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Lisa Dodson and Rebekah M. Zincavage, “‘It’s like a family’: Caring labor, exploitation, and race in nursing homes”

November 18, 2010 Leave a comment Go to comments

“‘It’s like a family’: Caring labor, exploitation, and race in nursing homes”

Lisa Dodson and Rebekah M. Zincavage

Gender & Society December 1, 2007 21: 905-928 [PDF]

This article contributes to carework scholarship by examining the nexus of gender, class, and race in long-term care facilities. We draw out a family ideology at work that promotes good care of residents and thus benefits nursing homes. We also found that careworkers value fictive kin relationships with residents, yet we uncover how the family model may be used to exploit these low-income careworkers. Reflecting a subordinate and racialized version of being “part of the family,” we call for an ethic of reciprocity and for concrete change toward valuing equally the humanity of those who need and those who give care.

AUTHORS’ NOTE: We are very grateful to Christine Bishop and the Better Jobs Better Care research team members for their collaboration in this project, sponsored by Robert Wood Johnson Foundation and Atlantic Philanthropies. We thank Wendy Luttrell, Marjorie DeVault, and Catherine Riessman for early comments and ongoing support. We also wish to thank the anonymous Gender & Society reviewers and Dana Britton for their thoughtful comments on this article. We are indebted to the men and women who participated in this study for trusting us enough to share their experiences and insights with grace and honesty. Finally, we want to recognize the outstanding contribution of the late Susan Eaton who believed that good care of vulnerable people is essentially tied to decent jobs for careworkers.

 

“[T]he same way I think about my mother, this is the same way I’m thinking about these residents. I consider them like they are my own. But it’s a very hard job, we don’t get paid enough for the job, and sometimes you feel like every day you do more and more and more, and the money is less.”
-Certified Nursing Assistant

Over the last two decades a “crisis in care” has provoked difficult questions and a complex critique about the meaning and value of purchased care in contemporary society. Historically family relationships and the market had been seen as separate worlds; one did not trespass onto the other. Yet carework, historically a taken-for-granted female activity, has increasingly demanded market valuation as millions of women left homemaking for paid employment, expanding the need for hired care providers. Today in the United States, with an ever-growing population of elderly and chronically ill people, long-term care has become an urgent and complex care demand.

As in the past, those who enter the low-paid care labor market tend to be poor women, often native-born women of color and immigrants (Dawson and Surpin 2001; Duffy 2007; Glenn 1992; Romero 1992). This paper draws from interviews, focus groups, observational data, and a survey from research in 18 long-term care residential facilities in Massachusetts. From these multiple sources, we explicate an ideology of family that consistently emerged as integral to the design and understanding of care for residents. Further, we examine how family ideology drives expectations of the kind of care provided by certified nursing assistants (CNAs) who, as one facility director put it, are “the backbone of the nursing home industry.” As theorized in scholarship on caring labor across disciplines (DeVault 1991; Folbre 2002; Kittay 1999; Stone 2005; Uttal and Tuominen 1999) our research uncovers the tension experienced by careworkers as they manage their work as both a job and as a commitment to care for fictive family members.

We begin this paper by situating our discussion in recent scholarship at the intersection of family ideology and purchased carework. This is followed by a brief description of the growing demand for long-term care, the nature of the work, and an overview of the workforce. Turning to our research, we identify a family model posited by both nursing home managers and CNAs as essential for providing good care to frail and dependent people. We reveal, however, this model of kinship is “one way,” benefiting the residents and nursing homes but essentially denying reciprocity to CNAs. We also explore the racialization of the occupation of the CNA, a dynamic that brings to mind the historical image of women of color working as domestics, servants, and nannies, expected to willingly sacrifice themselves and their families to take care of those who employed them (Glenn 1992; Hondagneu-Sotelo 2001; Omolade 1994; Romero 1992; Rollins 1985; Wong 1994).

Finally, we challenge the use of an institutional culture of family that is specifically designed to extract more work from the lowest-paid workers- often native-born women of color and immigrants. We join others who argue that meeting a growing public need for long-term care demands an ethic of reciprocity: considerate, high-quality care for those who need it, and respect and decent compensation for those who provide this critical labor.

AT THE INTERSECTION OF FAMILY AND THE LONG-TERM CARE MARKET

Throughout the last two decades both paid and unpaid caring labor has been examined from various angles. Feminist scholarship in particular has elucidated the gendered invisibility of carework and its association with economic disadvantage for those who do it, a care penalty that continues today (Crittenden 2001; England, Budig, and Folbre 2002; Folbre 2002; Williams 2000). As these and other scholars point out, regardless of the particular circumstance or configuration of the care exchange, the majority of this work continues to be performed by women. Deep in our cultural imagination is the mother figure who “peers into the face” of those for whom she cares, suspending self in favor of others (DeVault 1991; Ruddick 1980). As research on wage patterns reveals, the message of maternal self-sacrifice extends into the market and is reflected in low wages among occupations that are predominantly filled by women (England 1992).

Critical social theorists have focused on how family ideology structures carework within the domestic sphere in ways that disadvantage lowincome women who sell their care labor (Dill 1994; Hondagneu-Sotelo 2001; Rollins 1985; Romero 2001). These scholars point out that the family model is considered the “Golden Rule” or as Tuominen (2003) puts it, “do unto others as you would do unto your own kin.” Yet this model may prove tyrannical as appeals to kinship connection invoke a set of expectations that can remain unstated yet spin a complicated web of obligations (Anderson 2000; DeVault 1991; Hondagneu-Sotelo 2001; Romero 1992).

