Introduction

Aysel is a home help with a Turkish background working in The Hague, one of the larger cities in the Netherlands. When she enters the apartment of her client, a frail diabetic woman of Moroccan descent, she greets her in Arabic. Sitting down, Aysel takes the old woman’s hand and uses her finger to measure the woman’s blood sugar, holding her hand much longer than is medically necessary. The elderly woman talks a lot and they laugh. When she enquires about her values, Aysel responds by telling her the numbers in Arabic. Back in the car, Aysel tells me, “She is so sweet. I don’t understand a word she was saying. So, I hold her hand. And I learnt a bit of Arabic to use with her, and it helps … it immediately creates trust as I show that I am willing to go the extra mile for her” (fieldnote Kings Care).¹

Immigrants are growing older in their countries of residence, new immigrants are arriving each year, and home-care workers are increasingly coming from all corners of the world (OECD, 2020). Migration-driven super-diversity (Vertovec, 2007; Phillimore et al, 2018) is placing new demands on the care sector, especially in Europe’s larger cities. Although providing care in super-diverse settings means that care professionals must routinely deal with linguistic, religious, gender, income and educational differences, there has been scant research on how care workers are managing these demands (an exception is by Phillimore [2015]). If care workers were studied in the context of migration, the focus was mainly on migrants working informally in the homes of the frail elderly – the live-in carers (Bettio et al, 2006; Da Roit and Weicht, 2013; Leiber et al, 2021).

In many European welfare states, migration-driven super-diversity is posing new challenges for the public provision of care. Especially the use of home-care services varies greatly between immigrant populations, which has been explained by differences in care ideals (culture), the language barrier and inability to navigate complex bureaucracies (practical issues), and low levels of trust among potential care recipients. When public care is received, it may not always be sensitive to the needs of an increasingly diverse elderly population (Phillimore, 2015; Karl and Torres, 2016).

This article seeks to further our understanding of the challenges of providing good care in super-diverse settings by examining the micro-level encounters between care recipients and professional caregivers. We focus on two care organisations operating in the same super-diverse neighbourhoods of The Hague: one dating to the expansion of the welfare state in the decades following the Second World War; the other set up by Turkish-Dutch entrepreneurs in the early 2000s to cater (at first) to Turkish-Dutch elderly and that today has a super-diverse clientele. How do home-care professionals deal with situations where almost everyone comes from elsewhere? Analysing the differences in the care provided by these two home-care organisations may contain clues about how to improve access to good care in super-diverse settings.

Professional caregiving in super-diverse settings

‘Super-diversity’ – a concept coined by Vertovec (2007) and further developed by Meissner and Vertovec (2015) – points to the diversification of populations in many metropolitan areas due to global migration. Super-diversity can be seen as a lens to describe ‘an exceptional demographic situation characterized by the multiplication of social categories within specific locations’ (Wessendorf, 2014: 2). Super-diversity borrows from the older and more developed concept of intersectionality (Crenshaw, 1989), which springs from Black feminist scholarship and stresses the situational nature of categories of difference (Cho et al, 2013). While the super-diversity framework may be less equipped to analyse power relations (Foner et al, 2019), it does emphasise the fluidity of categories and is often encountered in migration-related research and policy (Bradby et al, 2016). Although super-diversity has sustained criticism as a theoretical framework, the concept can usefully be applied to analytically capture demographic developments (Boccagni, 2015; Geldof, 2016).

The demographic reality of super-diversity in many European cities undermines equitable access to good care. Vertovec (2007: 1048) argues that ‘most areas of service provision have not caught up with the transformations brought about by the new immigration of the last decade’. However, there has been scant research on how super-diversity affects access to public care. Applied to the care sector, super-diversity highlights two developments. First, people in need of care increasingly come from all corners of the world. In the Netherlands, this ‘diversification of diversity’ includes post-colonial immigrants from Indonesia and the Caribbean, guest workers from mostly Turkey and Morocco, various groups of refugees, and growing numbers of resident European Union citizens. Second, people sharing a country of origin can differ markedly in terms of migration status, generation, gender, language, education, income, faith, cultural practice and much else (Vertovec, 2007; Meissner and Vertovec, 2015). The lens of super-diversity allows us to examine care services without resorting to static and monolithic categories of putative ethnicity (Torres, 2015; Boccagni, 2015). An additional advantage is that it does not exclude the native population living in super-diverse neighbourhoods (Crul, 2016).

