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Correspondence: Address correspondence to Eileen J. Porter, PhD, RN, Professor, MU Sinclair School of Nursing, University of Missouri–Columbia, Columbia, MO 65211. E-mail: PorterEJ{at}missouri.edu
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Key Words: Home-care-helper typology • Formal–informal home care • Standby assistance
Most researchers have classified helpers in terms compatible with the definitions of informal providers as family and friends and formal providers as agency employees. Eustis and Fischer (1991) asked older home-care clients this question about aides employed by home-care agencies: "How do you regard the worker—as a friend, as part of your family, as a worker—or what?" (p. 450). Typical categorizations have been kinship and social ties (Christianson, 1988), resident and nonresident informal caregivers (Kemper, 1992), and formal versus informal providers (Tennstedt et al., 1996). Tennstedt, McKinlay, and Sullivan (1989) asked older persons to identify up to four helpful family members and friends; the most helpful person was designated as primary caregiver, and the others were secondary caregivers. Dilworth-Anderson, Williams, and Cooper (1999) categorized primary, secondary, and tertiary caregivers of older African Americans on the basis of tasks and responsibility level. Both studies compared elders' use of these caregiving systems and formal services.
Scholars have used the formal–informal dichotomy as a basis for quantifying services (Edelman & Hughes, 1990), providers (Kart & Longino, 1987), visits (Hanley, Wiener, & Harris, 1991), and hours spent by providers to give care (Kemper, 1992; Tennstedt et al., 1996). These epidemiological approaches could afford critical perspectives on key compensation issues such as fair expectations of workers and labor costs (Close et al., 2001). However, there have been few reports of older persons' views or practices relative to caregiver compensation.
The two dimensions of the formal–informal dichotomy (recipient–provider relationships and compensation) have been basic facets of home-care policy. In the past, there was concern about a possible reduction in government support for home care in the event of a substitution effect, in which informal helpers reduced their efforts upon the entry of formal helpers (Hanley et al., 1991). However, early support for the substitution effect (Greene, 1983; Weissert, Cready, & Pawelak, 1988) has not been evident in more recent studies (Cohen, Miller, & Weinrobe, 2001; Penning, 2002; Tennstedt et al., 1996) or in reanalyses of older studies (Penning & Keating, 2000). This outcome is consistent with the view that informal care and formal care are complementary in meeting elders' needs (DeFriese & Woomert, 1992). The complementary model is a blend of two hybrid models: (a) the compensatory model, in which formal care compensates for unavailable, but preferred informal care, and (b) the supplementary model, in which formal care is an adjunct to informal care (Denton, 1997).
Because multiple regression analyses have shown support for more than one hybrid home-care model (Denton, 1997), similar phenomena might cut across such models and their formal and informal referents. To capture any overarching phenomena, qualitative research is indicated where formal and informal home care converge (Barker, 2002; Close et al., 2001). The formal–informal dichotomy has been viewed as artificial (Rubenstein, Lubben, & Mintzer, 1994) and possibly irrelevant to older home-care clients, some of whom described aides employed by agencies as friends (Eustis & Fischer, 1991).
We report data from a descriptive phenomenological study of older women's experience of home care, in which we set aside the formal–informal dichotomy to focus on the women's perceptions about their situations. In conducting this study, we assumed that having helpers was both (a) contextual (Hinds, Chaves, & Cypess, 1992) to the home-care experience and (b) a facet of the women's life-world (Porter, 1995a; Schutz & Luckmann, 1973). We produced a new typology of home-care helpers with four categories that cut across the dimensions of relationships and compensation.
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After appraising other descriptive phenomenological methods, Porter (1994, 1995a, 1998) incorporated principles from Husserl's (1913/1962) book, Ideas, into a new method; the method was used previously with the guidance of Drew (1986, 1989). The main activities of the iterative approach are as follows: (a) critically analyzing and setting aside scholarly perspectives on an experience (Porter, 1995b, 2000); (b) spending time with persons who are living that experience to obtain relevant data; (c) discerning the features of the context of the experience and the intentions through which persons structure their experience; (d) inviting dialogue about findings (phenomena) with participants and scholars to engender "countercases" (Husserl, 1913/1962, p. 388); and (e) reintroducing scholarly views into the analysis.
