Abstract
Home care and aged care in English-speaking countries around the globe have enthusiastically taken up a model of work known as ‘relationship-based care’ (RBC). Part of the popularity of RBC is because it does not challenge austerity, underfunding, and extensive managerialism. Instead it works within and through them to foster caring connections between patients, staff, and families, and is able to do so because workers are willing to self-sacrifice for clients. Drawing on case study data collected using a ‘rapid ethnography’ methodology in two large Australian aged care organisations, this article explores workers’ experience of work and contributes to Bolton’s typology of emotion management in the relationship-based care endeavour. Our typology includes: (1) austerity-linked sacrifice; (2) official discourse; (3) faux control; and (4) compulsory time philanthropy. The article contributes to debates on care work, relationship-based care, emotional labour, and emotion management and working in the context of austerity and managerialism.
Introduction
Australia is fairly unique among industrialised countries, in that it did not fall into recession after the 2008 Global Financial Crisis (GFC) (Denniss, 2015; Varoufakis, 2014). Nonetheless, it adopted a series of policies that deepened and extended an austerity mindset and neoliberalism’s reach into everyday life (Khoury, 2015; Varoufakis, 2014). Significant among these are those aimed at reducing public sector employment and public delivery of services, restructuring labour markets and demanding sacrifices from citizens to ensure a better future down the road. Like other industrialised countries, an ageing demographic and concomitant growing need for care present a challenge to governments committed to cost containment and offloading services.
To address tensions in providing care in the context of ‘permanent austerity’ (Pierson, 2010), aged care organisations have adopted a revolving door of patient care models, including patient-centred care, person-centred care, family-centred care and, more recently, relationship-based care (Cropley, 2012; Koloroutis, 2004). These models recognise that service users and frontline care providers are frustrated and short-changed in the context of poorly funded, rushed and increasingly scripted interactions. These models exhort practitioners to return to the true basis of care – the patient, the person, the family, or the care relationship – in order to improve service quality and outcomes. Despite strong evidence that underfunding and managerialism are the main threat to care (Armstrong and Armstrong, 2016; Daly and Armstrong, 2016; Willis et al., 2017), these models target workers’ behaviours, emotions and attitudes, instead of system-wide social reform. Rather than provide the resources and tools needed to provide good care, these models place workers in an untenable position where they must exploit their own labour through unpaid work in order to make the system function and, in the process, buffer and mask the impacts of austerity and neoliberalism.
Drawing on qualitative case study data in two large, non-profit aged care organisations in Australia, this article analyses care work relationships in the context of austerity and reflects on the dynamics of relationship-based care (RBC). It finds that care is provided on the backs of the workers rather than being supported by government funding models and organisational practices. It also finds that RBC is a discourse mobilised by management and workers to address, though not resolve, unsolvable challenges in the austerity-ridden care workplace. The article develops a four-part emotional management typology of the conditions of austerity and relationship-based care. This research aims to extend Bolton’s (2004) classic four-part typology of emotion management in the workplace to analyse relationship-based care in the context of austerity and neoliberalism. Though based in the Australian context, the analysis may be applicable in the many other austerity-driven countries and contributes to understandings of neoliberalism, emotional management in the workplace, emotional labour and discourses of relationship-based care work.
The article begins with a review of the contexts in which aged care work operates in Australia. It moves on to a section on methods, followed by an analysis of our data and our typology of workplace emotional management, with comparisons to Bolton’s (2004) four-part model.
Contexts of the literature
Aged care work in Australia operates in multiple contexts, necessitating a review of a variety of literatures noted in the heading above. This section also introduces Bolton’s emotional management typology. Since the 1980s, governments in industrialised countries have been pursuing a shift from public to private service delivery (for-profit and non-profit) through contracting-out and valorising the private market as the solution to economic and social problems. Known as neoliberalism, this set of policies is nested within larger policy initiatives aimed at limiting government, legally mandating balanced budgets, cutting taxes, flexibilising labour markets, reducing the regulation of private corporations and creating improved conditions and opportunities for private profit-making (Harvey, 2007; Khoury, 2015). These policies diminish the resources governments have available to provide services, in effect locking governments into various versions of austerity (Evans and McBride, 2017).
Some argue that austerity is an ongoing aspect of neoliberalism (Pierson, 2010). Others argue that austerity became more dominant after the GFC, operating as a downward pressure on the public sector with spill-over effects on wages in all sectors, as well as on human services and social expectations (Varoufakis, 2014). Austerity is also seen as a means of regulating behaviour and insisting that sacrifices need to be made in the present for promised future gains (Clayton et al., 2015; Hayes and Moore, 2017). This aspect is particularly important in aged care in Australia where long waiting lists exist for home care funding and residential spaces, and minor funding increases serve as smokescreens for ongoing underfunding (Kaur, 2019; Laudner and Milton, 2019).
