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Elderly care in transition – Management,
meaning and identity at work
 annette kamp and helge hvid (eds)

Elderly care in transition – Management,

meaning and identity at work
A Scandinavian perspective

Copenhagen Business School Press

Elderly Care in Transition
– Management, Meaning and Identity at Work
A Scandinavian Perspective

© Copenhagen Business School Press, 2012

Typeset and e-book production: Sl Grafik
Cover design by Klahr | Graphic Design
1st printed edition 2012
1st e-edition 2012

e-ISBN: 978-87-630-9936-3

Copenhagen Business School Press

Rosenoerns Allé 9
DK-1970 Frederiksberg C
Denmark
Tlf: + 45 38 15 38 80
Fax: + 45 35 35 78 22
[email protected]
www.cbspress.dk

All rights reserved. No part of this publication may be reproduced or used in any form or by
any means – graphic, electronic or mechanical including photocopying, recording, taping
or information storage or retrieval system – without permission in writing from Copenha-
gen Business School Press at www.cbspress.dk.
Table of Contents

About the authors · 9

1. Introduction: Elderly care in transition · 13

Annette Kamp and Helge Hvid
Three types of criticism of modernisation · 15
Objectives and background of the book · 20
Introduction to the chapters of the book · 21
References · 26

2. Paradoxes in Elderly Care: The Nordic Model · 29

Hanne Marlene Dahl and Bente Rasmussen
Introduction · 29
A Nordic model in elderly care? · 31
State engineered professionalisation · 33
New Public Management: Context and ambiguity · 35
New Public Management as quality: Standardisation and free choice · 38
Quality, meaning and resistance · 39
Paradoxes · 41
Conclusion · 42
References · 45

3. The quest for the meaning of work: Competing concepts of

meaning · 51
Annette Kamp
Introduction · 51
The classic conceptions: Controversies on meaning, motivation and work · 54
Meaning of work: a critical perspective · 59
A management perspective on meaning · 63
Meaning from a transformation perspective · 69
Conclusion and perspectives · 73
References · 76
4. Knowledge at play: Positioning care workers as professionals
through scientific rationality and caring dispositions · 83
Andreas Fejes
Introduction · 83
Background · 85
Method · 89
Policy discourse on professionalisation · 90
Constituting a caring self: caring for and caring about · 92
Acknowledging caring dispositions · 95
Discussion · 100
References · 103

5. Meaning of work in elderly care in Denmark: Fragile

reconstructions · 107
Annette Kamp
Introduction · 107
Meaning of work – a dynamic approach · 110
The emergence of professional identities · 113
Home helpers at a crossroads · 116
Different perspectives – the meaning of work · 117
Meaning and identity in transition · 125
Concluding discussion · 128
References · 130

6. The meaning of work from subjective and intersubjective

perspectives – a daily conflict of creating and losing meaning
in elderly care · 133
Betina Dybbroe
Acknowledgement of workers’ subjective meaning in elderly care · 136
Subjective meaning · 140
The meeting · 142
A case of intersubjective and subjective meaning · 145
Meaning in the meeting of a care worker, a dying patient and relatives · 146
Subjective meaning in care work · 148
Subjective meaning in the meeting with societal structures · 150
Meaning from a managerial perspective · 153
Concluding remarks · 159
References · 160
7. New Public Management: Constructing a new management
identity in care for the elderly · 165
Bente Rasmussen
Introduction · 165
Power, freedom and self-discipline · 167
Managing public services · 169
Method and data · 172
Power and freedom to manage in nursing homes · 174
Boundless work in home-based care · 177
Power and freedom to manage? · 182
References · 186

8. Creating meaning in dementia care work – a story of (re)

professionalisation? · 189
Pernille Bottrup and Per Bruhn
Introduction · 189
A brief glance into the world of a dementia care centre · 191
Dementia care work – a historical perspective · 193
Creation of meaning as a learning process · 201
Meaning in dementia care – case analysis · 204
Summary and conclusion · 222
References · 227

9. The future of elderly care – beyond New Public

Management? · 231
Helge Hvid and Annette Kamp
The external perspective: Scandinavian elderly care as an object lesson · 231
The internal perspective: Scandinavian elderly care as a maltreatment
sector · 233
New Public Management and the quality of elderly care · 234
New outlook? · 236
Innovation in elderly care daily practice · 237
Gradual professionalisation · 239
Changes in local management? · 241
Changes in management systems? · 242
Beyond New Public Management? · 243
References · 244
 About the authors 9

About the authors

Andreas Fejes is an associate professor in Education at Linköping

University, Sweden. His research areas are lifelong learning, adult
education and workplace learning with a specific interest in how
subjectivities of adults are shaped drawing on poststructural theo-
risations. He has published numerous peer-reviewed articles, books
and book chapters. Currently, he is (with M. Dahlstedt), finalising
the book: The confessing society: Foucault, confession and practices of
lifelong learning, which will be published by Routledge in 2012. Fejes
is also editor of the European Journal for Research on the Education and
Learning of Adults.

