Introduction
To cope with the challenges brought about by their ageing populations, some Asian countries have actively developed new public long-term care (LTC) systems. Japan and Korea introduced public compulsory long-term care insurance (LTCI) in 2000 and in 2008, respectively (Campbell, Ikegami and Gibson Reference Campbell, Ikegami and Gibson2010; Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b), and Taiwan has been making preparations to follow suit in three to five years (Nadash and Shih Reference Nadash and Shih2013). In designing and operating the new LTC systems, home visiting social care services, in particular, have been strongly promoted by the respective governments due to their cost-reduction benefits and contribution to greater independence for older people (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b; Hale, Barrett and Gauld Reference Hale, Barrett and Gauld2010; Ikegami Reference Ikegami2007). As a result, many older people have begun to use home visiting care services providing a range of essential personal care services, such as assistance with exercise, bathing, preparing meals and housekeeping.
This research is primarily concerned with the relationships between these older people and home care workers under the new Korean LTCI system.Footnote 1 To explore this issue, although the researcher initially attempted to interview older people and home care workers, the actual interviews had to be conducted with family carers and home care workers owing to the frailty of older clients, the reasons for which will be explained in detail later. In the research, older people are defined as those aged 65 or over, and older (elder) clients are defined as older people using services under the LTCI. Given the increasing use of home care services, understanding the relationships between older clients and home care workers is crucial because these relationships are closely connected both with the quality of the services provided for older people and the working conditions and job satisfaction for home care workers (Barer Reference Barer1992; Iecovich Reference Iecovich2011; Ungerson Reference Ungerson2005; Walsh and Shutes Reference Walsh and Shutes2013). However, very few studies (Fujiwara et al. Reference Fujiwara, Tsukishima, Tsutsumi, Kawakami and Kishi2003; Research Institute for Advancement of Living Standards (RIALS) 1997) have explored these relationships in depth in the Asian context, although there has been a significant amount of research on such issues in the West (Aronson and Neysmith Reference Aronson and Neysmith1996; Doyle and Timonen Reference Doyle and Timonen2009; Eustis and Fischer Reference Eustis and Fischer1991; Iecovich Reference Iecovich2011; Karner Reference Karner1998; Piercy Reference Piercy2001; Piercy and Dunkely Reference Piercy and Dunkely2004; Porat and Iecovich Reference Porat and Iecovich2010; Ungerson Reference Ungerson2005; Walsh and Shutes Reference Walsh and Shutes2013).
Literature review: positive and negative relationships
Rummery and Fine (Reference Rummery and Fine2012: 323–4) state that care has three distinguishable facets that set it apart from other types of work: ‘a feeling or emotion involving a disposition towards others’, ‘the work and physical activity involved’ and ‘a social relationship’. In other words, caring refers not only to the processes of care-giving and care-receiving but also to the reciprocal emotional relationships that exist between carer and recipient (Ayalon Reference Ayalon2009; Graham and Bassett Reference Graham and Bassett2006; Karner Reference Karner1998; Walsh and Shutes Reference Walsh and Shutes2013). In particular, the third facet of care, the ‘social relationship’, is one of the most significant practical issues for older people and home care workers. Through regularly experiencing the use and provision of care services at home, older clients and home care workers are able to form personal, intimate and social relationships. However, this relationship is not a simple process, but rather a complex process of interpersonal exchanges that involve issues of dependency, power and responsibility (Rummery and Fine Reference Rummery and Fine2012; Walsh and Shutes Reference Walsh and Shutes2013). Moreover, ‘macro’-level issues such as policy, the organisation of the care system, its funding system and its regulation also affect the care relationships (Daly Reference Daly2002; Hale, Barrett and Gauld Reference Hale, Barrett and Gauld2010; Ungerson Reference Ungerson2005).
The majority of the literature has reported that close relationships often develop between older people and their home care workers, with genuine friendship, family-like and fictive kin (‘a substitute for actual family members and the assistive resources’ (Karner Reference Karner1998: 78) relationships not uncommon (Aronson and Neysmith Reference Aronson and Neysmith1996; Doyle and Timonen Reference Doyle and Timonen2009; Eustis and Fischer Reference Eustis and Fischer1991; Iecovich Reference Iecovich2011; Piercy Reference Piercy2001; Piercy and Dunkely Reference Piercy and Dunkely2004; Porat and Iecovich Reference Porat and Iecovich2010; Ungerson Reference Ungerson2005; Walsh and Shutes Reference Walsh and Shutes2013). A number of studies note some of the conditions upon which positive relationships are built, such as the continuity of care provision, the social isolation of older users, the frequency and duration of contact, and similarities between clients and care workers in terms of race, gender, culture or language (Barer Reference Barer1992; Piercy Reference Piercy2001; Porat and Iecovich Reference Porat and Iecovich2010). In particular, Hale's study (Reference Hale2006) in New Zealand found that from the perspectives of older people, successful relationships with care workers are possible when care workers are able to bring quality ‘attitudes, skills, friendliness and flexibilities’ (Hale, Barrett and Gauld Reference Hale, Barrett and Gauld2010: 65). For older people, such a positive relationship can serve to blur the boundaries between formal and informal care services (Aronson and Neysmith Reference Aronson and Neysmith1996; Ayalon Reference Ayalon2009), thus enabling older people to feel that their privacy and intimacy are secured (Ayalon Reference Ayalon2009; Karner Reference Karner1998). Furthermore, it has been argued that care workers who develop positive relationships with their older clients may experience an increase in their care-giving satisfaction, a reduction in their care-giving burden and a greater sense of achievement in their work. This in turn may lead to increased commitment to their work and improvement in the quality of services provided (Iecovich Reference Iecovich2011; Walsh and Shutes Reference Walsh and Shutes2013).