Contracting out has been one of the main mechanisms for moving public services to the non-profit and for-profit sectors. Claiming to ensure accountability and transparency, contracted-out human services, including aged care, are required by government funders to adopt New Public Management metrics and outcome targets (Cunningham and James, 2009). These metrics tend to standardise practice, erasing hard-to-measure, open-ended, relationship-based care practices and making it easier for lower credential, lower paid workers or even unpaid volunteers to perform the highly scripted, fast-paced work (Daly and Armstrong, 2015; Willis et al., 2017).
Whether private, public, non-profit or in the home, care work is highly gendered, with women forming the majority of service users, workers, volunteers and unpaid workers (Folbre, 2012). Like the private sphere of home, care work organisations operate on the naturalised, gendered expectation of the unending emotional labour expected of all women, regardless of wages, working conditions or other responsibilities (Baines and Armstrong, 2018; Folbre, 2012). These forces make it difficult to improve wages or conditions and leave care jobs vulnerable to transition back into unpaid care in the home and community.
Over the course of the last three decades, the Australian Government has restructured aged care funding to achieve savings while simultaneously claiming generous increases (Whiteford and Duckett, 2018). This restructuring amplifies ongoing shortfalls as the overall level of service provision has failed to increase relative to the population aged over 65 nor relative to the increased complexity of need and concomitant higher service requirements among older and frailer service users. The size of the workforce has also remained static in residential aged care and decreased in home care (Meagher et al., 2019). Today, waiting lists remain lengthy, with demand for service consistently outstripping supply.
In Australia, the federal government subsidises three main aged care programs (the subsidy varying according to the program and the person’s income and assets):
Commonwealth Home Support Program provides entry-level support services to enable older people to stay at home, of which 7% is run by for-profit providers.
Home Care Packages Program is delivered on a Consumer-Directed-Care (CDC) basis to enable the purchase of a range of services and equipment to assist older people living in their own home. Eligibility is assessed at four levels of care, from basic to complex (medical care is provided and funded separately); 35% of this program is run by for-profit providers.
Residential care and accommodation are available for older people unable to continue living independently; 37% of this program is run by for-profit providers (Royal Commission into Aged Care Quality and Safety, 2019).
The Australian Government recently announced an increase to these programs which gives the appearance that austerity has not affected this sector. However, as is characteristic of austerity policies, funding is not equal to need, even with occasional funding increases. For example, the 14,000 additional individual funded packages provided in 2017 were outstripped by more than 104,600 older Australians waiting for approved care packages (Woods, 2018). In 2019, the government promised $662 million to provide 10,000 additional packages totalling 24,000 packages across the two announcements, leaving some 80,600 people still on the growing waiting list (Kaur, 2019). Though some of the announced increases will go to residential care, government data confirm waiting lists for residential places of one year in some regions and well over 100 days in others (Laudner and Milton, 2019).
Despite inadequate funding, Australian aged care policy endorses ‘person-centred care’, which is recognised and promoted in the national care quality standards as ‘consumer’-centred care (Australian Aged Care Quality and Safety Commission, 2019). Just how this focus is to be realised is unclear: either in residential aged care, which has seen increasing service intensity; or in in-home care, where home care packages delivered via the CDC model have served to both fragment and lean-out service delivery (Meagher et al., 2019). While for-profit ownership in both residential aged care and home care remains below that in other similar OECD countries, it is rapidly increasing, with many non-profit providers taking on a for-profit ‘logic’ in the marketised sector (Meagher and Goodwin, 2015).
As public systems over the last 30 years became increasingly privatised and managerialised in work organisation and austere funding decreased further (Armstrong and Armstrong, 2016; Clarke and Newman, 2012), health and aged care providers sought new care models to ameliorate dissatisfaction and deteriorating quality. In order to grapple with the funding shortfall and reduce managerialism’s demand for time-consuming metrics, governments, health care providers and health care professions have adopted various ‘return to care’ models in which care would be restored to its imagined former centrality in service provision. These approaches promised improved patient care, employee productivity and workplace morale, alongside enviable and measurable improvements, and outcomes. Versions of these care models include patient-centred care, person-centred care, family-centred care, consumer-centred care and, the more recent term, relationship-based care – which encompasses ideas found in each of these models (Cropley, 2012; Koloroutis, 2004). Failing to elaborate these models in any detail, they have nevertheless been officially adopted by governments and/or regional authorities, such as in the UK, Canada and Australia (Australian Aged Care Quality and Safety Commission, 2019), while individual organisations are free to adopt RBC.