Despite the lack of research on accessing care in super-diverse settings, there are indications that the care provided to some immigrant groups is not good enough. Research shows that elderly immigrants in Europe are more likely to depend on informal care and less likely to use public home-care services, even as some immigrant groups are more likely to have health problems and at a younger age (Van den Berg, 2014; Karl and Torres, 2016). The lower take-up of professional care (compared to informal care) need not be problematic if people in need of care prefer care by family members. This is the case among some immigrant groups, albeit more often among older generations (Schans, 2007; Van den Berg, 2014). However, there are also indications that elderly immigrants suffer from language barriers and lack information about available services (Suurmond et al, 2016; Den Draak and Verbeek-Oudijk, 2020). Without assuming that immigrants are vulnerable by definition – many are highly educated or have become resilient and resourceful due to their life experiences (Torres, 2015) – newcomers in any society are at a disadvantage in navigating labyrinthine bureaucracies like the care systems of European welfare states (Bradby et al, 2016). Another factor that can lead to reliance on informal care is the absence of trust in health professionals (Phillimore et al, 2019). Such lack of trust is often based on experience, either their own or that of those they know. The care provided by the state is often not attuned to their needs or values (Van den Berg, 2014; Torres, 2015).

Scholars of care stress the importance of building relations of trust. Good care – ‘a practice of attentiveness’ (Tronto, 1993) – is best understood as ‘shared work’ involving professionals and their clients, family members and others (Mol, 2008). Good care is inherently relational (Duffy et al, 2015). It is not ‘person-centred’, but ‘relationship-centred’ (Kartupelis, 2021), based on meaningful engagement between caregivers and care recipients. Relational care generates a feeling of being known and accepted.

In professional care work, caregivers and care recipients meet each other as strangers before building up a relationship. Especially when entering clients’ homes, care workers must cross both subtle and more obvious social distances to build trusting relationships. Here, ‘social distance’ refers not to our recent experiences during the COVID-19 pandemic, but to the scale for social distance developed by Bogardus (1933 [1926]), encompassing warmth, intimacy, indifference or hostility towards particular social groups. In super-diverse settings, social distance may be due to country of origin, immigration history, gender, income level, educational attainment, generation, faith and much else. Care workers and recipients nevertheless share various values, interests and identities (Foner et al, 2019) that need to be found (Amin, 2002; Wessendorf, 2014). The purposeful closing of social distances within care work resembles what Putnam (2000) terms ‘bridging’, that is, promoting ties between diverse individuals across group boundaries. However, in care settings, the parties are not equal, as it is the professionals who largely determine the conditions of interaction (see Sretzer and Woolcock, 2004).

While the foregoing discussion highlights the importance of tailoring care to the needs of diverse individuals, this is becoming increasingly difficult. The differential treatment of clients based on their country of origin, religion or mother tongue is a political minefield, as ‘mainstreaming’ has become the key policy concept to integrate immigrants into public care services, even when they have special needs (Karl and Torres, 2016; Carlsson and Pijpers, 2021). Moreover, despite the lip service given to the ‘personalisation’ of care, professional caregiving is moving towards uniformity, not just for immigrants, but for everyone. The care sector suffers from a regulatory burden entailing excessive paperwork, heavy workloads and stringent scheduling. Although building up relationships by communicating with clients is essential for good care, it is time-consuming (see Phillimore, 2015; Van Wieringen, 2019). There is thus little incentive to accept challenging cases. The issue at stake is how home care can be improved for everyone living in welfare states with super-diverse populations.

Dealing with super-diversity in Dutch home-care policy

Home-care organisations must operate within the bounds of national policy. Compared to most European countries, home care in the Netherlands is well developed (OECD, 2020); a large percentage of the elderly use public care provisions, though budget cuts and New Public Management have swollen workloads (Oomkens et al, 2015; Van Wieringen, 2019). Around 17 per cent of home-care workers in the Netherlands are first- or second-generation immigrants, which is lower than in many other countries in Europe (ACVZ, 2021). Moreover, there are indications that specific immigrant groups use less formal care. Table 1 shows the reliance on formal and informal care among the four largest ethnic groups in the Netherlands for people aged 55 and above living at home.

