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Second generation Korean daughters : decision making in regards to caring for their elderly parents Kook, Joanna 2014

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     SECOND GENERATION KOREAN DAUGHTERS: DECISION MAKING IN REGARDS TO CARING FOR THEIR ELDERLY PARENTS by Joanna Kook B.Sc.N University of Alberta 2005  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE and POSTDOCTORAL STUDIES The University of British Columbia  (Vancouver)   August, 2014 ©Joanna Kook 2014  ii Abstract The thesis represents the process of decision making for second generation Korean daughters in regards to care for their parents. Using Grounded Theory principles, I analyzed the interviews of ten second generation Korean women in Vancouver and the Greater Vancouver Area of British Columbia.  The core variable identified in this study was: Reformulating generational care-giving relationships.  The core variable incorporated three stages of reflection for the women: 1) Contemplating Commitment, 2) Envisioning Possibilities, and 3) Re-contemplating Commitment.  The women’s reformulation was affected by several factors, such as finances, parental expectations, sibling help, and the type of care that their parents would require.  Re-contemplation of commitment was spurred by the women’s concerns about the level of physical care that the older adult would need.  The findings indicate that while all participants would like to provide care for their parents, they would re-contemplate their commitment and the need for long-term care if the physical needs of the parent were too great or if their parents’ conditions compromised the safety of their nuclear family.   iii Preface This dissertation is an original intellectual product of the author, J. Kook.  The interviews reported were approved by the Behavioral Ethics Research Board, Certificate number H11-02084.    iv Table of Contents  Abstract ............................................................................................................................... ii Preface................................................................................................................................ iii Table of Contents ............................................................................................................... iv List of Tables ..................................................................................................................... vi Acknowledgments............................................................................................................. vii Chapter I: Introduction ........................................................................................................ 1 Presenting the Issue......................................................................................................... 1 Filial Piety: Changing Views ...................................................................................... 3 Theoretical Perspective of Culture .............................................................................. 5 Cultural Expectations about Gender ........................................................................... 6 Purpose ............................................................................................................................ 7 Research Questions ......................................................................................................... 7 Assumptions .................................................................................................................... 8 Significance..................................................................................................................... 8 Chapter II: Literature Review ........................................................................................... 10 The Second Generation of Korean Care Providers ....................................................... 10 Placing Family Members in Long-term Care ............................................................... 13 Caregivers ..................................................................................................................... 15 Summary of the Literature Review ............................................................................... 18 Knowledge Gaps ....................................................................................................... 21 Chapter III: Methods ......................................................................................................... 23 Research Design............................................................................................................ 23 Sampling ................................................................................................................... 26 Recruitment of Participants....................................................................................... 26 Data Collection ......................................................................................................... 27 Procedures ................................................................................................................. 29 Data Analysis ................................................................................................................ 29 Coding ....................................................................................................................... 30 Memos....................................................................................................................... 31 Theoretical Sorting.................................................................................................... 32 Rigor in Grounded Theory ............................................................................................ 32 Reflexivity................................................................................................................. 34 Chapter IV: Findings......................................................................................................... 37 Study Participants: Who Are They? ............................................................................. 37 Reformulating Generational Caregiving Relationships ................................................ 38 Contemplating Commitment ..................................................................................... 39 Envisioning Possibilities ........................................................................................... 43 Family Values ....................................................................................................... 43 Parental Expectation ............................................................................................. 44 Sibling Involvement .............................................................................................. 47 Different Kinds of Care ................................................................................................ 48 Finances .................................................................................................................... 48 Children’s Resources ............................................................................................ 48 Parental Resources ................................................................................................ 50   v Emotional .................................................................................................................. 52 Re-contemplating Commitment .................................................................................... 53 Physical Care ............................................................................................................ 53 Perceptions of Long-Term Care................................................................................ 56 Summary ........................................................................................................................... 59 Chapter V: Findings, Discussion and Recommendations ................................................. 61 Discussion ..................................................................................................................... 62 Recommendations ......................................................................................................... 64 Nursing Administration ............................................................................................ 65 Nursing Education .................................................................................................... 66 Research Implications ............................................................................................... 67 Conclusion .................................................................................................................... 67 References ......................................................................................................................... 69 Appendix A ....................................................................................................................... 79 Appendix B ....................................................................................................................... 81 Appendix C ....................................................................................................................... 84 Appendix D ....................................................................................................................... 85 Appendix E ....................................................................................................................... 86 Appendix F........................................................................................................................ 87   vi List of Tables  Table 1 Coding Example.........................................................................................30 Table 2  Characteristics of Participants…………………………………………...38    vii Acknowledgments  I offer my gratitude to the faculty, staff, and my fellow students at the University of British Columbia as well as my co-workers who have inspired me to continue my work in this field. I owe thanks to my committee members, Dr. W. Hall, Dr. J. Oliffe and Dr. S. Wong whose contributions and feedback not only helped me accomplish this work but made it more insightful.  Thank you so much for all your time and energy.    A special thanks to Dr. W. Hall whose astute questions and comments not only increased the depth of this thesis but also taught me to question more deeply and more often. I thank Dr. W. Hall for her questions, answers, time and support throughout this entire process.    Thank you to my parents who have supported me through this process and for instilling in me the importance and value of continually learning throughout your life.  1 Chapter I: Introduction Presenting the Issue  There are over 140, 000 Korean people living in Canada today.   Thirty-two percent of these people live in British Columbia (Statistics Canada, 2006).  Korean immigration to Canada began in the early 1960’s and continues to this current day (University of Alberta, 2008). Immigrants, who arrived in Canada during the immigration wave of the 1960’s, are part of an aging population requiring care.  The number of Korean-Canadian people living in Canada aged 65 or greater has increased by seven percent from 2001 to 2007 and continues to grow (Statistics Canada, 2007).  Those Korean-Canadians who immigrated in the mid 1900’s have children born in Canada, or mainly raised in Canada, who may hold diverse values from their parents.  Thirty percent of Canadians of Korean ancestry is between the ages of 25 and 44 (Statistics Canada).  While many were born in Korea and emigrated thereafter 30% are Canadian born and represent a second generation. This study will refer to those born in Canada as second generation Korean-Canadians and those who immigrated as adults as the first generation of Korean-Canadian people. Vancouver has a large Korean-Canadian population, comprised of both first and second generation Korean-Canadians.  The British Columbia government has recognized the potential isolation of older Korean adults and a conversation has begun regarding building Korean community-assisted living and long-term care facilities (Hwang, 2008).  Affiliation with churches also enables some first generation Korean-Canadian older adults, living in Canada, to be less isolated and dependent on their children due to transportation, meals and recreation events provided by the churches (Hwang).   2  Questions have arisen about how the public health care system will be able to meet the needs of Korean-Canadian older adults and whether existing resources will be adequate for Korean-Canadian people to remain in the community as they grow older.  Much of the research examining health care barriers has been undertaken using samples of sponsored elderly parents of first generation immigrants (Choi, 2004; Hwang, 2008; Shin, 2008).  Research undertaken with the first generation immigrants may not be applicable to the experiences of their children.  While academic studies have focused on adult immigrants, it has often neglected the next generation of adults, the children of these immigrants (Zhou, 1997).  I was unable to locate any Canadian publications that focus primarily on the children of Korean-Canadian immigrants and their thoughts on elder care.    Professionals in the health care system should not assume that Korean-Canadian people who immigrated to Canada in the 1960’s and 1970’s will easily access health care resources as acculturation characteristics, including language proficiency and time spent in the new country, have been shown to be inadequate and inconsistent indicators of health care use by Korean-Americans (Shin, Song, Kim & Probst, 2005).  Although Canada and The United States of America have different models of health care, these findings may be relevant to the Korean-Canadian population in Canada.  Furthermore, research undertaken with the first generation of Korean-Canadian immigrants may not be applicable to the experiences of their children.  Previous research has focused on adult immigrants leaving second generation Korean-Canadian family members neglected (Zhou, 1997).     3 Filial Piety: Changing Views  Traditionally, many Korean people relied on filial piety to dictate caring for their elders (Shin, 2008; Choi, 2004).  The traditional concept of filial piety includes: 1) respect for parents; 2) physical and financial sacrifices for parents and 3) responsibility for parents (Choi).  Parts of this tradition involve particular gender roles in which the son is responsible for the parents’ financial decisions while his wife sees to their day-to-day needs (Shin).  Filial piety incorporates expectations that children will sacrifice their own desires for those of their parents in order to care for them as they age.  The traditional concept of filial piety has changed and continues to evolve (Wong, Yoo & Stewart, 2006).  Firstly, caregiving is no longer the responsibility of the sons and daughters-in-law.  Gendered expectations surrounding caregiving have changed and daughters are often the caregivers for their parents (Youn, Knight, Jeong & Benton, 1999).  Also, parents may no longer expect that their care will be guided by filial values (Wong, Yoo & Stewart, 2006).  Some Korean-Canadian older adults have modified their views about filial piety due to their changing perspectives on family and social support, as well as their increased biculturalism (Wong, Yoo & Stewart, 2006).  Factors that may have influenced this change are: 1) increased urbanization and industrialization which make co-residence for parents and children more difficult; and 2) the increase of dual-income households that make it difficult for women to be primary caregivers for their elderly parents (Wong, Yoo & Stewart). The evolving concept of filial values needs to be understood in the context of British Columbia and potential impact on the decision-making process of second generation daughters.   4  Korean-Canadian children who were born in Canada are a second generation and may have different views, attitudes and beliefs than their parents.  These differences might affect their views about providing physical, emotional and/or financial care for their older parents, as well as if and how they will access healthcare systems to aid in care.  Due to the limited amount of research on second generation Korean-Canadians who live in Canada, this study is intended to shed light on the decision-making processes of second generation daughters regarding the care of their older Korean parents.  