The loyalty trap in long-term care

Abstract

While the staffing crisis in long-term care has stimulated research into rising turnover rates, it is far from certain that the resulting proposals can address the causes of the crisis. Through group discussions with nursing home workers in Switzerland, this article focuses on workers who remain in the profession, arguing that their loyalty acts as a trap. Drawing on Hirschman’s concept of loyalty and Nies’ insights into the tension between the production of use and exchange values, we identify a conflict among workers between commitment to the social value of care and the alienation from a system that does not respond to residents’ needs.

Introduction

The institutional long-term care (LTC) sector is characterised by an intensifying staffing crisis across many OECD countries, which has been exacerbated by the COVID-19 pandemic (OECD, 2023). A combination of underfunding, increased workloads and growing care needs has led to high staff turnover rates in nursing homes (Pruszyńsk et al., 2022). Research exploring the perspectives of workers in Switzerland has highlighted the ‘vicious circle’ in which care work is carried out, marked by time pressures to perform pre-set tasks in an unpredictable environment and the aggravating role played by staffing shortages (Pons-Vignon and Schneck, 2024). The fact that many workers choose to resign or work part-time reflects Hirschman’s (1970) identification of exit as a strategy in the face of organisational decline. Beyond the material factors that influence employment decisions, we examine the deep-rooted loyalty that contributes to LTC workers’ willingness to remain in their jobs. This loyalty is characterised by employees’ professional commitment to the societal significance of caregiving. Although worker loyalty might help stabilise the sector (‘retention’ is indeed a core policy objective) in the short term, it can also reproduce – and conceal – underlying structural contradictions.

Despite high rates of turnover (exit), we must consider loyalty as a factor in LTC employment, given that many care workers remain in their positions longer than they plan to. Research thus highlights that the number of workers who express an intention to leave the sector far exceeds the number who actually do (Gaudenz et al., 2019). A longitudinal survey of Swiss healthcare workers has further revealed that intent to stay is substantially lower in institutional LTC than in other health subsectors, with 7% ‘not at all’ wanting to stay and 18% ‘not really’ wanting to stay (Jolidon et al., 2024). While many do leave, it cannot be assumed that all is well for those who do not; high reported intention to leave suggests a significant degree of dysfunction. To understand why LTC workers appear to have higher rates of loyalty, we examine empirical data from an original research project that explored the perspectives of workers regarding the problems in Swiss institutional LTC. We draw on Hirschman (1970) and Nies (2021) to examine how professional commitment supports loyalty under adverse organisational conditions, thereby creating a ‘trap’ for workers who lack voice to alter the system.

The next section provides a brief overview of the Swiss LTC sector and the issues it currently faces to situate our research context and questions. Following this, our conceptual framework positions the study within debates on the transformation of work in care settings, focusing on loyalty amongst care workers. Our theoretical framework combines the concepts of exit, voice and loyalty from Hirschman (1970) with an analysis of the tensions that emerge when work organisation emphasises producing exchange over use value (Nies, 2021). In doing so, we address a critical gap in research on the motivations of LTC staff remaining in the sector, despite its dysfunctions. The methods section outlines the use of conricerca (co-research) through group interviews to stimulate participant co-creation and analysis. The results section presents the key findings, namely that the production of exchange values undermines use values, and that loyalty is motivated by an underlying aspiration for change. The interviews reveal that workers have compelling ideas for change yet remain loyal to their roles with little opportunity to voice or enact them. The article concludes by setting out directions for future research and policy designed to address staffing challenges in LTC and promote worker organising.

The staffing crisis in institutional long-term care in Switzerland

Following the COVID-19 pandemic, the Organisation for Economic Co-operation and Development (OECD, 2023) suggested that workers in LTC need material improvements in their working conditions and not just a symbolic ‘applause’. During the pandemic, the importance and critical state of care became apparent across the globe, and Switzerland was no exception. These conditions actually preceded the pandemic and were worsened by it, with significant issues that continue in its wake. Simply put, there is a staffing crisis of care in Switzerland and workers in LTC are overextended, in part due to being burdened with growing administrative tasks (Ausserhofer et al., 2023). Additionally, worker expertise and experience are largely undervalued (Benjamin, 2015).

