Liminal and invisible long-term care labour: Precarity in the face of austerity

Exploring feminist political economy and feminist critical discourse analysis as methodologies in critical nursing research

AIMS

This paper explores two critical feminist methodologies for nursing research: feminist political economy and feminist critical discourse analysis. The aim was to appreciate varied methodological approaches available for nurses to understand complexities in healthcare environments, above and beyond socially normative ways of knowing.

DESIGN

Discursive paper.

DATA SOURCES

Published articles from nursing databases (CINAHL and ProQuest; no date restrictions) and interdisciplinary databases (Women's Studies International, Sociological Abstracts and Ovid MEDLINE; publication dates between 2017 and 2022).

METHODS

A discursive paper exploring and critically synthesizing the literature on feminist political economy and feminist critical discourse analysis to demonstrate how each methodological approach can be used in nursing.

RESULTS

The findings of this discursive paper suggest there is an opportunity to draw on interdisciplinary studies for creative insights into how these methodologies may be helpful for nurses' scholarship and programmes of research. Although few nursing studies explicitly name a feminist political economy or feminist critical discourse analysis approach, several studies apply principles of these methodological approaches.

CONCLUSION

There is an opportunity for these methodologies to be applied within the same project when there is a fit between the research questions and aims of both methodologies (studies where notions of gender and power are considered central and there are potential insights from exploring social progress, structures and the material, along with the social relations of discourses).

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Feminist political economy and feminist critical discourse analysis offer novel options for methodological analyses.

IMPACT

Application of these methodologies may benefit critical nursing scholars looking for diverse critical methodological avenues to explore and to broaden nursing's methodological toolbox towards meeting social justice aims.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

More than a visitor? Rethinking metaphors for family care in long-term care homes

Recent public and policy interventions aim to recognise formally the contributions of family care-givers to long-term residential care in Canada, with some arguing family carers are more than visitors and should be recognised as essential care-givers. These developments call for reconsidering how family care roles are understood and operationalised. Drawing on ethnographic research conducted in three care homes in Ontario, Canada, we present an in-depth feminist rhetorical analysis of the narrated lives and work practices of 12 unpaid family carers. Specifically, we explore how unpaid family carers themselves draw on broader discursive ‘ruling metaphors’ to interpret their roles and activities (e.g. as essential care-givers, visitors, team members), and how these metaphors invoke, organise and/or give rise to particular practices, responsibilities and relations. We contrast the stories of a family member who positioned herself as an essential care-giver and expressed a more onerous sense of individual responsibility with the stories of people who enjoyed the pleasures of visiting, who contributed as team members in ways that went beyond caring for their own relatives' care needs, and who embraced the possibilities that came with volunteering and with being able to influence change. Our analysis situates and contextualises participants' stories of their involvement and unpaid work in relation to their everyday material conditions and circumstances. We elaborate how different ways of understanding caring roles shape the nature of carers' unpaid work, as well as their options to share responsibility or set limits on that work. We also raise questions about the organisational conditions needed to help enact care as a shared collective responsibility.

The Moderation Role of Neuroticism for Anxiety among Burdened Dementia Caregivers: A Study on Care Giver-Recipient Dyads

Caregiving burden proves to be a risk factor of anxiety disorders and anxiety affection. The current study investigates how an endogenous personality dimension - neuroticism - moderates the association between caregiving burden and anxiety affection. Between 2015 and 2017, the study deployed a cross-sectional survey of 674 (response rate = 89%) older adults who were hospitalized for dementia at two hospitals. From all primary caregivers of these patients, 661 agreed to participate in the survey which yielded 661 matched dyads as the final sample. Caregiving burden, neuroticism, and anxiety affection were each measured by established assessment instruments. We employed multivariate OLS regression to test the moderator and regressor effects. We found that care burden is a significant risk factor of higher levels of anxiety affection (β = .17, p < .001), and accounts for 4.6% of the variance in anxiety. Neurotic personality is also significantly associated with a greater level of anxiety (β = .26, p < .001). Neurotic personality moderates the association between anxiety and care burden (β = .24, p < .001). Our findings suggest that social and healthcare workers should assess caregiver personality and burden as well as provide support, resources, and coping strategies to those with neurotic personality traits or high care burden in an effort to reduce anxiety among caregivers.

From volunteer work to informal care by stealth: a ‘new voluntarism’ in social democratic health and welfare services for older adults

In the context of current and expected demographic changes, the issues of which services the welfare state should offer and, ultimately, the very function of the welfare state are currently debated in Norway. The political discourse on health and care services for older adults has morphed into an accepted reality in which the system must be altered, prompting policy makers and stakeholders to find new and novel solutions to problems associated with population ageing. In this paper, we discuss one such proposed solution: the transformation of health and care services for the older adult population through the increased involvement of volunteers. We ask how volunteer efforts are articulated and delineated through official accounts and discuss the implications of such an articulation and delineation. We seek answers to these questions through a critical discourse analysis of recent governmental white papers. We investigate, in other words, volunteer efforts as a political instrument. We argue that the official representation of how efforts in health and care services should be re-aligned take the form of a distinct discourse of ‘voluntarism’. Within this ‘voluntarism’, volunteer efforts have been altered from a third sector comprising charity and non-profit organisations that contribute within or as a supplement to the largely public-run welfare system to a limitless and extensive concept that is blurring the boundaries to informal care.

