Consumer-directed care and the relational triangle. Power, subordination and competing demands – a qualitative study
| Date | 01 April 2019 |
| Pages | 436-453 |
| Published date | 01 April 2019 |
| DOI | https://doi.org/10.1108/ER-06-2017-0130 |
| Author | Graeme Edward Payne,Greg Fisher |
| Subject Matter | HR & organizational behaviour,Industrial/labour relations,Employment law |
Consumer-directed care and the
relational triangle
Power, subordination and competing
demands –a qualitative study
Graeme Edward Payne and Greg Fisher
College of Business, Government and Law, Flinders University, Adelaide, Australia
Abstract
Purpose –Following a recent government initiated change to a consumer-directed care model across the
Australian community aged care sector, the purpose of this paper is to explore frontline home support
workers’perceptions of relational changes with clients in power and subordination within the triadic
relationship between employer, employee and client.
Design/methodology/approach –Contextual interviews were held with managers (n¼4), coordinators
(n¼10) and semi-structured face-to-face interviews with support workers (n¼17) in three organizations.
Interview transcripts were analyzed.
Findings –Some workers did not perceive a power change in their relationships with clients. Others
perceived minimal change but were concerned about the incoming client generation (baby boomers) that were
more aware of their rights. Others felt subordinated to the client, perceived a loss of control or that felt treated
like an employee of the client. Consistent with the philosophy of consumer-directed care, senior staff
encouraged clients to treat workers in this way.
Research limitations/implications –Further research is recommended on worker and client perceptions
of relationships within the context of a consumer or client focused model.
Practical implications –A clear and realistic understanding of the locus of power within a triadic
relationship by all actors is important for positive workplace outcomes.
Social implications –The increasing ageing population makes it essential that workers’relationships with
clients and with their organization are unambiguous.
Originality/value –This study makes a contribution to theories about change and power transfer in the
implementation of consumer-directed care through the perceptions of support workers. Examinationof power
and subordination transfer through the perceptions of the actors of rather than through the prism of
organizational policy deepens the understanding of frontline service work and relationships.
Keywords Government policy, Home support workers, Employee relations, Non-profit organizations,
Organizational change, Consumer directed care
Paper type Research paper
Introduction
In OECD countries, the increase in aging populations, including the “tsunami”of aging baby
boomers Kirkey (2013, p. 1), and their care present major health and community challenges
(Hugo, 2007). There is also increasing longevity of populations. For example, in Australia
“the ‘old-old’population is growing faster than the total aged population […]”(Hugo, 2007,
p. 169). By 2050, it is predicted to be over 3.5m aged persons (Australian Productivity
Commission, 2011). Challenges in aged care also arise from medical advancements,
economics, and societal and consumer expectations (e.g. Christensen et al., 2009).
Traditional models of aged care vest decision making with the agency providing the care
(Benjamin et al., 2000; Swaine et al., 2016). To provide better outcomes for aged clients in their
homes countries have moved away from traditional agency-directed care models to consumer-
directed care (Benjamin et al., 2000; Glendinning et al., 2008; Kodner, 2003; Low et al., 2011;
Ottman et al., 2013). Consumer-directed care transfers the locus of power and decision-making
from the organization to the consumer or client (Benjamin and Matthias, 2001; Doty et al., 1996).
The extent of client control under consumer-directed care varies both between and
within countries. Models adopted range from clients having a greater say in agency-based
Employee Relations:
The International Journal
Vol. 41 No. 3, 2019
pp. 436-453
© Emerald PublishingLimited
0142-5455
DOI 10.1108/ER-06-2017-0130
Received 14 June 2017
Revised 27 March 2018
Accepted 18 May 2018
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/0142-5455.htm
436
ER
41,3
service provision, through to full control under “cash for care”systems (Doty et al., 1996;
Kodner, 2003; Laragy and Naughtin, 2009; Low et al., 2012; Sciegaj et al., 2004). During 2015,
the Australian Government legislated a consumer-directed care model across the
community aged care sector that provides substantial choice and control to clients
receiving care in their own homes (Commonwealth of Australia, 2015).
The consumer-directed theory of empowerment underpins consumer-directed care
(Kosciulek, 1999, 2005; Kosciulek and Merz, 2001). Consumer or client direction “is a
philosophy and orientation [by which] informed consumers have control over the policies
and practices that directly affect their lives”(Kosciulek and Merz, 2001, p. 210). The theory
provides a framework for the “delivery and the outcomes of processes about community
integration, empowerment, and improved quality of life”(Kosciulek, 2005, p. 41). Brown and
Ringma (1999) referred to consumer-directed care as providing “the transfer of power into
the hands of consumers”[with] relational factors [representing] an important feature in the
utilization of that power (p. 245).
Research within the USA and UK indicates that the effect of consumer-directed care on
client outcomes is overall more positive than under former agency directed models
(e.g. Benjamin et al., 2000; Carlson et al., 2007; Doty et al., 1996; Glendinning et al., 2008).
In Australia, early research on client outcomes under the new consumer-directed
care model conclude that the main policy objectives of client choice and control under
consumer-directed care are being met (Bulamu et al., 2017) and overall client satisfaction
with the services provided was evident (Ottmann and Mohebbi, 2014). Day et al. (2017) found
that the home-based clients stressed the importance of personal carer continuity and
reciprocal and credible relationships with support workers.
Health care organizations are highly reliant on their support workerswho primarily maintain
relationships with clients (e.g. Schopman et al., 2017). In the context of home care, support
workers provide client services that include personal care, domestic assistance and social
support (Clarke, 2015). Besides family and friends, support workers are the most involved in the
hands-on care of the elderly and recognized as the “cornerstone”of the long-term care system
(Kemp et al., 2009, p. 37). The relationship between client and support worker and the level of
empowerment within the relationship are important factors in the quality of client outcomes
(Baxter et al., 2008; Glendinning et al., 2000; Eustis and Fischer, 1991; Swaine et al., 2016).
Early research on workforce implications of the new consumer-directed care model in
Australia is limited to perceptions of the effect of the model on the day-to-day work of
professional managers, coordinators and support workers (Gill et al., 2017; Laragy and
Allen, 2015; Prgomet et al., 2017; You et al., 2017) and future support worker role
enhancement and skill development (Lawn, Westwood, Jordans and O’Connor, 2017; Lawn,
Westwood, Jordans, Zabeen and O’Connor, 2017). There appears little or no international or
Australian research on the perceptions of front-line support workers on the impact of the
change to client empowerment on their relationships with their clients and organizations.
The purpose of this current study is to fill this gap.
Research on front-line service work has recognized the shift from a traditional dyadic
relationship between employer and worker to a triadic relationship that includes the
customer or client (Bélanger and Edwards, 2013; Bolton and Houlihan, 2005; du Gay and
Salaman, 1992; Havard et al., 2009; Korczynski and Ott, 2004; Korczynski, 2009, 2013;
Leidner, 1993; Lopez, 2010; McCammon and Griffin, 2000). Research into this relational
triangle and front-line service work has occurred in a range of workplace contexts (Bianchi
et al., 2016; Bolton and Houlihan, 2010; Gittel, 2002; Havard et al., 2009; Wharton, 2009),
including the aged care sector (Brown and Korczynski, 2017; Cranford and Miller, 2013; Faul
et al., 2010; Lopez, 2010, 2014).
Based on concepts of power and subordination, Havard et al. (2009) proposed a topology
“built around six static ideal-typical”workplace situations in “relational or environmental
437
Power,
subordination
and competing
demands
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