Childcare research has uncovered how paid careworkers must walk a confusing line between the overlapping role of paid employee and substitute mother who is sincerely attached to children in her care (MacDonald 1998; Nelson 1994; Tuominen 2003). In this and other carework occupations, the complexity of balancing kinlike relationships and workplace roles converges in the lives of low-paid workers (Hondagneu-Sotelo 2001; Romero 1992; Uttal and Tuominen 1999).

Recent scholarship has engaged in the debate about the commodification of intimacy, directly challenging the “hostile worlds” notion that carework and compensation are incompatible (Folbre and Nelson 2000;
Himmelweit 1999; Stone 2005; Zelizer 2005). Zelizer (2005), in particular, suggests that caregiving may be bought without the loss of authentic feeling, arguing that, in fact, intimacy and economic transaction overlap all along the spectrum of care activities. However, she also points out that purchased intimacy is a carefully circumscribed exchange, marked by a clear boundary and distinct sets of understandings and practices (Zelizer 2005). While a market exchange does not preclude a meaningful relationship, neither does it ensure that the terms of purchase will be negotiated among equals.

In fact, scholars studying domestic and private service work have long pointed to structural inequality as built into the terms and practices of this labor market (Chang 2000; Anderson 2000; Glenn 1992; Hodagneu Sotelo 2001; Rollins 1985; Romero 1992). Further, they note that race, along with gender and class, is deeply embedded in the caring labor market in U.S. society. In previous centuries, unable to get manufacturing jobs, African American women and immigrants entered private households to work for upper-income families. Always the lowest rung on the occupational ladder, household carework was filled by successive waves of disadvantaged workers-disproportionately women of color-as others were able to “move up” (Collins 1991; Duffy 2005, 2007; Ehrenreich and Hochschild 2002; Glenn 1992; Romero 2001). With the emergence of a paid labor market for domestic and personal care, the low-wage jobs were seen as the “natural” province of women of color, immigrant, and working class women (Duffy 2005; Ehrenreich and Hochschild 2002; Romero 2001; Wong 1994; Glenn 1992; Collins 1991). Women of color have been perceived as eager to extend their “mothering” across racial and ethnic lines, benefiting the hiring, usually white and middle class, care consumers (Wong 1994; Mullings 1994; Omolade 1994; Harris 1982). While regional demography and historical eras shape this workforce, care labor has always reflected the hierarchies of race, ethnicity, class, nationality, and status.

THE CURRENT CARE CRISIS: LONG-TERM CARE FOR THE ELDERLY AND CHRONICALLY ILL

The outstanding demand for caring labor today is the long-term care of the nation’s growing population of dependent people: the frail elderly, chronically ill, and disabled. The labor force serving these populations is becoming increasingly diverse; immigrant employment grew by 72 percent in nursing care facilities during the 1990s (U.S. Government Printing Office 2004). Within long-term care specifically, 90 percent of workers are female and roughly half are racial or ethnic minorities; one third are African American (Paraprofessional Institute 2006; Scanlon 2001).

In contrast to other carework, long-term care is complicated because it is affected not only by market forces but also by a highly regulated, statefunded system. According to the Government Accounting Office (2004), 70 percent of long-term care costs are borne by federal and state governments.

Some care scholars point out that containing public spending has become a national policy priority that may intrude into the relationship between caregiver and care receiver, both in homecare and facility-based settings (Diamond 1992; Karner 1998; Stone 2000; Zincavage 2004). Additionally, recent research in nursing homes has pointed out how low staffing, a common way to reduce costs, undermines caregivers’ efforts to offer individualized care as CNAs are hard pressed to keep up with basic tasks, causing stress and exhaustion (Lopez 2006; Mutaner et al 2006).

The need for long-term careworkers is projected to expand rapidly over the next decades. During the last century the population of elderly people grew faster than all other age groups. The U.S. Census Bureau projects that the number of persons over 65 years old will grow to 80 million by 2030. While one in eight Americans was elderly in 1994, one in five will be elderly by the year 2030. Moreover, the U.S. population age 85 and older, those most likely to need assistance, is predicted to more than double to 8.9 million by 2030 (Scanlon 2001).

Currently more than 1.9 million individuals receive nursing home care (AAHSA 2007). Within these nursing homes, CNAs are on the front lines and work under the supervision of nurses. Comprising 65 percent of the total nursing staff, CNAs provide between 80 and 90 percent of direct care to residents (IOM 2004; Dawson and Surpin 2001). Contrary to a widespread representation of this work as unskilled labor, CNAs actually carry out a variety of complex tasks crucial to the well-being of residents. The primary component of their job is assisting residents with activities of daily living. This entails dressing, grooming, eating, bathing, toileting, and transferring; providing personal care, companionship, comfort, and interaction; as well as performing clinical tasks including exercise, blood pressure readings, observation and reporting of changes in residents’ conditions, checking of vital signs, application of dressings, and other medically related treatments. CNAs are critical members of the healthcare team and their jobs are both emotionally and physically demanding.