Currently, many older Korean people are cared for by their first generation Korean children.  These parents immigrated with their children or followed after their children had immigrated to Canada (Shin, 2008).  Often both children and parents have language barriers and are unskilled in accessing and using community resources.  These caregiving children now have adult children, the second generation.  Research suggests that some of this new generation, raised in a Western culture, have demonstrated more knowledge about accessing the healthcare system (Hwang, 2008).  Second generation Korean-Canadian people likely have fewer language and cultural barriers than the first generation as they are native-born Canadians that make-up part of Canada’s fluid and changing culture (Lee et al, 2010; Moon, Lubben & Villa, 1998).    British Columbia has a growing older adult population as well as a large proportion of potential second generation adult caregivers. It is important to understand the perspectives of these potential caregivers surrounding elder care to anticipate how the health care system can best assist them in caring for the older Korean-Canadian adults (Hwang, 2008; Statistics Canada, 2007).     5  Second generation Korean-Canadian children born in Canada were raised in homes that exposed them to both Western and Korean cultures (Kim & Choi, 1994).  The effects of such exposures would partly depend on the level of acculturation of their parents (Kim, Cain & McCubbin, 2006).  Children who identify with one culture in the home but were born into and live in a different culture often experience difficulty reconciling both identities when developing their own views, perspectives and identities (Song, 2009; Nieto, 1999; Eaton, 1991).  Differing perspectives and views affect decision-making about family members’ care.  Effects of dual-culture homes on second generation Korean-Canadian children may be one of the many factors influencing their views and perspectives regarding how they plan to care for their parents as they age. Theoretical Perspective of Culture  This study was viewed through a cultural lens that sensitizes the researcher to mechanisms by which culture affects the decision-making processes of second generation Korean-Canadians.  Using this lens allows the researcher to be more attuned to the effects that cultures may have on the individual.  Individuals views, ideas and opinions are not necessarily derived from their ethnicity. Their experience of culture is influenced by the society in which they were raised and the views and perspectives of that society.  Culture is also shaped by experiences of individual people (Smye & Brown, 2002).  Therefore, not all members of the same ethnic group will hold similar cultural values or perspectives.  In this study, I make the assumption that the cultural experience of a second generation of people is not the same as that of the previous generation.  The immigration of Korean people to Canada, the first generation, increases the potential for their children, the second   6 generation, to be affected by a different set of cultural expectations.  I have, therefore, framed this study using the perspective that culture is a dynamic process and the values and beliefs of the second generation Korean-Canadians may be different from those of the first generation and are unlikely to be representative of all of the other second generation Korean-Canadians in Canada.  In other words, culture is not an isomorphic entity.   Cultural Expectations about Gender  The Canadian Institute of Health Research defines gender as “the socially constructed roles, behaviors, expressions and identities of girls, women, boys, men, and gender diverse people” (Canadian Institute of Health Research, 2014). Gender influences how people view themselves, view others, act, and interact, and the distribution of power and resources in society (2014).    Patriarchal Confucianist beliefs and filial piety affect gendered expectations for some members of the Korean-Canadian culture (Kwon & Roy, 2007; Kim, 2001).  In traditional filial piety there is a hierarchal relationship between men and women.  Men are viewed as holding the power and authority in the family while the women are viewed as responsible for maintaining the household duties, including caring for young children and the elderly (Kim, 2001).  While these beliefs appear to have been diluted over generations, there is still a strong tie to traditional gender roles within many Korean families (Wong, Yoo & Stewart, 2006).  Working women must often fulfill multiple roles due to the expectation that they are responsible for the household and caregiving for all members of the household (Kim & Theis, 2000). Because, in general, women bear much of the burden for caring for their elderly parents this study aims to understand Korean-  7 Canadian daughters’ decision-making, within their family contexts, in regards to elder care for their parents.  It is important to note that it is not exclusive to Korean cultures to hold gendered expectations of caregiving.  Studies have demonstrated that women, in general, are more likely to provide personal care to family members and hold more responsibilities in performing household duties (Hequemborg & Brallier, 2005; Miller & Cafasso, 1992).   Purpose  Is the healthcare system ready to care for an aging population?  How do people regard elder care and process decision making? Does culture play a role in their decision making process? The purpose of this research is to describe how second generation Korean-Canadian daughters process decision making about care for their elderly parents.  This research will explain how Korean-Canadian daughters make decisions about caregiving and their intentions about how, why and if they will provide care to their older parents.  Due to the cultural lens used to conduct this study, special attention has been given to cultural issues that may affect the decision making of second generation Korean-Canadian children. Research Questions  Following grounded theory principles the research questions were developed. The research questions were: 1) what is the process of decision making regarding the care of their elderly parents by second generation Korean-Canadian daughters?  and 2) what are the connections between culture, gender and Korean Canadian daughters’ decision making in regards to their parents care?  Using these questions to guide the study, I used   8 grounded theory analytic methods, such as constant comparative coding and theoretical sorting, to create a substantive theory. Assumptions  Several assumptions frame this study: 1) culture is a dynamic process; 2) the concept of filial piety has changed across generations and 3) gendered expectations about women’s caregiving and nurturing roles are not culture specific. Significance  The number of Korean people living in Vancouver today exceeds 140,000.  Korean older adults make up a significant proportion of an aging population that continues to grow (2007).  Illnesses, such as Dementia and Alzheimer’s disease, also affect the Korean population (Choi et al., 2010; Jhoo et al., 2008).  In longitudinal studies with samples of Korean elders living in Korea, the incidence of Dementia and Parkinson’s disease, for those greater than 65 years, ranged from 8 to 11% (Park et al., 2010; Jhoo et al.).  The prevalence of Dementia and Parkinson’s disease has increased to 22% in people greater than 80 years of age (Jhoo et al.).  Furthermore, elders have manifested other cognitive impairments after the age of 65 at rates as high as 33% percent (Choi, et al.).  With Canada’s Korean-Canadian population aging, it is reasonable to argue that caring for those with age-related illness, such as Dementia and Alzheimer’s disease will present a challenge for their children and society in general.    It is important to describe second generation Korean-Canadian daughters’ decision-making regarding the care of their elderly parents because Korean-Canadians are a heterogenous group and little is known about their perspectives on caregiving for their parents.  Greater knowledge regarding their perspectives may provide information   9 that could sensitize healthcare decision-makers to the future needs of the older Korean-Canadian adults and their caregivers. This chapter has situated this study by providing a context for Korean-Canadians within Canada, the background on the traditional ways in which elder care was provided by Koreans in previous generations, the cultural lens by which the study is framed, and the significance and importance of studying this neglected population.  The following chapter presents a review of the literature, followed by a chapter describing the methods used for this study.  The study used grounded theory principles to guide the qualitative method.  The fourth and fifth chapter will be used to present study findings as well as recommendation and discussions of the findings.   10 Chapter II: Literature Review  An effective literature review requires a focused research question.  Using the Population, Intervention, Control and Outcome (PICO) format, a clear question was developed and inclusion and exclusion criteria for the study sample were developed.  The question developed was: What is the process of decision-making about managing the care of elderly parents by second generation Korean-Canadian daughters?  A general question guiding the review of the literature was: What is known about children’s decision making regarding elder care for their parents?  I gave special attention to those studies that included Korean samples.  Another criterion I used was only articles written in English due to my inability to read other languages.  I also limited the search to articles published in the last fifteen years in order to keep the research relatively current.  Not all articles were retrieved from peer reviewed journals.  Some articles were retrieved from cIRcle, UBC Library's Information Repository.  Using this criterion set, I performed searches on the databases: CINAHL, Web of Science and PubMed.  Search terms used to find the population included: Korean daughters, second generation Korean people, immigrants, ethnic people, children and caregivers.  Terms used to search the outcome of interest and topics were: elder care, long-term care, care of the elderly as well as decision-making, decisions and factors affecting decision-making.  I used Boolean “AND” operator to combine the search for studies. The Second Generation of Korean Care Providers  In a review of the literature, I found a paucity of studies reporting views and perspectives of the second generation Korean population in relation to elder care.  I   11 located only one study that specifically explored perspectives of the second generation Korean children surrounding elder care.  This article was entitled Remembering Sacrifices: Attitude and Beliefs among Second-generation Korean-Americans (Yoo & Kim, 2010).  Yoo and Kim (2010) interviewed and surveyed 124 adult children.  They recruited participants through snowball sampling via social networks, magazine announcements and various Korean-American organizations.  A limitation of this study is the homogeneity of the sample.  Due to the recruitment through professional organizations, the majority of the sample was middle class with high socioeconomic and education levels.  The sample characteristics limit the transferability of the results to other second generation Korean individuals because beliefs and attitudes may be more representative of education or socioeconomic level as opposed to the cultural group.  The authors used grounded theory procedures for analysis. After initial analysis, the authors used theoretical sampling to develop their concepts.  By using grounded theory principles and documenting their analysis thoroughly, the researcher increased the validity of the results (Corbin & Strauss, 1990).  The results of Yoo and Kim’s (2010) study indicated children felt a sense of gratitude towards their parents for sacrifices that were made on their behalf and their views about filial care were motivated by their gratitude.  Children often felt they had to “repay” their parents including: 1) obligation and duty for all they have done; 2) a form of appreciation for parental sacrifices and 3) meeting parents’ expectations for care in their old age.  While children mentioned filial piety in their reflections about care, they also considered factors such as proximity, finances, sibling compatibility with parents,   12 and effects on their relationships with spouses/partners and children.  Children expressed great concern about the financial barriers their parents faced.  Respondents spoke about parents’ lack of retirement plans, savings, or long-term insurance.  A number of parents also had communication barriers and the children discussed their role in translating for their parents historically and currently  Yoo and Kim’s (2010) study results also demonstrated marked difference in sons’ and daughters’ thoughts about elder care.  The sons’ responses to elder care were focused on duty whereas daughters’ responses revolved around challenges parents would have to face as they aged.  A large number of sons expected female siblings in the family to provide care for the parents rather than sons or their wives.  Furthermore, sons that did speak of caring for their parents did so in the context of sharing responsibilities with their other family members.  Daughters communicated their expectations to become caregivers to their parents and spoke of their brothers’ lack of ability to do so.  The American context of the Yoo and Kim (2010) study limits its transferability to second generation Koreans in Canada.  The American healthcare system and welfare systems differ from Canadian systems.  Such differences could affect decision-making surrounding elder care.  Also, participants were not limited to second generation Koreans.  The sample included what was referred to as the 1.5 generation.  The 1.5 generation represents those Korean children who were born overseas but immigrated to a Western country before adulthood.  The researchers did not provide specific information about the percentage of the 124 children that were second generation. Effects of culture on the 1.5 generation may be different than those for the second generation. Thus the results of Yoo and Kim’s (2010) study may not be applicable to second generation Korean children.     13  The paucity of Canadian research on this topic and the increasing numbers of Korean people and Korean elderly in Canada emphasizes the need to investigate the decision-making of Korean daughters about elder care with Canadian samples. Placing Family Members in Long-term Care Several authors have examined caregivers’ decisions to place family members in institutionalized settings such as long-term care.  Kong, Deatrick and Evans (2009) studied Korean immigrants’ experience of placing a non-English speaking family member with Dementia into an American nursing home.  Using qualitative descriptive methods ten family members were intensely interviewed.  Family members expressed surprise at considering nursing home placement and guilt about placements, in part, because staff members were unable to communicate with their family members and family members’ concerns about differing preferences in food, bathing and sleeping behavior. They also indicated nursing homes were better than they expected (Kong, Deatrick & Evans). Kong et al. (2009) highlighted the hardships for staff and family members arising from difficulty communicating wishes.  Family members viewed cultural training as important to appropriately care for patients and prevent misunderstandings.  The authors’ descriptions of the research process contributed to the validity of the study.   Using a mixed methods study design, Park, Butcher and Mass (2004) employed questionnaires and interviews to study the experiences of Korean family members when making decisions to place family members with Dementia into long-term care.  The authors reported results focusing mainly on the interview data.   Family members described feeling exhausted and deep sorrow, viewing their relationships as fractured and   14 expressing concerns about stigma.  Participants indicated that caregiving for their family members had compromised job performance because they were more anxious, less able to concentrate, and less motivated to continue working (Park et al., 2004).  Women caregivers were more tolerant about hardships over longer periods than male caregivers.  Women often viewed caregiving as an extension or continuation of their duties while male participants described hardships due to their unfamiliarity with caregiving tasks.  