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McAllum and Elvira 2015: Zeros or Heros?
Electronic Journal of Communication
Volume 25 Numbers 1 & 2, 2015

Zeroes, Service Providers, or Heroes?
Dignity and the Communicative Politics of Care Work

Kirstie McAllum
Université de Montréal
Montréal, QC, Canada

Marta M. Elvira
IESE Business School
Madrid, Spain

Abstract: All economies are confronted by a growing care crisis: Both public and private organizations are struggling to recruit and retain adequate numbers of workers willing to provide care for elderly or chronically ill persons. While some social commentators argue that poor pay and excessive workload, caused by under-staffing and insufficient funding, lie at the heart of the problem, we propose that the pressing labor shortages stem partly from the problematic relationship between care work and dignity and are influenced by the broader socio-political context. We elaborate on how dominant discourses construct specific “grammars of care” which indicate who should care, what constitutes care, and the actions proper to the care relationship. We show that the discourses of economic exchange, entrepreneurial professionalism, and communitarianism constrain care workers’ choices in important ways, thereby limiting workers’ ability to achieve workplace dignity. Finally, we call for action with some optimism: as the meanings attributed to care work are communicatively constructed, the grammar of care can be re-scripted in ways that enhance dignity.

When families cannot or choose not to take on the business of caring for elderly or chronically ill persons due to their own need for paid work, the needs of younger family members, or geographical dispersion (Harrington Meyer, 2000), privately-funded or government-employed care workers are hired to step in. Finding someone to care, however, is becoming increasingly difficult in graying industrialized economies. The working age population continues to decline, while the number of elderly persons is increasing. The proportion of the population within the European Union aged 65 and older will jump from 17% currently to 30% by 2060 (European Commission, 2012) and that of the United States is projected to almost double in size from 12% in 2005 to 19% in 2050 (Passel & Cohn, 2008). Nonetheless, the traditional care workforce is shrinking. Elder care, historically conn ected with the capacity of women, and more recently women from minority or immigrant backgrounds (Duffy, 2007), to “nurture” vulnerable others (Cancian & Oliker, 2000), is evolving, due in large part to changes in the nature of women’s labor force participation. Consequently, demand for paid care work already outstrips the available labor supply (Paraprofessional Healthcare Institute, 2008), creating a “care gap” where some miss out (Stone & Wiener, 2001). In fact, the care crisis has already begun: the U.S. alone will need 70% more workers by 2020 (U.S. Bureau of Labor Statistics, 2013).

Despite the urgent need to recruit and retain workers who can provide personal care and assistance with the activities of daily living, the sector is beset by high turnover (see Hussein, Manthorpe, and Stevens, 2010, for U.K. data and Potter, Churilla, and Smith, 2006, for U.S. data). U.S. estimates of turnover rates, for instance, range from 40 to 100% (U.S. Department of Health and Human Services, 2004). Core problems include the poor pay rate, lack of employment-related benefits, and part-time nature of much care work, which leave many care workers close to or below the poverty line. U.S. agencies announced that “almost 40% of aides receive government benefits like food stamps and Medicaid” (Greenhouse, 2013, para. 7). Other reasons include limited opportunities for career advancement, poor supervision and mentoring (Kopiec , 2000), significant risk of work-related injuries, and under-staffing, which forces care workers to speed up the pace of physical care and cut back time spent cultivating relationships (Bowers, Esmond, & Jacobson, 2000). Recent, and laudable, efforts to improve wages and promote more flexible, personalized relationships aim to address some of these pressing structural problems.

In contrast to the attention directed to structural constraints, the impact of care work’s occupational image, frequently depicted as a dirty job that involves “dealing with leaky bodies and unsettled minds” (Bolton & Wibberley, 2013, p. 4), on both current and projected labor shortages has received little attention in either academic or policy circles. Our objectives for this paper, then, are twofold. First, we develop a theoretical road map that explores how the broader political and socio-cultural frameworks within which care occurs construct care work itself and structure the relations between care workers and their clients in specific ways. Despite the variety of meanings that can be given to care encounters, each possibility is underpinned by an underlying structure or grammar that connects an agent to a beneficiary through the mediation of particular objects and actions (Taylor & Van Every, 2000). We utilize Taylor and Van Every’s work on grammars to analyze and critique the ways in which the discourses of economic exchange, entrepreneurial professionalism, and communitarianism specify the nature of these relations, who the actors are, who they are to each other, and the actions proper of the relationship. Second, since enhancing the sustainability of the care workforce is also linked to increasing its occupational prestige, we consider the implications of these various discursive configurations of care for care workers’ pursuit of workplace dignity. Given a growing tendency to treat chronically-ill elderly persons in their own homes, to improve their quality of life and cut the costs associated with care (Landers, 2010), we focus our attention on home-based care workers, who are particularly vulnerable to workplace indignity due to their low status and remote, decentralized workplaces .

Before we begin our review, we develop our theoretical framework of grammars of care. We then show how the grammar of care changes considerably when viewed through the lenses of economic exchange, entrepreneurial professionalism and communitarianism, with diverse consequences for the care work relation. We illustrate the impact of each discourse on how we understand care work by drawing on a wide range of studies from the organizational communication, sociological, management, and health care literatures. We pay particular attention to examples from recent empirical work in communication and sociology which used in-depth interviews and ethnographic shadowing of home-based care workers, as well as our own in-progress research data. These studies, underpinned by varied theoretical interests and disciplinary angles, such as organizational identification (Scott, 2014), socio-economic class and work conditions (Stacey, 2 011), and the construction of occupational meanings (McAllum & Elvira, 2013), have investigated care work experiences across different geographical contexts (North-Eastern U.S., Western U.S., and Spain, respectively). In order to develop dignity-enhancing grammars of care, we conclude by laying out a research agenda that builds on and extends this work.