According to the U.S. Bureau of Labor (2006), the injury rate for CNAs is among the top five of all occupations in the country. And despite their valuable role, wages are low. In Massachusetts, where we conducted our study, the median wage for CNAs in Massachusetts is $12.51 per hour (U.S. Bureau of Labor Statistics 2006). In this research we examine the role of CNAs, who have been described as the critical front line of long-term care or as low-skilled service work (Tuominen 2003; Himmelweit 1999; Glenn 1992). We explore the effects of an institutionalized family model of care in nursing homes, analyzing the benefits and burdens, against an ethic of kinship reciprocity (Stone 2000; Kittay 1999; Uttal and Tuominen 1999; DeVault 1991). We also draw out the kinlike relationship between paid caregiver and receiver, highlighting CNAs’ personal concern for vulnerable residents (Stone 2005; Zelizer 2005). Finally, we consider race and inequality as factors affecting the status and treatment of CNAs, and as a reflection of historical trends in which low-wage women of color and immigrants have long cared for higher-income families (Hondagneu-Sotelo 2001; Omolade 1994; Romero 1992; Rollins 1985).

STUDY APPROACH: EXPLORING KINSHIP AT WORK IN LONG-TERM CARE FACILITIES

Our examination of family ideology in long-term care comes from a study of work practices and relationships in nursing homes completed over the course of two years (2004-2005).2 The research included interviews, focus groups, observations, and a survey gathering information about care and work practices in 18 nursing homes across Massachusetts (MA).3

Participating nursing homes were recruited from a list of residential long-term care facilities in Massachusetts identified as within the top tercile by the Centers for Medicare & Medicaid Services and recognized by a research advisory committee as having a reputation for providing good care. Cross-sectional, nonrandom population sampling technique was employed to ensure variation in key dimensions, including location, ownership, unionization, and size. Given our sample selection, the findings here should be understood in the context of what are likely some of the better facilities in the state.

Site visits yielded focus groups with CNAs (N = 105), interviews with administrators (N = 18), assistant administrators (N = 2), directors of nursing (N = 16), nurses, both LPNs and RNs (N = 77), as well as various other management staff (i.e., activities directors, assistant directors of nursing, directors of human resources, directors of quality assurance, chief financial officers, social workers, staff development, and union
stewards; N = 32). Administrators provided a list of staff on duty each day to researchers. We were able to speak with every administrator, most unit supervisors, and a large percentage of all the CNAs.

Overall the CNAs in our sample were nearly 90 percent female and roughly 70 percent were under 44 years old. Their educational background was varied: 18 percent did not graduate high school, 30 percent graduated high school (and had no further schooling), and 11 percent obtained GEDs; over a quarter had some college courses while 10 percent had either an associates or a bachelors degree (7 and 3 percent, respectively). Half of the CNAs in this study spoke English as a second language.

The racial demographics of the participants varied greatly by facility location and, at times, within facilities; in some nursing homes the majority of CNAs were Haitian immigrants, in others the majority were Eastern European immigrants. Overall, the racial composition of our sample was 25 percent white, 10 percent African American, 9 percent white Hispanic, 6 percent Black Hispanic, 23 percent Haitian, 15 percent African, 5 percent other, 3 percent other Black, and just under 2 percent each of Asian Pacific Islander, Native American, and Other Caribbean, reflecting national trends (greater than 100 due to rounding).

All taped interviews, focus groups, and observational field notes were transcribed and coded with the aim of identifying patterns, key issues, contrasting themes, and concepts. The coding schema included inductive codes based on broad areas of initial interest, including the organization of work, care practices, and relationships. Our analysis for this paper focuses on in vivo codes or themes that emerged from the field research about the use of family ideology. Overall the study produced copious amounts of qualitative and quantitative data, but we confine our discussion here to the ways in which administrators, managers, nurse supervisors, and CNAs conceptualize and describe carework and careworkers.

Fictive Kinship Goes to Market

“… I tell them, think of this as your mother, how would you want her treated?”
-Manager

“Sometimes, we’re the family, but that’s part of being a CNA.”
-CNA

Across the 18 nursing homes in our study, whether nonprofit or for-profit, union or nonunion, “compassionate” and high-quality care was commonly expressed in the language of a family model of caring. In the many discussions about care quality and institutional approach, both management and frontline workers described creating a family as the best model of care for elderly and dependent residents.

The family model of care was reflected in the way managers often mentioned the importance of “bonding” and of CNAs establishing “authentic” relationships with residents. One manager described how, “In order to work in a long-term care setting or in a healthcare setting such as this, you have to be part of the family.” An executive director coined his facility’s philosophy as, “We take care of you like family.” Another elaborated, “I think the, ‘care-for-your-own-mother’ goes back to … you’ve got to do what’s right. And that you’ve got to go at this like it’s family …I think we approach our care more along the lines that this is family. You’ve got to look at these people like they’re your own mother or father.” This work ideology was not limited to top managers but was infused at all levels within the nursing homes. One nurse noted that creating a family-like environment had to be a shared goal of all staff: “You know, to make it a really family atmosphere, and we can only do that if the staff buy into it or are a part of it.” When queried about her managerial philosophy, another nurse manager explained, “I do have a lot of meetings, and the one thing I always push [to CNAs] is treat [the residents] like you treat your mother or your father or your sister. That’s important. That’s very important.”