More than half of the participants felt guilty about their decisions to place elders in long-term care; many struggled with the idea of filial piety when contemplating their situations.  Investigator triangulation was used by the researchers to increase the credibility of their qualitative findings (Denzin, 1978).   Caron, Ducharme and Griffiths (2007) interviewed fourteen caregivers to explore their decision-making processes about institutionalization for family members with Dementia. The researchers used Grounded Theory as their research approach.  The researchers did not specify the ethnicity of the participants interviewed.  Contextual factors affecting caregivers’ decisions to place family members were informal and informal support, physical environments of elders, and any precipitating events such as physical injuries.  Factors directly affecting caregivers’ decisions were family dynamics, interactions with health care providers, and the consequences they anticipated from elders’ institutionalization.  Although the study did not specify cultural effects, many of the family members felt guilty and viewed placement as a last resort.  Their perspectives were similar to the views of Korean caregivers in the study by Kong and colleagues (2009).     15 The three studies reviewed suggest that the decision to place a family member is in institutional care is complex.  Although none of the studies focused on second generation Korean Canadians, individuals who chose to place a family member in long-term care considered factors such as formal and informal support and consequences of institutionalization (Caron, et al., 2007).  Such factors were also contemplated by Korean caregivers who decided to place family members into long-term care; however, their decisions were complicated by Korean cultural expectations and fears of social stigma from the cultural group (Kong, et al., 2009; Park, Butcher & Mass, 2004).  The Korean caregivers were also affected by the potential for fractured relationships with their elders, as well as other family members (Park, et al, 2004).  Long-term care placement was seen as a last resort for all caregivers and they often exhausted themselves and all options before making decisions for placement. Caregivers  Of studies examining caregivers of immigrant elders, five studies dealt exclusively with Korean elders and their caregivers; however, they examined experiences of first generation Korean immigrants living in the United States (US).  Although the relevance of the identified studies to second generation Korean children living in Canada was questionable, I relied on the American studies to gain insight into this topic.  Kim and Theis (2000) located 30 Korean-American family caregivers through convenience sampling and interviewed caregivers using a semi-structured interview guide.  All participants were female; 25 were spouses, four were daughters and one was a daughter-in-law.  All participants stated that they were caregiving due to their filial duty to their spouses or parents and denied any joy in their caregiving responsibilities.  Any   16 positive feelings toward caregiving were due to a sense of fulfillment of their responsibilities and their opportunities to teach their children and grandchildren about love and filial responsibility.  The majority of participants indicated that they did not expect their children to provide caregiving for them.  Most caregivers had little or no help with caregiving from their children or other family members.  The women who worked described increased work stress and decreased job performance.    Yu (2000) interviewed Korean-American female caregivers and identified similar findings to the Kim and Theis (2000) study.  The women in Yu’s (2000) study described the burden of caregiving, their unwillingness to become future burdens for their children, strong presence of filial ties, and multiple roles of women.  The participants also identified burdens from the physical strain of daily caregiving and abuse from the care-recipients.  Many participants did not expect the same adherence from their children because they were capable of caring for themselves and speak English.  They did not believe that their children should have the same cultural expectations placed on them.   Burden was also described by participants in a narrative analysis study by Yong and McCallion (2004).  The researchers interviewed two Korean-born caregivers living in America and caring for their mother-in-laws.  Hierarchal relationships within the Korean family, anger experienced by caregivers, strained relationships with care recipients, and family support were important themes. In contrast to the burden described in Yu’s (2000) research, these study participants linked feelings of stress and burden to their perceptions of the injustice of their situations rather than the provision of physical care.  Both participants identified stress from the filial cultural obligation of being the caregiver for their mother-in-laws.  When women referred to community resources they indicated   17 resources were often not beneficial due to communication barriers between staff who worked in community agencies and care recipients.    Chung (2009) interviewed ten first-generation Korean participants to understand caregiving for older adults with Dementia in Korean-American families.  Caregivers described lack of  knowledge about the disease, limited social lives, no placement (into long-term care) due to guilt, multiple responsibilities, lack of family support, feelings of obligation rather than love, use of Korean adult day care facilities, lack of access to other resources due to communication issues, and caregivers’ declining physical health.   Chung’s theme about multiple responsibilities is echoed in the Yu (2002) and the Kim and Theis (2000) studies.  Caregiving out of obligation or filial duty was also described by participants in the Kim and Theis (2000), Yu (2002) and Yong and McCillion (2004) studies.  The caregivers in Chung’s (2009) study often felt a greater degree of obligation because they felt hurt and angry due to care-recipients’ past behavior.  Lack of culturally appropriate community resources was a common theme (Chung, 2009; Yong &McCillion, 2004).  In contrast to the Yong and McCillion study where community resources were not used eight out of ten participants in Chung’s study were using adult day centers.    In a study comparing American, Korean and Korean-American caregivers, researchers reported that the majority of caregivers were women (Youn, Knight, Jeong & Benton, 1999).  They interviewed 54 Caucasian caregivers, 44 Korean caregivers and 32 Korean-American caregivers.   Young and colleagues (1999) collected demographic information and used instruments to measure variables such as burden, depression, anxiety, and familism.    18 Their analysis of the data demonstrated that the white caregiver group reported the lowest levels of burden followed by the Korean-American and Korean groups respectively.  Lower levels of support and higher levels of emotional and physical strain increased the level of burden.  Caucasian caregivers expressed the highest levels of support while the Korean group reported the least support.  American Caucasian caregivers also experienced lower levels of anxiety and stress than the other groups.  The results of this study could be due to demographic differences between the groups, such as income, sex of the caregiver, employment or previous relationships between the caregiver and recipient rather than ethnic or cultural differences.  For example, within the white caregiving group, almost 26% were husbands and about nine percent were sons.  In the Korean group approximately seven percent were sons and in the Korean-American group nine percent were husbands and three percent were sons-in-laws. Summary of the Literature Review  By examining placement of a family member into long-term care, I was able to broaden my literature search to examine decision-making for Korean and non-Korean people.  The decision to place a relative into long-term care was complex and multi-faceted.  Caregivers considered factors such as support and potential consequences of institutionalization when choosing a long-term care facility (Caron, Ducharme & Griffiths, 2007; Kong, Deatrick & Evans, 2009; Park, Butcher & Mass, 2004).  The Korean caregivers’ emphasized societal expectations and social stigma associated with choosing long-term care placement (Kong, Deatrick & Evans; Park Butcher & Mass).  Korean participants commented on the “Korean way” of thinking and how traditional view about caring for the elderly at home made it harder to decide on long-term care due   19 to guilt experienced when considering this option (Kong, Deatrick & Evans).  Regardless of race, many study participants felt guilty about decisions they had made to institutionalize loved ones.  The majority of caregivers viewed long-term care as a last resort (Caron, Ducharme & Griffiths; Kong, Deatrick & Evans).  In the studies I reviewed, the majority of caregivers were women. Numbers of male caregivers were higher in American samples and were usually spouses of care recipients (Knight, 1999; Youn, Knight, Jeong & Benton, 1999).  In the Korean and Korean American samples the caregivers were female spouses, daughters and daughter-in-laws (Youn et al, 1999; Kim & Theis, 2000; Yu, 2002; Young & McCillion, 2004; Chung, 2009).  The caregivers were often mothers of small children, working outside the home and caregivers to their elders (Chung, 2009).  With increases in Korean working women throughout Canada (Human Resources and Skills Development Canada, 2001) potential burdens can be compounded by Korean Canadian women being expected to be responsible for the majority of household duties, such as caregiving (Kim & Theis, 2000). Male spouses and sons rarely served as caregivers (Knight, 1999; Kim & Theis, 2000; Yu, 2002; Youn & McCillion, 2004; Chung, 2009).  The inability to recruit male participants may speak to the lack of male caregivers in the Korean community or may be the result of the challengers researchers typically face when trying to recruit male participants (Oliffe, 2010).    Daughters and sons expressed differences in perceptions about caring for their parents.  Daughters thought deeply about the challenges that their parents would face and how they expected to care for them in the future (Yoo & Kim, 2010).  Sons commented   20 on the duty that they were expected to fulfill and the expectation of shared caregiving among them and their siblings (Yoo & Kim).     The sense of obligation was also discussed by the participants in many studies (Youn & McCillion, 2004; Kim & Theis, 2000; Yu, 2002; Chung; 2009; Yoo & Kim, 2010).  Participants spoke of filial ties or cultural expectations when discussing the care they provided.  The women, in these studies, often stated that they felt obligated to be care givers due to cultural expectations and filial values.  Obligations were stressed more by daughter-in-law caregivers than by daughters or spouses (Yong & McCillion).  Reasons such as love and payback of parental sacrifices were often described by daughters when speaking of caregiving (Kim & Theis; Yu; Chung; Yoo & Kim).  Daughters and spouses also discussed cultural expectations and filial expectations for providing care for Korean elders (Kim & Theis; Yu; Chung). Korean participants expressed concerns about the potential for fractured relationships with care recipients and family members if they placed elders into long-term care facilities.  Participants often believed family members would have negative feelings towards them because they did not fulfill their responsibilities (Youn & McCillion).    Stress and burden were also common themes.  For some participants, stress manifested itself as depression or physical illness (Youn & McCillion, 2004). Women linked their burden and stress to their multiple roles and limited family support, especially when daughters and daughter-in-laws were caregivers (Chung, 2009).  In addition to being primary caregivers, women described being expected to be the primary carers of young children and to work outside the home (Kim & Theis, 2000).     21 In the studies reviewed, levels of stress and burden were linked by participants to levels of family support (McKnight, 1999; Chung, 2009; Yong & McCillion, 2004; Yu, 2002);  stress and burden were inversely related to family support (McKnight, 1999; Chung, 2009; Youn & McCillion, 2004; Yu, 2002).  Women expressed increased stress, anger and physical complaints when there was little family involvement (Youn & McCillion; Chung).  Although caregivers felt obligated to take care of elders, other adults in the family often contributed little to their care (McKnight, 1999).  Lack of family involvement often had to do with geographical distance (Youn & McCillion).  Other reasons for limited family involvement were elderly caregivers’ unwillingness to disclose burdens, stress and needs to family members and the lack of support within Korean families in regards to elder care (Yu; McKnight).  Knowledge Gaps  I identified a number of gaps in the literature.  An important gap was the paucity of research involving second generation Korean children exclusively.  To my knowledge there is only one study that deals primarily with second generation children and their views surrounding elder care and filial ties but the authors failed to specify the percentage of study participants represented by second generation Korean adults (Yoo & Kim, 2010).  As previously indicated, this study may not be relevant to Korean-Canadian children because of differences in the American context, for example, healthcare, social and welfare systems.  The limited information available about the second generation Korean adults, the potential negative effects of caregiving for children who are caregivers, and the need to understand the decision-making of Korean second generation   22 children support a qualitative approach to explain how second generation Korean daughters make decisions about elder care.  This chapter summarized the studies I found relating to the Korean population in regards to their elder care decisions.  Due to the limited number of studies specific to the Korean second generation adults, studies that included first generation Korean and Caucasian participants were included.  In the next chapter I will describe the design of my study including ethics, sampling, data collection and data analysis.        23 Chapter III: Methods Research Design  Selecting a research method is driven by the research question under study.  In this study, my aim was to explain the process of decision-making about managing the care of elderly parents by second generation Korean Canadian daughters and factors influencing their decision-making.  Explaining how daughters make decisions requires a qualitative research design.  Due to the focus on a social process, I selected grounded theory as the research method. My research questions were: 1) what is the process of decision making regarding the care of their elderly parents by second generation Korean-Canadian daughters; and 2) what are the connections between culture, gender and Korean Canadian daughters’ decision making regards their parents care?   The grounded theory method draws from both the philosophical and sociological traditions and places great emphasis on understanding interaction, processes, and social change (Strauss, 1987).  Grounded theory is intended to develop mid-range theory through the use of systematic data collection and analysis of data (Glaser, 1992).  Some defining characteristics of the grounded theory method include: 1) concurrent data collection and analysis; 2) the use of constant comparative analysis: 3) memo writing to elaborate categories, define their properties, explain relationships between them and identify gaps in theorizing; 4) theoretical sampling aimed to develop and elaborate elements of the theory; and 6) identification of a core variable (Charmaz, 2006).  Characteristics that distinguish grounded theory from other methods of qualitative analysis are the use of constant comparative analysis, theoretical sampling, theoretical sensitivity, and the generation of theory rather than merely descriptions of the findings   24 (Glaser, 1992).  In this chapter, I will describe my approaches to ethics, sampling, data collection, and data analysis. In addition, rigor and reflexivity will be discussed.   Ethics   Because all research involving human subjects needs to be approved, I applied for and received approval from the Behavioral Research Ethics Board through the University of British Columbia.  