Dignity: a prerequisite for attractive work in elderly care

ABSTRACT

This article explores discourses of new public management (NPM) and dignity at work by considering how attractive work is represented by managers and professionals in Swedish elderly care. The analysis, guided by critical discursive psychology, uses qualitative interviews with 31 managers, nurses, physiotherapists, and occupational therapists at nine workplaces. Three storylines of how attractive work is represented were identified: salary and status, high-quality care, and working conditions and competence. These storylines revealed two strategies by which dignity is attained and defended: strategies of resistance and strategies of organizational citizenship. A conclusion is that identity, power, and position are key aspects for interpreting how managers and professionals navigate between discourses of dignity. Work in elderly care is under pressure from the major shift towards neoliberalism and the techniques of NPM. Discourses upholding NPM are present to only a limited extent, whilst discourses rejecting NPM principles and safeguarding dignity at work and dignity as care providers constitute the basis of the representations. Hence, another conclusion is that the consequences of NPM undermine prior conceptions of the importance of care work. Although dignity at work appears to be a prerequisite for attractive work, it may be an unattainable goal for organizations.

KEYWORDS:

• Dignity
• elderly care
• new public management
• critical discursive psychology

Introduction

The notion of dignity holds a central place in the philosophy of medicine and has become central to the discourse of care and caring for others (Nordenfelt, 2004; Yalden & McCormack, 2010). For professionals, performing satisfactory work in elderly care entails upholding core values and implementing working practices that address elderly people’s needs through applying a caring disposition and science-based knowledge (Dahl, 2000; Fejes, 2012; Grol & Grimshaw, 2003; Vabø, 2006). In the welfare state, at a policy level, “decent work” is clearly expressed as a core objective (Bolton, 2010). However, the dignity of employees’ working lives is rarely considered in workplace studies, although it is a critical factor in developing sustainable workplaces (see e.g. Gilabert, 2016). Working with dignity is crucial for all employees’ working lives, and self-respect is hugely dependent on how others treat us, especially in the workplace, as it affects us on a regular basis (Sayer, 2007). In the workplace, dignity is sometimes challenged or even denied (Hodson, 2001). Consequently, workplace processes can have a negative impact on employee well-being and job satisfaction. It has been suggested that understanding dignity at work is linked with the notion of good or bad work and workplaces and also with how we are perceived and valued as people in the workplace (Bolton, 2010, p. 160). In a context of global capitalism, this is especially relevant, Sharon Bolton (2010) argues, as labour is requested at ever-lower cost, and the worldwide economic downturn has forced a shift from emphasizing good work to any work.

In the Nordic context, the elderly-care system has undergone major transformations over recent decades (Kamp & Hvid, 2012). The politico-economic landscape has shifted, and forms of politics have changed from governance to governmentality (Heywood, 2002). The possibility of tempering market forces through legal regulations and ethical principles has decreased (Brown, 2003). In her critique of this shift, Larner (2000) explains that governmentality has been accompanied by a new kind of governance and different technologies of control. In line with these neoliberal ideas and techniques, new public management (NPM) has become central to both the Nordic and Swedish elderly-care systems (Dahl, 2012). NPM is characterized by its emphasis on managerialism and marketization. Although Swedish elderly care is a high-quality service available to all, fully funded through taxation, is regulated by the state (Anttonen & Sipilä, 1996; Esping-Andersen, 1999), and professionalization and unionization ensure care workers’ employment rights and working conditions (AFS, 2001), Sweden and the other Nordic countries are not immune to the demographic, social, and economic changes threatening the sustainability of elderly care. The Swedish case is therefore important in the context of an international discussion of dignity, neoliberalism, and welfare-state professions in elderly care. The consequences of this welfare-state-level shift at the workplace level for welfare professionals attempting to do satisfactory work is the subject of ongoing debate.

The literature illustrates how the neoliberal ideas embodied in NPM have influenced several aspects of elderly-care settings, as translated on top of pre-existing discourses. One example is the clash between economic and care rationalities (Vabø, 2007). Another example is that, in the Swedish context, the traditional labour relations, care ideals, and practices already established in elderly-care settings run counter to NPM policy (Keisu, Öhman, & Enberg, 2016). However, care workers’ professional identity is fundamental to their work, meaning that they are not passive recipients of discourse but rather can employ strategies of resistance (see also Dahl, 2012; Fältholm & Jansson, 2008). Still, by not bringing problems to their superiors’ attention, they have enabled the smooth functioning of NPM and its reproduction as a neoliberal policy. In comparison, managers are transforming their identity from that of welfare professionals in a professional hierarchy to an assumed empowered position in a managerial hierarchy with a leadership identity (Evetts, 2009; Keisu et al., 2016; Rasmussen, 2012). Another problem is that new types of professionalism focusing on codification, standardization, and managerial control are challenging and obscuring professional autonomy, discretionary judgement, and personal care (Dahl & Rasmussen, 2012; Fältholm & Jansson, 2008; Tufte, 2013). This transformation has also reproduced rather than challenged the gendered hierarchy (Hedegaard & Ahl, 2013; Sundin & Tillmar, 2010). Furthermore, intensified pressure has worsened working conditions (Rasmussen, 2004), and indicators of precarious employment structures have evolved (Theobald & Szebehely, 2013). How neoliberal ideas and major changes influence professionals’ dignity at work in elderly care is hence an emerging topic in constructing attractive work and retaining staff.