A Grammar of Care

Care work is, in and of itself, relational, as both a caregiver and a care recipient are required for care to happen[1]. Drawing on Taylor and Van Every’s (2000) work, we contend that the communication patterns, actions, and value attributions created by and resulting from the connection between those who give and those who receive care can be expressed in language by means of a finite set of basic sentence types that indicate cause, possession, changes of state or location, and so on. Across these types, we can use sentence grammar to indicate who acts (the subject), what is done (the action, expressed by a verb), and who or what receives the action (the direct object). We could certainly describe what care workers do, using this formulation. For example, Julie changes the bed linen or Maria makes a hot dinner. The fact that the recipients become some what invisible, however, is rather problematic, given that care implies the performance of a set of actions (cleaning, dressing, and conversing, among many others) that benefit the person who is cared for. Hence, we make use of Taylor and Van Every’s ditransitive construction whereby a sentence specifies how the subject acts on something or someone, the direct object, for a beneficiary, the indirect object, as in the following examples: John massaged James’ feet [direct object] or Julie told some funny stories [direct object] to Tina [indirect object]. Now, James is the beneficiary who feels better after the foot rub by John, and Tina, the indirect object, enjoys the telling of the funny stories.

Ditransitivity, Authority, and Agency

The ditransitive construction is useful because it enables a focus on different types of indirect objects or beneficiaries. Evidently, the beneficiary can be the care recipient, as in the case of James’ well cared-for feet. The beneficiary can also be interpreted more broadly. Tina’s family members, for example, may benefit from Tina’s good humor, thanks to Julie’s entertaining conversation. The beneficiary plays a significant role in structuring the care work relation, since it is the beneficiary in a sense who authorizes the actions of the subject, giving her or him the power to carry out a certain role. For example, James’ incapacity, illness, or old age impels, “calls upon,” and authorizes John to execute physical, tangible manifestations of care, while Tina’s loneliness incites Julie to initiate cheerful small talk. Within this relation, the subject is effectively transformed into an agent who is “acting for” the beneficiary and receives material or symbolic rewards for doing so (Taylor & Cooren, 2006).

The grammar can be extended even further, by situating each sentence within the context of a bilateral exchange, as the transfer of an object by the subject to the beneficiary requires a certain acceptance or response. James may relax his feet completely as a result of the foot rub or he may choose to kick John given the care worker’s proximity. That is, although one can suppose that an action (giving a foot rub), transforms the person who receives it (James) by the mediation of an object (possibly, a relaxing lotion), one can equally argue that the action that connects the caregiver and the care recipient transforms both of them. John links to James through the service rendered, just as Tina links to Julie through the storying. From this perspective, one can speak of multiple agencies: that of the subject, that of the beneficiary, and that of the action that expresses care.

Linking Sentence Grammar to Discourse

As Taylor and Van Every (2000) pointed out, the lexicon that is used to fill each grammatical structure draws on a much wider set of principles, rules, values, cultural norms, and commonly accepted knowledge or what we choose to call “discourse.” Using Putnam’s (2001) distinction between figure and ground in communication research, discourse creates taken-for-granted “ways of structuring the social world” (Alvesson & Kärreman, 2000, p. 1129) and acts as an opaque “ground” that frames and configures each exchange (Shotter, 1989). Unraveling the participants, actions, objects, and beneficiaries linked to each grammar enables us to assess what aspects of care are privileged and which concealed within these meaning systems (Mumby, 2005).

As each grammar generates an ensemble of duties, obligations, and rights for the participants associated with each role, the grammar of care framework also allows us to unpack their impact on dignity, which repeatedly emerges as a core concern of paid care workers (see Washington, 2014, for examples). Improving care workers’ experiences of workplace dignity is important, since indignity manifested by inadequate resourcing, incivility, and disrespectful treatment mitigates job satisfaction, generates physical and emotional fatigue, and frequently contributes to occupational exit. Although dignity is frequently depicted as an individual cognitive construct linked to perceptions and feelings of self-worth and self-respect (Hodson, 2001), we focus on dignity as an interactional quality that emerges in and that structures relations with others (Yalden & McCormack, 2010 ). Such interactions give rise to what Bolton (2007a) termed dignity at work, derived from good working conditions, civil treatment, respect for employees’ health and safety, and job security, and dignity in work, generated by affirmations of competence, recognition of the job’s significance, and respect for autonomy. In the following sections, we examine the ways that three discourses, economic exchange, entrepreneurial professionalism, and communitarianism, construct particular versions of the grammar of care for paid care workers. These discourses were chosen to represent the various points along the individualism-collectivism continuum (Arai & Pedlar, 2003): economic exchange emphasizes individual responsibility; personal entrepreneurship, personal agency; and communitarianism, social responsibility.

