Being able to provide sufficiently good care for older people: care workers and their working conditions in Finland

This study examines whether care workers in Finland feel able to provide adequate care for older people and analyses the working conditions that limit them from providing it. One third of the respondents felt that they were not able to provide sufficient care for older people. This was seen as being due to excessive workloads, a general lack of staff and accompanying physical and mental burdens. Improving care workers’ working conditions would enhance their work–life balance and allow them to help older people avoid situations of care poverty, that is, to receive the level of care they deserve.


Introduction
The care of older people in Finland has changed significantly over the past few decades (Tainio and Wrede, 2008;Wrede and Näre, 2013).New Public Management (NPM) has pushed for better-quality management in care services, more detailed documentation of them and care services to follow the directions and time restrictions specified in manuals.The aim of this has been to enhance the efficiency and quality of care in the sector.However, these changes have also reframed care workers' jobs as more structured and target oriented than has traditionally been the case.One example is the 'standardisation of time', which requires care workers to accomplish a particular task within a given time but, at the same time, prevents them from performing any additional duties above and beyond those specified in the care plan (see, for example, Satka and Hämeenaho, 2015;Tallavaara et al, 2016).A significant factor behind these changes has been the increasing lack of resources available due to financial constraints and human resources in the social care sector.In recent years, care workers have reported increasingly excessive workloads, job stress, burnout, a lack of flexibility in their work, health and safety issues, physical and mental health problems, and an increase in violence and threats made in the workplace (Trydegård, 2012;Kröger et al, 2018;Vehko et al, 2018;OECD, 2020;Ruotsalainen et al, 2020).
The working conditions of care employees affect not only their own work-life balance (for example, job stress and job dissatisfaction) but also the quality of care received by older people.A Finnish national report found that time pressures and staff shortages have increased the risk of abuse in residential care (Tallavaara et al, 2016).The same report also highlighted the fact that older people were not getting enough outdoor exercise due to insufficient staffing.Kangasniemi et al (2022) analysed official complaints about allegations of neglect in residential care settings in Finland (for example, regarding personal hygiene or being restricted from certain activities) and found that staffing issues, particularly in the private sector, were felt to be one of the main reasons for this.
Finland is an interesting case because it has been variously described as a 'welfare' (Kröger, 2003), 'social service' (Anttonen, 1990) or 'caring' (Daly, 2001) state, that is, one in which people receive the care they need through predominately tax-funded public services.Indeed, for the last few decades, long-term care (LTC) in Finland has faced the challenges of servicing an increasingly ageing population with less than adequate financial and human resources.The population of over-70s has increased from 0.45 to 0.62 million in the last three decades (Sotkanet, no date), at the same time as the coverage of home and residential care for people over 75 has dropped by 13 and 3.1 per cent, respectively (Säkkinen et al, 2021: 58, 65).In 2017, the LTC sector employed around 50,000 care professionals, of which roughly 70 per cent worked in residential and 15 per cent in home care settings (Kalliomaa-Puha and Kangas, 2021), but the sector will need an additional 30,000 full-time employees by 2030 to cover staff shortages (Eurofound, 2020).
Workplace conditions are a major concern in Finland due to this overall shortage of staff and the growing pressure to do more in less time.This has led to lower job satisfaction, higher job stress, poor teamwork, growing physical and mental exhaustion, and, in some cases, violence in the workplace (Tallavaara et al, 2016;Kröger et al, 2018;Vehko et al, 2018;Ruotsalainen et al, 2020).In many cases, care workers are leaving their jobs for others in related fields or even leaving the profession altogether because of these factors (Kankaanranta and Rissanen, 2008;Flinkman, 2014;Van Aerschot et al, 2021).Poor working conditions will thus also have a regrettable knock-on effect for the older people in their care; yet, there are currently few data about care workers' own views about the care they provide.This study aims to gain further knowledge about how staff themselves feel about the care they provide to older people with the restricted resources available.For this purpose, this study asks: 'Do care workers feel able to provide adequate care for older people?'; and 'What are the kinds of working conditions (in terms of workload, job flexibility and support) that prevent care workers from providing sufficient care?'

