In this section we move on to consider the impact of the mac-ro-organisation of the work on the work role. Janice Gross Stein (2001) argues that in the contemporary welfare service reforms, the overriding concern for effi ciency has made it a value rather than a means, turning effi ciency into a cult. Our material bears witness to how ‘the cult of effi ciency’ has re-shaped the work role of care workers in Finnish elderly care.
From the perspective of many practical nurses, the ‘effective-ness drive’ in the organisation makes the provision of quality care diffi cult or impossible. Tasks pertaining to clients’ basic needs govern day-to-day routines in the workplace, and all of our informants would like to see more time allowed for social contact. In their training practical nurses learn how the elder-ly can best be stimulated, but in working life there is no room for the social element. For many, contacts with the elderly in the social sphere were a decisive factor in their choice of occu-pation, and they are deeply disappointed at not having more opportunities to cater for clients’ social needs. Under these conditions, the work role does not offer them an agreeable defi nition of self and the lack of such fulfi lment creates seri-ous tensions for the individual (c.f., Ghidina 1992).
THE TYRANNY OF ROUTINES
The allocation of work in care is often justifi ed by the need to organise body care, household duties and nursing in a
‘rational’ way from an overall perspective: for example, in hospital-type care all the patients on a ward are woken up at the same time or in home-based care the meals of the elderly are taken care of by a separate organisation. In a hierarchi-cal organisational model this often means that care tasks are split up according to the degree of expertise they are assumed to require. Those at the bottom of the ladder are regarded as mechanical routines and require only limited knowledge (Eriksson-Piela 2003). This interpretation of the professional role undermines the carers’ own understanding of what their work should consist of. In this type of organisation individ-ual requests and emotions are disregarded. The fact that the organisation of Finnish elderly care currently emphasises ba-sic-care routines was refl ected in our material (see Chapter 5).
When describing what a typical working day was like, many started by listing the most mechanical tasks. Social contacts with clients seem to feature among the daily routines only in passing, and there are indications that instrumental work methods tend to minimise them. In addition to the routines related to the care of the patients’ bodily needs, there are oth-ers that are determined by the needs of the organisation, such as paperwork.
There’s always something to do: write a care plan, phone a rela-tive, do somebody’s hair here, cut nails there, look after your own patient (…) You must check [the body all over], that everything’s OK. Those who can’t get out of bed need their position changed, to avoid bedsores. (Amran)
One of our informants pointed out that when there was an in-strumental system that other carers and clients were used to, it was easier to act instrumentally and just to rely on routines rather than to ‘work against the system’.
You feel that the older clients and you yourself fall into the same pattern, I was a little disappointed in myself, how very quickly you get the feeling that ‘sod it, I’ll turn that one round now, and that one, that one, that one’. The routines just take over, some days when we’re short-staffed. (Kaarina)
The scope of the practical nurses’ work role is formed and re-formed by organisational decisions. In most workplaces they have the opportunity to infl uence for example the order of work tasks or allocation of clients, but on the policy level these opportunities are limited. Many home-care tasks that used to be performed by practical nurses are nowadays or-ganised on a centralised basis as so-called support services, and the carers concentrate on caring tasks. The reorganisation has changed both the contents and the rhythm of the work.
Traditionally, it included shopping, cleaning and washing up, which gave it the character of household work rather than care. Interviewees with work experience in home care stressed that it generally was less hierarchical. However, the differenc-es between practical nurse work in home care and in institu-tions narrow at the same rate as home care is streamlined.
Informants with experience from home care talked about the frustration not to be able to manage work in a satisfactory way in the allocated working hours:
You get so many who are in a bad way these days, and you know we’re not allowed to do overtime (…) it’s precisely this lack of time, so you feel stressed when you know you should take these old peo-ple out and that’s what they’d like, summer is coming and all, and wouldn’t it be smashing to sit out there for an hour or two with everyone, but we, we just can’t manage that. (Susanna)
THE WORKPLACE AS A HARSH REALITY
Many interviewees talked about how they, when coming to work as new employees, reacted negatively to the care work culture they encountered. Many opposed the uncaring nature of work practices, but were met with pressure from colleagues not to cause problems: ‘They were saying just you wait, when you’ve been here two or three years you’ll be like us.’ One of the interviewees laconically identifi ed a process through which care workers ‘learn’ to put up with what they feel is bad care: ‘That sort of thing makes you cynical.’ As new car-ers settle in, drawbacks do not stand out so clearly to them.
You lose your detached perspective on your workplace as you get to know your colleagues and begin to identify with them (Twigg 2000). The workplace itself and the colleagues’ exam-ple, rather than their words, socialise carers to treat emotions evoked by their work, including reactions to poor quality care, in the ‘right’ way (Molander 2003).
