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This chapter deals with a long and intense conflict between nurses and nursing assistants within the context of the Norwegian health care system. Caring work is culturally coded as female. A major issue embedded in the conflict concerns the definition of knowledge. The issue, it is argued, is not so much what constitutes knowledge, but what counts as professional expertise and theoretical knowledge when it comes to women's work, which is devalued. As a middle‐class women's occupation, nurses have strong aspirations that their work be acknowledged as a full profession. Their knowledge base is a combination of practical and theoretical knowledge, profoundly different from medicine they themselves argue. Such a "professionalisation" of care work is, however, threatened by the mere presence of nursing assistants and the overlapping work they do. For various reasons – not least strategic – the concept of basic care was introduced more than ten years ago. The term was rather vaguely defined, but seems to comprise all personal care for the patient and the patient's body, including intimate tasks such as washing, dealing with bodily waste products, feeding, etc. Making basic care the exclusive preserve of nurses and delegating the more "housewifely" tasks to nursing assistants effectively excludes the latter from caring work and, not surprisingly, they strongly oppose existing working boundaries and the redistribution of tasks. We investigate the power relationship between the two occupational groups and examine dual closure strategies. Interestingly, nurses have invested in a precarious strategy by reclaiming the hands‐on bodywork that is often labelled "dirty work". In Western societies these tasks are commonly left to working‐class women. The conflict is thus about both gender and class in an androgynous professional world. The aim is to explore the occupational conflict and to trace some of its implications for theorising professions. Professional tasks, knowledge claims, and the concept of dirty work are addressed, and professional projects and strategies discussed from a gender perspective.