While Dutch care policies do not explicitly refer to the needs of super-diverse populations (Carlsson and Pijpers, 2021), the emphasis on zorg op maat (‘personalisation’) should, in theory, give space for personally tailored care. However, the two policy mechanisms in place have serious limitations. First, people are free to select the organisation of their choice for personal care, provided that their health insurer has a contract with the organisation. According to the Explanatory Memorandum to the Health Insurance Act, this is part of ‘regulated competition’. If the existing range of care organisations does not meet clients’ needs, immigrants (or lesbian, gay, bisexual, trans and queer [LGBTQ] people or anyone else wishing to do so) can, in theory, set up a care organisation themselves. In practice, this has led to a plethora of care providers (122 home-care organisations in The Hague alone), leading to ‘consumer stress’ (Schwartz, 2004). Although health insurers must admit new players into the market, immigrant entrepreneurs undergo particular scrutiny, not only by insurers, but also by the Healthcare Inspectorate (Carlsson and Pijpers, 2021).

Second, all home-care organisations are expected to provide care appropriate to the needs and wishes of their clients. The Health Insurance Act stipulates that contracted care providers must consider the religious beliefs, personal convictions, cultural backgrounds and sexual orientations of their clients. While insurers must ensure that home-care organisations offer personalised care, this runs counter to other principles contained in the Explanatory Memorandum to the Health Insurance Act, most notably, that care organisations must provide suitable care that is both ‘efficient’ and ‘effective’. Funding for home care is largely based on the ‘procedures performed’ model of medical care, leading to ‘standardised’ personal care (Van Wieringen, 2019). One example of the emphasis on ‘efficiency’ – also due to the focus on mainstreaming – is that the use of interpreters has not been funded in the home-care sector since 2012.

Within Dutch policy, the responsibility to accommodate the needs of a super-diverse society mainly falls on the organisations providing care (Booij and Vink, 2014). While the changes required to cater to a super-diverse clientele must be implemented by care organisations and their staff, their room to manoeuvre is restricted by the framework of national policy. The question then becomes: to what extent can home-care professionals provide good care to everyone in a super-diverse society? We now move to the findings of our research among two very different home-care organisations.

Case studies and locations

To study how super-diversity is shaping professional care work, we selected as case studies two care organisations: Kings Care and Theresa (both pseudonyms). Their main characteristics are summarised in Table 2. Both operate in the same super-diverse neighbourhoods of The Hague (Transvaal, Schilderwijk, Moerwijk and Rijswijk), a city with 510,000 residents that, according to the Herfindahl–Hirschman Index, is the most diverse in the Netherlands (Jenissen et al, 2018). Over half of the city’s population (53 per cent) consists of first- or second-generation immigrants, the largest groups coming from Turkey, Morocco, Surinam and Poland.² About 29 per cent of the population of 65-year-olds has a migration background, a percentage that grows each year (CBS StatLine, 2017).

Theresa is a large organisation, with over 7,000 clients. It has been operating in The Hague and its surroundings for decades, providing home care and other types of care, including for people with disabilities. We focused on two teams operating in the aforementioned neighbourhoods. The staff we shadowed came from many different backgrounds (Iraqi, Thai, British and Dutch), while the clients were almost exclusively Dutch by birth or, if not, mostly from Surinam (formerly a Dutch colony). Kings Care is much smaller, with around 800 clients. Established at the beginning of the 21st century by a gerontologist of Turkish origin who noticed that many elderly Turkish immigrants did not want to use traditional home care, it operates in a limited number of neighbourhoods. At first, Kings Care worked exclusively with Turkish-Dutch personnel and clients. Today, both staff and clients are more diverse, including individuals with Moroccan, Iraqi and native-Dutch backgrounds.³