Understaffing and overwork are closely connected to the way care is organised and funded in Swiss LTC. The Swiss Federal Law on Compulsory Health Care (LAMal) positions insurance companies as a central funding body for LTC; nursing homes are managed either by municipalities as public institutions; or by foundations as non-profit private institutions; or by companies as for-profit private institutions. The share of private companies has been steadily increasing, with recent data showing that 47.3% of nursing homes were private, for-profit institutions (Federal Statistical Office, 2023).

This growing role of the private sector has followed the introduction of healthcare financing reforms inspired by new public management (NPM). ¹ NPM refers to the application of private sector organising principles to public entities (Knafo, 2020) through the introduction of performance indicators used to evaluate and reward (or punish) institutions in sectors such as care or education. Market principles have thus increasingly shaped care homes in Switzerland following cost-saving measures driven by the state and health insurance companies. Through the introduction of an indicator-driven form of governance, NPM reforms have encouraged standardisation and output focus in the labour processes. Indeed, as Béroud (2025: 92) observes in the French context, ‘the standards imposed to define the tasks to be performed and the time allocated to them are not set directly by employers – who are, in a sense, intermediaries – but by the funding bodies’.

In practice, the allocation of time to given tasks is mediated by tools such as the resident assessment instrument (RAI), which are designed to track changes in patients’ or residents’ conditions with a high level of detail. The resulting data is used to generate aggregate dependency scores, which then determine adjustments to the allotted time for care tasks. Such tools have played an ever-greater role in structuring care work, facilitating the entry of private actors with significant impacts on the labour process (Walker et al., 2022). Such tools however ignore the relational aspects of care and place a heavy administrative burden felt by workers (Knöpfel et al., 2018).

These pressures on the organisation of work contribute to an ongoing staffing crisis: in Switzerland, the annual staff turnover rate has increased from 20.3% in 2013 to 27.3% in 2023 (Obsan, 2025). Indeed, a recent nationwide survey highlights that – of all Swiss health professionals – workers in nursing homes had the highest intention to leave (Jolidon et al., 2024).

The crisis looks likely to worsen as demand will continue to increase rapidly, with the Swiss population requiring LTC services tripling by 2045 (Fuino and Wagner, 2018). It is predicted Switzerland will need an additional 900 nursing homes and 54,000 beds by the year 2040, an increase of 150% from current availability. As a result, the demand for staff will increase by 35,000 full-time equivalent LTC positions by 2035 (Pelligrini et al., 2022).

Swiss policymakers have attempted to mitigate this staffing crisis through various policy responses. The primary strategy is to recruit workers from neighbouring countries. In 2021, migrant workers accounted for 35% of the Swiss LTC workforce (OECD, 2020). Migrant labour is therefore crucial to the sector, which deploys recruiting strategies to attract new, often highly skilled workers. These workers are pressured to accept precarious employment or pay levels below their actual level of qualification, as credentials are not easily recognised or immediately transferrable (Newton et al., 2012). Another mitigation strategy has been to attract more young workers (ARTISET, 2025); however, many leave the sector quickly due to subpar working conditions (Aubry, 2012). In this context, we must consider the loyalty of current LTC workers in Switzerland to examine how it contributes to sustaining the current system.

Conceptual framework: The loyalty trap in long-term care

LTC has experienced rapid marketisation since the 1990s, with far-reaching consequences for quality of care and the way care work is organised (Walker et al., 2022). Even in the public sector, market logics such as performance measurement and cost-efficiency have been deployed with the introduction of NPM reforms, transforming the provision of care (Bos et al., 2020). Although these changes are often justified as efforts to enhance accountability and make care work (especially nursing) visible (Ernst and Tatli, 2022), they have also obfuscated the human-centred aspects that are fundamental to quality care work and undermined the professional autonomy that lies at its heart (Corcoran and Albertson, 2024).

