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

Abstract

Using feminist political economy, this article argues that companions hired privately by families to care for residents in publicly funded long-term care facilities (nursing homes) are a liminal and invisible labour force. A care gap, created by public sector austerity, has resulted in insufficient staff to meet residents’ health and social care needs. Families pay to fill this care gap in public funding with companion care, which limits demands on the state to collectively bear the costs of care for older adults. We assess companions’ work in light of Vosko’s (2015) and Rodgers and Rodgers’ (1989) dimensions for precariousness. We discuss how to classify paid care work that overlaps with paid formal and unpaid informal care. Our findings illuminate how companions’ labour is simultaneously autonomous and precarious; it fills a care gap and creates one, and can be relational compared with staffs’ task-oriented work.

Keywords

Austerity care work gender liminality long-term care nursing homes precarious work

Introduction

In 2003 there was a Severe Acute Respiratory Syndrome (SARS) outbreak in Toronto so serious that it made international headlines. During the outbreak, all hospitals and long-term care (LTC) facilities enacted quarantine measures and visitors were restricted entry. Privately paid ‘companions’ hired directly by families and estates to provide one-on-one care were not permitted on site because they were classified as visitors, not staff, even though the facility was their work site. Before the crisis, LTC management had not paid attention to how many companions worked directly for residents; however, companions became highly visible during the quarantine. At one facility companions were lined up outside the large atrium windows unable to get in, while the residents were seated in wheelchairs inside the atrium unable to get out. It was particularly remarkable because the size of the companion workforce rivalled the paid staff complement. According to a physician who worked at the LTC facility during the quarantine, nearly half of its ‘workforce’ had disappeared. At the time, this facility was atypical amongst peer organizations for its heavy reliance on companion labour as well as for the public way in which this shadow workforce was revealed. SARS pushed facility management to ‘see’ this otherwise invisible workforce. Management subsequently enacted policies, training, and quasi-staff-like requirements and hired a companion coordinator; yet despite these changes, the facility held no liability for companions’ working conditions such as hours, rates of pay, and holiday time or their rights to workers’ compensation in the case of illness or injury. Companions remained privately paid employees doing much of the same work as the care aides employed in this publicly funded and unionized facility, but without the same protections or benefits.

With the passage of time, little has changed at that facility. Most of the 120+ residents are cared for by a companion for at least a few hours per day, and some residents have 24-hour companion care to augment or replace the facility’s publicly funded care. However, much has changed at other facilities across the city because the ubiquity of companion care has increased. The rise of this form of care has occurred in the context of under-staffing, the key challenge in Ontario’s LTC sector as identified by a wide variety of stakeholders (Banerjee et al., 2012; Daly and Szebehely, 2012). Some families with financial means have chosen to employ companions to overlap with facility care as one strategy to address the care gap resulting from the under-staffing of publicly funded care.

LTC facilities function simultaneously as publicly funded health care sites and private households. LTC provides a useful example of this type of duality. Work is performed in people’s ‘homes’, which are formal workplaces and places where families and volunteers perform informal care work. In this article we use the example of companion care provided in LTC to highlight in-between, liminal and invisible labour because their labour is juxtaposed between the public, market and household spheres, is privately paid care provided in publicly funded settings, and is care provided mostly in private behind closed bedroom doors in quasi-domestic conditions (e.g. informal payment, lack of benefits).

To extend the analysis in ways that are meaningful for industrial relations and for care work scholarship, this article aims to explore care work within and between public and private spaces. Following the literature review and the method and methodology section describing the studies, we present findings about the content and conditions of companions’ care work. We draw on a regional and an international study to address the following questions: Who are companions and why do families employ them? What work is performed by companions? In what ways is companions’ work precarious or liminal? What are the risks of companion care? We assess companions’ work in light of Vosko’s (2015) and Rodgers and Rodgers' (1989) dimensions for precariousness. We discuss how the setting (e.g. in private homes, in LTC, in short-term hospital) and the funding (e.g. public or private) contexts affect the work. We also discuss how we should classify care work that is paid but overlaps with formal and informal care. Our findings illuminate how companions’ labour is simultaneously autonomous and precarious, lucrative and under-paid, liminal, invisible and permanently transitional.