Methods

The study relied on three methods. First, shadowing entailed the observation of interactions between caregivers and care recipients and, when appropriate, asking questions (McDonald, 2005). Shadowing is particularly suitable when the unit of analysis is not the individual, but social relations and interactions (Quinlan, 2008), as it allows access to practices that may seem self-evident and are not consciously articulated in interviews. Shadowing thus combines the advantages of interviewing (based on participants’ views of events) and participant observation (based exclusively on the views of the researcher) (McDonald and Simpson, 2014). We spent just over 100 hours (equally split between the two organisations) shadowing 18 home-care workers, involving a total of 138 home visits ranging from 5 to 90 minutes. Detailed fieldnotes were sent to the caregivers, who were asked to respond.

Second, we held four focus groups with a total of 19 care professionals (9 working at Kings Care and 10 at Theresa), where participants spoke at length about the challenges of providing care in super-diverse settings. Focus-group participants discussed case studies of caregiver–client interaction, for instance, the use of physical communication, the setting of boundaries and topics that emerged from our shadowing, thereby validating our observations. These discussions were transcribed verbatim. While most home-care workers at Theresa were native Dutch, others had Surinamese, West African and Thai backgrounds. Most staff at Kings Care had roots in Turkey; others had Moroccan or native-Dutch backgrounds. Their educational levels ranged from two years of post-secondary vocational education to four years for those trained as nurses. The former provide emotional and physical support; nurses are also allowed to perform simple medical interventions. We also interviewed four directors and team leaders, focusing on the policies of each organisation. These interviews were also transcribed verbatim.

Third, 36 care recipients were interviewed about their ideals and experiences of good care. The participants were randomly selected from the list of clients of the two organisations and then approached by the researchers; 17 were of the Dutch ethnic majority, while 18 had various other backgrounds, including Turkish (11), Moroccan (2), Surinamese (4), German (1) and mixed Pakistani/Dutch (1). The majority of interviews were conducted in the care recipient’s mother tongue. Most interviewees were of lower socio-economic status, though there were exceptions, mostly among native-Dutch and Surinamese-Dutch clients. The interviewees ranged in age between 50 and 95; the majority were in their eighties. Nearly all clients were in long-term care but well enough to agree to an interview. Reflecting the client population, we interviewed more women than men. As we conducted the interviews in the language clients were most comfortable speaking about their care needs and experiences, Turkish-Dutch care recipients were interviewed by a researcher of mixed Turkish and Dutch heritage, who also translated the transcripts. Native-Dutch clients were interviewed by native-Dutch researchers. Fieldwork at Kings Care was carried out between September 2016 and June 2017; at Theresa, fieldwork was carried out between July 2017 and February 2018.

Abductive analysis (Timmermans and Tavory, 2012) is a recursive process whereby researchers enter the field informed by theory, which is then fine-tuned in light of the collected data. The fieldnotes and transcripts of the focus groups and client interviews were read closely and analysed by first coding separately, based on our theoretical expectations and new codes stemming from the data, and then juxtaposing the findings. Under Dutch regulations, formal approval of an ethics committee was not required. The researchers are, however, committed to key professional principles in research practice in the Netherlands, such as avoidance of harm, confidentiality, right to withdraw from the study and so on. All necessary steps were taken to ensure informed consent for the interviews, sensitivity towards vulnerable participants and secure and anonymised data storage.

Good care means bridging social distances

When we compare the care practices of Theresa and Kings Care, we see that the differences are not substantive, but of degree. In both organisations, a nurse is responsible for medical indications and formulates a care plan executed by home helps. In both organisations, care plans are based, as stipulated by the insurer, on a strict rationing of time, with visits lasting 10 minutes (diabetes monitoring or administration of medicines), 30 minutes (showering) or 2–4 hours (complex and intensive care). The time squeeze that has rendered caregiving ‘clockwork’ thus similarly affects home helps employed by Theresa and Kings Care: all have little time to communicate with clients and invest in care relationships. The clients of both organisations voiced the same complaints: the high turnover rate among home helps and the time pressure to provide personalised care – “They don’t even have time to take their coats off” (RT11).

