Abstract
The Scandinavian countries, with care organized by their governments to provide all older people with access to the basic care and support they need, have long served as a model for others searching for ways to ensure quality and equity for both workers and those with care needs. Unfortunately, as this book makes clear, recent reforms in Scandinavia have used other countries as models for introducing markets in care provision and New Public Management (NPM) as a way to deliver services. Although the authors identify mixed consequences both among countries and between care at home and in nursing residences, they document the attempt ‘to replace care, as reciprocal human relationships, with the managed provision of functional tasks’ and the decentralization of responsibility that leaves units often ‘unable to carry out this responsibility’ (p. 233). ‘The purchaser-provider model has split up the unity of care work that was previously characteristic into an assessment of what should be done and the actual doing of care” while the devolving of responsibility has resulted in more red tape (p. 43).
There is a great deal to learn from this integrated and sophisticated collection. Unlike much of the North American research on long-term care, the multiple contributions are informed by theory that is clearly explained without simplifying their complexity. This theory, drawing heavily on Foucault and interactionist approaches but also building on a range of more structuralist and political economy perspectives, is disciplined by the primary data produced by the various authors in ways that support the goal of creating ‘a more nuanced image of how NPM is interpreted in the Scandinavian countries’ (p. 14). With the focus on the meaning of work and work identity in both home care and residential care, the studies of home helpers, managers and the teams involved in dementia care draw out the dilemmas and contradictions of work in care under NPM. For example, Bettina Dybbroe’s chapter explores how from a manager’s perspective ‘the troubling, but inherent part of the work, that is the experiences involved with working with human beings, is often seen as impediments to professional knowledge based practice instead of a source for meaningful practices for professionals as well as for their institutions’ (p. 153). She goes on to explain that what ‘the care staff saw as quality in work included quality for patients, which demands quality in working conditions for staff’, but management was content with different criteria for success under their NPM approach (p. 155).
A central theme is professionalization, understood primarily as more formal preparation for the growing complexity of elder care and, in Norway at least, as a project of unions (p. 34) as well as a way to recruit more workers. According to Bente Rasmussen, ‘one of the aims of NPM is the professionalization of management, i.e. changing managerial identity in public services from an identity based on ethical values of the profession and loyalty to the services provided to a general managerial identity’ (p. 165). The result is often conflict for the nurse managers struggling with their contradictory loyalties and the tension between promises of empowerment and centralized controls, especially through budgets. In their chapter, Hanne Marlene Dahl and Bente Rasmussen explain that NPM emphasizes standardization and believes quality is achieved ‘by codifying care tasks’ (p. 39). They argue that, while the codification of both professionalization and care tasks seem similar, these similarities ‘obscure that underlying them are different and contradictory understandings of what the work of home care is’ (p. 42). In his chapter, Andreas Fejes argues that in professionalization care dispositions ‘might be acknowledged, but are described as needing to be further developed by science-based knowledge’ (p. 100). Under NPM, caring dispositions become part of the professional repertoire, albeit still a less valuable part. In her later chapter, Kamp emphasizes how professionalization is providing some basis for negotiation of work and meaning. However, home helpers see both competencies and discretion as critical to care, an understanding that conflicts with NPM rationalization and standardization approach.
The editors also emphasize the importance of context, not only in terms of differences among countries but also within them. The importance of context is particularly evident in the chapter on managers. Rasmussen maintains that both the closed boundaries of residential facilities and the adequate financing of these nursing homes means that the managers ‘described a work situation that allowed time for relaxing and meaningful activities, like discussing their work with the nursing home employees and organizing social activities for patients’ (p. 175). This contrasts sharply with the situation of managers in home care, where the boundaries are not set and finances are tight. Managers felt caught between protecting their staff, as well as the quality of care they could provide, and their contractual obligations to management. However, managers in both settings found their role changed ‘from professional working side by side with their subordinates to the role of general manager’ working apart from nursing care (p. 176).
The concluding chapter convincingly summarizes problems with NPM, acknowledging that care ‘has to be pursued in spite of the system’ (p. 235), while arguing that we cannot return to the past and offering hope for the future. Yet the hope seen in greater integration among hospitals, nursing homes and home care that can lead to ‘far more varied duties’ for those working outside hospitals (p. 237) seems to be countered by the emphasis in many chapters on how this shift in the location of care leads to heavier workloads and less time to care. Similarly, the gradual professionalism that has the promise of both higher quality and more interesting work appears countered by the Pernile Bottrup and Per Bruhn chapter’s warning that professional knowledge without resources ‘may lead to strain from the internalization of unachievable professional goals and quality standards, as well as stress and burnout’ (p. 225). And the move ‘to improve the quality of front line leadership’ does not fit well with the chapter on managers that documents how ‘the responsibility for care within the budget was therefore effective in disciplining the local managers’ (p. 185).
The critiques of those emphasizing the Taylorist tendencies in NPM are reminiscent of those aimed at Braverman; not enough attention paid to contradictory developments and to resistance. But some of the strategies care workers use, such as reducing time on some tasks and spending more on others or doing extra work (41), do not seem to fundamentally challenge the system and a number of chapters seem to provide further support for just such Taylorist tendencies. The authors do, however, make a convincing case for developing a dynamic understanding of the interrelationship between ‘the social and the subjective’ (p. 158), for recognizing the collective development of meaning in work and for an emphasis on context as well as change. And not incidentally, the authors offer a way into many research studies in Scandinavia that are inaccessible to those of us who do not read a Scandinavian language.