Sampling
In 1997 the Health Sciences Institutional Review Board at the University of Missouri–Columbia deemed the study exempt from review because (a) it involved interview procedures, and (b) data were recorded so that participants could not be identified. The appropriate sample for phenomenological research is typically 6 (Morse, 1994) to 10 persons (Haase, 1987); to allow for attrition, we set the sample size at 25. First, to start the three-stage sampling process (Porter, 1999), we sought volunteers in a six-county region by asking intermediaries, such as service agencies, to disseminate information about the study (Porter & Lanes, 2000).
Second, we did purposive sampling, screening volunteers for common characteristics (Luborsky & Rubinstein, 1995) to enhance the fittingness (Guba & Lincoln, 1981) or relevance of findings to similar situations (Beck, 1993). We based inclusion criteria on factors associated with home-care use (Branch et al., 1988; Choi, 1994; Soldo, 1985; Wan & Arling, 1983; Wolinsky & Johnson, 1992). The inclusion criteria were as follows: (a) being 80 years of age or older, (b) living alone at home, (c) having been widowed for at least 1 year, (d) having children, and (e) living in the town where one had lived when married. To enable case comparisons on widowhood, motherhood, and relocation for other project aims, we selected 3 women who met criteria (a) and (b) and criterion (c), (d), or (e). The other 22 women met all criteria. Finally, to obtain sufficient data, we oversampled rural women (50%) and Black women (25%), who represented 25% and 5%, respectively, of older women in Missouri (U. S. Department of Commerce, 1992).
The extent to which a volunteer understands the participant's role in a proposed study is a more appropriate criterion for participation than a standardized mental competence test (Dubler, 1987). To appraise that understanding in this study, the interviewer read aloud the Informed Consent form and a brief description of the participant's role and asked the volunteer to describe the following: (a) general interview topics, (b) likely length of each interview, and (c) proposed duration of the study. Of the 26 original volunteers, 25 women gave appropriate answers and consented to participate; their confidentiality was assured. The women ranged in age from 81 to 96 years (M = 87.6 years). The average number of children they had was two. Thirteen women lived in urban areas, and 12 women were rural residents; 19 women were White, and 6 were Black.
Data Collection
An interviewer conducted three lengthy open-ended interviews with each woman in her home during the first 4 months of her enrollment. The in-depth interview is a social interaction (Rubenstein, 1988) in which persons construct summative statements about their lives (Frank, 1979). Using one interviewer was critical to establish the genuine rapport that was basic to data validity (Carp, 1989). All 25 participants were retained for the first three interviews.
Interviews were focused on seeking and having help at home; sources of data were relevant perceptions, actions, and intentions reported by the women (Porter, 1998). The interviewer asked this question near the onset of the first and second interviews: "Is anyone coming in to help you for any reason?" The interviewer asked the woman to describe each helper and the nature of the help. To obtain data about perceptions of helpers, the interviewer used probes, such as this: "Sometimes women who live alone experience changes in their relationships over time with the people who do things to help them. Please tell me what this has been like for you." Near the end of each interview, the interviewer asked a series of closed (yes–no) questions about having help (personal–mechanical) with selected activities of daily living and instrumental activities of daily living (Morris, Sherwood, & Mor, 1984). In response, some women mentioned additional helpers. For instance, one woman began her first interview by describing five helpers in detail, but she did not mention her neighbor until she was asked directly if she had help taking out the garbage. Thus, data from the questions about help with activities were supplementary to data obtained in direct questions about helpers.
All interviews were tape recorded and transcribed by the same professional transcriptionist; the interviewer edited the word-processed transcript while listening to the tape. To appraise data reliability, a consultant with expertise in qualitative methods (N. Drew) compared data from the first interviews of three women to data from their second interviews. To appraise data validity, a consultant with expertise in home care compared (a) interview questions with interview data and (b) data obtained from the three women. The consultants concluded that (a) the same types of data had been obtained from the same woman over time and from different women and (b) that data were relevant to the home-care experience.
Data Analysis
In our analysis, we focused on discerning the women's intentions relative to persons who were helping them at home. After the second interview with each woman, we (E. Porter and L. Ganong) discussed data about helpers, noting that the women were counting on key helpers to continue helping over time. Using inductive and deductive reasoning, we saw commonalities in the characteristics of certain helpers across cases. To refer to those characteristics, we invoked common language congruent with data (Husserl, 1913/1962; Porter, 1998), naming the categories of the initial typology as follows: regular helper, on-call helper, and can-will doer. One of us (E. Porter) used that typology to categorize helpers from three interviews of several women; another (N. Drew) delineated basic characteristics of some helper types in those interviews.
