Article Migrant healthcare assistants’ decision to work in long-term care: Experiences from Norway by Vyda Mamley Hervie Lecturer, PhD Department of Social Work, University of Ghana, Legon Ghana Department of Social Work, Child Welfare and Social Policy, Oslo Metropolitan University Norway E-mail: vmhervie@ug.edu.gh https://orcid.org/0000-0003-3276-0357 ___________________________________________ Keywords: elderly care, unskilled immigrant healthcare assistants, career progression, older people, Norway DOI: https://doi.org/10.31265/jcsw.v18i2.690 This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. http://creativecommons.org/licenses/by-sa/4.0/ Journal of Comparative Social Work 2023/2 96 Abstract In high-income countries, population ageing has a significant impact on the labour force and care demands. As a result, the tendency is to rely on migrant workers to meet workforce and care demands. Drawing on insights from Bronfenbrenner’s ecological systems theory, this study focused on unskilled migrant healthcare assistants in Norway’s long-term care. The objectives were to explore factors influencing the decision of unskilled migrant healthcare assistants to work in elderly care, sources of knowledge about work in elderly care, and challenges encountered in elderly care work. The key research questions were as follows: a) What factors influence the decision of migrant healthcare assistants to work in elderly care? b) What are the sources of knowledge/information about work in elderly care for migrant healthcare assistants? c) What are some of the challenges of working in elderly care for migrant healthcare assistants? Qualitative research and purposive sampling were used to recruit 20 participants: 13 unskilled migrant healthcare assistants and seven managers of long-term care facilities in South-Eastern and Northern Norway. Data were collected using in-depth individual interviews, focus group discussions and participant observation, and thematically analysed. Findings indicated that factors influencing unskilled migrant healthcare assistants' decision to work in the elderly care sector included cultural norms and values of caring for older people, nonrecognition of overseas qualifications and economic considerations. State-organized language learning programmes, Norwegian Labour and Welfare Administration (NAV) offices, as well as migrant family and community networks, provided crucial information about work in elderly care. Challenges regarding lack of career progression, temporary working contracts, low status and poor wages emerged. In conclusion, meaningful employment outcome through better opportunities for career progression are essential for unskilled migrant healthcare assistants’ well-being and care for older people. It would be useful for long-term care policymakers and stakeholders to address the challenges faced by its aged care workforce. Keywords: elderly care, unskilled immigrant healthcare assistants, career progression, older people, Norway Journal of Comparative Social Work 2023/2 97 Introduction The need for migrant healthcare assistants in the long-term care sector has been debated in various social work, social care and geriatric studies (Spencer et al., 2012; Cangiano & Walsh, 2014). One aspect of the debate argues that population ageing will lead to an increased number of older people with cancer, fractured hips and strokes (Rechel et al., 2013). Another aspect of the debate is focused on workforce challenges and the reliance on migrant care workers (Sowa-Kofta et al, 2019). In the Norwegian context, which is this article's focus, although the state’s agenda is on healthy and active ageing, rapid population ageing with its associated age-related conditions, such as dementia and the declining availability of family caregivers, has resulted in the reliance on migrant care workers. It must be mentioned that in Norway, care for older people is the responsibility of municipalities within the welfare state, and support is provided in nursing homes, or in the private homes of older adults (Norwegian Directorate of Health, 2012). Norway's policy on care for older adults (Norwegian Ministry of Health and Care Services, 2020) highlights the need for more health and social care workers with higher levels of expertise (Halvorsen, 2016). In other words, this policy emphasizes the need for older people to receive better quality care. A report by Statistics Norway stresses the high future demand for healthcare assistants, mostly from the migrant population, due to an expected increase in the number of older persons by 2035 (Tømmerås & Thomas, 2022). In addition, an analysis of older people's use of health and social care services in Norway found that between 2006 and 2011, migrants accounted for 13% of total person-hours in care for older people, and 40% of person-hours in Oslo (the capital city) due to high demands for care (Abrahamsen & Kjelvik, 2013). This analysis highlights the role of migrants in Norway’s long-term care sector. Long-term care is defined as support for activities for daily living, including ‘bathing, dressing, eating, getting in and out of bed or a chair, moving around and using the bathroom, often in combination with rehabilitation and basic medical services’ (OECD, 2020:26). Healthcare assistants are front-line care workers who support older persons with various activities of daily living (Preum et al., 2021). Among others, migrant healthcare assistants fill workforce Journal of Comparative Social Work 2023/2 98 shortages, relieve family members from elder care duties, and help meet care demands (Hoens & Smetcoren, 2021). The literature refers to uncertainties regarding titles used to determine who is labelled as an ‘unskilled’ and ‘unqualified’ healthcare assistant (McKenna et al., 2004). Similarly in Norway, the participants for this study are known as ‘pleieassistent or pleiemedarbeider’, which literally translates into care assistant. Essentially, there are no mandatory educational qualifications. Applicants must simply be interested in- and good at working with people to qualify as a care assistant (utdanning.no). In Norway, reference can be made to Health Personnel Act (https://lovdata.no/dokument/NL/lov/1999-07-02-64/KAPITTEL_2#%C2%A713), which requires authorization for professions such as nurses and auxiliary nurses. However, in contrast to these professions, the participants for the study (immigrant healthcare assistants) are employed as unskilled workers, and according to the Health Personnel Act, they cannot take on tasks that require these specific competences. In addition, Pleieassistent is not specifically mentioned in this law. Hence, the category of healthcare assistants who participated in this study is recognized as unskilled. According to the research, unskilled immigrant healthcare assistants are a category of the workforce utilized to meet current and future care needs (OECD, 2020; Overseas Development Institute (ODI) 2022). In Norway, elderly care is a municipal responsibility (Holm et al., 2017); participants were employed by the municipality, working in both institutional settings and in the private homes of elderly people. Overall, the number of immigrants in Norway has increased to nearly 1.5 million out of a total population of 5.5 million (SSB, 2023). In the context of this study, Abrahamsen and Kjelvik (2013) have argued that there is an increased number of immigrants with diverse backgrounds who deliver care for the elderly in Norway. Yet, factors influencing their decision to work in long-term care are understudied. To assist in understanding why immigrants work in long-term care, questions having to do with factors that influenced their decisions need to be addressed. For instance, what factors influence unskilled immigrant workers' decision to enter the long-term care sector, what is their knowledge about work in long-term care, and what challenges do they encounter? These are the main questions that this article aims to Journal of Comparative Social Work 2023/2 99 explore. The analysis contributes to the literature on migrant care workers in ageing societies by situating the analysis within the context of unskilled immigrant healthcare assistants in Norway’s long-term care. Relevant literature