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Correspondence: Address correspondence to A. E. (Ted) Benjamin, Professor of Social Welfare, UCLA School of Public Affairs, Los Angeles, CA 90095-1656. E-mail: tedbenj{at}ucla.edu
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Abstract |
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Key Words: Home-based care • Consumer direction • Workforce • Family caregiving
Research on informal caregivers has paid growing attention to the constructs of transitions and careers and to the importance of tracking caregiving over time. From this perspective, family caregiving is not a single episode but a series of dynamic experiences and statuses through which people move and whose stages, sequences, and transitions reflect some of the features of a career (Pearlin, 1992; Pearlin & Aneshensel, 1994; Seltzer & Li, 2000). This research has tended to define bereavement as the final stage of the family caregiving career, the point at which the death of the person receiving care produces a transition to a new status accompanied by various losses and gains (Seltzer & Li, 2000). We argue that these concepts may be especially important in understanding the work behavior of related caregivers following a caregiving experience.
In the recently completed Cash and Counseling Demonstration, about 70% of workers hired by adults receiving the cash option were family members, and most of the rest (about 20%) were friends (Dale, Brown, Phillips, & Carlson, 2005; Foster, Dale, & Brown, 2007). In California's In-Home Supportive Services program (IHSS), the largest consumer-directed personal assistance program in the country, about half the paid workers are family members and one quarter are friends, acquaintances, or neighbors (Benjamin & Matthias, 2004). Across programs, there is evidence that when given the choice, people older than age 65 are more likely to hire relatives as workers than are younger recipients. Expansion of consumer-directed services has begun to produce a pool of experienced home-based providers who have (at least for a time) been paid workers for their loved ones. Data on long-term employment from California indicate that despite very high turnover among all caregivers (Ong, Rickles, Matthias, & Benjamin, 2002), from 5% to 10% of former "related workers" (our shorthand for family and friends as paid home-based workers) continue to do home care/personal assistance work following their initial experience being paid to care for someone close to them.
There are at least three reasons for the lack of attention thus far paid to related workers. First, paying family members with public funds has been slow to find political acceptance (Linsk, Keigher, Simon-Rusinowitz, & England, 1992; Simon-Rusinowitz, Mahoney, & Benjamin, 1998); thus, it is fairly new as public policy and only now becoming widespread and well documented (Feinberg, Newman, Gray, & Kolb, 2004; Polivka, 2001). Second, researchers have assumed that most family and friends embrace paid home care work only temporarily because consumer-directed programs let them do paid supportive work for a familiar person for a limited time. Third, no one has yet asked what happens after this initial paid experience, because most research on issues of recruitment and retention has been confined to agency-based providers, very few of whom are friends or family of recipients. Consequently, experts have assumed that this related worker role is temporary, that there is little chance that these one-time workers will subsequently pursue service careers, and thus that questions about job retention are irrelevant.
In light of evidence that various social and economic pressures are reducing the amount of unpaid (informal) care families are able and willing to provide to older persons, the public sector is likely to face growing pressures to expand formal services, including paying families to care (Spillman & Pezzin, 2000; Wolf, 2001; Wolff & Kasper, 2006). Because demand for home care workers is certain to grow (Kaye et al., 2006; Montgomery et al., 2005; Stone & Wiener, 2001), research needs to address how all prospective workers, including related workers following their initial service experiences, make employment choices. Such research could challenge researchers' understanding of the boundaries between informal and formal service provision and provide insights into the recruitment and retention of what may be an expanding pool of future direct care workers.
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Understanding Recruitment and Retention |
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TOPAbstractUnderstanding Recruitment and...MethodsResultsDiscussionReferences |
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Other research has addressed retention issues facing aides/attendants employed by home care agencies. On the one hand, home care workers may be more satisfied with their jobs and less likely to leave them than nursing home employees. Some workers reportedly prefer home care jobs because they are considered less stressful (with only one client to care for at a time), more varied in terms of clients and settings, and more flexible with respect to hours and scheduling (Maiden & Maiden, 2004; Stacey, 2005). On the other hand, there is a persistent shortage of home-based workers, and their relatively low status, poor pay, and difficult working conditions mean recruitment is not easy and turnover remains high (Burbridge, 1993; Crown, Ahlburg, & MacAdam, 1995; Yamada, 2002). Research has identified various problems in the "work life" of home care agency workers, including inadequate training, heavy workloads, few tangible rewards for high performance (Carr & Kazanowski, 1994; Feldman, 1994), little or no supportive supervision (Dawson & Surpin, 2001), and vulnerability to job-related injuries (Bureau of Labor Statistics, 2001; Gregory, 2001). Agency workers also typically know little about their clients' conditions, are unclear about their specific roles and responsibilities, and have little decision-making discretion (U.S. General Accounting Office, 2001). On balance, these workers receive little recognition or respect from those they serve and the general public (Stone & Wiener, 2001).