A Grammar of Care Based on the Discourse of Economic Exchange

Political decisions about the provision, financing, and management of care for aged persons have changed radically over the past thirty-five years (Charpentier, 2002). Concomitant with stagnating economic growth after the 1970s’ oil shocks, many governments dismantled the infrastructure of the welfare state with its commitment to universal access to social assistance and initiated neoliberal reforms characterized by individual decision-making and user-pays financing. The “declining publicness of public services” (Baldock, 2003, p. 68) resulted in widespread de-institutionalization of care and, increasingly, its relegation to the “private” realm: both the private sphere of domestic/household spaces and the private sector, driven by the economic principles of self-interest, profit, and efficiency (Clarke, 2004). Goverments justified this two-fol d privatization by arguing that the market mechanism, which regulates producers’ and consumers’ exchange of valued resources (goods and services for money, or skills, knowledge, and effort for a pay check), enables increased production of a variety of goods and services at a lower cost. Consequently, during the 1980s, policy-makers in many developed economies transformed state payments to care providers into allowances for care recipients, reconceptualizing citizens who required care as consumers who could decide what they were willing to pay for in light of their own personal needs (Ungerson, 1997).

Within the capitalist market system, the value of every human activity, including aged care, is evaluated and calculated in monetary terms (Simpson & Cheney, 2007). Pay acts as a form of “feedback on job performance” (Clair & Thompson, 1996, p. 8) with financial remuneration linked to the perceived complexity of the action undertaken. Highly-educated care professionals tend to benefit from superior remuneration, and, furthermore, given the existence of considerable information assymetry (as in the case of a doctor’s superior knowledge of possible medical treatments for her patient), it is the producer rather than the consumer who determines the type of care provided. In contrast, care services that are considered less complex receive lower rates of pay, and, generally, the care provider must conform to the demands of the client. As Clair and Thompson aptly highlighted, the re sulting pay inequity “is an articulation of the currently accepted values embedded within the … prevailing socio-economic system” (p. 2). We consider how formulating personal care in terms of market-based economic exchange frames the care work relation.

The grammar of care associated with market-based economic exchange positions the subject as an unskilled worker who is forced to carry out dirty work for paying clients because he/she has no other employment options. Maria cleans up Mr. Tom’s poop is illustrative of the sentence grammar within this discourse. Within an economized framework, paid care workers like Maria receive low wages because the material tasks or actions specific to care work, such as cleaning up poop, are constructed as physically dirty, non-complex, and routine (Toynbee, 2007), and similar in kind to unpaid household work and the nurturing of family members typically provided by women (Hochschild, 2003). Hands-on personal care, especially that related to bathing and toileting incontinent older persons, is defined as unpleasant (Isaksen, 2002) and therefore carried out only by workers with &ldqu o;constrained” career choices or little autonomy to choose alternative work experiences and work places (Buzzanell & Lucas, 2013), due to lack of formal education, gender, race, and/or immigration status. Bolton (2007b) goes even further, arguing that domestic workers, who are driven by financial necessity to service the cash-rich but time-poor, constitute a twenty-first century “servant class.”

Two types of beneficiaries authorize Maria’s actions. Her care contributes to the comfort of Mr. Tom, whose age-related incontinence impels Maria to clean up the mess. Her work also benefits Mr. Tom’s children, Leanne and Donald, whose relative socio-economic privilege authorizes them to employ Maria and take on paid employment outside the home (Browne & Misra, 2003). Dyer, McDowell and Batnitzky (2008) attributed this shift in the organization of care labor to a desire to transfer to lower status persons the dirty work of dealing with dependent, aged, and diseased bodies (Wolkowitz, 2002) and transforming individuals who are “soiled, hungry, anxious  . . . into clean, replete, calm people” (Bolton & Wibberley, 2013, p. 3). Because society links cleanliness with good work and dirt with bad (Douglas, 1966), family members who contract out the care of elderly relatives have an incentive to reinforce the otherness of care workers and position themselves as occupational outsiders (Ashforth & Kreiner, 2013). Leanne, for example, presents herself to others as a full-time accountant who has hired a care worker rather than as a woman who provides personal care for her father.

The care work relation expressed by the grammar of economic exchange is characterized by unequal or complementary relationships (Bateson, 1972). The low pay associated with what Berg and Frost (2005) labeled a “dead end” job (p. 663) creates precarious and insecure working conditions and the attribution of a low-skilled status simultaneously confers a sense of being disposable and easily replaceable. Consequently, care workers tend to accept long hours and unsociable work schedules. In some cases, live-in carers work in conditions that resemble a total institution, working beyond their official hours and during “days off” (Anderson & Rogaly, 2005). In the context of home-based work, these exploitative conditions are frequently economically and socially invisible. Tarricone and Tsouras’ (2008) study of home care in Europe noted that in 2006, 83% of care workers in Italy were not born there, and that most of this workforce were “not licensed and work outside the oversight of regulatory bodies” (p. 11). Unlike other workers who band together to create a coherent workplace identity and occupational prestige, the dispersed care workforce is unable to create a collective community of coping (Korczynski, 2003).

In worst case scenarios, the care work relation can become one of domination (Kittay, 1999), where beneficiaries use threat of job loss, physical absence, or emotional manipulation to ensure that care workers respond as expected. The care worker becomes a mere tool or resource for providing comfort. Westerhof, Van Vuuren, Brummans, and Custers (2013) described this outcome in Buberian terms as the construction of an “I-it” relationship. Anderson (2000) argued that reducing personhood to one’s occupational role in this way dehumanizes and stigmatizes workers. Within the framework of economic exchange, care workers are called on to create and maintain “dignity-affirming conditions” (Buzzanell & Lucas, 2013, p. 19) for care recipients – frequently at the expense of their own dignity.

