Who cares for carers? Responsibilization and the discourse of self-care in health and social care literature during the COVID-19 pandemic. A critical review

Relationality

Relationality is an important aspect of social care and social work. It draws on individual emotional resources and the ability to empathise, and is the recognising of individual or family needs, support, including psychological support, and monitoring their situation. It takes place mainly face to face, in close contact, often in moments of crisis. During successive lockdowns of institutions for clients, when contact with them was limited, social workers may have redirected efforts to support the community in the pandemic crisis. However, this had a negative impact on the implementation of ordinary tasks, and the social workers’ ability to react in mental and suicidal crises, situations of domestic violence, and other difficult situations experienced by their clients (Du and Chan, 2021).

In the first weeks of the pandemic, a paradox emerged: social work as relational work became almost impossible, but social workers adapted to digital tools in order to do it anyway. When the usual mode of contact at home, in social welfare centres, or in a hospital was reduced, this firstly led to innovation, and secondly, caused problems. Communication with clients of social welfare centres, but also with the families of hospital patients and people in nursing homes, was spread over various channels: email, telephone, and instant messaging such as Messenger and Whatsapp. In some places, for the lack of other possibilities, private numbers, and private accounts on social media were used for this, which resulted in work spilling over into private life and sudden availability of employees to their clients outside working hours (Mishna et al., 2021). In nursing homes and palliative care, digital technologies were used in various innovative ways to connect patients with their families (Currin-McCulloch et al., 2021).

Inadequate preparation of institutions

The source of difficulties in HSCW work, similarly to many other areas of work and social life, can be summarised most generally as insufficient preparation for the crisis. Lack of preparation made ad hoc actions necessary, which caused information chaos, and many new guidelines coming from various agencies and institutions simultaneously (e.g. in the USA: national, state, local). Recommendations and regulations often changed at a time when employees expected clear information and directions (Behrens and Naylor, 2020; Billings et al., 2021; Glac and Zdebska, 2020; Nyashanu et al., 2020; Rossiter and Godderis, 2020). Moreover, the distribution of information was uneven in places where agency workers were engaged, as in the UK, where agency workers did not have National Health Service email accounts and thus could not receive information from the NHS (Billings et al., 2021).

Due to the establishment of new procedures, the number of responsibilities increased, including the need to learn new tools and ways of operating (Glac and Zdebska, 2020; McFadden et al., 2021b). In nursing homes, the greater number of duties was also due to staff shortages and the closure of these facilities to visitors – previously, they relied on relatives assisting patients in their daily activities (Hado and Friss Feinberg, 2020; Syed and Ahmad, 2021).

Fear for health

People working in medical facilities and nursing homes were particularly at risk of becoming infected with the coronavirus. In the first months of the pandemic, public opinion was especially focused on nursing homes, where the death rate from COVID-19 was particularly high (Behrens and Naylor, 2020; Huang et al., 2020; Khan et al., 2020). The high risk of illness and death had a negative impact on the morale and emotional well-being of both social workers and residents of nursing homes (Shaw, 2020). Moreover, people working in nursing homes were also afraid that they themselves would be a source of infection for their patients and residents, as well as for their relatives. Hence, in many places they made decisions to live for a while at the workplace or away from their home and family, to protect both groups (Billings et al., 2021; Nyashanu et al., 2020). This became a source of stress and limited workers’ ability to deal with emotional difficulties, for example, by spending time with their relatives or cutting themselves off from work and rest.

Stress, burnout, trauma

In the first part of this article, the particular ethos of social work was mentioned: vocation, dedication, and loyalty to clients and patients. During the pandemic, this ethos was a source of new tensions and moral dilemmas. Loyalty to patients proved to be difficult to reconcile with loyalty to family. This moral conflict also concerned the sense of commitment contrasted with the sense of danger and the need to take care of oneself (Vermeerbergen et al., 2021).

Many texts, both systematic articles and opinions, dealt with the well-being of social workers during the pandemic. The most important stressors and potential causes of burnout have already been described: increased uncertainty and information chaos, insufficient security and support from employers and institutions, fear for one's own health and others, moral dissonance and dilemmas, greater workload – more tasks and more working hours, the need to quickly and frequently learn new procedures and tools. Researchers very quickly noticed the need to diagnose and monitor the mental health and emotional well-being of people working on the front lines in the fight against the pandemic, especially HSCW. For example, in the United Kingdom it was noted that as many as 22% of them have PTSD symptoms, 47% – depression, and the same number – anxiety (Greene et al., 2021). Higher than average levels of depression and post-traumatic stress symptoms were found among Italian healthcare workers (Di Tella et al., 2020), and was significantly higher than in a normative sample level of emotional exhaustion (Barello et al., 2020). In Portugal, 53.1% of people in these groups experienced high levels of burnout, but anxiety, depression, and stress remained normal (Duarte et al., 2020). In Israel, symptoms of depression were reported by 33.6% of respondents, 11.7% reported serious difficulties in social and professional functioning, and 21.5% reported anxiety (Zerach and Levi-Belz, 2021). A study in China shows that 50.4% of participants had symptoms of depression, 44.6% of anxiety, and 71.5% of distress, and 34% suffered insomnia (Lai et al., 2020). All those dire effects could be exacerbated in line with ethnic inequalities. For example, in the UK, HSCW with black ethnic background reported a lower level of work-related quality of life than their white counterparts (McFadden et al., 2021c).