Annette Kamp is an associate professor at the Centre for Working

Environment and Working Life at Roskilde University. Her main
research interest is how new ideas of management and organisation
transform working life. In the later years her focus has been on NPM
and work in the public sector. Consequences for profession, identity
and meaning of work have been pivotal. Her work has addressed
work in elderly care, health care and public schools. She has pub-
lished numerous peer-reviewed articles, books and book chapters.
Kamp is also co-editor of the Danish journal: Tidskrift for Arbejdsliv
[Journal of Working Life].

Bente Rasmussen is a Professor in sociology at The Norwegian

University of Science and Technology (NTNU), Trondheim, Nor-
way. Her research interests are in work and organisation where she
has focused on technology, gender and new forms of organisation
resulting in the books Nye kvinneliv. Kvinner i menns organisasjoner
(New women’s lives) and Arbeidslivets klemmer (The squeezes and hugs
of working life) with Elin Kvande. She has published in the field of
gender and IT (young girls, women in computer science). Recent
publications have addressed changing employment relations and
forms of organisation in knowledge work and the introduction of
NPM in the public sector.
10 Elderly care in transition

Betina Dybbroe is an Associate Professor at the Department of

Psychology and Educational Studies, Roskilde University. Betina
Dybbroe is the director of Center for Health Promotion Research.
Her special conceptual interest is in questions of work identity, in-
teractions between professionals and citizens in health and care, de-
velopment of public care as welfare, life history as methodology, and
the relation between learning, action and health promotion. Her lat-
est relevant publications in English include: Andersen and Dybbroe
(eds.) (2011), Journal of Social Work Practice; Special Issue: Social
Work, Health Care and Welfare undergoing Transformation in Scandi-
navia, London; and Wrede, Henriksson, Høst, Johansson and Dyb-
broe (eds.) (2008): Care Work in Crisis – Reclaiming the Nordic Ethos
of Care, Studentlitteratur, Sweden.

Hanne Marlene Dahl is a professor in Care, Gender and Welfare

at the Deptartment of Society and Globalization at Roskilde Uni-
versity. Her main research interest is in the governance of care – in-
cluding govermentality and NPM – at various levels from a feminist
perspective.
She has recently investigated the meeting of consumerism with
a professional logic, the situation of au pairs in different EU coun-
tries, and has co-edited Europeanization, Care and Gender, published
by Palgrave Macmillan, as a part of her participation in the EU net-
work of Excellence CINEFOGO.

Helge Hvid is a professor at the Centre for Working Environment

and Working Life, Roskilde University (see www.aliv.ruc.dk). Helge
Hvid has a long career in working life research. Most of his research
is driving by an aspiration to expose the often unexploited possi-
bilities to create human development in current working life. He
has been involved in numerous research projects. In the latest years
about IT and working conditions, time and rhythms in working life,
efforts to improve psycho-social working environment. Helge Hvid
is the chief editor of Nordic Journal of Working Life Research.

Peter Bruhn is Sociologist, Consultant in Kubix. Bruhn’s special

interests are analyses, evaluation and development activities, pri-
marily related to learning, education and working environment in
 About the authors 11

private and public companies. Examples include: Project Wellbeing

– from extortion to enrichment, The Social and health department of
the Municipality of Copenhagen; Integrating working environment in
vocational training (2008); The Council of Working Environment.

Pernille Bottrup is master in cultural sociology, PhD. in organisa-

tional learning, consultant at Kubix. Bottrup has been working with
research and development concerning working life, workplace learn-
ing, the interplay between working environment, work organisation
and work-related learning, knowledge sharing, and new production
concepts within public and well as private organisations. Her special
focus has been on the concept of ‘learning space’ which describes
the organisational, technical, cultural, political and social elements
that influences the opportunities for learning at the workplace.
12 Elderly care in transition
 1. Introduction: Elderly care in transition 13

