Mountains of care: Organisational redesign and quality of working life in nursing homes

One out of two care workers experience excessive workload in nursing homes. Besides this, other worrying statistics were found in the Flemish Workability Monitor (2016) of the Social and Economic Council of Flanders as well. Similar results were found in other countries and regions. Issues with the quality of working life in the nursing home sector present a significant roadblock towards finding resolutions for the predicted labour shortages. An ageing population in industrialised countries will namely cause a growing demand for beds, and thus also lead to an increased demand for care workers. In addition to this increase in quantative demands, there is also a growing demand for qualitative life and care. Residents increasingly have more complex care needs and demonstrate a desire for more personalised care forms. The proportion of the population that is at working age and able to address these growing demands is decreasing. Improving the quality of working life is part of the solution with regard to avoiding labour shortages. It is, after all, difficult for these jobs with quality of working life issues to attract a sufficient number of new employees, to persuade those who left to return, and to retain experienced workers.

This doctoral dissertation researches whether the concept of ‘normalised small-scale living’ improves the quality of working life of care workers. The concept originated in Scandinavia, where it was developed in psychiatric centers. Since 1970 the concept of ‘normalised small-scale living’ started being introduced in nursing homes. Residents in normalised small-scale nursing homes live in a homelike environment, where they are offered the opportunity to live a life closely resembling the life they led before they moved to the care facility. It is striking that the concept barely refers to the embedding of care jobs into the larger organisational context, especially since it has been proven that the concept has an impact on the quality of working life. The resident-centered concept seems therefore to have lost track of the job of the care worker. This dissertation specifically examines whether insights from organisation studies could help improve the understanding of the quality of working life in normalised small-scale nursing homes.

In order to research the abovementioned, this dissertation makes use of a mixed-method research design. In the first phase, the impact of the care concept on the quality of working life was studied by conducting two literature reviews (the international and the Flemish context). In the second phase, the results of the first phase were explained and it was studied in what ways the quality of working life issues in normalised small-scale living could be resolved. The latter research made use of interviews with care workers and managers, surveys, on-site observations, focus groups, pedometers and administrative data.

This doctoral dissertation shows that ‘normalised small-scale living’ is a step in the right direction towards improving the quality of working life in nursing homes. Nursing homes that function according to principles of normalised small-scale living have jobs with higher job demands. These jobs, however, also come with more regulation capacity that helps address those higher job demands. The biggest issues are social isolation of co-workers and managers as well as the periodical peaks in time pressure. It was also found that these issues arose in different degree and form across nursing homes.

By using insights from organisation studies (and especially Modern Sociotechnical Theory), this dissertation shows that this can be explained by the various ways in which the care concept is realised in practice and, especially, by the various organisational contexts wherein the concept is implemented. The concept seems to be realised in organisations with different organisational structures as well as different built environments. This dissertation shows that this organisational embedding has a profound impact on the quality of working life of care workers in normalised and small scale nursing homes.

This doctoral dissertation makes use of insights gained from the Modern Sociotechnical Theory, while its findings contribute back to the theory. The Modern Sociotechnical Theory offers a framework to study the way in which tasks are divided up in organisations (i.e. organisational structure) and to explain how that impacts the quality of working life. This dissertation shows the importance of insights gained from the Modern Sociotechnical Theory when it comes to shaping organisational structures in a well-thought-out manner. It also confirms that organisational structures play an important role in creating jobs with a high or low quality of working life.