The concept of precarious employment is widely used, though its meaning and measurement are heavily debated (Kachi et al., 2010). Thus, precarity has been called ‘shadowy and contested’ (Vosko et al., 2009: 1). Vosko (2011: 194) notes that it is ‘work for remuneration characterized by uncertainty, low income, and limited social benefits and statutory entitlements’. Despite on-going debate, Vosko (2015) notes that the term can refer to a host of employment security deficiencies, and it is increasingly understood as labour market insecurity that extends beyond older debates about a precarious–secure jobs dichotomy to include multiple forms of labour market insecurity that can define any job (Vosko, 2015). Precarious employment is defined by gender, nationality, race, ethnicity, (im)migrant status, (dis)ability and age inequalities (Bakan and Stasiulis, 1997; Vosko et al., 2009; Zeytinoglu and Muteshi, 2000). As Cranford and colleagues note, ‘… the growth of precarious employment is gendered and racialized’ (2003: 6). Building on Rodgers and Rodgers’ (1989) work, Vosko (2015) argues that four key dimensions are central to measuring precarity. ‘Degree of certainty’ captures the impacts of short-term contracts, short-term employment relationships, and risk of termination. ‘Regulatory protection’ considers whether workers are protected by labour standards, statutory and social employment benefits, and whether regulations are enforceable. ‘Control over the labour process’ reflects the work organization and its execution. Finally, ‘income level’ measures the total direct and indirect income that workers receive, including their wages and payment as well as government transfers and government- and employer-sponsored benefits. Measurement of precarious labour requires documenting and contextualizing labour force conditions, including part-time, temporary and agency work. The ways in which precarious work is experienced in different sectors requires on-going scholarly attention.

Feminist care work scholars refer to reproductive care work performed mostly by women in private households as ‘invisible’ (e.g. Armstrong et al., 2002; Fox, 2009; Luxton, 1997). Invisible work may become visible in LTC because it juxtaposes the public and private realms. The liminality construct presents interesting conceptual room to examine invisible work, private work performed in public work spaces, and publicly funded work performed in private work spaces. For instance, Zadoroznyj (2009) examines the position of publicly funded ‘mothercarers’ going into private homes to provide care, while Daly et al. (2015) examine privately funded companions going into publicly funded facilities to provide care to residents. Zadoroznyj refers to these workers as ‘strangers’ who are welcomed by some new mothers for the anonymity they afford when providing intimate care such as laundry after the birth of a baby, and unwelcome by others for not being as familiar as family in these intimate family spaces. Daly et al. (2015: 260) focus on how companions occupy a place that is within the ‘blurry lines between formal and informal, paid and unpaid care work’ in LTC.

Over a hundred years ago, liminality was used by ethnographer Van Gennep (1909) to discuss ancient cultures’ transitional periods or rites of passage. Turner (1969) re-cast its usage to involve any period of change, but especially those involving rites of passage. Contemporaneous scholars have drawn on Turner’s concepts to refer to spatial and temporal transitions. For instance, Shortt (2015) uses liminality to show how hairdressers use ‘transitional’ work spaces such as lifts, doorways, stairwells, toilets and cupboards because these spaces have been neglected in the literature. A small number of cross-disciplinary scholars have re-introduced liminality to refer to subjects who are in spaces that are between two worlds, whether through choice, circumstances or a combination of the two (Daly et al., 2015; Giladi, 2010; Sweeney, 2009; Zadoroznyj, 2009). Sweeney (2009: 570), in referring to student tree planters, notes that ‘[l]iminality denotes a time/space where subjects are “betwixt and between”, neither “in” nor “out” and separated from familiar space, routine, temporal order or hegemonic social structures’. Indeed, as Daly et al. (2015) argue, liminal work as a construct can link formal and informal, paid and unpaid care work. In a similar way, Baines (2006) notes how paid care workers in the social services sector often perform unpaid work – in an ‘endlessly stretchable’ way – to meet an under-funded organization’s needs. Deserving of more attention are the blended and messy ways in which care work is at once formal and informal, paid and unpaid.

Method and methodology

We report findings from a regional and an international study using rapid team-based ethnographic methods (Baines and Cunningham, 2011). The regional study was conducted in seven residential non-profit LTC facilities in Toronto, Canada (2013–2015). We conducted ‘most similar’ case studies of informal and formal care involving week-long observations by eight team members in ‘secure units’ and public spaces (Yin, 2014). We conducted 203 key informant interviews with staff (including managers, nurses, personal support workers, housekeepers and dietary aides), family, volunteers, students and paid companions. Work observations occurred (7 a.m. to 11 p.m.) on LTC units; field notes captured sights, smells, sounds and events. Interviews were verbatim transcribed. Field notes and interviews were coded with what Boyatzis (1998: 184) describes as thematically ‘encoding qualitative information’ and feminist political economy theory (Armstrong et al., 2001; Mutari, 2000) with a focus on the intersections between paid and unpaid work, the work’s gendered assumptions, and the experiences of providing and paying for care. We generated a broad theme list after the interviews were completed, based on the literature and our field observations, and added themes that surfaced in the data.

For the international study, we conducted case studies of promising practices and healthy active ageing in 21 LTC facilities between 2013 and 2015 in Canada (Ontario, B.C., Nova Scotia and Manitoba), the United States (Texas), Germany (North Rhine-Westphalia), Norway, Sweden and the United Kingdom. We conducted rapid team ethnographies in the ‘full’ sites over four days, involving 12 to 14 researchers working in two teams of two on a secure and open unit from 7 a.m. until midnight or later, and one-day ‘flash’ ethnographies in the comparator site involving 14 researchers. Facilities were owned by public and private non-profit and for-profit organizations. We conducted 530 key informant interviews with managers, staff, residents, families, volunteers, paid companions and unions. For analysis, the site visit team discussed key themes over two separate days for each jurisdiction, reflecting on the content of interviews and observations. Annual presentations were made to the larger group of researchers to highlight emerging themes and discuss ideas. Presentations and discussions were informed by feminist political economy as well as by the inter-disciplinary perspectives of the team of scholars (e.g. medicine, nursing, social work, health services research, sociology, history, cultural studies, etc.).