However, negative relationships between older clients and care workers have also been reported by a limited number of studies (Doyle and Timonen Reference Doyle and Timonen2009; Fujiwara et al. Reference Fujiwara, Tsukishima, Tsutsumi, Kawakami and Kishi2003; Graham and Bassett Reference Graham and Bassett2006; RIALS 1997). Graham and Bassett (Reference Graham and Bassett2006: 345) point to the potential for negative reciprocity between care recipient and care worker, a concept described when ‘discord and conflict, coerced resignation, and asymmetrical understanding and expectations of one person of another characterized relationships that were without trust and compassion’. As a number of studies have shown, some care workers have been involved in conflicts not only with clients, but also sometimes with their family members, and this has often led to worker burnout and depersonalisation (Fujiwara et al. Reference Fujiwara, Tsukishima, Tsutsumi, Kawakami and Kishi2003; RIALS 1997; Yeoh and Huang Reference Yeoh and Huang2010). The origin of the negative relationship often lay in discrepancies in the expectations of the two sides. Home care workers noted that clients or their family members often made demands that lay beyond the care worker's area of responsibility (Doyle and Timonen Reference Doyle and Timonen2009; Fujiwara et al. Reference Fujiwara, Tsukishima, Tsutsumi, Kawakami and Kishi2003; Iecovich Reference Iecovich2011), demands that became the main source of conflict and worker burnout. A second source of conflict was the attitude of the care recipient towards his/her care worker or the unequal power relationship between employer (family member) and employee (care worker) in the home (Doyle and Timonen Reference Doyle and Timonen2009; Walsh and Shutes Reference Walsh and Shutes2013; Yeoh and Huang Reference Yeoh and Huang2010). It was noted that some older people exhibited prejudices against migrant care workers (including racial discrimination) and treated them unfairly. Alongside this, in Singapore, for example, migrant care workers experienced a range of physical or sexual maltreatment by family members, including ‘punches, pushes, slaps, bites and hair-pulling, as well as through the use of household items such as a wooden spatula, a broom, and a hot iron’ (Yeoh and Huang Reference Yeoh and Huang2010: 78). Yeoh and Huang (Reference Yeoh and Huang2010: 79) concluded that this violence occurs as a result of ‘the highly asymmetrical relations of power between a family member and a much younger, nonfamily female member of the household’. Finally, the social and structural contexts that care workers face can negatively affect client–care worker relationships (Kim Reference Kim2008; Walsh and Shutes Reference Walsh and Shutes2013). Since in many cases aspects of care workers' working conditions are poor – for example, they might receive low wages, have undergone insufficient or superficial training, have developed inadequate care skills and have a heavy workload – these can be the sources of stress, conflict or low quality of services (Kim Reference Kim2008; Nishikawa Reference Nishikawa2011; Rai Reference Rai2010). As a result, care workers may experience difficulty in providing a consistent standard of service, experience low job satisfaction and have a high turnover rate (Nishikawa Reference Nishikawa2011; Rai Reference Rai2010).
Caring for the older person and the new home care service in Korea
In East Asian countries, the long-term social care of older people has traditionally been the responsibility of their adult children. Under the strong influence of ‘filial piety’ (Hyo in Korean), which has its origins in Confucianism, adult children have believed that they are indebted to their aged parents and are obliged to repay this debt by taking caring of them (Chon Reference Chon2013b; Huang, Thang and Toyota Reference Huang, Thang and Toyota2012; Zimmer and Chen Reference Zimmer and Chen2012: 776). Within this framework, caring is regarded not as a simple act of responsibility out of love for their aged family member, but as a moral obligation and an expression of respect towards their parents (Cook and Dong Reference Cook and Dong2011; Sung Reference Sung2003). Therefore, family-based care for elderly parents has been customary, with adult children tending to look after their ageing parents (Cook and Dong Reference Cook and Dong2011; Huang, Thang and Toyota Reference Huang, Thang and Toyota2012; Sung Reference Sung2003; Zimmer and Chen Reference Zimmer and Chen2012). Direct caring work has been regarded primarily as a female responsibility. In Korea, many daughters-in-law and daughters have traditionally directly supported and taken care of their elderly relatives (Hong and Kim Reference Hong and Kim2008; Sung Reference Sung2003). Owing to this family-based caring culture, older people in East Asian countries have been reluctant to use formal and paid care services. In particular, there has been a reluctance to use nursing home services due to older people feeling a sense of abandonment by their family upon entering a nursing home or the feeling of ‘shamefulness in the eyes of others’ (Hong and Kim Reference Hong and Kim2008; Huang, Thang and Toyota Reference Huang, Thang and Toyota2012; Smith and Hung Reference Smith and Hung2012; Sung Reference Sung2003). When the use of formal services cannot be avoided, research has found that the recipients of such services and their families tend to prefer the use of in-home care services because this permits the older person to remain at home with their adult children (Huang, Thang and Toyota Reference Huang, Thang and Toyota2012; Smith and Hung Reference Smith and Hung2012). Nevertheless, with the increasing number of older people in need of LTC services in Korea and the growth of women's participation in the labour market, the shortage of social caring infrastructure for older people in terms of service-providing organisations and home care workers emerged as a national issue in the early 2000s (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b; Ministry of Health and Welfare (MHW) 2007a, 2007b; Sunwoo Reference Sunwoo2004). For example, only 0.4 per cent of older people had any access to in-home and community-based services in 2003, with the corresponding figure for nursing home services a mere 0.6 per cent (Sunwoo Reference Sunwoo2004).