Background of care workers in Finnish LTC settings for older people
The duties of a care worker in Finnish LTC settings for older people generally involve assisting them in their day-to-day activities, such as meals and personal hygiene, but can include other tasks depending on the user's care plan.Most Finnish care workers are practical nurses with three years of vocational training in health and social care.Their retirement age varies from 63 to 68 years old, with an option for part-time retirement from the age of 61 (Sulander et al, 2016).Most (around 65 per cent) are employed in the public sector; the rest work in the private sector -in either profit or non-profit organisations.On average, practical nurses in the public sector earn about €34,440 (£30,308) per year (Eurofound, 2020: 34), which is 23 per cent less than the national average annual pay of €43,188 (£37,972) (Official Statistics of Finland, 2021).However, on average, care workers in the private sector earn €2,400 (£2,112) less than those in the public sector, but the lowest pay in LTC work can be as little as €25,656 (£22,574) (Eurofound, 2020: 32).In a residential care setting, a minimum staff-user ratio of 0.5 is required (that is, five personnel per 10 users), but with new regulations that came into force in 2020, this ratio is set to increase to 0.7 by 2023 (Ministry of Social Affairs and Health, 2020).

Care workers' working condition and care quality
A care worker cannot provide adequate care if their work conditions are unreasonable (Trydegård, 2012), and poor management has been shown to significantly affect the quality of nursing care delivered (Newman et al, 2002;Westerberg and Tafvelin, 2014;Zúñiga et al, 2015;Ruotsalainen et al, 2020).Some of the management issues identified by care staff are a lack of recognition and support, poor communication between supervisor and care worker, a lack of autonomy in the work environment, and workplace discrimination.A study from Finland (Räikkönen et al, 2007) found that a lack of support from supervisors makes care workers see their own professional skills depleting and lowers the quality of care they deliver.Meanwhile, other studies have shown that supervisory support helps care workers navigate professional challenges and motivates them to respond better to service users' needs (McGilton et al, 2016;Escrig-Pinol et al, 2019;Virdo and Daly, 2019).Additionally, care workers need regular training to manage their work tasks and the right equipment for helping with the physically heavy tasks that caring for older people sometimes requires, especially since LTC workers also often have little or no prior training in caring for older people.
Research from nursing science has shown that poor working conditions can cause nurses to skip or ration some non-essential care services (Tønnessen et al, 2011;Haugan, 2014;Zúñiga et al, 2015;Henderson et al, 2017;Ludlow et al, 2019;Blackman et al, 2020;Senek et al, 2020).These studies identified some determining factors that might cause this to happen in a workplace: staff shortages; undue work stress; an unsafe workplace; time constraints; inadequate resources; a lack of teamwork, recognition or communication; a high administrative load; the facility's size; a lack of education or training among staff; and the sheer range of complex and often unique needs that older people have.When Schmalenberg and Kramer (2008) applied the 'Essentials of Magnetism' tool -eight work-related attributes essential for quality care -to measure the quality of care provided by nurses in hospitals, they too found similar factors to be important, for example, managerial support, autonomy in the job, adequate staffing and educational support among staff to promote quality care.Meanwhile, another study across nine different countries in Europe, Asia, North America and Australia emphasised that a better work environment in hospitals helps nurses provide better care for patients (Aiken et al, 2011).From this, it is reasonable to suppose that work conditions will also affect how any care worker can do their job, whether in a hospital or an LTC setting.
It is of particular concern that care workers in Finland are paid low and have higher work-related stress, which may contribute to the fact that it is also the Nordic country with the lowest care staff-user ratio (Kröger et al, 2018).Other common features of the Finnish LTC sector are high staff turnover, frequent sick leave and numerous vacancies (Elstad and Vabø, 2008;Trydegård, 2012;Van Aerschot et al, 2021).Staff shortages, in particular, exacerbate the situation for existing care workers because they must assist more people than they can handle, often needing to sacrifice their breaks to do so (Trydegård, 2012;Kröger et al, 2018).In many cases, care workers even avoid taking sick leave at the expense of their own health, which has been shown to have the knock-on effect of increasing stress (Elstad and Vabø, 2008).Long-term job stress and burden are a strong predictor for poor health and mental well-being in care workers, which may gradually affect the quality of care they deliver.
