From “Employer-Employee” to “Family of Choice”: The Development of the Relationship between Philippine Worker Immigrants and Elderly Care Recipients ()
1. Introduction
In the 1980s, Israel’s Employment Services expert committee approved a decision to bring in work immigrants to hold positions that could not be filled by the Israeli workforce, such as the field of personal and nursing care. While the demand for foreign workers in Western countries as well as in Israel increased, many women from the Philippines came to Israel as work immigrants in the field of personal and nursing care [1] - [3] .
The question of what enabled these women to successfully respond to the global market’s demand for caregiving and nursing can be considered by referring to female gender stereotypes and the cultural values, which traditionally lead women to fill the role of caregivers. The job of caring―both formally and informally―for elderly people has always been assigned to women. In Western countries, however, women’s entrance into the workforce and the modern way of life that requires young people to devote many hours to their job and to adjust to the requirements of the job has detracted from the family’s ability to support its elderly members. An increase in purchase power enables families to “purchase” services, which can relieve them of part of the burden of caring for elderly family members [4] [5] .
According to the values of Philippine culture, taking care of elderly people is considered a respectable job, because of the importance it attributes to family, the intergenerational dependency that characterizes families, the sense of privilege at being able to “repay a debt of gratitude to those who helped me” (utang no loob), and the importance of harmony in the interpersonal relationships. Hence, from a cultural perspective, Philippine women arrived in Israel with a worldview in which caring for elderly people is seen as a type of mission [6] .
2. Methodology
The current study is based on the constructivist phenomenological paradigm, which perceives the world as multiple subjective realities that are interpretation dependent [7] - [9] . It explores the dynamics, social interactions, and the processes involved in becoming a caregiver to elderly people [10] [11] .
2.1. Population and Sample
The study used a purposive sample [12] , which comprises a small number of participants. In the current study, 27 participants who were found suitable for the purposes of the study were selected from a group of 230 work immigrants employed as caregivers for the elderly. Some of the interviewees were recruited by the researcher directly, while others were recruited using the “snowball” method.
A criterion for sample selection was as follows: participants were work immigrants from the Philippines, with a permit to work legally in Israel, employed as caregivers of clear minded elderly individuals. The caregivers, who were residing with their employers in various areas throughout the country, had families of their own located either in Israel or in the Philippines (spouse and children, children and elderly parents, or a combination of the two).
As regards the demographic characteristics of the participants, six of them were between the ages of 38 and 42 at the time of the interview, four were between the ages of 43 to 48, and four were between the ages of 49 and 53. Two had husbands who had remained in the Philippines and nine lived with a companion in Israel. Twelve of the participants had children (seven of the women had children who remained in the Philippines under the care of the grandparents, while the other seven had their children with them in Israel). Thirteen of the participants had elderly parents, all of whom were residing in the Philippines.
The participants described themselves as Christian and attended church regularly; for most of them (11), the church served as a place of social and spiritual gathering. All of these women were living in the protected living residences along with the elderly care recipient. As to the characteristics of the elderly care recipients, all needed full-time help, due to poor functioning in the activities of daily living (ADL). For the most part, interactions between the caregivers and care recipients were conducted in Hebrew, interspersed with words in English, Yiddish, and Russian. The study participants had been employed at their current protected living residences for a period ranging between six months and 5.5 year.
