Narrative justification of companion work as a response to liminality

Data from both companions and organisational representatives supported our first (and over-arching) interpretive theme, in which we explore paid companions’ narratives as in part representing their attempts to maintain valued identities. Since companion work is often devalued, liminal and under-recognised, the value and worth of their role, and in some cases the very need for it, may be questioned by others, especially in residential care (see also Daly et al., Reference Daly, Armstrong and Lowndes2015; Brassolotto et al., Reference Brassolotto, Daly, Armstrong and Naidoo2017). As such, participants’ narratives reflect a need to justify their work to themselves and to expected perspectives of others (Mead, Reference Mead1934; Stacey, Reference Stacey2011).

The most obvious signifiers of low value – the low pay and precarious nature of the work – were compounded by situations in which companions described their role being questioned or critiqued by others. For instance, one independent companion mentioned that some family members question how much and why she is being paid for her work, adding ‘I have to show why am I so important to you, to your mom’. Another independent companion stated: ‘many people think that this should all be volunteer work’ and added: ‘I'd love to be able to do it volunteer, but I have to make a living too’. Likewise, an agency companion emphasised that her time is sufficiently valuable to warrant payment (rather than volunteering).

Even companions themselves sometimes reflected that they did not always know whether they made a difference in their work, as in the following excerpt:

Feedback and validation were challenging when resident-clients could not easily communicate appreciation to their companions; in these cases, appreciation from others (family, staff) were highly valued external sources of validation. As such, companions may have been particularly sensitive to experiences involving symbolic expressions of rejection or devaluation (and some expressed distress stemming from these experiences). Companions described times in which facility workers were standoffish, not acknowledging or thanking them, or communicating in a negative tone of voice. One independent companion indicated:

Facility representatives supported companions’ claims in this regard by explaining that facility staff often resent companions who yell at or manipulate staff, have unreasonable expectations, demand private medical information, are overly controlling of resident care, or circumvent staff and speak directly with family about concerns. The owner of a private care agency also confirmed that companions can be unwelcome:

Moreover, although facility representatives generally characterised companions as positive, they also spoke of risks involved, for instance when companions were neglectful (e.g. ‘more busy looking for the next job than spending time with that elder. Networking with all the families, are you doing what you're paid for?’ (facility CEO). One organisational representative also suggested that money that families spent on companions would be better spent towards hiring another health-care aide or recreation worker: ‘we could do it if we had the cash’.

In sum, companions’ accounts of their work can be viewed as narrative justifications of the value of their work. Companions are likely aware that they are doing work that could (or even should) be done by a paid health-care aide or recreational staff person: indeed, as one agency companion noted: ‘[facility staff] kept saying, “too bad you couldn't work here on the right team”’. It is within this context that we need to understand how and why companions sought to distinguish their work as distinct, essential and helpful within their narratives. How they did this (and how these ideas intersect with the narratives of organisational representatives) is illustrated in additional themes presented below.

Establishing the facility care gap: the lack of one-to-one contact

Our data further indicate that residential care companion services are positioned discursively as supporting older residents’ social and recreational needs in the context of gaps in such care (see also Brassolotto et al., Reference Brassolotto, Daly, Armstrong and Naidoo2017). Facility operators sometimes need to justify formally the engagement of paid companions in their facility; for instance, one care director described negotiating with unionised facility staff when introducing a formalised private companion programme (that actively co-ordinated and facilitated these services). To justify why they would not just hire more care staff, the participant explained how her facility invoked a vague dichotomisation of concepts of ‘care’ and ‘contact’, although she also alluded to workload pressures:

For both private agencies and companions, positioning companion work as filling a resource-based care gap is also an important part of establishing positive, non-threatening relationships with facility staff: ‘we're not here because you're not doing your job right. We're here to support you because we know you can't do everything for this person’ (private care agency owner). Echoing this idea, companion participants linked the need for their services to a lack of one-to-one relational time for paid facility staff. They emphasised how they are uniquely positioned to develop connections with residents, contrasting their ability and time against that of facility employees faced with heavy workloads. One agency companion described facility workers as ‘run off their feet’ dealing with daily needs: ‘they can't sit with someone for three hours which, I have a luxury … being able to do that’. An independent companion further reflected on facility staff workloads: ‘they talk about quality care, and it's like four people?! You can't possibly look after anybody properly with that’. Another independent companion expressed:

One agency companion who previously worked as a care aide remarked on the lack of relational interaction, interpersonal contact and ability to provide personalised care in that role:

An agency companion and one director of care also expressed a belief that volunteers are less able than companions to fill these gaps, because they are usually engaged in delivering group programmes rather than developing meaningful relationships over time with particular residents.