The Korean government therefore introduced a new LTCI system in July 2008. In terms of its service delivery system, staff from the National Health Insurance Corporation (NHIC) assess the older person and produce a document that details their overall condition (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b). This document is then delivered to the older person or his/her family member (MHW 2007b). Those who receive grades one (critical care needs), two (substantial care needs) and three (moderate care needs) are eligible to access and use LTCI services (MHW 2007b). An in-home service provider manager then visits and assesses the older person (drawing on the document produced by the NHIC staff) and makes a service contract with them. The provider manager is in charge of selecting and introducing a care worker compatible with the client, and the care worker then starts to provide services to the client (Chon Reference Chon2013a, Reference Chon2013b). However, owing to the absence of a care management system, it is not compulsory to produce a care plan (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b). As regards payment, older clients must meet 15 per cent of the total costs for in-home and community-based care services and 20 per cent for institutional care services (MHW 2007b). Benefit levels are capped and differ according to the types of services and grade awarded. Table 1 shows the monthly insured benefit limits for home visiting services (MHW 2007a).
Table 1. Monthly insured benefit limits for Korean long-term care insurance in 2008
Note: £1 is equivalent to around 1,700 won at 2013 exchange rates.
Source: MHW (2007a).
Care workers have been playing an important role in providing services in the field. As of June 2011, care workers in the in-home and institutional settings accounted for 93 per cent (262,720) of the LTC workforce (280,332) (NHIC 2011). In the in-home setting, their primary roles are to provide assistance with the activities of daily living (ADL) of older people and perform some housekeeping work; the carrying out of medical tasks is not permitted (Chon Reference Chon2013b; Kim Reference Kim2008). While migrant care workers play a significant role in providing home care services for older people in Singapore, Taiwan and Hong Kong (Huang, Thang and Toyota Reference Huang, Thang and Toyota2012), this is not the case in Korea, where only a small proportion of the care workforce is composed of migrant care workersFootnote 2 because only live-out home care workers are permitted to provide services under the LTCI.
Aim of the study
A limitation of the existing international literature is that it chiefly considers the one-sided perspectives of either care workers (Fujiwara et al. Reference Fujiwara, Tsukishima, Tsutsumi, Kawakami and Kishi2003; Karner Reference Karner1998) or older service users (Barer Reference Barer1992; Porat and Iecovich Reference Porat and Iecovich2010). More importantly, no empirical research employing a qualitative research methodology has been conducted to explore such issues within the new LTCI system in Korea.
The study aims to fill these gaps by contributing to the literature on the relationships between older people and their care workers in this East Asian context. By employing qualitative research methods, the experiences of 22 family carers of the elderly and service providers (home care workers and provider managers) are studied in detail for the first time in the context of the Korean LTCI system. The following questions are investigated:
1. How do family carers view the relationship between their elderly relatives and home care workers?
2. How do service providers view the relationship between their older clients and home care workers?
3. How is the provision and use of home care services conducted at home?
Methods
Research setting
The Korean government conducted three national pilot projects between July 2005 and June 2008 to test the newly designed LTCI systems, before introducing the new LTCI system in July 2008. For the pilot projects, 13 areas were selected according to their size. At the time of the field research, the third pilot project was being conducted. The city of Suwon was selected as the field research site. The rationale for selecting Suwon for this study can be found in the important and distinctive role that it played as part of the pilot projects (MHW 2007a, 2007b). In contrast to the other sites selected for the pilot projects, three pilot projects were carried out consecutively in Suwon from July 2005, a continuous period of more than two and a half years at the time of this study's field research. As a result, at the time of the research, Suwon had witnessed a significant increase in the number of service-providing organisations and direct care workers over the course of the three pilot projects, and many people in Suwon were aware of and understood this new LTCI system (NHIC 2008). The overall scheme of the third pilot project was almost the same as that of the final LTCI system implemented in July 2008. It was anticipated, therefore, that this research would reveal the issues related to the relationships between service users and care workers that would be likely to emerge after the implementation of the new LTC system at the national level.
Recruitment of the sample
The field research took place in Suwon from January to April 2008. The author conducted qualitative semi-structured in-depth interviews with a total of 22 interviewees, comprising ten family carers and 12 service providers (six care workers and six provider managers). In the research, family carers are defined as family members caring for older relatives and are the adult children or children-in-law of the older person using the home visiting care service provided under the Korean LTCI system. Most of the family carers lived with their elderly relatives (i.e. they were co-resident), but one family carer lived separately but near to the older person in their care.Footnote 3 Service providers comprise home care workers and provider managers. Home care workers are defined as those who directly provide services such as housekeeping and personal assistance services to older clients at home, and provider managers are defined as those who supervise their home care workers and occasionally provide direct care services when home care workers are absent.