This study draws on team observations and discussions about companions’ roles and families’ experiences, the coded interviews and coded field note data from the regional site, and themes raised during the international team’s in-depth discussions of the multi-country site visits. This article focuses on the labour provided by paid companions.

Findings

In this section, we identify who works as a companion, why they are hired by families, the parameters of companions’ work, and how precarity and liminality constructs explain the work. We have used italics in the quotations for emphasis.

Who are companions and why do families employ them?

Paid companions were usually racialized immigrant women with little formal education, although some held advanced health credentials from their birth country. In particular communities, Caucasian women speaking the given cultural group’s language were employed. Some companions held training as care aides, but for various reasons were never employed in LTC. Many had immigrated to be in-home nannies for children or older adults. Most started companion work by chance, for instance by following a client from home into the facility, through networks or by responding to online advertisements. Some companions were hired through a formal agency, which screened for training and security risk and provided families continuity of service.

Families hired companions as a supplement and even a replacement for publicly funded care work because they perceived that public care was insufficient in terms of quantity or deficient in terms of quality. We found the lowest numbers of staff in North American sites, where it was not unusual to find from a 1:8 to 1:12 ratio of care aides to residents on the morning shift. The staffing levels tended to be more robust in Germany and highest in the Nordic countries, with double to triple the numbers of staff, respectively. The ratio of staff to residents dropped precipitously on night shifts, and it was not unusual to have one care aide for around 30 residents in North America. We observed the highest numbers of paid companions in wealthy facilities in large North American cities, though there were at least some companions working in all of the North American sites, only a handful in the Nordic sites and none in the German sites. We found other forms of precarious labour in North America and Germany.

Families hired companions to perform relational one-to-one care that is more challenging in the context of under-staffing. For instance, companions took residents outside, to events or common areas, or visited other floors in the home. Depending on the facility and on the family, companions performed some combination of body work, including cleaning, dining and toileting care that overlapped with the staff’s work. Companions frequently supplemented or even replaced familial emotional and social care. Companions’ labour was most often contracted directly by families – often paid ‘under the table’ and without common labour force standards and protections – to provide one-to-one care to residents. In short, they were paid to work privately in public workplaces where they were not employees of the facility.

What are the parameters of companions’ work?

Each jurisdiction differently divided care work between formal and informal care workers. In North America, the formal work of staff was performed by professionals who provided the most complex body care, such as wound management, medication dispersal and documentation, and by non-professionals who provided the majority of hands-on body work, including washing, toileting and feeding care and documentation of routine bodily functions such as voiding and consumption. In Europe, the care was more relational. There tended to be more overlap between professional and non-professional roles, and in some places non-professionals also engaged in cooking, cleaning and laundry.

Though not the focus of this article, it is important to note that unpaid and informal care work also filled the care gap in publicly funded care: family and friends performed social, emotional and dining care work; students who sought credentials and training shadowed the staff and performed overlapping roles; volunteers provided social and other care that staff lacked time for and staff worked overtime without pay to meet residents’ needs. Paid companions straddled the boundary between formal and informal care. Unlike informal providers, companions were paid. In North America, companions’ work almost completely overlapped with care aides’ role. One care aide explains:

I help her with everything. I help her with all the activities of daily living. On Tuesdays is her shower days so the staff will shower her and then depending on the staff some will help me to dry her and get her dressed but most times I do that. They just shower her and leave. I said to them it’s okay because I know they’re busy, right? So I do the rest. Dry her hair, brush her teeth. I do everything. Change her before dinner. Like in the mornings after we wash her I change her before dinner so she’s clean when the other person comes. I don’t have to change her before that if she doesn’t have a BM because she doesn’t wake up early so her diaper is still … sometimes it’s just damp. I take her out. We go out every day. In the winter time sometimes we’re the only ones out there. (Private companion)

In contrast, one Swedish companion’s work was limited to social care with no body work. In both the Nordic and North American jurisdictions, the work also overlapped with the social and emotional care provided by families and volunteers.

The definition of what constituted companions’ proper role was contested and fraught, particularly in North America. We frequently heard from both companions and staff about tensions. In particular, as care aides were frequently rushed off their feet, they looked down on companions’ more leisurely work pace and time for interaction with residents and other companions, particularly when companions took residents outside. In addition, companions frequently had time to sit and chat together while ‘being with’ their residents – many of whom were living with dementia, and remained silent and excluded from conversations sometimes conducted in non-English languages:

We [are] just sitting down talking and they [care aides] come ‘What a good life!’ What we supposed to do? Everybody in the wheelchair. You know what I mean? (Private companion)

The differences partly reflect more task-oriented North American care aide work compared with European relational care. North American care aides lacked time to sit down for coffee with residents, while European staff were encouraged to because they cared for fewer residents and the systems supported social care. While North American companions had time for social care, they also spent time socializing with each other. In many cases, sitting and ‘being with’ residents took up most of companions’ time. From care aides’ perspectives, if companions avoided helping staff they were seen as ‘just sitting there’. If they helped out, they were perceived as taking over the staffs’ work, potentially putting their own health and certainly that of the residents at risk, positioning companions in a liminal role.