In the facilities adopting the increasingly popular “person-centered care” approach to long-term care, allowing the residents to reclaim the feelings of autonomy and living at home are care priorities (see Pioneer Network, Eden Alternative,Wellspring Models for examples. Eaton 2000; Haran 2006). In describing this approach managers would regularly talk about how a family would treat a fragile member, based on personal preferences and needs. As one manager asked, “Why should you have to get up when the facility wants; why can’t you get up when you want to, the way you do at home?,” critiquing the traditional institutional custom of waking all residents up in the morning at one prescribed time.

Across the nursing homes, several administrators, nurses, and CNAs spoke of residents as having been abandoned by their biological families. In response, some managers described encouraging CNAs to, as several put it, “adopt” residents, to regard them as actual family members. Managers saw this as a strategy to promote empathy and patience among CNAs, particularly with residents who were sometimes uncooperative.
One assistant director expressed it, “I encourage [CNAs] to think of [residents] as their own mothers.” Another manager advised CNAs to provide care for the residents “The way you would care for your own parents.” One administrator put it poignantly, indicating she teaches CNAs that “[CNAs] are [residents’] family now. The last face they see will be [the face of the CNA].” Certainly this is a compelling image of the job.

This theme was reflected in conversations with CNAs as well; many regarded themselves as fill-ins for absent family members. Many took on these roles in the belief that elderly people deserved kin care and because a personal relationship was an attribute of the job that was gratifying. We heard variations of these kin obligations, “You have to be their family. You have to be there for them.” One CNA told us, “You get attached to them. . . . It’s like having 40 grandparents in one room. Being there when the residents need things. When they don’t see a family member that don’t come in, we’re there.” During both focus groups and open-ended discussions with CNAs, many described kinlike attachment as part of how they conducted intimate and demanding care. “I think of my grandmother” was a common refrain.

In some cases CNAs, particularly those who were immigrants, were separated from their own kin. They described providing care to elderly residents as a substitution; doing paid care work in this setting allowed them to offer love and understanding that, under other circumstances, would have been given to one’s own family. One CNA said,

I can tell you that I miss my family probably in a lot of stuff that I have to do here. … But my answer is; I like this job because I help people and I have my mother alive. … No, my mother is not here. The thing is I focus on my mother here. And that made me do the best because I think if it was my mother, I want to give her-I think I take this job personal.

She explained that her mother was living but not in this country and she acts “as if this was my mother” passing on the attention to other elderly women. Another CNA echoed this connection, “I love them …I feel when I’m here, I [think about] my mother and my brother, that’s the way I feel. I love them.”

The combination of managers encouraging CNAs to adopt the residents and the willingness by CNAs to establish familylike bonds emerged as the pervasive culture in all these facilities. We note, however, that not all CNAs expressed attachment to all residents and a few claimed they attempted to limit their attachments because they were too emotionally demanding. We also heard from some managers and CNAs that they had known staff people (CNAs as well as nurses and managers) who, given their cold and even abusive tendencies, “had no business working with [the] elderly.” Yet overall, family connection was the most common understanding of how carework should be done.

Filling in as a family member also emerged as the key mechanism by which good care was judged and CNA performance evaluated. When queried about characteristics desirable in CNAs, one director of nursing said, “They [CNAs] have to be really caring,” while another expressed a similar sentiment: “I want to see a lot of hugging, touching, very loving and caring.” Managers also sometimes encouraged familylike “extras.”As one put it, “[CNAs] should bring in birthday cakes for the residents, or, go shopping on their own time for residents, make a big deal out of their birthdays … .”

Preferences for people who were more likely to adopt or bond with residents had, in some facilities, become institutionalized. In this vein we heard that managers were “looking for someone who is flexible, who is willing to go more than the eight hours.” The standard behavior for a CNA had evolved into a willingness to go above and beyond simple task completion and develop a kinlike relationship with residents as part of the job. Many of the CNAs in this research appeared to try to live up to this standard.

When asked what CNAs “liked best about their jobs,” overwhelmingly and across all types of nursing homes, they identified the residents or “doing something to help these people.” Nearly 90 percent of the CNAs surveyed regarded themselves as the person closest to the residents in their care. While many CNAs were critical of various aspects of how specific nursing homes were managed-in some cases management was described as respectful and considerate and in others referred to as mean-spirited and disrespectful-CNAs most frequently identified attachment to residents as the most gratifying part of their jobs. “The residents are what make the job good” as one CNA put it. While another explained “… a lot of [CNAs] treat [residents] like they’re family. You are their family. This is the only place they know.”

THE BURDENS AND THE BENEFITS OF “MAKING FAMILY” IN NURSING HOMES

From the viewpoint of the managers, some of whom were promoting the new “person-centered-care” approach, the bonds of kinlike relationship between CNAs and residents were very helpful. The general consensus was that CNAs possessed a critical understanding of residents’ preferences, recognized day-to-day changes in resident status, and thus were the most capable of providing care centered on the individual.
Managers referred to CNAs as being the “eyes and ears” of the facility or the “hearts and hands” of care; the people who really understood the needs and condition of the residents. Numerous managers spoke in heartfelt terms of their responsibility to promote quality of care within their institutions. “These people have lived their lives and made contributions and this is their end of life. We are the ones who are responsible for what that’s like,” said one nursing home director.

