When newly qualifi ed practical nurses discuss their work, they often talk about several different contexts, contrasting different employers and different types of work settings. On the basis of a qualitative interview material like ours it is, how-ever, impossible to systematically analyse the organisation of work with reference to concrete workplaces. Instead, we have paid attention to the way symbolic dimensions of workplace organisation are expressed in the way informants discuss vari-ous features of their work. Interestingly, hospital-type provi-sion of long-term care was often used as a sort of general point of reference by the informants when they were discussing the workplace. All of our informants had experiences of working in an institutional setting, at least during their training. Other forms to organise elderly care were often either explicitly or implicitly compared with this ‘hegemonic’ type of organising care. Apparently, working in a hospital-like organisation is a powerful experience for practical nurses, some of which had come to the conclusion that they would ‘never again’ work in a hospital. Institutional settings were frequently discussed as ‘bad’ workplaces, even though there were also accounts describing ‘good’ institutional care. Home-based care, on the other hand, was often considered as basically a ‘good’ way to organise care, but its recent changes were identifi ed by some informants as leading to poor quality of care. Underneath the relatively common and at surface simplistic characterisation of the workplaces as ‘good’ or ‘bad’ lie fundamental issues about the workplace ethos. In our material the experience of
a good or a bad workplace was associated with social relations with co-workers and others, i.e., ‘our team’. Such social rela-tions are important for supporting and legitimising the work-er’s defi nition of work and self. In a good workplace, workwork-er’s defi nition of work and of herself is supported and respected while in bad workplaces these conceptions are contradicted (Ghidina 1992, 76).
In the following we consider the expectations Finnish prac-tical nurses identify in the workplace. Previous research that relies on this same material argues that the work role of prac-tical nurses has turned out as vague rather than fl exible, like the policy makers initially intended (Wrede 2008). Here we further develop the analysis of how care workers encounter a vague work role. Furthermore, we consider how the concerns of the shortcomings of practical nurse competence, widely discussed since the training programmes were established (Vuorensyrjä 2006), become visible in the workplace experi-ences of practical nurses. This section further considers the impact of unclear and diverse work-role boundaries and re-sponsibilities.
QUESTIONED COMPETENCE
Practical nursing as an occupation has been subjected to wide-spread criticism, which has a variety of causes but has main-ly concerned their claimed lack of adequate competence and skills. The fi rst practical nurses were not favourably received by other care workers (Rintala & Elovainio 1997). Many of our informants had experienced some level of distrust, which is rooted in the notion that practical nurse training does not ‘go below the surface’. The interviewees were often surprised by the negative attitudes and the distrust that for instance nurs-es felt towards them when they came to workplacnurs-es as newly employed. During their training, thinking ahead to their fu-ture positions, practical nurses expected to be able to use the care methods and to perform the tasks they were learning, but, having entered working life, they realise that the compe-tence acquired at school does not inspire trust. The interviews
contain many references to their having to prove their exper-tise and competence, sometimes repeatedly, in order to be al-lowed to perform tasks they had been trained for. This exam-ple is from home-based care.
Even in quite simple jobs, say administering eye drops, we all had to show the public health nurse6 several times that we could do it.
She then gave her permission, but we still had to talk to the doc-tor, who asked a lot of questions. Only after that were we allowed to do those tasks. (Kristiina)
In an institutional context, the fact that the newly graduated practical nurses are evaluated by nurses as well as by clients and their family members becomes perhaps most tangible. No doubt the practice of ‘testing’ the newcomers is a common routine, which all who have recently passed their examina-tion are faced with, regardless of the fi eld, but there are also signs of a lacking recognition for the practical nurse compe-tence. One of our informants commented ‘there are certain things I could do as a trainee and I had my tutor there, but now that I’m a practical nurse I can’t do them‘ (Amran).
Several informants were, however, willing to recognise that the practical nurse training has shortcomings and many de-scribed a feeling of inadequacy and uncertainty due to the short period of training. However, given that the criticism of the competence of practical nurses may at times be justifi ed, it also needs to be recognised that the critical statements at times may be strategic claims, made in relation to allocation of personnel resources or other similar concerns. Indeed, es-pecially in home-based elderly care, the practical nurses’ for-mal competency actually represents an improvement, as the level of training in elderly care and in home help in particular traditionally was lower than in other sectors (e.g., Paasivaara 2002).
A potential source of both the insecurity among practical nurses themselves and of the questioning of their competence among other parties in the workplace is the disparity of the different training programmes in practical nursing. Kristiina,
for instance, who had worked in home-help services prior to her practical nurse training and had a formal qualifi cation for that work, felt that despite of her practical experience the shorter adapted programme that she attended was inad-equate: ‘You know, quite often we were just scratching the sur-face.’ In addition to the various adaptations of the training, another source of disparity in practical nurse competences was the element of practical training. Several informants were critical about the organisation of practical training, claiming that its focus was not always adequate. Also the quality of the guidance received in connection to practical training at work-places varied greatly.
One of the informants pointed out that to require a prop-er competence as a practical nurse one would actually need to complement the programme through independent study in one’s own time. Her interpretation of the situation is con-fi rmed by a recent study on practical nursing. At least to a certain extent, educators do expect practical nurses to be will-ing to commit themselves to ‘continuous self-development’, even in their free time (Vuorensyrjä 2006, 105). Such expecta-tions create a pressure for practical nurses to show what oth-ers defi ne as professional commitment in the sense of taking responsibility for the quality of care beyond that recognised by the organisation (Wrede 2008). The expectations for this type of commitment to the organisation were also expressed by others. Our informants commented, for instance, that rela-tives and clients often expected them to bear holistic respon-sibility for care, for instance, by being able to inform them about all of its aspects. The practical nurses themselves felt, however, that their work role did not support holistic respon-sibility for care. Indeed, they referred to the work role as a bar-rier against developing an overall understanding of the care of their clients.