In these narratives, facility staff generally tended to be characterised as struggling to do their best to meet psycho-social needs within workload constraints but as needing some help. In some cases, companion participants implied or directly implicated characteristics of facility staff or volunteers as contributing to these gaps. As one example, an agency companion noted: ‘the fact that there were some pretty crappy care-givers in the facilities that weren't helping [client with social/emotional needs], that also makes me want to do it even more’. In another example, an agency companion described her grief and bereavement when clients die as reflecting her emotional connections with clients. She then suggested that nursing home staff lack compassion and are emotionally ‘hardened’:

Another agency companion contrasted her own approach against that of facility staff:

Having established important psycho-social care gaps in the facility, companions positioned their work as filling these gaps, describing their work as enriching residents’ quality of life, emotional support, socialisation and integration, and human connection.

In these ways, participants actively drew on ideas about a crisis in health care for older adults, manifesting here as concerns about the inadvertent social neglect of residents in the context of staffing limitations and workloads. Participant narratives further reproduced the idea, however, that the work of social care should not be the purview of paid facility staff, whose role should be to focus on medical and task-based forms of care.

The production of moral value

In alignment with their stated role, companions emphasised the friend and fictive kin nature of their connections with residents (e.g. ‘I just call them all my friends’), reinforcing their own caring natures and identities as they distinguished their work from that of paid facility staff. Another way they did this was by emphasising the personalised supports they provided to clients (e.g. creating personalised music compilations, personalising the boards outside resident rooms, helping clients watch favourite television programmes, maintaining individualised grooming and clothing styles). One independent companion referred to this as ‘doting’ (i.e. an expression of love), and another as treating the client ‘like family’:

Another way in which companions prioritised relational aspects of their work, affection and caring was to highlight how they went ‘above and beyond’ in their work. As one independent companion stated, ‘I consider them more than just clients. They're a friend, therefore if you are a good friend, you would do what you can for your friend’. Additional excerpts from other participants include: ‘I have not run into any client … that I did not like and did not go the extra mile for’; ‘I do go above and beyond what is required of me … I'm glad to help’; and ‘I did way more with them than [the family] ever expected me to’.

Some companions described contributing unpaid time if needed or purchasing small items for their client with personal money. These narratives posit affection and caring identities as the true motivations for companion work and may bolster the sense of distinct moral value in companion work. One independent companion, for example, described not charging mileage or increasing her price when a client moved (despite a longer drive), and her account reinforced her claims about the quality of her relationships with clients as well as her caring identity:

Positioning their work as ‘little extras’ likely served another important function – to help companions (and organisational representatives) ensure companion work was not viewed as encroaching upon the scope of publicly funded (and sometimes unionised) facility services.

Participants also explained that their work does not feel like a job, e.g. ‘because I enjoy it’. In this way, they reinforced internal and caring motivations. Notably, a common critique of residential care facility staff is that they are doing the work ‘just for the job’ or pay (Cooke et al., Reference Cooke, Puurveen and Baumbusch2017), and companions indirectly contributed to this critique by distancing themselves from monetary aspect of their work, as in this excerpt:

Although organisational representatives generally echoed companion narratives of ‘not doing it as just a job’ and ‘going above and beyond’ (especially when speaking of independent companions), some expressed concerns about whether or not companions could maintain professional boundaries; contributing personal money, for instance, was interpreted as inappropriate or exceeding role boundaries.