But managers also discussed care strategies in more pragmatic terms. Competition for residents and demanding regulatory standards were major considerations in care styles and quality. Managers claimed that family members wanted to see their elderly kin clean and fed and, equally as important, receiving compassionate and affectionate care. Nursing homes are highly regulated by state and federal mandates and state officials periodically conducted visits to evaluate quality of care; infractions resulted in loss of revenue. Encouraging caregivers to form deep bonds with residents and thus go out of their way to take good care of them was discussed as humane as well as a boon to the institutional bottom line. Without a doubt, the family model was good for business.

Certified nursing assistants, as the people who were performing the majority of duties that constructed family, expressed a more ambivalent attitude. Most CNAs valued their role as caregiver and regarded themselves as the people who actually knew each resident. They also valued the affection that some residents were able to offer in response to their care. Yet as the primary direct care providers, CNAs also pointed to the stress and physical exhaustion involved in caring for 7 to 14 dependent people (as many as 22 in the evening and during the “graveyard shift”). In the survey, 93 percent reported that they work short-staffed occasionally, often, or always (44, 36, and13 percent, respectively). One summed it up, indicating “… it’s really just a big rush, the whole day. … like an assembly line, you know?” Moreover, the emotional challenge of fulfilling the expectations of a dozen “grandparents” was sometimes overwhelming.

Many CNAs expressed sentiments similar to one who said,

It’s not so much the [activities of daily living], helping them get washed up, helping them get dressed; it’s to be able to spend that quality time with them, other than doing the patient care. There’s more to being a CNA than just doing patient care. And these people don’t, some of them don’t have families that come in, so they kind of appreciate when you take that little bit of time and spend it with them.

Certified nursing assistants spoke of worrying about the residents over the weekends or in the evening. In fact, almost half indicated that they visit residents, unpaid, on their days off. CNAs suggested that in order to do their job they had to do more, feel more, and stretch themselves for the residents “because we are their family.” Three out of five CNAs reported that they came in early or stayed late to provide care to residents without being paid to do so, and four-fifths of the CNAs indicated they worked through their breaks in order to provide adequate care. Certified nursing assistants saw concern for the wellbeing of residents not as acts of accommodation to management demands, but as a reflection of ethical beliefs about caring for vulnerable fictive kin.

Despite authentic concern for residents, CNAs were critical about their value as workers within the nursing homes. It was common to hear CNAs remark that the pay was low and the benefits limited or nonexistent; some pointed out that their wages were not enough to cover their monthly bills. Most earned between $9 and $14 hourly and did not receive medical or other employment benefits. Overtime work was common, three-fifths of the CNAs reporting that they worked overtime at least once a month and a few admitting that they worked double shifts frequently. Moreover, at least one-third indicated that due to low wages they held more than one full-time CNA job.

While at all staffing levels individuals pointed out that “no one gets rich who works with the elderly,” many of the managers and facility directors readily agreed that the CNA staff were notoriously underpaid and that there was little or no room for advancement without further schooling. One woman explained, “We don’t have good benefits but … you come every day, it’s like family … .” Many managers expressed the belief that CNAs deserved more for the work that they did, and few denied the importance of their work. Yet given the “dead-end” trajectory of the job, the hard work caring for dependent, even immobile, people, and “bad wages,” some administrators suggested that the work had to be “a calling.” Several others echoed this sentiment, claiming that CNAs “can’t be in it for the money.” This framing of the work in terms of nonmarket motivations was echoed in numerous ways. It was common to hear managers and CNAs explicitly describe putting affection and family duty before money as the motivation for this job. One CNA described the job as being about love:

“Got to love them to do this type of work. You have to be caring; have to be honest with them, patient, loving. All that counts to be a good CNA. If it was for the money, I wouldn’t be here. I’m here because of the residents, I love them.” While another explained “I’m doing the work now for the patients not for the nurses [managers] … Not for the money. I’m doing it for the patients … Because the money, that’s not it. It’s not the money. It’s like you’re doing it for them to do it really is your heart. It’s your heart, you do it with all your heart.”

The traditional family model of women putting dependent people before other considerations was strongly rooted at all levels of the facilities.

BOUNDARIES WITHIN THIS FAMILY MODEL

For nursing home managers, the family model was a way to improve quality of resident care and to deepen a worker’s sense of relationship and responsibility, despite low wages and strenuous job conditions. On balance, for the institutions, the promotion of a family ideology offered considerable benefit and few burdens. But for the people who were performing the majority of direct care, the family model was much more costly. Set in the context of compensation that was by all accounts very low, the burden of “making family” was materially undervalued and largely borne by the CNAs.

Beyond the imbalance in costs and benefits, this formulation of fictive kinship had distinct boundaries. While kin claims made on CNAs were part of nursing home culture, kin claims made by CNAs were received quite differently, often exposing the nonreciprocal nature of the family model. In particular, we found examples of a carefully delineated version of family in policies regarding the death of residents, the response to CNA family concerns, and a consistent lack of recognition of the knowledge that CNAs develop regarding the care of residents.

