Being able to provide sufficiently good care for older people : care workers and their working conditions in Finland

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Being able to provide sufficiently good care for older people : care workers and their working conditions in Finland © Policy Press 2023 Published version Mathew Puthenparambil, Jiby Mathew Puthenparambil, J. (2023). Being able to provide sufficiently good care for older people : care workers and their working conditions in Finland. International Journal of Care and Caring, 7(4), 691-707. https://doi.org/10.1332/239788221x16752697246472 2023 1 research article International Journal of Care and Caring • vol XX • no XX • 1–17 • © Policy Press 2023 Print ISSN 2397-8821 • Online ISSN 2397-883X • https://doi.org/10.1332/239788221X16752697246472 Accepted for publication 01 February 2023 • First published online 03 March 2023 This article is distributed under the terms of the Creative Commons Attribution 4.0 license (http://creativecommons.org/licenses/by/4.0/) which permits adaptation, alteration, reproduction and distribution without further permission provided the original work is attributed. The derivative works do not need to be licensed on the same terms. 2023 Being able to provide sufficiently good care for older people: care workers and their working conditions in Finland Jiby Mathew Puthenparambil, jiby[email protected] University of Jyväskylä, Finland This study examines whether care workers in Finland feel able to provide adequate care for older people and analyses the working conditions that limit them from providing it. One third of the respondents felt that they were not able to provide sufficient care for older people. This was seen as being due to excessive workloads, a general lack of staff and accompanying physical and mental burdens. Improving care workers’ working conditions would enhance their work–life balance and allow them to help older people avoid situations of care poverty, that is, to receive the level of care they deserve. Key words care workers • working conditions • inadequate care • older people. To cite this article: Mathew Puthenparambil, J. (2023) Being able to provide sufficiently good care for older people: care workers and their working conditions in Finland, International Journal of Care and Caring, XX(XX): 1–17, DOI: 10.1332/239788221X16752697246472 Introduction The care of older people in Finland has changed significantly over the past few decades (Tainio and Wrede, 2008; Wrede and Näre, 2013). New Public Management (NPM) has pushed for better-quality management in care services, more detailed documentation of them and care services to follow the directions and time restrictions specified in manuals. The aim of this has been to enhance the efficiency and quality of care in the sector. However, these changes have also reframed care workers’ jobs as more structured and target oriented than has traditionally been the case. One example is the ‘standardisation of time’, which requires care workers to accomplish a particular task within a given time but, at the same time, prevents them from performing any additional duties above and beyond those specified in the care plan (see, for example, Satka and Hämeenaho, 2015; Tallavaara et al, 2016). A significant factor behind these changes has been the increasing lack of resources available due to financial constraints and human resources in the social care sector. In recent years, care workers have reported increasingly excessive workloads, job stress, burnout, a Brought to you by University of Jyväskylä | Unauthenticated | Downloaded 03/06/23 12:10 PM UTC Jiby Mathew Puthenparambil 2 lack of flexibility in their work, health and safety issues, physical and mental health problems, and an increase in violence and threats made in the workplace (Trydegård, 2012; Kröger et al, 2018; Vehko et al, 2018; OECD, 2020; Ruotsalainen et al, 2020). The working conditions of care employees affect not only their own work–life balance (for example, job stress and job dissatisfaction) but also the quality of care received by older people. A Finnish national report found that time pressures and staff shortages have increased the risk of abuse in residential care (Tallavaara et al, 2016). The same report also highlighted the fact that older people were not getting enough outdoor exercise due to insufficient staffing. Kangasniemi etal (2022) analysed official complaints about allegations of neglect in residential care settings in Finland (for example, regarding personal hygiene or being restricted from certain activities) and found that staffing issues, particularly in the private sector, were felt to be one of the main reasons for this. Finland is an interesting case because it has been variously described as a ‘welfare’ (Kröger, 2003), ‘social service’ (Anttonen, 1990) or ‘caring’ (Daly, 2001) state, that is, one in which people receive the care they need through predominately tax-funded public services. Indeed, for the last few decades, long-term care (LTC) in Finland has faced the challenges of servicing an increasingly ageing population with less than adequate financial and human resources. The population of over-70s has increased from 0.45 to 0.62 million in the last three decades (Sotkanet, no date), at the same time as the coverage of