In this study, I attended to three Tri-Council core principles that guide ethical research.  These three principles are: 1) respect for persons; 2) concern for welfare, and 3) justice (Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, 2010).    I respected the dignity of all participants by validating their experiences and by supportively responding to their comments.  If, at any time during the interview, the subject seemed distressed, I indicated that the participant could indicate a wish to continue or withdraw.  I gave precedence to their emotional needs over information for the study; no participants showed any signs of distress during the interviews.    For recruitment, the principle of free and informed consent was used.  I recruited participants using flyers that provided information in a way that was easy to read and understand.  When a person contacted me to inquire about the study I informed them about the research purpose, expected time commitments, nature of the participation, any foreseeable harm or benefits, and my identity.  The participants were supplied with a letter of information and a consent from (Appendices A and B) at least 72 hours before their interview time.  This gave the participants an opportunity to review the materials, ask questions about the study, and contemplate any potential harms or risks.  Also, I informed the participants that they had the right to withdraw from the study at any time.     25  I identified potential harms from this study that included: 1) possible emotional trauma arising from disclosure of childhood trauma or abuse during the interviews; 2) exposure of family dynamics that participants found distressing; and 3) fears about the risk of stigmatization by the community and family members if they were to known to have participated in the study.  I did not encounter any situations that were consonant with the first two harms. I was aware that the community members might have had a misconception that this study was promoting institutionalization of the elderly and judge any participants based upon this belief.  In order to minimize harm, the flyers I placed in the community were general and had no statements that include the words long-term care or institutionalization.   To decrease the risk of stigmatization and to protect the participant, I maintained a high level of confidentiality.  Participant names were removed from all documents and replaced with numbers.  In addition, identifying characteristics were removed.  I kept consent forms and contact information separately from the interview data.  I ensured that all electronic files were password locked.  All paper files were kept in locked filing cabinets to which only the researcher has the keys.  Because I know the identity of the participants’ total anonymity was not possible.   The benefits I identified arising from this study included the potential to sensitize health care decision-makers to the needs of the Korean elderly and Korean caregivers, the opportunity for caregivers or potential caregivers to receive recognition, the opportunity for participants to vent their feelings, and the demonstration of academic interest in second generation Korean people.   26 Sampling  Initially, I used purposive sampling.  In purposive sampling, criteria subjects must possess are used to select participants who have those characteristics (Panacek & Thompson, 2007).  The inclusion criteria for this study were: 1) adult Korean-Canadian women born in Canada; 2) women with parents that are first generation immigrants; 3) women with at least one living parent with the potential to require care in the near or immediate future and 3) women with the ability to read and speak English fluently.  The women might have identified a need for caregiving for parents based on physical, emotional or cognitive needs.  The exclusion criterion was that the women were current caregivers for their parents. Recruitment of Participants  Ten subjects were recruited that fit the inclusion and exclusion criteria.  I found it difficult to enroll ten participants in the study.  To recruit participants, I approached the Vancouver Korean Society, the University of British Columbia’s Korean Students’ Association, Korean churches, and cultural centers and Korean businesses such as grocers and left flyers which is located in appendix C.  I approached those establishments multiple times to access ten participants.  I also used snowball sampling to increase participant recruitment.    In the original research design, I intended to use theoretical sampling after I had developed some theoretical categories.  Theoretical sampling advances the development of the emerging theory by enabling the researcher to further theoretically develop codes and connections between categories (Glaser & Strauss, 1967).  Groups are chosen for particular characteristics needed to further theoretically develop codes and coded   27 connections between categories (Glaser, 1992).  I encountered two problems with Glaser’s approach to theoretical sampling.  The first was the limited number of participants recruited for the study.  The second was the inability to access information about the characteristics of the participants from the community until after they had volunteered for the study- a problem Glaser has never addressed.  All participants who volunteered, and met the inclusion criteria, were included in the study.    I ceased data collection after ten interviews because I determined that data saturation had occurred.  Data saturation occurs when new data no longer produces new insights or properties pertaining to the core theoretical variables and their properties and when all categories are elaborated and integrated into the emerging theory (Glaser, 1992). Data Collection   I used individual face-to-face interviews to obtain data.  I chose this method of data collection because interviews yield a higher quality of data and refusal rates for face-to-face interviews tend to be lower (Polit & Beck, 2008).  Also, as issues were divulged and ideas emerged, I was able to quickly respond and request the participant to elaborate.  The semi-structured interview format allowed for flexibility so I could adjust questions in order to gain more information or clarity (Duffy, Ferguson & Watson, 2004). Intensive interviewing fits particularly well with grounded theory because, although the approach is open-ended, the researcher can be directive and follow emergent ideas (Charmaz, 2006).  Demographic data, such as age, marital status and working status, were collected. The demographic questions I asked are located in Appendix D. I carefully chose the questions for the semi-structured interviews because questions should foster participant reflection and provide an avenue for in-depth exploration of the topic at hand (Charmaz,   28 2006).  To discover the central problem identified by the participants, I began with a general question and invited participants to enter the conversation.  The initial question I asked in the interviews was: How do you think you will approach elder care for your parents as they age?  The introductory question and remaining questions are listed in Appendix D.  The participants were given a choice of where they wanted to conduct the interviews.  I discouraged interviews at places such as coffee shops due to the noise level but was prepared to make exceptions for participants who did not feel comfortable in the other settings. All but two participants agreed to be interviewed in their homes.  The two interviews outside the homes occurred in a private room at churches.  It was important for the interviewer and interviewee to develop a good rapport early in the interview (Ryan, Coughlin & Crolin, 2009).  Researchers can achieve good rapport by being attentive, relaxed, and actively listening during the interview as this interview style is more conversational (Legard et al., 2003).  I used these methods to develop rapport, trust and create a comfortable space for the participant.  I provided opportunities for the participants to speak at their own pace and limited my comments unless it was to ask for clarification or more information about the topic of interest.  By using this approach, participants were more likely to be frank which increased the probability that the information gleaned reflected the truthfulness of participants’ thoughts rather than the participants’ beliefs about the appropriate response (Berg, 2009).  As interviews progressed I focused on themes that had begun to emerge in the interviews by adjusting the interview questions and topics between interviews and by requesting   29 elaboration of these topics and themes from the participants. All interviews were digitally recorded to ensure accuracy of transcription. Procedures  Interviews varied in length between thirty to seventy minutes.  I did a maximum of one interview per week to allow time for transcription, analysis, and adjustment of questions and topics between interviews.  Following grounded ground theory principles, sampling, data collection, and analysis occurred simultaneously (Glaser & Strauss, 1967).   Data Analysis   I used constant comparative methods throughout data analysis.  I constantly compared incidents from each interview with those from other interviews and also to the data within the same interview, which facilitates the development of patterns in the data and aids in grounding the developing theory in the data (Glaser & Strauss, 1967).  To begin, I compared the interview data of one interview with other elements in the same interview.  Following the second interview, I started to compare interview data with the data from other interviews to identify similarities and differences.  As concepts were developed I compared incidents with concepts and categories I was developing from the data set (Glaser & Strauss).  In grounded theory data collection is informed by the emergence of new incidents, categories, concepts, and themes.  The constant comparative method allows data collection and analysis to continually inform each another (Glaser & Strauss).  The initial analysis of the data informed me about where to go with the next interview and what to look for.      30  Coding  Initial analysis was undertaken using in vivo or open coding.  Open coding aids the researcher in discovering categories and properties (Glaser, 1992).  I analyzed each interview line-by-line; that approach allowed me to: 1) remain open to the data; 2) see the nuances that may have been missed during transcription or interviewing; 3) look critically at the data; and 4) see actions and identify processes of significance (Charmaz, 2006).  Furthermore, initial coding gave me direction for further analysis.  An example of this coding is seen below. Table 1   Coding Example Transcription Line by Line Coding Focused Coding  I think my mom, the most she would expect from my brother is financial care, if she was going to expect anything.  For me it would be both.  Like physical care, being present there, things like that and the financial care would be expected of me.  Mother would expect financial care from brother Would expect both physical care and financial care from daughter    Different expectations for men and women  Different types of care involved   The second level of coding I used was focused coding.  This coding is more directive and conceptual than line-by-line coding (Glaser, 1978).  At this level, I used the most significant or frequent codes found in my initial coding to filter large amounts of data.  This level of coding helped me to determine whether initial codes that were created were adequate.  During this process, I was able to clarify my thoughts and ideas about the   31 data.  The process often prompted me to return to the initial analysis and exploration of the topic with focused coding or in vivo coding.  Following open and focused coding I used selective coding.  Selective coding limits coding to only those incidents and variables that relate to the core variable (Glaser, 1992).  This analysis started after I had created a core variable from my previous constant comparison and data analysis.  The core concept then became a guide for further data collection and theoretical sampling.  An example of a category that related directly to the core concept, Reformulating generational caregiving relationships, was the type of care the older adult required.    Memos  Throughout the analytic process, I created memos to record my ideas about codes and how they related and connected.  Memos play a pivotal role in formation of theory because they start with exploration of the in vivo codes and then are used to describe how categories are developing, the properties of categories, relationships between categories and also how categories are integrated into the core category (Glaser, 1998).  Memo writing allows the researcher to explore a category from every angle and write whatever ideas occur, as well as the comparison of information from data and codes to categories and concepts (Glaser, 1992).  By writing memos, I developed my ideas so I could create categories.  As Glaser (1992) suggested, I wrote memos based on the theory that I was developing.  Initially, the memos I wrote were more general. As I continued to memo throughout my data collection and analysis my memos became more focused around understanding and developing the emerging categories. Examples of memos I wrote can be seen in Appendices E and F.      32  Theoretical Sorting  Theoretical sorting of memos enables the researcher to refine the theory and present it to others in words or writing (Glaser, 1992).  I began sorting by putting together the fractured data through using my memos (Glaser, 1992).  I sorted the memos in a theoretical outline that I used to prepare for writing.    To sort I used a method created by Charmaz which included: 1) sorting memo titles; 2) comparing memo categories; 3) considering how the ordering of memos reflected the participants` experiences; 4) thinking about whether the memo order fitted categories and 5) considering which memos created the best balanced participant experience, the categories developed and the theoretical statements (2006). Rigor in Grounded Theory  I attended to the rigor in my study, as defined by grounded theory, by addressing the fit, relevance, workability and modifiability of the created theory (Glaser, 1992).  Fit describes how closely developed concepts represent the incidents they describe (Glaser, 1998).  The core concept: reformulating generational caregiving relationships, encompassed participants’ decision making process about the care of their elderly parents, and the factors they considered to commit to a care path for their elderly parents.  A good fit is often related to meticulous and thorough constant comparison (Glaser, 1998).    The second aspect of rigor is relevance.  A relevant theory represents the concerns of the participants (Glaser, 1998).  By grounding the analysis in the data, I attended to the voices of the participants and represented what was relevant to them. The women indicated that their parents had provided care and support to them and how they had to   33 think differently about the nature of their caregiving relationships. The researcher must be mindful of effects of putting professional interest before emergence as that can result in research that holds no relevance (Glaser, 1998).  An aspect of relevance is grab.  Grab refers to the ability of the findings to evoke attention from those affected and involved in the study as well as that of the academic community (Glaser, 1998).  In my later interviews, the participants indicated they recognized my theory as applicable to their lives.  In one of my final interviews the participant indicated that my study had relevance and grab because she could see how others, in the same situation, would process decision making and the theory could alert her to factors overlooked in her decision making.  The third aspect used to evaluate rigor in grounded theory is the workability of the theory.  Workability describes the ability of the theory to explain how the participants’ common problem is solved even when there is much variation (Glaser, 1998).  A workable theory can explain problems in different situations with variation in elements.  The theory accounts for maximum variation in experiences (Glaser, 1998).  In my theory, the process of contemplating commitment, envisioning possibilities and re-contemplating commitment described the experiences of all of my participants and captured some of the variation they described.  