As expected, we found that the death of residents was inevitably part of the experience of work in nursing homes. But CNA’s accounts of losing one of “their” residents raised a challenge to the nursing home mystique about being “part of a family.” Several CNAs said that while they had been encouraged to care for a resident as a grandmother, they were discouraged to mourn her in that way. For nursing home managers, grief meant a potential disruption to an orderly workflow. Only a few nursing homes integrated the practice of allowing CNAs to attend residents’ funerals. While some CNAs reported that they appreciated the chance to participate in grieving, many could not give up a day of income to attend a funeral. In a more general sense, others found that the profound grief they felt did not dry up immediately after the funeral. As one woman explained, “It’s like your own family, is the way I see it. It’s not like for me it’s a stranger anymore. You know that person deeply, and then that person, one day, is just gone.”

One CNA gave a detailed account of coming to work and receiving no report of the death of a woman for whom she had cared for several years. In fact, she did not know this woman had died until she entered her room to find it emptied out. “I was very close to her,” she told us. “I cried and cried.” She went on to express how much she wanted and needed compassion from those around her: “… if you have someone die, you come in, you need like little hug … .” When she confronted the nurse supervisor, asking why no one had bothered to tell her of this resident’s death, she was told that they knew she would “overreact” and “not behave professionally.” In this case the family model was quickly discarded, in fact was treated as a liability when it was no longer useful to the nursing home.

Another element of the CNA role that indicated a distorted version of kinship could be seen in the way CNAs’ own families were treated. These families were excluded from the family model incorporated into the work, treated not as an extended part of a family circle, but largely as work obstacles. “Family issues are big [problems],” one manager acknowledged. Understaffing is a major impediment to good care and countless managers described families as a primary obstacle in supervising CNAs, specifically pointing to childcare issues, school vacations and holidays, and family health problems. A few supervisors were flexible, acutely aware of the problems facing working mothers, but others said they could “only go so far.” As one manager put it, “they have a real obligation here, these people [the residents] count on them and we count on them.” “This is a business, we have staffing levels we have to meet,” remarked another. One manager framed this as the need for CNAs to behave appropriately at work by keeping private family matters outside: “‘Leave them at the door’ I say. We don’t want the residents to get upset.”

Some CNAs recognized the paradox of their role. One said reflectively “I mean, I give [the residents] 100 percent of what I got. Maybe too much. More to them than I give my family.” Another young CNA said, “I spend much more time with [residents] than I do with my son.” Pointing to the institutional culture that puts the real and fictive families in competition, one CNA said, “[Supervisors] give you the feeling, they kind of make you feel like ‘We’re first and your family’s second.’ They try to put you on that track … .”

Another way nursing home managers contradicted the model of family was by failing to include CNAs in discussions of the care for “their” residents. Of the 18 long-term care facilities, 17 did not include CNAs in routine meetings that reviewed the changing health status and care concerns of each resident. This omission sometimes baffled supervising staff, as one nurse manager expressed “… some of the aides know far more about the people [her residents] than I do.” Others too pondered the absence of CNAs when care discussions took place; “I don’t know why we don’t include them … really we should,” and their absence was sometimes discussed as a staffing shortage issue. Supervisors reflected that, generally, CNAs were supposed to “report” their observations to supervisors but not be included in the collaborative process of planning. One CNA said, “They [management] don’t really ask us too much what we think.” In fact, despite their proximate role in caring for residents, less than a quarter of CNAs surveyed indicated that their supervisors even consistently
asked for input in care plans.

This gap between being credited as critical kin who are closest to the care receiver yet extraneous to the “thinking” part of care was critiqued by some CNAs. One remarked,

“Sometime you come to work … you don’t feel like … we are family too … . Like [management] don’t think you are nothing. You’re here only to clean people but you’re not really a person, you know? … They don’t treat you as a person.” And another added, “Yeah, they think we are nothing but butt wipers … that’s all.”

THE RACIALIZATION OF CNAS, “RACIAL SLURS,” AND ABUSE ON THE JOB

From our perspective, the nursing home work environment was an obviously racialized one. Women of color make up the overwhelming majority of the CNAs, and they report to white managers and care for white residents. Despite this, few of the nursing home administrators, unit supervisors, or CNAs themselves specifically raised the topic of race when discussing the culture of their work environments.

Nonetheless, over the course of the study, we heard several accounts of disrespect and verbal and even physical abuse that sometimes opened the door to talk about racism. When specifically asked about problems at work, CNAs spoke of being verbally abused and about residents who “are a pain,” and who are “scratching and slapping at you.” In one focus group every participant claimed that they had been physically assaulted at one time or another while caring for elderly people, many of whom were experiencing dementia. And in a context of discussing mistreatment of CNAs in general, several reported being called “nigger” and other equally charged racial terms in the course of doing their job.

Generally this was said with distaste, sometimes resentment, but also with a shadow of inevitability concerning working with people who “don’t know any better” because “they were raised in a different time.” Managers and nurses, too, framed expressions of racism as an aspect of nursing home work, yet we heard little discussion about the effects on the people to whom it was directed. One CNA told us “… let me tell you, those patients been brought up with their parents telling them stay away from Black people. Now it’s too late, you cannot do anything about it. And then we getting the abuse all over.” When asked what form the abuse would take, several individuals jumped in: “By telling you, ‘go away, don’t come, I don’t want you to touch me, you nigger, why don’t you earn a decent living?'” Another added “Some of them think … you come to steal their stuff … . But that’s their mentality.” Placing this in a broader context one CNA added, “that’s the way it is. This is America. That’s why this issue is there, it’s alive.”