Working with dignity requires dedicated and creative efforts by employees to maintain and defend their dignity through various strategies to create meaning and achieve self-respect at work, particularly if their work is put under pressure (Hodson, 2001). Whether and, if so, how these major moves towards neoliberalism have put pressure on professionals’ and managers’ dignity is of particular interest here. The aim of this article is to critically explore discourses of NPM and dignity in and at work by focusing on how attractive work is represented by managers and professionals in Swedish elderly care. The following research questions were considered. How is attractive work represented and imbued with meaning in elderly care? Is dignity attained and defended within these representations and, if so, how? How do managers and professionals navigate between discourses of dignity in an increasingly neoliberal setting? How are managerial and professional identities constructed?

The next section outlines the theoretical framework before the data and applied approach are described (i.e. critical discursive psychology). Next, the empirical results are presented, and then the theoretical analysis of representations of attractive work is discussed. In a concluding discussion, the analysis is summarized, the subject positions are outlined, conclusions are formulated, and theoretical and methodological considerations are presented.

Working with dignity in four domains

Scholars argue that the definition of dignity lacks conceptual clarity (e.g. Lukas, 2015). The concept embraces several definitions and meanings; for instance, human dignity (Menschenwürde) is possessed by all people to the same extent irrespective of opinions of them or their achievements (Nordenfelt, 2004) – a definition commonly agreed upon by scholars (Lawless & Moss, 2007). Furthermore, in some cases, dignity is a quality of interaction because individuals may or may not treat each other with dignity. In still other instances, dignity is a psychological or cognitive outcome whereby individuals achieve a “sense of” dignity, self-worth, value, self-respect, or esteem (Hodson, 2001; Lukas, 2015; Nordenfelt, 2004). Workplace dignity is assumed to be more complex than human dignity and theoretically distinct from it. In the process of working with the data, reading and rereading transcripts, the link between the informants’ representations of attractive work and Hodson’s (2001, p. 3) definition of dignity at work were found to be relevant, with dignity in the workplace being “realized through countless small acts of resistance against abuse and an equally strong drive to take pride in one’s daily work.”

Building on sociologist Randy Hodson’s (2001) analysis, this article applies NPM and dignity at work to create a theoretical framework to pinpoint how attractive work is represented in today’s Swedish elderly care. In order to define worker dignity and what is required to achieve dignity at work, Hodson provides an empirically grounded theory. Various workplace aspects such as mismanagement, abuse and exploitation, overwork, limited autonomy plus contradictions of participation in new team-based forms of production that invoke heightened employee involvement prevent employees from working with dignity. Employee dignity must therefore be safeguarded using various strategies. According to Hodson (2001, p. 17), these core strategies safeguard dignity at work in four behavioural domains: (1) resistance, (2) (organizational) citizenship, (3) the creation of meaning systems, and (4) the development of social relations. The first domain, resistance, constitutes either active or passive ways of working with dignity to counteract abuse, overwork, and exploitation. Sometimes these strategies are actively defensive while at others they constitute more subtle small-scale actions. Management demands and organizational agendas are explicitly related to the first and second domains. In the second behavioural domain, organizational citizenship, employees actively strive for dignity by trying to perform their jobs efficiently and with high quality, even in the face of abuse or overwork. This strategy entails taking pride in one’s work, and can be employed under optimal circumstances but also when organizational support is not available, as the purpose is to help caring production function smoothly and in a creative way.

The third domain, the creation of (new/independent) meaning systems, involves a variety of meaningful activities and strategies in everyday work (Hodson, 2001). These behaviours are loosely related to management demands and organizational agendas, containing strategies with foundations of meaning outside the workplace and its processes and activities. The strategies involved are sometimes built into stabilizing routines in everyday practices at work. For employees, these strategies bring order and some sense of control, although they are not linked to organizational production. The fourth behavioural domain, development of social relations, is the basis of a mutual defence strategy safeguarding dignity at work. It provides both formal and informal defence strategies against management abuse and other organizational agendas. Friendship, co-worker relations, social support, and solidarity are crucial for creating meaning at work. At the same time, such relations could counteract dignity if employees do not stick together or when conflicts lead to destructive processes.

Hodson’s (2001) theory has been criticized for lacking an understanding of the need for recognition and trust among employees and of how dignity relates to people’s vulnerability and dependence on each other. As Sayer (2007, p. 570) puts it, “The very fact that we need respect and recognition of our dignity for our psychological well-being shows our dependence on others and how they treat us. It is a contingent, vulnerable property, or it is not dignity at all.” Furthermore, Sayer argues that relations of respect and recognition (i.e. dignified employment) are difficult to achieve because of the instrumental and unequal nature of organizations. Hodson (2001) focuses instead on autonomy, self-reliance, and resistance, all of which empower employees and bolster their sense of agency. In the data analysis, the representations of attractive work turned out to deal with: salary and status, a good or bad working environment, competence, and the quality of care. Psychological or cognitive outcomes or trust among employees are not addressed in this specific theme. However, when dignified work is denied, the representations reveal the safeguarding of dignity through highlighting societal respect and recognition. Thus, some aspects of the critique of Hodson’s theory seem to be inadequate. A review of the literature revealed coherence between the nursing literature and Hodson’s theory of worker dignity (Hayes et al., 2006; Lawless & Moss, 2007). Accordingly, the applied theory of domains is suitable for this analysis. Still, the context of care is under-explored, and limited attention has been paid to its specific construction. The reason for this might “lie partly in approaches that privilege patient dignity over nurse dignity and which rely on the altruism and self-sacrifice of nurses to sustain patient care in environments dominated by cost-control agendas” (Lawless & Moss, 2007, p. 235).

