivers, for whom support is available. In line with other studies [35,36,37], the lack of awareness about being a caregiver posed challenges for effectively reaching the intended target group, and also for participation. Organizations considering the implementation of the intervention in the future 鈥� beyond the research context 鈥� should therefore carefully plan whom to target, and how and when to initiate the PA, including how to actually reach caregivers, also preventively. This requires organizations to actively integrate prevention of work-life disbalance due to informal care as a goal in their policy. This may also involve, as one study suggests, ensuring that occupational health services and social work departments 鈥� who may act as PA facilitators 鈥� proactively clarify their preventive roles regarding work-life balance within the organization [38].

Besides the need for balance-related improvements and caregivers not recognizing themselves as such, a key factor in PA implementation was the willingness to discuss caregiving tasks with the supervisor. Results showed that some caregivers preferred to keep their informal care tasks private, and mutual trust between caregiver and supervisor was not always present. In the Dutch context, employees are not obligated to disclose their personal caregiving situations to employers, meaning that organizations generally lack a clear overview of caregiving employees. While this approach respects employee privacy, it also limits the organization鈥檚 ability to provide timely, tailored support鈥攁 tension between privacy and transparency that organizations must navigate carefully. In this study, an important reason for hesitating to emphasize their caregiving role at work, was the fear of negative repercussions. Previous research has shown that there are potentially negative consequences of disclosing personal (health) issues at work, such as stigma, unaccommodating supervisor behavior and loss of opportunities [36, 39, 40]. Negative outcomes have been shown to be less likely in the case of early disclosure, especially when the caregiving employees鈥� work performance has not yet been significantly affected [41]. This evaluation showed that the PA was used by some caregivers as a vehicle for (early) disclosure. Furthermore, results indicated that involving a neutral professional can lower the threshold for conversation, mitigate negative attitudes and increase caregivers鈥� sense of security to discuss informal care. To achieve this, it is important that the facilitator is viewed as neutral (i.e. not just on the side of the employer), which appeared to be the case in this study, where the role was primarily filled by occupational social workers. In a previous PA study, where occupational physicians served as facilitators [42, 43], their perceived lack of independence hindered PA implementation, suggesting that employers should carefully consider whom to appoint in this role. Finally, despite the beneficial support experienced by both caregivers and supervisors from the facilitator, a few unsuccessful collaborations were observed. Further research is needed to explore the circumstances under which negative or positive responses to discussions about the caregiving role may arise.

On the side of the supervisors, their willingness to discuss informal care varied based on personal affinity, with differing levels of awareness of (the impact of) workers鈥� informal care duties observed among them [44]. Previous research indicated that personal experience of supervisors as a caregiver significantly impacted the active discussion of the topic in the workplace [45]. Yet, this study also pointed towards pivotal factors within the broader organizational context. Supervisors, tasked with supporting caregiving employees, sometimes found themselves in a challenging balancing act: providing solutions while preventing team tensions and meeting higher management鈥檚 organizational objectives. Coupled with the many other demands on their role, this often resulted in feeling overextended, limiting the perceived time available to address informal care thoroughly. Similar challenges were observed in a study examining the implementation of a dialogue-based participatory approach aimed at promoting sustainable employability of employees in low-skilled jobs [46]. For successful implementation of the PA, an enabling organizational environment, allocating time and attention to address informal care, is imperative. This is in line with other studies describing that a caregiver-friendly environment is constituted not only by formal regulations but also by a work culture encompassing unwritten rules and behaviors that prioritize employee wellness and work-life balance [5, 47, 48].

Implications for practice

Thus, caregivers, supervisors and employers share a collective responsibility in addressing informal caregiving. The PA intervention has the potential to support working caregivers, but its success depends on being willing and able to engage in discussions about informal care. Practical implications include raising awareness about caregivers鈥� daily experiences and the impact of balancing work with caregiving responsibilities, which can facilitate early conversations, timely solutions, and thereby contribute to prevention of absence or burnout [49]. Supervisors can aid this process by actively encouraging employees to reflect on their work-life balance, including caregiving responsibilities. Additionally, fostering a compassionate work culture that prioritizes prevention, and normalizes and allows time for open discussions about caregiving needs and challenges was shown to be an important precondition for the success of the PA.听This suggests that organizations need to invest in this aspect before implementing the PA in the future. In this context, higher management has a critical role to play, and future research on workplace interventions for caregiving employees could benefit from examining their perspectives on strengthening leadership commitment to a supportive culture.