Emotionally connected, friend and kin-like relationships also tended to be characterised by companions as a source of enjoyment and reward in the work, as in: ‘it's just like a nice feeling … when I had a week off, I miss [client]! He almost feels like a grandpa, or a dad. Closer to a dad’. Although participants emphasised that building these relationships takes work and skill, at least one companion positioned herself as innately positioned to do the work:

Agency companions generally expressed a greater sense of being constrained in developing close connections, for instance by organisational directives emphasising professionalism in their agencies. This could include agency policies requiring workers to wear uniforms; to address clients by their formal titles; or not to disclose aspects of their personal lives to clients, which were viewed by agency-employed participants as bureaucratic, formal barriers to establishing close relationships and connections. In contrast, independently employed companions tended to more commonly emphasise fictive kin relationships and personalised aspects of care. Though this may in part reflect their greater ability to nurture close relationships, independent companions’ work is arguably more precarious, and this may have motivated narrative efforts to position these elements as part of the added value of their service.

By downplaying the employment aspects of their role and foregrounding caring identities and motivations, participants’ narratives reproduce the assumption that payment for caring is somehow worth less than altruistic or voluntary forms of care. Folbre and Nelson (Reference Folbre and Nelson2000: 133) emphasised a need to move away from an either/or distinction between economic self-interest and caring motivation, instead viewing economic payment as ‘acknowledgement and appreciation of the worker's own intrinsic motivations’.

An emphasis on fictive kin and altruistic motivation has been noted in other studies of companions and workers in residential care (Dodson and Zincavage, Reference Dodson and Zincavage2007; Outcalt, Reference Outcalt2013) and has been connected to the naturalisation of emotional labour (Hochshild, Reference Hochshild1983; Johnson, Reference Johnson2015) within organisations and among workers. It is unclear in the present study whether or how the facilities in which participants worked, or agencies for which some were employed, actively encouraged companions to align with family care ideologies – indeed, some organisational representatives emphasised emotional boundaries. Daly and Armstrong (Reference Daly and Armstrong2016) suggest these pressures can come directly from families.

By themselves actively invoking fictive kin ideologies, companions can be viewed as inadvertently contributing to the devaluing and invisibility of their own work in economic terms, potentially enhancing their vulnerability to exploitation while also reproducing gendered and often racialised ideals about caring (Stacey, Reference Stacey2005; Dodson and Zincavage, Reference Dodson and Zincavage2007).

Helping not hindering: the ‘sliding scope’ of companion work

Although companions sought to distinguish their work from that of facility staff, they were also aware that to meet client needs in the facility work environment, they had to engage with facility staff in a positive and helpful manner that may help mitigate potential resentment towards them stemming from the position they hold. Trusting, positive relationships with facility staff (e.g. ‘not stepping on their toes’) can be instrumental, so that the companion can work effectively. For instance, one independent companion explained how she nurtures relationships with staff so that they will provide her with needed information and the ability to do certain things with the client (e.g. take them to an event): ‘I have to keep the nurses happy for your mother's sake’. Strong relationships with staff could also facilitate future work opportunities (i.e. when staff actively recommend companions to other families).

Given that staff may feel threatened by companions’ presence in the facility, companions spoke about how their work benefits staff, and positioned their roles not just as filling a resource gap (as earlier), but as actively benefiting staff. Most directly, when companions occupy their own clients, this creates opportunities for facility staff to focus on the care of other residents or other aspects of resident care. Companions spoke of helping to ease care aide workloads in phrases such as ‘one less to worry about’; they described keeping their own clients occupied and helping to distract and redirect clients who may be prone to agitation. As one independent companion noted: ‘it's helpful because [staff] don't have the time to sit there and be with her … So it's times like that that I can be a big help for the staff, the nurses…’ Lastly, one agency companion, after expressing her distress when treated poorly by facility staff (e.g. they don't know her name), added: ‘[facility staff] should be happy I'm here because I'm giving you a break by taking this client away from you for a while’.

Companions spoke about helping out non-client residents, characterised as an unprompted, conscientious response to need (e.g. as reflecting a caring identity). This could include conversing with non-client residents or helping them participate in recreational programmes, or in one instance, distributing food at events: ‘I know I didn't have to, but it was just [client] was fine by herself at that point, so I would do stuff like that’ (agency companion).