Feminist political economy scholars argue that care work has been systematically devalued because it is rooted in emotional labour and relational ethics that have historically not been recognised as productive labour which creates value in capitalist relations of production (Folbre, 2024). Instead, it is rooted in reproductive labour, which maintains the social and family structures that productive labour requires to develop (Barker, 2005; Federici, 2009). Even as care work has increasingly become provided for wages, it has tended to resist commodification in two ways. First, care work provided in households (historically the norm) is not considered as a value-adding activity in a market economy; it is furthermore labour intensive, with limited scope for automation to improve efficiency (England et al., 2002; Folbre, 2008). This is best illustrated by neoclassical economist William Baumol’s (1993) theory of the ‘cost disease’ affecting personal services: given the limited scope for increasing productivity, rising demand for services is likely to result in increasing demand for labour, unlike, for instance, in manufacturing. Put simply, if care needs increase, so will spending to hire the workers to meet them. This is the point most OECD societies have reached in relation to elder care, with Switzerland at the fore.

There may be yet another way in which workers providing care for wages resist commodification. They oppose, as other workers do, the use of their labour for purposes of accumulation (exchange value) rather than for what they consider to be its intrinsic, social purpose (use value). ² Nies (2021) identifies this value dissonance as the manifestation of enduring alienation amongst white-collar workers (specifically engineers and customer service advisors). She argues that in the execution of their tasks, workers always pursue subjective interests, which

. . . depend on the way in which one’s work activity impacts on others: colleagues, customers, clients or even society as a whole. Subjective work interests do not (primarily) revolve around a desire for self-fulfilment, but around perceptions of use value. . . . Even when hierarchies are flattened, self-organisation is implemented and greater autonomy is granted, . . . [a]lienation ensues from the worker being estranged from the product of his own work and from work outcomes being produced as a means to an end – as commodities and not as use value. (Nies, 2021: 44–45)

The subjective understanding of the use value of one’s job clashes with the way in which workers are made to carry it out, irrespective of material conditions or of managerial efforts to enhance individual ‘autonomy’. The ongoing relevance of the concept of alienation from one’s labour has been a central feature of discussions on meaningful work, from psychology (Dejours et al., 2018) to economics (Spencer, 2015). Such approaches share a critique of the neoclassical concept of the disutility of work, whereby work is considered undesirable per se and only a source of utility (satisfaction) depending on one’s pay level. Going beyond this instrumental view of work, it is possible to identify meaningful work ‘that enables workers to realise their potential’ (Spencer, 2015: 685), with both extrinsic and intrinsic dimensions. The former refers to conditions such as pay level, while the latter includes the environment in which work is performed and the degree of autonomy over it. While both intrinsic and extrinsic dimensions matter to meaningful work, the perceived social value of one’s occupation can vary between activities.

These insights help illuminate the tensions that Mol (2008) identifies among health professionals between what she calls the ‘logic of care’ (p. 75) and the ‘logic of choice’ (p. 28). She identifies the ‘logic of care’ as what drives workers’ actions: it describes the compulsion to respond to crises and emergencies as they arise by mobilising a worker’s expertise and empathy. Importantly, this approach to care requires fluid, adaptative behaviour that is not constrained by preconceived notions (and related performance targets) of what ‘good care’ means for a dignified life. The ‘logic of choice’ is embedded in market relations, and treats patients as rational consumers, who are individually responsible for making decisions on their health. The clash between exchange and use values is particularly acute for care work when it is transformed into a ‘productive’ job; it is then marred with internal conflict as well as mental and physical strain and its grounding in human connection is uprooted. The loyalty demonstrated by care workers may therefore not signal that they are satisfied with their working conditions but instead represent an effort to mitigate the negative impact of what they perceive to be a flawed organisation of care.

The emergence of indirect control mechanisms under NPM have become a focal point of many LTC workers’ frustrations. Workers continually need to navigate the ‘blurry boundaries’ between institutional rules and the residents’ needs and wants (Armstrong, 2023). Unlike direct control or supervision, these forms of oversight operate subtly yet powerfully in shaping the labour process by shifting responsibility onto workers to make whatever adjustments are needed—most often by intensifying their effort—to ensure that preset targets are met. While care workers appear to have some degree of formal autonomy, they are in fact constrained by strict time-use metrics that ‘guide’ their work according to unrealistic organisational expectations (Fleming and Sturdy, 2011; Langfred and Rockmann, 2016). In other words, they are forced to navigate workflows and accomplish targets with little guidance and minimal input to formulate the objectives. This dynamic creates a regime of ‘responsible autonomy’ (Friedman, 1977) in which workers internalise systemic failures and blame themselves for not meeting imposed standards.