Nonetheless, by foregrounding their vulnerability due to medical needs, physical incapacity, or desire for companionship, beneficiaries are able to disguise their dominant position and make their requests seem a natural matter of course. Consider how Sophie negotiated the parameters of the care relationship with her client in the following incident:

They made me kind of part of the family . . .. they expected me to be with her when the daughter was out of town on Thanksgiving. I said, “Well, I would like to visit my husband’s family in Southern California.” She said, “Well, I will need you because my daughter’s out of town and I need you. (Stacey, 2011, p. 80)

When their expectations collided, Sophie’s tentative expression of her personal plans for family time (“I would like to visit my husband’s family”) was ignored by her elderly client (“Well, I will need you”). Sophie did, indeed, spend her Thanksgiving working, putting her client’s need for care and dignity ahead of her own (Lawless & Moss, 2007). Blood relatives might well decide to take a break from caring in order to cultivate other personal relationships; for care workers, being “family” means being a dependable, on-call, all-hours resource, constantly available through time and space (Buzzanell & Lucas, 2006). Waerness (1984) also argued that the familial metaphor is usually applied assymmetrically, since beneficiaries seldom if ever go beyond the call of duty to meet the needs of care wo rkers.

A Grammar of Care Based on the Discourse of Entrepreneurial Professionalism

Over the last decade, the care sector has become more complex, with a mix of public, private, and nonprofit providers offering services to care recipients. In some countries, such as the Netherlands and Finland, this trend has been accompanied by quality monitoring of care (Timonen, Convery, & Cahill, 2006) and in others, such as the United Kingdom, requirements for specific skills training and education (McFarlane & McLean, 2003). These developments have created a distinctive grammar of care, which we name “entrepreneurial professionalism.” Since care workers must demonstrate their ability to deliver quality work, this grammar frames care workers as active rather than passive, autonomous rather than dependent, “enterprising subjects” (Du Gay, 2000) who choose particular life and career trajectories that meet their needs for meaning and achieveme nt (P. Miller & Rose, 1995). From this perspective, responsibility for personal success lies with the individual: the self-managing, entrepreneurial self (Scourfield, 2007) is expected to promote the value and dignity of his or her work through personal branding (Lair, Sullivan, & Cheney, 2005). Laura creates Mrs. Wheeler’s weekly meal plan exemplifies the sentence grammar that characterizes the discourse of professional entrepreneurialism: Laura presents herself as a valuable worker with sufficient knowledge of nutrition to construct a healthy menu, which confers on her the ability to self-manage. Care workers may engage in such occupational re-framing (Kisselburgh, Berkelaar, & Buzzanell, 2009), by aligning the skills that care work requires with the demands of other valued occupations, or by reconfiguring the actions of ca ring as a complex, professional service.

In the first instance, workers augment the value of their subject position by connecting them with those carried out by members of higher-status groups. Many unions for care workers, such as the Service Employees’ International Union (SEIU Healthcare, 2014), cluster care workers with other health professionals such as paramedics and nurses. Individuals who have given up another job or discretionary time to take on care work also transfer the positive social identity derived from their other life roles to care work. The parental care-givers in Miller, Shoemaker, Willyard and Addison’s (2008) study, for example, described how care work drew on skills developed in prior roles such as teacher, counselor, and insurance agent. Among the U.S.-based care workers campaigning for basic labor rights guaranteed by law, a care worker also explained her work (in Spanish) in terms of other occupations: “I’m a social worker, a psychologist. I wear so many hats on this job” (Peñaloza, 2012, para. 2). Individuals transform the negative valence attributed to care work by aligning tasks to occupations with a positive social value.

In the second case, care workers recast the nature of the actions they carry out as skillful and indispensable. Workers describe material tasks, however humble or intimate they may seem to others, as quality work when carried out with care and competence (Lucas, 2011). Such was the case for a care worker in Stacey’s (2011) ethnography who emphasized the skill required to bathe elderly persons:

Let me make this note. When I go in there – I’m going to tell you, if you ever meet one of my clients, they would tell you, I give them the best bath, shower . . . . Everybody do not know how to give a bath. (p. 118)

Moreover, care workers’ proximity and ongoing interaction with clients allows them to observe minute clinical changes. Participants in Scott’s (2014) study insisted that visiting health professionals needed to respect home health aides, since “we’re the ones that tell them [registered nurses] what’s going on with a patient, what needs to be changed” (p. 17). Boockvar, Bordie, and Lachs (2000) found that personal care aides in residential facilities recognized the symptoms accompanying the onset of acute health problems days before registered nurses detected them.

Other care workers focus on the generic skills that they use to manage a job that gives workers considerable autonomy and decision-making responsibility. The Direct Care Alliance (2012), a U.S.-based collective action group for care workers[2], foregrounds skills including “decision-making, problem solving, and communication in addition to content knowledge” (para. 4) as attributes of excellent care workers. Purkis, Ceci, and Bjornsdóttir’s (2011) comparative ethnography of home-based care work in Canada and Iceland also demonstrated that care workers faced complex communicative challenges as they negotiated the sharing of care work tasks with family members. This expanded task repertoire creates a sense of dignity in work or the self-worth and self-esteem that derive from work that is meaningful (Bolton, 2007a).

The beneficiary who authorizes the skillful enactment of care for recipients is, in this grammar, the care worker who draws on his or her skill set to provide the highest quality care. “Entrepreneurial professionalism” benefits care workers because it offers opportunities for creativity and enables them to set themselves apart from others, thus providing a means to secure and retain their clients. In Stacey’s (2011) ethnography, José’s care recipients, their families, and even neighbours recognized and affirmed his role in helping his elderly clients relive their younger years by doing their makeup. Not only did it make “such a difference to them when they would look in the mirror after I was done” but “when I’d bring them out, boy, you know, everybody would say, “Oh there goes José’s girls” (p. 112, our italics).