Purposive and snowball sampling methods were used for recruiting the interviewees (Noy Reference Noy2008; Patton Reference Patton2002). In terms of the practicalities of the research, the reciprocal nature of relationships was examined through the voices of family carers and service providers. The detailed sampling methods that were employed and the reasons for selecting this dyad sample rather one containing older people and service providers are as follows. Firstly, given the existing literature on the relationships between older people and their care workers, I therefore initially considered it best to conduct the interviews with dyads of older clients and their home care workers. In my pursuit of suitable interviewees, I initially adopted a purposive sampling method that entailed identifying older service users who could shed light on the research questions (Bryman Reference Bryman2004). In this regard, I sought the assistance of the vice-heads of the two local branches of the NHIC in Suwon, who were in charge of information on service users. However, the older people identified by this method were extremely frail, and the interviews that were conducted with them did not last more than five minutes. The interviewee's responses to questions were invariably brief and yielded no usable data (e.g. common responses were simply ‘I don't know’ or ‘my care worker is good’). As a result, I altered my initial sampling plan and elected to interview their ten family carers instead. Ultimately, this decision proved to be a fruitful one because the family carers were able to provide a range of information pertinent to the research topic. Secondly, although I endeavoured to interview dyads of care workers and family carers, some family carers were reluctant to recommend their care workers for interview, stating that they did not wish for the private service experiences of their parents to be revealed through interviews with their care workers. Other family carers interviewed recommended their care workers for interview. However, while some of these care workers' provider managers allowed interviews to take place, others cited the busy schedule of their employees and refused to allow their participation. Consequently, some provider managers participated in the interviews in place of the care workers under their supervision. Since the provider managers knew the actual situations faced by their care workers well and sometimes provided services for the older people in place of their care workers, they reported a number of vivid experiences relating to the research topics. Thirdly, to recruit care workers, I directly telephoned a number of home visiting service agencies and was able to recruit some care workers for interview. Employing a snowball sampling method, I asked these respondents upon conclusion of their interviews to recommend other interviewees who they felt would be able to competently report their experiences (Noy Reference Noy2008).
In terms of the criteria for recruiting care workers for interview, only those who had experienced providing assistance to their clients for more than one year were selected. As regards the recruitment of provider managers, only those who had been continually involved in or had directly provided services to older clients for more than one year at the time of interview were selected. Similarly, only those family carers who had experienced using services for their elderly relatives for at least six months were considered.
As regards the characteristics of the interviewees, all ten family carers in the sample were adult relatives of the service recipients: three daughters-in-law, two daughters, three sons and two wives of the older person. The family carers had been looking after their relatives for more than one year, and all of the interviewees' relatives had been using LTC services for more than six months. Most of the family carers were the primary carers at home, and they were therefore able to discuss their relatives' experiences of their home care workers and observe their interactions. The family carers also provided assistance to their relatives while the home care workers were absent. Although the three male carers interviewed were not primary carers, they had been actively assisting their elderly parents and helped the primary carers, their wives. Therefore, they also had considerable information about their parents' home care workers.
All 12 service providers interviewed were women and had backgrounds in social work or voluntary unpaid care work. Most of them had been working in the field for at least two years. The service times and frequencies of visits that service providers offered to their clients varied. In the research, it was reported that the home care workers interviewed had been providing services for their clients from two to five times per week, for two to four hours at a time, and had been continually taking care of their clients for between six and 24 months. The older people or their carers tend to use LTCI services within the monthly insured price limits received (see Table 1), and these limits significantly influence the frequency of home visits by home care workers and the duration of each visit (Chon Reference Chon2013a).
Data collection
To conduct this qualitative exploratory research, I devised and employed three types of semi-structured interview guides, one each for family carers, home care workers and provider managers. Since this is exploratory research on an area where little has been studied, I attempted to elicit responses on the issues that were of greatest importance to the interviewees (Bryman Reference Bryman2004; Mason Reference Mason2002). Questions about the experiences of using and providing care services at home and evaluation of the relationships between the older people and their home care workers were asked. I frequently used open-ended questions and probes, examples of which were as follows: ‘Would you talk to me about how you feel about your parent's relationship with your home care worker?’ (probe: ‘What makes you think so?’); ‘How do you feel about your relationship with older clients at home?’ (probe: ‘Do you have any difficulty in maintaining the relationship?’).
In terms of ethical considerations in undertaking this research, it should be noted that while it is very common in developed countries to make use of institutional review boards at universities or public organisations in approving the study's design and its ethical procedures, such ethical research considerations have not been seriously considered in Korea, and there was no such formal institutional review board available to assess this research proposal. In spite of this, I endeavoured to conduct the study ethically and to follow ethical practices throughout the research. I personally conducted all the interviews. Prior to commencing interviews, I explained the aims and procedures of the research, made sure that the interviewee's participation was their own decision and stated that the participants had the right to withdraw from the interview at any time. After obtaining permission from the participants, all the interviewees were asked to sign interview consent forms. Particular care was taken to guarantee the anonymity of interviewees and the confidentiality of collected data. Interviews generally took place at family carers' homes or in home care workers' meeting rooms at their agencies. The participants were enthusiastic about the research issues and actively reported their experiences. The interviews lasted between 40 and 90 minutes.