While creating a data set about helpers from all interviews, we found it evident that some women viewed certain can-will doers as essential to the opportunity to live alone, having referred to such a person as "my main helper." To label such a helper, we chose the term mainstay. We entered our decisions concerning the typology into a document that served as an audit trail (Guba & Lincoln, 1981). We entered interviews into QSR NUD*IST (Qualitative Solutions and Research Pty Ltd., 1997) as a data-management strategy.
During interviews over the next 32 months, the women were asked to comment on the relevance of the typology to their lives. They responded favorably and shared validating data. The women were volunteers, so their experiences might not have been representative of older women. However, representativeness, in the sense of generalizability (Kerlinger, 1986), is neither an aim of qualitative work (Morse, 1986) nor the main interest in basic research. Instead, the foci of basic research are "the relations among variables and why the variables are related as they are" (Kerlinger, p. 299–300). We articulate relationships among helper types in the form of a taxonomy to enable others to appraise the categories and to offer countercases. Revealing the uniqueness of each person's experience is a basic goal of the method (Porter, 1998). Therefore, we report data from each woman in the sample, referring to the women as Ms. A through Ms. Y.
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The On-Call Helper (OCH)
Each woman had at least one OCH upon whom she could call for help with a new problem or to provide transportation on an irregular basis. Ms. C called her friend to take her to "the grocery stores and the dime stores." About her son-in-law, Ms. D said, "Anything that goes wrong, and I don't know how to fix it, I call him. He fixes it." The women tapped OCHs in emergencies. When Ms. E fell, she did not call her RH housekeeper; she called three OCHs (a daughter-in-law and two friends), all of whom came to help her within moments.
Some women (i.e., Ms. E through Ms. L) related the perception of having a sufficient reservoir of OCHs. Ms. F doubted that she would have trouble getting a ride to an appointment with her physician: "I've got several people I could get, I think." These women expressed fewer worries about seeking help than did the women who felt a lack of OCHs (Ms. M through Ms. O). Although Ms. M's mainstays (housekeeper and son) or her OCH (daughter-in-law) usually took her to her many appointments, she was anxious because her other OCH (a friend and neighbor) planned to move.
The Can-Will Doer (CWD)
Of the 25 women, 18 women shared data consistent with our definition of the CWD as a helper who could and would take up a responsibility that was too difficult or impossible for the women to manage alone. In giving or relinquishing a responsibility to a CWD (such as managing money), the women also gave latitude in handling associated tasks (such as when to pay bills). Ms. F, who was blind, said this about her mail carrier: "She comes in, reads my mail to me. She'll tell me whether they're good, something that goes to the bank, something to throw away. She knows pretty well just what to do."
The women shared worries with CWDs and solicited their advice. Ms. P's two children were her CWDs, and she remarked, "Anything that's business or important, I tell 'em I want them to know. I don't want to decide it. I'm just not that good at it anymore." Ms. G said this of one CWD, who was her second cousin: "She seems to understand how I feel." Ms. N, who was estranged from her adopted son, sought her trust officer's advice about matters other than finances; the bank staff also took her to out-of-town medical appointments. Some CWDs assumed responsibilities at the woman's request, but other CWDs were proactive. After she made a mistake when paying a bill, Ms. A said that her older sister had decided to take over that responsibility. "She takes care of all of my bills. She makes out my checks, and she mails 'em."
Some CWDs also were on call to assist with problems in a particular realm. Ms. C's long-time friend, Bobby, took care of her home maintenance and some yard work. He came over often "to see what he needed to do" in the house, and she called him when she was "in trouble."
He'll do anything; he can do anything. If I get in trouble, I call him. One night I had to call him three times to put that old switch on in there. The lamp just kept kicking the lights out. I said, ‘Oh, Bobby, they're out again’. I know where they [fuses] are; my husband showed 'em to me. But I don't like to fool with them. I said, ‘I'm sorry,’ but he say, ‘That's alright, Miz Becca.’ And he'd go right on and fix 'em, but said, ‘Don't attach a lamp no more.’ I said, ‘I won't.’ So I haven't.
Ms. Q and Ms. R, who were the most vigorous women in the sample, had the help of several RHs and OCHs, but they had not turned over any responsibilities to a CWD. Five women (Ms. E, Ms. H, Ms. S, Ms. T, and Ms. U ) did not have CWDs, but they had mainstay helpers.
