Women Caring for Our Aging in Place Seniors Will Lose Out because of U.S. Immigration Policies

Most older people experiencing chronic health problems, physical disabilities, and memory losses are still able to age in place in their own homes. However, they often need help from others to enjoy healthy, active, and independent lives. They turn mostly to family members, mainly women and usually their daughters, daughters-in-law or wives. But caring for frail elders has become more demanding and complex, and these family members often feel physically and emotionally overwhelmed and burnt out. They concede that they cannot do it alone. Others find it more difficult to hold full-or even part-time jobs. Hiring home (direct) care workers to assist their loved ones can be an effective solution to ease their caregiving responsibilities. However, these personal care aides, home health aides, and nursing assistants are already in short supply. Moreover, going forward the aging of the baby boomer population will result in an even greater demand for their services even as these jobs are often unattractive to American-born workers and turnover is high. This country’s immigration policies will make it even more difficult for women caring for older persons to hire these workers. Over 25 percent of home care workers are low-skilled immigrants or foreign-born. However, the Trump administration’s policies reduce the number of immigrants entering the U.S. and specifically choke off the various pathways that enable low-skilled persons to be hirable in the home care sector. Female caregivers seeking relief from their caregiving responsibilities will lose out unless we remove these immigration barriers.     

Family Caregiver Communication in the ICU: Toward a Relational View of Health Literacy

We interviewed 18 family caregivers about their communication experiences in the ICUs at an urban hospital. Analysis of their narratives suggests health literacy is important in family caregiver/healthcare provider communication, especially as complicated illnesses move the caregiver deeper into decision making. Using the domains of Yuen et al.’s conceptual model of caregiver health literacy (2015), we identified three themes within the context of ICU communication: agency, coordinated communication, and caregiver’s evolving role. We saw family caregivers negotiating domains of health literacy as they built upon knowledge of the patient’s needs, their rights as family caregivers, and the hierarchy of the professional staff. We found that these narratives represent co-created, or relational communication, rather than individual health literacy skills. Conceptualized in the transaction of relationship, health literacy is enacted; it is socially constructed and is the scaffolding upon which family caregivers make decisions, care for their loved one, and care for themselves.     

Secondary victimization of rape victims: insights from mental health professionals who treat survivors of violence

Rape victims may turn to the legal, medical, and mental health systems for assistance, but there is a growing body of literature indicating that many survivors are denied help by these agencies. What help victims do receive often leaves them feeling revictimized. These negative experiences have been termed "the second rape" or "secondary victimization." If indeed secondary victimization occurs, then these issues may be raised in rape survivors' mental health treatment. In the current study, probability sampling was used to survey a representative sample of licensed mental health professionals about the extent to which they believe rape victims are "re-raped" in their interactions with social system personnel. Most therapists believed that some community professionals engage in harmful behaviors that are detrimental to rape survivors' psychological well-being. Implications for future research on secondary victimization are discussed.     

Another face of health care disparity: stigma of mental illness

In many everyday situations, individuals with mental illness face stigma that leads to discrimination. A growing body of evidence suggests that those with mental illness experience disparities in health care and that their medical needs are often overlooked. The purpose of this article is to increase awareness to this problem. Fictional vignettes in which individuals with mental illness seek medical care are presented, followed by discussion on the role discrimination may play in the level of care these patients received. To help alleviate disparities, nurses are encouraged to advocate and speak out when they suspect discrimination is affecting the quality of care of those with mental illness.     

Kinship Care for Children of a Parent With a Mental Illness

Little is known about “hidden” kinship caregivers of children of a parent with a mental illness (COPMI). An exploratory study surveyed 56 COPMI caregiver members of a kinship center administered by a school of social work in a large public university. The COPMI sample was a subset of a larger kinship caregiver study. Nearly one in four caregivers was providing COPMI kinship care. The COPMI caregivers reported numerous child behavioral crises and decreased caregiver physical and emotional health since they began providing care. Practice, policy, and research require development to increase support for COPMI caregivers and their families.     

The closing of a social HMO: a case study

A social health maintenance organization (SHMO) integrates acute and long-term care and provides an extended-care benefit for elderly who are at risk of institutionalization. This article reports findings from a case study of the termination of the Group Health SHMO in Minnesota. Interviews were conducted with social workers and at-risk elderly who had been receiving long-term care through the SHMO. The case study examines the post-SHMO transition and the process of replacing SHMO care coordination and longterm care services. Most of the elderly and their caregivers indicated they were "losing ground"--that is, they were paying more or getting less care. Some were paying more for less care. Because they tended to switch to private-pay arrangements and to rely more on informal care, it appears that their care system became much less stable after the closing of the SHMO.     