home and residential care for people over 75 has dropped by 13 and 3.1 per cent, respectively (Säkkinen et al, 2021: 58, 65). In 2017, the LTC sector employed around 50,000 care professionals, of which roughly 70 per cent worked in residential and 15 per cent in home care settings (Kalliomaa-Puha and Kangas, 2021), but the sector will need an additional 30,000 full-time employees by 2030 to cover staff shortages (Eurofound, 2020). Workplace conditions are a major concern in Finland due to this overall shortage of staff and the growing pressure to do more in less time. This has led to lower job satisfaction, higher job stress, poor teamwork, growing physical and mental exhaustion, and, in some cases, violence in the workplace (Tallavaara et al, 2016; Kröger et al, 2018; Vehko et al, 2018; Ruotsalainen et al, 2020). In many cases, care workers are leaving their jobs for others in related fields or even leaving the profession altogether because of these factors (Kankaanranta and Rissanen, 2008; Flinkman, 2014; Van Aerschot et al, 2021). Poor working conditions will thus also have a regrettable knock-on effect for the older people in their care; yet, there are currently few data about care workers’ own views about the care they provide. This study aims to gain further knowledge about how staff themselves feel about the care they provide to older people with the restricted resources available. For this purpose, this study asks: ‘Do care workers feel able to provide adequate care for older people?’; and ‘What are the kinds of working conditions (in terms of workload, job flexibility and support) that prevent care workers from providing sufficient care?’ Background of care workers in Finnish LTC settings for older people The duties of a care worker in Finnish LTC settings for older people generally involve assisting them in their day-to-day activities, such as meals and personal hygiene, but can include other tasks depending on the user’s care plan. Most Finnish care workers are practical nurses with three years of vocational training in health and social care. Their retirement age varies from 63 to 68 years old, with an option for part-time retirement from the age of 61 (Sulander et al, 2016). Most (around 65 per cent) are employed in the public Brought to you by University of Jyväskylä | Unauthenticated | Downloaded 03/06/23 12:10 PM UTC Being able to provide sufficiently good care for older people 3 sector; the rest work in the private sector – in either profit or non-profit organisations. On average, practical nurses in the public sector earn about €34,440 (£30,308) per year (Eurofound, 2020: 34), which is 23 per cent less than the national average annual pay of €43,188 (£37,972) (Official Statistics of Finland, 2021). However, on average, care workers in the private sector earn €2,400 (£2,112) less than those in the public sector, but the lowest pay in LTC work can be as little as €25,656 (£22,574) (Eurofound, 2020: 32). In a residential care setting, a minimum staff–user ratio of 0.5 is required (that is, five personnel per 10 users), but with new regulations that came into force in 2020, this ratio is set to increase to 0.7 by 2023 (Ministry of Social Affairs and Health, 2020). Care workers’ working condition and care quality A care worker cannot provide adequate care if their work conditions are unreasonable (Trydegård, 2012), and poor management has been shown to significantly affect the quality of nursing care delivered (Newman et al, 2002; Westerberg and Tafvelin, 2014; Zúñiga et al, 2015; Ruotsalainen et al, 2020). Some of the management issues identified by care staff are a lack of recognition and support, poor communication between supervisor and care worker, a lack of autonomy in the work environment, and workplace discrimination. A study from Finland (Räikkönen et al, 2007) found that a lack of support from supervisors makes care workers see their own professional skills depleting and lowers the quality of care they deliver. Meanwhile, other studies have shown that supervisory support helps care workers navigate professional challenges and motivates them to respond better to service users’ needs (McGilton et al, 2016; Escrig-Pinol et al, 2019; Virdo and Daly, 2019). Additionally, care workers need regular training to manage their work tasks and the right equipment for helping with the physically heavy tasks that caring for older people sometimes requires, especially since LTC workers also often have little or no prior training in caring for older people. Research from nursing science has shown that poor working conditions can cause nurses to skip or ration some non-essential care services (Tønnessen et al, 2011; Haugan, 2014; Zúñiga et al, 2015; Henderson et al, 2017; Ludlow et al, 2019; Blackman et al, 2020; Senek et al, 2020). These studies identified some determining factors that might cause this to happen in a workplace: staff shortages; undue work stress; an unsafe workplace; time constraints; inadequate resources; a lack of teamwork, recognition or communication; a high administrative load; the facility’s size; a lack of education or training among staff; and the sheer range of complex and often unique needs that older people have. When Schmalenberg and Kramer (2008) applied the ‘Essentials of Magnetism’ tool – eight work-related attributes essential