1. Introduction: Elderly care in

transition
Annette Kamp and Helge Hvid

Throughout the Western world, the elderly care sector is undergo-

ing change: it is being placed under management, professionalised
and systematised. While elderly care used to be part of the informal
economy, performed in families, it is now increasingly becoming a
professional activity performed in a new, growing sector, organised
either within or outside of the welfare state. This book looks specifi-
cally at working life in the elderly care sector – an important field
of occupation for women that is undergoing major transformation.
In Scandinavia, elderly care used to be one of the core compe-
tences of the welfare state and was provided as a universal public
service. When the sector was established, around 1950, the work
was developed on the basis of housewifely skills and virtues, which
had previously been the framework for informal elderly care: those
who worked in the sector were typically housewives, who based their
work on their identity and experience as housewives. However, the
sector has gradually been formalised and professionalised. Work
in elderly care is no longer a secondary occupation to the role of
housewife, but a primary occupation and a career, and it has become
unionised (Dahl 2000).
In many Western countries, elderly care is a low-wage sector with
a low status in the informal and in the private sector. It is therefore
particularly interesting to study the development of Scandinavian
elderly care characterised by universalism, professionalisation and
unionisation (Boris and Klein 2006; Rausch 2007). Here, different
and better conditions have been established for developing mean-
ingful work, whose contribution to society is recognised on a par
with other professional work.
However, in recent years there has been much criticism of the
way work in elderly care has developed in Scandinavia in the last 15
14 Elderly care in transition

years (Dahl and Eriksen 2005; Trydegård 2005; Szebehely 2006;

Wrede et al. 2008). This sector has become a testing ground for
neo-liberal management. Elderly care is in fact the area in which
there has been the biggest drive to apply new public management
(NMP) principles and methods in order to rationalise and increase
effectiveness. These changes have been introduced, among other
things, with reference to what is termed ‘the crisis of care’ in Euro-
pean debate. The argument is that, owing to the growing number of
elderly citizens, it is foreseeable that the sector will continue to grow
and thus constitute an increasingly large economic burden that will
have to be shouldered by increasingly few people. NMP involves
– roughly speaking – management via development of market-like
conditions. Typical features of this form of rationalisation are divi-
sion, codification and standardisation, so there are clearly similari-
ties with Taylorisation. Thus critical voices point out how this occu-
pation fundamentally defined by care orientation is being subjected
to an instrumentally management logic.
NPM, however, is not a coherent concept for rationalisation and
is not approached in the same way in the three Scandinavian coun-
tries. One of the book’s explicit goals is to create a more nuanced
image of how NPM is interpreted in the Scandinavian countries in
order to provide a basis for a more differentiated discussion of the
changes to the work and the sector.
With these new forms of governance, the understanding of man-
agement and leadership, expertise and professionalism is changing,
and subsequently the meaning of work and work identity in elderly
care is challenged. The social debates in this field are therefore: what
elderly care ought to be, what good and ethical care work is and how
it should be prioritised in society (see for example Gleerup (2009)
with regard to Danish discussions).
Thus, the meaning of work and work identity constitutes an im-
portant angle from which to approach the conflicts, dilemmas and
strains employees experience in their daily work. On a more general
level, it is also an important angle from which to approach the axes
of conflict in elderly care. These kinds of conflicts might be retrieved
in other areas of the Scandinavian welfare society.
The first wave of Scandinavian studies on NPM and the elderly
care sector focused particularly on these negative trends with regard
 1. Introduction: Elderly care in transition 15

to work and with regard to the citizens who are dependent on it.
This book presents a more differentiated and complex understand-
ing of the development by exposing how work in elderly care has
suffered a loss of meaning, but at the same time how different new
identities and universes of meaning have been created among the
employees. Thus the book also points to the potential that lies in
the employees’ expertise and their creation of meaning and identity.
The ambition of this book, therefore, is to look at the tensions
and contradictions of the developments that have taken place in this
field of work, with a view to identifying new territory and new scope
for creating good work.
Research into the modernisation and rationalisation of care work
brings up different types of ‘criticism of modernisation’. What they
have in common is the understanding of care work as a particular
activity, but they focus on different aspects. One criticism views care
work as building on a particular kind of knowledge and skills; an-
other considers care work as arising from a particular ethics, and a
third regards care work as a special form of service work. They point
out, in different ways, how the modernisation and rationalisation of
care work leads to particular problems or tensions.