Studies have shown that migrants’ motivations to work in elderly care include extrinsic reasons such as employment discrimination in other job sectors, financial rewards and career progression, as well as intrinsic motives such as job satisfaction and the desire to help others (e.g. Showers, 2022). In addition, migrants' cultural values, and societal norms of care provision for older adults, and the nonrecognition of overseas skills and qualifications, were significant in their decision to work in residential aged care facilities (Adebayo et al., 2023). Following employers' demand for host language requirements, it has been established that migrants' decision to work in the adult social care sector includes an opportunity to improve their English language and opportunities for job prospects in other sectors (Lan, 2022). This means that it is not uncommon for migrant healthcare assistants to experience challenges in their roles due to language requirements. Information from state- organized language programmes for newcomers, and family and cultural networks, are some of the common means used by migrants to obtain knowledge about sectors that experience staff shortages, such as elderly care (Kosny et al., 2020). In Australia, a study by Udah, Singh and Chamberlain (2019) revealed that host country employment programmes influenced migrants' access to jobs and wages; thus, an early initiation of migrants into host country education and skill development programmes could influence migrants’ chances of entering high-skilled professions and the formation of social capital, such as trust and access to new networks and opportunities. Despite the proven benefits of host-country education and skills on high-skilled employment and income, it has been found that migrants are overrepresented in the low-education category, and work in low-income earning employment sectors such as elderly care (Andersson, Eriksson, & Scocco, 2019). This has been attributed to a lack of knowledge of employment opportunities, challenges in transferring foreign educational degrees, particularly from less developed countries, and competitive entry requirements into high-skilled jobs Journal of Comparative Social Work 2023/2 100 (Gahwi & Walton-Roberts, 2022). Research in Nordic countries has identified some factors that may lead migrants to work in the long-term care sector. In Sweden, Torres and Lindblom (2020) found that despite discourses which portray care work for older people as devalued, migrant care workers continue to work for older adults, and draw on their cultural values and social norms of respect for older people to deliver culture-appropriate care. Similarly, in Finland, Näre (2013b) found that migrants are recognized as essential workers in elderly care, yet they are seen as lacking qualifications and skills, and therefore overrepresented in low-skilled positions. Studies in Denmark have also shown that migrants face major challenges to employment prospects due to a high skill bias of Danish occupational structure, a shortage of unskilled jobs, the language barrier, and migrants’ lack of vocational qualifications and cultural-specific skills (Brodmann & Polavieja, 2011; Thuesen, 2017). Like other Nordic countries, in Norway there is a relatively extensive body of work on migrant healthcare workers with formally recognized skills. Studies on migrants in long-term care have primarily drawn attention to migrants as a solution to the care deficit caused by an aging population, and the challenges that skilled migrant care workers face (e.g. Dahle & Seeberg, 2013). In most cases, the debate on care for older adults in Norway has been concerned with the politics behind the reliance on migrant care workers (Christensen & Guldvik, 2014). Part of the reason for this is that high unemployment rates among migrants in Norway make them a target group for the supply of labour resources through state initiatives such as Active Labour Market Programmes – ALMP (Thorud et al., 2014). Another reason is that migrants provide the necessary labour needed by the welfare state to supplement the looming staff shortage (Isaksen, 2010). Furthermore, the Norwegian literature on migrant care workers has shown that the overrepresentation of migrants in low-level positions within long-term care jobs may be influenced by their lack of Norwegian language competencies and cultural differences. It is worth noting that debates in Norway on care for older adults have also drawn attention to the diverse background of the staff. In one publication, Abrahamsen and Kjelvik (2013) reported that migrants from 168 different countries worked in the elderly care sector in the capital city, Oslo. Journal of Comparative Social Work 2023/2 101 It is well documented in the literature that migrant care workers experience discrimination in working conditions and salaries, and have limited opportunities for career progression (Behtoui et al., 2020; Schilgen et al., 2019). In addition, the unwillingness of natives to perform care work, due to its low social status and the focus of the welfare state to cut costs, are perceived reasons why migrants are employed in low-wage sectors like elderly care (Dahle & Seeberg, 2013; Orupabo, 2022). Thus, it has been argued that at the macro level, cuts to social care have also brought about an increased demand for cheap labour, and as mentioned earlier, high unemployment rates among migrants in Norway make them a target group to assist in the supply of labour in elderly care through state programmes such as ALMP (Bratsberg, Raaum, & Røed, 2016). The Norwegian literature has undoubtedly provided extensive information on migrants' experiences in care work. However, previous studies have primarily focused on formally recognized skilled workers (e.g. - nurses, auxiliary nurses). Taking these observations as a point of departure, I argue that the experiences of unskilled healthcare assistants in Norway’s elderly care workforce should be important for policy health makers and stakeholders in elderly care. This article therefore focused on unskilled healthcare assistants, in which the perspectives of migrants have been understudied. Moreover, as mentioned earlier, migrants in Norway are overrepresented in ‘low-skilled occupations’ (Thorud et al., 2014, p. 65). More specifically, the objectives are to explore factors influencing unskilled migrant healthcare assistants’ decision to work in elderly care, sources of information about work in elderly care, and the challenges encountered. Theoretical Perspectives Theoretically, the study is guided by Bronfenbrenner's (1979) ecological systems theory, as it explains the importance of understanding how individuals are embedded in- and affected by multiple environmental systems ranging from immediate settings to larger contexts. Ecological systems theory has been contextualized by other researchers (c.f. Naidoo et al. 2020) to help explore perceived facilitators and barriers to career development among immigrants. The theory provides insight into individual, cultural, familial and broader macro–social factors that influence migrants to consider Journal of Comparative Social Work 2023/2 102 careers in specific sectors, such as long-term care (Leong & Tang, 2016). The ecological systems model was initially developed to examine how a child's development is influenced by the environment in which that child grows (Brofenbrenner, 1979). According to Brofrenbrenner, natural environments affect human development within interrelated systems in immediate and remote settings. He categorized these as five interrelated systems: microsystem, mesosystem, exosystem, macrosystems and chronosystem. Interactions between the ecological system could contribute to- and influence the lives of immigrant healthcare assistants in elderly care. Ecological systems theory applies to this study as interconnected factors that could influence migrants' decision to work in elderly care. In the Oslo and Akershus region and Troms and Finnmark County where this study took place, the proportion of migrants is significantly high (SSB 2020). In both municipalities, there are other migrant groups from various countries since the municipalities are centrally located, and migrants have been found to live more