In Finland, by placing importance on the of task-specific and time-restricted aspects of care work, staff find it much harder to address older people's needs as they changewhich they do because of their often-fragile health.Care workers often feel powerless to affect the daily planning of their work, as they must follow a strict time schedule, especially in home care (Ruotsalainen et al, 2020).Systematic documentation of the care process is also mandatory in Finland to ensure quality and the service user's safety; however, this has increased the amount of paperwork required.In spite of these changes, care workers' own interpretations of how these work conditions have affected the care they provide has not yet been explored in Finland.This study aims to fill this knowledge gap using quantitative survey data collected from care workers working in Finnish home and residential care settings.

Methodology
This study used the NORDCARE survey data collected in 2005 and 2015 from care workers working with older people in four Nordic countries: Finland, Norway, Sweden and Denmark.In 2005, the NORDCARE questionnaire was sent to 1,200 participants in each Nordic country, and in 2015, this figure increased to 2,000.Participants' addresses were randomly collected from trade union membership lists for both surveys because most care workers in Nordic countries are trade union members.In Finland, this was done by contacting the Finnish Union of Practical Nurses (SuPer), the Trade Union for the Public and Welfare Sectors (JHL) and the Union of Health and Social Care Professionals (Tehy) who supplied their addresses.This approach helped researchers to reach the participants easily.The questionnaire was first pretested on a small group of care workers before the main data collection was made.The questionnaire covered various topics relating to the workplace, working conditions and workers' relationships with service users, their colleagues and supervisors.It also included questions about each participant's physical and mental health, whether they were planning to quit, and background information (for example, age, sex and education).The overall response rate in Finland was 61 per cent (N = 726) in the 2005 survey and 55 per cent (N = 976) in 2015.Women (97.3 per cent) and native-born (97.5 per cent) respondents had a higher representation in the total sample population.

Dependent variable
To answer the present article's research question of whether care workers feel able to offer adequate care for older people in LTC, the study looked into one particular question in the Finnish NORDCARE survey: 'Do you feel inadequate because the care recipients are not receiving the help you think they should receive?'Although this question is somewhat indirect, it does ask them directly about making a selfevaluation from their own perspective.In this respect, it was the most suitable survey question for this study, as care workers often feel inadequate when they are unable to meet the needs and wishes of care recipients (Sørlie et al, 2005;Lützén et al, 2006;Jakobsen and Sørlie, 2010;Banerjee et al, 2012).The choice was also justified because researchers have previously used this question as an independent variable to indicate care workers' feelings of not being able to provide enough care (Meagher et al, 2016;Simmons et al, 2022) and their relationship with users (Strandell, 2020).Answers to this question were measured on an ordinal scale of 'never', 'rarely', 'yes sometimes' and 'yes most often' in the survey; however, for the purposes of this study, 'never' and 'rarely' were merged as there were so few (n = 23) of the 'rarely' responses.The final variable for this study comprises only three groups.

Independent variables
Based on the previous literature (see, for example, Schmalenberg and Kramer, 2008;Tønnessen et al, 2011;Westerberg and Tafvelin, 2014;Ludlow et al, 2019;Blackman et al, 2020), in the present study, working conditions were categorised under six subheadings for easier interpretation.The first subheading addressed the issue of Excessive Workloads.Under this subheading, participants were asked which kinds of shift (weekday day, weekday evening, weekend or night shifts) they needed to assist too many service users.This was measured as a continuous variable (with 0 = no shifts; 1, 2 and 3 = one, two and three kinds, respectively; and 4 = too many in all four kinds).'Paid overtime work' was also measured as a continuous variable, though with a five-level ordinal Likert scale ('never', 'less often', 'every month', 'every week' and 'more or less every day'), as was the 'skip or shorten lunch break' variable.Finally, the variable that defined 'too much working time spent on documentation' was originally measured as a four-level ordinal Likert scale but then recoded as a dichotomous variable of 'agree' or 'disagree'.