Providing an example of the nebulous but inspiring discourse underlying RBC, in 2004, Manthey wrote: ‘I am convinced that the chaos we are experiencing in health care will settle down when we truly focus on the patient’ (2004: p.10). Similarly generalist and ideological, and ignoring workplace conditions and austerity policies as factors underlying ‘the chaos’, Koloroutis (2004) asserted that RBC has three components: the relationship between provider and patient; the care provider’s relationship with self; and the care provider’s relationship with others; with the first being the most important. All three components engage the care worker in changing and governing their own behaviour and emotional states to exert control over care relationships and to settle ‘the chaos’. Presumably, if outcomes do not improve, the care worker is held responsible for failing to appropriately build care relationships, regardless of the conditions of work or lack of concrete directives.
Though RBC provides some scholars with a way to identify problems in the current context of underfunding and constraint, the strategies fall short of organisational and social policy change. For example, Campbell (2009) notes that: ‘new technologies, unceasing workplace restructuring and demanding regulatory and legislative mandates have pushed nurses away from the bedside and into a world of computers, data, and equipment’ (p.1). According to Campbell (2009), RBC provides a way to get nurses back to building relationships with patients and their families and may act as a catalyst for change, though the focus of change is almost exclusively on the use of individual relationships as a tool for improved care. This emphasis on relationships between staff and clients means that emotions and emotion management are central to RBC.
Bolton’s emotional management typology
Writing in the 1980s, Hochschild (1983) analysed emotion regulation in service work and defined emotional labour as the ‘management of feeling to create a publicly observable facial and bodily display’ among workers in order to speed up the service endeavour and to attain other organisational goals (p.13). Numerous studies expanded Hochschild’s thesis to explore worker agency, emotional dissonance, resistance and enjoyment of emotion labour (Badolamenti et al., 2017; Bolton and Boyd, 2003; Delgado et al., 2017; Elliott, 2017; Guy and Newman, 2004; Ikeler, 2016; King, 2012). Contributing to this debate, Bolton (2004, 2009) drew on Hochschild’s work and identified four types of emotion management in service workplaces, including nursing care: (1) pecuniary (emotional management for profit or to reduce costs); (2) prescriptive (organisational and/or professional rules of conduct); (3) presentational (general social rules); and (4) philanthropic (a gift, given without strings attached, to the organisation, colleagues or service users). This typology provided researchers with a way to theorise the complex social relations involved in emotional labour and service work in its many forms and sparked many subsequent analyses (Badolamenti et al., 2017; Baines et al., 2012; Delgado et al., 2017; Elliott, 2017; King, 2012). Arguably, under the specific conditions of austerity and RBC, emotional management requires further theorisation.
Methods
These data are drawn from two case studies in Australia that are part of a larger, international comparative research project on the relationship between decent work and quality aged care in Australia, New Zealand, Canada and Scotland. Using an approach known as rapid ethnography (RE) (Armstrong and Lowndes, 2018; Baines and Cunningham, 2011), data were collected from multiple sources, including through interviews, ‘shadowing workers’, informal interviews and discussions with managers, workers and clients/residents, reviewing internal documents and mapping of policy documents. While conducted over a relatively short, intensive period of time, this methodology ensures multiple perspectives and rich data (Armstrong and Lowndes, 2018) and allows links to be drawn between the ‘everyday’ life of aged care work, the organisation in which it takes place, and the national policy and regulatory context in which the work is done (Pink and Morgan, 2013).
The studies took place in a residential care site and a home care service site that were part of two large national non-profit organisations. Both organisations had positive reputations in the aged care sector. Qualitative data included in-depth, semi-structured interviews (28) with 12 managers (three female and nine male) and 16 staff (12 female, four male). In addition, nine care staff (all female) were shadowed for an average of 4.5 hours each (range 4–5 hours), for roughly 40 hours. Participant observations (24 sessions) provided the third source for data collection. Data were collected through informally engaging with staff, residents and family members, observing the kitchen operations, meals, a bus trip, several staff handovers, a case conference, various on-site activities and a tour of headquarters. The average length of observation was 3 hours (range 2–6 hours). Field notes were taken in situ and transcribed as soon as possible after data collection. Interviews and discussions during observations included questions about forms of quality care most valued by clients, their families, workers and the organisation. Questions were also asked about the organisation, conditions of work, changes in work overtime and about the management of care on a day-to-day basis.