Dignity earned through actions creates different positions, and people can be more or less dignified without awareness of their own position within the hierarchical structure (Nordenfelt, 2004). Nordenfelt argues that three subtypes can be identified within this form of dignity at work, and they are contingent and contextual: the dignity of merit which depends on social rank and formal position in life; the dignity of moral stature which is the result of the moral deeds of the subject as a virtue; and the dignity of identity which is the integrity of the subject’s body and mind, often dependent on the subject’s self-image. In this article, these types of dignity, seen through the lens of Hodson’s (2001) four-domain typology in the care of older people, are applied to illustrate the discourses embedded in the organizational culture of elderly-care work. Nordenfelt (2004) has been criticized for his assumptions concerning objectivity and subjectivity. However, it seems that these types of dignity “all play a role in our common Western discourse” (Nordenfelt, 2004, p. 70; cf. Wainwright & Gallagher, 2008). Note that, during its rise, the labour movement referred to recognition and respect, even though it explicitly focused on gaining material wealth (Gilabert, 2016; Sayer, 2007).

Material and analytical approach

The data consist of 31 semi-structured interviews with four middle managers (one man and three women), 10 first-level managers (two men and eight women), and 17 employees in three occupations (five nurses, six physiotherapists, and six occupational therapists; three men and 14 women). In the following, participants who are members of these three occupations will be referred to as “professionals.” The professionals and managers worked at nine different workplaces (one private and eight public and elderly-care institutions) in four Swedish regions. Four were nursing homes, two were rehabilitation centres for the elderly, and three were geriatric wards in hospitals. All of the interviewees’ contracts of employment are safe until further notice. The managers’ leadership experience varied from 1 to 13 years (M = 5 years), and their occupational backgrounds differ, as some of them had been working as registered nurses or occupational therapists, whereas others had been working as social workers. One is currently working as a physician, and one has a background as an after-school teacher. The professionals have been working within their occupations at different workplaces for between 6 and 32 years, but at their current workplace for between 1 and 15 years (M = 5 years).

The selected workplaces were identified from a prior questionnaire distributed in 2012 to professionals in which the 1,024 respondents were asked to identify elderly-care facilities that they regarded as well-functioning, which could serve as examples of good workplaces in elderly care. The managers at these workplaces informed their professionals about the research project, and contact information was compiled for those who were interested in joining the interviews. All professionals who expressed interest to their manager were contacted and included in the study.

Attractive work was a central theme of the interviews with all managers and professionals. In the interviews, the question of how to recruit and retain professionals in elderly care was addressed. The interviewees were also asked what changes they believed the future might bring and how elderly-care institutions should or could adapt to these changes. Furthermore, the interviews also discussed the impact of manager priorities on job satisfaction for the professionals and on being attractive employers that can retain professionals in the sector.

The interviews were transcribed verbatim, and MAXQDA11 software was used to facilitate the qualitative analysis. As the author’s interest lies in how interviewees speak and how their identities are constructed and reproduced via social interactions, the analysis was guided by critical discursive psychology (Edley, 2001; Wetherell, 1998). How the informants use language in various interactions with each other was deemed germane (Potter & Wetherell, 1987). Two central concepts in the analysis were emphasized: interpretative repertoires, in this analysis called “storylines”, and subject positions. Storylines are “a family of related plots which carry with them recognisable characters, expected situations and anticipated outcomes” (Jones, 2002, p. 6). For the interviewees, these resources provide various ways of speaking about and relating to NPM and dignity in work through the lens of their representations of attractive work in elderly care (Edley, 2001). In general, the interviewees’ representations showed that they alternate between frustration and anxiety on the one hand and positive expectations of the future of the elderly-care sector on the other. How they speak about the phenomenon is of interest, and no differences were found among the interviewees concerning the nine workplaces at which they work.

Some ways of speaking that were particularly available to the professionals and managers represent culturally dominant ways of understanding the phenomenon (Jones, 2002). In the structural analysis, which involves reading, organizing, and coding the transcribed text, three storylines are constructed. The first storyline, salary and status, concerns how the occupations are valued in the labour market and the workplace. The second storyline, high-quality care, concerns politicians’ responsibility for achieving core values and goals in elderly care. The third storyline, working conditions and competence, concerns the professionals’ working conditions and their competence and career structures. Generally, all the storylines were presented by both the professionals and the managers during the interviews. However, the two groups differed in the ways in which they used the storylines; the way in which they represented them had, to some extent, a different focus. The interviewees were able both to draw upon and resist various storylines. In this way, critical discourse psychology acknowledges professionals and managers as both the product and producers of discourse (Edley, 2001).

When the interviewees spoke about attractive work in elderly care, they drew on the various storylines in combination and to varying extents, resulting in a number of subject positions. “Subject position” is the second concept emphasized here and is defined as “locations within a conversation. They are the identities made relevant by specific ways of talking” (Edley, 2001, p. 210). In an interview, how the informant talks about the phenomenon of interest can change, as can the identity of the informant. A useful technique is to be aware of who is implied by a particular discourse when identifying a subject position. One assumption is that managers speak in different ways from professionals because they occupy different positions in the organizational hierarchy. Identifying subject positions is not straightforward and requires experience, as well as intense reading and rereading of the data. During the analysis of the transcribed interviews with managers and professionals, various meanings of attractive work in elderly care were found. In these discourses, connections were made between the various storylines formulated by the professionals and managers in elderly care, including patterns of three subject positions which were connected to these storylines: the bureaucrat, the opponent, and the defender.