Moral distress, a concept developed in nursing ethics, occurs when nurses know the ethically right decision but are constrained from acting on it by organisational policies (Jameton, 1984). Moral distress has been extended to describe the psychological stress experienced when similar organisational constraints prevent care workers from upholding their values (Peter and Liaschenko, 2013; Young et al., 2017). Drawing on Nies (2021), we argue that when standardised routines and bureaucratic requirements obstruct care workers’ commitment to meaningful care, they experience emotional and ethical tension. This reflects frustration not only with the way the work is organised but also with the perceived purpose of the labour process—particularly when it appears oriented toward generating exchange rather than use values.

To understand how care workers react to these frustrating conditions, Hirschman’s (1970) essay on exit, voice and loyalty provides a useful framework. Exploring how individuals respond to dissatisfaction within organisations, institutions or states, he argues that loyalty affects the choice between exit (such as leaving a political party or ceasing to buy a particular brand) and voice (expressing one’s opinion with the intention to influence the organisation’s behaviour). Strong loyalty may limit exit and promote voice, while low loyalty may precipitate exit. Although Hirschman’s initial focus was on member (e.g. of political parties) or customer responses to declining organisations, the framework has subsequently been deployed in labour studies to analyse worker behaviour towards their employers (Allen and Tüselmann, 2009; Freeman and Medoff, 1984). While Hirschman argues that voice is activated by loyalty, and therefore reduces exit, we focus in this article on how loyalty can be shaped by forces other than voice in the context of care work.

In one instance, loyalty was discussed in contrast to Hirschman; Ruiner et al. (2020) argue that loyalty causes exit which then stimulates voice, as workers feel exit is the only way to push for change. Whether this is the case of course depends on organisational responses to exit; in long-term care, the latter mostly entail attempts to mitigate exit without questioning the structure of care provision. We therefore argue that exit is the strategy whereby a worker will leave a poor working environment, and voice refers to a worker who actively seeks to change or influence the operations of the organisation for the better. Loyalty entails a worker who forgoes exit in the hope that voice will develop and the situation will improve. As Hirschman (1970: 78–79) argues, ‘the expectation that, over a period of time, the right turns will more than balance the wrong ones, profoundly distinguishes loyalty from faith . . .; in comparison to [an] act of pure faith, the most loyalist behaviour retains an enormous dose of reasoned calculation’. In other words, there is an implicit expectation that employers will – by themselves or under pressure from workers – seek to address the concerns that underpin loyalty. When employees perceive respect and a shared purpose, loyalty is strengthened, which can lead to expressing constructive voice rather than silent withdrawal or exit (Rousseau, 1995). In short, an employee sees a future with the organisation that embodies their values through solicited input and expects a cooperative endeavour (Schrag, 2001).

Aside from the hope of making their voice heard, workers can also remain loyal for more instrumental reasons. ³ Berntson et al. (2010) found that workers with low employability tend to be more loyal to their organisation. Conversely, job insecurity tends to lower commitment to the organisation because the future appears unpredictable (Sverke and Goslinga, 2003; Sverke and Hellgren, 2001). Workers in care homes can also experience poor working conditions, as well as pressures linked to the labour process (Maslach and Leiter, 2017); they nonetheless display a sense of loyalty through their attachment to residents as part of their professional ethics (Baines and Daly, 2015; Lopez, 2006). Indeed, according to Whitfield (2021: 345), ‘connections with care recipients [assist] workers in coping with low pay and insecure contracts’; the consequence of this loyalty is an increase in emotional exhaustion, potentially leading to burnout and exit from the sector (Lightman and Kevins, 2019; Rodriquez, 2014).

By considering Hirschman and Nies together in the context of the nursing home sector, we can gain deeper insight into care worker loyalty. Hirschman suggests that loyalty can delay exit and entails hope for voice-driven change. For Nies, however, loyalty functions less as a strategic delay and more as a binding constraint that conceals the suffering of workers who are committed to the use value of their work. Based on this framework, we explore what loyalty means for LTC workers in Swiss nursing homes.

