“We just take care after each other” Relational health strategies of nurses and nursing aides working in residential long-term-care as a mechanism of in and exclusion in care teams

2.1Research team and reflexivity

The participatory research team consisted of four Dutch-majority women and Moroccan-Dutch woman, working as academic researchers (SD, TA, ZB, PV). The academic researchers were experts in gender, intersectionality and (occupational) health (SD, PV), participation in LCT (TA), Islam, diversity and community health (ZB). The community researchers, four women and one man, from diverse cultural backgrounds, were experts by experience as paid and unpaid care workers, three of which were trained as advanced nursing aides. Interviews were conducted in a couple existing of an academic researcher (SD, ZB) with one of the community researchers (OP, UJ, YJ, NS).

2.2Design

This participatory, qualitative interview study was a sub-study in a broader participatory health research project [36, 37]. This project “Negotiating Health” aimed to unravel how the health of paid and unpaid care workers in residential LTC was shaped by intersecting social determinants of health, such as gender, class, race, disability sexuality and age [24–32]. Participatory health research aims to understand how peoples’ lived experiences are shaped by structural inequalities, together with those whose life or work is subject to the study [38, 39].

While quantitative research has been traditionally dominant within occupational health research, researchers emphasized the added value of qualitative research [34]. Qualitative research aims to understand people’s experiences, behaviors and interactions, it can provide insights about new or relatively unknown phenomena and help to understand the larger social context that shapes peoples’ subjective experiences [33, 34].

Epistemologically, our research is grounded in phenomenology (focusing on lived and subjective experiences), critical theory (unraveling how these are shaped by structural inequalities, using critical theory such as intersectionality) and participatory approaches (not doing research ‘about, but doing research ‘with’ people) [33, 37].

In ‘Negotiating Health’, interviews were conducted with hired employees and self-employed care workers, men and women. This article focusses on the experiences of women working as hired employees within LTC organizations. Findings from other studies are published elsewhere [38, 41].

Participants of the current interview study were recruited through organizations (such as the professional associations for nurses and nursing aides, unions, LTC organizations, support organizations for informal caregivers), through social media as well through the personal network of community researchers. Participants were approached with a general invitation flyer. Inclusion criteria were: being an (advanced) nursing aide, identifying as women, 45–67 years of age, combing paid and unpaid care responsibilities. Eventually, 20 care workers were purposively sampled, also including some nurses, who were higher paid, as a deviant case. Participants came from diverse geographical locations in the Netherlands. As a result of our recruitment strategy, via mainstream channels and organizations, our sample largely consists of white, Dutch majority, women (see Table 1). All participants that responded to our flyer were included; hence our population can be characterized as an ‘convenience sample’ [33]. Interviews were conducted until reached data-saturation was reached within this particular population. Interviews were conducted in a duo of academic researcher (authors) and a community researcher (authors). Interview were mostly conducted at home with the participants. Some participants wished to be interviewed or at their workplace, in a public space or at the university. In two instances, the interview was conducted in presence of a colleague or partner. One interviewee [R17] was so supportive of our study that she proposed to organized a meeting in her home to discuss our preliminary findings with her and seven of her colleagues (total N = 8 participants). This natural group discussion [33] was facilitated by two academic researchers and a community researcher (author names). This meeting was audio-recorded and transcribed ad-verbatim.

2.3Data collection

Participants provided consent before participating. The topic list for this study was developed based on literature and by the community researchers who identified themes and topics that were relevant to them during a six-month photovoice project that was conducted prior to this qualitative study [38]. Themes included balancing paid and unpaid care work, financial concerns, age-related health issues, such as menopause, and health strategies of care workers while working in LTC (Appendix #1 and #2). Interviews are recorded and transcribed ad verbatim. Field notes were made by both interviewers separately, after the interview. Interviews were conducted in Dutch. Quotes in this article are translated by the first author. Member checks were conducted by feeding back summaries of the interviews when participants indicated that they would appreciate that.