Yet, Kings Care reaches a much more diverse population of care recipients than Theresa. Kings Care clients are also, by and large, more appreciative of the care they receive. Most notably, they more often expressed feelings of trust in their caregivers. We often heard the expression: “I trust them like my children.” When shadowing the home helps, we witnessed more relational care and counted more successful interactions in which there was meaningful connection. Although it is not always easy to pinpoint what constitutes a ‘successful’ care relation, awkward interactions are easier to spot. Our observations support how Collins (2004), in Interaction Ritual Chains, describes a successful interaction: one that produces feelings of solidarity and unleashes emotional energy, resulting in all parties feeling more self-assured and expansive. In care relations, the latter can be replaced by feeling more comforted and comforting.

The most important difference between the two care organisations is that staff at Kings Care are encouraged by management to create connections with care recipients. When both sides feel a connection, care is transformed from a contractual obligation into an interpersonal experience, as was seen in the introduction when Aysel took the first steps to bridge social distance by learning a few words of Arabic.

This interaction has little meaning for both sides. Angela is not well equipped to bridge social distances; for her, country of origin is not the only factor that creates social distance. She also has difficulties bridging the distances created by income and education. She feels that she cannot be “direct” and be herself with wealthier clients, who are “not my kind of people”. In contrast, we noticed, Angela is very caring for people “like herself”. Then, she has physical contact with her clients, cracks jokes, chats with them about what to cook tonight and divulges things about herself, building up a relationship.

The need to bridge social distances in care work is, of course, not a new phenomenon. While differences due to class and gender were more dominant in the post-war period (see Jamin, 1999), the differences today are arguably more multifaceted and complex. Confirming one of the tenets of the super-diversity framework, we observed numerous instances of social distance between caregivers and care recipients sharing a country of origin due to: level of education (for example, more highly educated nurses caring for illiterate elderly); language (for example, Kurdish and Turkish speakers among immigrants from Turkey, and speakers of Berber languages and Arabic among immigrants from Morocco); national orientation (for example, a district nurse of Turkish origin who considers herself largely Dutch treating an older patient with strong cultural links to the Turkish community); religious beliefs (for example, a home help wearing a headscarf visiting a secular family); political orientation (for example, Gülen supporters versus Erdogan supporters); and generation (for example, older and younger people). We also witnessed numerous cases of immigrant care workers taking care of elderly native-Dutch persons, a situation more common in the Netherlands today than some decades ago. This means that all caregivers must learn to bridge a multitude of social distances, irrespective of whether they share a country of origin with their clients.

Three strategies to bridge social distances

The previous section recounted examples of bridging social distance. This section discusses three strategies used by home-care professionals to build trust with clients: (1) taking their wishes seriously; (2) finding common ground; and (3) using the terms of kinship. As we will see, the employees of Kings Care practised these strategies more often and more successfully than their counterparts at Theresa.

Strategies to maintain social distance

As social distances are bridged, the expectations placed on home helps can become intense, at times, excessive. Another recurring theme was the need among professional caregivers – as private persons, as employees and as professionals – to maintain distance from those they cared for.

First, caregivers must protect their privacy. It was not uncommon for care recipients, especially clients of Kings Care, to repeatedly ask for their private phone number. Especially elderly immigrant care recipients who spoke little Dutch wanted to know about their caregivers’ private lives. However, home-care workers worried that this could generate gossip and were reluctant to share much about their private lives: “I never say who my father or mother is, which city I come from or where I live. Even if I live in the neighbourhood, I don’t tell them” (focus group, T1); or, as Selin says, “I only tell them inconsequential things, like my favourite food or my grandma’s favourite recipes” (field notes, Kings Care).

There is a difficult balancing act between doing ‘something extra’ that increases trust in the relationship and setting boundaries. One focus group participant summed it up by saying, “A small extra task repeated over several months becomes a major extra commitment” (focus group, K2). Doing ‘too much’ creates problems down the road. After all, they are workers within a care system that pays them based on scheduled hours and procedures, not on ‘doing something extra’.