Initial research on workers in consumer-directed programs indicates that related workers prove to be committed to their jobs, with service periods about half again as long as those of strangers hired to care (Matthias & Benjamin, 2005). Related workers report high levels of satisfaction, but being a related caregiver has costs too, especially in terms of the higher worker stress associated with working for someone you are close to emotionally (Benjamin & Matthias, 2004; Foster et al., 2007).
Under consumer direction, worker recruitment becomes a private issue shifted to service recipients, who frequently turn to family and friends for paid help. It seems likely that most related workers do not define their initial hiring as a career decision but one based on personal considerations of duty, friendship, and (perhaps) convenience. If one addresses retention and asks what happens to related workers after they have had a taste of direct care work in consumer-directed home care, one confronts some potentially important conceptual differences when compared with traditional workers. First, the character of the job may be defined by the relationship between a single worker and his or her consumer–client rather than by agency routines, expectations, and rewards. Second, there is no formal organization (e.g., nursing home or home care agency) that defines terms of the work relationship like workload and scheduling; instead, these are negotiated between the consumer and worker. Third, although workforce research generally pays less attention to care recipient characteristics like functional needs and cognitive status, these may be potentially important factors in understanding the experiences of related caregivers.
The current study focused on two sets of former workers: those who have left the field of caregiving (whom we label Leavers) and those who are currently working as caregivers (whom we label Stayers). We examined retrospectively the experiences of related workers and attempted to understand how background and experience affect the decision to stay in or leave home care work. More specifically, we addressed three questions: (a) Who stays and who leaves caring work after exposure to it? (In what ways do Stayers and Leavers differ?); (b) What seems to account for career choices by related workers to continue (or not) in caring work? and (c) To what extent might related caregivers be a potential future pool of long-term care workers? We adapted frameworks used in studies of worker retention in formal organizations to fit a consumer-directed home care context.
Staying and leaving may be influenced by the demographic and socioeconomic characteristics of related workers and their work histories. For example, more educated workers are more likely to have other career options, and thus we expected them to be Leavers, whereas those with previous experience in health-related work are more familiar with service occupations and thus may be more likely to be Stayers. We also expected that the nature of the experience in providing home care to a relative or friend (what we term the index work experience [IWE]) may be important in differentiating Stayers and Leavers. For example, those who have had more demanding work experiences while serving sicker clients may be less likely to stay, whereas those who have experienced more familial support and less pressure to care will be more likely to stay. Finally, worker attitudes about the relative appeal of caring work should be associated with the likelihood of deciding to continue doing it. Those who come away from the IWE with a more positive view are more likely to stay.
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Methods |
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Compared with all related program workers in California, the survey sample had slightly more friends, women, and older workers; and fewer Asian/Pacific Islanders. Active refusers (those who indicated on the phone or in writing that they chose not to participate) were more likely to be male, White, or Asian/Pacific Islander (data not shown). Although the sample was generally representative of program workers, readers should keep these differences in mind when interpreting study results.
Data Source/Study Variables
We assigned respondents to the outcome variable, staying in or leaving caring work, based on a series of screening questions. We classified respondents as Stayers if they were currently working in a job for pay involving care for any disabled person or older adult in any of various settings, including home, nursing home, or other settings. We classified them as Leavers if they were doing other kinds of paid work, were unemployed, or were retired.
Respondents provided information on sociodemographic characteristics, including age, gender, race and ethnicity, education, income, household composition, personal health, and employment history. Respondents answered a series of questions about their IWE providing services to their family member or friend, including the needs of the recipient and the nature of the services provided. We drew these items primarily from our previous studies of consumer-directed home care (Benjamin & Matthias, 2001, 2004; Benjamin, Matthias, & Franke, 2000). Questionnaire items also addressed reasons for working, attitudes toward the IWE, stress and satisfaction, reasons for leaving, and attitudes toward future employment. We adapted questions pertaining to job role and job rewards from the Job Role Quality Questionnaire (Marshall, Barnett, Baruch, & Pleck, 1991) and from our previous interviews of IHSS workers (Benjamin & Matthias, 2004). We also drew survey items from the Better Jobs, Better Care Evaluation Survey (Kiefer et al., 2005), the California Statewide Survey of Caregivers (Scharlach et al., 2003), and the National Long Term Care Survey (Cafferata & Stone, 1989). Data on intensity and duration of services came from the statewide database of service users and providers.