centrally (SSB 2020). In these municipalities, migrants usually work in long-term care due to barriers to accessing skilled jobs, qualifications recognition and lack of language proficiency (Abrahamsen & Kjelvik, 2013; Christensen et al., 2017; Ramm, 2013). Furthermore, employment is a means for migrants to develop new skills, earn an income, gain social acceptance and contribute to the labour market (Andersen, Osland, & Zhang 2023). The microsystem refers to an individual's immediate surroundings, in which individuals interact more closely with people in this environment. Brofrenbrenner (1979) explained that within the microsystem layer individuals are not passive, but instead actively contribute to the experiences and activities of the environment. For migrant healthcare assistants, the microsystem is their innermost environment and system where interactions and physical contacts occur. This layer includes family, neighbourhood, schools and peers. Here, the migrant is at the centre of the system, and prior practices, such as work experiences with older persons, play a role in making career decisions to develop individual aspirations. However, the migrant is surrounded by immediate settings such as family members and friends, who also play prominent roles in assisting with making career choices. Thus, if schools do not provide information on broader career prospects to migrants, they may be compelled Journal of Comparative Social Work 2023/2 103 to rely on information provided by family members, which would lead them to work in long-term care. The mesosystem refers to connections and interrelationships between the microsystems that impact the individual. One example is the relationship between a migrant's family and the community, between the migrants' home and Norwegian language school, or between peers, school and home. Hence, if migrant families are not involved in wider community networks and activities, they could miss the opportunity to obtain additional skills such as language proficiency, which is a prerequisite for high-skilled jobs. The exosystem refers to interrelationships between two or more settings that affect an individual's development through other people involved in the individual's life (Bronfenbrenner, 1979). For instance, migrants may be motivated to pursue careers in elderly care due to religious beliefs in a family, which define success as giving back to communities through care for older persons (Odom et al., 2007). Therefore, although the migrant may not be directly involved in the family's religious beliefs, the family's religion could indirectly affect the decision to work in the long term. The macrosystem refers to the larger context in an individual’s environment. It includes culture and sub-culture, as well as values, norms and practices which impact an individual's development. The macrosystem impacts development within the other layers, that is, the microsystems, mesosystems and ecosystems, and the individual looks up to the macrosystem to explain possible experiences (Crawford, 2020). At the macro level, national and political agendas and other external policies could be imposed into the system, and the indirect influence of such broader policy agendas could be reflected in why migrants choose to work in elderly care. As a result, the macrosystem points to the complex interaction between policies and access, and highlights how this can potentially disadvantage minority populations. For example, at the macro level, policies such as budget cuts for long-term care could lead to low wages and poor working conditions, thereby making the sector unattractive. At the same time, the demand for professional skills, language fluency and the competition for highly skilled jobs could potentially deter migrants from entering the skilled labour market. Consequently, with limited opportunities, some migrants may particularly enter employment such as elderly care due to flexible entry requirements. Bronfenbrenner's chronosystem refers to how the influence and events Journal of Comparative Social Work 2023/2 104 of time affect an individual in a lifetime. Concerning time, the chronosystem describes how constant situations and changes can impact the individual in an environment. In addition, the chronosystem highlights the impact of transitions on an individual's development. For instance, the sudden realization that elderly care work may result in a lack of career progression could affect the decision to be a healthcare assistant. If the migrant leaves the job market, it could affect future aspirations. Using the ecological systems theory enables me to grasp the multiple and interconnected influences of both person and context that influence immigrants’ lives, and how these contribute to the decision to work in elderly care. Moreover, the ecological systems theory made it possible to understand how multiple systems, both direct and indirect, in the migrant’s environment could serve as information channels to encourage or discourage work in elderly care. Finally, the ecological systems theory enabled me to understand how the interplay of national policy agenda and complex cultural and socio-economic factors could influence the migrant worker’s decision to enter the elderly care sector. Methods Research design This study used a qualitative research approach involving individual in-depth interviews, focus group discussions and observation of the participants. A qualitative approach was used because it has been applauded as relevant for research that deals with complex and sensitive issues that attempt to explore the meaning of a situation from the perspective of individual experiences and participants' broader social contexts (Silverman & Patterson, 2021). A qualitative research approach therefore allowed me to gain insights into the experiences of migrant healthcare assistants and managers of Norwegian long-term care institutions. Study site and recruitment of participants The study was conducted in nursing homes and private home care services in the Oslo and Akershus region, and Troms and Finnmark County in South-Eastern and Northern Norway, respectively. Within private home care, the study also took place in what is known in Norway as a ‘bo og servicesenter’ - literally a ‘housing and services Journal of Comparative Social Work 2023/2 105 centre’. This is a care facility owned by the residents, who receive services in the same way as someone would in a private home. In both study areas, the number of migrants in elderly care is significantly high (Abrahamsen & Kjelvik, 2013; Ramm, 2013). Purposive sampling was used to recruit participants to ensure that they had the necessary experience and knowledge (Silverman, 2021). The research sample included unskilled migrant healthcare assistants who provided care for older adults, and managers of long-term care institutions. Migrant healthcare assistants and the managers of long-term care institutions were included in the study due to their daily interactions with elderly people who require care for activities of daily lives. To participate in the study, the migrant healthcare assistants should directly provide care for older people in institutional settings, as well as in the private homes of elderly people, and should have worked for at least a year. Not included were migrant care assistants whose work requires authorization, such as auxiliary nurses, and those who have worked for less than a year. For the managers, the inclusion criteria were for individuals who had directly supervised migrant healthcare assistants for at least two years in long-term care institutions. This was to ensure that the managers had interacted with the migrant healthcare assistants for a prolonged period, and were knowledgeable on the research topic. A total of 20 participants were recruited for the study, comprising 13 unskilled migrant healthcare assistants (five males and eight females) and seven managers (all females) of care facilities for older adults. All the migrants had participated in state- organized language programmes. In effect, the participants fit the research sample criteria. Data collection and analysis procedures This article is part of a larger ethnographic study which explored the roles and experiences of migrant