The second subheading of Staff Shortage, third subheading of Feeling Burdened and fourth subheading of Subjected to Violence consisted of one variable each, which were: (1) 'staff shortages due to sickness, leave, or vacancies;' (2) 'feeling physically and mentally burdened'; and (3) 'subjected to physical violence or threats'.The variables under the second and fourth subheadings were measured as continuous variables on a five-level ordinal Likert scale, ranging from 'never' to 'more or less every day'.However, 'feeling physically and mentally burdened' was summed from four separate variables each measured on a five-point Likert scale, ranging from 'never' to 'almost always', concerning: (1) 'feeling physically tired after work'; (2) 'back hurting after work'; (3) 'feeling mentally exhausted after work'; and (4) 'having difficulty sleeping because of work worries'.To predict the internal consistency of these four variables as a group, Cronbach's alpha was calculated, and an alpha coefficient of 0.720 indicated that it was relatively high.The level of burden was then calculated by considering the median value of all four variables: the higher the median, the greater the level of physical and mental burden felt by the participant.
The fifth subheading explored the Level of Autonomy at work.This consisted of two variables: (1) 'Can you affect the daily planning of your work?'; and (2) 'I feel like the management does not trust the staff; there is too much monitoring and control'.Both variables were measured on a four-point ordinal Likert scale, which was eventually recoded into a dichotomous variable of 'more often' or 'less often' (first variable) and 'agree' or 'disagree' (second variable).
The sixth and final subheading was about Support in the Workplace, consisting of three variables.The first two -(1) 'support from immediate supervisor' and (2) 'training to manage work tasks' -were recoded as a dichotomous variable ('more often' or 'less often') from a four-point ordinal Likert scale (from 'most often' to 'never') by merging 'sometimes', 'rarely' and 'never' answers into 'less often'.The third variable in this subheading was measured as a 'yes' or 'no' answer to a question as to whether there was 'adequate equipment for physically heavy tasks'.
'Demographic characteristics' concerned such information as: the year of data collection ('2005' or '2015'); the respondent's age (as a continuous variable); education or training in caring for older people ('up to two years' or 'more than two years'); place of work ('residential care', 'home care' or 'other'); and type of employer ('public', 'private profit' or 'non-profit').Originally, the questionnaire had six responses for education or training in caring for older people, but because there were so few (N = 87) for the first four ('no training', 'less than one month', ' 6-11 months' and 'one to two years'), these were merged together into a new category called 'up to two years'.The place of work variable was also recoded so that those care workers working in more than one setting (that is, residential and home care) were 'other'.
The ethical principles for the research were strictly adhered to throughout the present study (for example, informed consent and the anonymisation of data), butas suggested by the Finnish Advisory Board's Guidelines on Research Integrity (TENK) -ethical approval was not sought for this study because the participants were neither minors nor people with limited capacity.

Analyses
Descriptive analyses were used in the present study to describe the data.This included frequency, mean and standard deviations, chi-square tests (for categorical variables), and one-way Anova (for continuous variables).Using the STATA 16 software, ordinal logistic regression was carried out to examine the association between the dependent variable (a three-level ordinal scale) and the independent variables, and the proportional odds assumption was verified using the Brant Test.The results showed statistically non-significant (p > 0.05) results, indicating that the proportional odds assumption had been met.Multicollinearity was then checked using the standard method of variance inflation factors (VIF), and the result value was also found to be within the acceptable range (VIF < 2.5).Results from the analyses in STATA were reported in an odds ratio (OR), with their confidence intervals set at 95 per cent.

Results
According to 31 per cent of the respondents in 2005 (N = 650), they were not able to give older people the help they felt they deserved, whereas in 2015 (N = 955), this had increased to 35 per cent (see Figure 1).This means that in both years, roughly a third of all respondents felt that they were unable to give older people enough support.However, only less than 15 per cent of the respondents in both periods felt that the older people received enough support.
The mean age of participants was 45.7 years (see Table 1); most of them had had more than two years of training or education in caring for older people (n = 1,017; 63 per cent); most worked in residential care settings (n = 1,097; 68 per cent); and more than three quarters worked in the public sector.Most participants also felt that they were required to assist too many people on at least two of their shifts (M = 1.6 ± 1.4) and needed to work in paid overtime jobs every month (M = 2.4 ± 0.9), while 58 per cent (n = 938) felt that they needed to spend more time on documentation.