The project «Workplaces in the health care sector: gender, class, ethnicity» (2003-2005) was financed by the Norwegian Research Council's programme for workplace and labour market research. The project was initiated in order to explore some consequences of the increasing number of employees from immigrant backgrounds within the health care sector. Specifically, we wanted to study if, and how, employees from immigrant backgrounds were included in their workplaces, as well as if and how the organization of work and the existing hierarchies were influenced by the increasing ethnic diversity in the workplace. We have conducted fieldwork in two separate workplaces: a hospital and a nursing home, both in the Oslo area. The focus is on the workplaces, rather than on the employees. The two workplaces are described in separate chapters in this report, which is intended to communicate the results back to the institutions where we conducted the research. In this way, topics that are of special relevance to each of the two institutions respectively are easily accessible to the reader. We also hope that this structure will make the report useful for leaders and employees within these two types of institutions. Furthermore, in the report, we compare the two workplaces and also refer to the fact that they both form different parts of a larger context. This, in turn, provides them with different conditions for dealing with differences in ethnicity, gender and class. In this way, the report presents two examples of more general trends and tendencies in this sector of the labour market. Our main findings may be summed up as follows: In the hospital, the majority of the nursing staff had a Norwegian ethnic background. The nursing home had a significantly higher proportion of nursing staff from immigrant backgrounds. In the nursing home ward where we conducted fieldwork, more than 20 ethnic groups were represented, and a minority of the staff was from a Norwegian background. There was thus little ethnic diversity among the hospital staff, and a high degree of such diversity among the nursing home staff. It is easier for qualified applicants from immigrant backgrounds to find work in the municipal part of this sector, such as nursing homes, than in the central government owned health enterprises, such as hospitals. It is, furthermore, easier for applicants with so-called «Western» backgrounds to find employment in hospitals than it is for applicants with «non-Western» backgrounds. Differences in recruitment and employment practices play an important role here. This is already common knowledge to applicants from immigrant backgrounds, so that many of them do not think it is worth the trouble to apply for jobs in hospitals. A consequence of this self-strengthening process is that hospitals in districts with ethnically diverse populations fall far short of the government goal that the workforce should reflect the composition of the population which it serves. Equality, difference and discrimination are central topics in this study. How questions related to these topics are conceived of and dealt with is important to the workplace and to each employee. There were systematic differences between the ways in which such issues were handled in the two workplaces. At the hospital, the policy was that «everybody was treated the same», which presupposes that everybody was the same, since the expectation was that similar treatment be received in similar ways. Those who came through as different were thus viewed as deviating from, or falling short of, the ethnic norm, which was Norwegian. Coming from a Norwegian background thus became an advantage in itself. Other ethnic identities were stigmatized. In order to avoid open stigmatization, employees from immigrant backgrounds under communicated this aspect of their identities. At the nursing home, the policy andpracticewerecompletelydifferent. The municipality had established an active diversity policy aimed at combating the discrimination of all minority groups. The employees at the nursing home had little direct contact with the municipal administration, yet they trusted that questions of discrimination were competently addressed and that it was legitimate to bring cases of discrimination upwards in the system if necessary. When it came to the likelihood of changing the deeper, structural features that enabled such single cases of discrimination, however, there was less confidence among the employees. In the nursing home ward, we found no tendencies to stigmatization of ethnic identities. Here, community was built on common experiences as immigrants in Norway, and on the diverse needs of the nursing home residents. Regarding the significance of the ethnic composition of the workforce for the organization and tasks, we found that, at the nursing home, the very diversity made for a clear focus on what the employees did have in common, namely the residents and their well-being. At the hospital, we did not find any parallel to this. Here, a vast majority of the employees did have a common ethnic background: they were Norwegians. It is thought-provoking that, in the hospital, which was the institution with the larger number of patients from immigrant backgrounds, we found the smallest proportion of employees from immigrant backgrounds. One might have expected to find that these relatively few employees be viewed as a particularly important resource for the institution, since the number of patients from immigrant backgrounds was increasing. That this was not the case, can be understood in light of the stigmatization of ethnic difference which we have already mentioned. The consequence was that, at the hospital, little use was made of the employees' real or informal competence that derived from their immigrant backgrounds. This said, we did find that a few of the employees themselves took the initiative to make hospitalisation easier for patients from immigrant backgrounds, by speaking a common language other than Norwegian, and in general show flexibility and understanding for their special needs. Our point is that such practices were discouraged by the structural framework. Our findings support the view that what it means to have a «sufficient» knowledge of Norwegian in order to work, for instance, as a nurse in Norway, not just depends on «objective» criteria such as language test results. It also depends on one's knowledge and skills when it comes to the silent parts of language, the cultural codes within the health care sector, and on how other people in the workplace receive what one intends to express. Equally important are structural conditions such as the organization of work, and labour market fluctuations: As other studies have found, when labour is scarce, the required level of language competence is lower than it is when there is a surplus of labour. Correspondingly, as long as it is more difficult to recruit ethnic Norwegians to nursing homes than to hospitals, the required level of Norwegian language competence is likely to be lower in nursing homes than in hospitals. Norwegian hospitals have gone through major reorganization processes in recent years, to a large extent as part of the reform trends broadly known as New Public Management. This has implied a decentralisation of responsibility, along with rigorous demands as regards efficiency and economy. The distribution of nursing tasks in the hospital wards was rigid and meticulously directed from the ward leadership. This organization form left little room for finding flexible solutions in order to maximise use of the employees' total competence. Thus, many relational and structural factors interplay when applicants or employees from immigrant backgrounds are deemed to have «sufficient» or «insufficient»skillstowork inthe health care sector. Existing competence hierarchies in this sector determine what is recognised as status and salary trigging competence. Knowledge associated with medical science, modernity, masculinity, social elites, rationality, formal education, individuality, and Norwegian-ness or Western-ness, is privileged in this system. Needless to say, the recognition of medical competence is not a problem in this sector. What does emerge as problematic is, however, that a host of competence forms that do not necessarily lead to better health or care work are recognised because they are associated with medical competence. Norwegian-ness is such a competence form. Furthermore, it is problematic that this privilege by association simultaneously undermines other competence forms that may well be important to health and care work, without being recognised as such. This brings us back to the issue of political management, especially within the fields defined as the recruitment of health care personnel on the one hand, and racism and discrimination on the other. In order to achieve the explicit political goals of increasing the number of people from minority groups recruited to the health sector and to central government employment, active measures should be implemented at all levels. One problem in this context is that the possibilities for political management are limited when hospitals as employers are defined as semi-governmental health enterprises. This increases fragmentation and obfuscates lines of responsibility. The municipal nursing home was subject to explicit guidelines within the two political fields mentioned, and the lines of implementation and responsibility were clear. The lack of explicit and clear guidelines for the implementation of policies within these fields in the hospital sector needs to be further studied and amended. ; Denne rapporten er et resultat av prosjektet «Arbeidsplasser i helse- og omsorgssektoren: kjønn, klasse, etnisitet». Prosjektet, som ble gjennomført fra 2003 til 2005, var finansiert gjennom Norges forskningsråds program for arbeidslivsforskning. Bakgrunnen for prosjektet er den økende andelen ansatte med innvandrerbakgrunn i denne sektoren. Sektoren har allerede en høyere andel ansatte med innvandrerbakgrunn enn for eksempel servicesektoren har. Forskerne har gjennomført feltarbeid ved to arbeidsplasser, et bo- og omsorgssenter og et sykehus, begge i Oslo-området. Hensikten med prosjektet har vært å utforske hvordan ansatte med innvandrerbakgrunn, i vid forstand, inkluderes i det eksisterende arbeidsmiljøet, og hvordan arbeidsorganisering, arbeidsrelasjoner og hierarkidannelser påvirkes av at ansatte med innvandrerbakgrunn er rekruttert inn i helse- og omsorgssektoren. Prosjektet fokuserer altså ikke på ansatte med innvandrerbakgrunn, men på to arbeidsplasser der innvandrere er blant de ansatte. Spørsmålene som reises i rapporten er viktige, ikke bare for de ansatte selv, men også i et større perspektiv. De kan bidra til å belyse hva som hindrer innvandrere i å få innpass på arbeidsmarkedet, og hva som kan gjøres for å inkludere også disse arbeidstakerne.

This article highlights implications of two aspects of glocalisation – migration and New Public Management – at different levels in the Norwegian health care sector. They meet in the concept of competence, the central principle of hierarchisation in this sector. 'Norwegianness' emerges as an important informal competency, while there is a need for allowing the conceptual alignment of 'migrancy' with medical competence. Most immigrants who are not able to align themselves with 'Norwegianness' hit what Nirmal Puwar calls the 'concrete ceiling of race', while a few manage to find jobs further up through assimilating into pre-existing schemas of 'Norwegianness'. This may lead to a loss of competencies useful in a diverse society. In the absence of political will to counteract this tendency, it is likely to cause growing inefficiency in the sector.

This article highlights implications of two aspects of glocalisation - migration and New Public Management - at different levels in the Norwegian health care sector. They meet in the concept of competence, the central principle of hierarchisation in this sector. 'Norwegianness' emerges as an important informal competency, while there is a need for allowing the conceptual alignment of 'migrancy' with medical competence. Most immigrants who are not able to align themselves with 'Norwegianness' hit what Nirmal Puwar calls the 'concrete ceiling of race', while a few manage to find jobs further up through assimilating into pre-existing schemas of 'Norwegianness'. This may lead to a loss of competencies useful in a diverse society. In the absence of political will to counteract this tendency, it is likely to cause growing inefficiency in the sector. ; This work is published under a Creative Commons Attribution Non-Commercial No-Derivatives License