healthcare assistants in Norwegian elderly care. The study was approved by the Norwegian Social Science Data Services (NSD), and adhered to the ethical guidelines of the researcher's institution (Oslo Metropolitan University) and the National Committees for Research Ethics in Norway. I also gained permission from institutions of long-term care where migrant healthcare assistants and managers were recruited. The data for this article was gathered in two stages. Journal of Comparative Social Work 2023/2 106 The first included fieldwork, in-depth individual interviews and focus group discussions carried out between October 2014 and July 2015 in nursing homes and private home care facilities in Norway. This stage also involved the observation of participants, in which I gained a deeper insight into workplace practices where I was able to touch, feel, smell and experience the world of work of the unskilled migrant healthcare assistants. The second stage involved a comprehensive review of a range of policy documents and literature relevant to the participants’ experiences, which was carried out between December 2022 and June 2023. Combining these two stages provided me with empirical knowledge of the unskilled healthcare assistant’s positions in relation to policy reviews and updated literature on migrant care workers motivations and experiences in aged care. An interview guide was used to collect data for the individual in-depth interviews and the focus group discussions. The individual in-depth interviews enabled me to have a one-on-one interaction with the participants, who helped provide in-depth information, while also allowing for individual discussions on issues that may have been sensitive (Silverman, 2021). Focus group discussions were used to establish a dialogue among the participants, provide insight into group patterns and explore topics not discussed during individual interviews (Nyumba et al., 2018). Following the literature’s precaution on ethical challenges associated with focus group discussions (Sim & Waterfield, 2019), the focus groups used in this study were thoroughly briefed about the public nature of the discussion. Participant observation enabled me to engage with the participants in their everyday work setting, physically experience some of their tasks and work contexts, grasp unconscious behaviours and reactions, and gain insights from the views of both the participants and the researcher (Guba & Lincoln, 1981). Combining individual in-depth interviews, focus group discussions and the observation of participants provided rich data (Silverman, 2021). Individual in-depth interviews and focus group discussions were conducted in either English or Norwegian, depending on which language the participants knew best. For three of the interviews, I used an interpreter to enable the participants to understand and express themselves in their native language. Thirteen individual in-depth interviews and two focus group discussions were conducted with the migrant healthcare Journal of Comparative Social Work 2023/2 107 assistants. Focus group sizes were between six and eight members to ensure group diversity and enable the participants to speak to the subject matter in a group setting (Nyumba et al., 2018). To complement the research with the migrant healthcare assistants, I also conducted individual in-depth interviews with seven managers of care facilities for older adults, who had from seven to 15 years of experience in the sector. All of the participants were provided with information about the study, including their right to withdraw whenever they deemed fit. When informed consent was obtained, interviews were conducted at a time and place convenient and safe for both the participants and I. Individual interviews lasted between 45 and 60 minutes, while the focus group discussions lasted between one and three hours. After obtaining permission from the participants, the individual in-depth interviews and focus group discussions were audio-recorded, transcribed and saved onto a computer with a secured password. To ensure confidentiality, pseudonyms have been used, such that they do not relate to the original names of participants. Audio recordings from interviews and those recorded in Norwegian were also transcribed into English. Data analysis followed Flick's (2022) and Clarke and Braun’s (2017) approach to thematic analysis, which consisted of organizing data, familiarization with the data, generating initial codes, reducing data into themes, reviewing themes, and representing data in a discussion, figures or tables. In the first instance, transcripts were read several times for familiarity with the data. Significantly, this stage of the analysis included closely reading and taking notes of the differences and similarities, in addition to a critical evaluation of how notes from observation are evident in the transcripts. After this, the transcripts were coded in a line-by-line manner to generate initial codes – that is a code was assigned to basic phrases and sentences that described meanings of why migrant healthcare assistants enter elderly care work. Since the study focused on how individuals (micro level) are affected by relations among settings in larger contexts (macro level), it was important to reflect on how codes fit within these interactions as well. Next, phrases and sentences with similar meanings or commonalities were grouped under the same code and given a new code. In other words, the initial codes were developed, merged into new categories, and expanded to generate themes. Following this, the assigned codes were severally Journal of Comparative Social Work 2023/2 108 reviewed, and I explored similarities and difference, echoes, amplifications and contradictions in the experiences and perceptions of the migrant healthcare assistants and managers of the long-term care institutions, and connected these to help explain the themes. To enhance accuracy and consistency and resolve discrepancies that might affect the data, different phases of the analysis process were discussed with the supervisors of the project. Furthermore, to improve rigor and trustworthiness, the analysis was discussed with an assigned opponent (retired research professor) and colleagues at peer debriefing seminars (Connelly, 2016). Findings Sociodemographic characteristics of the participants At the time of research, nine of the participating migrant healthcare assistants were fully employed, and six were partly employed. They were between the ages of 26 and 50, including diverse ethnic backgrounds and nationalities, and came from three continents: Asia (5), South America (1) and Africa (7). In addition to their diverse backgrounds and nationalities, the participants arrived in Norway on different pathways - 10 of the participants came to Norway as refugees, and five joined their partners for either marriage or cohabitation. Regarding education, the highest levels attained by the migrant healthcare assistants were university (7), college (1), senior high (3) and vocational training (2). The subsequent section presents the findings of the study under the following themes: (a) factors influencing unskilled migrant healthcare assistants’ decision to work in elderly care, (b) sources of knowledge about work in elderly care, and (c) challenges encountered by unskilled migrant healthcare assistants in the elderly care sector. Factors influencing unskilled migrant healthcare assistants’ decision to work in elderly care The migrant healthcare assistants shared their experiences about why they decided to work in elderly care, and the managers shared their perspectives as well. The main factors that emerged through the analysis were: (a) cultural norms and values of caring for older people, (b) nonrecognition of overseas qualifications, and (c) economic incentives. Journal of Comparative Social Work 2023/2 109 Cultural norms and values of caring for older people A primary factor that influenced the decision of the unskilled migrants to work in elderly care was their cultural norms and values for caring for older people. Providing care for older adults was regarded as invaluable, and presented to me as an essential feature of their otherwise very diverse cultures. This was mostly the