Participant talk about conscientious helping indicated a point at which the scope of companion work can potentially creep beyond social forms of care. Data from some of the organisational representatives we spoke with indicated that in some facilities, companions that were trained as health-care aides were explicitly tasked with hands-on personal care during the initial transition into a care facility, during medical crises and hospitalisation, or at the end of life. None of the companions we recruited, however, appeared to be engaged in such an explicit and formalised way in personal care. However, some companions described lifting or transferring their own clients, and occasionally helping to monitor or assisting them during showering or toileting. As identified by Brassolotto et al. (Reference Brassolotto, Daly, Armstrong and Naidoo2017), in some cases this was motivated by a dominant concern for their client, who may be faced with a long wait when care aides are busy (e.g. moral distress). Although requests for this kind of help from staff were rare, companions positioned themselves as strongly motivated to help out facility staff, and this was often met with appreciation. For example, one independent companion explained how the workers tell her that she is ‘part of the [facility staff] family’:

Another independent companion explained that when the facility is short staffed, she will often feed her client as well as shave him and change his clothes: ‘it's not really in my job description, but I do it’. An agency companion further described her work with a residential client:

Another agency companion who had training and experience as a care aide stated: ‘I help feed that client or put away dishes or I'll do this or that, whatever. I'm a helpful person that way, I don't say ‘that's not my job’ (laughs) or anything like that’.

Alongside, and sometimes countering this desire to be helpful, however, was a strong sense of the personal risk involved in non-social forms of help, such as lifting heavy clients, and this motivated many companions to limit their involvement in personal care tasks, even when requested to help by paid care staff. Some organisational representatives expressed similar concerns from a risk management perspective (e.g. potential harm to residents). One representative also raised concern that staff might become overly reliant on companions: ‘our responsibility is to provide that care for every resident here. So we shouldn't be stepping back and waiting for someone else to provide that care’ (recreation manager).

Drawing on and reproducing fear and anxiety about facility care

Over the last decade, several high-profile cases of elder abuse have been covered in the Canadian media, as in other countries (Lloyd et al., Reference Lloyd, Banerjee, Harrington, Jacobsen and Szebehely2014). In their study of media depictions in the United States of America (USA), Miller et al. (Reference Miller, Tyler, Rozanova and Mor2012: 725) concluded that ‘the predominantly negative media reports contribute to the poor public opinion of nursing homes and, in turn, of the people who live and work in them’. Though comprehensive data on public attitudes towards Canadian nursing home care is lacking, qualitative research has documented families’ concerns about care gaps and resident safety, often as these motivate their involvement in advocacy and monitoring (e.g. Barken et al., Reference Barken, Daly and Armstrong2016).

This broad public distrust and even fear of nursing homes can be viewed as providing opportunities for companions to further legitimise their involvement in non-social aspects of resident care. In one excerpt, an independent companion explained that facility staff do not have the time needed to feed her client. In contrast, a recreation supervisor explained that one of the drawbacks of companions in her facility was an assumption that develops among family members that if they do not have a companion, the resident would not get fed. She believed some paid companions have a vested interest in perpetuating perceptions of inadequate attention to feeding needs, to ensure they have ongoing sources of clients. Another example highlights the irony involved: the representative of a different facility looked favourably on companions who also were trained as care aides, and explained how in these situations, there is no need for facility staff to be present. She then complained, however, that some companions tell families that ‘staff never come in the room’ or provide care, which can harm the facility's image.

Public distrust and anxiety about residential care quality and safety further helps companions distinguish a role as resident advocates, and as such, several spoke of advocating, monitoring the daily life and care of the resident, or liaising between the resident and the staff. This included identifying and pointing out issues of concern for the residents’ quality of life or medical condition, or relaying client complaints, needs and preferences to facility staff or family. For example, one independent companion stated:

Independent companions may have more ability to advocate, as agency companions can be limited by policies prohibiting direct communication with family or staff (i.e. they must relay concerns through the agency).

Although organisational representatives sometimes characterised companion advocacy as beneficial (e.g. when companions identify safety issues or when families live out of province), they were concerned about what they characterised as inappropriate advocacy – for instance, when companions lacking background or expert knowledge try to manipulate staff or interfere with how care is provided to non-client residents. These characterisations reinforce companions’ marginalisation as peripheral workers, rather than as part of the care team.