2.2. The Research Tool
The research tool was the semi-structured interview. Data were collected based on in-depth semi-structured interviews [13] . The interview included a short questionnaire regarding participants’ socio-demographic characteristics and was conducted according to an interview guide, which served as the basis for approaching the main issues explored in the study. The interview guide was constructed based on the professional literature available on the subject of Philippines work immigrants in Israel, and it included key questions, which were intended to elicit descriptions and interpretations that play a central role in the interviewees’ worldview, focusing on their perceptions of their role as caregivers of elderly individuals, the role of the elderly care recipient in their lives, and their own role in the care recipient’s life [14] [15] . The interview revolved around their perceptions of their identity as caregivers for elderly people (e.g., “if one of your friends from the Philippines told you that she was coming to Israel to work as a caregiver for elderly people and asked you about the job, what would you tell her?”); Their perceptions of the role of caregiver (e.g., “how do you know what you are supposed to do for the elderly person you take care of?”, “How do you know what the elderly person under your care needs and when it is needed?”); their attitudes towards the elderly person under their care (e.g., “what does the elderly person who you care for represent for you?”); their attitudes towards the care recipient’s family members (e.g., “do you think that the care recipient’s children are good to their elderly parent?”, “how is their attitude expressed?”); and their perceptions regarding their own place in the life of the elderly person for whom they care, that is, what they represent for the elderly care recipient (“what do you think you mean to the elderly person under your care?”, “what do you think the elderly person under your care thinks about you?”). The study was approved by the Haifa University’ ethics committee. The participants were told about the study’s goal and the reason for recording the interview and also about their rights to stop the interview in every point of it. Based on the participant’s agreement all of the interviews were tape recorded and transcribed. The length of the interview ranged between one to two hours.
2.3. The Qualitative Analysis
In the process of analyzing the interviews, basic content components were organized into major themes (while identifying reciprocal relations among the themes and constructing explanations). The content analysis was conducted in three major stages. In the first stage, the researcher focused on repeated readings of the interviews, in order to obtain a comprehensive understanding of the contents of the texts [16] . In the second stage, the researcher identified, categorized, organized, and encoded the parts of the interviews that were identified as significant units corresponding to the subject of the study [8] [17] . In the third stage of the content analysis, the researcher integrated and synthesized the units of significance that had been identified [8] [18] .
3. Results
Analysis of the interviews demonstrates the caregivers’ perceptions of their role, in the context of the interactions they had with the care receiver throughout the period when care was provided. In presenting the results, any future reference to Philippine work immigrants refers specifically to the participants in the sample and not to the entire population of Philippine work immigrants who are caregivers.
The first theme presents the caregivers’ perceptions in the early stage of employment, as they attend to the process of acquaintance and the employer-employee relationship that emerged between the caregiver and the care receiver. The second theme focuses on the manner in which the caregivers perceive their role in the context of their professionalization and the manner in which they differentiate the different types of support they provide. The third theme describes the change that takes place in their perception of the role and of their impact on the lives of the elderly people under their care. As part of this theme, the caregivers expressed their opinions about their employers’ perceptions of the professional and social role that the caregivers play in their lives.
The first theme: The process of getting acquainted―the employer employee relationship
The interviewees described the first phase that takes place as they begin their role as caregivers as a fairly simple process, in terms of the physical strain in their work. Most of these women are experienced in housework chores such as cleaning and cooking, and the only differences they experienced were related to gustatory preferences, daily routines, the size of the meals and the quantities consumed, the types of cleaning substances, and the like. As regards their living conditions in the home of the care receiver, they described difficulties adjusting, due to the gaps between the habits and needs of the elderly care receiver and their own needs. They described daily care that is instrumental and functional and made light of the many hours in their workday; however, their descriptions did emphasize the verbal interactions and the expressive behaviors that characterized the experience (such as the touch of a hand or eye contact that reflects attentive listening). In their accounts, they stressed the things that they do that are beyond the purview of what is expected according to the role definition. One of the caregivers described it thus.
Her daughter told me which room I would be mine. They had prepared a small cabinet and a small TV in the room. That’s fine, because I am small and I don’t need a lot of space. Then she made me a cup of tea and we sat in the living room and talked. The elderly woman didn’t look at me at all but just kept rocking in her chair. The daughter also didn’t make much eye contact. It was somewhat unpleasant, but after the daughter left and I began talking with the elderly woman, things got a little better. I asked her many questions about food and cleaning, so that I could prepare things the way she liked. She was a little angry that I was asking so many questions, but I explained that that way we would get along and get to know each other sooner. I am very quick with cooking and cleaning. In one hour I can prepare a splendid meal―that includes doing the dishes and cleaning up. However… The point is to make food that the woman enjoys and is accustomed to.