Third, although home-care workers are rarely considered medical professionals (Freidson, 2001), they do bring to their jobs a set of strategies to craft better care, a set of personal qualities and professional values of care (Stacey, 2011; Tufte and Dahl, 2016). They therefore often stress which tasks are part of their work and which are not. If they ‘do something extra’, they generally tell the client while explaining the rules and regulations that place boundaries around the provision of home care. In this, care workers were often backed up by the care organisation: “They know very well that we stick to Dutch law, Dutch rules and the health insurers’ requirements. We all have to comply with these regulations and they know it. They’re just testing their boundaries to see what they can get away with” (focus group, K1).

Discussion and conclusion

While a growing number of elderly immigrants across Europe need care, its public provision is not tailored to the new demographic realities of super-diversity, an analytical concept that goes beyond a simplistic ethnic lens (Torres, 2015). One indicator is the unequal use of home care, which may be explained by differences in care ideals (culture), language barriers and inability to navigate labyrinthine bureaucracies (practical issues) (Van den Berg, 2014; Bradby et al, 2016; Suurmond et al, 2016). However, these explanations do not suffice. There is also lack of trust (Phillimore et al, 2019), often based on past experience. Many elderly with migrant backgrounds simply feel that state-organised care does not provide good care for them.

Our study of two home-care organisations operating in the same super-diverse neighbourhoods of The Hague revealed a range of experiences. The clientele of Kings Care was more diverse and more content about the care they received. Our observations from shadowing caregivers in their home visits, the focus groups with professionals and the interviews with clients all pointed to the importance of investing in relational care to increase equity. In super-diverse contexts, this means that social distances that arise from differences in cultural expectations of care, language, income, education, faith, gender and much else must be actively bridged to build trust (see Putnam, 2000). If such bridging fails, care relations and interactions are less successful, and care given by the care organisation is less valued.

Home-care workers employ various strategies to bridge social distances: by taking recipients’ wishes seriously (by doing something extra, such as helping to navigate bureaucracy); by actively trying to find common ground; and by using the language of kinship, approaching care recipients as if they were family members. We also found that care workers who humanised their interactions more often had to prove their professionalism. While finding the right balance between bridging and maintaining distance is a challenge, this cannot be attributed solely to super-diversity, as it is a challenge for relational care work for everyone.

Bridging social distances does not come naturally in the Dutch case study, in contrast to what some studies of super-diversity in everyday life seem to suggest (Wessendorf, 2014). We found that the mission of care organisations, their policies and the way they support their personnel influenced how home-care workers seek to bridge distances with their clients. While recruiting care workers with different migrant backgrounds is often seen as a solution to improving care in super-diverse societies, Phillimore and colleagues (2018) point out that such attempts at matching are no longer practically possible in super-diverse settings, where both caregivers and care recipients come from everywhere. Boccagni (2015) further argues that ethnic matching is not necessary because migration background is no longer the only or most important marker. Nevertheless, we found that immigrant caregivers often took more effort to bridge social distances, not just those of language and country of origin. They seemed more aware of the importance of reaching out, perhaps due to their experiences of being cultural brokers in their own lives (Waldring et al, 2018). They did so especially when they were encouraged to do so by the management of the care organisation.

In the broader scheme of things, the differences in the care provided by Theresa and Kings Care remain small. National care policies in the Netherlands do not currently allow taking the new realities of migration-driven super-diversity seriously. Although, on paper, care policies allow adapting care to individual needs, the imperative of efficiency leads to uniform and standardised care, squeezing caregivers of the time needed to invest in the individual relationships that bridge social distances and develop trust – the oxygen of good care. Although, in some instances, care professionals feel supported by welfare state guidelines, especially when dealing with ‘demanding clients’, they need sufficient time and space to build trust within relationships.

Although the research was done in the Netherlands, the results are probably more broadly applicable. Bridging social distances should therefore become an explicit policy goal in the equitable delivery of care in welfare states. Care organisations must train their workers to provide relational care – a new professional competence in super-diverse societies. It goes against the goals of welfare state retrenchment, but national care policies must give caregivers and their clients enough time to bridge social distances. Providing good care in super-diverse settings cannot be left to the good graces of individual caregivers and responsive care organisations. Welfare states should invest more in bridging social distances in increasingly super-diverse societies.

Conflict of interest

The author declares that there is no conflict of interest.