Crises in care – compassion and body work

The news in 2014 was regularly punctuated with stories of care home residents suffering abuse. As a result, care workers have been prosecuted and sentenced and homes have been closed, yet hidden camera exposes produced by residents’ relatives and by documentary film makers continue to highlight further incidents. The picture is grim. So it’s perhaps unsurprising that we have heard resurgent calls, from politicians, professional bodies and journalists, for a return to ‘compassionate care’. These calls usually emphasise the need for care workers to be re-trained so that they can learn (or re-learn) empathy. Sometimes this is juxtaposed to an emphasis on professional qualifications. For instance, UK Prime Minister, David Cameron suggested that ‘nurses should be hired and promoted on the basis of having compassion as a vocation not just academic qualifications’.

Yet, this widespread interpretation of recent crises in the care sector misunderstands the logic of care work. Simply put, it ignores the fact that care work is a type of what scholars have termed ‘body work‘: paid work that requires workers to touch, manipulate or otherwise work on, and in direct contact with, the bodies of others. For various reasons, summarized below, body work is extremely difficult to standardize or make profitable. Yet a privatized care regime is premised on companies’ ability to do precisely this: realize profit through standardization and capital-labor savings. In this context, one in which private care companies attempt to achieve largely unachievable goals, there is no reason to believe we have seen the last harm to residents nor a shift away from care practices that systematically undermine the dignity of those being cared for. Meanwhile, care workers employed by private companies have become residual casualties; unable to compensate for the structural problems endemic to privatized body work and demonized by the media when things go wrong.

Care, body work and profitability

So, why is body work so tricky to make profitable? In short this comes down to the fact that bodies are varied, unpredictable and indivisible. These three features are simultaneously obvious yet rarely made explicit in discussion about care work.

1. Variability: Our bodies vary, in size, shape, but also with respect to our responses to stimuli and our communicative capacity. This presents a problem for managers trying to rationalize the workplace, because it makes it more difficult to develop one-size-fits-all or standardized labor processes. Concomitantly, bodily variability and the complexity this introduces makes mechanization (and the substitution of capital for labor) difficult. In consequence, even today there are few mechanized implements that can adequately substitute for a human being doing body work; tasks as simple as turning a body over are not actually simple to mechanize.
2. Unpredictability: Allocation of human labor between bodies is difficult to manage because bodily need is highly unpredictable. For instance, if I and the residents on either side of me all need to use the toilet at the same time all three of us would need a care worker’s assistance simultaneously. It is quite possible, however, that after this none of us would need help for several hours. On another night the pattern may be completely different. It is similarly difficult to predict more major demands, for instance when a resident falls and requires significantly increased assistance. This means that the staffing levels required to reasonably (and with human dignity) accommodate peaks of bodily demand are significantly greater than those required at most times, and especially periods of low demand. Yet without a way of predicting when peaks will occur there is no obvious way to accommodate these short of ensuring staffing levels are always high enough to deal with peak demand (a costly management strategy, and not one that sits easily with a profit motive).
3. Indivisibility: That (living) bodies cannot be divided up is obvious, but important. I cannot take my legs to be massaged in one room, while I am fed in another and have my hair washed elsewhere. This means that, unlike most other work which can employ a division of labor to reorganize the labor process, body work has to be completed serially (one aspect of the body dealt with at a time) and must occur where and when bodies are present. This places constraints on the ability of managers to re-structure or cheapen labor processes: information systems and Indian call centers are of little help.

Conceiving of care work as body work and taking seriously these specific attributes of body work serves to expose the material obstacles facing private care companies: Labor requirements are high (in relation to capital) and very difficult to reduce or systematically reorganize. Furthermore, labor is required at unsociable hours, in specific places and unpredictable quantities. Notwithstanding the low wages typical of the sector, meeting these labor demands will hit private profit.

Care companies attempt to ameliorate these constraints on profitability by encouraging residents to recalibrate their own ‘need’ (for instance by ‘becoming accustomed’ to less attention) as well as by more brutal but everyday procedures. The latter include substituting feeding tubes for the (slower, but more sociable) process of helping residents to eat through their mouths. It also includes putting residents in diapers, rather than hiring sufficient staff to be available to take them to the toilet when they wish; even leaving residents in diapers for hours after these have been soiled. And, as the recent crises have demonstrated, sometimes companies simply fail to meet needs. None of this is good care. But neither is it surprising in a context in which the staffing levels required for peak demand are costly and where profitability is the objective. US studies (1, 2) have shown that for-profit care homes are more likely than public or not-for-profit to employ feeding tubes. In the UK, an ethnographic study by Joe Greener, who worked in a care home, shows that the impetus to rely on labor saving techniques (such as diapers), even where they undermine patient care, increases in conditions of squeezed profitability.

It’s not about compassionate care

These systemic problems are, however, obfuscated in public debate that focuses on ‘care’. This is because the language of ‘care’ conflates two different processes: ‘caring for’ (the material body work tasks) and ‘caring about’ (the intrinsic desire to help). The government’s solutions, insofar as these emphasize ‘compassion’, relate to the latter. Yet, if we look at the details of recent scandals, it is clear that most incidents of ‘uncaring’ behavior relate to material or body work tasks: residents were not provided with sufficient food or drink, were not taken to the bathroom when needed or were not turned over in bed.

In fact, studies of residential and domiciliary care work have repeatedly shown that workers do ‘care about’ those people that they work with and use their own time and resources to do additional, and unpaid, work in an attempt to ameliorate the deficiencies of the system. Additionally it is because care workers do ‘care about’ the people with whom they work that they continue in work that often occurs at unsociable hours and may pay at or below minimum wage. The problem is that caring about residents is insufficient without the time, workforce and resources necessary for the body work involved in ‘caring for’ these people.

Finally it is worth noting that care, the word itself, allows for little discursive nuance. We do not describe people as ‘a bit caring’ or say that someone ‘cares a little’. Rather, we tend to understand caring as binary: I care or I do not care; any shortfall from full caring thus marks workers as ‘uncaring’. Yet, in the context of underfunded body work this is an impossible standard. In this light, we should instead, as suggested by John Kennedy, in a recent JRF report,

Be appreciative of the million and a half people who work in our social care sector. They are your friends, relatives and neighbors. They care for us and our own. Judge them by the reality of humanity not by an idealized, unattainable expectation.

So, what is to be done?

The first thing we can do is recognize that care work is not about making widgets, but nor is it simply about making people happy. Rather it involves work with bodies (body work) and this is complex and expensive to organize on the labor market, something exacerbated by the involvement of private companies, seeking profitability. Once we recognize this we have a choice: retain the current system and learn to live with recurrent ‘care crises’ or decide, as a society, to prioritize decent care, something that will require radically increased funding, to cover peaks in need, and a move away from private provision. In the meantime, we can stop demonizing badly paid care workers caught in a structurally intolerable and irresolvable position.

Rachel Lara Cohen is Senior Lecturer in Sociology at City University London. This article was first published by Discover Society. It is based on a longer article (pdf) published in Sociology of Health and Illness.