Three types of criticism of modernisation

‘Masculine professionalisation’
Since the early 1980s, Scandinavian feminist research on elderly care
has been concerned with the particular traits of care work. The fact
that it is primarily women, who work in the occupation, both as paid
and unpaid workers, has been of key importance to this research
and has paved the way for a rich tradition of research with leading
names such as Rosmari Eliasson, Martha Szebehely and Kari Wær-
ness. One of their goals was to show that care as an occupation is
characterised by a particular rationality; a care rationality, as Wær-
ness calls it. Wærness (1984) points to a care rationality that is not
abstract or formal. The assessment of what should be done and how
is based on knowledge of the citizen and her/his situation. In other
words, the job involves a relational and contextual rationality. At
the same time the job demands a high level of empathy. ‘Good care
16 Elderly care in transition

builds on personal knowledge and the ability to understand what

help is needed in the situation.’
Wærness’ work is first and foremost a lead up to the debate on
professionalisation in the field. She questions whether it is at all rel-
evant to formalise competences and emphasises that developing the
profession on the basis of abstract knowledge follows a traditional
male rationality. Is it at all possible to capture the knowledge that
is essential to perform care work with this approach? She indicates
that this kind of professionalisation serves to hide and degrade other
types of knowledge, which are physical and experience-based.
Tronto (1993) has since softened the one-sided criticism of pro-
fessionalisation as being detrimental. She follows on from Wærness’
work but defines care work via four phases that serve to clarify the
qualifications and skills involved: caring about: recognising needs;
taking care of: taking responsibility and assessing scope for action;
care-giving: the activity itself, the job; care-receiving: how the work
is received, reflection and feedback. Thus she stresses the ability to
recognise needs (empathy) and the obligation to perform care as a
part of the occupation. Both are highly complex tasks that rely on
training that is part of basic socialisation, but which should also be
conceived as part of professional education, training and identity.
The discussion recurs in more recent research into the profes-
sionalisation of care work. For example, Dahl proposes an alterna-
tive concept of professions encompassing the kind of physical expe-
riences that care work is characterised by (Dahl 2000), and current
writing on the subject, such as Andreas Feje’s chapter in this anthol-
ogy, also examines the processes of professionalisation. Here, the
focus is particularly on the dynamics between the devaluation and
revaluation of certain knowledge and skills.

Care ethics
Another angle from which to approach the discussion of the ratio-
nalisation and modernisation of care work is the particular ethic
that characterises care work. Here, the focus is specifically on caring
ability as a fundamental competence we acquire through our own
history as care-receivers. For example, the existentialist philosopher
Løgstrup (1991) points out that a basic condition of human interac-
 1. Introduction: Elderly care in transition 17

tion is being vulnerable and dependent upon one another. None of

us get through life without at some stage being dependent on oth-
ers and their help and care. The care ethic is an obligation towards
those closest to us; it is about ensuring that we fulfil the needs of the
weak. Furthermore, Virginia Held, for example, stresses that care is
also an activity that holds intrinsic meaning; it generates and repro-
duces human relations (Held 2006).
From this perspective, the meeting between the elderly/the citi-
zen and the care-giver is thus the key factor in care work, and possi-
bilities and conditions for this meeting become the starting point for
critical examination of the development of the occupation (Eliassen
1995: Liebst and Monrad 2008). Inspired by this ethical discus-
sion, some care theorists see a problem in the extent to which mod-
ernisation and professionalisation of the occupation leave room for
‘authentic care relationships’ (Eriksen 2001). According to Eriksen,
authentic care relationships are those where care work realises the
essence of care and gives life to and nurtures the care-receiver. Like
Løgstrup, Eriksen sees caring ability as something that is learned
early on in life through socialisation, and which is part of something
overall human. In her criticism of the development of elderly care,
she talks of ‘imprisonment of caring ability’ and shows how the rou-
tine of the work can hinder care skills from properly unfolding. Thus
rationalisation and professionalisation of the work are portrayed as
hindrances to the development of authenticity. This is a highly po-
larising description claiming that ultimately good, authentic care is
prevented from developing in modernised care.
The relational and the emotional aspects undoubtedly play a ma-
jor role in care work, and therefore the discussion of care ethics gives
an important contribution towards understanding how care work is
changing. However, this angle may be criticised for placing too great
an emphasis on the notion of care work as a calling. When work is
perceived as a calling, it is difficult to see it as a paid occupation;
taken to extremes, it may support the idea that care work is best
performed as voluntary unpaid work. If, however, elderly care is per-
formed as paid work, care ethics encourages care workers to intensi-
fy their work and approach it as being without boundaries (Rasmus-
sen 2004; Lund and Hvid 2007). At the same time, this perception
also veils the fact that even if human relationships at work can be
18 Elderly care in transition

