"We just take care after each other": Relational health strategies of nurses and nursing aides working in residential long-term care as a mechanism of in- and exclusion in care teams.

BACKGROUND: The health of care workers in residential long-term care (LTC) is under pressure. Scholars emphasize the importance of gender-sensitive and intersectional approaches to occupational health. OBJECTIVE: To unravel how the health of nurses and nursing aides is shaped by gender, class, age, sexuality and race. METHODS: A qualitative participatory study. A participatory research team, consisting of academic scholars and nursing aides, conducted semi-structures interviews (N = 20) and one natural group discussion (N = 8 participants) to validate our findings. Thematic data-analysis was guided by gender and intersectionality theory. RESULTS: Empirical findings suggest that gendered norms limit possibilities for self-care for female nurses and nursing aides. Feeling uncared for by society and LTC organizations, paid care workers describe how they take care of each other. These relational health strategies require a feeling of sameness, limiting space for diversity and disability within care teams. Care workers seen as 'cultural other', or those who experienced (chronic) health issues, financial struggles or informal caregiving, risked being excluded from relational care within care teams, which negatively impacted their health. CONCLUSIONS: Care workers' relational health strategies are a gendered and care ethical response to the lack of societal and political care for LTC, but can become mechanisms of exclusion within care teams. This can be understood as a sign of exhaustion, shaped by adverse working conditions and leading to moral stress. The lack of societal appreciation needs to be addressed by occupational health physicians and LTC organizations, to counter mechanisms of exclusion among paid care workers.

Squeezed out: Experienced precariousness of self-employed care workers in residential long-term care, from an intersectional perspective.

AIM: To understand self-employed long-term-care workers' experiences of precariousness, and to unravel how their experiences are shaped at the intersection of gender, class, race, migration and age. BACKGROUND: In the Netherlands, increasing numbers of nurses and nursing aides in long-term care (LTC) opt for self-employment. Societal organizations and policy makers express concerns about this development, as self-employment is seen as a risk factor for poor health. Self-employment is not necessarily precarious work but can contribute to the precariousness of specific groups. Knowledge about inequities among self-employed nurses and nursing aides in long-term care is lacking. DESIGN: A participatory, qualitative interview study. The research team consisted of four academic researchers and five (un)paid care workers. METHODS: Semi-structured interviews with 23 self-employed nurses and nursing aides in LTC (2019-2020). Data were analysed from an intersectional perspective. RESULTS: First, we describe that feeling precarious as a hired employee-due to increasing workloads, health risks, poverty and discrimination-shapes care workers' choice for self-employment. Second, we describe inequities between self-employed care workers who could (financially) afford to turn to self-employment as a health strategy and those who felt squeezed out of the organizations due to poverty or discrimination. They more often dealt with precarious work in the context of precarious lives, negatively impacting their health. Third, we describe how negotiating an entrepreneurial identity with a caring identity required material sacrifices and thus contributed to self-employed care workers' financial precariousness, particularly as women. CONCLUSION: Our findings indicate that working in LTC is becoming increasingly precarious for all care workers, both for hired and self-employed, with younger, lower-paid and racialized women with unpaid caring responsibilities seemingly most at risk for precariousness. IMPACT: Our findings urge policy makers and care organizations to develop gender and diversity-sensitive policy responses to address these inequities.

Navigating Voice, Vocabulary and Silence: Developing Critical Consciousness in a Photovoice Project with (Un)Paid Care Workers in Long-Term Care.

Photovoice is a widely used approach for community participation in health promotion and health promotion research. However, its popularity has a flip-side. Scholars raise concerns that photovoice drifts away from its emancipatory roots, neglecting photovoice's aim to develop critical consciousness together with communities. Our four-year photovoice project aimed to unravel how the health of (un)paid care workers was shaped at the intersection of gender, class and race. This article springs from first, second and third-person inquiry within our research team of (un)paid care workers, academic researchers and a photographer. We observed that critical consciousness emerged from an iterative process between silence, voice and vocabulary. We learned that photovoice scholars need to be sensitive to silence in photovoice projects, as silence can be the starting point for finding voice, but also a result of silencing acts. Social movements and critical theories, such as intersectionality, provide a vocabulary for participants to voice their critical perspectives to change agents and to support collective action. We discuss our experiences using Frickers' concept of 'epistemic justice', arguing that critical consciousness not only requires that communities are acknowledged as reliable knowers, but that they need access to interpretative tropes to voice their personal experiences as structural.