The Regional Ethical Review Board at Umeå University approved the study (dnr. 2012–28-31 Ö).

Findings

Salary and status

The salary and status storyline illustrates professionals’ and managers’ ideas about what characterizes attractive work and concerns how their occupations are valued in the labour market and the workplace. Professionals differed to some extent from managers in that their representations consisted of a much more straightforward argument highlighting the importance of a higher salary. This is illustrated in this comment from a professional: “A key factor for retaining competent staff in the future is to revise the unfavourable structures for career and salary.” Professionals explained that obtaining special training seldom resulted in them receiving a higher salary. The salary levels resulted in major problems attracting professionals and substantial personnel shortages. While the managers’ representations included the significance of earnings development, in comparison with the professionals they were somewhat ambiguous and sometimes even uncertain about whether salary is a relevant incentive for working with fragile and older people. This is illustrated in an answer that one manager gave to a question about how to recruit and retain staff strategically:

IP:

There are different needs if you’re going to become a surgeon or an anaesthetist, but if you’re going to care for this group of fragile, vulnerable patients, you’ve got to have tenderness both in your hands and your eyes and that’s why most of them choose to work in elderly care. You want to care; you want to help. Thus, the selection is a good starting point in itself. This being said, I think we have to go back to the roots. A little bit like Florence Nightingale.

I:

It doesn’t seem as though the salary is being used as a means to attract and retain professionals then?

IP:

Ah, it’s not, no. It’s not that, I don’t believe that’s why they choose this. I don’t believe that.

How higher salaries relate to the characteristics of attractive work within elderly care is illustrated in the representations in which professionals compared their occupations with those of predominantly male workers in other labour-market sectors, such as technicians in manufacturing industries or IT engineers. This is illustrated in an answer to a question on what factors are important for professionals to continue in the profession and work within elderly care. This professional said:

If I had a higher salary, it would surely make me stay in this work. My husband, for instance … It makes me tired. I’m working with people and I feel proud of the good work that I’m doing. However, he doesn’t feel the same. He has a job where he’s programming software with a salary three times higher than mine. It’s ridiculous.

In the representations, the meaning of attractive work was constructed through the interweaving of higher salaries and status, and sometimes the unions and sometimes politicians were described as key actors with major responsibility for the situation. This is illustrated in a comment by one professional: “They have to give all of us a higher salary if they want us to stay in the sector. There has to be higher status in working with people than in building a car at Volvo. They must do something about that.” One professional stated that the unions were not determined enough and needed to act more strongly in relation to the employer in shaping societal opinions. The professionals explained that if the trend towards devaluing care work continues, the point of no return will get closer because the effort will not be worth the reward. The representations also reflected scepticism about whether politicians actually valued professionals’ work and its importance for older people and their health. If more men worked in the elderly-care sector, the work and occupations would be valued more highly, speculated one interviewee. Managers located the problem with the politicians, how the media portray the sector, and how individuals working in the sector present and conceive of themselves. Some managers thought that the most successful way to recruit staff would be to have professionals learn to articulate and embody their knowledge so that they would have greater self-confidence and hence be better ambassadors for their occupations. During the interviews, the managers’ ambiguity about the importance of status was also revealed. When, for example, pay differences between the municipality and county council were discussed, one manager said, “I believe that they might have become wiser over the years and not see status as that important anymore.” According to her, recently graduated professionals often prioritized family life and chose to work in municipal settings so that they did not have to work evenings and weekends.

The setting of individuals’ earning rates was also among the representations in this storyline. This concept is the result of a change within Swedish labour-market relations 30 years ago. Before the change, earnings were based on an employee’s age and time in the job, whereas today these structures are no longer in place. Instead, salary is individually negotiated between the employer and employees, which has disrupted the previous power relations. The professionals criticized these procedures, addressing equity problems when comparing the skills of recently graduated staff to those of senior employees. They also doubted whether individual salaries are the best practice for successful earnings development for professionals as a group. The frustration is illustrated in one professional’s comment: “I think that the individual salaries are nothing but empty words!” Furthermore, they criticized the differences between salaries in urban and rural areas because earnings are often lower in the city. One manager criticized this management practice of having salary differentials because the budgets are too restricted, which leaves managers with very little money to distribute among their employees.

High-quality care

What constitutes attractive work within elderly care is described in the second storyline, high-quality care. Both managers and professionals constructed the meaning of attractive work in this storyline, and during the interviews they revealed that thoughts of the future bothered them a lot. The population is ageing, which is putting greater pressure on elderly-care settings. In these representations, the most important prerequisite for progress in elderly care was how politicians governed it. One professional illustrated this when asked how to recruit and retain professionals within elderly care:

When I read the papers or listen to what everyone who works within politics is saying and their ideas, I get frightened about what is about to happen. I feel worried about the present as well. What will happen to me when I get old and need care? What will happen? How will everything be then? With all the cutbacks and everything else that they’re talking about.

These representations mirrored anxiety about what will happen to elderly people if the resources are insufficient to ensure the quality of care. Convictions about a lack of resources, which undermine the achievement of high-quality care, were also present in the representations about the everyday reality of working in and managing elderly care. Continuing this way will not work, said one manager: “People will not be able to work when working conditions get worse and worse and worse every year. It’s not sustainable.” Another manager said that she wished she had an innovative idea for solving the problems but that increasing the available resources was the most important action to take to create attractive work and high-quality elderly care. Employees who bridge the gap by working even harder will be doomed to failure, said another manager. In this storyline, the representations of both managers and professionals also reflected concern and scepticism about politicians’ knowledge, insight, and/or capacity to transform the troubling situation. This concern is illustrated in the following comment:

They have to be tough and firm with the priorities, and I’m not sure it’s possible given the present structure, political boards, and so forth. There are tough decisions to be made that the voters might find problematic. I don’t believe they will be able to make these decisions.