(Laura)
This description demonstrates the degree to which the interviewee understands and is familiar with her role as caregiver, and that her top priority is to attend to the functional and physical needs of the elderly woman under her care.
Laura’s reference to the daughter of the elderly care recipient suggests that she sees her as an agent responsible for reducing the gaps between the two parties and, therefore, once introductions were over, she left the two parties alone together. It should be noted that in the majority of the accounts, the children of the elderly care recipients acted as translators between their parent and the caregiver at the early stages of the acquaintance, especially if the caregiver had only been in Israel for a short time.
The following description is a caregiver’s account of differences encountered in eating habits and tastes, which required creative solutions.
Already in my very first days there [in the home of the elderly employer], I could tell there would be problems. She can’t stand the smell of fish and I eat fish every day. She told me she never lets anyone bring fish into the house! At first, I stopped eating fish, but soon I started to have stomachaches, so I talked about it with her and I told her I would try to make sure she would never even know that I was preparing fish, and honestly… I began cleaning the fish while she was taking her afternoon nap or late at night. I was afraid it would bother her and that she would feel too uncomfortable to mention it, so I kept asking her [if she noticed]. I’d clean the fish and immediately take the leftovers out to the trash receptacle down the street. I always kept a lid on the pot when I cooked fish chowder, to keep the smell from spreading. I opened all the windows in the kitchen and closed the door, so there wouldn’t be any smell, and that’s how I managed things…
(Maria 1)
Maria’s description expresses the feeling of alienation that exists before a relationship has been established, and Maria’s need to tend to her own well-being. She felt compelled to mention that at first she was prepared to relinquish her own habit, but due to the fact that she felt ill as a result of the imposed change in her eating habits, she had to take action. Nevertheless, she conveys a message of awareness and a clear understanding that she must be considerate towards the elderly woman, (her employer in whose home she was residing), her needs, and wishes.
In the next example, the interviewee tells about the problems that arose from living in the home of the elderly care recipient and his wife.
At first the elderly man sat in his armchair the whole time and his wife told me what to do. She told me that she was the only one who could tell me how to care for him. In the afternoon, after I helped him get in bed, I went into my own room for a while and then she opened the door to my room without knocking. She told me that the door has to remain open so that I could hear them whenever they called for me. I remember that in the first few weeks I was startled each time she would walk into my room without any warning, without even addressing me first. I felt that she was constantly examining me. I never made a mistake and I never did anything she didn’t ask. I always did only what she told me to do. It took her a long time to trust me. My friends told me that that’s the way it usually is at first and that it made sense that things should start out that way. I thought that for me things would be different, because I’m very friendly and in the Philippines people always wanted my company, but I realized that here I’m like everyone else…
(Lia)
It appears that this interviewee expected to be treated differently than her Philippine friends had been treated. Her honesty and the simplicity with which she described her position as an employee in the home of the elderly and their attitude as employers reflect her disappointment from the first stage of acquaintance with the care recipient and his wife.
The quotes presented here reveal the dilemmas related to simple daily interactions in the context of providing functional and instrumental care, which becomes much more complicated when the caregiver is living in the home of the care recipient. The caregivers attempted to adjust their behaviors to what they believed was expected of them. Some of them asked for clarification and asked questions; however, it appears that the passage of time and getting to know the habits of their employers determined the quality of the next stage, in which the relationship between the two parties is established.
Furthermore, the examples related to this theme of early acquaintance revealed that in the triangular relationships between the caregiver, the care receiver, and the care receiver’s family members, responsibility for the content and quality of the interaction lies for the most part with the family members, be they spouses, children, or grandchildren of the care recipient. The interviewees indicated that the family members initiated the interaction, directed it, and determined its contents.