The Mainstay
Ten women spoke of a person or two without whose help they believed they could not live alone at home. The mainstay's help was systematic in pattern and type, but it was not necessarily frequent. Some mainstays managed multiple responsibilities during monthly visits, as did one of Ms. K's daughters, who handled business affairs and shopping. The other daughter checked on Ms. K daily, took her to appointments, and provided posthospitalization care at home. Ms. K said, "I can't do without them. I wouldn't be living here without that help."
Mainstays shared several key characteristics. First, whereas the women trusted a CWD to carry out certain responsibilities, the level of trust with a mainstay was absolute and pervasive. Ms. A trusted her CWD (older sister) with her money, but Ms. V said this of her mainstay (housekeeper): "I would trust her with my life." Second, mainstays were "versatile," as Ms. V noted. Each mainstay did a variety of tasks, and the tasks varied across the sample. Two mainstays (of Ms. M and Ms. V) were privately paid housekeepers; they had volunteered or consented to take on transportation, shopping, banking, and personal care as those needs arose. Ms. W had an RH housekeeper and RH nurses, but her mainstay (sister) did her shopping, banking, transportation, and errands. "Fact, she does just about all of it." Two mainstays were registered nurses (Ms. T's grandson and Ms. U's friend, who was "like a daughter"). Their help ran the gamut from transportation, cleaning, and bathing to medication monitoring, food preparation, financial management, and (for Ms. U) coordination of care given by others.
Finally, the women viewed mainstays as companions who were willing to help them indefinitely and to do more as needed, acting out of affection and loyalty—not out of duty. Ms. T could not recall how her grandson began coming each week to help her. "I guess he just loves his grandma." Of her mainstay (housekeeper), Ms. V said, "She has absolute devotion to me." Thus, the mainstay was a consistent, predictable presence in a woman's life, as well as a partner to the woman in her intention to "stay here as long as I can."
Comparisons of the Types of Helpers
Both RHs and OCHs were task specialists. Although RH kin and OCHs were likely to have volunteered to help with certain tasks initially, they were not likely to take on new tasks unless asked to do so. Most RHs were more directly involved in the women's lives than OCHs. For instance, Ms. K's RH housekeeper from the Area Agency on Aging, whom she described as "willing" to do the job, came every week. In contrast, like other women with OCHs, Ms. F contacted a particular OCH on occasion. However, when the women felt the need to contact an OCH, they anticipated a favorable response, because the OCHs were known to be "available" to help. As Ms. F said, "I gen'lly know who to call."
In contrast to RHs (who came and left as scheduled) and OCHs (who waited to be called), CWDs did not wait to be called. The involvement of CWDs was more comprehensive. They came without being asked or, while they were present, they volunteered to do other tasks within the realm of their responsibility. As Ms. Y said of her only CWD, "She's not the only one that's helped me. But she's so faithful." Ms. D had two people who helped with home repair. About her OCH (brother-in-law), she said, "I had a little trouble with my bathroom. I called him. ‘Hey, what'll I do?’ He said, ‘I'll be over and see it.’ " However, of her CWD (son-in-law), Ms. D said, "Well, he'll come by, and he wants to do this and that." Some women and their helpers had arrived at broad interpretations of the helper's primary responsibility. One housekeeper, a government agency employee, was an RH for Ms. W, but she was a CWD for Ms. F and Ms. X; she took them to the grocery store on her own time when they had no other transportation.
Finally, compared with the ordinary definitions of formal and informal helpers, the women had varying points of reference for some helpers. Of the seven women with a home-care nurse—a prototypical formal helper by virtue of employment status—just four women (Ms. B, Ms. U, Ms. V, and Ms. W) spoke of the nurse in terms of an RH who did certain tasks and left. Ms. F and Ms. Y's nurses were also OCHs whom they called for advice and to request extra visits. Ms. C said that her CWD (nurse) would "do anything," such as make appointments, provide transportation, and "straighten out" medical bills with her daughter by long-distance telephone.