Politicians have to take the problem more seriously and devise strategies to provide high-quality care, one professional said. The representations highlighted that retaining welfare-state privileges requires increasing taxes and that citizens have ever-higher standards and demands.

Politicians and welfare-state-level governance were addressed in both managers’ and professionals’ representations of how attractive work is constructed. In addition, in this storyline, the representations also addressed the content of their occupations and how the required qualifications were changing over time. Currently, working with elderly people who have a multiple diagnosis is an advanced and highly skilled job. Thus, in discussions about recruitment, interviewees highlighted the importance of having long-term strategies to ensure workers’ competence. The professionals (primarily occupational therapists and physiotherapists) also often addressed the importance of meaningful activity and rehabilitation for older people, which are often cut back when resources are declining. Facilities for training and rehabilitation are seldom available, and the equipment is limited. In their representations, the professionals described themselves as dissatisfied with being ignored but still responding to the situation with acceptance and the intention of making the best of it. At the same time, explained another professional, increases are expected in elderly people’s demands for an active life at a societal level. Other types of ability are also important for providing high-quality care, as illustrated in one manager’s answer to a question about how to recruit and retain professionals within elderly care:

How would you do that? That’s an interesting question. It’s the million-dollar question, I guess. I don’t know if I’m the right person to answer that. I think you have to be able to show the appeal of the challenge itself. [You could stress that] what are needed are the smartest individuals, the ones with most passion, and the ones with the most creative solutions. Here you could use your cleverness, be a clever physician, a clever nurse, a clever occupational therapist; [that] it’s nothing like working on an assembly line.

While the required skills include those learned in formal education, other types of skills are also needed. Working in elderly care also requires wisdom and passion and professionals who are practically magicians at sorting out things for fragile and elderly people, explained the manager. In this storyline, despite problems with limited resources, the interviewees constructed the meaning of attractive work by emphasizing the underlying importance and joy of working with older people. This is illustrated in this comment from a professional: “Pardon me for saying this, but people should be able to look beyond these wrinkled faces. Not focus so much on their actual age. We should be able to recognize that through their long lives, they have had great experiences.”

Working conditions and competence

The third storyline, working conditions and competence, is another aspect of how the professionals and managers construct and attribute meaning to what constitutes attractive work. However, the managers differed from the professionals in that their representations mainly highlighted the consequences of changing working conditions, while the professionals’ representations were broader. They included career and competence development structures as being important aspects of the working conditions in elderly-care settings.

In this storyline, one emphasis was on how to organize work within elderly-care settings to create a safe and secure workplace for recently graduated professionals. They need to learn to put into practice the evidence-based practices they learned in higher education because they are not always comparable, the interviewees clarified. In a municipality, for example, trainee nurses can be temporarily employed although they are not yet sufficiently trained. As one manager said:

You’re not experienced enough to work independently within elderly care. The physicians are not always around to answer your questions. That’s one explanation. Secondly, as I understand it, higher education for nursing is more theoretical than it was before. Back then, you built a base of more practical knowledge. Combining the theoretical and the practical makes the work harder, and it takes more time to feel confident working with us.

As a professional, it is important to describe your assessment of the patient at work thoroughly and independently, said one interviewee. In this storyline, attractive work was constructed as allowing staff to be independent and have significant potential to influence how the work is organized and performed. The job is not repetitive but involves a variety of tasks, and professionals require pedagogical competence in working with the needs of fragile and older people. In this storyline, the problem with recruiting and retaining professionals is addressed as a problem caused by the increased work demands and by structures in the system of higher education. In addition, the professionals emphasized that they are also responsible for the working environment, for example for the well-being of recently employed individuals, as illustrated by one professional:

It’s important that we help students who work with us during their trainee period to experience all the positives. So they can see and feel that we enjoy our work. Otherwise, everything will go down the drain … and that would be really sad because the work is stimulating. I’ve worked in many different areas, child psychiatry, burn victims, but working with elderly people is very satisfying. My dream is that other people can recognize that and, in addition, be able to cope with it.

Elderly-care work requires a high degree of cohesion among the professionals and an almost excellent workplace, this professional further explained. Working conditions were central in both the managers’ and professionals’ representations of the basis for attractive work. Internal organizational factors were emphasized, such as having a clearly defined vision and strategies, well-formulated objectives, a moderate amount of time spent keeping medical records, a good working climate, and proper support from the first-level manager.

With a large proportion of older people staying in their homes until the end of their lives, professionals are needed to work in home-care services. However, the isolated working environment in patients’ homes causes difficulties for recruitment in the elderly-care sector. Working in home-care services is considered less attractive and more difficult because these professionals are geographically isolated, while if they worked in a nursing home or on a geriatric ward at a hospital, they would be part of a team of professionals working together on a daily basis. The consequences are greater difficulties in recruiting staff to home-care services, as the managers explained. At the same time, the tight deadlines for stays in geriatric wards “undermine the identity of the rehab profession” because occupational therapists and physiotherapists have restricted amounts of time to perform the work they are trained to do, said one professional.