2.4Data-analysis

Data collection and data-analysis was done iteratively and collectively. First, data was discussed in monthly –audio recorded and transcribed verbatim –dialogue meetings with the research team, including the community researchers. Second, the first author conducted an inductive thematic analysis using Maxqda. Third, these findings were validated in the natural group discussion. Fourth, after the thematic analysis, an intersectional perspective was applied to deepen our understanding of the ways initial themes were shaped at the intersections of e.g. gender, class, race, migration status, sexuality, disability and age [24–32, 42]. This round of data-analysis and coding in Maxqda was done by the second author, in close collaboration with the first author. This intersectional analysis enabled a more in-depth understanding about the societal inequalities that became visible in interviewees’ experiences. The outcomes from each round of analysis were discussed with the community researchers, who validated our findings and added insights from their own experiences as well as from the interviews they had conducted. The community researchers were not involved in the writing of this article, as they are not proficient in English. All findings and insights are discussed with them; all (co-authors) consent to the content of this article. The community researchers played a major role in the conception, preparation, data-collection and analysis of this study. Not including them as co-researchers was considered unethical to the academic researchers, particularly in a PHR process [43].

2.5Quality and rigour

In line with our epistemological approach, this study adheres to quality criteria for qualitative research such as credibility, transferability, dependability and confirmability, which are rooted in phenomenological, social constructivist and critical theory [33, 44]. The following strategies were employed to enhance the quality and rigour of our study [44]. The study was conducted with a team of multiple academic and community researchers. The community researchers were experts-by-experience as low-paid care workers in LTC. The academic researchers had expertise in the field of LTC, gender and occupational health. Intensive dialogue about the findings contributed to the credibility of our study. At the request of our participants, member checks on our study findings were conducted by sending a summary of preliminary findings and requesting feedback. Data collection and analysis were done iteratively and impacted following interviews. Data was coded by two researchers (first and second author) supervised by a senior-researcher (last author). Codes were discussed extensively until consensus was reached (researcher triangulation). Interviews were conducted until data saturation was reached, which supports the dependability of our findings. Findings were discussed with societal and LTC organizations in steering group meetings. Their reflections validated our findings, which contributed to the confirmability of our study. Although our study is restricted to residential LTC for older people, our findings contribute to a better understanding of gender in health care workplaces and how these gendered (work) environments affect health. This contributes to the transferability of our findings.

2.6Ethical considerations

This study was evaluated by a Medical Ethical Review Committee which confirmed that the Dutch Medical Research Involving Human Subject Act did not apply (dd. April 17th, 2018). Transcripts were anonymized and audio-tapes and transcripts are stored anonymously and will be archived until five years after completion of the study. Participants signed informed consent forms which are securely stored.

3.1‘You have to get sick first, before you can start taking care of yourself’

This theme addresses the normative ideas that shape the ideal care worker. Interviews showed how many participants foreground their ‘caring identities’ as a prerequisite for being a good care worker. This caring identity is often performed through self-sacrifice and silencing one’s own body:

‘My mother likes clean curtains, so if she asks me to come, I won’t say no. And at the end of the day, you are in pain and then don’t even dare to say so. (..) So, yes, I go on even if I am in pain.’ (R3)

In practice, several participants use painkillers, to literally silence their own bodies. Many describe how self-care is not just out-of-character, but rather a taboo. Self-care is not socially accepted within care settings, as it would compromise their caring identity. Participants describe how self-care only becomes legitimate after having compromised one’s health at work, both physically and mentally, for example with burn-out:

‘You have to get sick first, before you can start taking care of yourself.’ (R5)

3.2‘They won’t say to us, go home and get some rest’

Many participants in our sample feel uncared for by society and LTC organizations, translating into feelings of pain, anger and frustration. Care organizations’ focus on production and quality of care comes at the expense of care workers’ health and caring responsibilities. Most care workers understand these problems as structural, and describe how ‘good’ managers have to deal with shortages of personnel and that a large ‘span-of-control’ makes it impossible to take care of their team:

‘Even if we would all be working seven days a week, we still couldn’t fulfill all shifts. Do you understand? So, the manager won’t see to us, just go home and get some rest’ (R10)

Several care workers critique these larger structures and express hope that care workers will organize themselves to critique this lack of appreciation. At the same time, many care workers can hardly envision a different (political) reality, compromising their hope for change:

‘I: Does it make you angry? R: No, I don’t get angry. I do my work with love, so, no I don’t get angry. I: But would you like it to be different? R: Well, they won’t allow it to be different because the insurance company won’t pay for it. I: Do you think it would be a good idea if the insurance companies would pay for it? R: Yes, but I don’t think so ...   well, that won’t happen. I: but would you like it to happen? R: definitely, because the people we care for really need it’. (R2)

3.3“We just take care of each other”: relational health strategies

As a result of the lack of societal and organizational care, care workers turn to each other to protect, support and maintain their health. This relational health strategy is a response to the political and organizational context. Lacking hope for political change, they consider it their individual responsibility to find solutions within this system:

‘I have a great sense of duty, and loyalty to the organization that I work for, and my team, and if I have the drive to ...   I just don’t like to quit. So, it puts me in the mode of, where are possibilities to keep going’ (R9).