The second theme: the second stage of the relationship―caregiver and client
It appears that, either through previous experience as caregivers or based on friends’ reports, the Philippine caregivers are familiar with the characteristics of the relationships with their employers and their family members. The more experience they have, the more aware they are that the first stage of acquaintance is an essential part of the process; nevertheless, it seems they never get used to it.
Each time, the first stage is difficult, and I already have experience caring for four different clients―in- cluding the current one. First, I took care of one elderly gentleman for four months, then moved on to care for another one, and when he passed away I took care of his wife, and now I'm on my fourth client. I thought caring for men would be easier, because they know they need it and they are less fussy, but it’s really not the case. I think they’re all good people, but it takes them a while to adjust. Also I need time to adjust to each new client. I always think that the last elderly person I cared for was the best ever, and later I understand that it’s just nostalgia. Just like sometimes, when things are bad, I think that things were better at home in the Philippines, but that’s not true. I wouldn’t be here if it was.
(Rachel)
New beginnings are always difficult. Each time I find it difficult, and I'm lucky to have support from the elderly person’s family members, who try to help, in addition to my friends. There’s always a crisis at first… I’m not sure if it can be avoided…
(Laura)
These two interviewees clearly used similar expressions, and they weren’t the only ones: “Each time I find it difficult”, “it takes time to adjust”, “new beginnings are always difficult”. From their point of view, being aware of the difficult part of the acquaintance process is an inseparable part of the relationship and often this is something they discuss with their friends in Israel even before they leave the Philippines.
The interviewees told of having a social support group in their neighborhood (i.e., where they stay on their days off). These groups are usually focused around the church, which serves not only for prayer, but also as a place for social gathering. When they gather at the church, they share feelings with each other, tell stories―both the pleasant and the less pleasant ones―about the elderly for whom they care, and discuss difficulties. Each of them contributes from her experience and offers advice. Those who are newcomers to the role of caregiving listen carefully. The interviewees in the study reported that they were not alone in experiencing difficulties during the first stage of acquaintance; rather, this was part of every caregiver’s experience. One of the caregivers described it as follows.
The first stage is the most unpleasant one and we always pray that it will pass as fast as possible. If one of us mentions that she thinks that this stage is over, we are so happy for her―we even applaud her and sing to her.
(Thea)
The interviewees described an additional factor that comes into play in the relationship following a short acquaintance period, namely, the expressive factor. During the first acquaintance stage, the interviewees described feeling that they were under constant observation. Employers wanted to determine that, as caregivers, they could provide everything that was expected in return for their remuneration, and that they were honest, trustworthy, and devoted to their role. They felt it was up to them to prove that professionalism was their first priority. According to their reports, as the relationship gets stronger, the needs, wishes, and habits of the elderly person become familiar, and they feel more comfortable in the caregiving relationship. Then they are more likely to take initiative and to reveal their emotions to the care recipient and his or her family members.
I give him a shower in the morning, every morning, and I know he is embarrassed for me to see him naked. So I pretend that I’m busy handling the soap and try to avoid looking at him. I also avoid eye contact, because I know he’s uncomfortable. And I know he knows I do this for him, because he thanks me after the shower. But for shaving for example, he doesn’t thank me. When I shave him, I sing him songs from my home in the Philippines, songs that my older sister used to sing, and he really loves that… I even learned one song in Yiddish and I sing it to him…
(Anna)
She has one grandson, and every time he visits I hear him ask her: “does the Philippine woman treat you well?”. I never hear him asking if her doctor treated her well, if the nurse at the HMO treated her well, he only asks about me. I’m even more upset that he refers to me as “the Philippine woman” rather than by my name. I’ve been with her for almost 2 years now.
(Laura)
Based on the interviewees’ descriptions, it appears that the more experience a caregiver has, and specifically the greater the number of elderly people she has cared for, the more she tries to shorten the first phase of acquaintance and reach a stage in which she can offer more support and encouragement for the elderly person; thus, the care provided assumes a more holistic meaning.