Finally, the professionals’ representations of attractive work in this storyline often reflected the importance of further education, competence development, and career opportunities. The managers, however, did not speak in this way. A comment by one professional illustrates how the professionals reflected and discussed the theme of how to recruit and retain professionals in elderly care:

You have to be able to find a use for every individual’s competencies. This is a deficiency, but something I wish the first-level manager and the management board could improve. To focus and develop each individual, thereby differentiating the tasks. As an example, if someone is well organized, he or she could get more responsibility or be able to build a career as a deputy in another department.

Furthermore, the representations reveal that requirements for developing competence are linked to the changing and increasing demands on professionals. The professionals believe that new and different types of dementia and other types of cognitive diagnoses require people working in elderly care to receive regular education and competence improvement.

Analysis

Salary and status as working with dignity

In the first storyline, salary and status, both professionals and managers emphasized their construction of meaningful representations of what constitutes attractive work, but they drew on different discourses. The professionals’ arguments about higher salary and status were straightforward. The managers’ representations, however, were ambiguous, and sometimes they even doubted whether salary and status are a relevant incentive. One manager even made this quite explicit by saying, “A little bit like Florence Nightingale.” According to Lawless and Moss, “references to dignity are often accompanied by references to the centrality of altruism in nursing practice” (2007, p. 228; see also; Keisu et al., 2016). This illustrates the apparent contradiction in the ongoing tension for care workers in seeking to balance their own needs (benefit to self) and the needs of patients (benefiting others). One interpretation is that the value of professionals’ altruism, which underlies the assumptions in the managers’ representations, illustrates their role as employees with a leadership identity in that they focused on the logic of organizational effectiveness (e.g. Evetts, 2009; Fältholm & Jansson, 2008; Rasmussen, 2012). The managers hence drew on a neoliberal discourse of organizational effectiveness, in line with the principles of NPM (Vabø, 2006).

Furthermore, the analysis revealed how professionals are working with dignity when defending their status and position as nurses, occupational therapists, and physiotherapists by using the strategy of resistance, a domain that Hodson (2001) argues is used when workers are subjected to pressure. The resistance is actively defensive, as was expressed in comments such as, “It’s ridiculous” or “There has to be higher status in working with people rather than in building a car at Volvo,” which some professionals made when comparing working with people with occupations and tasks embodied by men. In comparison to other (male) occupations in Sweden that require a university education, these occupations are subject to low pay and status (SCB, Statistics Sweden, 2014). In a study of nurses in Australian elderly care, the nurses addressed the need to care for themselves in order to “survive.” Thus, they associated dignity with self-preservation and respecting and valuing oneself and others, and this depended on receiving an adequate income for their work (Yalden & McCormack, 2010). One interpretation is therefore that the professionals’ strategy of resistance is linked to the discourse of dignity at work, which addresses professionals’ position and status in society and the labour market. It refers to lower social rank and formal position in societally ordered hierarchies (i.e. dignity of merit; Nordenfelt, 2004).

High-quality care as working with dignity

The second storyline, high-quality care, was used in quite similar ways by both the professionals and the managers. However, the professionals’ closeness to core activities resulted in some difference to the way in which they constructed attractive work. Both groups represented the meaning of attractive work within elderly care by highlighting how politicians govern it. The argument that a lack of resources undermines achieving high-quality care included both explicit critique as well as anxiety about the future. This is illustrated in comments such as “I don’t believe they will be able to make these decisions” and “I get frightened about what’s going to happen.” Both the managers and professionals were troubled by the lack of prioritization at a societal level because of the increasingly advanced and highly skilled work required by elderly people with multiple diagnoses, as well as the greater demands from elderly people themselves. They also expressed scepticism about politicians’ knowledge and insights. Both managers and professionals argued for proactive strategies for recruiting professionals. The critique about the lack of strategies on a societal level reflected their wish as dedicated elderly-care advocates to maintain and defend their dignity as care providers. They used the strategy of resistance when actively defending the core value of care, and they hoped that changes would be made but were still worried that they would not be (Hodson, 2001). According to Gilabert (2016), employees respond in dignified ways when they cannot avoid exploitation, domination, or alienation at work when dealing with those in positions of power. Hence, they take themselves seriously. Gilabert (2016, p. 190) argues that the “relatively poor and weak can gain some dignity in this way. And the relatively rich and powerful lose some dignity when they use their superior resources and power in unjust ways; for example, by undermining or failing to promote the condition-dignity of others.” If those in elderly care suffer too much indignity, this implies that the politicians and society have failed to show respect and concern for the elderly-care sector, its employees, and elderly people.

However, the professionals’ representations also revealed an attitude of functioning smoothly, doing their best with what they have, and having as their guiding principle doing what was best for the fragile and older people. Hence, the professionals maintain and defend their dignity through the strategy of organizational citizenship, which means that they perform their jobs efficiently even though resources are limited. The professionals take pride in their work with older people, doing things such as providing rehabilitation training in creative ways with limited facilities and equipment. Other studies have also reported how, during the workday, employees overcome problems that could undermine or threaten their dignity through “multiple small acts” (cf. Hodson, 2001; Stacey, 2005; Yalden & McCormack, 2010). A study of nurses’ genetic termination procedures for women who end a wanted pregnancy at hospitals in Canada reveals how the caring disposition and function became a coping strategy (Chiappetta-Swanson, 2005). Through work procedures, nurses minimized patients’ pain, and the quality of care they provided transformed their job from “dirty work,” as they found dignity and satisfaction in their work. Hence, another interpretation is that the professionals’ and managers’ strategies of resistance and organizational citizenship drew on a discourse of dignity as care providers, emphasizing the quality of their care for fragile and older people instead of the limited resources. This discourse is tied to their identity as managers, nurses, physiotherapists, and occupational therapists and to the integrity of the subject – values they embodied through their education and experience as welfare professions (i.e. dignity of identity; Nordenfelt, 2004).