This study demonstrated that the PA facilitated access to and utilization of various support measures for caregivers, often through functional and social support from their supervisors. While the literature has extensively highlighted flexible work policies as a key solution for working caregivers, there is growing recognition that these policies can also lead to blurred work-life boundaries and increased caregiver imbalance over time [50,51,52]. The PA trajectories in this study unveiled numerous other options and leverage points to enhance work-life-care balance, aligning with the individual situation and needs of caregivers. To effectively assist caregivers in the PA, it is therefore essential for employers to supply information about these options and clear guidelines on when they can be used. While the intervention was offered in the work context, solutions in caregivers鈥� personal lives or caregiving situations were also needed to maintain balance and work performance. Employers can assist by providing referrals and information about external support options, thus alleviating the burden on caregivers to find suitable support independently [53, 54].

Finally, implications for the PA intervention involve updating the training manual for improved communication to stakeholders regarding the process and expectations, including the option to tailor the PA timeline to individual preferences. As was also found in the multi-domain PA study of Schaap et al. 2023 [23], caregivers sometimes found it challenging to make changes in their situation, and some required more time to identify the main bottlenecks and appropriate solutions. Additionally, caregivers indicated that maintaining a good balance was an ongoing process requiring constant effort, that is subject to changes in caregiving, their personal lives, and work. In some situations additional PA meetings, longer-term evaluation moments or re-starting the PA when new challenges arise, may therefore be of use.

Methodological considerations

The strengths of the current process evaluation lie in our use of a rigorous methodological approach based on frameworks by Steckler and Linnan (2002), and Carroll et al. (2007), integrating both qualitative and quantitative methods. Utilizing diverse data sources and examining multiple user perspectives facilitated cross-verification, enhancing the credibility and comprehensiveness of the findings.

As a limitation of the current process evaluation, however, we should consider the potential for selection bias. Process facilitators and caregivers who already had positive views of the intervention and strong relationships with their supervisor might have been more likely to participate. Compared to other participant groups, considerably fewer supervisors felt inclined to be interviewed, and approximately a quarter of them did not complete the questionnaire after the PA. Direct contact with supervisors was limited due to their involvement in the PA through the process facilitators, potentially resulting in missed perspectives. Additionally, participating organizations were all relatively large, with a substantial HR and occupational health support structure and a relatively high number of white-collar jobs. As the implementation and reception of caregiver support interventions may differ in smaller enterprises or other jobs such as blue-collar sectors [44], for instance due to limited facilitation capacity or lack of (finances for) solutions [16], this limits the generalizability of the results. Moreover, almost 80% of our research population were female, reflecting the tendency in Dutch society for women to assume caregiving roles. Given that women often face distinct societal expectations around caregiving, the results may reflect gender-specific challenges and support preferences that could differ in a more male-dominated sample, potentially affecting both the perceived need for and engagement with the intervention. Finally, a more general limitation of this study is that caregivers were recruited within a research context, thus our findings provide limited insights into how caregivers and supervisors can be effectively engaged and motivated to utilize the PA beyond this setting, in real-world practice.

Conclusions

This process evaluation assessed the implementation and stakeholder experiences of a workplace participatory approach (PA) intervention designed to support caregiving employees in balancing work, personal life, and informal care responsibilities. Out of 57 caregivers assigned to the intervention group, 48 participated in the stepwise intervention, with 20 completing all seven steps and 30 involving their supervisors. Implementation of actions to improve work-life balance was limited due to not all caregivers experiencing challenges. Despite overall positive experiences of caregivers, supervisors, and facilitators with the PA, various contextual factors hindered implementation and supervisor involvement. The degree to which informal caregiving was deemed discussable in the workplace, together with the quality of relationships between employees and their supervisors were found to be particularly important. This implies that before the PA intervention is offered and implemented, organizations should already focus on raising awareness and creating a compassionate and supportive environment in which caregivers feel safe to share their situations. Moreover, for sustained support of working caregivers, the PA should be viewed as an ongoing process rather than as a one-time intervention, adaptable to the evolving needs and circumstances of caregivers.