The institutional restructuring of service provision and the narrowing down of the scope of public responsibility have contributed towards a welfare mix in home care for the el-derly. The strategic role municipal home care now plays dif-fers from the comprehensive responsibility it previously held.
The curtailed municipal home care caters for those elderly who have the most severe care needs. The elderly whose care needs are less severe or of the ’wrong kind’ are no concern of the public sector. Public services aim at providing a last re-sort scheme, basic service for the sickest elderly, rather than universal service available to all citizens on the basis of care needs. Regulatory changes refl ect a new defi nition of the di-vision of labour among the state, the market and the family.
What has resulted is an increasingly medicalised public ser-vice along with a non-uniform mix of diverse serser-vice settings and care work cultures.
In the resulting institutional matrix, the frontline care workers in public elderly care have lost their license to pro-vide socially defi ned care. The power to organise the everyday care has been transferred to the managerial elite and the poli-ticians in the municipalities. The care workers who provide socially-defi ned care appear to be the biggest losers when their room to defi ne and to control their work is considered.
The discussion about the views and strategies of the unions of care workers illustrates the disconnectedness of their re-sponses to the restructuring of elderly care. The wave of neo-liberal policies that is here characterised as the introduction of a medico-managerialist care culture in public elderly home care appears to have contributed to the polarisation and frag-mentation of care workers. As a result of the deregulation, the diverse groups who carry out socially defi ned care in non-public organisational settings have disintegrated. A new dis-tribution of employment opportunities can be discerned be-tween those who work in the regulated outsourced services
and those who work in services that clients purchase directly from the market.
The emerging social order in the Finnish public home care for the elderly has become reorganised along the cultural order of ‘upstairs and downstairs’ in which only the upstairs is enti-tled to professionalism (Wrede & Henriksson 2004). Thus the implementation of the neoliberal elderly care reforms created inequalities in the division of labour, evoking traditional pro-fessionalism with its divisive, conservative and individualistic tones (Henriksson et al. 2006). Implementation of the medi-co-managerial care culture in the public elderly home care has strengthened the position of the key experts, the medical doc-tors and nurses, whereas the competence in socially-defi ned care that practical nurses partly represent is not recognised.
To be sure, practical nurses are registered health care profes-sionals authorised to provide general nursing care, but their skill and competence in social care are challenged, excluded and devalued.
By reconfi guring the skill and competence in public home care for the elderly, policy makers have set up a hierarchi-cal and task-oriented care work culture. The restructuring of home care has resulted in an institutional devaluation of so-cially-defi ned care. Despite the educational ideals and the pol-icy rhetoric, career opportunities have appeared only for the more educated professionals, for instance, as managers or spe-cialised experts. In contrast, the autonomy available for the frontline workers in their practical work is curtailed. The or-ganisation further blurs their work role through an unclear system of task transferrals. The lack of recognition of the oc-cupational or organisational license to perform nursing tasks appears to be a constant cause for confl icts in the workplace.
A further structural hindrance to stable work roles for prac-tical nurses has been the high prevalence of temporary con-tracts. Benefi ting from the high unemployment rates of the recession years in the 1990s, municipalities created a buffer of the temporary workforce in the public sector. The large group of temporary care workers had poor employment rights and
few opportunities to develop their skill and competence. These terms and conditions restricted the autonomy and agency of the frontline workers. In turn, these processes also seemed to generate other pressures, including recruitment problems and boundary struggles for unions. Probably the most severe threat caused by this lack of recognition from the perspective of the frontline care workers is the related crisis of professional commitment and identity that increasingly seems to frighten away potential recruits, especially young people.
As discussed above, geriatrics rather than gerontology has emerged as the new core expertise in municipal home care, both at the municipal level and in the national planning of cost-effective elderly care policy. Policymakers are prone to look for answers to the problems identifi ed in elderly care in health care expertise in general and geriatrics in particu-lar. This is demonstrated by one of the most recent policy documents that focused on the need to intensify the medical contribution in elderly care (MHSA 2006). Not surprisingly, the rapporteur recommends the promotion of education and knowledge formation in the subspecialties of geriatrics, such as geriatric psychiatry and pharmaceutical medicine.
In this chapter, we have shown how the care-friendly and the care worker-friendly universalist welfare state became ques-tioned and dismantled through the neoliberal policies imple-mented since the 1990s. In the reformed institutional matrix, care and economic effi ciency are constantly juxtaposed, giv-ing superiority to the latter. When analysgiv-ing the developments resulting from this austere neoliberal ethos, we have come to underline the ideological chasm between the care-friendly welfare state and its democratic professionalism and the cost-controlling state with its elitist professionalism. In the face of the emerging inequalities in relation to the eligibility for pub-lic services and in occupational and employment opportuni-ties for care workers evident in the Finnish society as well as globally, we suggest that researchers, policy makers and citi-zens once again become concerned about social justice and the equal distribution of resources. Such concerns entail posing
questions similar to those once so potently posed by feminist scholars of the 1970s and the 1980s, at the same time taking into consideration the increasing complexity of our societies.