Prior Transitions From One Helper Type to Another
The women remarked that the nature of the help given by some persons had changed over time. Some RHs had volunteered to do more or had responded to requests for more help, and others gradually had become CWDs or mainstays. Ms. H, who was blind, had hired Annie 3 years earlier to take her on errands. Gradually Ms. H called Annie more often and relied on her help to purchase important items. When Ms. H. became very ill, she called Annie, who took Ms. H to the hospital and notified her children (who lived a distance away). Ms. H, who said that Annie was her "main help," described their relationship as a "gradual thing": "It didn't happen overnight." Thus, the women could not simply ask a RH or an OCH to substitute for a CWD or a mainstay. Regardless of whether they were kin, CWDs and mainstays had been involved and had stayed involved in the women's lives. The breadth of their involvement had developed over time, whether it was with one key responsibility (the CWD) or multiple facets of living alone (the mainstay). Furthermore, the intensity of the involvement fluctuated in synchrony with the woman's needs, whereas the relationship itself, for various reasons, withstood time's test.
Variations in Compensation Across Types of Helpers
Whether they were housekeepers, nurses, or case managers, some RHs were on a public payroll for those tasks. However, some persons who were paid to be RHs also functioned as OCHs, CWDs, or mainstays. Some women gave these helpers extra money or gifts, but others did not do so. In the case of private hires and other personal arrangements, there was a wide range of payment mechanisms. Some women did not pay family members for help regardless of the helper's gender. Concerning RHs, most women paid male neighbors and their sons and grandsons for jobs such as lawn mowing. Some women paid female neighbors back for help in some manner, but few women paid their daughters or granddaughters for help with transportation, shopping, or cleaning. There was some exchange of goods for services. Ms. M asked her son and daughter-in-law to use her car when they transported her. The women typically paid the OCHs for "big jobs," because they had to make special arrangements to secure such assistance. To repay some OCHs for smaller jobs, such as running errands, some women offered to treat them, perhaps by buying lunch while they were out. The women who could afford to hire RHs wanted to do that, rather than expecting or asking CWDs or mainstays to take up the task.
The greatest range of variability in compensation was for CWDs and mainstays. Typically, the women did not mention paying for the labor of CWDs and mainstays who were kin, although some women paid for the parts when those CWDs did repairs. Some women did not pay CWDs for any tasks, whereas others paid CWDs for some tasks. Ms. H paid her CWD (driver) "quite a lot of money." Ms. V said that she could not pay her housekeeper enough, so she named the housekeeper as beneficiary of a certificate of deposit. In contrast, Ms. M often gave her mainstay, Jill (a friend who cleaned the house and provided transportation), "a little gift" rather than paying wages. Jill supervised her daughter's lessons while at Ms. M's house, so Ms. M. said that Jill viewed part of her time as "free."
The variability in compensation of helpers was particularly evident within the situations of some women. Ms. L paid her grandson (RH) to mow her lawn. She paid her son (CWD) to repair her home. "He don't have any money, and so I pay him." She did not pay her daughter (CWD), who checked on her twice a day and brought her medicine. She relied on a male friend (RH) for transportation. "I can always get him any time I want him; that's worth a lot. So I pay him." When Ms. L had knee surgery, a friend (CWD) volunteered to stay with her; while continuing her job, she stayed for 3 weeks, doing the shopping and errands, preparing meals, and providing personal care. As to compensation, Ms. L said, "I just gave her what I wanted to. I didn't pay her any specified salary. She wasn't doin' a whole lot, other than to be here with me."
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Another possible limitation—the question of the mutual exclusivity of the categories of the helper typology—requires a more detailed explanation. Like the formal–informal dichotomy, the categories fail to meet strict standards of exhaustiveness and mutual exclusivity. Whereas those standards are critical in some methods, they are inappropriate to a method in which it is acknowledged that a perfect understanding of experience is not possible (Husserl, 1913/1962). In accord with our method, we attempted to detail the distinctions of each type of helper, seeking to reveal "the essential connections" (Husserl, p.193) among the categories. The categories are not a complete characterization of the women's helpers, but, in their incompleteness, we believe that they are more revelatory than the dichotomy of the nature and diversity of the helpers.
The new typology of home-care helpers can be viewed as a logical extension of the implication that there are theoretical crossovers between formal and informal home care. After comparing formal and informal providers on variables such as the number of hours of care provided to long-term-care insurance claimants, Cohen and colleagues (2001) noted, without further explanation, that most of the care was "standby assistance" (p. 183). The idea of standby assistance could be compared with Antonucci's (1985) concept of support reserve. Our findings are a more definitive elaboration of such terms. We assumed that having help was contextual to the home-care experience, and we viewed all helpers identified by the women as standbys. The commonplace terms for types of helpers are consistent with the women's words. They did not speak of support reserves, but they had much to say about helpers who were standing by them.