It seems that practical nurses fresh out of school are not prepared for how heavy the work they are taking up really is, even though our informants typically had other working life experience prior to entering care work. According to their accounts, their training conveys an idealised picture of what care should be like, but in many workplaces staff shortages and insuffi cient funding restrict the facilities for care, and the carers’ own possibilities of exerting infl uence are limited. The workload appears too big in most workplaces where elder-ly people are being cared for, regardless of whether it is an old people’s residence, a hospital or the client’s home. Some pointed out that this would have negative effects on the gen-eral standard of the care given, despite efforts to maintain the level. At the same time as working as effi ciently and as quickly as possible, you are conscious of neglecting somebody, which triggers constant stress.
The work may be heavy on several levels. When asked to describe what they felt that was heavy in their work, the in-terviewees mentioned the working hours, the physically de-manding tasks (lifting, showering) and the mentally stressful duties (the care of demented or mentally ill old people). The care of the demented is taxing because the relationships with clients become monotonous, and the contacts may feel un-satisfactory (see Chapter 5). Exhaustion may result in indif-ference: ‘When they’re demented, they get forgetful and keep asking you lots of things, the same questions again and again
… 20–25 times a day (…) you get fed up with it.’
Several informants identifi ed the task of caring for men-tally ill clients as particularly diffi cult and sometimes unsafe.
One of our informants told about the anxiety involved in car-ing for a particularly threatencar-ing client:
She used to dig out all sorts of belts and knives and she sat down near you and clearly wanted to show you that now … scare you a little, I think. I haven’t got her out of my mind, because she was always so threatening. I used to wonder where I could go when she’s sitting … if she really did something. (Helena)
There are demented old people in most workplaces, and some-times mentally ill, too. The informants who commented on the pressure created by the presence of such clients identifi ed working alone as the major concern. Facing aggressive behav-iour when working alone made the carers feel uncertain and powerless. Other aspects of working solo also made them feel unsafe. Several interviewees pointed out that working night shift on their own felt unpleasant for them as well as for the old people.
Doing the round at night is a bit spooky. If there were an accident
… I remember somebody had had a fall and there was blood all over the place when I went there … it was pretty awful. You open the door and see just blood. Then there’s somebody sitting there in the dark. (Samira)
Situations where carers are overburdened appear highly prob-lematic from the point of view of good care as there were hints that unethical actions could occur in circumstances beyond the carers’ control, such as in cases of undermanning, stress and possibly exhaustion. Our informants discussed such oc-currences as shortcomings of the system, when carers faced unreasonable working conditions.
They didn’t have enough staff and there were older carers suffer-ing from stress (…) they were unpleasant to the clients (…) If I’d been in charge there, and had seen how those carers … I’d have sent them on sick leave. (Jamila)
Another informant had worked in care units where she saw the standard of care going down, although she herself felt that she was trying her best all the time. She pondered on how work pressure necessarily resulted in a changed attitude
towards the clients that she could not have imagined earlier.
Instead of providing holistic care, she was focusing on spe-cifi c tasks.
At the time (on a long-term ward) I was thinking there’s no sense in this and no point in me here slaving my butt off twisting and turning these people without any sort of break, so that’s how it was (…) when [I was] studying and thinking about these things I thought I’d never take that kind of an attitude towards patients, but there you are … (Kaarina)
The organisational drive for effi ciency thus became visible in her work as an orientation towards specifi c tasks that she de-scribed as ‘twisting and turning’. The same expression was used also by another informant who refl ected how alienat-ing these practices must feel from the point of view of the client:
The carers seemed to be there for their own sake and to get their job done somehow. As long as you can have your coffee break soon, then some turning and twisting and that’s your job done.
I was thinking is that how they lie there all day, nobody talking to them, now and then they get some food stuffed down their throats and that’s maybe the only contact when they see a carer at all. (Maria)
One of our informants, who herself was currently unem-ployed and considered elderly care workplaces in the pub-lic sector as generally inhospitable and poorly run, pointed out that the carers themselves also needed some stimulus to be able to provide good care. Otherwise machines could do it just as well.
I felt that everything human and all charity had gone out of it, it was just a matter of doing your job (…) with the demented I sup-pose it’s hard, it’s terribly hard, but then there should be some-thing offered to the staff to offset this and then they’d cope again and not be like robots… (Anneli)
Many of our informants, newly qualifi ed carers, found the prospect of becoming so cynical that they could live with pro-viding bad care daunting, and many interviewees emphati-cally distanced themselves from this kind of workplace ethos.
One said she would rather quit before she became like that:
‘I’ll quit the very day I start showing such a sour face.’