Notes
1 This chapter develops empirical analysis earlier reported in Henriksson
& Wrede 2004, Wrede & Henriksson 2004, 2005 and Henriksson et al.
2006. These publications include a more detailed empirical analysis of the documents used.
2 The set of documents was mainly collected for the Academy of Finland project Service Professions in Transition (2001–2004). The documents had three foci, national policy, local policy in the city of Helsinki and a discussion of home care in the trade union publica-tions of occupapublica-tions in the health care sector. At the national level, we privileged policy documents originating from state policy actors. At the local level, our materials originated from one central project of elderly care reform. It was governed by the social authority in the local context, but the central experts in the project group were primarily health care professionals. Our choice of trade union publications excluded trade unions that exclusively represent social care occupations. The systematic review of the union publications covered the years 2000–2004 and the review of the Helsinki policy documents the period 2002–2004. We have since continued to collect diverse materials on elderly home care in two Academy of Finland projects: The Politics of Recruitment (Henriksson) and The New Dynamics of Professionalism within Caring Occupations (Wrede).
3 In Finland there are more than 400 municipalities, which vary greatly in size, economic capacity, demographic structure and the service needs of the population. Currently, a major structural reform is being carried out that will substantially cut the number of municipalities.
4 A trans-sectoral occupation was also created for the administration of elderly care. In English, the programme is called a ‘Degree Programme in Human Ageing and Elderly Service’ (occupational title in Swedish geronom). This degree corresponds to the nursing and social work programmes which all are offered at the polytechnics. ‘Geronoms’
remain rare in elderly care administration. Apparently, many of them work in tasks below their educational level, for instance, as practical nurses (Kuntalehti 2007). They are not, however, registered as health care professionals and therefore lack the formal qualifi cation required for nursing tasks (Supreme Administrative Court 2006).
5 Health care professionals are described in the Act (559/1994) and Decree (564/1994) on Health Care Professionals. Health care profession-als include a) licensed professionprofession-als, b) professionprofession-als having a permit c) professionals with a protected occupational title. Registration as a health care professional is the basic requirement for many nursing tasks and for the provision of medical care.
References
Ala-Nikkola, M. (2003) Sairaalassa, kotona vai vanhainkodissa? Acta Universitatis Tamperensis 972. Tampere: University of Tampere.
Borgman, M. (1998) Miten sosiaalialan työntekijöiden ammatilliset tulkinnat rakentuvat? Tutkimuksia 95. Helsinki: Stakes.
Finnish Government (2003) Hallituksen esitys Eduskunnalle laeiksi sosiaali- ja terveydenhuollon suunnittelusta ja valtionosuudesta annetun lain 4 §:n, sosiaalihuoltolain sekä sosiaali- ja terveydenhuollon asiakasmaksuista annetun lain 12 §:n muuttamisesta. HE 74/2003.
Freeman, R. (1999) Institutions, states and cultures: health policy and politics in
Europe. In J. Clasen (Ed.) Comparative Social Policy. Concepts, Theories and Methods (pp. 80–94). Oxford: Blackwell Publishers.
Henriksson, L. (2008) Reconfi guring Finnish welfare service workforce:
inequalities and identity. Equal Opportunities International 27(1), 49–63.
Henriksson, L. & Wrede, S. (Eds) (2004) Hyvinvointityön ammatit.
Tampere: Vastapaino.
Henriksson, L., Wrede, S. & Burau, V. (2006) Understanding professional projects in welfare service work: Revival of old professionalism?
Gender, Work and Organization, 13(2): 174–92.
Julkunen, R. (1994) Hyvinvointivaltiollisten professioprojektin katkos.
Tiede & Edistys, 19(3), 200–13.
Julkunen, R. (2001) Suunnanmuutos. Tampere: Vastapaino.
Koskinen, S., Ahonen, S., Jylhä, M., Korhonen, A-L. & Paunonen, M.
(1988) Vanhustyö. Helsinki: Vanhustyön keskusliitto.
Kovalainen, A. (2004) Hyvinvointipalvelujen markkinoituminen ja sukupuolisopimuksen muutos. In L. Henriksson & S. Wrede (Eds) Hyvinvointityön ammatit (pp. 187–209). Tampere: Vastapaino.
Kröger, T., Anttonen, A. & Sipilä, J. (2003) Social care in Finland:
stronger and weaker forms of universalism. In A. Anttonen, J.
Baldock, J. & J. Sipilä, (Eds) The Young, the Old and the State. Social Care Systems in Five Industrial Nations (pp. 25- 54). Cheltenham:
Edward Elgar.