Bearing the Costs of Our Eldercare Policies

For many caregivers, rendering aid to frail parents, grandparents, siblings, and spouses comes at a high price: compromised physical and mental health, disturbed relationships with spouse and children, truncated opportunities for social life, and, for caregivers who are employed, declining job performance. Using the 1982 National Long Term Care Survey's "Survey of Informal Caregivers," this study investigates how the sociodemographic characteristics of caregivers, care requirements, the availability of backup caregivers, and conditions of employment affect the likelihood that caregivers will suffer work constraints. Estimations of both the probability of work constraints and hours of work reveal that proxies for work conditions figure prominently, as do care requirements. In the model of constrained work, ill health, financial burdens, and primary responsibility for care are significant determinants; the estimation of hours of work revealed that low income and competing care demands wielded major influence. Women and white caregivers are employed fewer hours, while spouses are more likely than other informal caregivers to face constrained work. Occupation. as an indicator of work conditions, is shown to be an important addition to the factors considered in investigations of circumstances that affect caregivers' experiencing work constraints.     

Bearing the costs of our eldercare policies: work constraints among employed caregivers

For many caregivers, rendering aid to frail parents, grandparents, siblings, and spouses comes at a high price: compromised physical and mental health, disturbed relationships with spouse and children, truncated opportunities for social life, and, for caregivers who are employed, declining job performance. Using the 1982 National Long Term Care Survey's "Survey of Informal Care-givers," this study investigates how the sociodemographic characteristics of caregivers, care requirements, the availability of backup caregivers, and conditions of employment affect the likelihood that caregivers will suffer work constraints. Estimations of both the probability of work constraints and hours of work reveal that proxies for work conditions figure prominently, as do care requirements. In the model of constrained work, ill health, financial burdens, and primary responsibility for care are significant determinants; the estimation of hours of work revealed that low income and competing care demands wielded major influence. Women and white caregivers are employed fewer hours, while spouses are more likely than other informal caregivers to face constrained work. Occupation, as an indicator of work conditions, is shown to be an important addition to the factors considered in investigations of circumstances that affect caregivers' experiencing work constraints.     

Effects of a Foster Parent Training Program on Young Children’s Attachment Behaviors: Preliminary Evidence from a Randomized Clinical Trial

Young children who enter foster care experience disruptions in care and maltreatment at a point when maintaining attachment relationships is a key, biologically based task. In previous research, we have found that young children experience challenges as they form attachments with new caregivers. They tend to push their new caregivers away, even though such children are especially in need of nurturing care. Further, many caregivers do not respond in nurturing ways when their children are distressed, which we have found is problematic for young children in foster care. We developed an intervention that is designed to help caregivers provide nurturance even when children do not elicit it, and even when it does not come naturally to them. This paper presents preliminary findings of the effectiveness of this intervention on children’s attachment behaviors. Forty-six children were randomly assigned to either the experimental intervention or to an educational intervention. For three consecutive days, attachment behaviors were reported across three distress-eliciting situations. Children whose parents had received the experimental intervention showed significantly less avoidance than children whose parents had received the educational intervention. These preliminary results suggest that the intervention is successful in helping children develop trusting relationships with new caregivers.     

The workplace perspective on supporting family caregivers at end of life: evaluating a new Canadian social program

There is a growing realization that employers need to accommodate the issue of work-life balance for employees who are also providing care for family members or friends in palliative or end-of-life situations, as this phenomenon is only expected to increase within developed nations in the future given demographic trends and health care restructuring. This research aims to uncover the expectations that Canadian employers/human resources (HR) professionals have of the Compassionate Care Benefit (CCB), in addition to their experienced realities of having staff utilize this social program. The CCB provides employed family/informal caregivers with a job-secured work leave and six weeks of employment insurance benefits while they take time off to provide care to a dying family member or close other, often at home (in the community). Five focused discussions were implemented with employers/HR across Canada. Using thematic analysis, the data reveal how well (or not) the CCB meets caregivers' needs, as well as the informational and procedural needs of workplaces. In light of these findings, suggestions for program improvement, with respect to the CCB, are made in order to advocate for continued support of family/informal caregivers whose voices are rarely heard.     