However, while care workers use professionalism as a positive strategy to enhance the dignity attributed to the tasks of caring, professionalism also changes the relationship between subject and recipient. That is, professionalism does not just dictate the field of action but also the manner in which tasks are carried out (Lively, 2001). Specifically, “doing” professionalism (Cheney & Ashcraft, 2007) foregrounds the ability of the professional worker to be self-controlled, resilient, and able to moderate the expression of excessively positive or negative emotions (Kramer & Hess, 2002). Given that some care recipients, despite their physical reliance on those who care for them, react with ingratitude or disrespect, care workers are frequently called on to manage their emotions. Laura, for example, may be confronted by an angry Mrs. Wheeler who insis ts that last week’s favorite meals should not figure on this week’s meal plan. As Taylor and Van Every (2000) pointed out, the “transfer of an object [here, the selection of the care recipient’s preferred foods for inclusion in a menu] . . . to a recipient may be rejected as well as accepted” (p. 92).

In such cases, care workers downplay, dismiss, or excuse their their clients’ words or actions, by referring to their superior state of health, physical strength, and professional status. When care workers’ mental and physical resources exceed those of care recipients who cannot control their (re)actions, care workers continue to provide care, irrespective of recipients’ behavior. Our own data set contains many examples, as in the following case:

The clients, they curse, they call me bad stuff. That’s normal because they have Alzheimer’s. They’re not really aware. They call me “Nigger,” “Bitch,” this, that. “You’re lousy.” My favorite thing to say is “I love you too.” If they were in a normal state of mind, I’d be hurt maybe. But I just think it’s their condition, it’s the Alzheimer’s or it’s the whatever condition they have.

In order to maintain the care relationship, the care worker chooses to remain “professional” by ignoring these types of comments and justifies care recipients’ behavior by referring to their state of health. Nikolaidou and Karlsson’s (2012) ethnography also documented how a care worker omitted to mention a care recipient’s openly racist comments in the record of care: “The caregiver chooses not to document the incident [in the institution’s daily journal about resident behavior] and does not report it in any other way” (p. 513). Care workers actively structure the care work situation by strategically deciding what to pay attention to.

Similarly to the grammar of economic exchange discussed in the previous section, care work relations are unequal or complementary. The core difference is that, within the grammar of entrepreneurial professionalism, care workers place themselves in the dominant position, as their relative power authorizes them to provide care to those who are mentally vulnerable and physically weak.

A Grammar of Care Based on the Discourse of Communitarianism

According to its advocates, communitarianism inspires participation, commitment to the greater good, and the development of sustainable, community-based relationships (Etzioni, 1994). From a communitarian perspective, care workers are framed as social heroes, since their work not only provides direct benefits for fragile or dependent community members, but also creates external benefits or spill-over effects for other individuals and institutions (England, 2005). By dedicating significant amounts of time to “being with” care recipients rather than solely “doing” tasks for them, care workers empower recipients as they develop their emotional, physical, and intellectual capacities (Lips-Wiersma, 2002). The verbs within this grammar of care tend to point toward this transformative potential. In the case where Ron listens closely to Mrs. Wilson’s de scription of her grandson’s graduation, Ron’s attentive presence and questions about the details of the ceremony are likely to maintain Mrs. Wilson’s cognitive and linguistic abilities and affirm her connection with family members. These enhanced outcomes benefit not only Mrs. Wilson’s immediate family circle but all community members, since a culture of caring creates community connectedness and social cohesion, fostering expectations that members who become dependent will be looked after in their turn.

However, the benefits that recipients gain are intangible and difficult to measure using traditional economic instruments, and such services are unable to be effectively organized by the market mechanism, which under-provides them. Rather than rely on the “ice-cold” market economy driven by rationality and the calculation of interests in monetary terms (Latour, 2013, p. 386), communitarianism builds on the “love economy,” made up of informal networks of local connection that fall outside the national economic statistics collected by governments (Henderson, 2006). Communitarian perspectives insist that human dignity is not well served by emphasizing individual responsibility and the right to self-realization (Bellah, 1998), as the grammars of economic exchange and entrepreneurial professionalism suggest, but by promoting the “social dimension of human existence&rdq uo; (Ackerman, 1995, p. 650). This discourse proposes that persons are embedded within specific communities, including but not limited to families, neighborhoods, schools, nonprofit and voluntary organizations, churches, mosques, and synagogues. Consequently, these memberships, which derive from one’s place in the social structure, shape one’s understanding of who one is and who one should be for others (Baynes, 1988) and specify responsibilities as well as privileges (MacIntyre, 2007). In the following section, we consider how a communitarian grammar configures the care work relation.

