Abstract
Labors of Love, by Jason Rodriquez, uses rich ethnographic data to reveal workers’ experiences of care within nursing homes. He shows how constraints from reimbursement policies to regulatory requirements shape the types of care provided and workers’ interpretations of their work. Rodriquez presents data from two nursing homes: Golden Bay (for-profit) and Rolling Hills (nonprofit). While organizational scholars often focus on the differences between for-profit and nonprofit organizations, Rodriquez argues that reimbursement and regulation function similarly across profit status and that nonprofit nursing homes must adopt some ostensibly for-profit practices in order to remain in business. These constraints affect workers’ relationships with one another, their interpretations of the meaningfulness of work, and their sense of dignity in their work.
For instance, in Chapter Three, Labors of Love focuses on how floor staff (nurses, certified nursing assistants) and administrators (managers, office staff) define quality care according to differing logics of quality. Floor staff defined quality care by their interactions with residents, providing necessary services and bending the rules to do what they perceive is best for each resident. Administrators defined quality care as tasks that are properly documented and compliant with the plan of care for each resident. Administrators’ interpretations are derived from reimbursement policies that Rodriquez claims turn residents “into the personification of reimbursable activities that are neatly measured and quantified for the state” (p.25). Administrators and floor staff misunderstand the motivations and interpretations of the other group, leading to conflict over documentation standards and priorities of care.
Rodriquez argues that given these constraints on workers, floor staff often turn to emotional rewards to find meaning in the work. Chapter Six highlights several cases where staff bond with residents in meaningful ways. These bonds gave workers a greater sense of purpose: some residents became “like family,” others offered friendship, and attachments allowed workers to advocate for residents they had grown to love. While these relationships produced emotional rewards for staff members, Rodriquez also emphasizes that those bonds could be leveraged to gain compliance from residents. By using emotional labor skills, staff could often (although not always) align residents’ behaviors with the practices and norms derived from the reimbursement and regulatory systems. Workers likely do not see their behavior as manipulative; instead they focus on their own emotional rewards, allowing them to find dignity even as the work is demanding, sometimes demeaning, and often includes abuse and loss.
An additional theme permeates the narrative, offering new insights into caring work. Throughout the book, Rodriquez shows a series of games that workers play in order to keep the nursing homes running, while also trying to change how care is provided. Chapter One focuses on Medicaid reimbursement policies, highlighting how the audit process orients administrators toward documenting a high degree of dependency of residents. Chapter Two describes the Center for Medicare and Medicaid Services (CMS) inspection of the facilities. In both cases, administrators have developed strategies to walk a delicate line between accurately accounting for care and creating fraudulent records. Often, definitions of care activities are vague enough that different parties may use the terms differently. For instance, Rodriquez describes a situation in which residents with dementia were counted as being “supervised” during meals because a staff person was in the same room. The auditor refused this interpretation; she corrected the record, which resulted in lower payment for those residents (p. 31). Auditors know workers are walking a fine line and have developed their own counter-strategies. Meanwhile, floor staff are used as pawns in this game but rarely know the rules they are expected to play by. Administrators try to prepare floor staff for the game, but because floor staff and administrators fundamentally see the world differently, they fail to understand the stakes of the game.
Some staff members also played games with administrators in an attempt to change the organization. Chapter Five focuses on the food budget for nursing homes and features a dietary manager named Flo, who reacted to a diminishing food budget by “working-to-rule” (pp. 106–111). Instead of ordering food and supplies as needed by the residents, Flo began only placing orders when the budget allowed. Her hope was that other staff, residents, and residents’ family members would notice the deficiencies and complain. With enough complaints, Flo thought that the administrator would grant more funds for the kitchen. While Flo’s attempt to game the system did result in more complaints, the administrator was pleased with the budget and did not increase funds. In this case, Flo’s game backfired.
Labors of Love is accessible and appropriate for a range of student and scholarly audiences. Rodriquez is a reflexive ethnographer who is relatable and human in his narrative. However, this focus on narrative does come at a cost to theoretical development at times. Specifically, Labors of Love could have gone further to engage theories of power within nursing home work processes. How do floor staff use power when they refuse to adopt administrators’ emphasis on documentation? How do administrators use power as they classify residents along degrees of dependency? How do residents resist these definitions of dependency, and what does that mean for workers? Rodriquez presents engaging examples of each of these but does not analyze them through a power lens. These instances serve as starting points for larger conversations about incentivizing quality care, improving care practices, and deeply changing the culture of nursing homes. Chapter Eight closes the book by suggesting policy changes that may improve nursing home care and link quality of work to improved resident experiences. These suggestions may be useful as we rethink nursing home care, but before they are implemented, we must also reexamine questions of power to anticipate how the various parties within nursing homes will react.