Caregiving transitions: Developmental and gendered perspectives

Providing care for family members is a life event that both reflects and influences family dynamics. Caregiving careers, or the length of time a person provides care, are characterized by a series of transitions to which they must continuously adapt. Women are more likely than men to assume the caregiver role and this role encompasses gender inequalities associated with work and caregiving expectations. This article presents qualitative data from interviews conducted with caregivers who participated in a community-based supportive services program. The experiences of these women provide insight into how caregivers transition into their role, strategies for supporting new and experienced caregivers, and their concerns for their future. Developmental and gendered perspectives of caregiving were used as a context to analyze their experiences.     

Factors Associated With Caregivers’ Use of Support Services and Caregivers’ Nonuse of Services Sought

Informal caregivers may face barriers accessing services like respite care, training, and support groups. Using multinomial logistic regression, I modeled caregivers’ probability of using all services sought (“all services used”) and nonuse of any services sought (“any unused services”) as a function of caregiver and care-recipient characteristics. Care-recipient health and function, especially dementia and need for medical task assistance, were associated with all services used and any unused services, and any unused services were more likely among adult children caring for their parents, caregivers of Black and Hispanic older adults, caregivers providing intensive care, caregivers living in metropolitan areas, and residents of states that spend more on increasing access to caregiver services under the National Family Caregiver Support Program. Regularly scheduled caregiving was associated with higher likelihood of all services used, but not with any unused services. Steps should be taken to increase access for caregivers who provide intensive care, care to dementia patients, or assistance with medical tasks and for Hispanic families.     

How can context and discourse affect teachers’ and mental health professionals’ interactions with adults with mental illness?

Patients with severe mental illness may have needs different from those of patients with more limited illnesses and might benefit from other types of intervention than traditional treatment. We interviewed health care professionals from two open, short-term psychiatric wards and teachers from two schools for adults with psychiatric diagnoses. The focus was to explore how differences in contextual factors such as time, tasks, and organizational demands might affect the actions and attitudes of health care professionals and teachers, as well as the potential consequences for patients and students. Data were collected through qualitative interviews. Participants included 14 health care professionals and 14 teachers. The informants worked with patients and students with similar diagnoses and illness durations. All interviews were conducted during the informants’ work time. Findings and interpretations showed that both teachers and health care professionals were engaged in their work and in the wellbeing of students and patients. However, they described marked differences in practice, including the amount of time spent with students/patients, the organization of their work, main tasks, amount of control over their tasks, and social structure. These differences seemed to affect relationships with students/patients, attitudes toward students/patients, norms and values, and opportunities for patient empowerment. Our findings suggest that while existing psychiatric health care might be appropriate for limited short-term problems such as single-episode depression, a model with a supportive environment, based on stable relations and possibility for learning, may improve personal development and mental health for persons with severe mental illness and disturbances in self-experience.     

What Are Strategies to Advance Policies Supporting Family Caregivers? Promising Approaches From a Statewide Task Force

Family caregivers are the cornerstone of the long-term supports and services infrastructure in the United States, yet they often contend with many challenges related to this role. Public policy has been slow to change, leaving many caregivers vulnerable to health and economic consequences. Using models of policy making, we identify barriers to advancing policies that support family caregivers and overcome policy drift. We draw on discussions from the California Task Force on Family Caregiving as it prepares state policy recommendations. Identified strategies include identification of caregivers in health care and workplace settings to promote political consciousness raising, collecting and reporting on data that frame caregiving as a policy problem, borrowing policies and language from overlapping fields to emulate their policy successes, and presenting supportive caregiver policies as solutions to other policy problems. By presenting specific strategic approaches to advance caregiving policies, we provide tools to address the growing gap between caregiver needs and policy responses.     

Role conflicts & coping strategies in caregiving. A symbolic interactionist view

Institutional health care delivery is characterized by interdependency among caregivers and between caregivers and care receivers, which leads to role conflicts. This article examines role conflicts and coping strategies of health care aides who are faced with differing expectations of RNs and residents. Guided by a symbolic interactionist perspective, ethnographic data from 12 RNs, 15 health care aides, and 32 nursing home residents of Italian-Catholic and Anglo-Saxon descent in Toronto, Ontario, Canada, was gathered. Results showed that health care aides differed in how they handled role conflict and their elderly clients' concerns. Health care aides were more likely to reject conflicting role expectations from residents than from RNs.     