Through a communitarian lens, care workers are framed as individuals with a calling to care (Hall, 2004). Care workers in Stacey’s (2011) study argued that, since the tasks themselves could indeed be dirty and difficult, demanding sacrifice in terms of time, physical exertion, and out-of-pocket expenses, only individuals who understood what care truly “meant” should be allowed to enter clients’ homes. These care workers measured their worth by making comparisons with the actions carried out by other informal and formal care providers. Specifically, care workers evaluated themselves positively against those below them, such as absent or dysfunctional family members and paid care workers who were dishonest or unreliable. Such was the case for a care worker in Hokenstad, Hart, Gould, Halper and Levine’s (2000) study, who deemed the care worker on duty dur ing the Christmas season incompetent and insisted that she go home:

It was Christmas time. I couldn’t work Christmas Day because I have kids. The patient’s husband had to go out of town for family business. So he said, “Could you do me a favor? Could you come by and just check on the other aide?” When I got there, the aide complained about the patient: “She won’t do this, she won’t do that.” And I’m looking at [the patient] and [she] is gray. I said, “Just get her up to the bed.” I wound up doing it all, and I wasn’t even working. I said to the other aide, “Go home. Just go home.” (p. 309)

In contrast to the grammar of entrepreneurial professionalism, where care workers invoked other professions to gain legitimacy, care workers also distanced themselves from occupational groups above them such as physicians and other medical professionals who were too impersonal or too busy to actually care for clients. A care worker in Stacey’s study specified her superiority to registered nurses who “do a lot of paperwork. They don’t spend their life with people. They don’t know” (p. 121).

Care workers’ subject position, premised on a talent for caring, transforms the nature of the actions proper to the grammar of care, since the material tasks entailed in caring for recipients are inextricably linked with caring about them (Baines, Evans, & Neysmith, 1998). In stark contrast to the grammar of economic exchange’s interpretation of care as the routine repetition of unskilled tasks, a communitarian vision highlights competencies such as empathy and spontaneity (Frost, 1999) that enable care workers to adapt care practices to meet the needs of specific recipients. Sass’ (2000) study of interactions within a nursing home, for example, showed how care workers’ creative use of personalized “courtesies [or]  . . . performances of enhanced kindness” (p. 343), such as stopping to chat, closing windows to avoid i maginary drafts, and listening to concerns, was transformative for residents. The skills needed to notice, connect, and respond (K. I. Miller, 2007) not only lend a sense of meaningfulness to the work itself, but tend to build and sustain positive relationships between care workers and recipients.

The beneficiary who authorizes care, in this case, is the care worker who has a vocation as a “caring self” (Stacey, 2011) that can only be actualized relationally, by connecting with members of the community who need their services. Since giving care expresses who the self is, care workers step into the caring role as a matter of course. The aide in Hokenstad et al.’s (2006) study, for instance, didn’t think twice before she dropped in to check on her client, even though she wasn’t officially working during the Christmas holidays. As long as recipients have a need for care, care workers who identify themselves as particularly talented and skilled in nurturing take responsibility for doing so. The care work relation that is established is one of responsibility expressed through ongoing availability, to protect care recipients from individuals who lack a vocation to care and who would b est serve the community in other roles.

Comparing the Grammars of Care

Before we proceed, we summarize in Table 1 how each grammar of care instantiates particular types of understandings about the subject, actions, objects, and interagent relationships (Taylor & Cooren, 2006, p. 121).

Table 1
Discursive Constructions of the Grammar of Care


Grammar of Care


Economic exchange

Entrepreneurial professionalism


Element emphasized by the discourse




Position of the subject (care worker)

Zeroes: workers who are unskilled with limited options and an inferior socio-economic position

Service providers: workers with highly developed technical skills and superior physical, mental, and emotional resources

Heroes: workers who have an innate vocation to care for others

Perceived nature of the actions/object

Routine, dirty and stigmatized

Professional, complex and worthy of respect

Personalized and nurturing

Beneficiary who authorizes care worker’s actions

Care recipient who is ill or elderly and who possesses superior financial resources

Care worker whose superior status allows them to ignore mistreatment or abuse

Care worker with a vocation to care and recipients whose needs enable care workers to actualize their calling

Type of relation and impact on the care worker

Relation of control: Function

Relation of professionalism: Fraction

Relation of responsibility: Fusion

The three discourses that we have outlined construct each element of the care work relation quite differently. A grammar of care based on the discourse of economic exchange constructs care workers as zeroes who are incapable of aspiring to more worthwhile, complex work. Because “we do what we are” (Taylor & Cooren, 2006, p. 121), care workers are thus expected to accept minimum wages, poor conditions, and overwork, because they have no or little intrinsic value beyond the provision of material labor. In a grammar of care based on entrepreneurial professionalism, care workers demand respect due to the complexity of their job. Care workers invert the previous frame, by claiming, “We are what we do.” By linking worth to the enactment of a professional performance, however, care workers need to continually prove their worth by using their skills to provide service to recipients. The co mmunitarian grammar of care, in contrast, constructs care workers as heroes because they build up the community by caring. Each grammar’s subject position is linked to a distinctive notion of care: zeroes who must care “labor” for recipients; service providers who know how to care embody a professional “attitude” as they give care, and heroes who want to care embody the “virtue” of care (Kittay, 2011, p. 52).

Discussion: The Implications of the Grammars of Care for Care Workers’ Dignity

Despite the importance of quality workplace experiences for employees’ dignity, pinpointing what constitutes dignity at work remains problematic (Cheney, Zorn, Planalp, & Lair, 2008). One perspective situates dignity as inherent and equally distributed to all human persons, due to their capacity for self-determination (McCloskey, 2010). However, contemporary organizations value employees differentially according to the contribution that their personal and professional qualities make to organizational goals (Sayer, 2009). This instrumentalized perspective of work relationships and rewards, which foregrounds merit, social position, and organizational status, implies that workers can earn and lose dignity (Smith, 2007). In order to consider both inherent and earned dignity (Lucas, 2011), we employ Bolton’s (2007a) twofold conce pt of dignity to frame our discussion of the implications of each grammar for care workers’ dignity. Bolton distinguished between dignity in work, related to intrinsic benefits including autonomy, meaningfulness, and a sense of accomplishment and dignity at work, manifested by extrinisic factors such as positive working environments, workable timetables, and respectful treatment.