Data analysis
After the field research, all the collected data were transcribed and each interview transcript reviewed many times. ATLAS-ti (version 5.5.9) software was used to assist in coding and analysing all the transcripts. For the coding process, a three-stage thematic analysis method was adopted (Flick Reference Flick2006; Neuman Reference Neuman2006). Firstly, ‘open coding’ was performed. Rather than adhering to any particular concept or a specific destination for the coding, the original data were coded in terms of recurring concepts, phenomena and issues, which produced a large number of codes. Next, in order to discover the concepts or themes that were revealed by the research, ‘axial coding’ was performed by refining and linking the open codes. Finally, after detecting a number of core themes, ‘selective coding’ was carried out by scrutinising all the collected data and previous codes and examining them selectively for cases that illustrated themes (Neuman Reference Neuman2006). The data analysis process was iterative and time-consuming, and I had to frequently go back and forth between the original coded data and the themes researched (Mason Reference Mason2002). To conduct member checking, I sent the transcripts of the interviews and a summary of analysis of the research to some of the research participants and received feedback from them.
Findings
The issues that emerged from the research data were broader and more diverse than was initially expected. The findings of the research are divided into two parts. The first part concerns the evaluation of the relationships between home care workers and older people, and the second part relates to the frequent changing of home care worker. Although the opinions of family carers and service providers differed on some of the research topics, the opinions of home care workers and provider managers were very similar. In their supervisory capacity, provider managers were regularly informed of their care workers' experiences in the field, and this led to their understanding of and sympathy for the situations and difficulties faced by their care workers.
Evaluation of the relationships between home care workers and their clients
Family carers and home care workers exhibited significantly different views on the relationships between service users and care workers. While many family carers described and assessed the relationships in positive terms, many service providers reported somewhat negative experiences and described the difficulties that they experienced.
Satisfactory care workers: family carers' perspectives
Most (eight out of ten) family carers expressed satisfaction with the relationships between their parents and care workers and approved of the fact that their relatives were able to receive new formal care services at cheaper prices due to the new LTCI system. They also reported that their relatives' home care workers had positive attitudes, good personalities, were faithful and trustworthy. Some family carers said that the home care workers cared for their elderly relatives as though they were their own parents. This could be related to the tradition of filial piety culture in Korea. One daughter-in-law said:
They [father-in-law and care worker] get along with each other well … Her quality of care work is very good … I am 100 per cent satisfied with her … She takes care of him as if he were her own parent. (Family carer, 39 years old)
Other family carers also expressed similar satisfaction with their home care workers, noting that they bore the strains and difficulties of their work with good grace and maintained good relationships with their clients. Two family carers stated that the home care workers patiently dealt with the difficult personalities of their elderly relatives (who could be obstinate, brusque or impulsive), did not complain and did their best to provide services to their clients. One son carer said:
My mother's personality is obstinate and eccentric … I feel really sorry for her care workers … Looking back on the care workers who worked here, they were really fantastic. (Family carer, 63 years old)
However, two family carers reported that their elderly relatives had somewhat negative or uncomfortable relationships with their home care workers. One daughter-in-law stated that her mother-in-law experienced difficulty in developing a positive relationship with her care worker due to the care worker's indifference towards the delivery of agreed service time: ‘The care worker left our home earlier than her official finishing time. For example, she was supposed to work from 2 pm to 5 pm, but she was not here when I came home at 4.40 pm’ (family carer, 53 years old). The other daughter reported that ‘the care worker kept saying that my mother should be sent to a nursing home … My mother disliked the idea of a nursing home’ (family carer, 63 years old). It was reported that the reason that the home care worker repeatedly expressed this view was her belief that the client was too frail for care in the home environment and that this placed undue stress on her daughter as the primary carer. Owing to the strong influence of Confucianism and ‘filial piety’, however, many Korean older people are reluctant to enter nursing homes (Kim Reference Kim2004). Despite this, the home care worker continued to make this recommendation, and as a result, the elderly person was unhappy and upset with the home care worker.
Unreasonable requests and sexual harassment by elderly users: service providers' perspectives
By contrast, most of the service providers negatively assessed their relationships with older clients and pointed out that demanding behaviour and sexual harassment by their service users were the main causes of tensions or conflicts. Similar to accounts found in existing studies (Doyle and Timonen Reference Doyle and Timonen2009; Fujiwara et al. Reference Fujiwara, Tsukishima, Tsutsumi, Kawakami and Kishi2003; Iecovich Reference Iecovich2011), many of the service providers reported that older clients or their family carers often made unreasonable demands, including demands that they primarily perform housework and cook for other family members or bathe clients unduly frequently. The service providers reported that their primary role was often misinterpreted by clients and their family carers to be one of domestic workers or ‘housekeepers’ rather than to support older people with their ADL and emotional needs and to provide counselling. It is likely that the unreasonable demands of clients resulted from the inexperience of service users and their lack of understanding about what constitutes care provision.
However, the service providers stated that even though home care workers realised that such demands were inappropriate and were not part of their remit, all but one of them – who always told clients, ‘I can't do it!’ (care worker, 59 years old) – tended to accede to the demands. There are four main interrelated reasons for care workers' acquiescence to unreasonable demands, and these reasons appear to point to the unique situation underpinning the development of relationships between older clients and home care workers in Korea. Firstly, due to the absence of a care management system in Korea's LTCI system, care workers do not use care plans (Chon Reference Chon2013a). As a result, some care workers had no specific work to undertake at the time of the demands and therefore consented to them. In the words of one care worker: ‘I find it awkward to simply sit there quietly doing nothing’ (care worker, 46 years old). By contrast, the strict use of detailed care plans in Canada has led to instrumental and bureaucratic provision of services (Sims-Gould and Martin-Matthews Reference Sims-Gould and Martin-Matthews2010).