Data Analysis
For the categorical comparisons, we used t tests to determine differences in mean scores and chi-square tests to determine differences in proportions. We used logistic regression to determine which variables were related to staying or leaving when other relevant variables were controlled. We calculated odds ratios for each parameter estimate. We dropped from the analyses respondents with missing data. The predictor variables were either dichotomized and recoded to equal 0 or 1, or included as continuous variables, where appropriate.
We introduced predictor variables in three stages: first the sociodemographic variables (Model 1), then the work history and IWE variables (Model 2), and finally attitudinal variables (Model 3).
Because the sample was relatively small, we had to limit the number of predictor variables. We included variables in the regression equation if they were significantly related to outcome (Stayer vs Leaver) in the univariate analyses, if they were independent of other predictor variables, and if there were responses from all respondents (e.g., we could not use current hourly wage because only respondents currently working provided that information).
Because there were 26 questionnaire items about attitudes toward the IWE, it was necessary to reduce these for use in the multivariate analysis. To do this we used a common factor model, principal components analysis with varimax rotation, and identified four factors of interest.
Factor 1, labeled Stressful Work, included seven items: too much work to do, emotionally hard situations, took too much out of me, caused very much stress, was physically hard, often felt isolated, too much responsibility. The range was 7 to 35, and Cronbach's alpha was.827.
Factor 2, labeled Rewarding Work, included five items: helping was rewarding, work was interesting, a chance to learn new things, made me feel needed, having a lot of different things to do was rewarding. The range was 5 to 22, and Cronbach's alpha was.756.
Factor 3, labeled Career Fit, included four items: the work fit my job skills, it fit with my interests, provided steady employment, I had all the training I needed. The range was 4 to 20, and Cronbach's alpha was.634.
Factor 4, labeled Work Value, included five items: helping made a difference in client's life, the work was boring (reversed), gave me a sense of accomplishment, lots of flexibility in work schedule, did not let me use my skills (reversed). The range was 5 to 20, and Cronbach's alpha was.464. The low alpha indicated that this factor was not as internally consistent as the others and thus would be more difficult to interpret.
We used SPSS statistical software (SPSS, Chicago, IL, 2004) for all analyses.
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Results |
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Caregiving Attitudes
As reported in Table 4, Stayers and Leavers generally described their reasons for engaging in paid caregiving in different terms. Stayers were more likely to cite reasons involving helping others and making a difference in people's lives, whereas Leavers frequently cited less altruistic reasons like having steady work or having a flexible schedule. We also asked a series of questions about how in hindsight respondents assessed their paid caregiving experience. A factor analysis yielded four dimensions described earlier: (a) Stressful Work, (b) Rewarding Work, (c) Career Fit, and (d) Work Value. Findings suggested little difference on all but the third dimension. Stayers were more likely than Leavers to agree that the IWE fit their career skills and interests. Although this difference was not large, it did indicate that a positive view of the IWE when viewed in a career context was associated with subsequent decisions about caring work. Finally, Stayers were much more likely than Leavers to affirm that they would consider being a caregiver again for someone else, whether family or friend or not. Surprisingly, more than 40% of Leavers mirrored Stayers in this view.
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Those who cited helping others as a reason to engage in paid caregiving were more likely to become Stayers. Those who perceived the work as fitting their skills and interests (i.e., had lower, more positive scores on this scale) were also more likely to be Stayers. Although the factor score for Work Value was not statistically significant in Table 4, it emerged as significant in the context of other variables in Table 5. Those who disagreed that the IWE had yielded positive benefits for the recipient and worker were more likely to be Stayers. Finally, those who were receptive to assuming the caregiver role (and paid employment) again in the future for someone outside the circle of family and friends were more likely to become Stayers.
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Discussion |
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For one thing, Stayers seem to be those family members and friends with past links to caring work and fewer options in other employment areas. We defined the IWE as the triggering event that drew related workers into caring work, but this was less true for Stayers than Leavers. More Stayers had done this kind of work before, and so they had already incorporated the experience into their own occupational self-definitions. Compared with Leavers, Stayers were less likely to be college graduates, so their educational profile probably better fit low-wage work (Montgomery et al., 2005). Other data revealed that Leavers were not only less likely to have been employed in health care prior to the IWE, but also less likely to be employed at all and more likely to be out of the workforce. But those Leavers who were working consistently had higher hourly pay than Stayers, so working Leavers probably had higher expectations that for most precluded doing lower paying service work. Stayers had to meet their income needs by holding more than one (typically low-paying) job.