case among participants with African and Asian backgrounds. One participant narrated how the care she had earlier provided for her parents and grandparents in her country resulted in her decision to work for older persons: As the eldest female in my family, I was responsible for caring for my parents. My grandparents also lived with us on the same compound, and I was the one who took care of my grandmother because she was bedridden. Working for older people here is like caring for my grandparents in my country. It is part of how I grew up. Looking back, I can say that this characteristic of my culture also influenced me to work here (female healthcare assistant, 39 years). Most of the healthcare assistants also argued that they needed to provide care for their older family members in their home country. One participant explained that she felt guilty for not being present to care for her parents in her home country. Therefore, she decided to work for older adults: I left my country because of marriage, and this means I miss the opportunity to be physically present to take care of my parents who are ageing. Serving my older parents is very important because, in my culture, that is how you get blessed to live longer. I was once a cleaner, but I used to feel very guilty for not being able to care for my parents when they needed me most. By working here, I can practice and live by my cultural values of caring for older people, which is an important part of my being (female healthcare assistant, 45 years). From the above point of view, the primary factor that influenced the decision of migrant healthcare assistants to work in elderly care was their cultural norms and values of caring for older people. Moreover, they found it easier to work in elderly care due to their inability to provide care for their parents and/or ageing family members in their home country. Hence, work in elderly care was described as a means of fulfilling a cultural obligation of care that was vital for the migrant care givers. Both the unskilled migrant healthcare assistants and the managers of long-term indicated that the cultural values that support care for older adults were necessary, as older people rely on care services for their activities of daily living. In some Journal of Comparative Social Work 2023/2 110 instances, migrant healthcare assistants took on complementary roles due to the unavailability of family members. A manager expressed this as follows: Some of the residents do not have family members who live nearby, and they depend on the care workers for most things, including hospital appointments. It is easy to see a cultural connection centred on respect and support for older people with the care provided by migrant healthcare assistants. This may be one of the reasons why migrants like to work here. In most cases, migrants are seen as part of the family. This makes it easier for older people to deal with issues of loneliness. We have a lot to learn from this culture, which values old age and makes older persons dignified (manager, long-term care). In the above extracts, unskilled migrant healthcare assistants were presented as being more respectful toward the elderly, and as having cultural qualities that treat older people with dignity. In addition, these unique qualities of the migrant care workers were depicted as bringing good values of caring to the workplace, and as something that society could learn from. Treating older people with respect was not only presented as important for workplace relationships, but also for supporting older people who deal with issues of loneliness. The manager’s comment also raised concern over the declining ability of family members to provide care for their older family members, and the challenges this can present. Nonrecognition of overseas qualifications Some of the unskilled migrant healthcare assistants explained how they experienced difficulties in obtaining employment based on professional qualifications from their country of origin. For this reason, unskilled migrants were forced to work in sectors such as elderly care that needed extra hands, as explained by this participant: I am a nurse from my country. After I completed my Norwegian language course, I started looking for nursing jobs. However, it became difficult for me to practice as a nurse because the system does not allow me to directly transfer the diploma from my country. I decided to work for older adults because the sector had vacancies. The work I am doing is below my professional ranking and competence, but I do not have much of a choice (male healthcare assistant, 29 years). For some participants, their plans changed after allowing themselves time to search for jobs: I never planned to do this work, but I wasted so much time thinking I could work as a hospital administrator or accountant. It was all about the paperwork, countless demands for documentation and endless waits. At one point, it felt like a war between me and the system. I became very frustrated and accepted to work here because at least they responded to my application and offered me a job within a short period (male healthcare assistant, 37 years). Journal of Comparative Social Work 2023/2 111 The decision for unskilled migrants to work for older adults, particularly according to managers of long-term care institutions, was because of staff shortages shaped by public policies. A manager clarified this as follows: I think some migrants decide to work here because they do not have work experience in Norway, and they have challenges using their degrees and qualifications from their country. The problem is that the sector experiences budget cuts, the wages are low, and work is flexible because we cannot offer jobs on a 100 per cent permanent basis. This means that we are not able to retain some of the staff we recruit, especially those with a professional background in care work. Coupled with the high demand for care, we are mostly short of staff. The policy preference is to spend less and thus far, it is mostly migrants who accept care assistant jobs and stay in it for a considerably longer period (manager, home care). The above accounts highlight some of the constraints migrants face in entering the labour market. For instance, due to challenges in securing employment, and their lack of work experience in Norway, the migrants were forced to accept positions below their qualifications and professions from their home country. The reference to statements such as ‘I became very frustrated and accepted to work here because at least they responded to my application and offered me a job within a short period’ are particularly interesting as they resonate with the words of the manager that the opportunity to easily secure a job in elderly care due to lack of staff motivates migrants to work in the care sector. Economic Incentives Another contributory factor, economic incentives, was quoted as being important. This was highlighted by the unskilled migrant healthcare assistants, as employment in the sector ensured them of an income to pay the bills. One interviewee illustrated this as follows: I needed money to pay the bills, so when it became apparent that it would take me a long time to find an engineering job, I decided to accept this work. My wife is currently unemployed, and I get worried when I cannot provide for my children, especially my teenage girls. The money could be better, but having a paid job is better than begging on the streets. In addition, I need to send money home to take care of my parents. I must admit that the monetary aspect was essential to me (male healthcare assistant, 40 years). Some participants were convinced that working in elderly care leads to financial independence: It is also about money. To live on state support kills my spirit. I would rather work in elderly care than live on State support. To be able to work and make my own money means a lot to me. I derive joy from working, and most importantly, I feel good knowing that I can work and contribute to society by paying my taxes and taking care Journal of Comparative Social Work 2023/2 112 of myself. I like to be financially independent, and that is why I work here (male healthcare assistant, 48). Given the opportunity, the unskilled migrant