Mean scores for the total population showed that a large proportion of the care workers who took part reported having experienced staff shortages (M = 3.3 ± 1.0), physical and mental burdens (M = 3.3 ± 0.8), and physical violence or threats (M = 2.4 ± 1.2) in the workplace.However, these mean scores were higher for each of these variables among those who 'most often' felt that they were not giving older people the care they deserved: staff shortages (M = 3.7 ± 1.0), burdens (M = 3.7 ± 0.8) and physical violence or threats (M = 2.7 ± 1.3).In other words, care workers who experienced a regular shortage of staff at work, who felt physical and mental burdens quite often, and were frequently subject to physical violence or threat often felt unable to provide care older people deserved.
Whereas almost three quarters (n = 1,156; 72 per cent) of participants reported feeling unable to influence their daily planning of work, only 36 per cent (n = 586) reported too much monitoring and a lack of trust from management.In fact, most felt that they 'less often' received support (n = 988; 62 per cent) from their immediate supervisor, and an even greater proportion felt that there was little training in the workplace (n = 1179; 74 per cent).Nevertheless, about two thirds of respondents (n = 952; 61 per cent) felt that they did have adequate equipment to do the physically heavy jobs in their workplace.
Table 2 shows the relationship between the working conditions of care workers and their perceived ability to give older people the support they deserve.All the variables  used to measure working conditions showed statistically significant results in the univariable analyses, except three of the background variables; in the multivariable analyses, nine of the 12 variables (after controlling for all of them) showed statistically significant results.
The outcome from the multivariable analyses showed that care workers who assist too many people on their shifts (OR = 1.49; p < 0.001) increase the odds of feeling unable to provide older people with the level of care they deserve.This is understandable if the number of service users exceeds the usual limit.Equally, those who felt the need to 'skip or shorten their lunch breaks' (OR = 1.18; p < 0.01), that they were spending 'too much of their time on documentation' (OR = 1.40; p < 0.01), that there were 'staff shortages' in their workplace (OR = 1.15; p < 0.05) or 'physically and mentally burdened' (OR = 1.68; p < 0.001) were more likely to feel that the level of care they were providing was insufficient.In contrast, those who felt supported by their immediate supervisor (OR = 0.63; p < 0.01) or relatively autonomous, that is, able to have some say in their daily work plan (OR = 0.73; p < 0.05), were less likely to feel that their support was inadequate.
The variables of 'paid overtime work' and 'subjected to physical violence or threats' showed a statistically significant result in the univariable analysis.However, they lost this when controlled for all variables in the multivariable analysis.Meanwhile, the education/training variable (OR = 0.75; p < 0.05) showed a statistically significant result in the multivariable analysis.In other words, care workers with more education or training were less likely to feel that their support was inadequate.There was no statistically significant difference in feelings of inability to provide the necessary support between care workers employed in residential care and those in home care.Overall, these results are impressive, as they suggest that there is indeed a strong association between the working conditions of care workers and whether or not they feel able to provide older people with the level of care they need.Notes: M = mean; SD = Standard Deviation.The ordinal variables paid overtime work, skip or shorten lunch break, staff shortages, and subjected to violence are coded as 1 = never, 2 = less often, 3 = every month, 4 = every week and 5 = every day.

Discussion
The present study has examined whether Finnish care workers felt able to provide sufficient care for older people and found that one in three often felt that they could not.The physical and mental burdens accompanying excessive workloads and staff shortages proved to be key contributing factors to this.These results confirm those of previous studies that have examined the quality of care services in residential and home care settings (Westerberg and Tafvelin, 2014;Zúñiga et al, 2015;Ruotsalainen et al, 2020).Similar findings were made in nursing studies that looked at cases of missed, prioritised, rationed and unfinished care in residential care facilities (Henderson et al, 2017;Ludlow et al, 2019;Blackman et al, 2020).Small numbers of staff repeatedly emerge as one of the significant factors in these studies, as it can exacerbate other factors, such as workload and burnout, which, in turn, increase the physical and mental burdens on staff.There are already reports on how time pressures and staff shortages have increased the risk of abuse in residential care and caused older people to miss out on the outdoor exercise they are entitled to (Tallavaara et al, 2016;Kangasniemi et al, 2022).