In what ways is the labour of companions precarious and liminal?

In this section, we apply a precarious labour framework (Rodgers and Rodgers, 1989; Vosko, 2015) to analyse the content, organization and positioning of companions’ labour.

Degree of certainty

Companions experienced tremendous job flux because residents are typically quite ill, frail and enter with multiple disabilities and medical conditions. In some places, residents die shortly after arriving at the facility (around three months). In other places people stay as long as 10 years, though the average is three years. Averages capture the variability and uncertainty of residents’ stays. As a result, companions’ job security is highly unstable. However, other factors contribute to their labour insecurity. As one respondent noted, families frequently changed companions for reasons such as ‘fit’. When we asked how facilities managed turnover, one manager spoke for many when she reported the following:

The problem is it’s hard to manage them because private duties are changed like gum. Like today it’s someone, next week it’s someone else, the week after it’s another person. Some family members are so volatile that at the blink of an eye they’re gone. So it does get challenging in terms of some family members and their philosophy in terms of who they’re bringing in. You know, they may not even have the proper background but, you know, we’re not recruiting these people. (Manager)

What this manager’s point conceals is the flip side: that some companions cultivated job security by ensuring families’ insecurity. Indeed, some companions played a surveillance role by acting as the families’ eyes and ears and ensuring families thought staff did not or could not provide good enough care, or performed careless work. This positioning created serious tensions and sometimes toxic relations between companions and staff while it secured companions’ employment, but it did little to affect their liminal status in a workplace that was not formally their own. Companions also protected their positions by ensuring they chose their own replacements while on holidays or days off. Frequently, companions’ own family or friends would perform replacement labour to ensure another companion did not take the work.

While many companions described staying for an extended period with a particular resident, others left with little warning. We were told by a family that companions would leave without notice if better opportunities arose. Another spoke of quickly leaving a position because of how the family treated her:

A: ‘What’s wrong?’ I said ‘I don’t know. I thought he was talking to your sister.’ And then after that she called back again and then she said ‘I don’t know what’s going on but you should know because you’re the only one and my dad there. You know better.’ I said ‘I will phone you if there’s something wrong. Don’t worry. I’ll let you know if there’s something wrong with your dad. I’ll phone you right away.’ I was so upset. She was still saying I do something to her dad. … Maybe this is my last week. I will not come back anymore. I am not happy working here. Maybe somebody is better.

I: You didn’t like the way that she talked to you.

A: I didn’t like it. No, because for me I’m doing my job properly and if you don’t trust me I don’t belong here. I can go to somewhere else that can trust me better than staying here and have doubts. So I’m not happy with that. They paid good but I don’t need it. (Private companion)

In this way, families were insecure about being able to retain companions. Companions exerted considerable control and autonomy over their work, prized independence and invoked trust as a symbol of their power and autonomy.

Regulatory protections

In this otherwise highly regulated industry, there is regulatory lapse regarding companions’ roles and responsibilities. In addition, neither the same expectations vis-a-vis training nor the same workplace protections were afforded to companions. In particular, North American companions described family paying with envelopes of cash. Even those whose employers paid the statutory benefits – such as employment insurance and pension – often did not pay workers’ compensation benefits. The result was that sickness and workplace illness and injury were borne almost exclusively by companions.

Control over labour process and autonomy

Companions worked quite autonomously for families who were typically absent. Even if employed by agencies, companions only reported to off-site managers and typically were mandated to have little direct interaction with families. Facility management were not usually aware of which companions worked for whom, so companions avoided facility oversight as well. As companions frequently took residents away from the unit to common spaces or to the outdoors, or worked in the residents’ room behind closed doors, they were afforded even more autonomy. Furthermore, turnover made it challenging for the management and staff to keep track of companions. One manager, reflecting a widely held managerial perception, noted the difference between the facility’s policy and practice:

Our policy says that we want to know who is here but the reality is because people are changing night and day, um, that it’s the family’s onus to come and tell us. There is no auditing we can do to say ‘Hey, who is that?’ (Manager)

This lack of oversight resulted in companions’ universally prized autonomy. In conjunction with this autonomy, companions dealt with arbitrary facility rules and random instructions from the family. Despite the challenges, most companions talked about not wanting to trade their work for that of the staff care aides:

I: So do you think of [this place] as your workplace?

A: Uh, as a private, yes. If [this facility] offer me a job I wouldn’t take it.

I: You wouldn’t take it?

A: No. No. I wouldn’t take. I don’t like the way that they manage. As a private, yes.

I: You get more choice, more freedom.