enriching and meaningful, there can also be conflicts and problem-

atic relationships between care-receivers and care workers. Numer-
ous studies show how this may be the case (Astvik 2002; Denton et
al. 2002; Büssing and Höge 2004; Munk-Madsen 2006).
The essentialist understanding of care, as presented here, has
also been criticised from a constructivist point of view. It is criticised
for lacking an understanding of the history and context in which
ideals have developed. Daly and Rake, for example, show that this
care ideal is a maternal ideal in certain classes. One expects to a
varying degree to be at others’ disposal, depending on gender, class
etc. (Daly and Rake 2003). Furthermore, the perception of the el-
derly and their needs should be seen as culturally embedded (Fraser
1990). For example, studies on elderly care show how new under-
standings of the elderly and their need for care are historically con-
structed, and these form the basis for the societal organisation of the
work. Active aging is an example of a new interpretation of aging that
has encouraged a new interpretation of the needs of the elderly. The
focus is on rehabilitation rather than care. The idea of rehabilitation
is to concentrate on strengthening the scope of the elderly to realise
their (remaining) potential instead of focusing on their weaknesses
and sufferings (Dahl 2005; Larsen 2010).

Care work in service bureaucracies

Critical organisational sociology offers a third perspective on mod-
ernisation and rationalisation of care work. Here, care work is viewed
as a particular kind of service work.
The characteristics of service work are: 1) it is transitional; 2) it
is variable, i.e. it is constantly being adapted to the customers’ needs
and expectations; and 3) interaction between the customers and the
service workers is (often) an inseparable part of the product.
Scholars in the field emphasise that service work differs greatly
from traditional industrial work. Orientation towards the customers
is a key element of service work, and the relationship with the cus-
tomers is thus an essential element. At the same time, rationalisa-
tion and development of work should also take into account relation-
ships, which create value. This means that instead of characterising
the work merely via the relationship between capital and work, we
 1. Introduction: Elderly care in transition 19

now have to talk in terms of the service triangle, with the relation-
ship to the customers being, so to speak, the third arm (Korzcynski
2002).
This tradition offers new insights in the understanding of care
work in that it underlines the special problems associated with ra-
tionalisation of service work. Rationalisation often involves the in-
troduction of bureaucratic management forms, such as those we
also see in connection with NPM. However, emphasises Korzcyn-
ski (2009), these management forms involve a major focus on man-
agement means, while they have a much lesser, if not inadequate,
concept of goals, which come across as crude and inflexible. Since
service is based on the idea that the customer is in charge and has
options, there has to be considerable flexibility with regard to the
customers’ wishes. Otherwise it is not possible to maintain the no-
tion of customer sovereignty. Thus there is a contradiction between
standardisation on the one hand and delivery of the customised ser-
vice on the other – a contradiction that fundamentally leads to an
unstable and fragile order.
This means that it is difficult to completely mechanise and in-
strumentalise care work. The contradictions that rationalisation
creates are ultimately left to the service or care worker to resolve.
Therefore researchers such as Gabriel (2009) argue that it is im-
portant to focus on the emotional tasks that this kind of work in-
volves and which in reality make it difficult to increase the tempo.
Gabriel points out that there are particularly powerful emotional
dynamics at play in care work. It is precisely because care, as dis-
cussed with regard to care ethics, draws on meaningful experiences
in our earlier lives that dilemmas and contradictions in care work
also activate strong emotions.
Gabriel underlines that care work is unique because it often in-
volves making an extra effort – something outside of the normal
routine – and he observes that carers only do this for selected clients,
those who are considered to be deserving, such as the nice old lady
who is lonely. He believes that contradictions and dilemmas in ser-
vice work often lead to distinctions being made between the custom-
ers; in other words a stereotypical division into good and bad: there
are irritating, demanding and unreasonable customers and there are
those who deserve to be treated as more special. Thus, according to
20 Elderly care in transition

Korczynski (2009), the management of service organisations should

develop strategies for managing these contradictions. He regards the
use of human resource management as such a strategy, which means
that tensions are discussed and redefined and become ‘balanced’.
Moreover the management – in order to compensate – can introduce
backstage arenas in which the emotional tensions can be played out.
The debate on care as service work thus has similarities with the
two other criticisms of modernisation; however, greater emphasis is
placed here on common traits shared with other service work and
problems in the ongoing rationalisation of service work. Some care
work issues are thus also evident in other types of service work.
And this is where, inspired by Arlie Hochschild (1983) and Sha-
ron Bolton (2005), the concept of emotional work is brought in to
capture the special qualifications the work demands and the special
efforts it can involve.
These three angles thus help in different ways to understand the
conflicts that arise when the Scandinavian version of NPM and care
work are brought together. Some of the contradictions and conflicts
may stem from the fact that NPM is not one coherent management
concept, but should rather be seen as a bundle of different manage-
ment approaches. As this is the main theme of chapter 2 in the book,
we will not go into any further detail here.