healthcare assistants would prefer to be employed in sectors more aligned to their qualification and professions from their home country. However, the responses above suggest that constraints aside, migrant healthcare assistants desired to be financially independent, create meaningful connections with the state by paying taxes and to discourage the social menace of street begging. Some managers also expressed the need for migrants to work to earn an income as clarified as follows: Working offers many opportunities, and the money could also be why people, including migrants, choose to work here. I know everyone says the money here is negligible, but before we employ people, we tell them about the salary. Some migrants tell me they want extra shifts because they need the money to send home to their relatives. So maybe I can say that some people are attracted to work in this sector because of the money they receive (manager, long-term stay unit). In the above candid statement, the manager reiterated the migrants’ sentiments by stating that migrants render their services because of the financial rewards. In addition, the manger revealed that though work in elderly care offers migrants the opportunity to work, the wages are low. In many ways, these characteristics of elderly care institutions, including policy preference to spend less on the sector, make migrants care workers ideal for healthcare assistant jobs. Sources of information about work in elderly care In terms of knowledge about work in elderly care, some of the participants mentioned that the primary sources of their information were teachers at Norwegian language schools (usually during state language programmes), family members and friends, and job notices from the Norwegian Labour and Welfare Administration (NAV). One participant explained that it was a teacher at the state-organized language programme who recommended work for older people: During the final year of my Norwegian language course, my teacher mentioned that elderly care sector always needs extra hands, particularly from men. The teacher also said I was not too fluent in Norwegian, and elderly care was a good place to practice and master the language for higher job prospects. I did not know about this type of work, and I was surprised that men could also do such jobs. I just followed the advice (male healthcare assistant, 40 years) Journal of Comparative Social Work 2023/2 113 Some family members provided information about work in elderly care, as it was often challenging for migrants to obtain employment in other sectors. An interviewee explained how suggestions from family members and friends encouraged her to work in elderly care: When I arrived in Norway, I started applying for jobs because I never wanted to stay home doing nothing. However, I was never invited for an interview. My mother-in-law advised me to find a job in elderly care. My friend's wife told me that she started working in home care before becoming a nursing assistant. She suggested I apply for elderly care work, but I was unsure if I wanted to do this type of job. Later, I met a woman from my country who told me about how language was used as an excuse to deny her work for many years. She also motivated me to consider working in elderly care. That is how I ended up here (female healthcare assistant, 37 years.) The Norwegian Labour and Welfare Administration (NAV) often played a crucial role through job adverts for career prospects in elderly care. In most cases, it was only about the vacancies; thus, a piece of concrete knowledge about what the work entails was often lacking: During orientation, some migrants mention that NAV informed them about working here. Therefore, I believe NAV provides information about our work. However, it is one thing to get information and another to know what the work entails. I experience that migrants from certain cultures do not encourage males into caregiving, so the men feel uncomfortable and nervous when approaching the residents, especially when bathing or cleaning up older women. In general, many migrant healthcare assistants are not used to providing care in formal settings (managers, long-term care). At the time of the study, the participants had been living in Norway for many years: as a result, many of them used the study to reflect on how they got to know about work in elderly care. Through the participants’ experiences, I was able to obtain an idea of their knowledge and integration process into the elderly care labour market. For some migrant healthcare assistants, suggestions to work in the elderly care sector have paid off. However, for others, their experiences point to challenges, as will be discussed in the next theme. Challenges in elderly care work A thriving working environment was seen as important for both migrant healthcare assistants and older adults. Nonetheless, several unskilled migrant healthcare assistants faced barriers while working in elderly care. This included a need for career progression and permanent working contracts. Others attributed their challenges to low status ascribed to work in the sector and poor wages. This interviewee expressed her views on challenges: Journal of Comparative Social Work 2023/2 114 The job is challenging and more stressful when you cannot progress in your career. It starts with the struggle to obtain a permanent working contract. I have been working here for over five years and am still in the same position. I want to progress to the next level, where I can be certified to administer medicines and perform basic medical tasks. The only way is to take the courses, and I have applied. However, my manager has explained that I will have to wait for my turn. It is not easy to get another job because this is the only work experience, I have in Norway. I am stuck in the same position, which is not good for my career development (female healthcare assistant, 34 years). In general, some of the adverse effects of working in elderly care were expressed in terms of lower wages and status: Care assistants are undervalued in society because the job is poorly paid, and the nature of the work is such that we are in constant touch with unpleasant things like cleaning incontinence and vomit. Unlike working with children, perceptions of doing work that is physically tainted are higher in care for older persons. Moreover, even among healthcare professionals, care assistants are undervalued because the nurse is more likely to ask me to do what they see as dirty work. Additionally, when the family members come over, they look down upon care assistants by treating us as people without knowledge. I work very hard, but I do not have any sense of professional identity and dignity in my job (female healthcare assistant, 38 years). Some participants expressed challenges faced in care work for older people in terms of the stigma around migrant men in care work: When I sit with male friends from my country and talk about work, they still laugh at me for working in elderly care. In my culture, men are not involved in care work, especially for adults. It is seen as an abomination for the male child to clean his mother even when she is sick. Traditionally, care work is for females, and a man who engages in such work is considered weak or not strong to handle tough jobs. I sometimes feel bad and uncomfortable doing this work because of the stigma attached to men in care work (male healthcare assistant, 44 years). A manager added the following comment on employment conditions in elderly care: I understand the concerns of the staff because it is important to have job security and a routine. I wish I could give everyone here full-time employment, get everyone to go for skill development training to move to the next position and raise everyone’s wages to the highest level. I understand the desire to progress on the job. However, it is not in my power to make such decisions. Every year, the State tries to prioritise care for older people, but we still need to cut expenses because the budget allocated cannot cater for everything. Reducing expenses means paying low wages and reducing the number of staff employed on a full-time basis. Coupled with the physically demanding nature of the work, most young people, especially