Dignity and the Grammar of Care Based on Economic Exchange

The low wages, long hours, and framing of care tasks as dirty work limit the resources that care workers can use to construct their work as a reasonable and dignified choice: money, security, opportunities for leisure, and meaningfulness (Ciulla, 2000). Further, care workers’ low status due to their lack of economic and social privilege renders them vulnerable to workplace bullying (Lutgen-Sandvik & Tracy, 2012). Given the systematic devaluation of their work and their person within the discourse of economic exchange, care workers face considerable obstacles to resisting and openly denouncing mistreatment, high workloads, and burnout. Instead, they are reliant on beneficiaries from whom they “receive” dignity, even though this dignity is frequently instrumentalized as a means to ensure compliance.

In good situations, care workers may find dignity at work through quality working conditions and positive relationships (Bolton, 2007a). A care worker in Coeling, Biordi and Theis’ (2003) analysis of care dyads, for example, commented that “I get really happy feelings at times because . . . I get a chance to spoil her and she eats it up, so l like that” (p. 23). Nevertheless, it is not care workers but beneficiaries who determine whether or not care workers have opportunities to attain and affirm their dignity, since it is care recipients and/or their families whose actions and attitudes (such as “eating it up”) indicate the value accorded to the care worker’s efforts.

Dignity and the Grammar of Care Based on Entrepreneurial Professionalism

At face value, the discourse of entrepreneurial professionalism seems to enable care workers to “claim” dignity in work, by emphasizing the complex and skillful nature of material tasks (Bolton, 2007a). However, professionalism has two opposing effects on care workers’ pursuit of workplace dignity, since tolerance of relational mistreatment, which denies care workers’ dignity at work, can undermine the dignity earned by carrying out a quality professional task (Hodson, 2001). Care workers can resolve this fracture between the material and emotional aspects of care in two ways.

One option involves muting internal inconsistencies by linking dignity in work with “being in control of oneself, competently and appropriately exercising one’s powers” (Sayer, 2007, p. 568, our italics). In this case, professionalism acts as a system of control that constrains care workers’ emotional displays, dictates their relational practices (Real & Putnam, 2005), and normalizes emotional labor, which generates an interior separation of the care worker from the performance of care. The limits to agency, which were externally imposed in the discourse of economic exchange, become internalized (Hochschild, 2003). Moreover, the self-control needed to remain professionally polite permits care recipients or their families to continue to exhibit poor behavior.

Alternatively, care workers can claim dignity by emphasizing their superior skills and health status vis-à-vis care recipients who are marginalized by weakness and dependence. Care workers take their relative privilege as a warrant to exercise power over recipients (Collopy, 1995). Foner’s (2004) study showed that care workers whose dignity rests on controlling what falls within their sphere of influence can easily become Neros: implacable, rigid tyrants who physically or emotionally abuse recipients. The outcome for the care relationship is the alienation of the subject from the recipient.

Dignity and the Communitarian Grammar of Care

The communitarian grammar of care fosters both dignity in work, through the performance of valued tasks, and dignity at work, linked to the creation of positive workplace relationships. However, other sources of dignity at work, such as opportunities for occupational advancement and pay rates that do justice to their highly developed “emotional capital” or the skill they accrue in managing difficult characters with complex needs, are often lacking (Illouz, 2007; Reay, 2004). Care workers are expected to serve the community by doing their job “for love,” rather than money (Folbre & Nelson, 2000).

Moreover, although a communitarian discourse “recognizes” the dignity of care workers, who, through their heroic and dedicated service, give power to recipients by developing their capacities and independence (England et al., 2002), this recognition is contingent on care workers’ continued commitment to the care relationship (Hodson, 2001; Lee, 2008). Agency becomes limited to the moment of initial choice when one “determine[d] one’s ends” (Brennan & Lo, 2007, p. 50), by making the decision to respond to the vocation to care. By privileging community over agency, individuals can become “trapped” by current attachments and determined by decisions and goals inherited or chosen (Kymlicka, 1988, p. 191). Folbre (2001) described the possibility of these c are workers becoming “prisoners of love,” bound by ties of affection so strong that they become a form of “emotional hostage” (England, 2005, p. 390).

Those who can avoid taking responsibility for care or remunerating it more highly, thanks to care workers’ dedication, have vested interests in promoting a grammar of care that translates the ability and “preference for attending to others” (Stephens, Fryberg, & Markus, 2011, p. 39) into a “duty” to care (Harris & Bichler, 1997). Families are released from their care obligations; hiring agencies can continue paying substandard wages; and governments benefit from structural care arrangements that allow individuals to be cared for in the community rather than within institutionalized settings. Given the tension between the increasing cost of providing face-to-face care and the inability of recipients to pay for these services, government policy-makers, who are sitting on a demographic time bomb, have vested interests in promoting the growth of “Big Society” (< a href="#corbettandwalker2012">Corbett & Walker, 2012). De Wit (2012), for example, documented how political rhetoric represents home-based care as a form of empowerment that enables “individuals and communities to bring about change and to work altruistically towards their own well-being” (p. 115).