A: Because let’s say I heard a long time ago they was hiring people two days and that I could apply. And I even knew the president at the time and I never asked him. No. No. (Companion)

Many companions wanted the autonomy to decide when and how to work. For instance, most cared for more than one resident per day and a few reported caring for overlapping residents. Companions followed this strategy to ensure that should their main resident die, they could still maintain access to the building and could thus easily recruit new clients. Many companions also reported that they would actively solicit new families by offering to fit in an hour here or there to keep their ‘foot in the door’.

We heard from facility managers about their challenges with companions. One spoke for many when she noted the following:

No one has come up with the perfect system yet to manage private duties simply because the families do what they want. It’s their own personnel and its very difficult for [facility] employers to keep an accurate head count or to ensure that the information we have is current. (Manager)

This manager described how, despite the challenges, the presence of companions was nonetheless helpful to facilities and staff:

So there’s all sorts of issues that come in with private duties but the reality is it does help [our facility] and some residents do benefit from having an extra person with them. (Manager)

A puzzling question was why unionized staff allowed companions to work in their workplaces. We heard from staff and managers that, in the presence of understaffing, they appreciated the extra set of hands. Despite their appreciation, they were also quick to seize on companions’ indiscretions. Using cell phones and speaking in a foreign language in front of residents was frequently cited by staff as a ‘problem’.

… one caregiver would just sit in the corner with that resident and not do anything and she’d be on her phone. Like, that’s a no. You have to interact with the resident. You have to talk or read to them or do one-to-one stuff. (Activity staff)

Consequently, while companions sometimes worked in ways that staff considered uncaring, because neither staff nor managers directed companions’ work, both seemed willing to accept the extra help though it came with strings or questionable approaches.

Income and security

Paid companions reported incomes from C$10 to $23 per hour. Companions often worked between 8 and 10 hours per day, some for six or seven days per week. Many earned more than the full-time facility staff. Companions usually were paid more when families hired directly and even more when family paid ‘straight’ or the proper employment benefits. They earned the least when employed as agency companions receiving minimum wage (between C$10 and $12 per hour), but were better covered in terms of job security and basic statutory protections such as workers’ compensation.

When asked about payment, one paid companion reported how one family followed employment standards right from the beginning, and even though many families wanted to be able to claim the costs of the care on their taxes, companions still had to ask to get the ‘proper’ benefits.

A: Even I started with her like two hours in a day, we started right straight.

I: Do some families want to do it under the table?

A: Um, no because they want to claim it for expenses. We understand that too. But sometimes we have to ask proper things because we need to live properly too. Otherwise you end up nothing too. It’s a good feeling to do it proper like … what you call it? … in old age time you have all those things too. (Private companion)

Interestingly, this companion’s experience was atypical. We frequently heard from companions that they were paid cash, without any benefits:

I: So how do you manage pay?

A: They send to me by mail. They transfer for me. Alternate way, cheques. Some of them, that lady that I take care of for my friend she work at the bank … She just pay me every single Friday in cash. She brings envelope with the cash. (Private companion)

Working for an agency provided additional job protection and security though lower pay; it also restricted companions’ autonomy by placing more rules and restrictions on companions:

We’re not supposed to accept gifts like Christmas, birthday or anything and we’re not allowed to give our cell phone numbers or any telephone numbers to the family. And whatever is happening to the client we have to call the office, not the family. (Agency companion)

Working for agencies was not a guarantee of sufficient hours:

… some of the [agency] caregivers they only have lesser hours, like four hours in a day or something. Yeah, and it’s not every day that they’re getting the four hours, right? So it’s really not enough. (Agency companion)

While agency companions had more workplace protections, they were also typically paid less, had somewhat less autonomy and flexibility, and were more typically precarious in terms of their relationship to their employer, even while they performed a liminal role within the facility. Whatever companions were paid, their labour was a significant cost for families. Many families could not afford these labour costs over the long term, and we heard about class issues separating those who purchased assistance from those who did not.

What are the risks of companion care?

Companions’ work posed some risks to residents, to themselves and to facilities. There were typically no facility rules about formal training requirements. Though families frequently hired trained care aides, they just as often hired people with little formal training. This lack of training created some conflicts between what families wanted, what facilities suggested and what the companions did:

… we have a couple of private duties that are employed by a family member to exercise their mom so they take her for walks and, you know, the director of care has concerns because the resident is really not functionally able to do what those private duties are trying to do so it becomes a concern for the resident’s wellbeing. So that’s the sort of thing that we would step in and say ‘No. We can’t allow this to happen.’ (Manager)

It is clear that companions provided an extra set of hands and they often had very free reign to aid their own residents, but the rules changed when ‘helping’ other residents. Not all companions were aware of unspoken rules, and they noted that they acted differently depending on which staff were on duty. One agency companion talked about the tricky space between caring for their own resident and ‘helping out’ with another resident. She noted, unlike many others, that she had to be wary of rules:

… it’s not teamwork here … sometimes it’s worked where there’s been somebody, a staff that’s alright with people helping and it works out good. But I don’t know legally where I stand if somebody … like I say, if I’m helping somebody and they fall. (Agency companion)

Agency companions tended to follow more rules, and talked of reporting and documenting requirements for the agency.