natives, do not like working here (manager, long-term care). Several important issues are illustrated here. The first is the notion that elderly care job is challenging and more stressful when there is lack of career progress. Secondly, the undervaluing of the healthcare assistant is justified by emphasizing the dirty nature of the job through contact with incontinence and bodily fluids. Thirdly, the quote illustrates how certain cultural stereotypes of caregiving easily transform into Journal of Comparative Social Work 2023/2 115 stigma. In this way, the stigmatization of migrant men in low status care jobs by members of their community demonstrate how cultural demands of gender roles can operate as a form of challenge for migrant men to work as healthcare assistants in elderly care. Finally, the manager’s emphasis on budgetary issues implies that the challenges that migrant healthcare assistants encounter are not necessarily because of their migrant background. Instead, it is a question of priority for the sector. As in previous quotes, here the manager revealed that as managers they cannot do much to change the conditions of service with regard to job insecurity, part-time contracts, low wages and a lack of career progress. Although the manager has the goodwill for healthcare assistants to progress in their career, the capacity to solve these challenges are beyond her. Tellingly, the categories of ‘job insecurity’, part-time employment contract’, low wages’, a ‘physically demanding job’ and a ‘lack of career progression’ reveal subtle forms of challenges that make healthcare assistant jobs unattractive, particularly for native Norwegians; hence, the major issue with staff shortage and retention. In addition, this points to the role of the state in shaping recruitment and the retention of staff in elderly care. The comments made here suggest that migrant healthcare assistants primarily fill the staff shortages, as they are a response to current and future labour shortages. Addressing their challenges is crucial for the effective performance of their roles, and an enhancement of their career. Discussion The study explored factors influencing the decision of unskilled migrant healthcare assistants to work in elderly care, sources of knowledge about work in elderly care, and the challenges encountered in elderly care work. The study focused on the problem within Norway, and how various interconnected systems around the migrant healthcare assistant could contribute to work in elderly care. It was found that the cultural norms, values and belief systems (macrosystem) of caring for older people influenced the decision of migrant healthcare assistants to work in the elderly care sector. Many migrant healthcare assistants in this study associated their role in providing care for older persons in Norway with a responsibility to the family members in their home country. Moreover, due to the inherent cultural belief of Journal of Comparative Social Work 2023/2 116 blessing associated with care for the elderly, it was gratifying for some migrant healthcare assistants to work in long-term care. For this reason, working in elderly care to give back to society is accepted and regarded as a duty among the migrant participants. Relating this to the ecological systems theory, it could be explained that while migrant healthcare assistants could be motivated by themselves (microsystem) to work in elderly care, the cultural values, beliefs and norms (macrosystem) of their country of origin could further influence them to work in elderly care. Similar findings were observed by Sethi (2022), who reported that a profound cultural responsibility to care for ageing parents and the challenge to provide physical care from afar could be prominent in the decisions of migrants to do care work. In addition, the study found that working in elderly care is still perceived as low status work with low wages. Here, is important to note that, in Norway, macrosystem policies focused on keeping costs down in the long-term care sector could contribute to shortage of skilled personnel and low workforce retention. Moreover, the high demand for care and the unavailability of family members to care for older people has led to an increased demand for care workers. In this study, unskilled migrant healthcare assistants play an important role in filling the gaps of staff shortages and at the macro level, their employment can be seen as a strategy for cutting down healthcare expenditure as it is more common for migrants to accept low wages. As Hussein, Stevens, and Manthorpe (2013) argued, macro level policies of countries could act as contexts that influence the decisions of migrants to work in strategic sectors such as long-term care due to the sector's increasing demand for labour. Another reason migrants enter elderly care is the non-recognition and difficulty in transferring their overseas qualifications. Most often, some migrants experience issues of qualification and skills mismatches. When migrants have no other form of economic support, they are likely to accept jobs below their levels of qualification and skills (Stoevska, 2021). In this study, some of the migrants with higher overseas qualifications in nursing were compelled to take up lower positions as healthcare assistants as they awaited approval of their nursing registration. A study by Adebayo et al. (2023) on migrant care workers in Australia elderly care facilities noted that the lack of acceptance of overseas qualifications could significantly motivate migrants to take up lower Journal of Comparative Social Work 2023/2 117 positions in residential aged-care facilities. The need to earn an income may also compel migrant healthcare assistants to work in elderly care. Migrant healthcare assistants who participated in this study described how they had to do elderly care jobs to earn an income to care for themselves as they faced financial challenges. Thus, migrant men, who perceived caregiving as a traditionally female role, entered elderly care for financial support. In their studies, Choi (2019) and Bruquetas‐Callejo (2020) found that, among migrants, economic considerations were key in the decision to enter long-term care employment. Furthermore, some of the migrants lived in homes (microsystems) where their partners were unemployed, and they needed money to provide for the basic needs of their families. For some migrants, working in elderly care was prestigious as they could earn an income and not rely on state support. Yijälä and Luoma (2019) suggested that migrants have a positive sense of identity when they can advance their economic well-being through employment instead of living on social benefits. Regarding knowledge about work in elderly care, it was found that the sources of information included families and migrant community networks, state-organized language learning programmes and the Norwegian Labour and Welfare Administration (NAV) offices. Some migrant healthcare assistants indicated that they obtained knowledge about work in elderly care during their enrolment in state- organized Norwegian language learning programmes, or during visits to the Norwegian Labour and Welfare Administration office, which administers programmes such as unemployment benefits. When related to the ecological systems theory, it can be argued that interactions between migrants (microsystem) and the mesosystem (e.g. Norwegian language school) played a crucial role in the decision of unskilled migrants to consider work in elderly care. On the other hand, others received information about work through families and social networks within the migrant community. Here, it could be explained as a person in an environment, as the migrant healthcare assistants’ immediate environment (microsystem) influenced their decision to work in elderly care. In a study on how migrants search for employment opportunities, Janta and Ladkin (2013) reported that migrants received information about job opportunities through technologies like the Internet. On the contrary, migrants included in this study did not Journal of Comparative Social Work 2023/2 118 obtain information about work through online sources. Instead, findings from this study are consistent with Battisti, Peri and