Although all these women were of the same ethnic background, they varied in marital status, number of siblings, presence of children in their lives, age, and involvement of work outside the home.     The final aspect of rigor in grounded theory is modifiability, which is the ability to alter the theory based on new data that are compared with existing data.  A substantive grounded theory should readily modifiable in order to develop better fit, relevance and workability (Glaser, 1992).  The theory I developed of Reformulating Generational   34 Caregiving Relationships and the process by which reformulating is achieved could be modified with collection of new data to develop a greater fit or potentially fit other areas, such as Caucasian Canadian children’s care of elders in institutional settings.  The characteristics I have described increase the rigor of my work and the theory I developed.  In contrast to quantitative studies, grounded theory does not define rigor by concepts such a reproducibility, generalizability or reliability (Glaser, 1992).  Studies that attempt to replicate the results of a study are valuable not by their validation of existing theory but their ability to speak into the fit, relevance and workability of a theory that may cause researchers to modify the theories they have created (Glaser, 1992).  Furthermore, traditional generalizability does not apply in grounded theory as it is focused on process analysis not unit analysis (Glaser, 1992).   Reflexivity  Because my research was influenced by my assumption that culture is changing, I used reflexivity to attend to my cultural competence throughout the research process.  This reflection started during the literature review and study design in an attempt to reduce my bias and prejudice.  Although I am part of the same ethnic heritage as participants I did not assume that I would be culturally sensitive or that participants’ experiences would reflect my experiences.  A study by Temple, Edwards and Alexander (2002) showed the use of Asian research assistants did not ensure cultural competence and sensitivity.  Assistants who were educated in the Western system often had prejudices about Asian culture that were similar to those of non-Asian research assistants.  Because I am western-educated, I used four of the five constructs of cultural competence   35 in order to reflect on the ways in which my prejudice and bias could affect the research process.    Cultural competence rests on five constructs to increase cultural sensitivity and understanding when doing qualitative research with ethnic populations.  These five constructs are: cultural awareness, cultural knowledge, cultural skills, cultural encounters and cultural desire (Campinha-Bacote, 2002).  I was directed by the first three constructs to gain knowledge in cultural history, geography, politics, and communication relevant to the Korean and Canadian culture.  Because the participants are part of both the Korean and Canadian culture I collected information about the histories and the current cultural norms of each country.    The participants had the potential to be affected by both cultures in varying degrees; therefore, I did not assume that they had the same understanding or preferences for communication.  A basic knowledge of Korean and Canadian cultural norms, such as preferred modes of communication and physical contact, helped prevent me from inadvertently offending a participant, thus impairing the ability to openly communicate.  The fourth concept, of actively seeking out encounters with different cultural groups, was not used as I have experience in interacting with people of different ethnicities and cultures. I did, however, reflect on the interactions I have had and analyzed them in order to gain a better understanding of the different people I encountered and my experiences in interacting with them.    The fifth construct, cultural desire, emphasizes the researcher’s recognition of cultural differences by respecting the participants’ cultural differences (Jones, Bond & Cason, 1998; Pergallo, 1999).  This understanding of cultural differences is relevant   36 between cultures as well as within cultures.  Because the participants are products of two cultures it was important for me to realize that the cultural identities held by the participants might have differed.  I reflected about the extent to which participants were affected by each culture, as well as their personal experiences, and their potential effects on views and perspectives that were uniquely their own.  I respected the differences between participants by allowing them to set the tone for communications and through awareness of my own personal perspectives and biases that could have affected their interviews or my analysis.  Furthermore, I kept a journal of my thoughts and assumptions.  Through journaling, I was able to be reflexive about how I was viewing the data (Kleinsasser, 2000).  Reflexivity allowed me to critically reflect on my own biases and prejudices and acknowledge my role in the research process (Schwandt, 1997).  By increasing my awareness of my unique perspectives, prejudices, biases, and judgments I could better manage my opinions and separate them from the data in order to create a more honest analysis.  In this chapter, my study design, approach to ethics, sampling, methods for data collection, and approaches to analysis were discussed.  Also described was how I increased the rigor of the study using grounded theory principles as well as the use of reflexivity to help reduce cultural bias and assumptions.  The following chapter will include a description of the participants and the study findings detailing the core concept and outlining the participants’ process of decision making in regards to care for their aging parents.   37 Chapter IV: Findings In the findings chapter, I will explain how second generation Korean-Canadian women participants decision making about care for their elderly parents.  To generate a greater understanding of the participants’ context, I will first describe the ten women who took part in the study.  Following this description, I will present the core variable involved in their decision making and the themes that support this concept. The core variable identified in this study is: Reformulating generational caregiving relationships.   My substantive theory demonstrates how second generation Korean-Canadian women’s plans towards caregiving for their elderly parents are processed through a reformulation of their previous or current relationships with their parents.  The reformulation is affected by the women’s attitudes, particularly the positive or negative ways in which they viewed their past and current parent-child relationships.  During this reformulation, the women navigated through stages of reflection: 1) Contemplating Commitment, 2) Envisioning Possibilities, and 3) Re-contemplating Commitment.  The categories supporting the stages of reflection include: family values, different forms of care, parental expectations, sibling involvement, and perceptions of long-term care facilities.  These categories are present throughout their process of reformulation and present themselves in different stages of reformulation process. Study Participants: Who Are They?  The ten second generation Korean-Canadian women who participated in the study shared some demographic information.  The women were ranged in age from 23-47 years.  All but two participants were married, and all but three were parenting children.  Their work status varied from student to full time employee.   38 Table 2    Characteristics of Participants Variable n Age     20-25  1     25-30  3    30-35 2    35-40 3    >40 1 Marital Status     Married 8    Unmarried  2 Children at home     No children 3    One child   3    Two children  4 Working Status     Student 1    Part time   6    Full time 3    All participants were second generation Korean-Canadian women who spoke English fluently.  The women were Canadian born children of Korean immigrants.  Participants lived in the greater Vancouver area. Reformulating Generational Caregiving Relationships  The core category, reformulating generational caregiving relationships explains Korean-Canadian women’s shifts in their caregiving attitudes.  The women went through   39 a process in which they reformulated their traditional caregiving relationships by reflecting about how they could make their wishes, to provide care for their elderly parents, a reality and how this would affect their nuclear families.  The women’s reflections were affected by many factors.  The women, in the study, all stated that they would like to provide care for their parents but how they thought that caregiving relationship would look was affected by many factors. They indicated they are not motivated by the same factors that affected previous generations.  Contemplating Commitment  The women reflected upon the caregiving provided by previous generations and what they would do.  All the women stated that they would like to provide care for their parents as they aged.  However, what the caregiving would be and how it would look like was unclear to the women.  Secondly, the women reflected that, in previous generations, children were expected to and did provide elder care for their parents.  The women indicated they were uncertain about how caregiving would occur because multiple roles, separate living arrangements, finances, and sibling help added layers of complexity that the women had not contemplated in this initial stage: P05: I’ve always thought that it would be my responsibility to take care of them.  Um...I haven’t figured out exactly how it’s gonna be or what it’s gonna look like in 10, twenty years from now.   The women described a shift in their thinking because they regarded their motives and reasons, and the factors affecting their decision making as contemporary rather than reflecting traditional filial piety or motives seen in previous generations.  The initial   40 contemplation surrounding their provision of care stemmed largely from the reasons they would want to provide care for their parents.  The women referred to reciprocity, which they thought about as mutual exchange of favors or privileges. For these participants, reciprocity took on a new meaning.  Rather than a mutual exchange occurring in the present, the women regarded their intention to provide care as demonstrating an appreciation of sacrifices their parents had historically made for them.  They wanted to give back for past giving but they were also contemplating the relationships within their families and the emphasis their parents had placed on their family life and wellbeing: P07: Yeah...it’s the whole coming to Canada.  Leaving a lot of things behind.  You know the sacrifices they made in trying to do businesses, and trying you know an established home, a family environment.  All those things.  Especially when we hear what they could have done if they stayed in Korea and their primary reasoning for coming is for the sake of the family...I don’t think paying back is, is exactly the right way of saying our response is.  I think it’s um...hmmm...there is an element of that but it’s not like we owe them in the bitter way but there is a sense of appreciating what’s been done and this kind of value of the family. As the participants reformulated their plans for caregiving they differentiated between “having to” and “wanting to” care for their parents. Participants demonstrated discomfort about the idea when asked if it was a child’s role or job to care for her parents: P:6 I don’t wanna say it’s a job per say.  I would hope that you were doing it out of love and uh…a sense of responsibility.   41  As participants contemplated their plans to become the caregivers rather than recipients of parental care, they were unwilling to view the care of their parents as work because it diminished their motives.  They emphasized the loving intention behind the care they intended to give.  Those with loving relationships with their parents stated providing loving care was their primary consideration when reformulating generational caregiving relationships with their parents: P10: It has everything to do with that’s my mom and dad.  They love me, I love them.  They cared for me; I want to take care of them.   In the initial phase of reformulation, participants described parental sacrifices such as moving from their home country, financial losses, and potential missed opportunities and careers. They were clear that their willingness to care for their parents had less to do with reciprocating their parents’ sacrifices and more to do with the sacrifice relating to positive relationships.  Their commitment to making the decisions to care for their parents was increased and accepted more readily when the parent-child relationship was seen as positive.  Their anticipated sacrifices were also more readily accepted.  It was their recollections of their positive family environments that enabled the women to contemplate providing care for their elderly parents and, therefore, reformulating roles within their current parent-child relationship.   When women described family environments and relationships as poor or even harmful they indicated children did not feel a sense of responsibility to care for elders as they aged.  One participant discussed the relationship her husband’s family had with her father-in-law:    42 P8: We (participant and sister-in-law) would…like…we wouldn’t put him in a home that easily but I know his kids would be like “yeah, put him in a home”.  They don’t have that attachment with him because they grew up with him but he was there physically but not emotionally or mentally or anything. Although the participants stated that they would plan to provide the same care for their in-laws, the women indicated their anticipation of the sacrifices they would have to make did not provide them with the same sense of satisfaction that caring for their own parents would bring.  The women anticipated they would focus more on the sacrifices than on the joy of caregiving.  They highlighted the difference between “wanting” to care for their own parents, while only caring for their in-laws due to “need” or “obligation”.  Reformulating their generational relationships with their in-laws was based much more on a sense of responsibility to the larger family than on a sense of love: P5: I feel like it’s what I’m supposed to do.  If it came to that, it would be something I needed to but if it were my in-laws I would feel like it would be a lot harder.  I would do the same thing but I would do it because I felt like I needed to do it not because I wanted to do it.   While participants also considered other factors in their decision making process, the relationship between the parents and children was at the core of reformulating of generational caregiving relationships.  The first stage was focused on their thoughts about their motives for providing care, in particular their anticipated acceptance and satisfaction with their reformulation.   43 Envisioning Possibilities  While the core of reformulating generational caregiving relationships is the relationship between child and parent, there are several other factors that affected the process of reformulation.  During the phase of envisioning possibilities, the women took into account family values, parental expectations, different types of care, sibling involvement, and their perceptions of long-term care.  As they were envisioning possibilities, the participants moved on to re-contemplating their commitment based on their potential options and the care they could provide for their parents as they aged. Family Values  Many participants in this study had experienced family caregiving for the elderly through their own grandparents.  2 out of 10 participants had grandparents that lived with them when they were growing up and four had observed their parents providing care for their grandparents.  Participants who had direct experience of family members caring for grandparents normalized this behavior; many of the daughters were not aware of different options for elder care until they were much older.  Furthermore, many of their extended family and friends had similar arrangements for elders.  The exposure to family provision of elder care influenced women’s views of possibilities for providing care for their parents and provided a place to start envisioning care.  These participants had positive perceptions of multi-generational families and described the benefits of having the elderly cared for by their children:  P:6  The earliest memories I have are living with my grandparents on my mom’s side….and I definitely see the uh…benefits of living together   44 because obviously they brought culture and language that would otherwise not be there.   