Methods

This study draws from five group discussions conducted with nursing home workers in Switzerland as part of a research project funded by a trade union. We adopted an approach inspired by conricerca (co-research) traditions (Alquati, 1962,1965). Rooted in mutual learning between researchers and participants, co-research positions the latter not merely as interviewees but as co-researchers of their own working conditions. The aim of this approach is also to empower workers to develop autonomy while producing knowledge (Roggero, 2014). We sought to combine conricerca with participatory health research (PHR) (Wright, 2013), which has gained popularity in the public health field since the 2000s. Its primary objective is to gain new insights and design strategies with those who are affected by diseases or other health challenges, leveraging their active involvement in the research process (Wright, 2021). In participatory approaches, participants are not viewed by researchers as mere objects of study but instead participate in its design and implementation, contributing their own interests and perspectives (Brunsmann, 2020). Although PHR has thus far mostly focused on the involvement of patients, it is well-suited to centring the perspective of care workers. By combining these similar methodological approaches, we sought to generate insights into the contradictions of care work by engaging workers in collective reflection on their lived experiences and perspectives.

Group discussions are a useful methodological approach as they entail a ‘carefully planned discussion designed to obtain perceptions on a defined area of interest’ (Krueger, 1994: 6), thus offering a flexible and participatory way of gathering qualitative data. They also provide the opportunity to obtain in-depth knowledge about the attitudes and perceptions of specific groups of people on a particular issue. It is a method of collecting data that draws not only on individual experience, but also on the collective elaboration of shared knowledge and experiences (Gibbs, 2012). To follow the co-research approach, we developed questions and prompts through a consultative process with 10 care workers who were members of the union supporting the project and who acted as co-researchers. The researchers trained them to facilitate group discussions, which proved invaluable because it ensured that the participants were engaged by peers who understood their situation and stimulated engaging discussions. ⁴

A total of 26 workers (of whom 22 were female) from various frontline care professions ⁵ participated in five group discussions. The discussions lasted approximately 90 minutes and were held in German and French (two each) and Italian (one). We utilised an online survey tool (Findmind.ch) to recruit participants, a process that had high uptake, 1505 people took part in the survey with 200 indicating they wanted to participate in the group discussions. However, few participants were actually able to participate in the physical discussions when we contacted them. Through feedback we found that many were exhausted from their work schedules and commitments in their personal lives. Given our goal to elicit in-depth discussions, we were satisfied with organising five events (despite having aimed for more originally) and were grateful for the time these workers took to participate. However, we recognise that the limited number of participants may introduce bias, not least related to the over-representation of workers with particularly strong views. Additionally, the group discussion did not allow us to differentiate between professional (or other) perspectives, as we did not identify individual contributions to the exchanges. We observed a striking convergence of views that flowed across the discussions, which not only proved useful for this study but will also be instrumental in developing further research based on participant perspectives.

The discussions were semi-structured, with three guiding questions supplemented by prompts about everyday work routines, perceptions of care quality and organisational pressures. The questions were:

1. What constitutes ‘good care’ from the point of view of workers?

2. How do working conditions influence the quality of care?

3. How does the way care is organised affect workers’ relationships with residents and other staff?

In practice, the discussions were shaped by participants’ concerns, often moving organically between themes. The group discussion format not only generated rich empirical data but also created space for workers to articulate issues they often kept to themselves while at work.

Data were audio recorded, transcribed verbatim, and analysed using thematic coding. The method for the analysis was based on the coding methods from Kelle and Kluge (1999) to create different categories and incorporate relevant elements. These categories were theoretically driven and reinforced through empirical data, which also served to create an ‘unexpected’ category.

Findings

As described above, the findings presented in this section reflect perspectives that converged during the group discussions. The quotes are therefore drawn from all participants and generally capture shared viewpoints, though we also highlight instances where opinions diverged.

Our key finding, which we explore through three interrelated themes, is that the loyalty of nursing home workers constitutes a trap rather than a way to activate their voice. The first theme that emerged from the data is the contrast between the way workers see the value of their labour and the NPM-inspired demands that shape care provision in practice. This clash underpins a kind of frustrated loyalty, the second theme where workers remain in their position as they individually hope to be able to realise the use value of the care they provide, while expecting problems to be noticed and addressed. However, workers’ frustration is not something that care home management has the ability to respond to, as it relates to the structure of care financing and provision. Voice is therefore even more needed, because it ought to be loud enough to be heard in policy discussions, which do not solicit inputs by workers. As a result, loyalty turns into a trap as workers’ aspiration to systemic change is blunted by their lack of voice, as revealed in this last theme.