CONCLUSION
In this chapter we have examined the work role of the prac-tical nurse in elderly care the way it is described by pracprac-tical nurses when they talk about their work. Our analysis has been guided by an idea of the division of labour in the workplace as a negotiated order. In other words, the work role is not stable and constant, but embedded and subject to frequent defi ni-tions and redefi nini-tions in negotiani-tions and confl icts between different actors at different levels. The work role can there-fore be given widely disparate meanings in different contexts, such as in training and working life. The occupation in focus in this chapter is one that is found at the lower levels of the occupational hierarchies, so the practical nurses themselves are not powerful parties in the negotiations on their work role. Instead, their work roles depend on the attitudes, values and politics of others with more power in the shaping of the workplace and its ethos.
In our analysis, we have explored what we in the begin-ning of the chapter identifi ed as a crisis concerbegin-ning the qual-ity of elderly care in Finland, paying attention to how prac-tical nurses describe their work role. Our central conclusion is that the work role in many respects functions as a barrier to quality care in that it does not offer a stable source of self-defi nition in the workplace (c.f., Ghidina 1992). On the basis of our study, at least some of the problems of the work role appear to be related to the questioning of the competence of practical nurses. The vagueness of the work role, in its turn, appears to be a constant source of unmet expectations for all of the parties involved, i.e. care organisers, other profession-als, clients, relatives and practical nurses themselves.
From the perspective of practical nurses themselves the un-clear occupational boundaries of practical nursing are relat-ed to organisational structures and practices and, in part, to organisational non-action. There are no signs in our mate-rial that organisations would be taking effective measures to tackle the distrust nurses and others show to practical nurs-es. Instead, a motley set of workplace-level control measures are practiced to monitor their competence and regulate their practice. The organisational neglect of attending to the vague-ness of the work role is further made worse by the emphasis on effectiveness, constituting a problematic foundation for workplace ethos in elderly care. From the point of view of our informants, it is not the quality of care or the needs of clients or care workers that are prioritised. Instead, the over-riding emphasis on austerity in the politics shaping elderly care suggests to practical nurses that decision makers do not care about fulfi lment of other than the most basic needs of the clients. There is also a sense that the wellbeing of the care workers themselves is not valued. The lack of consideration for their perspective creates from their point of view a cri-sis of commitment, fuelled by a sense of powerlessness that many care workers feel in the face of increasing pressure at the workplace.
The present austerity of resources felt by our informants in many workplaces seems to put their commitment under test rather than supporting it, as it seems that carers are more pa-tient-oriented when they take up their fi rst jobs after qualify-ing, and the more work experience they have, the less sympa-thetic they become. Thus our examination of the experiences of practical nurses in the workplace indicates that the prac-tical nurse’s work role often may restrict patient-orientation.
Accordingly we maintain that the differences between work-places, which mostly appear to be about work organisation and the ethos it supports, are more important for the delivery of the quality of care than differences in carer performance.
Defi cient work organisation produces poor care, which in turn may trigger processes in the carers that may result in
their becoming accustomed to providing insuffi cient and un-satisfactory care.
The care work practical nurses do is all about working with people, and thus involves a constant quest for the right choic-es (Hughchoic-es 1984). Carers make decisions with an immediate bearing on other people, and promoting the welfare of anoth-er human being is, ideally, the ultimate goal of their actions.
Given the present pressure to ration care, practical nurses are also expected to be able to prioritise. Although care work is not particularly rewarding in terms of pay or status, and most of those employed in that sector fi nd their opportunities re-stricted and experience diffi culties and stress, the work in itself offers certain rewards. Since practical nurses work with peo-ple, they often receive direct feedback. The feeling of being appreciated by their clients and being important to them is very gratifying (Twigg 2000). If the care is not good, negative feedback from the clients can be taxing and may trigger self-defence, particularly as practical nurses commonly share the cultural image of the ideal care worker as self-effacingly and boundlessly caring.
Daniel F. Chambliss (1996) calls care work a noble and at the same time terrible profession, a view shared by many who study care work (see Chapters 3 and 13). Helping other people is indeed noble work that may feel rewarding, but at the same time carers are potentially exposed to exploitation. Because of this exposure of carers to organisational neglect, instead of emphasising the distinction between patient-oriented ver-sus instrumentally oriented carers, we prefer to highlight the confl ict between theory and practice as the decisive element.
No carer is exclusively one type or the other, every one is a bit of both. Under the confl icting pressures of working life, some may fi nd patient-orientation mentally very hard and many may end up ‘working like a robot’. In the emerging litera-ture on the linkage between job satisfaction and ethics-related work factors, this phenomenon is recognised as ethics stress and related to the ethical climate of the workplace (Ulrich et al. 2007). When inquiring where to place the responsibility
for the present crisis of the quality of care it is, however, also important to go beyond the workplace and consider current elderly care policy (see, e.g., Chapter 4). There is reason to
for the present crisis of the quality of care it is, however, also important to go beyond the workplace and consider current elderly care policy (see, e.g., Chapter 4). There is reason to