I already know how unpleasant the beginning can be. There are a lot of silences; you talk less about things and talk only about the job. The elderly person might say she’s hungry, she’s tired, she wants to go to bed… Of course I do what I’m told and I give her what she asks for. But I know things could be more pleasant, and that’s why I try to strike up a conversation about family and about life…
(Maria 2)
One elderly woman who was under my care earlier, before Mrs. H (her current employer), was always apologizing any time she asked me to do anything. I asked her to stop apologizing and she started to cry and said it was hard for her to see other people work for her. I told her I was there for her: I was doing things for her the same way I used to do things for my parents before I came here, or for my children, and like she probably did for her children.
(Maria 1)
The quotes presented here suggest that in the triangular interaction between the elderly person receiving care, the caregiver, and the care recipient’s family members, the person who is responsible for initiating the interaction and for its content at this stage of the relationship is the caregiver. Interviewees’ reports indicated that they were familiar with the dynamics and the stages of becoming better acquainted and that they were interested in creating a situation that would relieve the sense of discomfort and unpleasantness.
In the descriptions provided in the last two quotes, the interviewees used similar expressions to convey the discomfort that resulted from the strange combination of intimate care without a close relationship, and indicated the need to close this gap in the relationship. Maria (1) noted that the elderly woman under her care apologized for asking her to do her job, a job for which she was being paid. In her response, she intimated that the day-to-day chores she performed for the elderly woman were merely part of her “family duties”, just like when helping a family member―there is no need for apologies or forgiveness.
In the following quote, from the interview, Rachel explains how she encouraged the elderly woman under her care to construct her narrative using the family’s photo albums. It was the care recipient who determined which photos and which family members she wanted to talk about in detail.
I think the best way to get close to the elderly person under my care is through photographs. I asked her to show me family photos and to tell me about them… I especially asked her to tell about her grandchildren and great-grandchildren, because I already know that sometimes relationships with children can be a source of tension, and I don’t want to cause her to be in a bad mood; on the contrary, I want us to laugh together and pass the time in peace and quiet, as much as possible. This way, the elderly woman learned to trust me and I learned faster what offends her and which topics are sensitive, and then I avoid these areas, unless she brings them up.
(Rachel)
Rachel clearly indicates that with the passing of time, and generally within a short while, the atmosphere becomes more relaxed and interactions include longer and more descriptive sentences. The way that Rachel found to create intimacy enabled her to hear subtle voice modulations in her employer’s speech, indicating different degrees of sensitivity and openness, a feature that was absent in the first stage of the relationship.
Most of the caregivers agreed that it was their responsibility to decrease the gap and increase the intimacy of the relationship with their elderly employers, especially with those who had no previous experience living under one roof with a foreign caregiver. From the caregivers’ perspective, the greatest concern they had was what might happen if they did not manage to create a pattern of expressive interactions with some degree of intimacy. That would mean that the care they provided would remain on the functional and instrumental level. Without the necessary foundation, their relationship with the elderly care recipient would be limited to the giving and receiving of instructions. These are essentially existential concerns. Some of the caregivers were afraid that if they did not manage to forge a closer relationship with the elderly person under their care, this person would be uncooperative, and as a result they would have no choice but to leave the position. In such a case, it was more than likely that they would have to leave Israel and go back to the Philippines. That almost happened to Thea.
I know someone who didn’t get along with the elderly person under her care, and that was why she didn’t get along also with the rest of the family. She was a poor sight… From one day to the next, she stopped smiling and was always saying how lonely and frustrated she felt, because she didn’t quite know what to do. At the end, she asked to terminate the agreement and leave.… She was lucky, because she was able to find another family.
Actually, I can even tell you: it was me. At first I was so ashamed that I couldn’t stay on with that family. I kept saying “what’s wrong with me? Why is this happening to me?” I always get along well with people of all ages. I never had a problem connecting with people. Today I understand that not everyone can handle living in their own house with the caregiver in close proximity. Sometimes even if the person can manage it, the family makes it impossible to build a relationship.