Issues Concerning Recipient–Provider Relationships
We found that multiple helpers with various responsibilities were interacting with the women. Rather than limiting the women to reports of a particular number of helpers (Tennstedt et al., 1989), we asked them to describe their helpers and to report who helped them with specific activities. Accordingly, we learned that, on average, the women had eight helpers, compared with the average of two to four caregivers reported by Tennstedt and colleagues.
We also noted a marked variability in recipient–provider relationships. Here, the new typology affords a perspective that builds on the work of other scholars. Tennstedt and colleagues (1989) found that primary caregivers engaged in tasks requiring "somewhat regular involvement" (p. 680) such as personal care, whereas secondary caregivers undertook "more intermittent help" (p. 680), such as shopping. Like those results, our findings suggest that it is problematic to define an informal helper, in part, as one who helps "regularly" (Cohen et al., 2001, p. 181). The women distinguished between persons whose help was routine and persons who were on call. We needed three categories (RH, CWD, and mainstay) to characterize the diversity of helpers with routine involvement. The OCH could be compared with the secondary caregiver of Tennstedt and colleagues, but beyond the intermittent nature of the help, the predictability of the OCH's response to the call for help was a critical parameter.
As implied in the findings about CWDs and mainstays, the issue of how the older woman manages her responsibilities over time is critical. Like Dilworth-Anderson and colleagues (1999), we defined helper types in part on the basis of reports of the degree to which helpers had accepted or taken up responsibilities. In contrast to the description of the tertiary caregiver as one who engages in a specialized task while having little decision-making responsibility, we found that some CWDs did specialized tasks and had concurrent responsibility for certain decisions. Ms. A, an African American woman, said that her sister began paying her bills when Ms. A made a mistake. We had no information from Ms. A's sister about this, so our perspective is incomplete. Studies are needed of the interactions of older women and their helpers over time as older women turn over responsibilities and helpers take up responsibilities.
If elders structure their home-care experiences around common metrics, such as having a mainstay, then the notion of service substitution cannot be understood in terms of a distinction between formal and informal providers. The language used to describe helpers should be consistent with the nature of elders' experience. The burgeoning movement of consumer direction in long-term services (Meiners, Mahoney, Shoop, & Squillace, 2002; Squillace & Firman, 2002) has led to a melding of aspects of formal and informal care for some older persons. Under the auspices of such a program, older clients or family members can become case managers (sometimes with the authority to hire and fire helpers); family and friends can become paid providers. Because the range of possible helpers is no longer restricted to employees of particular agencies, the realm of the informal expands by extension into the formal arena. If helpers in such programs are referred to as daughters, sons, grandchildren, or friends (Meiners et al., 2002; Squillace & Firman, 2002), the relationship (rather than the nature of the help) could become the focal point of analyses. To more clearly reveal the complexity of the home-care experience (Benjamin, 1992; Porter 1995b), helpers in consumer-directed programs could also be described as mainstays, can-will doers, or regular helpers, for instance.
Although researchers must continue exploring unanswered questions about facets of formal care and informal care, our approach is a counterview to research focused on one type of care or the other. For instance, noting that researchers had emphasized the care provided by families to the exclusion of care provided by friends, Barker (2002) described "unpaid, nonprofessional, nonkin caregiving relationships [characterized by an] unscripted ordinariness [typically focused on] the mundane tasks of everyday life" (p. S166). For women in this study, unscripted relationships were not limited to nonprofessionals. In the manner of CWDs, the professional RHs of several women had taken up more responsibilities to assist the women on their own time. The new typology of helpers is one platform from which researchers can engage with nonprofessional and professional providers alike to learn about the nature of their work.
Issues Concerning the Compensation of Helpers
Our results also offer new perspectives about the compensation of home-care helpers. When helpers are categorized in terms of the nature of their assistance rather than according to the formal–informal dichotomy, the potential value of their help might be more evident. However, some women did not compensate some helpers, particularly female kin. The interrelated influences upon such findings require further study, including (a) the older woman's financial situation; (b) societal values about the relative worth of help given by males and females (Close et al., 2001); and (c) long-standing patterns of mutuality among female kin. A woman's perceptions of her interactions with a helper could influence perceptions about compensation; such perceptions were not neatly divided along formal and informal lines. Some women, who described certain interactions with kin as focused on a task, spoke of some interactions with paid helpers, including agency employees, in terms of spending time together.
