Reimbursement comes from the heart: The organizational structure of emotions and care-work in nursing homes

This dissertation is a comparative, ethnographic study of emotion-work in two nursing homes – one part of a large, for-profit chain, the other part of a small, non-profit chain – and examines how nursing care-workers grapple with tensions between meeting organizational demands in an increasingly market driven field and providing compassionate care in times of personal crisis. Based on eighteen-months of fieldwork, sixty-five in-depth interviews and analysis of company documents, my research connects the financial and regulatory structure of long-term care to the emotional lives of staff in both nursing homes. While scholars have analyzed the consequences of medical reimbursement regimes on health care systems, my research uncovers the processes by which those consequences are created, and shows how their effects on residents are mediated through staff. Chapters 2-4 examine how proprietary status shaped the experience of work. Many scholars argue that for-profit facilities and non-profit facilities have become isomorphic since the imposition of market forces on long-term care. Although there were similarities between the two nursing homes, they were also strikingly different in their approach to reimbursement. While the for-profit won corporate awards for deftly maneuvering through the market, the non-profit’s community-oriented mission left them with a half-million dollar budget deficit. This section shows the processes by which market forces discipline community-oriented health services organizations such as nursing homes. Given this context, chapters 5-8 turn to how the staff used emotional attachments with residents to give their work dignity and meaning. Contrary to the established view that emotion work alienates employees, I argue that nursing care-workers used emotions – their own, their residents, and their colleagues – as resources in novel ways, even as their emotions were shaped and constrained by the financial and regulatory structure of long-term care. Emotions were shaped by organizations but they were not simply imposed on workers. Nursing care-workers themselves produced emotions, sometimes in ways consistent with organizational goals, and sometimes not, but they consistently found in their emotions a set of resources to manage the strains of their work lives