Our RE methods involved ‘insider’ (local) and ‘outsider’ (from another country) researchers in interviews and observations (Dwyer and Buckle, 2009). This provided an opportunity to understand local contexts as well as to question taken-for-granted assumptions. In addition, the team met daily to discuss emerging themes, lingering questions and to identify areas where a closer focus might produce richer data. Data analysis used NVivo 12 software (QSR International Pty Ltd), initially focusing on inductive and abductive coding (Bazely, 2009). The frequent use of the RBC related terms, such as ‘person-centred’ care, ‘relationship-centred care’ and ‘consumer directed care’ in the data prompted a closer examination of the way that such RBC discourses called upon care workers to build relationships but failed to provide the necessary contexts or resources. The long-term interests of the researchers in emotional labour drew them to re-examine Bolton’s (2009) typology of emotional management as one possible way to illuminate the data. At this point, data analysis involved working between Bolton’s typology and the data in multiple readings (Bazeley, 2009). Ethics approval was received from the universities involved. Limitations to this project include the relatively small number of organisational studies and the qualitative method which precludes generalisation but provides rich insights and may also permit applicability across many spaces.
Aged care workplace relationships and relationship-centred care in the context of austerity
As noted above, Bolton (2004, 2009) identified four types of emotion management in service workplaces: (1) pecuniary (emotional management for profit or to reduce costs); (2) prescriptive (organisational and/or professional rules of conduct); (3) presentational (general social rules); and (4) philanthropic (a gift, given without strings attached, to the organisation, colleagues or service users). Drawing on exemplar quotes from the data, this section discusses a typology of emotional management in the specific conditions of austerity and RBC discourses including:
austerity-linked sacrifice (combining aspects from Bolton’s outline of both pecuniary and philanthropic emotion management);
official discourse (like Bolton’s prescriptive emotion management but specific to RBC);
faux control; and
compulsory time philanthropy (like Bolton’s philanthropic emotion management).
Austerity-linked sacrifice
Variants of RBC were the official models of both aged care services studied. The Director of one organisation described RBC as their version of the government-termed ‘consumer-focused care’, stating: ‘We call it relationship-based care. That’s [the organisation’s] wording.’ This Director aligned relationship-based care with their organisation’s documented values, which he described as using one’s job ‘to make it that special for the clients’. The Director explained that the use of RBC had been in place in their organisation for the past two and a half years and had stemmed from the government’s focus on ‘consumer-care . . . as in providing one-on-one care . . . individual care basically’. Providing care to the client focused on the individual’s specific interests and needs was paramount under this interpretation of RBC.
In each organisation it was difficult to identify what made it RBC, rather than just good, indifferent, poor care or a mix of all four. It is safe to assume that care and emotion are part of every care workplace, but for care to be RBC, it must emphasise relationships to the resident or client first and to the self and organisation second. By placing the needs of the clients first, the interests of the workers were overshadowed. The data suggest that many frontline workers sacrificed wages and workplace conditions, due to the increasing intensity of their roles and lean staffing. This quote from a researcher’s informal group discussion with personal support workers reveals the workers were aware they were making sacrifices and were frustrated: ‘In relation to pay, they all make it clear that they feel they do not receive sufficient income for the effort they put into the work. Comparisons are made with their grown-up children on triple or double the wages.’ Workers also uniformly noted that the work is very hard, physically and emotionally.
Participant observation notes continued:
Jacquie remarks that she doesn’t think they are valued and that this was unfair as they were dealing with people’s lives. Their sense of being undervalued touches on relationships with the clients. They all stress how the relationships are crucial to understanding what is going on in their lives and health and sense of well-being . . . this crucial aspect of their role (talking to clients) is seen to be undermined by the pace of work, and the short-staffing. Pat describes the [personal support workers] as the ‘eyes and ears’ of the organisation. She also added that management in the home could come to you when you had ‘three things in your hand, including a client, and will still ask you to do something else’.
One of the workers commented further that the personal support workers could get the same or better pay for less stress in non-care service work, including at McDonald’s. These quotes reveal that the workers are aware of their centrality to RBC as well as the improbability that RBC can be provided in fast-paced, short-staffed environments with a high workload. The workers are also cognisant of their importance in the organisation but feel that no matter how hard they worked, management would ask them to do more and keep their wages low.