Kuntalehti (2007) Geronomi on vanhustyön ammattilainen. Kuntalehti 15(3), 47.
MHSA (2001) Sosiaali- ja terveydenhuollon työvoimatarpeen
ennakointitoimikunnan mietintö. Komiteamietintö 2001:7. Helsinki:
Ministry of Health and Social Affairs.
MHSA (2003) Ailasmaa, R. Sosiaali- ja terveydenhuollon työvoiman ja koulutuksen ennakoinnin työryhmä. Kuntien sosiaali- ja terveydenhuollon henkilöstö 1990–2001. (Retrieved 2003-10-15.) www.
stm.fi /Resource.phx/hankk/hankt/ennakointi/tyovoima.htx.i1535.
ppt
MHSA (2004) Valtakunnallinen omaishoidon uudistaminen. Selvityshenkilö Elli Aaltosen ehdotukset. Working group reports 2004:3. Helsinki:
Ministry of Health and Social Affairs.
MHSA (2005) Palveluseteli. Käyttöopas kotipalveluun. Sosiaali- ja
terveysministeriön oppaita 2005:1. Helsinki: Ministry of Health and Social Affairs.
MHSA (2006) Geriatrisen hoidon ja vanhustyön kehittäminen.
Selvityshenkilö Sirkka-Liisa Kivelä. Sosiaali- ja terveysministeriön selvityksiä 30/2006. Helsinki: Ministry of Health and Social Affairs.
Paasivaara, L. (2002) Tavoitteet ja tosiasiallinen toiminta. Suomalaisen vanhusten hoitotyön muotoutuminen monitasotarkastelussa 1930-luvulta 2000-luvulle. Acta Universitatis Ouluensis D Medica 707. Oulu:
Oulun yliopisto.
Pitkänen, M. (2005) Raskasta mutta antoisaa. Työvoimapoliittiseen vanhustyön koulutukseen osallistuneiden käsityksiä vanhustyöstä.
Unpublished master’s thesis. Tampere: University of Tampere, Department of social policy and social work.
Rauhala, P-L. (1996) Sosiaalipalvelut käytäntönä. In J. Sipilä, O. Ketola, T. Kröger & P-L. Rauhala (Eds) Sosiaalipalvelujen Suomi (pp. 121–55).
Juva: WSOY.
Simonen, L. (1990) Contradictions of the Welfare State, Women and Caring.
Municipal Home Making in Finland. Tampere: Acta Universitatis Tamperensis ser A vol 2. 95.
SuPer (2002) Välittäminen on elämän perusvoima. Juhani Palomäki asiaa johtamisesta. SuPer 49(2), 7.
Supreme Administrative Court (2006) Kunnallisasia—
Työsopimussuhteinen toimi—Toimen täyttäminen—Kelpoisuus—
Lähihoitaja—Hallintolainkäyttöasia. KHO: 2006:28. Helsinki:
Korkein hallinto-oikeus.
Suoniemi, I., Syrjä, V. & Taimio, H. (2005) Vanhusten asumispalvelujen kilpailuttaminen. Tutkimuksia 97. Helsinki: Palkansaajien tutkimuslaitos.
Tedre, S. (1999) Hoivan sanattomat sopimukset. Tutkimus vanhusten kotipalvelun työntekijöiden työstä. Joensuu: Joensuun yliopiston yhteiskuntatieteellisiä julkaisuja 40.
Tedre, S. (2004) Likainen työ ja virallinen hoiva. In L. Henriksson
& S. Wrede (Eds) Hyvinvointityön ammatit (pp. 63–83). Tampere:
Vastapaino.
Tehy (2003) Kotiavustajat pois sairaanhoidosta. Tehy 22(11), 29.
Terveydenhoitaja (2002) Terveydenhoitajat laillistetaan nyt myös sairaanhoitajina. Terveydenhoitaja 28(8), 6.
Vaarama, M., Luomahaara, J., Peiponen, A. & Voutilainen, P. (2001) Koko kunta ikääntyneiden asialle. Raportteja 259. Helsinki: Stakes.
Vaarama, M. & Noro, A. (2005) Vanhusten palvelut. Duodecim Terveyskirjasto. Retrieved 2007-09-28. http://www.terveysportti.fi / terveyskirjasto/tk.koti?p_artikkeli=suo00058
Vuorensyrjä, M., Borgman, M., Kemppainen, T., Mäntysaari, M. &
Pohjala, A. (2006) Sosiaalialan osaajat 2015. Sosiaalialan osaamis-, työvoima- ja koulutustarpeiden ennakointihanke (SOTENNA):
loppuraportti. Jyväskylä: Opetusministeriö, Euroopan Sosiaalirahasto, Sosiaali- ja terveysministeriö, Suomen Kuntaliitto.