Facility managers expressed dismay over potential problems with companions. Some noted how they had to emphasize to staff that even if a resident had a companion, staff remained responsible for that resident’s care. One manager recounted a story of serious gangrene due to staff not checking the resident’s feet because the companion told them she was doing the foot care, even though the resident was not allowing her to remove socks.

While companions did their work in open and common spaces, there was significant time spent alone with residents, often behind closed doors in the private space of the bedrooms. This served to make their work invisible and lacking oversight. Companions said the resident’s bedroom was their workplace:

I: Do you find you have a particular spot that you consider your work space here?

A: Yes. Actually to do the stuff that we do. Right here in this room.

I: So that’s where you tend to come when you’re here.

A: No. We go everywhere. Downstairs. I take her downstairs. If we’re going to colour, like I try and tell her I need some help here and we’ll sit there. But I take her downstairs, out in the front now that the weather is nice. This room is always free. Her bedroom is nice. She likes her Polish music. I can put that on for her when she’s really anxious. (Private companion)

Despite identification with bedrooms, most indicated that they could not leave any of their own personal belongings there. In effect, the bedrooms functioned in much the way that the open, common spaces did in that companions left little of their own mark on the space.

Companions were also positioned between the family and the market spheres. Like other care workers, companions described relationships that were ‘like family’, though this was not accepted universally as a good thing:

You get attached to them because you feel like they are your grandma, your grandpa, something like that, your family. And they’re nice. And you’re getting something for your life too from them so you better love them, make them [live] longer. (Private companion)

Many companions also reported talking to family members daily, or taking photos and sending them: ‘I take picture every single day because they [family] can’t come every day’ (private companion). This emotional work was an important element of companions’ liminal position between family and the marketplace in which they participated.

In some instances, companions talked about families not understanding boundaries. One companion told of being asked to attend Christmas dinner with sons who flew in from overseas. They invited her. They called her Aunt. She resented it. She described how she had her own sons she wanted to be with at Christmas, and the family’s invitations were more about their own sense of guilt and desire to not be alone with their father. This companion revealed how she wanted them to understand it was just a job to her; they wanted her to act like family. This tension in terms of the expectations to act like family and the reality of not being family revealed the liminal and in-between nature of this emotionally intimate work.

Discussion and conclusions

In general, LTC facilities for older adults are highly gendered working and living spaces. Almost universally, women comprise the majority of workers and residents and there are a large number who work part-time. Like those on staff, companions are almost all women, and most often immigrant women of colour, although some are also Caucasian women unattached to the formal workplace (e.g. retired, former homemakers, etc.). As in other areas of elder care, there is a care gap driven by under-funding and under-staffing (Burke, 2008; Daly et al., 2011, 2015; Diamond, 2001; Fine, 2012; Foner, 1994; Harrington et al., 2000; Lopez, 2007).

While precarity captures the tenuous position of some companion work, it does not fully capture the work’s transitional and contradictory nature, and therefore its liminal positioning. Our findings show that companions are paid privately to work in places where they are not employees, in publicly funded workplaces that are also private households. Their work bridges a gulf between informal and formal care because they are paid by families to work for a single resident to perform care that extends the limits of the publicly funded care on the one hand, but that duplicates the staffs’ formal care work on the other. It is both a replacement and a substitute, much like the work of the ‘mothercarers’ described by Zadoroznyj (2009). Informal unpaid care is performed by families, but the same activities are also performed by companions paid to extend the reach of familial care. Interestingly, companion care also overlaps with the paid work of the staff, but unlike staff, companions are not normally a part of the formal care team. As Lyon and Glucksmann (2008) note, the contemporary study of work must look at the same labour activity and analyse how it is formal and informal, paid and unpaid. Paid companion care overlaps with unpaid and informal family care and with paid formal staff care. We argue that paid companions’ labour is performed in the spaces between formal and informal care, or even at the margins of informal care.

Is companions’ labour precarious? Like most precarious work, it is done without even the most basic of labour protections, but it is curiously carried out with high degrees of autonomy. It is often invisible and is not counted because it is performed behind closed doors in places that are both public and private spaces. We found that insufficient staffing and austere public funding led to a care gap that differed depending on the jurisdiction, which in turn created both families’ desire for paid care and paid staff’s tolerance of companions. Managers reported that they felt as though they had to police companions’ behaviours, and staff noted that companions interrupted work flow even while providing an extra set of hands.

Managers had no control over what or how families compensated companions, nor whether families were paying proper statutory benefits. Companions were typically lacking in standard statutory employment protections; however, for some, this was preferable as they had other sources of income or wanted to be paid in cash. Others saw this as an opportunity to easily go elsewhere if the situation changed. We also found that companions performed emotional and social care, like family would, and engaged families with photos and phone calls that also served as a bulwark against job insecurity. But families also imposed on companions to ‘feel’ as though they were family and pressured them, for example, to devote precious holiday time to aid in the service of the resident. Therefore, our study found that unlike staff, companions had few workplace protections, enjoyed greater autonomy and performed care work at a much slower pace and in a more relational manner. Most companions had more than one client during the week, so as to retain access to the building following a resident’s death – an indicator of companions’ precarious position.