Violence and abuse are frequently part of care workplaces (Baines and Cunningham, 2011; Bannerjee et al., 2012). As will be discussed below, though various strategies were enacted to address this aspect of care work (e.g. medicating residents, distracting, leaving the room), most were effective only some of the time, while solutions that worked all or most of the time were fatalistically presumed to not exist or not apply to aged care. Sacrificing this aspect of health and safety and modulating one’s emotions in relation to it is an expected aspect of care work, though other studies confirm that understaffing and ‘flexible’, constantly changing, lower skill workforces are the major factors exacerbating violence in the care workplace, while higher, more stable staffing ratios significantly lower violence (Bannerjee et al., 2012; Willis et al., 2017).
Austerity-linked sacrifice also overlaps with philanthropy, as will be discussed below. This emotional management involves the gendered expectation from management and funders that the workforce will work beyond paid hours because, as a gendered labour force, they cannot help giving and caring endlessly, despite working conditions, work intensification and low wages. This includes the sacrifice of personal time in the form of a gift of unpaid work and ‘little extras’ that the workforce expects of themselves and management depends on to stretch scarce funding (Daly and Armstrong, 2015).
Official discourse
Bolton’s (2004) second type of emotional management is prescriptive. It focuses on organisational or professional rules of conduct. Professional rules are not decisive in aged care in the era of austerity as cost-savings measures mean that most frontline care employees are categorised as lower ‘skill’, and are lower waged and not professionalised. They generally invoke their personal values and organisational rules as a guide for appropriate behaviour and use of emotion.
As articulated within RBC literature, the RBC model advocates the development of genuine, caring relationships with residents, the self and others in the organisation, but underfunding and standardisation have resulted in tight routines in which there is little or no time to foster relationships. Managing competing care rationales generated emotional dissonance, or conflict between the commodified self and the authentic self when performing emotional labour (Hochschild, 1983; King, 2012). Workers felt that they had authentic selves and that sharing this was part of the job: ‘it is about that relatability, about being that real person’. As noted above, the intensification of emotion work under RBC provided little time for close relationships. For example, a supervisor told us that some workers had trouble in ‘setting up the routine of the relationship-based care, where we let the clients sleep in, get up at their [own] time’. This disruption of routine was experienced by frontline care staff as increased workload and the inability to get everything done by close of shift. Some workers experienced unfinished work as emotional dissonance and resolved it by doing unpaid work: ‘If we can’t finish it [the work], we still do the handover . . . if I feel it’s something that’s my responsibility, I might stay back 10 to 15 minutes, or I might stay back half an hour if I need to’. We argue later in this article that this unpaid overtime is a form of compulsory time philanthropy, characteristic of care work in the era of austerity.
In another example, referring to the residents, one manager noted that, ‘sometimes you have certain behaviours that may throw the routines out completely and unsettle some staff’. This included simple things like residents who wander as well as residents with more challenging aggressive behaviours. These behaviours cannot be predicted, planned or routinised, and they disrupt the routines that have been central to completing high volumes of work in the austerity-saturated workplace. These behaviours can be a major source of stress for staff and create emotional dissonance as RBC expectations generate unachievable workloads in austere contexts where staff are already overstretched. Despite being seemingly overstretched, some managers disagreed with the idea that higher staffing would be helpful, as they thought it would lower productivity. As one noted: ‘Unfortunately, you put on more staff it doesn’t actually improve the care because, as we know, staff start to slacken off because someone else is picking up this and that, and that’s what we always find’.
At the homecare site, workers had very limited organisational relationships, despite the official discourse of RBC. Some homecare workers spoke explicitly of ‘not having a team’ and ‘feeling lonely’ in their work as they only have contact with their supervisors, mostly by phone and text. Supervisors confirmed this, observing: ‘It’s quite lonely out there. Yes, they go and see their people in their homes but in between times they’re on their own as opposed to working in a team.’ In one instance, this isolation seemed enhanced by the supervisor’s insistence that the worker needed to build relationship-based care with an exclusive focus on the client, rather than the client in the larger context of their other relationships. Though RBC includes working with the client’s family, in this example, the home care worker was reprimanded for contacting family. The worker had become concerned about one of her elderly residents who was saying that she wanted to die and was giving away all her possessions. When contacted, the client’s daughter dismissed the worker’s concerns, telling her that her mother had a long history of this kind of behaviour and complained to the supervisor. As the supervisor stated:
The care worker was like, ‘She spoke to me horrible’. I said, ‘You over-stepped. You should have come to me. I could have given you all this feedback, but you chose to go straight to the daughter. That’s not your role. Your role is to support the client, do changes in the care plan and be there for the client; never approach a family member.’