Secondly, some care workers found it emotionally difficult to reject inappropriate demands from older clients owing to the influence of traditional filial piety. One said:
The elderly couple wanted me to do all their domestic work … If I didn't do the work, the granny was disappointed … I initially began to take on more of the housework because they reminded me of my father and mother. I can't avoid it. (Care worker, 56 years old)
Thirdly, service providers had difficulty in clearly differentiating services for the elderly from services for other family members. In other words, home care workers and provider managers were often unsure as to where the boundary between their role as providers of services specifically for elderly users and ‘housekeepers’ lay. As a result, some care workers argued that there is a need for comprehensive guidelines that delineate the roles of home care workers and the services can be provided to older clients.
Finally, two care workers reported that they voluntarily and willingly did such domestic work for other family members without any requests from service users or their family carers, stating that they did so in order to assist the family carers. One care worker stated that she did so as ‘it is helpful for the daughter and daughter-in-law of the family’ (care worker, 62 years old). It seems probable that this voluntary housework was undertaken because some service providers had not received systematic instructions from their supervisors on the terms of service provision, or even if they had, they did not follow the instructions.
The service providers' acceptance of tasks outside the scope of home care provision meant that their workloads gradually increased, and care workers felt that they were being treated as ‘housekeepers’. Such demands negatively affected their ability to perform their care tasks properly and resulted in negative feelings about their relationship with their clients.
Unexpectedly, sexual harassment by older clients was another prominent source of tension and concern between service users and care workers. It was found that some male clients harassed or verbally abused female care workers by unexpectedly touching them or hugging them without permission. In the Korean cultural context, adult men and women seldom hug each other except when they are in very close relationships, such as those involving relatives or couples who are romantically linked. One provider manager said:
When I had meetings with our care workers, I heard a number of stories about it [sexual harassment]. For example, one elderly man revealed his penis and wanted it to be touched by our care worker. He once touched the bosom of a care worker, and sometimes he would suddenly fondle and kiss care workers … It's a big worry. (Provider manager, 44 years old)
A small number of female clients suffered from mental problems and were verbally abusive. One care worker said:
An elderly person with long-term dementia … asked me how my sexual relationship with my husband was last night … It's really unpleasant! (Care worker, 51 years old)
Sexual harassment occurred not only from clients with mental health problems but also from those with physical health problems. The home care worker interviewees reported that although only a small proportion of them had directly experienced such harassment, those who had felt ‘severe betrayal’ because they felt that their dedication to providing assistance to the client had been met with disrespectful behaviour in return. This caused them severe distress, especially when they did not report the incident to their supervisor and instead kept it to themselves. Such instances inevitably led to a significant change in the relationship between the elderly client and their home care worker.
In order to tackle the problem of sexual harassment in the field, it was reported that the provider managers intervened in the matter either by issuing a warning to the clients or family carers or by giving instructions to their care workers. In spite of these interventions by provider managers, the sexual harassment problem was not always resolved, and the provider managers therefore had to withdraw the older person from their client list or change their home care worker.
The frequent changing of home care workers
Half of the family carers interviewed reported that although they had good relationships with their relatives' care workers, the care workers frequently changed. Similarly, seven of the 12 service providers also reported that they often changed clients. However, the reasons given by the family carer and service provider interviewee groups for such frequency of change were significantly different.
Personal matters and demands of users: family carers' perspectives
From the perspectives of family carers, two main reasons were given for the frequent changes of home care workers. First, family carers stated that they believed that private and personal matters, such as their care worker finding another job or moving to another area, were the main reason. One said that ‘the care worker stopped working because of her family problems’ (family carer, 45 years old).
Second, a few family carers reported that they or their elderly relatives sometimes requested that their home care workers be changed. It appears that conflicts between service users and providers might provide one explanation for the changes of home care workers, changes that might arise from either a direct request by the users or a personal decision by care workers. For instance, one son carer stated:
My mother has such a bad temper … Because of my mother's personality, her care workers are continually changing … My mother goes too far with the care workers … Some of her previous care workers couldn't tolerate her personality … I really feel sorry for them. (Family carer, 63 years old)
This had been an ongoing problem for the family. The personality of the older person had led to tensions with her care workers and to her changing them seven times during the two years of LTC that she had received at the time of the field research.
Due to such changing of care workers, some of the family carers had the opportunity to compare and evaluate the quality of care workers and the services provided by them:
We didn't want to change the care worker, but she chose to leave after eight months [of working]. She was really fantastic and a real professional … But the current care worker is not good at caring because she is short of training and experience in this area. (Family carer, 60 years old)
As a number of studies show (Barer Reference Barer1992; Piercy Reference Piercy2001; Porat and Iecovich Reference Porat and Iecovich2010), the provision of services by a familiar face is one of the basic conditions for the forming of positive relationships, and the frequent changing of home care workers can negatively affect the stability of the relationships between the client and their home care worker. Such conditions are therefore unlikely to foster the development of continuity of services.
Home care workers' challenging situations: service providers' perspectives
In contrast to the accounts of the family carer interviewees, service providers reported more direct reasons for the frequent changing of care workers, pointing to a number of difficulties faced by care workers that hinder their ability to perform their duties effectively, negatively affect their relationships with older clients, and thus contribute to the high burnout and turnover rates of home care workers (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b; Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012).