Table 2 provides a summary of the implications of each grammar of care for care workers’ dignity.

Table 2
Grammars of Care and Care Workers’ Dignity


Grammar of Care


Economic exchange

Entrepreneurial professionalism


Issues for care workers’ dignity

Downgrading the value of the work itself means care workers cannot find dignity in the work; dignity at work comes from good relationships with recipients

Upskilling the inherent value of tasks enables care workers to affirm the dignity of their work; as professionals, they tend to accept poor treatment from recipients, making dignity at work harder to attain

Although care workers benefit from positive relationships and recognition of the value of their work, this dignity is contingent on continued/continual service

Dignity determined by


Care workers’ enactment of professional behavior

Care workers’ commitment to the relationship

The three grammars of care generated by current dominant discourses present the relationship between care work and dignity in diverse ways but lead to similar outcomes: Care work is demanding, whether it is constructed as dirty, complex, or as requiring significant emotional and time investments. Ashforth and Kreiner’s (1999) question, “How can you do it?” for example, can be equally used to belittle dirty work, to emphasize the technical competence of skilled caregivers, or to admire the sacrifices of those individuals who carry out such difficult work. Although the construction of care workers as service providers or heroes seems to offer greater hope for dignity, we propose that all three discourses provide, at best, a precarious foundation. Each discourse imposes limits on care workers’ choices, often considered as a “pathway to dignity” (Buzzanell & Lucas, 2013, p. 5) and constrains their agency (Gagné & Bhave, 2011).

Re-Crafting the Story: Creating New Grammars

Despite our argument that not one of the current discursive formulations offers solid support for the dignity of care workers, we remain optimistic that new grammars of care are possible, since the meanings attributed to care work, and by extension, care workers’ dignity, are communicatively constituted and therefore malleable (Fine & Glendinning, 2005). As Rescher (2008) pointed out, “things are the stability-patterns of variable processes” (p. 15), and the apparent cohesion of discourses should not blind us to their communicative accomplishment through time. An occupation cannot itself appropriate actions, meanings or value; actions are negotiated and attributed to an occupation by individuals (Bencherki & Cooren, 2011).

While home-based care workers and the occupational collectives that represent them should be at the forefront of the development of new grammars of care that transcend the “money versus love” dichotomy that dominates the care literature (Zelizer, 2005), we believe that scholars from the fields of family, health, organizational, intercultural, and political communication have much to contribute. We identify three areas of research that warrant theoretical and empirical exploration. First, future research needs to take account of the increasing complexity of home-based care which may lead to the evolution of current grammars. The grammar of care based on economic exchange, for example, has taken for granted the existence of a vulnerable migrant workforce. However, in some cases, it is not care workers but care recipients, such as elderly Germans moving to Eastern European care facilities, who are crossing national an d linguistic borders, requiring reconceptualization of the relationship between immigration, care, and vulnerability (Connolly, 2012). Changes in home-based care technologies, which introduce a new set of actions and objects into the care relationship, are also likely to have repercussions for the grammar of entrepreneurial professionalism (e.g., Elvira, Hoang, & Rodriguez Lluesma, 2013). Second, we call for research into interaction among the grammars of care, in order to consider what happens within care relationships when care workers, recipients, their families, and employing agencies draw on and combine different grammars. Empirical work could also investigate if care workers draw on different grammars as the care work setting and their communication partners change.

Third, research into alternative grammars could usefully compare the grammars of care that structure the occupational image and dignity claims of other caregiving professions, such as community nurses, physiotherapists, counselors, and religious leaders. Assessing the impact of care workers’ integration into and recognition within interdisciplinary home-based care teams forms a particularly useful setting for such work. Expanding the range of cultural and linguistic contexts studied could also generate new frameworks. Cameron and Moss (2007) specified that care’s etymological roots in Germanic languages such as English, Danish, Dutch, German, and Swedish foreground “sorrow, anxiety, concern” and the actions of tending and nursing (p. 53). They note that other languages interpret care more broadly: in Hungarian, gondoskodás refers to emotional and social wellbeing as well as physical health, while the Spanish term cuidado encompasses anticipation and prevention of danger.

Without over-specifying the forms that new grammars of care might take, we suggest that, in order to offset the disadvantages of existing grammars, they should expand the recipients of care to include care workers themselves, recognizing the need for and allocating resources to self-care. New grammars should also expand the range of beneficiaries who authorize care. Complementary rather than symmetrical relations underpin current grammars, which implies that the care work relation always favors the interests of one party over the other, with privilege and disadvantage shifting according to the grammar (McIntosh, 2012). It is our hope that new grammars of care, constructed from the bottom up, will acknowledge interdependence rather than dependence and create a relation of reciprocity that recognizes the contribution and dignity of each agent in the care work relationship.


We would like to express our thanks to Kristen Lucas and Mary Dunn for their helpful insights on dignity and the discourse of entrepreneurial professionalism, Jim Taylor and Elizabeth Van Every for their input on our use of the “grammars,” and Caryn Medved and the two anonymous reviewers for their thoughtful comments and suggestions on earlier versions of this article. We also thank the European Commission for their financial support within the 7th Framework Programme: Marie Curie International Reintegration Grant (PIRG05-GA-2009-249235).

End Notes

[1] This also holds true in self-care which requires the caregiver to consciously and reflexively turn his or her attention to the self, which, as an object of analysis, receives his or her gaze.

[2] We were saddened that the Direct Care Alliance ceased to function as an independent advocacy organization on June 30, 2014 due to lack of funding.


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