Some workers were quite positive about their relationship with their supervisors. For example: ‘Dana is fantastic; she goes to bat for all of us and she recognises when we’re having a tough time, like we had an influx of clients and care workers and she gave us that great talk on, “You know, I know you’re all struggling, but hang in there, we’ll get there”’.
Faux control
Faux control is a dynamic that is not identified in Bolton’s (2004, 2009) work, which arguably predated the Global Financial Crisis and explicit austerity policies. Faux control is an emotional management strategy that gives workers the impression that they have control in situations where there is little control, and which are exacerbated by lack of specific training (e.g. mental health training or de-escalation techniques), understaffing and austere underfunding. Under this emotional management type, control remains with management and the institution. Our data confirm that sometimes, in order to undertake care, workers exercised faux control, as well as improvising their own solutions and developing mock routines that got the work done.
For example, as noted above, abuse and aggression are part of everyday work in aged care. Workers and management reported that ‘aggression can happen very often’, but unlike psychiatric facilities, staff are not provided with mental health or de-escalation training. Confirmed by several supervisors and our observation notes: ‘We don’t teach de-escalation techniques like you would in a mental health service because that’s not what we’re doing . . . we give them [the staff] permission to leave and to call their manager and talk through with their manager what’s going on’. Often it is not possible for staff to leave aggressive situations for a variety of reasons, including the resident blocking the exit. As one worker related, ‘He had Delores and someone else bailed up in his room. It was very scary. It’s also happened to Heather on more than one occasion.’ In this example, workers had the faux control to manage their emotions and safety by exiting dangerous situations, though they lacked any capacity to do so. The workers told us that they developed their own solution or mock routine that paralleled management’s routine. They carried their personal mobile phones and called each other for assistance.
Supervisors emphasised that the staff are ‘special dementia carers not bodyguards. It’s about managing their behaviours with brains not muscles.’ Medicating residents was reported as a strategy for managing and controlling aggression; however, it was not always effective. If the violence escalated, the resident would be transferred to a more secure facility. In the meantime, staff developed their own solutions; namely, to try to relate to the person behind their diagnosis or anger, and thus normalise and excuse violence, just as women do in situations of domestic violence (Baines et al., 2012; Banerjee et al., 2015). As one worker told us, one client was quite verbally abusive but ‘you knew it wasn’t at you. It was just at his situation . . . then he would kiss my hand . . . and apologise.’
Families of home care clients were also a source of verbal abuse, particularly in relation to scheduling visits. A similar solution was used – namely, workers excused and normalised the abuse. As one worker noted:
Everyone handles it differently but it’s quite a common thing in scheduling because you’re basically ringing up to give them bad news that ‘your favourite care worker isn’t coming today’ . . . it’s usually the carer, cause they’re under quite a bit of stress looking after their parents . . . Some of them swear, some of them are just angry but . . . you just have to take it as they’re just venting.
The same worker noted further that, ‘If they keep going, then that’s when we escalate it to managers, saying, “Well, I’m sorry, but I’ll have to get the manager to call you back”’. This emotional management dynamic provided an additional form of faux control in a situation where a largely female work force absorbed verbal abuse and managed their emotions in high stress situations, while management maintained overall control and provided few options for dealing with this major stressor and workplace health and safety problems.
Death of service users was another site of faux or quasi-control. RBC encourages the development of an authentic, caring relationship with the client and family that ends abruptly with the death of a client. Echoing the comments of many, as one worker put it, ‘It’s devastating. When you’ve known them for a long time, it is very hard.’ As confirmed by one supervisor: ‘It’s very hard for workers because they have to cut off when the client dies’.
Managers told us that usually primary workers were permitted to attend the funeral of their regular clients, though one staff member noted: ‘You can go to the funerals in your time off. But they don’t really encourage people to go on work time any longer.’ Other workers and managers, who may have formed relationships with the client and family, were not allowed time off. Doka (1989) calls this disenfranchised grief or grief that is de-legitimised and given no space for expression. This silencing of grief was experienced as a hardship by workers who expressed deep sadness at being unable to say goodbye to the client or the family. Though relationship to the self (such as feeling and resolving the grief) and to the client’s family (such as offering support and sympathy) are part of RBC (Koloroutis, 2004), expression of grief seemingly had no place on the job. Workers could debrief with supervisors or seek up to five off-site counselling sessions, but as one supervisor told us, workers ‘need to learn to let go gracefully’, by which she meant that they should manage their emotions in ways that did not impact on routine or productivity because ‘they still had to take care of the living’. In these worksites, workers’ faux control over the genuine caring relationship with the client and family ended suddenly when the client died.