(Thea)
The third theme: Forging the relationship and changing the way it is perceived
The relationship between the caregiver and the elderly care recipient acquires a new dimension when the place and the direct involvement of family members are factored into the relationship. Until this stage, most of the interactions between the elderly person’s family and the caregiver were indirect and any communication was usually conveyed through the elderly person without addressing the caregiver directly. Any direct interactions that did take place were related mostly to informing the caregiver about the care recipient’s habits and giving instructions regarding functional care, accompaniment, and so forth. This theme focuses on the three components that are part of the care giving interaction: the foreign caregiver, the elderly care recipient who needs the service, and the elderly person’s family members. In this theme, the emphasis is on the elderly care recipients’ role in determining not only the content and the quality of the interactions, but also the circumstances under which they choose to involve their family members in the process of establishing the caregiving relationship. The elderly person chooses the degree to which family members are involved in the relationship, which can be anywhere along a continuum ranging from random assistance on functional, instrumental, and verbal issues, to full cooperation with the caregiver (in every aspect: functional, instrumental, emotional, expressive, and verbal). This continuum has implications not only for the relationship between the caregiver and the care recipient’s family members, but all-the-more so for the relationship between the family members and the elderly care recipient.
Most of the interviewees described family members taking part in providing care for the elderly person in need. This care and assistance is provided in various areas of life, such as accompanying the elderly person to medical examinations, calling daily to provide support and encouragement, doing the weekly shopping, and chitchatting. The caregivers noted that there were tasks in which they could not play the role provided by the family, for example on holidays and at family events (such as weddings, or other life-changing transitions of their grandchildren), or on other significant occasions such as family memorials.
Her grandchild makes sure to visit her once a week and she very much looks forward to this visit. She tells me how successful he is and that he’s a very prominent lawyer. At first I didn’t like him. The way he speaks is a little unpleasant to the ear, cold and alienating. He uses short sentences and you get the feeling he is impatient. At first I was a bit offended by him and I was offended for Grandma as well, but later I understood that that’s the way he speaks to everyone, including his grandmother, and that it’s not directed at me personally. Grandma isn’t offended because she’s used to it. I needed to get used to it. Now I too wait for his visits and he asks me how I am doing and about my parents in the Philippines. He’s nice.
(Laura)
At this stage of the interview, Laura refers to the elderly woman under her care as “Grandma”, and this phenomenon is noticeable among all of the interviewees. They referred to all family members according to their role in the family: Grandma and Grandpa, Auntie and Uncle, Great Grandma, etc. However, it is important to note that these epithets were introduced only in the later stages of the interviews, not right away at the beginning. This may indicate that gradually, in the course of the interview, the interviewees began feeling more at ease and were able to be more expressive, conveying a type of mini narrative of their acquaintance process with the elderly care recipient.
Auntie keeps telling me that she just doesn’t know how she ever managed without me, before I came to stay with her. She says that there was always someone looking in on her, making sure there was food and that the place was clean. Her own children helped too, but she says that with them she felt uncomfortable. For example, she wanted to have her tea in a transparent glass and not in a mug, because that’s how she was used to it, but when they brought her the tea in a ceramic cup, she wouldn't ask them to switch it. Auntie said that right away I brought her the tea in a glass, as if I knew ahead of time how she liked things.
Later, when the family came to visit, she told them that I could “sense” her needs even without her saying anything. I was a little taken aback when she said that, because I was afraid that the family would be upset that Auntie was so very pleased with me, but I watched their faces and they weren’t angry. They were pleased. I think it’s also good for them when Auntie is satisfied and content.