Self-care as a remedy

As a response to the above-described challenges, some authors, both academics and social work practitioners, proposed and promoted self-care, while researchers studied coping strategies and the forms and scope in which self-care was practiced in HSC occupational groups. The emphasis on self-care resulted from statements made by crucial organisations: the World Health Organisation, the National Health Service, American Centres for Disease Control and Prevention (CDCP), and the National Association of Social Workers (NASW) all recommended self-care to deal with difficulties during the COVID-19 pandemic (Miller and Reddin Cassar, 2021).

Self-care was defined either directly or enumeratively. In the context of the analysed literature, the common and shared notion may be summarised as an ‘intentional practice of mindfulness to maintain physical, emotional, and spiritual well-being’ (Downing et al., 2021). Agencies recommended various practices to the general public, for example, healthy eating, maintaining a sleeping routine, regular physical activity, limiting alcohol intake, connecting with others, doing enjoyable activities (CDCP, n.d.). Appealing directly to social workers, NASW advised making time for self-reflection and avoiding burnout by journaling, positive affirmations, taking a ‘mental health day’ and practicing positive thinking (NASW, n.d.; Vasquez, n.d.). Others made similar recommendations to HSCW, and proposed meditation, doing sport, yoga, proper sleep, contact with loved ones (Downing et al., 2021; Felder, 2021; Ross et al., 2021), taking time off when needed (Downing et al., 2021), and setting boundaries (Hansel, n.d.; NASW, n.d.). Seeking individual help (e.g. therapy) was also frequently advised. These authors focused solely on individual practices of HSCW. While some of their propositions may be broadly available, others require some skills and knowledge (setting boundaries, yoga, meditation) or structural and practical opportunities (taking a day off, therapy).

Others formulated recommendations for organisations. These included ensuring workers’ access to supervision and counselling and providing them with training, for example, workshops on coping techniques or particular challenges of working in the times of Covid (McFadden et al., 2021c; Rubin and Rassman, 2021). Based on practical experiences and solutions of the first months of the pandemic, creation of support groups was also advised (Cooper and Zerden, 2021; Kusmaul et al., 2020; Rubin and Rassman, 2021).

Individual coping strategies are an important factor explaining the differences between self-reported levels of well-being of workers with similar job demands (McFadden et al., 2021c). It is therefore crucial to monitor the ways in which workers manage stress. Studies dating from pre-Covid times demonstrated that social workers and HSCW around the world engaged in self-care only moderately or ‘sometimes’ (Miller et al., 2021a, 2021b). A study conducted in the United States has shown that during the COVID-19 outbreak, the frequency of self-care practices among HSCW significantly decreased. The practices that were measured included professional development, cultivating professional relationships, spending time with family and friends, monitoring emotions, triggers and reactions to clients, or taking time for relaxation (Dorociak et al., 2017; Miller and Reddin Cassar, 2021).

Organisational conditions of self-care

Various empirical studies performed during the pandemic have shown that organisation of work and the social environment are important factors for workers’ well-being. For example, a study in the United Kingdom demonstrated that fear of infecting others, lack of support or opportunity to talk to management about problems, a sense of stigmatisation, and lack of access to personal protective equipment were predictors of high risk of PTSD symptoms, while high household income lowered the risk of mental disorder (Greene et al., 2021). Studies in Northern Ireland and Canada indicated a significant relationship between well-being and organisational factors. Perceived effectiveness of communication and accurate and timely information from the organisation on COVID-19-related issues was an especially strong predictor of psychological well-being (Jordan et al., 2021; Wilbiks et al., 2021; Wu et al., 2020). Availability of PPE, ventilators and other resources, actions to reduce the risk to HSCW of contracting COVID-19, and support regarding decisions and individual priorities are also important in reducing moral distress (Plouffe et al., 2021).While individual coping strategies are an important factor, conditions of work and organisational factors may be crucial in workers’ access to their usual self-care methods. The individualising perspective on self-care turns out to be even more insufficient in the light of research demonstrating that the organisation of work is very important for the possibility of using self-care tools, including those provided by the employer. A panel study in the United Kingdom showed a decline in well-being among HSCW over the course of several months of the pandemic (between May and July 2020 and between November 2020 and January 2021), possibly, as the authors note, caused by increasing environmental demands in jobs, that did not allow employees to apply their usual coping strategies (McFadden et al., 2021c). The importance of the employer’s role was demonstrated in observations regarding problematic self-care solutions, such as psychological consultations and support groups available only during working hours, while simultaneously duties and tasks were intensified. Conversely, overworking prompted unwillingness to stay longer in the workplace to participate in consultations. Access to self-care solutions was sometimes unequal, as it depended on the form of employment (exclusion of employees and agency workers) (Billings et al., 2021). Moreover, the risk of infection could be unevenly distributed even among representatives of one occupational group. For example, a UK study has shown that HSCW from ethnic minorities were more likely to be delegated to the frontline and infected patient-facing roles (Kapilashrami et al., 2021). Systemic racial bias and inequalities were exacerbated, leaving minority groups exposed to more stress and with less support and opportunities for self-care.

