Hybrid, Changing Care Roles

As my second point of engagement with the eldercare literature, I look into the vast body of studies on the role of the care worker and care user. Accordingly, in the following pages, I present the main findings of relevance to my study of the relative as a less well-studied role in care, for while the relative, as mentioned in the beginning of the chapter, is not a central theme of Scandinavian eldercare research, the roles of the care worker and the care user pervade it.

Fortunately, as I will show below, this literature offers the important insight that roles in care are non-stable and contingent, thus changing with the changing functions and relationships of eldercare. As such, this literature was also part of what spurred me to study the role of the

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relative in this light of non-stability and contingency. Before continuing, however, I will first highlight that I use the terms care worker and care user consistently. I do this in full awareness of the fact that the studies referred to use varying concepts for the care worker – such as employee, professional and caregiver – as well as various concepts for the care user – such as care receiver, consumer or client – and that great significance is often attached to the particular term used. However, it is beyond the scope of the thesis to delve into these differences and meanings in any detail.

4.1 The Care Worker Role

The role of the care worker is a pertinent theme running through the eldercare literature.⁶¹ One branch of descriptive quantitative studies describes who care workers are with regard to gender, age, education, etc., and what types of tasks they perform.⁶² Another phenomenological and hermeneutical branch focuses on care workers’ experiences of their working conditions and their work satisfaction and is also influential. Both branches saliently find that care work entails high physical and mental demands, that care workers often experience violence at work, and that they have a high rate of sick-related absence and work-related accidents.⁶³ In a review of eldercare literature on care workers’ experiences, Trydegård (2005) concludes that care workers experience their work as varied and meaningful, but also as entailing high physical and social demands.⁶⁴ These negative aspects also emerge in later studies, also showing that care workers perceive their work to be emotionally loaded and conflict-ridden and that they feel unappreciated and unacknowledged for their efforts, not least because of challenging relationships to relatives.⁶⁵

The negative effects of NPM and consumerism experienced by care workers is a dominant theme amongst researchers such as Dahl (2009, 2012), Vabø (2006) and Rostgaard (2006, 2012). Their studies elucidate how care workers experience the introduction of NPM and consumerism and the related management tools, such as freedom of choice, flexible homecare, quality standards, competitive tendering, voucher arrangements and purchaser-provider splits,

61 For a review of Nordic eldercare research focusing on the care worker see Trydegård 2005.

62 Ervik 2019; Häggström & Bruhn 2009; Häggström & Kihlgren 2007: 693, 695; Kröger 2011; Ramvi & Davies 2010: 445-446; Ramvi & Ueland 2019; Szebehely 2005: 17; Trydegård 2005: 145, 155.

63 Häggström & Bruhn 2009; Häggström & Kihlgren 2007; Kröger 2011; Ramvi & Davies 2010; Szebehely2005: 17;

Trydegaard 2005; 2012.

64 Trydegård 2005.

65 Häggström & Kihlgren 2007: 694; Ramvi & Ueland 2019: 5-6.

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as fundamentally changing the nature of public eldercare and adversely impacting their work and relationship to care users.⁶⁶ The literature carries the main conclusion that NPM has fundamentally changed the relationship between care user and care worker, forcing care workers to focus on schedules and registration rather than on face-to-face interaction with the care user, shortening the time available for interaction and shifting attention away from the individual needs of the care user and onto only the needs that can be formalized, standardized and measured. All of this impedes the formation of a trusting and ongoing relationship between the care worker and care user, considered essential to the act of caregiving.⁶⁷ These changes are moreover shown to cause feelings of guilt and frustration amongst care workers, which become manifested in physical reactions such as stress, headaches and exhaustion.⁶⁸