Compulsory time philanthropy
Bolton (2009) argues that gifts in the form of philanthropic or altruistic acts are part of workplace emotion management. These freely given gifts are provided to make clients or others feel better and may not be part of the regular workload. Compulsory time philanthropy overlapped with the first form of emotional management discussed in this article, namely austerity-linked sacrifice. Austerity sets up the conditions under which there was insufficient funding to hire enough staff to ensure quality care and thus not enough time to care; workers then ‘choose’ to undertake unpaid work or compulsory volunteer work to fill the gaps. Management and supervisors were adamant that unpaid care work was the workers’ ‘choice’. This ‘choice’ overlaps with our third form of emotional management, faux control, in that it shifts responsibility for unmet care to workers from management but does not shift control over how the work will be undertaken, the volume of the work, or how the workers will be assessed or disciplined if problems arise.
The data show that two dynamics of compulsory time philanthropy operated in the aged care organisations studied: (1) it is a choice; and (2) organisational philosophy. In the first dynamic, management and some workers agreed that undertaking unpaid work was a choice: ‘That’s a choice and it’s my choice . . . I’m sitting at home doing nothing anyway. I might as well be at work being productive.’ Unpaid work included working through breaks, coming in early and/or staying late, and taking unfinished work home with them. In the words of one worker: ‘I just sort of break it up over the week and do a couple of hours each night’. In terms of missed breaks, a researcher noted: ‘Susie indicates it is her break, and she is able to take it. She stresses that this is not always the case.’
Though most of the workers were in non-professional job categories, one of the organisations encouraged workers to respect ‘professional boundaries’ and not to volunteer outside work hours. As a head office manager noted: ‘People say, “Oh, I love coming into the facility on a Sunday in my free time”. And I’m, “You just broke professional boundaries – straight up”.’ The head office manager was concerned that unpaid work violated workplace health and safety regulations, and sought to avoid breaches of this policy, though as the first quote shows, they were not entirely successful at preventing it.
The same organisation developed a formalised RBC program. Their organisational philosophy valorised ‘going the extra mile’ and promoted altruism as a multi-program, organisational thread, or mantra. This mantra popped up in conversations (and complaints), as well as on websites and in printed material, continually re-weaving the organisation in a putatively shared commitment to the benefit of others in the form of the sacrifice of time, skills and energy on the part of workers and management. In implementing the RBC program at the study site, workers were encouraged to spend time with individual residents in specific activities. Despite the view of the head office manager, these activities were often undertaken on unpaid time. Supervisors emphasised that workers could freely choose to volunteer their time: ‘They choose to do that themselves to provide it’. Similarly, ‘they’re choosing to do that for her’ and ‘if they wanted to take them shopping, for instance, or to the library, they could do that. Swimming. It’s their choice.’ In contrast, workers reported that ‘the “voluntary” activities are not entirely voluntary’ but rather were ‘a condition and expectation of’ ‘working here and getting sufficient hours’. Field notes also showed that among frontline workers, ‘there was a concern that they would not be paid for any additional work in the [RBC program] . . . although they were enthusiastic about the ideas and values behind it’.
Discussion
Focusing on two areas of aged care work, namely residential and home care, in the specific contexts of austerity, late neoliberalism and RBC in Australia, this article draws on qualitative data to develop a four-part typology of emotional management dynamics, including:
austerity-linked sacrifice (like Bolton’s pecuniary but with aspects of philanthropic);
official discourse (like Bolton’s prescriptive; specific to RBC);
faux control; and
compulsory time philanthropy (like Bolton’s philanthropic).
The analysis above highlights the similarities and differences from Bolton’s classic emotional management typology.
As noted earlier, Clayton et al. (2015) argue that austerity is a means of regulating behaviour and insisting that sacrifices in the present will generate future gains (also Hayes and Moore, 2017). The emotional management dynamics undergirded by austerity strategies and logics provide an overarching aura of self-sacrifice, not just for the future but also for those receiving and providing care in the present. To this, we would add that many of these sacrifices involve strategies of emotional management, particularly the suppression of emotional expression and deferring one’s own needs so that others might benefit. However, suppression of emotional expression is not consistent with RBC, which is intended to foster positive emotional connection and engagement. Austerity-linked sacrifice is like Bolton’s (2004) notion of pecuniary goals, in that they are aimed at reducing costs and extending scant resources.