Our results also suggest that having some autonomy in one's job and support from one's immediate supervisor allows care workers to provide service users with the care they need.This autonomy allows care workers to modify their activities according to older people's needs and wishes, which are often unique and prone to change.In recent years, some efforts have been made in Finland for home care workers to adjust their work shifts, for example, from morning to evening or vice versa, according to service users' needs (Vehko et al, 2018).Previous research has also highlighted the social aspect of care work because being able to socialise increases the meaningfulness of older people's lives (Escrig-Pinol et al, 2019) -as it would for anyone.For example, having a coffee with the service user or listening to their stories brings a significant change to the caregiving process.Previous findings also confirm that care workers who receive support from their immediate supervisor are more likely to be able to navigate challenges in their work and provide the care their service users need (McGilton et al, 2016;Escrig-Pinol et al, 2019;Virdo and Daly, 2019).Furthermore, effective teamwork between care workers enhances their job satisfaction and well-being -also helping them provide the care service users really need (Mickan, 2005;Blackman et al, 2020).
The results of this study show that a full one third of care workers often felt that they could not provide older people with the care they deserved.This has clear implications for both the workers and service users alike.If care workers feel unable to provide adequate care, the risk of 'care poverty' among service users is accelerated.Care poverty means 'a situation where, as a result of both individual and structural issues, people in need of care do not receive sufficient assistance from informal or formal sources, and thus have care needs that remain uncovered' (Kröger et al, 2019: 3).In the present case, care poverty is more of a structural issue because one third of the care workers surveyed felt that they were not able to provide the level of care they would have liked, which is primarily due to the lack of financial and human resources in the Finnish LTC sector.As a universal welfare state, Finland aims to provide sufficiently good-quality care services for any person who needs them.However, without the necessary initiatives and resources, this aim is very hard to achieve.Earlier literature has elaborated on the various consequences of leaving older people with unmet care needs; these can range from increasing health problems (Kehusmaa et al, 2012) and a higher probability of hospitalisation (Sands et al, 2006) to depression (Choi and McDougall, 2009), a lack of meaning and purpose life (Haugan, 2014;Escrig-Pinol et al, 2019), and a higher risk of mortality (He et al, 2015).
Another critical issue is that inadequate publicly funded care puts more of the responsibility on the older person and their family members.Any gaps in care left by inadequate public services must be filled in some other way, yet not all users have equal access to the emotional or financial resources to do this.A comprehensive discussion is necessary at both national and regional levels to find a way to address the structural implications of care poverty among older people.Perhaps the most immediate way would be to improve the working conditions of care workers by, for example, increasing the number of staff and giving them more autonomy and support in their job.
To ensure sustainable LTC in Finland, staff shortages and poor working conditions in the care sector need to be tackled.It is clear that improving the staffing ratio would alleviate some of the stress care workers have to deal with and allow them to deliver better care.However, there have been prolonged staff shortages in Finland, which then exacerbate other issues (for example, workload, job stress and burden).Staff shortages may also force authorities to further tighten the already-stringent needs-assessment criteria for older people to have access to public care services.At the moment, public services are predominantly available for those older people with diagnosed physical disabilities or moderate to severe memory disorders.Improving the staffing ratio would give care workers sufficient time to assist the care users, not only on the personal level but also on the social and emotional ones.Although the present centre-left government took some measures in 2020 to improve the staffing ratio in residential settings (Ministry of Social Affairs and Health, 2020), challenges still remain.The plan is to gradually increase the staff-patient ratio in residential care to 0.7 by 2023 (or seven care personnel per 10 users).However, to satisfy this new regulation, Finland will need 4,000-5,000 more care workers at an additional cost of €238 (£209) million per year (Kalliomaa-Puha and Kangas, 2021).With a high turnover of staff, a low pay scale, many care workers soon retiring and declining general interest in care professions among students, this will clearly be a difficult challenge to surmount.Furthermore, recruiting care workers from abroad faces a whole set of challenges of a different kind in Finland (Vartiainen et al, 2016;Kalliomaa-Puha and Kangas, 2021).In the end, the level of financial and human resources that the government invests in LTC will be crucial in determining the future of care for older people.