Our findings invite questions about the relationship between the formal–informal dichotomy and home-care payment policies. The long-standing association of formal care with paid help and informal care with nonpaid help was not evident in this study. Compensation was a more common feature of nonkin relationships, but the women paid some helpers who otherwise would be defined as informal (by virtue of being family members or friends). It is problematic to define an informal carer as a person who helps but does not receive regular payment (Cohen et al., 2001). Furthermore, because the women's paid helpers did other tasks without compensation, it cannot be assumed that a paid helper's assistance is limited to that for which pay is received. Therefore, we question the empirical soundness of formal care definitions in which the provider's status as a hired person (Coward & Dwyer, 1991) is linked to a source of payment (Penrod et al., 1994). Informal roles such as grandson and formal roles such as nurse are not clear indicators of the economic value of the assistance provided to older women who live alone. A great deal of variability in economic value to the woman (and to society) is masked behind such prototypical roles (Hooyman, 1990). Hidden costs of home care could be revealed by analyzing services of regular helpers (whether formal or informal) who also function as OCHs, CWDs, or mainstays.
Such detailed analyses of costs and benefits are particularly important with regard to CWDs and mainstays. The women with mainstays viewed them as ensurers of a continuing opportunity to live alone at home, but mainstays were (a) not compensated at all, (b) compensated for housekeeping instead of caretaking, or (c) compensated for coordinating care when they also provided care. Home-care insurers do not recognize mainstays as a critical class of helpers, let alone compensate them. We cannot suggest a compensation scale for such helpers, but we can raise this question. What is it worth to an older woman who lives alone (and to the society in which she lives) if she has a helper who is trustworthy, versatile, concerned, and committed to enabling her to live at home? The efforts of CWDs and mainstays should be highlighted in public policy discussions, and home-care agencies should create job descriptions for them in line with women's descriptions of their valued helpers.
Perhaps public financing for home-care helpers could be based in part on each older woman's perceptions of the importance of a helper's efforts in enabling her to live alone at home. Such a suggestion is fully consistent with the philosophy of consumer-directed home services (Squillace & Firman, 2002), but it seems impractical. Policies for home-care reimbursement vary by locale and fluctuate in usage during a single episode of care. The uniqueness we found in each woman's situation is duplicated on a different scale within the policies that influence her care. Thus, readers must ascertain whether the helper typology is more useful than the formal–informal dichotomy in assessing persons in their caseloads or in explaining needs within their jurisdictions.
Summary: The Potential Utility of the New Typology of Home-Care Helpers
Husserl (1913/1962) argued that findings of phenomenological studies can be put to various uses, but they remain ever incomplete and "capable of being extended" (p. 382) through further study. Although the categories of the new typology of home-care helpers should not be viewed as clear-cut entities, the typology is a basis for further research. Researchers who seek responses to open questions about standby helpers could introduce the four categories as topics of conversation, enabling a woman to compare helper types. Researchers who use the formal–informal dichotomy to study the provision of home care could use the typology as a companion framework to study recipients. For instance, Penning (1990) asked older persons if they had someone on whom they could rely in time of need. Our findings suggest that any woman with an RH, an OCH, a CWD, or a mainstay could answer that question affirmatively. To obtain more precise data about standby helpers, researchers could ask older women if they have a helper who (a) comes regularly only to do a specific task, (b) would come to help with a task if called, (c) had taken over a responsibility, or (d) was consistently providing the help they needed to live alone.
Our method enabled us to propose a typology of home helpers that cuts across the two key dimensions of the formal–informal home-care dichotomy—relationships and compensation. Compared with a dichotomous classification, this phenomenological study yielded a descriptive categorization that is perhaps more in keeping with the complexity of the home-care experience. Findings should be applied in keeping with the circumstances from which they originated—not in a standard manner, but in particular situations. Finally, we invite researchers and practitioners to engender countercases to the categories, thereby stimulating an ongoing renewal of ideas about this typology of home-care helpers.
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1 MU Sinclair School of Nursing, University of Missouri–Columbia, Columbia, MO.
2 Division of Nursing, Saint Joseph College, West Hartford, CT.
Decision Editor: Linda S. Noelker, PhD
Received for publication April 3, 2003. Accepted for publication October 15, 2003.
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