Thus, as this literature brings to light, the content and relations of care work change with changes in eldercare policy, as such changes are brought about with the introduction of NPM and its related management tools. In addition to these insights, the literature offers relevant findings specifically concerned with changes in the role of the care worker. Apart from Dahl’s (2000) influential historical discourse analyses of the homecare profession and developments in the ideal of professionalism, there is also another branch of studies concerned with the ways in which NPM, consumerism and marketization affect the role of care workers and their relationship to care users.⁶⁹ This includes a range of studies by Højlund, la Cour and Knudsen, who use Luhmann’s systems theory to display the role of the care worker as contingent and hybrid, changing with the many NPM tools.⁷⁰ For example, Højlund and la Cour (2001) show how care workers are met with different expectations depending on the NPM tool at hand, their being expected both to follow standards and written agreements and to stray from these and adhere to the premises of the individual care interaction, a situation that causes what Højlund and la Cour term ‘role stress’.⁷¹ Overall, these studies conclude that the care worker role is not a single role but a hybrid of co-existing and sometimes conflicting expectations, and that the care worker role and care user role are co-constructed – or, put differently, they have

66 Dahl 2009; Dahl et al. 2015; Ericson-Lidman et al. 2015: 162; Häggström & Kihlgren 2007; Kröger 2011; Rostgaard 2006:

457; 2012; Szebehely 2005: 17; Trydegård 2005, 2012; Vabø 2005: 79-80, 97, 100, 103; 2006.

67 Bergschöld 2018; Dahl 2000; Dahl et al. 2015; Ericson-Lidman et al. 2015: 162; Häggström & Kihlgren 2007; Højlund 2001; 2005: 117-118,122; 2009; 2012; Højlund & Knudsen 2008: 263-264, 269; Højlund & la Cour 2001, 2014; Kröger 2011; la Cour 2003; la Cour & Højlund 2001; 2019; Lewinter 2003; Rostgaard 2002, 2006, 2011, 2012, 2015; Szebehely 2005: 16, 17, 18, 21; Trydegård 2005, 2012; Vabø 2005, 2006, 2009, 2012.

68 For reviews of Nordic studies of care workers’ work-related health issues see Trydegård 2005 and Vabø 2005.

69 Blaakilde & Swane 1998, Dahl 2000; Højlund 2012; Højlund & Knudsen 2008: 263-264, 269, la Cour & Højlund 2001;

2014; Thorsen 2003; Vabø 2003, 2005, 2006.

70 Højlund 2012; 2014; Højlund and Knudsen 2008: 263-264, 269; la Cour og Højlund 2001.

71 Højlund & la Cour 2001; la Cour & Højlund 2001.

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constitutive effects on each other such that changes in one are also observable as changes in the other.⁷² What this literature highlights is thus how the roles of care are hybrid, contingent roles in the sense that the roles change with changes in eldercare policy. Furthermore, as roles change, so does the relationship between the roles.

4.2 The Care User Role

The care user is also the subject of significant attention in eldercare research. There are three branches of this research: a descriptive branch concerned with quantitative aspects of care users, such as their age and the types and levels of services they receive; a branch of qualitative studies concerning how care users perceive the care they receive; and a branch of critical research focusing on how care users experience recent reforms in eldercare.⁷³

What comes to light in the care user literature is that the care user role is also hybrid and changing, same as the care worker role.⁷⁴ This is shown both by interpretative and constructivist analyses examining the expectations and demands that care users encounter and how these inform their care user identities,⁷⁵ and by systems-theoretical analyses examining how various reforms and tools hold specific expectations for the care user as a general addressee in eldercare communication.⁷⁶ A predominant theme in this literature pertains to how from the 1980s and 1990s onwards consumerism, marketization and the NPM tools have constructed new roles for care users, expecting them to act as service consumers, empowered partners of dialogue and free-choosing, self-optimizing agents. ⁷⁷ For instance, Vabø (2006) argues that consumerism presents elderly citizens like kings taking over the command from rigid bureaucrats and career-driven professionals, but also argues that this image of elderly citizens bears little resemblance to the frail, confused elderly citizens in contact with the homecare system.⁷⁸ Likewise, Rostgaard (2005, 2006, 2011) shows how NPM technologies in the Danish eldercare of the 1990s and 2000s have cast care users in new roles where they are expected to leave their role

72 Højlund 2012; 2014, Højlund & Knudsen 2008: 263-264, 269; la Cour & Højlund 2001; Lewinter 2003; Rostgaard 2006;

Vabø 2006.