Working conditions and competence as working with dignity

In the third storyline, working conditions and competence, the overall working conditions in elderly care, such as independence and the importance of having influence, were highlighted as necessary for making work attractive (cf. Gilabert, 2016). The participants also showed a strong interest in how the transformation of the elderly-care sector affected working conditions. In the representations, it becomes clear that working within elderly care is challenging and stressful and requires highly skilled professionals. Because of the difficult working conditions and heavy workload, job satisfaction in the work can become lost, as this comment illustrates: “My dream is that other people will recognize that and, in addition, be able to cope with it.” Hence, some described starting work in elderly care as difficult for recently graduated professionals: “You’re not experienced enough to work independently within elderly care.” Creating a safe and secure workplace was therefore regarded as a problem to be addressed at the societal level, through the structures of higher education, and at the organizational level, where professionals have responsibility for the recently graduated.

At the same time, it is obvious that these representations were not an explicit critique but were twofold. On the one hand, they reflected a vision of what the workplace should look like (governed by a well-defined vision and goal, supportive and fostering independence and influence). On the other hand, in their focus on recently graduated professionals, the representations revealed how the workplace actually operates. One interpretation is that managers and professionals subtly defend their dignity through the strategy of organizational citizenship (Hodson, 2001). They create meaning and achieve self-respect at work, making the best of the situation through acceptance or even resignation (cf. Yalden & McCormack, 2010). Thus, one effect is that they give precedence to the core value and principles of high-quality care over their own well-being. In Finnish nursing homes, downplaying or ignoring problems in the physical environment was shown to be a common strategy for maintaining status and positive identity among care workers (Laulainen & Hujala, 2016). Hence, another interpretation is that, through organizational citizenship (as in the second storyline, high-quality care), professionals and managers drew on a discourse of dignity as care providers as they addressed the quality of care for fragile and older people.

To some extent, the professionals’ representations differed from those of managers in this storyline in that the professionals included an additional aspect when constructing and attributing meaning to attractive work. They criticized the organization and their managers for the lack of career and competence structures. According to Sayer (2007, p. 568), dignified employment is difficult to achieve because of the instrumental and unequal character of organizations, but “[to] be dignified or have dignity is first to be in control of oneself, competently and appropriately exercising one’s powers. Most obviously, then, dignity is about self-command, and autonomy.” In this regard, the interpretation is that when professionals experience structural deficits, they use a strategy of resistance to defend actively their competence and ambition at work, which they believe should be prioritized and valued more highly (Hodson, 2001). Hence, an interpretation is that professionals use a strategy of resistance linked to a discourse of dignity at work in order to address their position and status in the labour market (as in the first storyline, salary and status).

Concluding discussion

The aim of this article was to critically explore discourses of NPM and dignity in and at work by focusing on how attractive work is represented by managers and professionals in Swedish elderly care.  They are located within the ongoing struggle between liberal welfare discourses of equal rights and neoliberal discourses. The analysis of managers’ and professionals’ interview transcripts therefore illustrates representations of various meanings of attractive work within elderly care. Patterns emerged within and, to some extent, between the managers and professionals. Three storylines were constructed: (1) salary and status, (2) high-quality care, and (3) working conditions and competence (see Table 1). While both professionals and managers emphasized three similar themes (i.e. storylines), there are some differences between the two groups in content and the ways in which meanings are constructed. Hence, different and conflicting identities are produced.

Table 1. The storylines represented by the interviewees (in line with Hodson, 2001): safeguarding the domains of dignity, staff group, the available subject positions, and discourses used.

Storyline	Domain of dignity	Staff group	Subject position	Discourse
(1) Salary and status	Absent from representations	Managers	The bureaucrat	(A) Neoliberal discourse of organizational effectiveness
	Strategies of resistance	Professionals	The opponent	(B) Discourse of dignity at work
(2) High-quality care	Strategies of resistance	Professionals and managers	The defender	(C) Discourse of dignity as care providers
	Strategies of organizational citizenship	Professionals	The defender	(C) Discourse of dignity as care providers
(3) Working conditions and competence	Strategies of organizational citizenship	Professionals and managers	The defender	(C) Discourse of dignity as care providers
	Strategies of resistance	Professionals	The opponent	(B) Discourse of dignity at work

The interviewees drew on three discourses of attractive work: (A) the neoliberal discourse of organizational effectiveness, (B) the discourse of dignity at work, and (C) the discourse of dignity as care providers. The first discourse was articulated only by the managers, and the second only by the professionals, whilst the third was articulated by both groups. This illustrates the impact of their different positions in the organizational hierarchy (i.e. as employer and employee, respectively).

Within these discourses, connections between the three storylines were identified and constructed, including patterns of three subject positions available to both the managers and professionals. The concept of dignity frames the rationale between the different subject positions that were constructed from the data. The first position, the bureaucrat, is linked to the neoliberal discourse of organizational effectiveness. This position is an abstract figure stressing approaches of altruism that would be of benefit for elderly care as an institution from a neoliberal economic perspective (i.e. Dahl, 2012; Keisu et al., 2016). The bureaucrats (in this case, managers) use strategies that emphasize a well-functioning bureaucracy when constructing the meaning of attractive work. Thus, accountable and (economical) responsible working subjects are produced.