Romiti (2022) and Lehwess-Litzmann and Söhn (2022), who reported that information about job prospects through job centres and family and community networks was central in the labour market integration of migrants. However, this study found that despite information about work in elderly care, the migrant healthcare assistants did not have detailed knowledge about how care work occurs within formal institutionalized settings. Still, it is important to acknowledge that while the migrants had knowledge about work in elderly care, some of the managers were concerned that the unskilled migrant healthcare assistants did not have a detailed knowledge about how care work occurs within formal institutionalized settings. Further studies may be warranted to explore how this concern affects services provided by unskilled migrant healthcare assistants with special attention to quality-of-care outcomes. Finally, the unskilled migrant healthcare assistants who participated in this study encountered challenges in the form of having temporary working contracts, a lack of career progression, and the stigma ascribed to work in elderly care and poor wages. This finding adds to studies on concerns about relatively poor working conditions and employment outcomes for migrant care workers in long-term care (Charlesworth & Malone, 2022; Lovelock & Martin, 2016). Whereas challenges such as low wages can be addressed through policy directives for increased funding (Van Houtven et al., 2021), the issue of stigma towards elderly care workers (in this case for migrant men) may be more challenging to address, as it involves cultural perceptions on conservative values that strongly divide work in terms of masculinity and femininity, and perceives elderly care as feminine work. However, it is the responsibility of state agencies and stakeholders, including social work educators, to promote initiatives such as men in healthcare jobs to educate and motivate job-seeking migrant men to train as health workers (Dahl, Bergsli, & Van der Wel, 2014; Kårstein et al., 2020). Nevertheless, one main message from this study is that interventions to support the labour market integration of populations such as migrants not only influence unskilled migrants to work in sectors such as elderly care but rather, it reveals that the organization of the elderly care sector itself is influenced by challenges such as low levels of funding, which contribute to a declining availability of skilled personnel and a Journal of Comparative Social Work 2023/2 119 unwillingness of young natives to work in the sector. Unskilled migrant healthcare assistants thus play a crucial role in elderly care, as they are employed to fill in care gaps, and are considered as labour needed to help meet current and future care demands in the elderly care sector. Conclusion and Implications for policy and social work practice In conclusion, meaningful employment outcome through better opportunities for career progression are essential for unskilled migrant healthcare assistants, and for efforts to improve care for older people through the employment and retention of workers with culturally diverse backgrounds. The conclusion involves some policy and practice implications. First, since the study showed that institutions such as the Norwegian Labour and Welfare Administration (NAV), as well as state-organized language programmes, played crucial roles in disseminating information on work in elderly care, collaborative practices between stakeholders, including social workers and transition programmes such as Norwegian language schools and NAV, are of significance given their ability to establish links between migrants and labour market sectors experiencing staff shortages. For instance, in Norway, policy initiatives and employment strategies (e.g. ALMP and NAV 2006 Reform) provide a framework to include populations such as migrants into the workforce by providing the skills and competencies needed by employers. Yet, as this study indicates, employment policies and labour market programmes are not enough. Effective labour market initiatives for unemployed migrants therefore need to consider other factors, such as the role of professional social workers in supporting migrants to access opportunities for upward career and social mobility through comprehensive follow-up strategies (cf. Hansen & Gubrium, 2021; Håvold, 2018; Røysum, 2013). As argued by Jones (2012), this is because, the unique role and essential training of social workers enable them to support migrants by adopting a ‘holistic view of problems facing immigrants from a micro, mezzo, and macro perspective’ (p. 52) and by so doing, advocate for structural changes to help empower immigrants (Lin et al., 2018). Secondly, since migrant men who work in elderly care were found to be stigmatized because their role does not meet their cultural expectations of masculinity, it may be beneficial for policymakers to review Journal of Comparative Social Work 2023/2 120 and improve interventions to maximize the benefits of men in healthcare jobs (Kårstein et al., 2020). Moreover, since access to relevant information is essential, stakeholders such as the Norwegian Directorate of Health, the leaders of migrant communities, the media and social workers could collaborate to promote education on work in elderly care, particularly among migrant men. Finally, considering challenges of population ageing in high-income, such as the declining availability of informal caregivers and a shortage of skilled personnel in elderly care, it is important for policymakers and society to recognize the role of unskilled migrant healthcare assistants in meeting current and future care demands. Consequently, the challenges relating to a lack of career progression, temporary working contracts, a low status and poor wages need to be addressed for the well- being of unskilled migrant healthcare assistants and the care for older people. Strengths and limitations The sample of migrant healthcare assistants and managers of long-term care institutions enriched the study's understanding. Although the findings could be applied to similar settings, they cannot be generalized, as the sample was limited to unskilled migrant healthcare workers in Norway. The experiences of other migrant healthcare assistants in other geographical locations might differ. Journal of Comparative Social Work 2023/2 121 Declarations Funding The time-away leading to the writing of this research finding for publication was made possible with financial support from the project - Building a New Generation of Academics in Africa (BANGA-AFRICA), which is funded by the Carnegie Corporation of New York. This funding does not influence the work reported in this paper. Acknowledgements The author would like to thank Professor Marie Louise Seeberg (Oslo Metropolitan University/NOVA, Norway) and Dr. Darryl Humble (Salford University) for their constructive feedback on the manuscript. Warm thanks also go to Lisa Hardisty (University of Salford, Manchester), Karen Kinghorn (University of Salford, Manchester) and Yaa Frimpomaa Kankam (University of Ghana) for their support during the writing of the manuscript. Ethics Approval: The study was conducted according to the ethical guidelines of the Norwegian Social Science Data Services (NSD). 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Refugee Survey Quarterly, 38(3), 314-340. https://doi.org/10.1093/rsq/hdz009 Strukturer bokmerker Migrant healthcare assistants’ decision to work in long-term care: Experiences from Norway Abstract Introduction Relevant literature Theoretical Perspectives Methods Research design Study site and recruitment of participants Data collection and analysis procedures Findings Sociodemographic characteristics of the participants Factors influencing unskilled migrant healthcare assistants’ decision to work in elderly care Cultural norms and values of caring for older people Nonrecognition of overseas qualifications Economic Incentives Sources of information about work in elderly care Challenges in elderly care work Discussion Conclusion and Implications for policy and social work practice Strengths and limitations Declarations Funding Acknowledgements Ethics Approval: Consent to Participate: References