Since this study's data come from the years 2005 and 2015, it is necessary to mention some changes that have taken place over the last two decades in Finnish LTC.A comprehensive report on the working conditions of care employees (Kröger et al, 2018) showed some positive improvements, for example, the availability of assistive devices to reduce heavy lifting in home care.Also, home care workers now have a greater degree of autonomy in adjusting their work time from morning to evening shifts, or vice versa (Vehko et al, 2018).There have also been changes in the age structure of care workers, as a large cohort of care workers retired after 2005 and were replaced by young workers.However, the overall state of care for older people has not improved.The number of service users in home care has increased (Alastalo et al, 2017) because of ageing-in-place policies and cost-saving measures, while the staff-shortage situation has simultaneously got worse (Alastalo et al, 2017;Eurofound, 2020).Home and residential care users are reported to be in poorer health than before (Vehko et al, 2018), and stress at work has also increased significantly for care workers in Finland compared to other Nordic countries (Kröger et al, 2018).The number of care workers who intend quit their job has also increased (Kankaanranta et al, 2008;Flinkman, 2014;Van Aerschot et al, 2021), and the nursing profession is becoming less attractive as a possible career for students (Yle, 2022).
Since the goal of this study was to examine care workers' perspectives of their ability to deliver care in general, separate regression analyses were not conducted for each care setting (that is, residential versus home care) or for the different years of data collection (that is, 2005 versus 2015).However, these were included as independent variables in the analyses.Outputs from the chi-square test and univariable ordinal regression also support the assumption that there is no statistically significant difference between care workers' perceptions from different settings or different years.However, a separate multivariable ordinal regression was conducted for each setting and year to reaffirm the findings.The variables of workload, staff shortages and burden showed similar results as in Table 2.
This study is among the few that examines the adequacy of providing care for older people from the perspective of the care workers themselves.Although the data set for this study is from 2005 and 2015, it is still relevant and generalisable to the present day because the situation for care workers in Finland has barely improved since then.It is also worth noting that care workers' and care recipients' expectations differ (Brimblecombe et al, 2017); it may be possible that care workers set their caregiving expectations at a higher level than the care recipients themselves and then report feeling unsatisfied if they fail to fulfil them.It is also possible that care workers with difficult conditions at work will feel that they are not providing the care they would like more readily than those working in better conditions.The study data used here lack information about the proportion of service users each care worker was assisting.It could be concluded from the question, 'Are there any of your shifts in which too many service users require attention?',that workers with too many people to assist -in more than two of the four shifts -felt that they were providing inadequate care more often (see Tables 1 and 2).Nevertheless, the findings cannot be ignored because care workers are surely some of the bestplaced people to describe the situation of the people they are caring for.More comprehensive studies are clearly needed to explore more precisely the needs that care workers think are being left unmet (for example, personal, practical, social or emotional) and why this might be happening.
Using the cross-sectional data from two years increased the sample size of this study and helped assess any changes that might have occurred in the intervening decade, even if that was not the main research goal.Changes in the background profiles of care workers (for example, their age, education level and conditions of work) may have influenced their views too.For example, when multivariable ordinal regression was conducted separately for 2005 and 2015, the autonomy variable become nonsignificant in the residential care setting.However, the variables of workload and burden were significant in both years.Furthermore, the subheadings for independent variables (based on the earlier literature) simplified the categorisation of respondents' work conditions.However, one must take into account that a single-item measurement may not capture the theme as a whole, and this is clearly a limitation that needs to be considered when interpreting these results.
To sum up, a full one third of the care workers surveyed expressed being unable to provide the level of care that they felt older people deserved.The factors that contribute towards this are staff shortages at work, excessive workload and being physically and mentally burdened at work.Improving the staffing ratio and increasing the autonomy of staff were seen as two ways to improve these working conditions, which would, in turn, better care for service users.

Figure 1 :
Figure 1: Percentage of care workers who think care recipients are not receiving adequate help (N = 650 in 2005; N = 955 in 2015)