The women indicated normalization of elder care, as a family responsibility, became rooted in their own value system as they aged.  Their experiences likely contributed to the development of a value system that emphasized strong family bonds and familial sacrifice:  P:7 We want to uphold a certain value in the family, that we think the family…that our relationships are worth sustaining even when all the hard things that come with um…them needing so much as elderly people. Their personal value systems influenced their decision making when considering the different options for elder care and was key in their process of envisioning their possibilities within their reformulation of generational caregiving relationships. Parental Expectation  The participants’ descriptions of elders’ expressions of their wishes and expectations revealed some diversity round elder care.  They described some parents who were quite explicit about what they wanted and other parents who had never discussed it with their children.  The participants who had never discussed changes in function with their parents indicated that denial and the taboo nature of such topics, such as death and illness, caused their lack of communication.  That lack of communication hampered some daughters’ abilities to envision possibilities because they did not have access to their parents’ preferences. Also, participants who described their parents as highly independent believed that conversations about caregiving did not need to take place as the time for caregiving was in the distant future.     45  Even participants who had not discussed expectations with their parents had considered potential possibilities for care when that time emerged.  They indicated that their siblings had spoken of providing care without discussing the plans with their parents.  Children who did not openly discuss future care with their parents envisioned possibilities with the assumption that their parents would want to be cared for in the family home.    Some participants stated that their parents held on to the tradition of family members providing care for older adults in the family home and would never want to be placed in an extended care facility while other participants indicated their parents had expressed a desire not to burden their children.  Despite the discrepancy in expectations and the expression of these expectations, as part of envisioning possibilities, the majority of the participants stated that they wished to honor their parents’ wishes regardless of their own expectations. P3: If I felt really, really, really strongly about something they were against I think I would end up probably listening to what they wanted and listening to them…I’m not going to make them go, it just won’t happen.   Only one participant stated that she was aware of her parents’ expectations but would not uphold them.  In this situation, the participant’s mother had stated she would like to be put in a nursing home when she required care.  The participant expressed that she would feel guilty placing her parents in a home due to the close relationship she has with her parents, the sacrifices her parents had made for her, and her belief that her parents would not thrive in a long-term care facility.  Although the participant seemed to be a negative case in comparison to the other participants, it is important to note the way   46 in which the participant interpreted her mother’s wishes when envisioning possibilities.  The participant did not interpret her mother’s wish as unreservedly a preference for nursing home care but as another sacrifice to avoid being a burden to her children: P4: My mom clearly said put her in a home so it won’t be hard on us.  So no expectations…it’s just more…I guess I feel obligated.  Well not obligated, I wouldn’t say that but more to give back for what they have done.   This participant resisted the notion that her parents would make further sacrifices because it violated commitment to reciprocity with her parents in reformulating her caregiving relationships.  Such an interpretation led her to believe that her parent’s true wish was to be taken care of in the home.  By framing parents’ wishes as about sparing their children a burden, the participant did not view her plan to envision possibilities as undermining what her parents wanted.   Some participants reformulated generational caregiving relationships by contemplating what parents were requesting as actually wanting to be cared for by their children.  Participants’ desires to preserve their relationships with their parents and to provide a nurturing environment provided reasons to:1) assume parents would want to be cared for in the family home even when plans had not been discussed with their parents and 2) override what their parents had stated they wanted in the future.     47 Sibling Involvement All but one participant came from families with more than one child.  All discussed the notion of traditional filial piety but the participants tempered that notion by taking into account other factors such as fairness to siblings, proximity to parents, lifestyle choices, and the closeness of the relationships between the parents and children.  Also, as they envisioned possibilities, the women stated that they did not feel comfortable burdening their brothers with complete responsibility: P9: So, as for my mom um…because I have a younger brother and in our culture, as the male, as the son, he is sort of the one responsible for supporting and taking care of my mom.  I think we would kind of…but it’s unfair to do that so I think we would split the time half and half.  If someone needs to be taken care of all the time, for example if she is ill then I think we will need to share that responsibility.   The women embraced the idea of shared care.  All participants expected help from their siblings when caring for their parents and from their partner’s siblings when caring for their in-laws.  The women envisioned various forms of shared care such as: 1) some siblings providing more financial care while others would provide more of the personal care; 2) having parents stay with certain siblings for certain times of the year and rotate the time amongst the siblings; and 3) care division by proximity of the children.  Although all participants embraced shared care, the possibilities differed based on the circumstances of the family members who would be involved in care.   Shared care did not mean that participants contemplated all of the siblings dividing up all care similarly among them.  Participants described division of care based   48 on the nature of the sibling’s time and resources.  This included financial resources, other roles, space in their homes, and the time in the siblings’ lives.  One participant described the division of care she had discussed with her sisters.  Because one sister had not married and had no children it was agreed that she would provide more of the hands on care while the other two sisters would provide more financial care.  None of the participants in this study envisioned adhering to traditional rules and standards of filial piety where the oldest male son and his wife were expected to provide all of the care for his elderly parents. Different Kinds of Care  The participants envisioned three different types of care including emotional, physical and financial support of their parents.  How the participants envisioned providing care in the future depended greatly on what type of care was needed. Finances All participants mentioned finances as a major factor when envisioning the possibilities for providing elder care.  Finances influenced how they imagined who would do the caregiving tasks, where the parents would live, and what children would have to potentially give up to provide care for their parents.  Two distinct discussions arose around finances: the finances of the child and the finances of the parents. Children’s Resources When discussing their personal finances in relation to providing care for their elderly parents the issues that arose were the size of the children’s home, the ability to get outside help, the ability to afford long-term care, and whether children could afford to stop working to provide care.     49 When contemplating situations where parents would require increased physical care participants described envisioning two options: 1) keep the parents in the home while making necessary changes to the home and have help, such as a live-in caregiver and 2) keep the parents in the home with no changes to their current situation.  If the resources were available, participants acknowledged options that would make it easier to have their parents in the home, including renovations to create separate living spaces and provide privacy for each family or buying a larger home to achieve space and privacy and hiring a caregiver to provide physical care.  P3: I’m very lucky that I am employed and I am comfortable and I do have the resources, I think, to provide that type of care [referring to hiring a caregiver].  If I didn’t have the finances, I think it would be really, really tough.  Yeah…I have no idea how that would work. The increased availability of resources gave some participants the freedom to envision a wide range of options to keep their parents in their original homes while managing their own privacy and/or providing all their personal care.  Participants with fewer resources did not indicate they had less commitment but the increased freedom that increased finances allowed enhanced the contentment they had expressed about making the decision to care for their parents in the home.   P6: I wouldn’t want to quit my job, I wouldn’t want to um…you know…put my life on hold but if it came to that and they needed it, the only person who would sacrifice their time is me.   50 Participants with minimal financial resources were more likely to emphasize the difficulty of providing care for the elderly and the burdens they would face.  This did not, however, did not decrease their resolve to care for their parents as they aged.   Parental Resources When envisioning possibilities participants also took into account the current and potential future states of the parents’ finances.  Many participants discussed whether their parents were currently financially stable, what plans they had put into place regarding retirement, and how these factors affected their envisioning of providing financial assistance to their parents in the future.  Although all participants linked parental resources to their decision-making, their views about its effects varied.  The parental situations ranged from completely independent with a solid retirement plan to parents who currently required financial assistance. Some  participants were experiencing or expected to experience both extensive and minimal parental resources due to different financial situations between their parents and their in-laws. In envisioning possibilities for providing care, varying financial situations influenced choices.  Participants who viewed their parents as financially stable envisioned different possibilities for providing care in the future:   P5: Um…but I think that in terms of elder care I do believe my parents will be able to fund their necessities, their food, their clothing, their housing, things like that.  What I think more that I can provide for them is emotional care, just being there and spending time with them.  Whereas my in-laws it will be more like I will need to financially pay for things.  Um…in terms of housing costs, food costs and those costs.      51 Women who expected their parents to be financially solvent in their older years discussed care more in terms of emotional care or physical care.  Those women who were unsure about their parent’s financial stability took more time to consider the potential financial ramifications in their lives.   P2: I think if it was his parents, I mean they could just live where they are living, it’s not very far, it’s in the basement.  Um…and I mean if they needed a lot of help...hmm…I don’t’ know if we would be able to afford extra help, maybe a couple times a week.  Honestly, I think we would probably just do it.  I don’t know if anything else would be an option. All participants stated that, although they would be willing to provide assistance, their financial situations made it impossible to provide financially at this time or to potentially give larger sums once their parents or in-laws could no longer work.  One participant even discussed the possibility of combining households before the parents were dependent due to their lack of ability to sustain two households once their in-laws were no longer financially independent.  Reformulating generational caregiving is particularly salient at a point when parents have lost financial freedom and are dependent on the child for financial care.  Although commitment remained to reformulating intergenerational caregiving, the participants’ abilities to envision possibilities were affected by the financial security of themselves and their parents.  Participants indicated their decisions to provide care would persist but how they planned to provide care and their contentment with their decisions to provide care was altered.     52 Emotional   Caring for their parents emotionally was not seen as a great burden by the majority of participants.  The women most commonly referred to emotional care as companionship and spending quality time with their parents. Participants who indicated that their mother and father had a close relationship did not contemplate having to provide emotional care for their parents, as the parents provided support to each other.  Women describing some parental relationships indicated their parents would hide things from them so they did not emotionally burden them or cause them worry.  Some women described the need for emotional care in the future, such as providing a companion for their living parent when another eventually passed away.   Only one woman described being burdened by emotional care.  Her mother historically had consistently leaned hard emotionally on the participant to provide companionship and emotional support.  The participant stated that her mother was a very private person and did not like to disclose her troubles outside of the family.  Moreover, her mother was divorced and not in a supportive partner relationship.  She described the effects of her mother’s reliance on her and her brother: P1: I guess she’s always leaned on me more. My mom is a very prideful person and I think the reason she will talk to me as opposed to someone else is because she is too prideful to tell other people what is going on.  And that is what she usually does say that “I need you and your brother because I can’t tell anyone else”.   The participant indicated that if her mother re-married, she would not feel this burden so heavily because she envisioned her mother in a supportive partner relationship.    53 For this participant envisioning possibilities in reformulating intergenerational caregiving was focused on physical and financial possibilities as she was already an emotional caregiver for her mother. Re-contemplating Commitment  As the women envisioned the possibilities of care, a change emerged in their level of commitment depending on the type of care their parent would require.  The women were able to envision caring for older parents that required emotional or financial assistance but moved into re-contemplation when they were asked to envision providing care for a parent that required physical care such as feeding, help with mobility and bathing.  Physical Care  Participants were anxious about the amount of physical care their older parents might require. Their initial contemplation was based upon the image of their parents as physically independent.  While the participants could contemplate commitment to their parents living with them while they remained quite physically independent they re-contemplated commitment when they considered increased care needs, such as toileting, bathing and feeding and decreasing health. The phase of re-contemplating commitment began as they envisioned themselves providing their parents with physical care.   They hesitated to say they would put their parents into care but the possibility crept into their descriptions:  P7: Um…I think if…if there was a serious illness.  If it was just some kind of manageable condition like diabetes where it was just regular visits or something like that we could take care of them.  