During one observation in a hallway, we watched an incident that suggested the acute racism experienced by the CNAs. A very frail white woman was being attended to by two women (both were Jamaican women). The resident had been sitting alone singing a song and they had joined her, singing along. The exchange was initially described in field notes as a familylike moment until abruptly the resident started yelling at the two CNAs in rank, racist terms. One of the two quickly walked away but the other chided the elderly woman to stop, “that’s not nice … why do you talk like that?” she asked. The nurse at the central nurses’ station nearby shook her head. When asked about the incident, the nurse explained that it was an unfortunate aspect of work, not uncommon, and
“really unfair” to the CNAs. She spoke with an air of inevitability about this aspect of work.

Some CNAs suggested that racial bias entered their work assignments as well. In one of the numerous focus groups in which the participants were exclusively women of color, one participant said, “Like if we are Black CNAs and white CNAs, they are not treated the same way … . If white CNAs work on the unit, it’s supposed to be like four [CNAs per unit] but they put five [CNAs on the unit, thus reducing the workload], because it’s white people. If you Black, they’ll put three. They don’t care about you.” While the other CNAs agreed by nodding; when asked for more information they were reticent to say that a specific manager behaved this way, rather, “Everywhere, not only here. Everywhere.”

Managers were the least likely to raise the issue of race, but early on in the fieldwork we became aware of a term they used that we subsequently learned was common institutional language, the problem of “racial slurs.” While meeting with one nursing home director we were interrupted by a phone call and, after finishing, she remarked that a resident had been using racist language toward the CNA who cares for her. She added that “racial slurs are common problem” in nursing homes and when asked, other directors concurred. In fact, the phenomenon of “racial slurs” is so commonplace that some facilities have included it on a general list of resident behaviors. Overall, managers seemed to regard racial insults as a disturbing if inevitable experience for workers of color in nursing homes.

Beyond the institutional adaptation to verbal racial abuse as “racial slurs,” a more subtle and pernicious culture emerged, a racialized version of the CNA. In discussing their supervision of CNAs and the importance of providing authentic affection to residents, some supervisors referred to a cultural proclivity to do carework. Several managers spoke of the warmth of Caribbean people’s cultures and one manager suggested that Haitians are “naturally” suited to providing care for elderly people: “They [Haitian CNAs] have a culture of respecting the elderly … they are warm and patient … they have that approach.” On the other hand, language barriers were a concern and a few managers remarked that “they” don’t want “to move very fast” from one task to the next; most overt cultural/racial comments were wrapped as “compliments.” Consistent with historical stereotypes surrounding race and carework, some administrators expressed a belief that CNAs of color were uniquely suited for their jobs.

DISCUSSION

In the course of this research an ideology of family emerged as integral to the way that care was conceptualized by managers and direct care workers. We have examined the contours of this family model as one that can offer considerable benefit to frail and dependent people and also to the institutions responsible for providing them with decent care. As we so often heard, the devoted “hearts and hands” of CNAs are good for residents and good for business. Encouraging CNAs to consider residents as their own mothers and fathers builds a morally obligated and emotionally devoted worker, likely to stretch herself to give good care to her kin.

We do not mean to diminish the degree to which CNAs valued their relationship with many of the residents in their care; overwhelmingly they identified these relationships as the best aspect of their job. Many CNAs
used fictive kinship to establish connections with elderly and infirm strangers for whom they were going to provide the most intimate care duties: changing soiled undergarments, washing, feeding, soothing, and, in most cases, witnessing their deterioration. And many nursing home managers spoke admiringly of their work.

Yet the family construct appeared to institutionalize an expectation of self-sacrifice or of putting “adopted” kin above all else. The gendered role of family caregiver is without boundaries, orbits around the needs of others, and is “a calling” too sacred for such base calculation as market valuation or in words from this research; “it is not about the money” (Crittenden 2001; DeVault 1991; Folbre 2002; Nelson 1994). While relationships emerged as foundational to high-quality care for people who certainly need it, emotional work comes at a high cost. The institutional use of a family ideology creates a workplace culture ripe for the exploitation of the lowest-paid direct care workers.

We are not suggesting that CNAs are being “tricked” into providing affectionate care. Our findings reflect those of others who have uncovered how determinedly paid care givers resist a commodification of their labor that negates their feelings, even to the point of bending or breaking rules (Stone 2000). We also agree that authentic caring can be purchased. The fact that CNAs received wages did not turn their care into market exchanges devoid of affection. Quite the contrary; above all, they valued relationships with residents. Yet we also found these monetized care exchanges do have distinct boundaries and, above all, “differentiated social ties” (Zelizer 2005), with the lines that are drawn markedly in favor of resident need and nursing home interests. Similar to the sharp imbalance of power between employer and domestic worker, nursing homes managers have the freedom to vacillate between the CNA as trusted kin or contracted worker, whichever offers the greatest advantage at any particular moment (Dill 1994; Glenn 1992; Hondagneu-Sotelo 2001).

Beyond a gendered family culture of self-sacrifice, the CNA role also embodied a racialized version “of part of the family.” Critical race theorists have long pointed to an archetypal figure, the caregiver of color, as engrained in the American social imagination (Collins 2005; Glenn 1992; Harris 1982; Jones 1985; Omolade 1994). Wong (1994) argues that the society’s “black mammy” of old is “open to permutations” based on the changing needs of the times. The CNA emerges as one of them. This historically familiar caregiver is expected to be devoted to the people for whom she cares even though they are not her kin, even though she is paid less than her own family needs to survive, and even though they may abuse her.