The nature of the IWE may have shaped views about caring work as a future occupation, although the data provide only a snapshot of how this happens. Leavers were more likely to work with recipients who were close relatives and had more emotional and behavioral problems; these problems may have accounted for the higher monthly service hours authorized for recipients served by those who became Leavers. Yet Stayers were more likely to provide activities of daily living assistance and help with arranging other services, and their average duration of service exceeded that of Leavers. This suggests that Stayers were intensively involved in the service process. We also find that for Stayers this involvement was more likely to reflect their own choices and less likely to reflect family views about who should do the caring work. Having choice about the caregiving role may be associated with positive attitudes toward caring work.
Attitudes about the IWE and service work generally may not readily distinguish Stayers from Leavers, because there was much overlap in their views, but some distinctions seem salient. Stayers were more likely to report altruistic reasons for service work, suggesting that there are positive attitudes about this type of work that extend beyond obligation or income. Stayers were more likely to view the caring work experience as fitting their career skills and interests. However, they were less likely than Leavers to conclude that their caring work had significant value for the recipient or the worker. These views suggest that Stayers might bring altruism and compatibility to the service experience but do not have unrealistic ideas about the impact of their work. Alternately, Stayers may not be as closely connected emotionally to the recipient, may not have other job options, and thus may be more critical of the work as their primary job. Viewed either way, we think this profile may describe the views of a "typical" home care worker, which Stayers have become (Mickus, Luz, & Hogan, 2004). By contrast, Leavers better fit our original conception of family (or friend) caregivers. They seem more likely to enter the work out of a sense of obligation and/or because of family pressure, provide intensive services on a one-time basis, and find the work valuable. They then move on to other work (because they have that option), re-enter retirement (because that was their original plan), or drop out of the workforce (for a variety of reasons).
We were surprised that despite this portrait of Leavers, so many seemed willing to consider doing caring work again not just for family or friends but also for someone they did not know. (We were also surprised that close to 1 in 5 Stayers indicated that they would probably not.) It is conceivable that there was some positive response bias among Leavers and negative bias among Stayers, but clear differences remain. We suspect that these findings indicate a widespread but latent willingness to consider caring work among related workers, whatever their present employment choices. Moreover, given that 5% to 10% of current IHSS program workers are likely to become Stayers despite the virtual absence of systematic outreach to them, we conclude that many more experienced workers could be recruited back into long-term care work. We recommend that states and counties that have introduced consumer direction and paid family caregiving consider interventions as simple as debriefing related workers at the termination of their IWE, making them aware of caring work as an alternative career path, and providing them with information on specific opportunities in the field. More active outreach may increase the likelihood that this pool of hidden workers becomes part of the answer to the continuing need for a stable and capable workforce to serve frail elders and others with disabling conditions.
At least three limitations of this study suggest the need for caution in interpretation and for further research. First, this was a study of related workers following employment in one program in one state, so extrapolating findings to other states and populations should be done cautiously. This task is made easier because California is a large and diverse state and the IHSS program provides mainstream services to a broad population. Second, the study sampling strategy yielded one slice of the Stayer population (and perhaps the largest one): home care workers employed by a large state program. However, this strategy may have limited the extent to which the sample was representative of the full range of Stayers, including those working in nursing homes, assisted living facilities, and other work sites. Third, the study was retrospective, which allowed us to consider subsequent work history but also relied on worker recall in describing and assessing their attitudes and experiences. Although recall and hindsight may be what matters in this context, we recommend that a prospective study examining family and friends as they enter and leave paid caring work experiences would provide a more accurate and refined portrait of decisions to stay or leave.
Gerontological research has long addressed the experiences of family members caring for loved ones, and only recently has research begun to examine direct care workers hired by agencies or families to provide personal assistance and other care. Our study findings suggest some unifying ideas that may bridge what have been two distinctive research areas. First, with growing frequency under consumer-directed programs, family members can also become formal paid workers, blurring the lines between informal and formal. Second, although the vast majority of paid related caregivers currently do not continue with this work, some do not terminate their direct service careers following the death of a loved one. The presumed final stage in the informal care career, bereavement, may be followed by a transition to a new stage, namely paid care for others. Third, researchers still have much to learn about how these career decisions are made, what influences the choice to stay or to leave paid care work, and what the consequences of these choices are over time.
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Footnotes |
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Department of Social Welfare, University of California, Los Angeles, School of Public Policy and Social Research.
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