If it came to the point   54 where they couldn’t…I don’t know like function really well on their own or get around really easily then I think we might need to put them…I know their big dream is to never be in a nursing home. Um… yeah…we would keep them as long as we could.  Although participants wanted to provide complete care for their parents and have long-term care as a last option, their unwavering commitment was transformed into re-contemplating commitment when they crossed a line between independently functioning adult parents who lived in participants’ homes and elders who required help with activities of daily living.  Providing parents with physical care initiated a re-contemplation of commitment and re-consideration of long-term care as an option because they: 1) were not at home to provide 24/7 care; 2) did not feel qualified to provide that type of care; 3) believed their parents would be safer in a long-term care facility; and 4) could not afford to hire outside help.  Participants re-contemplated their commitment as they considered the limitations of their abilities to provide direct physical care.   Women re-contemplated their commitment when they envisioned having parents in their homes who could not manage physically in terms of safety.  Recognizing challenges to providing adequate care for dependent older adults raised questions for the women not only about the safety of their parents but also about the safety of their own families. By moving to re-contemplating long-term care as an option the participants were continuing to reformulate their generational caregiving relationships.  Although they indicated their willingness to provide physical care they questioned whether it was actually a feasible, long-term option.     55 P9: If the circumstance was that I had to work and take care and I just couldn’t because there wasn’t enough time and just physically I wasn’t able then that’s ok but I’m there and I can then I think yeah…I would do it. Participants indicated that their ideal outcome was to have their parents in their homes as long as possible.  Their commitment to the idea of having their parents live with them as long as possible was only re-contemplated when they questioned their abilities to provide safe and adequate care for their parents in the home.   Participants descriptions of unsafe environments included situations where the parent could cause harm to themselves due to lack of adequate supervision and when the medical issues of the parent were too complex to be taken care of by the women at home.  Also, when the women considered the safety of their nuclear family they worried about the potential for the older adult to inadvertently cause harm to the family: P7: I’ve heard stories where even though like the mother-in-law is physicially healthy like mentally she is not there so she would leave the stove on and she would imagine she was doing things that she did when she was younger.  In those situations, if it was risking everyone’s safety then we would consider it [long-term care] too. Even contemplating placing their parents into a home was mentally distressing for the participants.  Their inability to provide physical care was in conflict with their value systems and what they believed were parental expectations.  Their acceptance of their possible decision to consider long-term care was determined by whether their decision was based on want or need:   56 P9: I think if I…yeah because I think I would feel really guilty if I couldn’t’ do it just because I didn’t want to.  If the circumstance was that I had to work and take care and I just couldn’t because there wasn’t enough time and physically I wasn’t able to then that’s ok but if I’m there and I can then I think I…yeah…I would do it. In re-contemplating commitment, long-term care still remained a last resort for elder care that would only be considered when the participant felt the parent needed a higher level of care than they could provide, or compromised the safety of the home, or the safety of the family.  The final phase of re-contemplating commitment during the reformulating inter-generational caregiving relationships occurred when the women envisioned they could no longer ensure their parents’ safety when providing care or that the parents’ presence in the home could potentially affect the safety of their nuclear families. Perceptions of Long-Term Care The participant’s perceptions of long-term care affected recontemplating commitment and reformulating caregiving relationships.  Participants with negative perceptions of long-term care did not think their parents would thrive in a long-term care facility.  They imagined limited attendance to cultural diversity within long-term care facilities and believed that their parents would not be content in them.  The women indicated that the older adults would lack comfort from provision of familiar foods and language; contemplating lack of comfort for their parents resulted in them dismissing long-term care as a viable option.  They were only willing to contemplate long-term care if it could cater to their parents’ cultural food preferences and familiar language.   57 P5: I think the biggest reason why putting them into care homes would not be my first option is, especially the care homes in B.C. and Canada right now, um…kind of cater to the general Caucasian population.  So a lot of the food in these homes are western food and a lot um…the programs are catered to the people who just speak English and as my parents get older I notice that their English skills deteriorating and they prefer to speak in Korean and um…my dad does volunteer at a care home and the one thing that he notices, the one thing that the Korean seniors miss is eating kimchee, eating their smelly Korean foods but it’s not possible because they don’t have a kitchenette and the only food accessible to them is in the cafeteria.  So I think that is one of the driving factors, if I can find one that can give them food and the programs that they like I wouldn’t rule it out completely.   Another reason long-term care was not the preferred option when recontemplating commitment for the participants was the significant meaning they associated with placing their parents in long-term care. For these women, who had described their contemplation of commitment to care for their parents as rock solid, placing their parents in long-term care symbolized abandonment and a failure to provide a nurturing environment: P6: I think it just feels like you are kind of abandoning them and maybe there’s a stigma with that but um…yeah…it just it almost just kind of feels like you’re not doing as much as you can.  I think that’s probably what it   58 boils down to: are you doing as much as you can for your loved one and if not then it just…it’s just something that you just feel guilty about I guess”. The original contemplation of commitment to caregiving for their parents and their sense that failing to provide care created a barrier to considering long-term care as a viable option for the care of their parents when re-contemplating commitment.  During the envisioning stage, long-term care was only seen as a possibility if all others were exhausted.   During re-contemplation of commitment, the participants recognized that, while they would not choose long-term care as a first option for older adult care, they might need it if they could no longer safely provide care for their parents.  Reformulating generational caregiving relationships incorporated long-term care as an option only when the nuclear family might be threatened by providing care at home or the older adults’ requirements for care and safety exceeded the capacity of the participants to provide care.   The women viewed care of the older adult in the home as impossible under circumstances of financial distress, risk for safety, and undesirable geographical conditions.  Financial distress was linked to safety as it did not allow for the recruitment of help in the home, required a participant to leave her job to provide more care at home, and created barriers to renovations to the home that would allow for a safer physical environment.  Participants who were geographically separated from their parents, or whose siblings were separated, understood that they could not provide care from a distance. Under those conditions, they would consider long-term care.  Even in those situations, the women first considered the possibility of re-locating their parents.   It was difficult for the participants to reformulate their initial commitment and they attempted to envision possibilities where they could still provide care in the home.    59 Ultimately, envisioned possibilities, in which factors did not allow them to safely take care of their parents and nuclear family, forced a re-contemplation of their commitment.   The process of reformulating generational caregiving relationships, with these participants, was seen to be continuous.  Participants reformulated their commitments as they continued to envision different possibilities and different consequences of their decisions.  They would continue this process of contemplating commitment, envisioning possibilities and re-contemplating commitment as the circumstances in their lives changed and different factors were introduced.   Summary   Second generation Korean-Canadian women considered many factors when making predictions about prospective decisions regarding their parents and their in-laws.  The core element of the parent-child relationship had the greatest influence when processing their decision making.  While reformulating generational caregiving relationships the participant’s initial commitment to caring for their parents as they aged was rooted in the positive relationship they had with their parents and the love they wished to return by providing care for their parents.  While envisioning the possibilities, the participants incorporated factors such as family values, parental expectations, finances, types of care, sibling involvement, and perceptions of long-term care.  The possibilities produced by this stage of the process led into a re-contemplation of commitment as situations were envisioned which brought into question the participants’ abilities to provide safe care for their parents and/or provide a safe environment for their nuclear family.  Their re-formulation of caregiving relationships re-defined the participants’ roles as caregivers to their parents and moved them to consider situations   60 where outcomes, such as placement into long-term care, would have to be considered.   While all of the factors they identified influenced their decisions, feeling content with their decision and their distress at considering long-term care were, at the core of the process, due to the relationships between parents and the women.   The central theme of the parent-child relationship was interwoven throughout all discussions and foundational in the development and process of reformulating caregiving relationships.   61 Chapter V: Findings, Discussion and Recommendations In this chapter I discuss the key findings of this study and their contributions to understanding the decision making process of second generation Korean-Canadian women in regards to care for their elderly parents.  I consider the implications of my findings for nursing care, nursing administration, future research and education to provide targeted care for the Korean elderly and their second generation Canadian-Korean families.  From this study emerged a preliminary theory regarding the decision making of second generation Korean-Canadian women in terms of care for their older adult parents.  The process of reformulating caregiving relationships extends the literature that examines perspectives of Canadian caregivers for Korean parents. Current theory on elder care focuses on the first generation of Korean people, children who were actively taking care of their elderly parents and the impact and burden that caregiving has on the caregivers.  The key factors in affecting their decision making included children’s and parent’s finances, sibling involvement, level of care the parents would need, safety of their own family and parents, family values, parental expectations and their perceptions of long-term care.  All of these factors were seen and discussed, in some degree, in the literature review but this research examines the processes of decision making and the re-formulation of their caregiving relationships, which is not evident in pre-existing literature. Also, motivations behind the participants’ decisions and re-formulations are new findings from this research.  While much of the previous research indicated reasons such as filial piety, repayment and guilt as reasons for providing care for older parents, this research highlighted different reasons for providing care.  The participants in this   62 study were very hesitant to describe their willingness to care as filial piety, repayment or guilt.  They were very clear in stating that this caring was an expression of the love they had for their parents and a demonstration of the positive relationship they had.     Discussion  The women first entered into a process of contemplating commitment.  The first significant finding was participants’ motivations to care for their parents.  Discussions surrounding the daughter’s motivations for caring centered on wanting to give back to their parents who had sacrificed so much, and the need to provide a nurturing care environment and elder care as a demonstration of their positive and reciprocal relationships with their parents.  In contrast, previous literature described motivations for caring as the fulfillment of filial obligations (Chung, 2009; Kim & Theis, 2000; Yong & McCallion, 2004; Yu, 2000). My study highlights women’s desire to return the loving relationship to the parent from the child by caring for them as they age.  The women in the current study indicated they had moved beyond filial values when processing their decision making.  Another significant finding was the contentment and sense of fulfillment that caregiving for their elderly parents would bring as the daughters provided care.  The women’s contentment with providing care extends previous work because previous literature framed elder care in terms of burden and sacrifice; satisfaction in their caregiving responsibilities was mostly framed in the context of fulfilling their obligations (Chung, 2009; Yu, 2000; Yong & McCallion, 2004).   In this study, the participants linked the positive relationship they had with their parents to their increased satisfaction and contentment with their decisions to provide   63 elder care.  The women indicated that they would provide the same care for their in-laws but the level of satisfaction they had with their decision and the anticipated sacrifices was decreased.  This decrease in satisfaction when caring for their in-laws is consistent with previous research.  Previous literature based solely upon daughters-in-law reported their feelings of a strong sense of burden while caring for their husband’s elderly parents (Yong & McCallion, 2004).    Another interesting finding was participants’ expectations about sibling involvement and responsibility.  The women who had siblings and had participated in the current study, all expected help from their brothers and sisters in caring for their elderly parents. The participants in this study anticipated sharing physical care based on gender of the parent, comfort level in providing care, and parental preferences.  Financial care was based on availability of resources of the children.  Previous research focused on women, in particular daughters, as caregivers for their parents (Youn et al, 1999; Kim & Theis, 2000; Yu, 2002; Young & McCillion, 2004; Chung, 2009).  Yoo and Kim (2010) indicated study participants who were sons expected to share responsibility with their sisters but sisters did not think their brothers could provide the care their parents needed.   Although all the women in my study valued family and wanted to care for their elderly parents as long as they could, they did discuss situations when they would consider placing their parents into a long-term care facility, notwithstanding their resistance to housing their parents in long-term care.  Resistance to residential care is consistent with previous research (Park, Butcher & Mass, 2004; Caron, Ducharme & Griffiths, 2007; Kong, Deatrick & Evans, 2009); however, the reasons family members contemplated placement differ.  In this current study, there was much less focus on the   64 societal stigma associated with placing parents into long-term care (Kong, et al., 2009; Park, Butcher & Mass, 2004).  