Companions also helped produce precarity for paid staff. With companions filling a care gap, it relieved immediate pressure on staff and facilities and longer-term pressure on governments to improve public sector funding and staffing. Families’ hiring of companions also did little to improve the precarity of many of the paid care aides who were employed part-time or on contract but who wanted full-time work and benefits. Companions did cultivate demand for their own services by emphasizing the care gap and staff over-work, highlighting the need for families to retain or increase their hours, and surveilling and reporting on staff (in)activity or lack of responsiveness to families. This positioning distanced companions from care aides who could otherwise be allies, because companions did provide staff with an extra set of hands.

In what ways is companions’ care work liminal and invisible? Based on our findings, and using feminist political economy as our theoretical framework, this study found that companions’ labour was both liminal – situated between formal and informal care – and largely invisible, like most domestic labour. In some places more than others this liminal and invisible labour force redressed the paid staff care gap due to state austerity measures. The concept of liminality captures the contradictions inherent in companions’ invisible positioning between the public, the household and the market spheres (Clement and Vosko, 2003; Mutari, 2000). The space occupied by companions also highlights the limits of state, private household and market roles in care. Families’ use of companion labour limits the state’s responsibilities to collectively bear the costs of care for older adults, which further individualizes this work to families, shifts the work organization and the conditions of work for paid staff, and creates more care inequality between residents. Companions lack power while working in places where they are not employed; yet they also retain power because families are reliant on their presence to watch over staff. Overall, their work is highly autonomous despite occurring in a sector that is prone to heavy regulation (Daly et al., 2015). There is demand for the work because it fills a care gap, but it also de-stabilizes the sector because it removes pressure to risk sharing the costs of better staffing by the public sector. It also removes pressure to improve working conditions and lessen precarity for part-time or contract care aides who desire full-time work and benefits.

Depending on the family and the work arrangement, it can be lucrative or under-paid. Furthermore, in jurisdictions, especially in North America, where care aides’ work is highly task oriented, companions can provide relational care for the individual. Hiring companions to work in public, often unionized, facilities but under the table and outside of the reaches of state protections makes this work permanently transitional, liminal, invisible and precarious. As a result, there are risks for companions, families, staff, facilities and, importantly, for the residents with whom they work.

Future research that considers liminality in terms of the juxtaposition of publicly paid care in private settings and privately paid care work in public settings can help us to better elucidate who does what care, and the contours of state, market and household responsibilities for funding, delivery and administration of care roles. Furthermore, considering ‘boundary work’ in these liminal spaces may help us to refine the contours of labour precarity.

Footnotes

Acknowledgements

We would like to thank Dr Alison Jenkins Jayman and Ms Magali Rootham for editorial support with the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research funding was from the Canadian Institute for Health Research (CIHR) operating grant ‘Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care’ (http://tamaradaly.ca/invisible-women/) (File# 276064: Tamara Daly, Principal Investigator) and a Social Sciences and Humanities Research Council grant ‘Reimagining Long-term Residential Care: An International Study of Promising Practices’ () (File# 412-2010-1004: Pat Armstrong, Principal Investigator).

Biographical notes

Tamara Daly is an Associate Professor in the School of Heath Policy & Management at York University and holds a CIHR Research Chair in Gender, Work and Health. She is a health services researcher and a political economist who studies health equity through interdisciplinary lenses that address aging and long-term care, health and social policy, formal and informal care systems, conditions of care and care work, and how gender and ethnicity shape access to health and social care.

Pat Armstrong is a Distinguished Research Professor in the Department of Sociology. She has authored, co-authored or co-edited over 20 books, and has served as an expert witness on women's work and to pay equity in more than a dozen cases before bodies ranging from the federal court to federal human rights tribunals.

References

Armstrong

Amaratunga

Bernier

(2002) Exposing Privatization: Women and Health Care Reform in Canada, Aurora, ON: Garamond Press.

Armstrong

Coburn

(2001) The political economy of health and care. In: Armstrong

Armstrong

Coburn

(eds) Unhealthy Times: Political Economy Perspectives on Health and Care in Canada, Toronto, ON: Oxford University Press, pp. vii–x.

Baines D (2006) Staying with people who slap us around: Gender, juggling responsibilities and violence in paid (and unpaid) care work. Gender, Work & Organization 13: 129–151. DOI: 10.1111/j.1468-0432.2006.00300.x.

Baines

Cunningham

(2011) Using comparative perspective rapid ethnography in international case studies: Strengths and challenges. Qualitative Social Work 12(1): 73–88.

Bakan AB and Stasiulis D (eds) (1997) Not One of the Family: Foreign Domestic Workers in Canada. Toronto, ON: University of Toronto Press.