Their solution to the lack of organizational care and support, is taking care of each other:

‘If they don’t take care of their employees, the employees just have to take care of themselves.’ (R19)

‘You receive more support from your own colleagues, than from a manager.’ (R4)

Many care workers speak of care teams in terms of a ‘family’ that takes care of each other:

‘We are just one big family (..) Because we work well together and keep each other safe.’ (R5)

Relational health strategies were strengthened by shared experiences, for example in this team where menopausal transition yielded solidarity among team members:

‘We take care of it together ( ...  ) We are all going through menopause. So, we all have moments that we just can’t do it, and then we are there for each other. That is all really easy and good’. (R5)

3.4“Some just want to stick together”: the flip-side of relational health strategies

This theme describes how these relational health strategies can contribute to exclusion within care teams. Not everyone is equally included in ‘the family’ of a care team. This ‘family atmosphere’ often required the exclusion of those who did not fit:

‘I: How does this atmosphere came about? R: Well, that took us a long time. We had to throw all the rotten apples out of the basket.’ (R8).

Participants in our sample who were not financially dependent upon their care work, often because they could fall back on their male, high-or-middle classed, partner income, and could afford to work part-time to restore their health or do unpaid care work, narrated more extensively about solidarity within teams. They embodied the ideal worker, and were easily included within the team. This respondent for example shared how not being financially dependent upon your care work made it easier for her to be a ‘good colleague’:

‘I have a small contract, for 8 hours. ( ...  ) See, if you work 24 hours a week then you have to work. But I can work. If a colleague is sick or has a party to go to, I can just see, no problem, I can take your shift’. (R18).

Those who cannot adhere to the normative expectations of the ‘ideal care worker’, more often experienced exclusion from care teams. Exclusion was shaped by (dis)ability, for example because when participants suffered from health issues and had to set their boundaries (self-care):

‘You can just handle less. ( ...  ) And some colleagues don’t accept it. ( ...  ) For example, when I said, I can’t do it, it’s just too heavy, they would say: well, just try anyway. ( ...  ) I would be like, come on. Some colleagues really had little sympathy for me.’ (R13)

The normative ideal of ‘being available’ was also reproduced with teams, as a marker of solidarity and involvement. Often, this availability was made possible by heterosexual relationships or not having young children. Women who are not always available, for example single mothers, do not fit the norm and could not always count on sympathy from team members:

“This is a group of women who would say like “Well, I also had to take care of my children when I was your age. ( ...  ). So, I am not going to take her children into account now.’ (R8)

The participants in our study often expressed frustration about the ‘younger generation’ as they were not embodying the norm of self-sacrifice, according to the ‘older generation’:

‘Those young girls, they come and work with us, but then also want to play sports on Saturday, go to the movies on Sunday. They go to the gym two times a week and out to party one time a week. (..) I would be like, (cynically) you want to combine all of that with working in long-term care?’ (R22).

Women who are facing financial precarious situations, do not fit the norm and were othered. Many care workers, who were not financially dependent, implicitly stated ‘doing it for the money’ compromised women’s caring identity:

‘They told us: “In many nursing homes people work for the money, but here in (name organization), you work for people.” To me, that was a great compliment.’ (R9)

Sameness was also challenged when women who were seen as ‘culturally other’ by the dominant group within a care team, also experienced exclusion:

‘Always these questions. Oh, you don’t drink alcohol? No? I just get sick and tired of it. Also. Also, with Ramadan: “You shouldn’t do it. It’s not healthy”. Pfff, just very tiresome.’ (R10)

Those who faced exclusion within care teams, as they could not adhere to the norm, experienced negative health effects as a consequence of these experiences of exclusion, further stressing their health. Who does and does not fit in the team, was distinctly shaped by norms of the ‘ideal worker’, and embraced or pushed out by these relational health strategies:

‘I can understand if you don’t feel well sometimes, and that you share it, so you can take care of each other. But after two to three times, you start thinking “hmm”. And, after the fourth time, you are like, cursing to yourself, I am not here to do both our jobs. I am already running faster than I can. I know, we cannot all carry the same load, but after a while you just think to yourself, can we please get somebody else to work here?’ (participant FG).