Most of all, the service providers interviewed pointed to the challenging working conditions faced by home care workers, citing the highly labour-intensive nature of the caring work itself (Razavi and Staab Reference Razavi and Staab2010) and their arduous working conditions, which appeared to stem largely from the unreasonable demands of elderly people, as noted above. The more the care workers met the demands of the older person, the more their own physical health suffered, with painful backs and waists commonly cited as physical symptoms arising from their working conditions. As a result, some of the care workers expressed that they had considered changing their clients or had contemplated leaving care work altogether. One care worker said:
Now after one month of caring for him, my back really hurts … I worry that I may have to stop working, but I have to keep working to make money. (Care worker, 54 years old)
In such cases – and similar to the cases involving excessive demands and sexual harassment by older clients – provider managers decided whether and how to change their care workers' assignment to cases. They were also able to take decisions about discontinuation of the provision of services. Altering care worker staffing was one of the means that they frequently employed to intervene in problematic cases.Footnote 4 For instance, one care worker stated:
Of course, family carers can also request a new care worker, but the power of my manager is absolute. It is within the discretionary power of my manager to mix the difficult and easy cases. (Care worker, 46 years old)
In addition, many service providers reported that the following factors contribute to the high rates of care worker burnout and turnover: care workers receive insufficient rewards for their work and inadequate incentives to continue working in the LTC market and to develop and maintain positive relationships with their older clients. Firstly, it was found that the home care workers received poor treatment in terms of pay and travelling expenses, an experience similar to care workers in other East Asian countries (Huang, Thang and Toyota Reference Huang, Thang and Toyota2012; Nishikawa Reference Nishikawa2011; Yeoh and Huang Reference Yeoh and Huang2010). A care worker said:
Pay is low. But looking after people is a very demanding job … Although we are working from a sense of duty, we can't help thinking about money. (Care worker, 51 years old)
Research shows that on average Korean home care workers are paid an hourly rate of around £4.11 (7,000 won; £1=1,700 won) and receive only £325 (560,000 won) per month, including travel allowances (Chon Reference Chon2013a; Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012).
Secondly, Korean home care workers have difficulty in obtaining enough working hours to meet their financial needs (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b; Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012). As noted earlier, only live-out care workers are permitted under the LTCI system, and the home care workers interviewed were in charge of one or two clients per day and provided services to clients from two to five times per week for two to four hours at a time. In keeping with this finding, Seo et al. (Reference Seo, Kim, Moon, Lee and Lim2012) found that Korean home care workers work 17.1 hours per week on average.
Moreover, as Table 2 shows, prices for home care services under the LTCI system have been fixed at a low level by the government, and minimum hourly payments have not been set for care workers (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b; Kim Reference Kim2008; Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012).
Table 2. Half-hourly unit price of home care services in the third pilot project
Note: £1 is equivalent to around 1,700 won at 2013 exchange rates.
Source: MHW (2007a).
Finally, home care workers receive insufficient welfare benefits. None of the home care workers interviewed was registered with or paid any of the four essential social insurances for employees in Korea at that time: the national pension, health insurance, unemployment insurance and industrial accident compensation insurance. One care worker said:
In the case of other companies in general, if I am sacked I can receive unemployment benefit, but not here. If I am unlucky, my health condition may worsen. Actually, my back is not good at the moment … but there are no guarantees in my job. You can understand why some care workers don't want to work here. (Care worker, 50 years old)
These deficiencies in the terms and conditions of employment appear to contribute to the high turnover rates of care workers in Korea. Indeed, a recent study found that 48.5 per cent of new home care workers left the Korean LTC market less than six months after they started work (Chon Reference Chon2013b).
Discussion
This research adds to the discussion on the issues of the relationships between LTC home care workers and their clients in an East Asian context. The particular significance of this study is that it investigates the unexplored issues through the direct accounts and voices of both family carers and service providers under the new Korean LTCI system. Overall, it was found that family carers reported that their elderly relatives were satisfied with their home care workers, that the care workers were trustworthy and faithful, and that they dealt well with the sometimes difficult personalities of their clients and maintained good relationships with them. However, service providers reported that home care workers experienced a number of difficulties such as demanding behaviour, sexual harassment by service users and poor treatment, and that these problems negatively affected their relationships with clients. It seems that such contrasting views on the nature of the relationships between home care workers and their clients stemmed from the fact that while clients were happy to receive these new care services, which had been available only to a very small proportion of older people prior to the introduction of the new LTCI system, the care workers faced considerable obstacles to developing stable relationships with their clients, as evidenced by the frequent changing of care workers. Overall, the findings suggest that the relationships between home care workers and their clients are lacking in stability.
Some of the findings of this study are consistent with previous research. For instance, from the perspective of family carers, service users were seen to have ‘positive’ relationships with their home care workers (Aronson and Neysmith Reference Aronson and Neysmith1996; Eustis and Fischer Reference Eustis and Fischer1991; Karner Reference Karner1998; Piercy Reference Piercy2001; Piercy and Dunkely Reference Piercy and Dunkely2004), while from the perspective of service providers, some conflicts between clients and home care workers were evident (Doyle and Timonen Reference Doyle and Timonen2009; Fujiwara et al. Reference Fujiwara, Tsukishima, Tsutsumi, Kawakami and Kishi2003; Iecovich Reference Iecovich2011). In addition, care workers were exposed to poor working conditions and treatment in terms of pay and welfare benefits (Nishikawa Reference Nishikawa2011; Rai Reference Rai2010).