Also the vagueness of the boundaries of their work role was a problem. While clients expected a holistic service from the organisation, they at the same time might express doubts about the practical nurses’ ability to do certain tasks, as they
had an expectation of a traditional division of labour where nurses and doctors control the important knowledge about care. On the basis of our material, practical nurses met the ex-pectation to limit themselves to an auxiliary work role most commonly in home care where recent reforms had changed the tasks of the carers. At the same time as both clients and their relatives might question their competence, practical nurses still felt that they were expected to be much more than wage earners. Practical nurses also sometimes themselves ide-alised care work. The portrayal of the ideal carer as open, pa-tient, honest and cheerful, as well as reachable at all times by clients and their families contributes to the creation of high expectations that are diffi cult to meet in practice.
UNCLEAR BOUNDARIES AND RESPONSIBILITIES
Despite the discrepancy between the work roles in training and in working life, there seemed to be some kind of con-sensus among practical nurses about the core of their work role. The interviewees found it natural that their work was to a large extent concerned with so-called basic care, i.e., tak-ing care of the bodily needs of the clients. They did not ex-pect such duties to be delegated to others. The majority of them did, however, question the expectation that care was to be combined with housekeeping tasks. On the basis of their training they had not expected these duties to be a substan-tial part of their work role. Particularly for those working in the institutional settings, the toughest bit to accept seemed to be that they were often expected to combine care work with household chores, such as cooking and cleaning, rather than with social contacts. In their view such responsibilities on top of their other care tasks not only make it diffi cult to devote time to individual clients, the situation on the ward may feel chaotic when the carers constantly have to divide their time between different jobs and several clients.
I was on shift alone and we had a couple of the demented clients wandering all over the place (…) And then I also had to make
macaroni soup and a couple of clients’ relatives were demanding attention all the time, some clients wanting something and then you had to keep an eye on the demented wanderers who, honest-ly, may relieve themselves wherever they fancy, tear up the plants and knock the radio over. Sort of ‘I’ll go and pull on that nice fl ex’
and the others shouting ‘Keep off that, it’s the telly’. And there’s my soup burning any moment and I know one of the visitors will eat some of it, and of course it’s not nice for the clients either if it’s burnt. (Johanna)
Many carers felt that this kind of household work was not compatible with the practical nurses’ work role, and that it prevented them from doing what they considered to be their proper job well. In addition to this unclear boundary ‘down-wards’ in the cultural hierarchy of tasks, the practical nurses’
accounts suggest a lack of clear defi nition ‘upwards’ in the hierarchy. Many practical nurses experienced that there was no clear understanding in the workplaces of what they could and could not do in terms of nursing. Vague boundaries were drawn, but practical nurses often felt that the nurses want-ed to restrict their work role to the extent that nursing tasks would be allocated to them only exceptionally or by special authorisation. By contrast, many felt that there on the organ-isational level was pressure on them to take on more nursing tasks, but without proper institutional support. The transferral of tasks that nurses considered as nursing was also problemat-ic from the point of view of occupational boundaries. Where the so-called basic care of clients is concerned, it is clear that nurses happily pass on less pleasant tasks to practical nurses, but they are less eager to give up valued tasks. As one of our informants put it, ‘there are some (nurses) who think that we should just be clearing shit … nothing else.’
Our informants did not express a shared understanding of what kind of work role they should have. However, since their training does not fully correspond to the work role in the workplace, they often pointed at the unclear elements in their duties. Many felt that they were forced to perform tasks
that are not a part of their job and that they have too many tasks and too little time:
I’m not too keen on fi ddling with jabs … some do but I …and take dressing wounds, not that I think it looks awful or something when you touch them, but it’s not my thing … so more of this other kind of caring (…) I’m not a nurse, and I’m never going to become one… (Susanna)
For others, however, expansion of tasks may be a welcome op-portunity to keep up the skill and competence they had ac-quired at school. One of our informants who at the time of the interview was employed as in a service home for elderly clients, had previously worked in a central unit where the cli-entele was constantly changing, because the unit served as an intermediate station. She regrets not having more oppor-tunities to make use of her knowledge in her new position.
While she herself felt confi dent and was prepared to assume responsibility for her decisions, her colleagues often reacted strongly to them:
Sometimes when you start applying antifungal ointment they’re upset and how can you do that without the doctor having seen this athlete’s foot, so maybe they’re very unsure of their own com-petence (…) yes, in some matters I’m ready to take the responsibil-ity (…) just use some common sense. (Maria)
Distributing medicines is a task that was often mentioned by our informants as one showing a particularly wide variety of practices. Some of our informants had met with categorical total exclusion. In lack of explanation based on formal crite-ria there was only speculation about the potential reasons for what was interpreted as lack of trust:
Where I’m working now, none of us has access to the medicine cabinet, the nurse deals with that (…) [I don’t know why] maybe something went wrong with the medicines at some point. (Sari) From the point of view of those who were not allowed to do this task the situation was experienced as a mismatch between
training and work role. They felt that too much importance was attached to medicine distribution in their training, as they were not permitted to do it in practice. Their criticism exemplifi es practical nurses’ frustrations with the confl icting pressures they encounter. They react in different ways: while many practical nurses may criticise their narrow work roles, others feel that they are forced to accept taking on a lot of re-sponsibility, even when they are not comfortable with it, due to the shortage of staff.