The analysis highlights the way that, though official discourses are in Australia and elsewhere, RBC’s principal effect is to govern at a distance (Rose et al., 2006), coordinating the conduct of multiple players and organisations in dispersed workplaces across regions and countries, including Australia. As an official discourse, RBC is not delineated in detail in government or organisational documents; nevertheless, it acts as an overarching, multi-site, authoritative discourse on rules of conduct and acts, aspiringly, as a form of workplace emotional management. When government departments officially adopt relationship-based or client-centred care, such as in the Australian home care CDC model, they provide additional reach and authority, though few details on how to conduct such RBC in its many sites of operation.
Studying American nursing homes, Lopez (2007) notes that when resources were inadequate, management often relied ‘on shop floor organisation and informal work methods to sustain the illusion that externally-imposed rules are being followed’, resulting in a mock routinisation or an informal way of doing things that paralleled mandated rules, a form of faux control (p.229). Our analysis confirms that sometimes, in order to undertake care, workers exercised faux control, as well as improvising their own solutions and developing mock routines that got the work done. This analysis suggests that RBC operates as an extra-local, emotional management dynamic that redistributes some responsibility to workers (faux control) while workplace control remains centred with management and managerial models that remain viable due to the continuing austerity-linked sacrifices of care workers.
Unpaid work (austerity-linked sacrifice and compulsory time philanthropy) is common in the female-majority care sector and pivots on the notion that women’s capacity to care is elastic and constantly expandable whether in the home, community or workplace (Daly and Armstrong, 2015; Folbre, 2012; Skinner et al., 2013). The literature confirms that care workers tend to expect unpaid care work from themselves and each other, and management expects the same (Baines and Armstrong, 2018; Folbre, 2012). Unpaid work extends scarce resources, and in the austerity-driven care workplace, unpaid work becomes compulsory and normalised. This analysis shows that the ideological discourse of RBC is, in practice, highly dependent on the paid and unpaid work of female majority, low wage care workers to make it appear as if the system is functioning at acceptable and sustainable levels (austerity-linked sacrifice and compulsory time philanthropy). The leaned-out, fast pace and routinisation of this work conflicts with RBC because care relationships are inherently individualised and impossible to incorporate into standardised responses. However, rather than advocating for enough funding and staffing so that non-standardised, genuine care relationships can be fostered, discourses of RBC work to placate workers and managers with a soothing narrative of placing authentic relationships at the centre of the care endeavour (official discourse).
The analysis also suggests that at the level of everyday work, RBC is not the cure-all to neoliberal, austere, managerialised care. In its lack of differentiation of other models of care and operation largely at the level of discourse, the analysis suggests further that RBC is a weak form of emotional management in the context of late neoliberalism. RBC operates largely at the ideological level, coordinating an extra-local, multi-site ‘feel good’ narrative about returning to the basics of care and authentic care relationships, while everyday practice and emotional management continue to be shaped by the austere relations of underfunding and managerialism. RBC functions as a cover-up, making it appear that the government and management are engaging in positive, far-reaching change rather than just cutting funds and creating conditions in which most workers and managers have neither the time nor the resources to build or sustain care relationships.
Conclusion
This analysis developed a typology of emotional work in the context of austerity: (1) austerity-linked sacrifice (like Bolton’s pecuniary but with aspects of philanthropic); (2) official discourse (like Bolton’s prescriptive; specific to RBC); (3) faux control; and (4) compulsory time philanthropy (like Bolton’s philanthropic). The argument presented in this article underscores that in the context of austerity, even where no direct system-level funding cuts or organisational-level staffing cuts had been made, emotions and emotion management in the workplace were delimited by inadequate funding, staffing and resources. Though this article focused on RBC as an archetype of client-based, family-based and person-based care models, their outcomes are the same as they all operate within the constricting relations of late neoliberalism. Though well-motivated, these nebulous and ill-defined care models distract workers, policy-makers and the public from the serious ongoing underfunding of aged care, questions about the quality of care and unsustainable demands placed on care workers. As such, these issues require further exposure and examination. In addition, further research into other forms of gendered care work, models of care and austerity in countries and situations beyond Australia are important in order to deepen this analysis and further assess this emotional management typology in relation to other circumstances and contexts.
Footnotes
Acknowledgements
The authors would like to thank the anonymous reviewers and editors of WES, as well as the research participants who so generously gave their time and experience.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this article draws on research conducted as part of Australian Research Council Discovery Grant: DP170100022.