for quality care – to measure the quality of care provided by nurses in hospitals, they too found similar factors to be important, for example, managerial support, autonomy in the job, adequate staffing and educational support among staff to promote quality care. Meanwhile, another study across nine different countries in Europe, Asia, North America and Australia emphasised that a better work environment in hospitals helps nurses provide better care for patients (Aiken et al, 2011). From this, it is reasonable to suppose that work conditions will also affect how any care worker can do their job, whether in a hospital or an LTC setting. It is of particular concern that care workers in Finland are paid low and have higher work-related stress, which may contribute to the fact that it is also the Nordic country with the lowest care staff–user ratio (Kröger et al, 2018). Other common features Brought to you by University of Jyväskylä | Unauthenticated | Downloaded 03/06/23 12:10 PM UTC Jiby Mathew Puthenparambil 4 of the Finnish LTC sector are high staff turnover, frequent sick leave and numerous vacancies (Elstad and Vabø, 2008; Trydegård, 2012; Van Aerschot et al, 2021). Staff shortages, in particular, exacerbate the situation for existing care workers because they must assist more people than they can handle, often needing to sacrifice their breaks to do so (Trydegård, 2012; Kröger et al, 2018). In many cases, care workers even avoid taking sick leave at the expense of their own health, which has been shown to have the knock-on effect of increasing stress (Elstad and Vabø, 2008). Long-term job stress and burden are a strong predictor for poor health and mental well-being in care workers, which may gradually affect the quality of care they deliver. In Finland, by placing importance on the of task-specific and time-restricted aspects of care work, staff find it much harder to address older people’s needs as they change – which they do because of their often-fragile health. Care workers often feel powerless to affect the daily planning of their work, as they must follow a strict time schedule, especially in home care (Ruotsalainen et al, 2020). Systematic documentation of the care process is also mandatory in Finland to ensure quality and the service user’s safety; however, this has increased the amount of paperwork required. In spite of these changes, care workers’ own interpretations of how these work conditions have affected the care they provide has not yet been explored in Finland. This study aims to fill this knowledge gap using quantitative survey data collected from care workers working in Finnish home and residential care settings. Methodology This study used the NORDCARE survey data collected in 2005 and 2015 from care workers working with older people in four Nordic countries: Finland, Norway, Sweden and Denmark. In 2005, the NORDCARE questionnaire was sent to 1,200 participants in each Nordic country, and in 2015, this figure increased to 2,000. Participants’ addresses were randomly collected from trade union membership lists for both surveys because most care workers in Nordic countries are trade union members. In Finland, this was done by contacting the Trade Union for the Public and Welfare Sectors (JHL) and Union of Health and Social Care Professionals (Tehy) who supplied their addresses. This approach helped researchers to reach the participants easily. The questionnaire was first pre-tested on a small group of care workers before the main data collection was made. The questionnaire covered various topics relating to the workplace, working conditions and workers’ relationships with service users, their colleagues and supervisors. It also included questions about each participant’s physical and mental health, whether they were planning to quit, and background information (for example, age, sex and education). The overall response rate in Finland was 61 per cent (N = 726) in the 2005 survey and 55 per cent (N = 976) in 2015. Women (97.3 per cent) and native-born (97.5 per cent) respondents had a higher representation in the total sample population. Measurement Dependent variable To answer the present article’s research question of whether care workers feel able to offer adequate care for older people in LTC, the study looked into one particular question in the Finnish NORDCARE survey: ‘Do you feel inadequate because the Brought to you by University of Jyväskylä | Unauthenticated | Downloaded 03/06/23 12:10 PM UTC Being able to provide sufficiently good care for older people 5 care recipients are not receiving the help you think they should receive?’ Although this question is somewhat indirect, it does ask them directly about making a selfevaluation from their own perspective. In this respect, it was the most suitable survey question for this study, as care workers often feel inadequate when they are unable to meet the needs and wishes of care recipients (Sørlie et al, 2005; Lützén et al, 2006; Jakobsen and Sørlie, 2010; Banerjee et al, 2012). The choice was also justified because researchers have previously used this question as an independent variable to indicate care workers’ feelings of not being able to provide enough care (Meagher et al, 2016; Simmons et al, 2022) and their relationship with users (Strandell, 2020). Answers to this question were measured on an ordinal scale of ‘never’, ‘rarely’, ‘yes sometimes’ and ‘yes most often’ in the survey; however, for the purposes of this study, ‘never’ and ‘rarely’ were merged as there were so few (n = 23) of the ‘rarely’ responses. The final variable for this study comprises only three groups. Independent variables Based on the previous literature (see, for example, Schmalenberg and Kramer, 2008; Tønnessen et al, 2011; Westerberg and Tafvelin, 2014; Ludlow et al, 2019; Blackman et al, 2020), in the present study, working conditions were categorised under six subheadings for easier interpretation. The first subheading addressed the issue of Excessive Workloads. Under this subheading, participants were asked which kinds of shift (weekday day, weekday evening, weekend or night shifts) they needed to assist too many service users. This was measured as a continuous variable (with 0 = no shifts; 1, 2 and 3 = one, two and three kinds, respectively; and 4 = too many in all four kinds). ‘Paid overtime work’ was also measured as a continuous variable, though with a five-level ordinal Likert scale (‘never’, ‘less often’, ‘every month’, ‘every week’ and ‘more or less every day’), as was the ‘skip or shorten lunch break’ variable. Finally, the variable that defined ‘too much working time spent on documentation’ was originally measured as a four-level ordinal Likert scale but then recoded as a dichotomous variable of ‘agree’ or ‘disagree’. The second subheading of Staff Shortage, third subheading of Feeling Burdened and fourth subheading of Subjected to Violence consisted of one variable each, which were: (1) ‘staff shortages due to sickness, leave, or vacancies;’ (2) ‘feeling physically and mentally burdened’; and (3) ‘subjected to physical violence or threats’. The variables under the second and fourth subheadings were measured as continuous variables on a five-level ordinal Likert scale, ranging from ‘never’ to ‘more or less every day’. However, ‘feeling physically and mentally burdened’ was summed from four separate variables each measured on a five-point Likert scale, ranging from ‘never’ to ‘almost always’, concerning: (1) ‘feeling physically tired after work’; (2) ‘back hurting after work’; (3) ‘feeling mentally exhausted after work’; and (4) ‘having difficulty sleeping because of work worries’. To predict the internal consistency of these four variables as a group, Cronbach’s alpha was calculated, and an alpha coefficient of 0.720 indicated that it was relatively high. The level of burden was then calculated by considering the median value of all four variables: the higher the median, the greater the level of physical and mental burden felt by the participant. The fifth subheading explored the Level of Autonomy at work. This consisted of two variables: (1) ‘Can you affect the daily planning of your work?’; and (2) ‘I feel like the management does not trust the staff; there is too much monitoring and control’. Both Brought to you by University of Jyväskylä | Unauthenticated | Downloaded 03/06/23 12:10 PM UTC Jiby Mathew Puthenparambil 6 variables were measured on a four-point ordinal Likert scale, which was eventually recoded into a dichotomous variable of ‘more often’ or ‘less often’ (first variable) and ‘agree’ or ‘disagree’ (second variable). The sixth and final subheading was about Support in the Workplace, consisting of three variables. The first two – (1) ‘support from immediate supervisor’ and (2) ‘training to manage work tasks’ – were recoded as a dichotomous variable (‘more often’ or ‘less often’) from a four-point ordinal Likert scale (from ‘most often’ to ‘never’) by merging ‘sometimes’, ‘rarely’ and ‘never’ answers into ‘less often’. The third variable in this subheading was measured as a ‘yes’ or ‘no’ answer to a question as to whether there was ‘adequate equipment for physically heavy tasks’. ‘Demographic characteristics’ concerned such information as: the year of data collection (‘2005’ or ‘2015’); the respondent’s age (as a continuous variable); education or training in caring for older people (‘up to two years’ or ‘more than two years’); place of work (‘residential care’, ‘home care’ or ‘other’); and type of employer (‘public’, ‘private profit’ or ‘non-profit’). Originally, the questionnaire had six responses for education or training in caring for older people, but because there were so few (N = 87) for the first four (‘no training’, ‘less than one month’, ‘ 6–11 months’ and ‘one to two years’), these were merged together into a new category called ‘up to two years’. The place of work variable was also recoded so that those care workers working in more than one setting (that is, residential and home care) were ‘other’. The ethical principles for the research were strictly adhered to throughout the present study (for example, informed consent and the anonymisation of data), but – as suggested by the Finnish Advisory Board’s Guidelines on Research Integrity (TENK) – ethical approval was not sought for this study because the participants were neither minors nor people with limited capacity. Analyses Descriptive analyses were used in the present study to describe the data. This included frequency, mean and standard deviations, chi-square tests (for categorical variables), and one-way Anova (for continuous variables). Using the STATA 16 software, ordinal logistic