The women in this current study linked residential placement to their lack of ability to provide nurturing environment for parents and fears for safety for their nuclear family members. The importance of the comfort of familiar language and food was present in this study, which aligned with previous research (Kong, et al., 2009; Park, Butcher & Mass, 2004).    A major factor in the participants’ consideration of long-term care was the level of physical care that the parents would need.  This was found to be the point in the study where participants would start to re-contemplate their original commitment.  Concern about demands of physical care and abilities to provide physical care is consistent with the literature that presents caregivers as being in a state of physical and mental exhaustion before considering placement into long-term care (Park, Butcher & Mass, 2004; Caron, Ducharme & Griffiths, 2007).    Struggling with the decision to place a parent in long-term care is not only expressed by Korean-Americans but also expressed by Caucasian Americans (Park et al., 2004; Ducharme et al., 2007).  Recommendations The study highlights the value of family that second generation Korean-Canadian women hold and their struggle with placing their parents in healthcare institutions.  Increased knowledge of the culture of ethnic groups can increase cultural competence and allow for targeted culturally sensitive care for the patient and family (McGee & Johnson, 2013). By understanding the value these women place on family, nurses, in acute care facilities, can support the families of older adult Korean-Canadian patients to get the patients back to their own homes, possibly with supports in place. Nurses, in long-term   65 care facilities, can increase family members’ satisfaction with long-term care placement and patients’ comfort, care and safety in their new home by: 1) providing interpreters when able to increase communication with the parent to increase the daughter’s ease at having someone else care for her parent, 2) welcome the family at the bedside, 3) engage them in the care of the patient; and 4) communicate the patient’s status and needs with the family.  Also, nurses can enquire, through family members, about the patient’s preferences in food, clothing, and schedules as well as their personal history and interests in order to provide more informed care.  This enquiry could also provide reassurance to the family that the nursing staff would like to provide comfort and best care for the patient. Nursing Administration This study accentuated daughters’ intentions to care for their parents in their homes as well as their struggles with the idea of placing their parents in long- term care.  In order to support these women in providing care in the home, community-based nursing administration could increase numbers of home care workers and respite care workers, as well as time available to older adults from these care providers.  Because the women in this study would consider long-term care if the physical requirements for care exceeded resources, home care workers could assist family members by incrementally increasing their abilities to keep older adults at home, thus decreasing the time they would spend in a long-term care facility.  Respite care for women might increase the likelihood of longer term commitment to caring for their parents at home because the women could receive breaks to go on vacation or gain some much needed rest.    66  The findings point to the need for administrators to consider enhancing culturally competent care facilities.  In these facilities, the staff could be educated to increase their cultural competence by providing care that is suitable for varying cultures.  These institutions could make arrangements to survey families about preferences so they could provide food that the older adult preferred. This can provide relief for the family as they are no longer responsible for bringing in food for the patient, as well as increased quality of life for the patient (Jina, 2009).  In addition, other comforts such as culturally appropriate music, art and entertainment could be added. Nursing Education Canada is a multicultural country.  Older adults from many different cultures and ethnicities will be accessing healthcare.  Because there is often a shift in cultural mores from one generation to the next, nursing students require education about such shifts.  Second generation Korean-Canadian women may have different care motivations from the previous generations, as well as from future generations.  Nursing schools are highlighting cultural competence as an expected competency in order to graduate (Aponte, J., 2012).  Cultural competence is assisted by: 1) teaching nurses about self- awareness and introspection, 2) providing education on the evolution of culture, and 3) giving nurses opportunities to work with different cultures.  Daughters in this study were worried that long-term care facilities would not be attuned to care for their parent’s wishes and that they would not receive properly care.  By increasing the cultural competence of nurses in long-term care, nurses will be equipped to care for different cultures which may decrease the worries of children placing their parents in long-term care.   67 Research Implications This study is limited to a small group of women who live in the greater Vancouver area.  The study results are not meant to be generalized to other groups or other places.  Recommendations for further research would be to develop a survey from the qualitative findings and test it with a larger group of this population. Also recommended is the study of second generation Korean-Canadian men in regards to this topic.  Questions regarding how the male second generation Korean-Canadian population view elder care, how they expect to respond to this, and what their expectations are would be valuable as their thoughts, opinions and processes may differ from that of the women and would provide valuable insight into the decision making process of this subset of the Korean population and how this may affect the care of their parents.   Conclusion The women in this study wanted to care for their parents as they aged.  The interview was draining for many of women as some of them had not thought, in-depth, about all the possibilities. They had only imagined care in regards to caring for independent parents. During the interviews, some of the women had to come to terms with a vision of care that they did not believe was ideal.  Through a process of reformulating generational caregiving relationships, the women envisioned their possibilities for providing care by taking into account issues such as finances, sibling help, and their own personal family values and views on long-term placement.  Their re-contemplation of commitment was based largely on the need for physical care and loss of parents’ independence, and potential harms they envisioned.  The consideration of long-term care was difficult for the women; it was only considered when women contemplated   68 physical needs becoming overwhelming or the safety of the parent or their immediate family becoming an issue.  The women remained committed to providing care for their parents as long as they could.  In order to support these women in caring for their parents as they age, initiatives need to be aimed at increasing home supports and respite care, emphasizing cultural competence in nursing education, and using these skills in the workplace.            69 References Aponte, J. (2012). Cultural competency in baccalaureate US nursing education: Hybrid Holistic Nursing Practice, 26 (5): 243-58. doi: 10.1097/HNP.0b013e318263f2c9 Berg, B. (2009). Qualitative Research Methods for the Social Sciences. Boston, MA:  Allyn and Bacon. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of  healthcare services: A model of care. Journal of Transcultural Nursing, 13, 181- 184. doi: 10.1177/10459602013003003 Canadian Institutes of Health Research, Gender and Health. (2014). Definitions of Sex  and Gender. 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Annual Review of Sociology, 23, 63-96. doi: http://dx.doi.org/10.1146/annurev.soc.23.1.63                79 Appendix A Participant Information Letter   University of British Columbia School of Nursing T201-2211 Westbrook Mall Vancouver, B.C. V6T 2B5 Phone: (604) 822-7417  Title:  Second Generation Korean Daughters: How do they make decisions in regards to caring for their elderly parents? Description: The study will attempt to understand the decision making of second generation Korean daughters.  The participants of this study will be interviewed for 1-2 hours and asked questions about how they will manage the care of their elderly parents and what factors affect their decisions.  The interviews will be recorded by digital recorder in addition to the interviewer making notes.  The data obtained will be used in this study and may be made published.  The participants may be contacted after their initial interview to obtain clarification of the data.  Participants may contact the primary research, Joanna Kook, at any time.  Risks and Benefits: The benefit of this study is its potential to sensitize health care decision makers about the needs of the Korean elderly, encourage an academic interest in second generation Korean people and provide an opportunity for participants to express their frustration at their current elder care situation.  Risks include: 1) the potential of emotional trauma that comes from disclosure of sensitive information.  The researcher will have a list of counseling resources available upon request. Voluntary Participation: Your participation in the study is voluntary.     80 Confidentiality: The information provided will be transcribed.  All names or identifying characteristics will be removed from the transcription.  Contact information will be kept separately from transcripts.  All information will be kept in files that are in locked cabinets and files that are password protected on the computer.  The researcher cannot guarantee total anonymity, as they identity of the subjects will be known by the researcher. Right to Withdraw: You may withdraw from the study at any time.   81 Appendix B Consent Form   University of British Columbia School of Nursing T201-2211 Westbrook Mall Vancouver, B.C. V6T 2B5 Phone: (604) 822-7417  Second Generation Korean Daughters: How do They Make Decisions in Regards to Caring for Their Elderly Parents? I. Who is conducting the study? Principal Investigator: Dr. Wendy Hall, Faculty of Nursing Co-Investigator(s): Joanna Kook, University of British Columbia Masters of Nursing Student II. Why are we doing this study? The purpose of this study is to understand how second generation Korean daughters make decisions about how they will manage care of their parents as they get older.  This will help us learn more about the future needs of the Korean elderly.  We are inviting you to shed light onto this important topic. III. What happens if you say “Yes, I want to be in the study”? If you say ‘Yes’, here how we will do the study: -you will be contacted by the researcher to set up a time and place to hold an interview.  You may choose the setting you are most comfortable with. -there will be one interview that will last 1-2 hours.   82 -the interviewer will digitally record the interview.  These recordings will be stored on a password locked computer and their transcriptions will be kept in a locked filing cabinet.  During transcription any identifying characteristics will be removed. -you will be asked questions by the interviewer. -after the interview you may be contacted again by the researcher in order to clarify information or ask follow-up questions. IV. Is there any way being in this study could be bad for you? There is a risk that the questions asked by the researcher could make you upset.  Participants are not required to answer any questions they do not want to.  The researcher will have a list of counseling resources available for you should you want it. V. What are the benefits of participating? The benefit of this study is its potential to create a greater understanding of the future needs of the Korean elderly.  Also, you might benefit by being given the opportunity to vent frustrations of feelings you have been having about caring for the elderly. VI. How will your identity be protected? Your confidentiality will be respected.  All participants will be identified by a code number.  The identities of the people who match those codes as well as any other electronic data will be kept on a computer that is password protected.  Only the researchers listed on the top of first page of this document will have the password.  All paper documents will be kept in a locked filing cabinet.  Any identifying characteristics of the participants will be removed from the transcriptions. VII. Who can you contact if you have questions about the study?   83 If you have any questions or concerns about what we are asking you, please contact the study leader or one of the study staff.  Names and telephone numbers are listed at the top of the first page of this form. VIII. Who can you contact if you have complaints or concerns about the study? If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-588-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. IX. Participant Consent and Signature Page Taking part of this study is entirely up to you. You have the right to refuse to participate in this study.  If you decide to take part, you may choose to pull out of the study at any time without giving a reason and without any negative impact on your community standing.   Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study.  _______________________________________________________________________ Participant Signature     Date  _________________________________________ Printed Name of the Participant Signing Above    84 Appendix C Flyer  Are you a Korean Woman born in Canada?  Have you ever thought about how your parents will be cared for as they age?  If so, we invite you participate in a study regarding how you plan to make decisions surrounding elder care.  Please contact Joanna Kook to participate in this interesting study    85 Appendix D Interview Guide Introductory Question: How do you think you will approach elder care for your parents as they age? Further questions: 1) What factors affected your decision to make this approach?  2) What is the child’s role in caring for elderly parents? 3) Can you describe any expectation you feel, in regards to caring for the Korean elderly? 4) Are there different expectations for daughters and sons? 5) Can you describe to me the relationship you have with your parents?  6) How are decisions made in your family?  Is the health care decision making process different? 7) Who is involved in the decision making process?   86 Appendix E Demographic Questions 1) How old are you? 2) Are you married? 3) Do you have children at home? 4) Do you work outside the home?             87 Appendix F Memo Example 1: After First Interview -first impulse is bring parents’ home- states it’s an expectation “guilt based feelings”  -initial statement that there would be no reasons to put them in long-term care -factors mentioned: husbands opinion/voice- is this a larger voice than her own???  -finances  -size of home  -marital status  -stage of child rearing  -working status  -situation- need vs. want of parent  -parents health -initially stated no reasons to put into long-term care but there are some factors she would consider -parental expectations different between her parents and in-laws- DIFFERENT RELATIONSHIPS? -Not much help from her brother- is this going to be a theme or is this her perception or individual to her circumstance???       Expectations different between men and women? Or just this case?   88 Memo Example 2: After Seventh Interview   -different factors- what affected them most- what impacted their decision the most?                Finances—affect the decision but multiple options???  How much does it affect the process? Caregiving—will do both- recognize the hardship---are willing to do it---levels of satisfaction are different in different circumstances----in-laws vs. own parents- LOVE is a major motivating factor—reciprocation not the right word to describe their feelings…  TYPES OF CAREGIVING- major impact on what they can do and provide SAFETY OF FAMILY AND PARENT- major influencing factor    Initial all say they will provide care Concrete decision?  Process where their decisions change???? Initial decision—factors---decision again How do the major factors affect the process??  Do they??? 

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