(Maria 1)
It became clear that this was one of the most noticeable issues referred to by the interviewees, i.e., their need for recognition from the elderly care recipient’s family members. These caregivers knew from experience the extent of the family’s influence on the elderly employer, particularly regarding the quality of care provided by the caregiver; however, they also influenced the elderly person’s mood. The caregivers’ ability to have a realistic view of the family situation motivates them to establish a consensus as soon as possible about the quality of care they provide and especially about the quality of the interactions between themselves and the elderly person under their care. At the same time, they are evidently aware that they are walking a thin line.
The caregivers rely on the elderly care recipient (or on the spouse, if the elderly person is incapacitated) to help them forge a connection with the care recipient’s family members, and sometimes they even encourage them to do so…
I told Esther (the elderly care recipient): “Grandma, it’s really important to me and I really appreciate the fact that you don’t ask me to leave the room when your friends or your son come to visit. It makes me feel good to know that you consider me part of the family. Sometimes, when your daughter comes and you talk about your health, you send me on a chore, to hang out laundry or to do some shopping or something else… I feel like maybe you don’t want me to hear the conversation, but I’m not sure why, because, after all, I’m the one who takes you to the doctor so I know how you’re feeling… If you told me that it’s important for you to be alone with your daughter, I myself would find something to do when she arrives. Just tell me, so I know”.
(Maria 2)
4. Discussion
Analysis of the interviews indicated that the main factors that affected the Philippine work immigrants’ caregiving experience were their interactions involving their own relationship with the elderly care recipient and those involving relationships with the care recipients’ family members. Philippine caregivers in Israel are engaged in constant dialogue with social structures and situations related to their being “the Philippine care giver” and they contend with the negative implications of the related―and demeaning―gender stereotypes. This stereotype predominates to such an extent that there is no mention in the Israeli professional research of male Philippine caregivers (although in Israel they are part of the work immigrant scenario). The task of caring for the elderly has always been considered as pertaining to the woman's domain both formally (through the family) and informally (through occupation).
According to the cultural values in the Philippines, taking care of the elderly is a respectable occupation, due to its positive contribution to maintaining family values and its recognition of the interdependent relationships among family members of different generations [6] . The work of the Philippine caregivers is typically characterized by a sense of aloneness. They are employed on an individual basis in the home of an elderly client, and (with the possible exception of the care recipient’s spouse) are alone with the client most of the time. Thus, the work they do leaves them isolated from their colleagues, in addition to being geographically distant from their families in the Philippines. The caregivers spend the majority of their time (with the exception of one free day a week) with the elderly client and perhaps with the client’s family members. Due to the intimacy involved in this work, they are likely to develop close relationships with the elderly clients and with their relatives. The caregivers are familiar with the changes in the elderly clients’ physical and mental condition, as well as with the family relationships and family dynamics.
The interviews with the Philippine caregivers highlighted the complexities of their role, which on the one hand develops along a linear continuum, as presented here in the three themes, and on the other hand it is characterized by a spherical development, in terms of the relationships with their elderly client and the surrounding family. In general, and based on the current findings, the relationship between the elderly clients and the Philippine caregiver can be defined as a dependent relationship throughout all its stages, although its particular features are altered by the passing of time, such that a greater sense of mutual trust develops.
The linear relationship that develops begins with the employer-employee relationship, in which the caregiver depends on the client for her income and occasionally for her Israeli work visa. The elderly client (or a representative with power of attorney) is responsible for paying the salary, while the caregiver is obligated to provide the proper care, as defined by Israel’s health and welfare system. For the most part, this care comprises functional and instrumental tasks. The elderly client depends also on the caregiver’s to provide the best care possible, while demonstrate a professional and respectful approach. The second stage on the continuum is the caregiver- client relationship. This stage is characterized by a dyadic relationship in which the elderly client is more dependent on the relationship that is the caregiver; at this stage, consistent effort and the passing of time are crucial elements in the relationship. Finally, in the majority of cases, a close and intimate relationship develops, which is patterned after familial relationships, since these too are characterized by mutual dependence. This continuum, which emerged from the narratives presented by the caregivers, consists of a constructive, cognitive-intellectual component, whereby the narrator organizes emotional and sensory experiences into theoretical structures within one’s personal information system, which imbues these stimuli with meaning [19] . The narrative presented by the caregivers in the current study suggests that they experience their caregiving as a process that ultimately aims to create close, semi-familial relationships between them and their elderly clients. In contrast to the findings in a study by [20] , findings in the current study indicated that the caregivers preferred to reach the “farthest end” of the relationship continuum and to live and work in a “family of choice” environment, rather than remain at the employer-employee stage of the relationship continuum. Ayalon’s study, however, found that the Philippine caregivers were ambivalent about becoming part of the elderly client’s “family”.