regression was carried out to examine the association between the dependent variable (a three-level ordinal scale) and the independent variables, and the proportional odds assumption was verified using the Brant Test. The results showed statistically non-significant (p > 0.05) results, indicating that the proportional odds assumption had been met. Multicollinearity was then checked using the standard method of variance inflation factors (VIF), and the result value was also found to be within the acceptable range (VIF < 2.5). Results from the analyses in STATA were reported in an odds ratio (OR), with their confidence intervals set at 95 per cent. Results According to 31 per cent of the respondents in 2005 (N = 650), they were not able to give older people the help they felt they deserved, whereas in 2015 (N = 955), this had increased to 35 per cent (see Figure 1). This means that in both years, roughly a third of all respondents felt that they were unable to give older people enough support. However, only less than 15 per cent of the respondents in both periods felt that the older people received enough support. Brought to you by University of Jyväskylä | Unauthenticated | Downloaded 03/06/23 12:10 PM UTC Being able to provide sufficiently good care for older people 7 The mean age of participants was 45.7 years (see Table 1); most of them had had more than two years of training or education in caring for older people (n = 1,017; 63 per cent); most worked in residential care settings (n = 1,097; 68 per cent); and more than three quarters worked in the public sector. Most participants also felt that they were required to assist too many people on at least two of their shifts (M = 1.6 ± 1.4) and needed to work in paid overtime jobs every month (M = 2.4 ± 0.9), while 58 per cent (n = 938) felt that they needed to spend more time on documentation. Mean scores for the total population showed that a large proportion of the care workers who took part reported having experienced staff shortages (M = 3.3 ± 1.0), physical and mental burdens (M = 3.3 ± 0.8), and physical violence or threats (M = 2.4 ± 1.2) in the workplace. However, these mean scores were higher for each of these variables among those who ‘most often’ felt that they were not giving older people the care they deserved: staff shortages (M = 3.7 ± 1.0), burdens (M = 3.7 ± 0.8) and physical violence or threats (M = 2.7 ± 1.3). In other words, care workers who experienced a regular shortage of staff at work, who felt physical and mental burdens quite often, and were frequently subject to physical violence or threat often felt unable to provide care older people deserved. Whereas almost three quarters (n = 1,156; 72 per cent) of participants reported feeling unable to influence their daily planning of work, only 36 per cent (n = 586) reported too much monitoring and a lack of trust from management. In fact, most felt that they ‘less often’ received support (n = 988; 62 per cent) from their immediate supervisor, and an even greater proportion felt that there was little training in the workplace (n = 1179; 74 per cent). Nevertheless, about two thirds of respondents (n = 952; 61 per cent) felt that they did have adequate equipment to do the physically heavy jobs in their workplace. Table2 shows the relationship between the working conditions of care workers and their perceived ability to give older people the support they deserve. All the variables Figure 1: Percentage of care workers who think care recipients are not receiving adequate help (N = 650 in 2005; N = 955 in 2015) 14 55 31 13 52 35 0 10 20 30 40 50 60 70 Rarely Yes, sometimes Yes, most often 2005 2015 n=92 n=127 n=360 n=492 n=198 n=336 Brought to you by University of Jyväskylä | Unauthenticated | Downloaded 03/06/23 12:10 PM UTC Jiby Mathew Puthenparambil 8 Table 1: Descriptive statistics of care workers who think they are providing inadequate care Variables Total population Rarely Sometimes Most often p-value n (%) or M (SD) % or M (SD) % or M (SD) % or M (SD) 1. Demographic characteristics Year 2005 654 (40) 14 55 31 0.143 2015 976 (60) 13 52 35 Age M (SD) 45.7 (11.7) 43.9 (13.0) 46.6 (11.3) 45.0 (11.8) 0.003 Education/training Maximum 2 years 588 (37) 11 56 33 0.023 Yes, more than 2 years 1,017 (63) 16 51 33 Place of work Residential care 1,097 (68) 14 51 35 0.229 Home care 339 (21) 13 58 29 Other 176 (11) 14 52 34 Type of employer Public sector 1,210 (78) 12 54 34 0.030 Private (for-profit) sector 218 (14) 20 50 30 Third (not-for-profit) sector 117 (8) 13 57 30 2. Working conditions Excessive workloads Too many persons to assist in different shift 1.6 (1.4) 0.7 (1.1) 1.4 (1.4) 2.4 (1.3) 0.000 Paid overtime work 2.4 (0.9) 2.3 (0.9) 2.3 (0.9) 2.5 (1.0) 0.000 Skip or shorten lunch break 3.2 (1.2) 2.7 (1.3) 3.0 (1.2) 3.7 (1.1) 0.000 Too much documentation Agreed 938 (58) 10 52 38 0.000 Disagreed 675 (42) 19 54 27 Staff shortages Staff shortages due to sickness, leave or vacancies 3.3 (1.0) 2.9 (1.0) 3.2 (1.0) 3.7 (1.0) 0.000 Feeling burdened Feeling physically and mentally burdened 3.3 (0.8) 2.9 (0.8) 3.2 (0.8) 3.7 (0.8) 0.000 Subjected to violence Subjected to physical violence or threats 2.4 (1.2) 2.1 (1.2) 2.3 (1.1) 2.7 (1.3) 0.000 Level of autonomy Can you affect the daily planning of your work? 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