Objectives and background of the book

This book is based on original studies of elderly care in the Scandi-
navian countries in which elderly care has constituted a major sector
of the formal economy. The various chapters in the book – which
focus on management, meaning of work and work identity – provide
a diagnosis of the dilemmas present in elderly care today and the
challenges for developing a good, healthy occupation. At the same
time, the book strives to develop an understanding of work that can
function both critically and constructively with regard to the de-
velopment of working life. Finally, by focusing on the workplace,
the book also helps us to understand how NPM in Scandinavia is
characterised by conflicting trends in addition to showing us where
 1. Introduction: Elderly care in transition 21

pockets of resistance and opportunities exist for transforming and

reinterpreting the prevailing rationales.
The book grew out of a research network between Scandinavian
researchers with a shared and enduring research interest in elder-
ly care and development of work in elderly care. Furthermore, re-
searchers in the network share a preoccupation with the changes
that have been going on in connection with NPM and an interest for
women on the lowest rung of the labour market.
The network was established in 2008 on account of a four-year
research project: The meaning of work in the elderly care sector,
funded by Arbejdsmiljøforskningsfonden (The fund for research on
working environment). The authors come from different areas of ex-
pertise, such as political science, education and profession research
and work sociology. We consider this diversity in particular to be a
huge strength that has enriched the network’s discussions and has
made the book more intense and more nuanced.

Introduction to the chapters of the book

For a long time, the Scandinavian model for elderly care has ap-
proached this area as a public task. In chapter 2, Paradoxes in elderly
care: The Nordic model, Hanne Marlene Dahl and Bente Rasmussen
explain the changes that have taken place over the last ten years and
discuss how they have created new breaches and contradictions in
the work. The professionalisation of the work, which has been driv-
en by both the state and the trade unions, has led to empowerment
and greater autonomy for care workers. However, the development
of new forms of neo-liberal management in the form of NPM and
quality reforms, with emphasis on greater standardisation and con-
trol, is now pulling in the other direction and is undermining this
autonomy. The authors underline how these forms of management
are being developed through adaptation to and negotiation between
new and existing structures. The result is highly contradictory. And
the authors point out that in reality, it is difficult to implement free
choice (for the elderly) and business excellence as a management
principle. Work in elderly care is thus characterised by contradic-
22 Elderly care in transition

tions with regard to professionalism, autonomy and meeting the in-

dividual needs of the elderly. The starting point of the chapter is the
Danish experience as an example of a classic Scandinavian model,
but at the same time it also draws on experiences from Norway and
Sweden and thus sheds light on the differences in the way the sys-
tems have evolved.
The question of the meaning of work is experiencing a renais-
sance in the debate on good, healthy occupations. In chapter 3, The
quest for the meaning of work: Competing concepts of meaning, Annette
Kamp argues that a focus on the meaning of work is of interest when
discussing changes and shifts in care work. It can help us to dis-
cuss shifts in the concept of care, work identity and social relations.
However, meaning and the construction of meaning are perceived
in a variety of ways within different scientific traditions. Kamp
identifies three theoretical perspectives on the meaning of work: a
management perspective, a critical perspective and a transforma-
tive perspective. She discusses their implications and how they can
be used in her literature review. She points out that the focus of the
management perspective on meaning and the individual realisation
of human potential in the service of the organisation can mean yet
another normative demand in working life. The critical perspective,
with its focus on loss of meaning, contributes useful insights, but
often has a tendency to be backward-looking, towards better times.
The transformative perspective has a greater focus on conflicts and
dynamics and is more open to a discussion on how work can develop
in local contexts.
What is a professional care worker? What kinds of knowledge
and experience are valued? In the fourth chapter, Knowledge at play:
Positioning care workers as professionals through scientific rationality and
caring dispositions, Andreas Fejes examines how different kinds of
qualifications – emotional and abstract – are constructed as more
essential or less essential for improving the quality of elderly care
work. Fejes looks at education programmes established to increase
recruitment and improve the quality of Swedish elderly care. Based
on a discursive analysis of both policy and practice, Fejes points
out that emotional qualifications involved in a caring disposition are
considered to be a cornerstone of professional identity. A caring dis-
position constitutes the starting point for being qualified through
 1. Introduction: Elderly care in transition 23