Companions (especially independent companions) frequently characterised the monitoring and advocacy aspects of their work as helping families, including being the family's ‘eyes and ears’, and easing families’ worries and burden. In this way, companions also position themselves as filling a family (as opposed to facility) care gap, normally due to geographic distance. For example, one independent companion stated: ‘I'm an extension of the families’ eyes and ears and a lot of times the families are either far, far away and I can phone them and advise them of what I see’. An agency companion further reported:

Agency companions were less likely to emphasise helping families, perhaps in part because they have less direct interaction with families (who are not their direct employer).

In sum, through recounting stories in which they noticed and responded to quality concerns or errors in facility care, companions emphasised the need for and importance of their own work while drawing on and reinforcing distrust, anxiety and fear about facility care.

Drawing the line at behavioural management while reproducing dementia stigma

The increasing complexity of resident care needs (including cognitive impairment) in Canadian facilities has been well documented and can contribute to experiences of workplace violence (Banerjee et al., Reference Banerjee, Daly, Armstrong, Szebehely, Armstrong and Lafrance2012) and other resident behaviours that can be difficult or time-consuming for staff to respond to. In the region in which the present research was conducted, an estimated 63 per cent of facility residents have moderate to severe cognitive impairment (Canadian Institute for Health Information, 2013). There has also been increasing media attention to workplace violence; unions have raised concerns about resident acuity and dependency levels, given the lack of staffing increases (Manitoba Nurses Union, 2018).

Several organisational representatives in this study characterised paid companions as a helpful way for facilities to help manage residents with advanced dementia who exhibit agitation, responsive and reactive behaviours, in part to alleviate the burden on facility staff. The recreation worker at one facility noted that in part due to inadequate funding for recreational staff, his facility encourages the use of companions for residents with reactive or potentially violent behaviour. A social worker at another facility added: ‘if we need a paid companion, it's not for “happy Joe” … it's for someone who is verbally or physically responsive, anxious, angst ridden’. The owner of a private care agency explained how companions in her agency are employed by families for this reason, for instance to help reduce agitation during ‘sundowning’ hours.

The perspectives of companions and organisational representatives differed markedly on behavioural management. Companions very rarely emphasised their roles in behaviour management. One exception is an independent companion who described how, because of the nature of her relationship with one of her clients with dementia, she evades the brunt of the woman's reactive behaviour: ‘there's one lady she can snap at me once in a while, not very often, but she's difficult with the staff, but I'm her friend, I'm not staff, so it is different so I don't get that same thing’. Yet overall, the dominant companion narrative was of the emotional struggle of working with clients who express screaming, agitation, socially inappropriate behaviour, mood swings and negative moods, coarse or rude language, and forms of aggression. As one agency companion reflected: ‘sometimes I'm emotionally beat at the end of the day’. More broadly, companions described the challenge and effort in trying to understand and develop personal connection with clients with communication difficulties, dementia or responsive behaviour (companions often receive little to no training in these skills).

Several companions drew on related narratives about the inability of residents with advanced dementia to benefit from social interaction, in explaining their preference not to work with these clients. Three excerpts serve as examples:

In their talk about who benefits most from their services, companions defined and asserted control over their work boundaries and working conditions at the same time as legitimising their services. Agency companions may have less ability than independent companions to choose their clients, however; moreover, for all companions, economic necessity may dominate. Yet the relative absence of in-depth training, workplace supports and disability benefits may contribute to companions’ hesitation about working with residents with advanced dementia or those who may be potentially aggressive. In downplaying their effectiveness working with residents with advanced dementia, companions may draw on and inadvertently reproduce the stigma of dementia – the assumption that residents with advanced dementia do not benefit from social interaction. Such ideas can contribute to stigmatisation and social exclusion of these residents within nursing homes (Bruce, Reference Bruce, Innes, Archibald and Murphy2004; Dobbs et al., Reference Dobbs, Eckert, Rubinstein, Keimig, Clark, Frankowski and Zimmerman2008).