When the production of exchange values undermines use values

A recurring theme across the group discussions is the idea that care is a vocation rather than simply an occupation. Many of the participants convey a deep personal commitment to their caring mission, describing their roles in terms of its social value, even while facing structural challenges. One participant reflects, ‘once upon a time, [our] work was a vocation, a passion’, highlighting how care work is inspired by an intrinsic motivation and purpose that goes beyond the duties associated with a job. All participants share an understanding of care that corresponds to Mol’s (2008) logic of care: workers ought to be responsive to constantly evolving needs while following a professional and empathetic approach focused on the well-being of the residents, who should have ‘a life with dignity’.

Living with dignity depends, fundamentally, on the relationships that workers form and sustain with residents. ⁶ As one participant explains, ‘the resident’s relationship with me is crucial’, and another noted, ‘when the relationship is good, there are also more beautiful moments and experiences’. The participants see care work as a relational and responsive process rather than as a series of tasks. They emphasise that to actualise the use value of care, they need to go beyond standardised routines: ‘good care is not what I measure and read in the documentation about how something was done. The question is whether the resident actually feels noticed, whether they are recognised in their need for help and their suffering.’

Despite pervasive dissatisfaction with the current state of the LTC sector, the participants consider the profession of care as more than a job – a vocational calling founded on a clear understanding of its social meaning. One participant concludes, ‘nursing is still the best job in the world’, suggesting that they continue to find intrinsic meaning in their role. However, that meaning is not reflected in the way that care work is valued in practice, by the organisation of care.

The major obstacle to fulfilling the workers’ vision of care is the increasing standardisation of the labour process. Participants describe their daily work as resembling an ‘assembly line’, some comparing the rhythm to that of the military. They lament that the current labour process focuses on trying to do more without adequate resources: ‘there are more and more tasks and residents, and we have to work faster and faster’. Given the interpersonal nature of care work, this pressure to increase individual productivity generates unbearable pressure.

The emphasis on standardisation and efficiency in care provision has been driven by a growing focus on the achievement of targets, particularly related to the recommended time for performing certain tasks depending on a resident’s degree of dependency. Participants refer specifically to the influence that the resident assessment tools, such as RAI, have on the labour process. One participant explains, ‘if you use only RAI, [work is] extremely standardised’, highlighting the contradictory effects of these tools on care work in practice. On the one hand, some of the participants note that these instruments render aspects of their work more visible and support continuity of care for the resident. On the other, most agree that these tools end up making the labour process more rigid, which undermines the ability to respond to residents’ changing needs, which constitutes the heart of the logic of care. Ultimately, the residents are viewed as a number instead of a person: ‘sometimes I have the feeling that the residents also become an economic factor’.

The documentation demands and stiff labour process also introduce forms of responsibility without autonomy, whereby the participants feel individually accountable for outcomes while being constrained by organisational limitations. They describe a scenario in which the number of residents that must be attended to is greater (even if tools such as RAI ‘measure’ their needs) than what they can perform while following the logic of care. The participants thus feel that they are left to handle situations without adequate resources; they experience mounting stress from trying to complete the work that is prescribed. One participant explains,

Sometimes we could not meet these timelines because a resident was unwell or very tired and we could not continue working at the normal pace because the resident’s situation did not allow it. However, it was extremely important for the employer that we got the residents ready on time, as agreed.

Participants highlight the suffering associated with the burden of such individualised responsibility: ‘Sometimes I wonder how it got to the point where we have to work non-stop and then still the blame [when things go wrong] is put on us as professionals.’ Another participant says, ‘[It is] difficult to manage [the daily care of residents] in a way that respects the individual because we have to juggle with the times that are allocated to us.’

The participants experience this pressure as at odds with the commitment inherent to their professional role, hampering them from providing a high level of care: ‘[Our] professional role does not allow us to provide just any [care] work, but we make an effort to do the best work.’

The labour process described by the participants creates an environment conducive to frustration and exhaustion. While care is a collective endeavour, much of the work is individualised, putting significant pressure on each worker. Despite these frustrations and pressures, workers form and maintain a strong sense of loyalty, as detailed in the next subsection.