abstract and theoretical knowledge to meet future challenges. Thus

care workers are positioned as people who lack scientific knowledge.
Fejes sees a problem in the fact that abstract knowledge is construct-
ed as true knowledge, while experience-based emotional knowledge
is subordinated. But, he stresses that the ability to be caring is in fact
understood as being productive, and points out that this represents a
shift in comparison to Wærness’ classic analysis. She found that this
type of knowledge was merely underrated and marginalised (Wær-
ness 1984).
The debate on development on work in elderly care has particu-
larly focused on neo-Taylorian characteristics and the negative con-
sequences in the form of loss of autonomy and meaning of work.
Annette Kamp shows in chapter 5, Meaning of work in elderly care in
Denmark – fragile reconstructions, how processes of change can also
open the door to new perspectives and provide scope for creating
new meaning and identity at work, even if dilemmas and contradic-
tions are characteristic. Here, the construction of meaning is re-
garded as a dynamic and ongoing process. The chapter is based on
an in-depth case study of home helpers in two districts which has
been subjected to NPM-inspired reforms over a long period. Kamp
points out that the meaning of work depends on the opportunities
available for constructing a positive work identity, i.e. an identity
that is recognised collectively and socially. She identifies three dif-
ferent possible constructions of identity: one focuses on the nursing
elements of the work; one emphasises the home helpers’ ability to
survey the home and the elderly and solve problems; and one high-
lights the social elements of the work. The chapter concludes with
a discussion of the possibilities and the perspective for developing
work along these lines.
Work in elderly care involves ‘heads, hearts and hands’. The
meeting between the staff and the elderly is not just ruled by ratio-
nal knowledge and practical experience. It is also ruled by emotions,
reciprocity and subjectivity. These emotional aspects of the work
are what Betina Dybbroe particularly emphasises in chapter 6: The
meaning of work from subjective and intersubjective perspectives: A daily
conflict of creating and losing meaning in elderly care. Here, the focus
is on the importance of subjective experiences, emotions and so-
cialisation in the meeting between the staff and the care-receivers.
24 Elderly care in transition

The subject is understood to be a creative actor seeking to achieve

individual meaning while seeking a sense of belonging in the social
world. The chapter centres on a case involving a dying patient, the
patient’s next of kin and the nurse, who is the central carer. The
nurse feels an individual responsibility for doing good work in a situ-
ation characterised by conflicting considerations and lack of clarity
about what is good and right in the situation. This leads to guilt,
shame and frustration. The subjective and emotional side of care
work is ignored in the management of elderly care and, according to
Dybbroe, these aspects are also given too little consideration in most
research in the field.
One of the basic pillars of modernisation of the public sector is
the professionalisation of management. This implies a change in the
identity of the manager from care professional to general manager.
In chapter 7, New public management: Constructing a new manage-
ment identity in care for the elderly, Bente Rasmussen looks at the
consequences of this development in a case study of managers in
two types of institutions in Norway: home care and nursing homes,
where managers are given ‘freedom to manage’. The new manage-
ment identity is supported through the decentralisation of respon-
sibility; at the same time the managers are governed from above via
standards and contracts, in which they are made responsible for sup-
plying a cost-effective service to the elderly. Rasmussen shows how
this involves tensions that hinder the development of management
identities corresponding to the new management ideals. Managers
in care homes are, however, better able to take on the new manage-
ment identity than managers in home care. In home care reconciling
the economic and quality-related demands was impossible, and sub-
sequently living up to the new management ideal proved unfeasible.
She shows that the transformation of managers’ identity is not a
smooth process. The managers are struggling to live up to both their
professional care ethos and the new economic rationale, and this is
putting them under pressure.
While NPM is generally perceived as pushing towards de-profes-
sionalisation and standardisation, counter-movements can also be
seen. In chapter 8, Creating meaning in dementia care work: A story of
(re)professionalisation, Pernille Bottrup and Per Bruhn examine the
 1. Introduction: Elderly care in transition 25