Lessons from the evolution of 401(k) retirement plans for increased consumerism in health care: an application of behavioral research

Employment-based health and retirement benefit programs have followed a similar path of evolution. The relative decision-making roles of the employer and the worker have shifted from the employer to the worker, and workers are more responsible than perhaps they ever have been for their well being--both in terms of their health in general and their financial security during retirement. This shift has been supported, in part, by legislation--namely ERISA, the HMO Act of 1973, the Revenue Act of 1978, and most recently, the Pension Protection Act. This Issue Brief does not pass judgment on this development or address who should bear the responsibilities of preparing workers for retirement or of rationing health care services. The current trend in health care design is toward increased "consumerism." Consumer-driven health is based on the assumption that the combination of greater cost sharing (by workers) and better information about the cost and quality of health care will engage workers to become better health care decision makers. It is hoped that workers will seek important, necessary, high-quality, cost-effective care and services, and become less likely to engage providers and services that are unnecessary and ineffective from either a quality or cost perspective. As employers look ahead toward continually improved plan design, there may be benefits in considering the lessons learned from studying worker behaviors. Specifically, there is evidence about the effects of choice, financial incentives, and information on worker decision making. As a result of research in this area, many retirement plan sponsors have moved toward plan designs and programs that recognize the benefits of well-designed defaults, simplified choices, required active decision making, framing, and commitment to future improvements. With respect to choice, it is now known that more is not always better and may even be worse in some cases. Just as fewer shoppers actually bought a jar of jelly when it was one of 24 as opposed to one of six, evidence has shown that people tend to be less likely to join a company-sponsored retirement plan when more investment options are offered. More choice can also lead to lower satisfaction. It is also known that workers may not be able to appropriately sort through many complex alternatives and that education is not always as effective as employers would hope. Decision complexity often forces people to find a way to simplify, and one of the easiest rules of thumb is to pick the option with the lowest short-term cost, even when that alternative is more costly in the longer run. It is also known that, for good or for bad, choices are constructed on the fly; preferences are dynamic, and logic does not always apply. Financial incentives are helpful in motivating behavior, but they do not affect everyone's decisions. Despite significant financial incentives to participate in 401(k) plans, many workers choose not to. Similarly, despite many of the financial incentives embedded in health care plan design, it can be expected that these incentives will not effectively motivate and engage all workers. One seemingly rational approach to improve workers' decision making is to provide education and guidance to help them sort through complex alternatives and to demonstrate the value of financial incentives. Certainly, providing education and guidance in the form of decision support tools may be an employer's responsibility. However, some studies have shown that, even when "educated" workers have the intent to make improved decisions, they often lack follow-through and fail to take action. In short, education and guidance may not be enough to foster improved health care consumerism. Some employers have begun to design benefit programs with a view toward overcoming behavioral tendencies that negatively affect workers' well-being. Newer retirement plan designs involve careful consideration of default choices. These defaults apply unless workers actively choose a different alternative. Typically, the default attempts to "nudge" workers toward optimal behavior. In the case of 401(k) retirement plan design, more employers are moving toward a default of automatic enrollment in the plan, with automatic investment in a diversified portfolio. Still, additional empirical research and experimentation may be needed to further understand the effects of new retirement plan design features. Future work may also precisely illuminate how the lessons discussed in this Issue Brief may apply to health care plan design that results in improved health-related behaviors. Given the impressive preliminary results in improving retirement planning behaviors, such research and experimentation are likely to be worthwhile.     

Future anxiety: Clinical issues of children in the latter phases of foster care

Children in foster placement are often considered clinically in terms of the issues that led to their being separated from their families. Placement has been recognized as a powerful intervention in the lives of children and families, with ramifications of its own extending through time. Despite the movement towards permanency planning, children continue to be exposed to periods of uncertainty, ambivalence, and ambiguity about the resolution of placement. This uncertainty, along with the intrinsic transience and marginal identity connected with the role of foster child, reduces the child's sense of stability, attachment, and predictability. Children in foster care often feel powerless, and may resort to disruptive behavior in an attempt to influence decisions about their future. Other responses include depression, withdrawal, and passivity. Future anxiety is a system issue, which needs to be addressed by the adult caregivers in the child's life. The reality is that children in foster placement often face chronic loss, and caregivers may resist sharing in the child's experience. This dynamic makes the development of a support system to help the caregiver manage feelings about the child and his or her role in the child's life a necessity. Four case examples are discussed, illustrating interventions in working with issues of future anxiety.He is also a consulting psychologist for the Family Life Center at the Massachusetts Department of Social Service.