Reform, Resist, Rebel, and Reframe: Nursing Home Workforce Approaches in Four Countries

Overview: COVID-19 has ravaged an-already precarious caregiving workforce that relies heavily on immigrants and women of color. Using an intersectional feminist framework, this case study compares four countries’ approaches (Germany, Italy, Japan, United States) to address this human rights issue. Data includes government documents and databases, press releases, reports, and media.Proposal text: Background

Throughout the world, COVID-19 has ravaged nursing homes that provide critical health and social services for older adults and persons with disabilities. This crisis, however, provides possibilities for transformation. Attention in many countries has turned to concerns about a declining workforce to care for a growing aging population in nursing homes. In the United States, over half of direct care workers in nursing homes are women of color, and over one-third earn less than 138% of the poverty-level (PHI, 2019). Many other countries similarly rely on low-paid women of color and immigrant women to deliver these services (Sowa-Kofta et al., 2019). Using an intersectional feminist approach—which presents a framework for seeing how various forms of oppression operate and exacerbate each other (Crenshaw, 2020; UN Women, 2020)—this comparative case study examines responses by four countries to address workforce concerns in nursing homes. It concludes with suggestions for social work practice and policy on leveraging lessons learned from all four countries to develop a more holistic and equitable approach that supports this workforce.

Methodology

This study employs a comparative case method (Mills, Durepos, and Wiebe, 2012) that compares data from four countries during the COVID-19 pandemic: Germany, Italy, Japan, and United States. These countries comprise the top countries globally in the percentage of their aging population, including the “oldest old,” which are most likely to require nursing home care. They also have similar trends in declining workforces and growing reliance on low-wage women of color and immigrant women to provide formal caregiving. Data includes primary and secondary sources from government documents and databases, press releases, reports, and news articles.

Findings

Each country’s approach was categorized using Lorber’s (2010) intersectional feminist framework for identifying solutions to inequality as reform, resist, or rebel. This study also adds a new intersectional feminist category for understanding inequality: reframe. Each country employed all of these four approaches to address workforce concerns in nursing homes. The dominant approach from all four countries, however, turned to downstream solutions that failed to address structural issues of discrimination and inequity for this mostly female workforce. Downstream solutions included invoking temporary caregiving assistance from noncaregivers in the private and government sector (e.g. military). At various moments of acute crises (e.g. during Delta surge, initial Omicron outbreak), calls for structural change emerged but were almost immediately buried by an avalanche of downstream solutions.

Discussion and Implications

The overwhelming failure to invoke substantive structural change speaks to the immense challenges that persist. However, each country proposed structural solutions and long-lasting transformations–and often during the most challenging times for nursing homes in the pandemic. These calls for transformation need sustenance to survive, and social work can provide that support through clinical practitioners employed in nursing homes and those indirectly supporting this workforce. Macro-level social workers can also support these efforts through community action and policy. Finally, social work educators can use this extended intersectional feminist framework to help students understand and respond to inequality at local, state, national, and international levels.