development within the field of dementia. Dementia has become a

medical speciality supported by theory and methods. In this case,
better-staffed special institutions with greater work autonomy have
been set up. Bottrup and Bruhn shed light on the opportunities and
restrictions for developing a specific professionalism in this field.
The analysis focuses on the scope for learning in work, the options
for shared reflection and the subsequent development of profession-
al identity. The analysis shows how the structuring of meetings and
artefacts (as well as different concepts) represents a limitation in this
process, as it primarily allows single-loop learning. Cooperation be-
tween the different areas of expertise, which ideally are thought of as
taking place within a cross-disciplinary team, are thus both reward-
ing and full of conflicts. Bottrup and Bruhn point out that placing
greater emphasis on development of competence both outside and
within work to consolidate the initial professionalisation of the field
is necessary.
What does the future hold for elderly care in Scandinavia? In the
ninth and final chapter of the book, Hvid and Kamp try to answer
this question: The future of elderly care: Beyond new public manage-
ment? Elderly care has been at the forefront of the implementation
of NPM, and all of the book’s other chapters investigate in different
ways how NPM has affected the sector. It is simultaneously pointed
out, however, that NPM has not been pushed through complete-
ly. There are also other management rationales at stake. This last
chapter, which picks up the thread again, argues that many differ-
ent types of activities in elderly care currently point beyond NPM.
This is the case in the development of work in elderly care, profes-
sionalisation in the field, the development of local management and
the development of management systems in the sector. Against this
background, it is shown that elderly care may not only be the first
sector to become part of NPM, but also be the first to leave; giv-
ing more autonomy to employees and citizens and by creating more
broad-based jobs demanding greater competence.
26 Elderly care in transition

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 2. Paradoxes in Elderly Care: The Nordic Model 29

2. Paradoxes in Elderly Care: The

Nordic Model
Hanne Marlene Dahl and Bente Rasmussen

Introduction
Meaning is created in particular contexts. The Nordic welfare state
provides a particular context, characterised by universalism, home
based care and state engineered professionalisation, for care workers
within elderly care. Here we outline how recent forms of neo-liberal
governance (New Public Management) and its focus upon quality,
meets and is translated into both standardisation and free choice
creating paradoxical situations in the Nordic welfare state. Not only
does NPM become paradoxical in itself, new paradoxes arise be-
tween NPM and professionalism challenging the existing frames of
meaning for care giving workers.
The Nordic welfare model, characterised by Esping-Andersen
(1990) as a Social Democratic welfare regime, is associated with a
political commitment to universal social security and publicly fund-
ed care services. As it is tax financed, it requires a greater share
of public expenditure of Gross National product (GNP) compared
with other models. The success of the model can be seen in relatively
low income inequality, high rates of full employment, especially for
women, a relatively high level of gender equality and a high birth
rate compared with other welfare models (Kautto et al. 2001; Esp-
ing-Andersen 2007).1
Nordic universalism means that care for the elderly is the re-
sponsibility of the state rather than the responsibility of the family,
as is the case of the conservative welfare model (Esping-Andersen
1990). When home care for the elderly was introduced, in the 1950s
and 1960s, as part of the public welfare programs in the Nordic

1 The Nordic model (i.e. the Danish) not only ensures the best coverage and low
poverty rates for elderly but, comparatively, is the cheapest one if both pensi-
ons and social services are considered as total costs (Sarasa and Mestres, 2007).
30 Elderly care in transition

countries, the overall goal was to enable older people to continue

their normal lives as long as possible by staying in their own homes.
This was warmly welcomed as an alternative to the institutions for
the elderly which were associated with limited personal freedom and
stigmatisation stemming from the poor-law era (Dahl 2000; Szebe-
hely 2003). Home care made the elderly independent of daily help
from their children when their health failed, and it also implied a
freedom for daughters to choose paid employment despite having
ailing parents who needed care (Vabø and Szebehely, forthcoming).
Home care became very popular among all social groups in the
Nordic countries and state subsidies contributed to the growth of
home care services (Szebehely 2003). Although the expansion was
followed by policies of rationalisation to meet increasing needs for
care, the number of elderly living at home and receiving public care
services is very high in the Nordic countries compared to other Eu-
ropean countries. There are, however, differences between the Nor-
dic countries. Throughout the 1990s Denmark steadily increased
the number of elderly receiving home care, whereas the number
decreased in Sweden and remained stable in Norway.2 Denmark is
therefore the Nordic country with the most extensive home care ser-
vices with 22% of elderly above 65 years receiving home care in 2010
(Danmarks Statistik 2010).
The increasing need to get more care out of the available public
funds has provided the ground for introducing changes inspired by
New Public Management (NPM). NPM is a global trend that con-
tains a common set of ideas rather than a common practice (Clarke
and Newman 1997). NPM’s main ideas concern marketisation and
managerialism. These ideas travel and are translated into particular
national contexts (Sahlin-Anderson 2002). They must be studied
at an organisational level as processes of social construction within
specific institutional and historical contexts. They are appropriated
in national and local environments where national governmental
traditions and professional and institutional practices have shaped

2 There are difficulties in comparing the countries because in Norway personal

care, such as bathing, belongs to the home nursing services (now merged into
home care and nursing) and in the other countries this is a task for the home
help services (Lewinter 2004). The numbers for Finland are also not directly
comparable (see Szebehely 2003).
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