Frustrated loyalty

The individualised, task-focused labour process generates emotional strain, in part due to the limitations it places on worker interaction with residents, who have relational as well as medical needs. While workers need the time and ability to respond to these complex needs, which manifest themselves unpredictably, they are increasingly restricted through the standardised labour process. The latter aims to promote efficiency and consistent outputs, and relies on extensive documentation. The participants identify these administrative duties (reporting, for instance) as a major contributor to their distress, one lamenting the ‘huge increase in administrative workload. . . . We all find ourselves behind computers entering data, and it takes an enormous amount of time.’ Another participant reports, ‘We talk more about administrative things . . . we forget the persons themselves.’ Ballooning administrative duties, which participants perceive as rooted in the exchange value function of their role, further exacerbate their distress by taking time away from nurturing relationships with residents.

Administrative duties are not just time-consuming; they contribute to imposing a new, managerial logic that conflicts with the logic of care and creates tensions for workers when they look after residents. As one participant explains: ‘We try to take time and talk with them [residents]. It doesn’t count [towards the organisational metrics that measure one’s work]. We are wasting time [according to the formal organisation of work].’ The quote conveys how activities essential to human dignity have been marginalised and rendered invisible in the prescribed labour process. The mismatch between what the participants value and what is imposed in their daily work causes considerable distress for them. This clash ‘cuts the nurse off from her primary role, which is to provide care according to her own assessment, not the assessment mandated by a person or by insurance. The nurse is deprived of her proper role with patients.’ Other participants reflect on the discouragement they experience due to their inability to work as they think they should: ‘When I was still working in care, you often had a guilty conscience [for not providing care].’ Another adds: ‘When my expectations are so high, but the reality is so far removed from them, I go home every evening with my head down.’ Most of the participants paradoxically remain loyal in their jobs despite the distress caused by misalignments in the organisation of care provision. Although they experience immense frustration in performing their jobs, participants convey a high degree of commitment to their role. Loyalty thus manifests not in the hope that change will occur organically, but through a commitment to providing the best possible care to residents despite organisational hurdles.

There was broad agreement among participants that their loyalty is not to the management or the institution, but to the residents and the profession: ‘The residents rely on us to be there for them and I don’t want to let them down.’ Workers strive to do right by the residents and risk being poorly evaluated against the organisational values they disagree with. One participant explains how this commitment can turn into a trap: ‘You feel responsible and think that the residents and patients will suffer if you say “no” [to their requests].’ The impossibility to say ‘No’ to residents’ requests offers a crucial insight into the suffering of care workers. Requests, which often involve the ringing of an alarm bell, are usually not urgent, all the more so when residents feel deprived of human contact. Workers, however, cannot know how serious the problem is in advance and feel compelled to respond, following the logic of care, despite being aware that unexpected interruptions make it difficult to complete their prescribed tasks. These disruptions also increase their stress levels, particularly as workers may have to leave another resident in the middle of a procedure. Such situations reflect workers’ deep commitment to the use value of care work and their frustration with the pressures from management which would have them refuse or discourage requests, so as not to ‘waste’ productive time. Workers feel trapped in a vicious circle as they are well aware that the more residents feel isolated, the likelier they are to demand attention.

Participants recognise that they are caught in a loyalty trap that compounds the effects of the stress they are under – due both to the above-mentioned tensions and to the extremely strenuous character of the work. One participant explains: ‘It’s sometimes a dilemma between protecting our own health and the fact that we might let someone down. This piles up the pressure.’ Such stress ultimately has negative psychological and physical effects and may increase absenteeism. Workers lament that they are constantly required to do more than is sustainable, ‘always giving 200%. The problem with that is that we are damaging ourselves because it might give the impression that everything is going well when we know that it’s not.’ Such overextension constitutes self-harm through individual commitment to one’s job, as a direct consequence of the belief in its social value. However, as the workers acknowledged during the group discussions, doing so reproduces rather than addresses the systemic failures of the sector.