Among the caregivers with extensive experience working in Israel, the first two stages on the continuum were considered more problematic, which is an indication of their desire to reach the third stage, which for them constitutes a comfort zone. In the third stage, although they perform the same tasks and invest the same amount of effort, in terms of the dependence relationship and their overall feeling, this type of relationship is preferred.
Although the current study focused mainly on the narratives of the caregivers, the issue of the triadic relationship also emerged. This relationship, which includes the elderly client, the caregiver, and the client’s family members, is characterized by a slight imbalance of power. While the dyadic relationship is basically reciprocal, in the triangular relationship, the family member is the least dependent of the three. Although family members depend on the caregiver to a certain extent, because they wish to establish reliable and routine care for their relative, it can be assumed that for them, the interpersonal aspect is marginal, and one caregiver might be as good as the next. The family members also invest less emotionally than do the caregiver or the client [20] . Excluding the issue of dependence, it appears from the caregivers’ interviews that the involvement of family members relates to the functional and instrumental aspect of care and less to the expressive-emotional aspects. A study by [14] clearly indicated that Philippine caregivers typically consider their role to be more than merely physical tasks, and emphasize the social and emotional support they provide. The same study clarifies that while these caregivers take the physical tasks of their job very seriously, they treat this aspect as the foundation on which the relationship is built, and they invest their efforts in the social and emotional aspects of care as much as in its instrumental aspects. Ayalon was surprised that the findings in her study indicated that the clients’ family members, especially spouses, attributed a great deal of significance to the quality of the emotional care provided by the caregiver [20] . Spouses reported that they saw a connection between the care recipient’s social and emotional condition and the relationship with the caregiver. It appears that the caregivers’ active efforts to shorten the period of initial acquaintance with the client and the family, i.e., the employer-employee stage, benefits all those involved in the care triad. This is particularly beneficial for the children of elderly clients. The caregivers attempt to shorten this stage, because they wish to reach a particular point in the development of the relationship. This pertains especially to experienced caregivers and less so to first time caregivers. Apparently, family members require a greater amount of time to create a foundation of trust in the caregivers, and according to the interviewees, the younger generations in the family base their trust on the quality of the physical, functional-instru- mental care provided to their elderly relative.
The description of the shift in the relationship between the Philippine work-immigrant caregivers and the elderly care recipients was intended to enhance our understanding of the importance of the caregiver in the life of the elderly person and in the family in general. The number of elderly who reside in the community is constantly increasing, while there has been no change in the number of Israelis who are prepared to provide round-the- clock care. Hence, elderly persons in need of assistance will continue to depend on work immigrant caregivers, mainly women. As the essential role and the added value that the caregiver represents in the life of the elderly care receiver becomes clearer, it will be possible to provide the caregivers with better training and enable them to provide better care, by addressing their abilities, needs and desires, for the benefit of the elderly.
Finally, it is important to note that the findings of the study and the theoretical generalizations that derive from them are of limited scope, due to several factors. First, the study focused solely on the caregivers, although throughout the study, the care recipients and their families were constantly mentioned. Thus, the linear development of the caregiver-care recipient relationship should be examined also from the perspective of the elderly care recipients, their spouses, and other family members relevant to the relationship.