Wærness, K. (1984) Caring as women’s work in the welfare state. In H. Holter (Ed.) Patriarchy in a Welfare Society (pp. 67–87). Oslo:
Universitetsforlaget.
Wærness, K. (1992) Bettering the public care services—the only realistic alternative for strengthening the welfare of ordinary people in need of care. In J. Sipilä (Ed.) Sosiaalipalvelujen kehitystrendejä eri maissa (pp. 176–202). Tampere: University of Tampere.
Wrede, S. (2008) Educating generalists: fl exibility and identity in auxiliary
nursing in Finland. In E. Kuhlmann & M. Saks (Eds) Rethinking Professional Governance. International Directions in Health Care (pp.
127–40). Bristol: Policy Press.
Wrede, S. & Henriksson, L. (2004) Kahden kerroksen väkeä: Kotihoidon ammatillinen uusjako. In L. Henriksson & S. Wrede (Eds)
Hyvinvointityön ammatit (pp. 210–34). Tampere: Vastapaino.
Wrede, S. & Henriksson, L. (2005) The changing terms of welfare service work: Finnish home care in transition. In H.M. Dahl & T. Rask Eriksen (Eds), Dilemmas of Care in the Nordic Welfare State. Continuity and Change (pp. 62–79). Aldershot: Ashgate.
Staffi ng Levels and Well-being of the Residents with Dementia
Päivi Topo and Saila Sormunen
In Finland regulations defi ne in what situations a person has the right to residential care but the content of residential care as such is not defi ned. However, the Finnish constitution de-fi nes privacy and autonomy as basic rights. As a consequence, physical restrictions in residential care should not be used without good reason and only temporarily. The right to pri-vacy is understood as the resident’s right to a home-like en-vironment when living in a residential care institution and that sharing a bedroom with others is acceptable only if it is seen to support the well-being of the resident. A third rel-evant basic human right defi ned in the constitution is that of human dignity. This right means that the mental needs of a person in residential care should be met (Pajukoski 2006).
As legislation gives only very general rules for practices in residential care more specifi c criteria for good care are under continuous discussion and are based on wide consensus (for example STM 2001). When looking at services and care for people with dementia the criteria for good care are even more complex to defi ne because clients have limited abilities to be involved in assessing services due to their problems in cog-nition. People with problems in cognitive functioning use 80 %–90 % of beds in long-term residential care in Finland (Noro et al. 2005). In order to understand the current state of residential care, we need to pay attention to how the needs of people with cognitive problems such as dementia are met and what is their well-being when living in care institutions.
Dementia syndrome affects the person broadly, with dete-rioration in abilities to remember, to learn and to act logical-ly, to express oneself, to discriminate, to behave sociallogical-ly, to orientate, and to show initiative. As the syndrome progresses the person affected becomes fully dependent on the help of others.
As people with dementia cannot look after or speak for themselves, they are one of the most vulnerable groups in so-ciety. Several researchers have argued that dementia is a deep-ly social issue and that the psychosocial environment has a strong impact on the well-being of people with dementia.
Some researchers have raised questions about the negative at-titudes of society towards people with dementia, demanding alternative ways to assess the situation related to people with dementia, their caregivers, and the content and quality of ser-vices (e.g., Gilliard et al. 2005, Bond et al. 2002).
We can already see in Finland that some residential care in-stitutions have diffi culties in recruiting enough care workers for short-term tasks and also for permanent positions. Ageing of the population has happened more rapidly in rural areas than in urban areas and has been speeded up by migration of the younger generations to towns. As a consequence the need for elderly services in rural areas has increased at the same time as the number of potential care workers has been decreasing.
Already at the end of the 1990s it was found that the qual-ity of care varied signifi cantly between residential care institu-tions and even between units in the same institution (Vaarama et al. 1999). Since the 1990’s, the debate has been on-going about the quality of elderly care and several improvements have been demanded. The main concern has been an insuffi -cient number of care staff but more recently the treatment of clients has received attention. The Ministry of Social Affairs and Health has reacted to this debate by naming a large ex-pert group that compiled recommendations for quality assur-ance in elderly care (STM 2001). Later, the Ministry launched programmes for the municipalities for developing elderly care services. An updated version of the recommendations will be published in 2008.
In this chapter we will fi rst make an overview of the recent developments of elderly care in Finland and present the chal-lenges involved. The care of people with dementia is one of the main challenges for the care system and dementia care is in the frontline if a care system faces a crisis such as lack of suitably trained care workers. Second, we present our empiri-cal study in two dementia care units. Our goal was to assess the quality of care from the point of view of the residents and to focus on psychosocial issues. We studied two care units:
one with a low level of staffi ng and the other with staffi ng level in accordance with the national guidelines. At the end of the chapter we discuss the question of possible care crises in the near future from the point of view of residential care services for people with dementia.