The second subject position, the opponent, is linked to the discourse of dignity at work and refers to an abstract figure who criticizes the present societal norms and values which reproduce inequality between men and women at work. Opponents (in this case, professionals) use strategies to safeguard their dignity as professionals when constructing the meaning of attractive work. Therefore, they argue for, and emphasize the importance of, fair rewards such as salary and status because of the effort, knowledge, and loyalty they have invested in their work. Consequently, accountable and dignified working subjects are produced.

Finally, the third subject position, the defender, is linked to a discourse of dignity as care providers. It refers to an abstract figure who protects and justifies high-quality care for fragile and older people when constructing meaning about what attractive work contains. Defenders (in this case, both professionals and managers) use strategies for safeguarding the dignity of elderly-care settings and the care produced within them. Accordingly, dignified care is produced by responsible and professional working subjects.

In this article, three subject positions are available to the managers and professionals. The managerial identity is linked to two: the bureaucrat and the defender. The professional identity is also linked to two subject positions: the defender and the opponent. Hence, the managerial and professional identities are merging in that they both draw on discourses of high-quality care, but also diverging, as the managerial identity is linked to a neoliberal discourse of organizational effectiveness, whereas the professional identity is linked to a discourse of dignity at work.

To sum up, this article extends previous research in the area of dignity at work, as well as the literature on professions and NPM. It highlights the importance of hierarchical position to the ways in which interviewees employ or resist the ideology of neoliberalism. The professionals’ and managers’ representations of what constitutes attractive work reflect the challenges of working with dignity. The conflict between elderly people and worker dignity is one essential example of the tensions between identity, power, and position. When professionals articulate the importance of high-quality care, they are positioned within an ongoing tension in seeking to balance their own needs (benefit to self) and the needs of older people (benefiting others; Keisu et al., 2016; Lawless & Moss, 2007). One consequence of their devotion to work is the “blurring of lines” between themselves and their tasks, as well as between their own and their employer’s interests (Crowley, 2012). Another example of the tension between identity, power, and position is the professionals’ straightforward arguments highlighting the importance of a higher salary and status in achieving attractive and dignified work. Managers are ambiguous and uncertain about whether salary is a relevant incentive for employees working with fragile and older people. This argument is accompanied by references to altruism in the professionals’ practice that reveal tension between the managerial identity and the professional identity that protects and safeguards their dignity as professional workers (e.g. Evetts, 2009; Fältholm & Jansson, 2008; Rasmussen, 2012). Furthermore, the professionals’ criticism of the lack of career and competence structures in the light of managers’ silence in their speech about this particular subject is another example of the tension between identity, power, and position.

The analysis reveals that work in elderly care is under pressure from the major shift towards neoliberalism and its ideology and the techniques of NPM. Competing discourses and power positions interact in the ways in which managers and professionals position themselves. This draws attention to the instability of the impact of neoliberalism as embodied through NPM in worker subjects. Non-unitary subjectivities are thus produced as though they are “playing” managers and professionals, a concept that Leonard ( 2003, p. 218) uses to “demonstrate the ambiguities and complexities which exist in the relation between work and subject” among nurses and doctors in the British National Health Service. The first conclusion is therefore that identity, power, and position are key aspects for interpreting how managers and professionals navigate between discourses of dignity in a neoliberal setting. Being an accountable and responsible working subject in elderly care involves managers who somewhat embrace the principles of NPM whilst professionals protect, defend, and safeguard dignity in and at work. Nevertheless, discourses upholding NPM are present to only a limited extent in the representations, whilst discourses rejecting NPM principles and safeguarding dignity at work and dignity as care providers constitute the basis of the representations. Hence, a second conclusion is that the consequences of NPM undermine prior conceptions of the importance of care work. Although dignity appears to be a prerequisite for attractive work in elderly care, the analysis also demonstrates that dignity at work may be an unattainable goal for organizations (Lukas, 2015).

Theoretical and methodological considerations

There is a risk that informants may feel obliged to participate when a researcher is doing on-site visits. Therefore, written information was distributed beforehand. The interviewees were informed, and gave their consent, that data from the interviews may be published in a research article in which all identifying characteristics of individuals or workplaces had been removed. The procedure seemed to generate trust between researcher and informants, and they were given the opportunity to ask questions. Many of them did so, as the research project seemed to interest them.

In Hodson’s (2001) four-domain typology, different strategies are employed to safeguard dignity at work. In this article, the representations illustrate two of these domains (strategies of resistance and organizational citizenship). Notably, Hodson (2001) identified strategies of resistance in rigid and controlling or poorly managed workplaces, whereas organizational citizenship was used when participation was high and the workplace well organized. It cannot be determined whether these behaviours originated from any in particular of the nine workplaces in this analysis, likely due to the limited number of individuals interviewed at each workplace. Two strategies, the creation of meaning systems and the development of social relations, were not used in the representations of attractive work. If other qualitative methods, such as observation, had been applied in the article, more or different types of strategies might have been identified.

Acknowledgements

I would like to thank the informants in this project, who so generously shared their experiences and views of their work in Swedish elderly care. Besides myself, the interviews were conducted by my colleagues Ann Öhman and Birgit Enberg. I wish to thank both of them for their productive collaboration and warm support during the work on this research project.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Funding

This work was financed by Forte; Swedish Research Council for Health, Working Life and Welfare; dnr. (2011- 1140).