Banerjee

Daly

Armstrong

(2012) Structural violence in long-term residential care for older people: Comparing Canada and Scandinavia. Social Science & Medicine 74(3): 390–398.

Boyatzis

(1998) Transforming Qualitative Information: Thematic Analysis and Code Development, Thousand Oaks, CA; London; New Delhi: SAGE Publications.

Burke

(2008) Who will pay for better care? The Political Quarterly 79(4): 628–636.

Clement

Vosko

(2003) Changing Canada: Political Economy as Transformation, Montreal, QC: McGill-Queen’s University Press.

10.

Cranford

Vosko

Zukewich

(2003) Precarious employment in the Canadian labour market: A statistical portrait. Just Labour 3(6): 6–22.

11.

Daly

Szebehely

(2012) Unheard voices, unmapped terrain: Care work in long-term residential care for older people in Canada and Sweden. International Journal of Social Welfare 21(2): 139–148. DOI: 10.1111/j.1468-2397.2011.00806.x.

12.

Daly

Armstrong

Lowndes

(2015) Liminality in Ontario’s long-term care homes: Paid companions. Care work in the space ‘Betwixt and Between’. Competition & Change 19: 246–263.

13.

Daly

Banerjee

Armstrong

(2011) Lifting the ‘Violence Veil’: Examining working conditions in long-term care facilities using iterative mixed methods. Canadian Journal on Aging 30(2): 271–284.

14.

Diamond

(2001) Making Gray Gold: Narratives of Nursing Home Care (digital edn), Chicago, IL: University of Chicago Press.

15.

Fine

(2012) Employment and informal care: Sustaining paid work and caregiving in community and home-based care. Ageing International 37(1): 57–68.

16.

Foner

(1994) The Caregiving Dilemma, Los Angeles: University of California Press.

17.

Fox

(2009) When Couples Become Parents: The Creation of Gender in the Transition to Parenthood, Toronto, ON: University of Toronto Press.

18.

Giladi

(2010) Liminal craft, exceptional law: Preliminary notes on midwives in medieval Islamic writings. International Journal of Middle East Studies 42(2): 202a, DOI: 10.1017/S0020743810000322.

19.

Harrington

Kovner

Kayser-Jones

(2000) Experts recommend minimum nurse staffing standards for nursing facilities in the United Sates. The Gerontologist 40(1): 1–12.

20.

Kachi

Inoue

Toyokawa

(2010) Associations between contractual status, part-time work, and intent to leave among professional caregivers for older people: Results of a national cross-sectional survey in Japan. International Journal of Nursing Studies 47(8): 1028–1036.

21.

Lopez

(2007) Efficiency and the fix revisited: Informal relations and mock routinization in a nonprofit nursing home. Qualitative Sociology 30: 225–247.

22.

Luxton

(1997) Feminism and Families: Critical Policies and Changing Practices, Halifax, NS: Fernwood.

23.

Lyon

Glucksmann

(2008) Comparative configurations of care work across Europe. Sociology 42(1): 101–118. DOI: 10.1177/0038038507084827.

24.

Mutari

(2000) Feminist political economy: A primer. In: Bainman

Boushey

Saunders

(eds) Political Economy and Contemporary Capitalism: Radical Perspectives on Economic Theory and Policy, New York: M.E. Sharpe, pp. 29–35.

25.

Rodgers

(1989) Precarious Jobs in Labour Market Regulation: The Growth of Atypical Employment in Western Europe, Brussels: International Institute of Labour Studies.

26.

Shortt

(2015) Liminality, space and the importance of ‘transitory dwelling places’ at work. Human Relations 68(4): 633–658.

27.

Sweeney

(2009) Producing liminal space: Gender, age and class in northern Ontario’s tree planting industry. Gender, Place & Culture 16(5): 569–586. DOI: 10.1080/09663690903148432.

28.

Turner

(1969) The Ritual Process Structure and Anti-structure, Ithaca, NY: Cornell University Press.

29.

Van Gennep

(1909) The Rites of Passage, London: Routledge.

30.

Vosko

(2011) Managing the Margins: Gender, Citizenship and the International Regulation of Precarious Employment, New York: Oxford University Press.

31.

Vosko LF (2015) Introduction. In: Comparative Perspectives Database on Precarious Employment. Available at: http://www.genderwork.ca/cpd/?page_id=2 (accessed 9 March 2015).

32.

Vosko LF, MacDonald M and Campbell I (eds) (2009) Gender and the concept of precarious employment. In: Gender and the Contours of Precarious Employment. New York: Routledge, pp.1–25.

33.

Yin

(2014) Case Study Research Design and Methods, 5th edn. Thousand Oaks, CA: SAGE.

34.

Zadoroznyj

(2009) Professionals, carers or ‘strangers’? Liminality and the typification of postnatal home care workers. Sociology 43: 268–285.

35.

Zeytinoglu

Muteshi

(2000) Gender, race and class dimensions of nonstandard work. Industrial Relations 55: 133–167.