Care precarity among older British migrants in Spain

Northern European international retirement migrants are often viewed as affluent and use migration as a route to a better quality of life. However, as these migrants transition into the ‘fourth age’, the onset of age-related illnesses, frailty and care needs can lead to increased levels of risk and insecurity. Through 34 qualitative interviews with older British migrants in Spain, the paper explores how these migrants access and experience care as they age. It draws on a lens of precarity that allows an understanding not only of individual care needs, but of the political, economic and social context in which they are situated, including social protections and public safety nets. The findings suggest that distant family relationships and limited access to formal social protection can both create and exacerbate precarity. These older migrants therefore develop different strategies to access care that include drawing on informal relationships and voluntary organisations within the British community in Spain. The paper contributes to understanding how international retirement migrants manage their care needs, and theoretically extends our understanding of how the intersection of old age, migration and care can create new forms of precarity.

Long-Term Care Facility Workers' Perceptions of the Impact of Subcontracting on their Conditions of Work and the Quality of Care: A Qualitative Study in British Columbia

Subcontracting long-term care (LTC), whereby facilities contracted with third party agencies to provide care to residents, became widespread in British Columbia after 2002. This qualitative study aimed to understand the impact of subcontracting from the perspective of care workers. We interviewed 11 care workers employed in subcontracted facilities to explore their perceptions of caring and working under these conditions. Our overarching finding was one of loss. Care workers lost wages, benefits, security, and voice. Their working conditions worsened, with workload and turnover increasing, resulting in a loss of experienced staff and a loss of time to provide care. These findings call into question the promises of quality and flexibility that legitimated policies permitting subcontracting, while adding to the mounting evidence that subcontracting LTC harms both workers and residents.

Liminal space and the negotiation of care work in extra-care housing

This is a qualitative case study of care work in a liminal space, specifically the case of an extra-care housing residence, which is an innovative housing alternative for elderly people in need of care in Sweden. The study is an exploration of social care workers' perceptions about their workplaces and their understandings of themselves, which are shaped by their embeddedness in architectural space. The extra-care housing residence appeared as a liminal space in which two dominant spaces - home care services and residential care - underpinned the staff's perceptions of an unclear workplace and their identity work.

Maintaining the ‘caring self’ and working relationships: a critically informed analysis of meaning-construction among paid companions in long-term residential care

In Canadian residential long-term care, paid companion services are increasingly viewed as helping to meet older adults’ psycho-social needs. Complementing the critique of these services from a political economy perspective, analyses of companions’ talk about their work can illuminate not only why companions stay in devalued and often invisible work, but also how social assumptions and circulating narratives about nursing homes and older adults are implicated in this process. In this article, we draw on in-depth analyses of interviews with both companions and organisational representatives. We interpret companions’ accounts in relation to their need to justify the necessity for their work to their employers (families), to nurture good relationships with the facilities in which they work, and to maintain a sense of identity as a responsible, conscientious and ‘caring self’. In this way, these precarious workers inadvertently reproduce dominant narratives, including those that stigmatise dementia and residential care, and facilitate the privatisation of person-centred, relational care. Organisational representatives generally reproduce similar assumptions about care responsibilities, in a context in which facilities are increasingly challenged to meet a range of resident needs. Discussion highlights tensions around responsibility for psycho-social care in nursing homes, highlighting organisational vested interests in avoiding risk and downloading responsibilities to families and to private, independent and temporary workers.

Experiences of moral distress by privately hired companions in Ontario's long-term care facilities

Purpose

To explore long-term residential care provided by people other than the facilities' employees. Privately hired paid "companions" are effectively invisible in health services research and policy. This research was designed to address this significant gap. There is growing recognition that nursing staff in long-term care (LTC) residential facilities experience moral distress - a phenomenon in which one knows the ethically right action to take, but is systemically constrained from taking it. To date, there has been no discussion of the distressing experiences of companions in LTC facilities. This paper explores companions' moral distress.

Design

Data was collected using weeklong rapid ethnographies in seven LTC facilities in Southern Ontario, Canada. A feminist political economy analytic framework was used in the research design and in the analysis of findings.

Findings

Despite the differences in their work tasks and employment conditions, structural barriers can cause moral distress for companions. This mirrors the impacts experienced by nurses that are highlighted in the literature. Though companions are hired in order to fill care gaps in the LTC system, they too struggle with the current system's limitations. The hiring of private companions is not a sustainable or equitable solution to under-staffing and under-funding in Canada's LTC facilities.

Value

Recognizing moral distress and the impact that it has on those providing LTC is critical in terms of supporting and protecting vulnerable and precarious care workers and ensuring high quality care for Canadians in LTC.