However, the research findings also point to some interrelated factors that may affect the relationships between care workers and their clients in the Korean context. Firstly, at the individual level, it appears that Korea's inexperience of using and providing home care services may have a significant effect on the relationships between clients and their home care workers. In the study, some clients misunderstood the care workers' roles and regarded them as ‘housekeepers’, demanding that they provide services outside their areas of responsibility. Similarly, many care workers accepted such demands and did not clearly understand where the boundary between their role as providers of services specifically for older people and ‘housemaids’ lay. In addition, the traditional Korean culture of filial piety also seems to have affected the relationships. In particular, home care workers tended to regard and treat their clients as though they were their own parents or experienced emotional difficulties in rejecting their unreasonable demands.
Secondly, at the care agency level, it was found that the actions of provider managers affected the relationships between care workers and their clients. As has been shown, provider managers not only intervened in some problematic cases, such as those involving sexual harassment, but also made crucial decisions on the assignment of the home care workers under their supervision. Ultimately, the provider managers exercised significant control over whether the relationships between the clients and care workers continued or were brought to an end.
Thirdly, at the macro level, the position of home care workers within the Korean LTCI system negatively affected the relationships between clients and care workers. Despite the challenging nature of their work, care workers received poor treatment in terms of pay, working hours and welfare benefits (Kim Reference Kim2008; Rai Reference Rai2010; Walsh and Shutes Reference Walsh and Shutes2013). This is primarily because Korean home care workers have difficulty in obtaining enough working hours to meet their financial needs, and prices for home care services in the LTCI system have been fixed at a low level (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b; Kim Reference Kim2008; Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012). As Peng (Reference Peng2010: 473) argues, care workers' jobs are viewed by the Korean government as ‘inferior and contingent and therefore deserve low status’.
The findings of the research are significant because the challenging situations faced by care workers in Korea have continued to worsen (Chon Reference Chon2012, Reference Chon2013a, Reference Chon2013b; Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012). As a result, many provider managers have had enormous difficulties in recruiting and retaining care workers (Chon Reference Chon2013a, Reference Chon2013b; Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012), and many former care workers have left the LTC field altogether, with approximately 800,000 certified care workers no longer working within the care field as of 2011 (NHIC 2011). A recent study (Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012) estimates that there was a shortage of 19,720 care workers (medium scenario) in 2012 and that this number will increase to 151,205 in 2030.
Limitations and strengths of the study
The obvious limitation of this research is that it is very small-scale, both in terms of the number of interviewees and the fact that the fieldwork was conducted at a single research site. Given this, the findings should be treated with some caution, especially as regards its comparative application to other research findings. Nevertheless, the study has a number of strengths. Most of all, this study is the first empirical research to examine some of the unexplored issues related to the relationships between home care workers and their clients under the Korean LTCI scheme. Furthermore, by adopting a qualitative research methodology, the study examined the issues in depth from the perspectives of stakeholders in the LTCI system.
Conclusion
This research has aimed to explore the relationships between clients and home care workers under the Korean LTCI. It was found that the family carers interviewed positively evaluated the relationships, but the service providers assessed them in much more negative terms. Service providers' negative evaluations chiefly originated from a number of difficulties experienced by home care workers, such as excessive demands by clients or their family carers and sexual harassment by the older person. Since these difficulties have not been resolved in the field, it appears that they may contribute to the frequent reassignment of home care workers and high staff turnover in the LTC field in Korea (Seo et al. Reference Seo, Kim, Moon, Lee and Lim2012). This suggests that the relationships between clients and home care workers have been lacking in stability and the conditions for the development of positive relationships and continuity of services have not been developed (Barer Reference Barer1992; Piercy Reference Piercy2001; Porat and Iecovich Reference Porat and Iecovich2010).
The findings of this research raise some important policy implications. In order to tackle challenging issues such as unreasonable demands and sexual harassment from service users, the government needs to play a more prominent role in ensuring that clients and home care workers have a clear understanding of their responsibilities, a better appreciation of what is, and what is not, reasonable behaviour, and a recognition of the need for mutual adaptation (Barer Reference Barer1992; Fujiwara et al. Reference Fujiwara, Tsukishima, Tsutsumi, Kawakami and Kishi2003). At the same time, and more fundamentally, the overall working conditions and treatment of care workers should be improved. Urgent action in this area is required because such structural challenges are serving to undermine the relationships between clients and home care workers in Korea. Both the government and society in general need to reappraise the view that the role played by care workers in society is ‘inferior and contingent and therefore deserve[s] low status’ (Peng Reference Peng2010: 473). In addition, the low prices charged for home care work under the LTCI system should be increased, and the government should ensure that the increased revenue generated from higher charges should be used to raise the income of care workers. Through these policies, it is anticipated that the conditions for bringing about more positive relationships between clients and their care workers will be improved (Barer Reference Barer1992; Piercy Reference Piercy2001; Porat and Iecovich Reference Porat and Iecovich2010).
As this is exploratory research, further research needs to be conducted within the Korean LTCI system. In order to explore in depth the factors that lie behind the findings of the study, a mixed methodology, large-scale study needs to be conducted. In particular, the working conditions, treatment and the needs of home care workers should be explored more extensively and in greater depth. Finally, the Korean case might point to the need for greater international collaboration in comparing how the relationships between older people and home care workers may vary across the differing national and regional contexts for home care provision.
Acknowledgements
Funding for this paper was provided by Namseoul University. This work is a revised version of part of the author's doctoral dissertation.