In recent research Berdes and Eckert (2007) examined how the family care model interacts with racial abuse in nursing homes. They suggest that the family model is useful to offset the potential for lowered care quality that might be expected when workers are racially abused. As the authors put it, “When neither good wages, benefits, nor job prestige are present to serve as motivators, when hope of advancement is slim, when the work itself is onerous” one of the only pillars of maintaining good care is the “emotional ‘currency'” that may sustain quality, “even [to] those residents that actively abuse them.” In this same vein, Gates (2004) documents that CNAs are slapped, punched, kicked, spat at, scratched, or bitten, yet argues that violence in nursing homes is simply treated as part of the job. Our research reflects these studies. Yet while CNAs did not describe most residents as racist or violent, the nursing home is a highly racialized and stratified workplace. The most common institutional response to CNA abuse among managers was to frame it as an inevitable element of the work.

Despite the ways that this model of family served to exploit CNAs, we believe that a version of familial relationship is at the heart of good care and of gratifying carework. CNAs taught us that their job demands not only physical strength but also artistry, intuition, skill, patience, and finally (though certainly not in all cases) affection or, as so many said, love. When this critical work is rooted in an ethic of reciprocity, the kinship model is not inherently exploitive. But so long as CNAs are relegated to that particular “part of the family” where women of color and immigrants have been assigned for centuries, the use of family ideology can easily become tyranny at work (Childress 1986).

We conclude by raising several concrete points for further discussion and research. On-the-job abuse that CNAs experience demands more study and institutional intervention (Gates 2004). While it is generally understood that people with dementia are challenging care receivers, we heard very little about how these issues affect frontline workers in the myriad nursing home workshops, training sessions, and care meetings.
The abuse of CNAs, including racial abuse, should be an integral discussion in long-term care. We posit that the best strategies for change will come from those who are “in the trenches.” However, as low-wage and subordinate workers, CNAs are unlikely to speak this truth to the conventional structure of power in most nursing homes (Dodson and Schmalzbauer 2005).

Certainly there are also legal strategies that could be pursued. For example, a Fair Labor Standards approach to hazard pay might provide some compensation for frontline workers who are abused. Alternatively,
embarking on a class action or civil rights strategy could spark serious attention in the industry. And it may be that compensatory or legal approaches are necessary, for as long as these work conditions are felt
“only” by low-wage workers, they may continue to be treated as an unfortunate but unavoidable “part of being a CNA.” In addition to the acute matter of abuse, the outstanding issue for CNAs is that their wages are very low, in many cases below federal poverty levels (Smith and Baughman 2007). This is an issue that is gaining attention; a growing group of eldercare scholars argues for approaches to caring for dependent people that consider better jobs as integral to better care (Eaton 2005). And research and programs directed toward the cultivation of career pathways for frontline careworkers have become a focus of longterm care research (see Robert Wood Johnson http://www.rwjf.org/).

From another angle, collective bargaining and strong union representation may be the most viable means of ensuring that this growing workforce is paid a sustainable income and receives job benefits. Unions may also be the channel through which CNAs enjoy a change in their institutional status and gain the respect that their critical work merits. For example, a new approach to the provision of long-term care led by the Service Employees International Union (SEIU) is based on cooperation between labor and management and promotes the inclusion of CNAs in all aspects of nursing home planning, training, and implementing work (Rosenberg 2005). Not only does this approach necessarily elevate the voice and centralize the knowledge of CNAs but simultaneously supports better quality of care for residents.

From all quarters of this study, administrators and frontline workers regarded a caring relationship between CNAs and residents as essential to the well-being of elderly, chronically ill, and dependent people. Managers and frontline careworkers alike spoke of family relationship as an essential ingredient for long-term care. Reflecting the thinking of those who do the work, we argue that, when fully valued, kinship in carework is not inherently exploitive. Yet a critical concern for dignified and familylike care of one segment of our people does not justify sacrificing the humanity of another, in this case, those who do the job of caring.

NOTES
1. Data reported on here were gathered as part of the project entitled
“Improving Institutional Long-Term Care for Residents and Workers: The Effect of Leadership, Relationships and Work Design Project.” Research was funded by
20 GENDER & SOCIETY / Month XXXX
the Better Jobs Better Care collaboration of The Robert Wood Johnson Foundation and Atlantic Philanthropies administered by The Institute for the Future of Aging Services.
2. The project was approved by the Institutional Review Boards at Brandeis University, Boston College, in addition to facility-specific IRBs for NFs that had their own IRBs.
3. For a more detailed discussion of study design and methods, please see project final report at http://www.bjbc.org/
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Lisa Dodson is a research professor in the Sociology Department, Boston College, teaching and researching in the areas of poverty, work and family, and carework in low-income America. She is currently writing a book about middle and working class collaborations that are a response to growing inequality.

Rebekah Zincavage is a doctoral candidate for a joint PhD in Sociology and Social Policy at Brandeis University where she teaches courses on family, poverty, and inequality. Her research interests include carework, social inequality, work and family policy, and research methodology.

Gender & Society December 1, 2007 21: 905928Gender & Society December 1, 2007 21: 905-928
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