Viewing self-care critically: towards the ethic of care

Critical approaches to self-care, which incorporate a broader organisational perspective, have been discussed in the field for some time now. For example, Miller and Grise-Owens proposed a notion of organisational wellness, which draws attention to the ‘larger system’s role in employee well-being’ (Miller and Grise-Owens, 2020: 6). Pyles notes the dangers of a neo-liberal model of self-care and advocates for a healing justice framework (Pyles, 2020). Pyles’ views are similar to those that inspired this article; however, I argue that the broad notion of neo-liberalism is not as helpful for understanding the deficiencies of the neo-liberal self-care approach as the more specific notion of responsibilisation. Viewed from the perspective of governmentality studies, responsibilisation may be presented as a logic, and individualised self-care as a technique of governing carers towards managing their own effectiveness at work, in spite of organisational difficulties. The carer, as a Foucauldian homo æconomicus, should accept difficult circumstances and look for solutions in oneself: their behaviour, thoughts and emotions, which all can be managed with self-care tools. By introducing this technique of governing, the institution limits its responsibility and shifts it onto an individual. As a consequence, carers are compelled to deal with their own, as well as organisational and systemic issues. One of the strategies to mitigate the responsibilisation process is to propose and implement an alternative mode of governmentality, which partially relocates the responsibility from an individual worker to the employer and a workplace as an organisation.

Various authors develop the ethic of care, based on values of mutual responsibility, intersubjective action and participation (Posselt, 2021: 2). In the neo-liberal approach, HSCW are tasked with caring both for others and for themselves, because their care for others is not reciprocated. The ethic of care introduces reciprocity and collectivity to the caring relationship. It is a movement toward a caring democracy (Posselt, 2021). I consider community care to be the practical implementation of the ethics of care. It integrates individual self-care with what Miller and Grise-Owens (2020) called ‘organisational wellness’. These notions should be considered complementary, and not as a dichotomy. The focus on individual self-care, as presented in the previous part of this article, prompts organisational leaders to ‘fail to recognise their role and place all responsibility on employees for their own well-being’. However, individual practitioners also ‘abdicate or do not know how to access their power to affect their own well-being through intentional self-care’ (Miller and Grise-Owens, 2020: 6). Yet, I argue that the power imbalance between the workers and the organisation they work in, as well as the crucial role of organisational factors in the workers’ well-being (as shown in the pandemic crisis), make organisations powerful actors in ensuring individual well-being of their employees. While responsibilisation neglects ‘the social and political culture in which individual responsibility is embedded and experienced’ (Gray, 2009: 328), the pandemic crisis has demonstrated its adverse consequences for individual HSC workers. The concept of community care is based on this assumption and calls for the workplace role to be extended in providing individuals with self-care opportunities beyond individual responsibilisation and in accordance with the ethics of care.

In an organisational context, community care may be defined as institutionalised self-care (Chamberlain, 2020). Organisations that support self-care should not relegate the task of caring by oneself entirely to the worker, but facilitate it or actively provide tools for self-care through the appropriate arrangements. This may mean adjusting the budget and work process to this goal, as well as considering existing conditions which may affect self and collective care in the organisation. For example, peer support may be difficult to implement if the team consists mostly of inexperienced workers with only few experienced ones to provide advice and support, as suggested by the study in which it was described not only as a relief but also as a burden (Billings et al., 2021). Chamberlain (2020) provides some examples and tools of collective care (sabbatical, ‘pillow day’ to stay home, spaces in the workplace to rest, etc.) and they all require an active role of the organisation to make self-care possible and effective, instead of becoming one more task for the workers to manage by themselves. Self-care should be promoted in a credible and reliable way, with leaders setting an example and encouraging a supportive atmosphere in the workplace. The commitment of the organisation may be formalised in a document to which workers can refer. Burnout and excessive stress prevention should be in place and workload has to be monitored and managed in order to make participation in any self-care activities possible. Trade unions must play a part in the process, as enterprise-wide activities, such as those postulated and monitored by trade unions, are more effective (Farr, 2021).

Interestingly, although they refer to responsibility discourse, as indicated above, NASW 2012 policy statements, which were later amended for better inclusion of self-care language (Murray, 2021; NASW, 2012, 2020), present elements of community care as well. This promotes the employer’s role in providing the worker with individual self-care tools (workshops, educational materials), but also in organising time and space for actual implementation of these tools (encouraging time off, staff retreats, spaces for meditation) (NASW, 2012: 269). As demonstrated by research suggesting failed institutional support for the employees (Billings et al. 2021), providing them with learning opportunities such us webinars on self-care, or administrating peer support groups providing psychological help is only one part of the task. Work needs to be organised in such a way that workers actually have time to use and benefit from these tools. Enabling self-care through protected time to attend it is crucial (Hanna et al., 2021).