73 For a review of Scandinavian studies of the care user see Højlund 2005. See also Rasmussen et. al. 2015

74 Højlund 2006; 2009; 2012; 2014; Højlund & Knudsen 2008: 263-264, 269; Højlund & la Cour 2014; Rostgaard 2006, 2011; Vabø 2006.

75 For a review of this tradition in Nordic studies from 1995-2004 see Højlund 2005: 123-126. See also Vabø 2006

76 Højlund 2004; 2006; 2009; 2012; 2014; Højlund & Knudsen 2008: 263-264, 269; Højlund & la Cour 2001, 2014;

Rostgaard 2006; Wamstad 2016.

77 Dahl 2000; Højlund 2005, 2006, 2009, 2012, 2014; Højlund & Knudsen 2008: 263-264, 269; Højlund & la Cour 2001, 2014; Rostgaard 2006; 2011; 2015; Vabø 2006; Vamstad 2016.

78 Vabø 2006. For similar conclusions see also Wamsted 2016.

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as welfare client and re-materialize as active welfare consumers, autonomous users, critical free-choosing consumers, experts on their own needs and quality and self-responsible welfare agents.⁷⁹ These scholars draw the relevant conclusion that the care user role contains multiple co-existing and sometimes conflicting expectations for the care user.⁸⁰ As such, Højlund describes the role as ‘a hybrid’, demonstrating the care user role as at once a unifying role as a service consumer and a series of simultaneous roles depending on the management tools through which the care user is observed.⁸¹ For example, he demonstrates how when elderly citizens are observed through assessment tools, their role is ‘more or less to remain passive, to be observed and to be decided upon’.⁸² When observed through the tool of freedom of choice, they are expected to act as active decision-makers, albeit in a rather restricted way. Finally, when observed through the tool of preventive home visits, they are expected to act as empowered dialogue partners.⁸³ Højlund further shows how old care user roles exist even as new care user roles emerge, which is how the elderly citizen also continues to be expected at times to act as a passive receiver of care instead of as a service consumer.⁸⁴ He concludes that the care user is expected to switch between different roles, and must thus show themselves capable of role pluralism.⁸⁵

All in all, the literature on the role of the care worker and care user provides a relevant backdrop to the thesis, serving to qualify both my research interest and the historical systems-theoretical approach I have chosen. Notably, the literature highlights how the two roles are non-stable ones that change when the imperative of NPM and its many tools are introduced in eldercare; how the roles are hybrid roles containing many co-existing role expectations; and how the roles are contingent in the sense that changes in the one are established with changes in the other and with changing relationships between the two. As such, also this literature spurred me to take a longitudinal historical approach to the role of the relative as a similarly non-stable, hybrid and contingent role that changes with changing functions and relationships of public eldercare. The complexity of the two roles elucidated in the systems-theoretical studies referred to above has further spurred my systems-theoretical approach to my own study of the role of the relative, as

79 Rostgaard 2006: 455-456, 458-459; Rostgaard 2011, 2015.

80 Højlund & Knudsen 2008: 263-264, 269; Højlund 2004: 190, 193-196; 2005: 124-125; 2006; 2009; Højlund 2012: 101;

2014, Højlund & la Cour 2001; Rostgaard 2006; Vabø 2006.

81 Højlund 2005: 124-125; 2009; 2012: 101, 2014.

82 Højlund 2012: 95.

83 Højlund 2006; Højlund 2012: 95-101.

84 Højlund 2005; 2006.

85 Højlund 2004; 2005; 2006; 2009; 2012; Højlund & la Cour 2001.

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the systems theory has already proven to be a productive approach demonstrating a sensitivity to change, uncertainty and complexity. With the other two roles in care already an established theme of eldercare research, providing a study of the relative’s role becomes a relevant contribution to the literature. However, besides offering such a third and thus far missing piece of the picture, my contribution to this literature will also be that of a modest call for further research. With my final analysis of the years from 2010–2020, I demonstrate how the changes in the eldercare policy of this period contain changes in the role of the relative that are sufficiently significant to warrant further research on the role of the care worker and care user in current eldercare policy.