The loyalty trap is therefore a source of individual suffering. One participant says that providing care ‘really is an effort and many become exhausted over time. I also think that this is not appreciated enough’, highlighting the consequences of remaining in the trap. Loyalty does not seem to improve the situation, but instead produces (and normalises) exhaustion, which can exacerbate understaffing, greatly compounding the problem, as one participant describes, ‘absenteeism is recurrent’. Another explains, ‘as [workers] are tired, as they do more than they should, they actually get sick more often. And when they’re sick, they’re not replaced.’ The workers that remain face heavier workloads and become further entrenched in the loyalty trap and its individual consequences – until some of them decide (or are forced) to leave.

Not blind loyalty: The underlying aspiration for change

The participants not only feel constrained in their tasks but silenced in their ability to advocate for reform. They are acutely aware of many areas requiring improvement and they have ideas; however, remaining loyal (i.e. not leaving their position) does not give them voice to push for substantial changes. Regarding their relationship with the employer, participants note a ‘lack of recognition from the hierarchy’, which is often ‘not supportive’. This lack of support and recognition, from the employer or indeed the health system as a whole, has a strong effect on the participants throughout the groups.

One participant explains that ‘if I feel that my needs or concerns are not taken seriously, cooperation becomes almost impossible’. This sentiment represents a recurrent theme throughout the discussions: care work entails a collective process that should be organised through cooperation and relationships with colleagues. However, the current labour process tends to marginalise such cooperation, due to its focus on individual performance metrics.

The participants explain that loyalty acts as a trap that hinders their ability to express themselves as they do not want to take actions that could harm residents. Instead, they become exhausted trying to maintain the level of care:

I always wonder why it is so difficult to reach out and network with other workers in care. Everyone is somehow trapped in their own world, maybe because of the stress and working conditions, and has no energy left to fight for change, which unfortunately leads to exploitation.

Participants repeatedly refer to the fact that they need to be present to care for the residents. One participant, while discussing collective action, explains that ‘[going on strike] is difficult in the care sector. Imagine if all the carers in the whole of [Canton X] went on strike.’ These reflections reveal the barriers that prevent substantial change by constraining the possibility of collective organisation – which, according to Hirschman, is the implicit expectation of loyalty. In the discussions, different perspectives emerged between union members and non-union members regarding industrial action. The former articulated a more systemic, politicised view of the context that produces adverse conditions, regretting that non-union members’ sacrificial focus on the caring needs of residents amounted to giving employers a ‘free pass’ that acts as an obstacle to organising. It does not mean, however, that care workers do not try and push back against standardisation and the exchange value imperatives associated with the organisation of care.

Despite the entrenched barriers, acts of everyday resistance by workers surface throughout the discussions. Participants describe minor but meaningful strategies to subvert the exchange value logic of the labour process in favour of more person-centred care. One participant describes how their team adjusts routines:

My team has a very good relationship with the residents and sometimes takes an unconventional approach, not the way it might have been dictated by the care home management in the past. We break up the structure to do things differently internally.

A participant comments: ‘If we have to do [a care task], we do not count the minutes because everyone’s pace is not the same and they are not all in the same situation’; and another explains, ‘we break away from that [RAI] a little bit, that is, if we do a daily structure we do it because it brings real benefit’. These strategies represent deliberate efforts to reclaim the vocational and social meaning of their work.

The vocational meaning of work embodies the use value in providing care. One participant defines their motivation as ‘my priority is the resident first’; and another conveys how they maintain this attitude: ‘I think it’s about letting go of the pressure to perform and putting the person back in the centre.’ In doing so, the participant demonstrates that voice exists but the lack of available organisational channels prevents its expression beyond micro-level adjustments. ⁷

The participants also reflect on the limits of these small acts of resistance, recognising the potential consequences, such as reprimands from management, who insist on the prescribed organisation of work. However, many seem prepared for this outcome: ‘My professional conscience is to take good care of the resident, even if it means being reprimanded by the bosses for a supposed delay. I do it.’ Workers also fear that the care of residents might be adversely impacted by collective action. One participant explains: ‘We don’t have to talk about going on strike straight away but simply learn to distance ourselves [from the prevailing organisation of work].’ With the recognition of the potential implications of collective resistance, participants discuss possibilities for greater actions to harness their aspiration for change.

All the groups recognise the problems in the labour process and identify possible solutions to actualise the use value of their work. These solutions range from greater collaboration between staff around decision making, putting residents at the centre of care planning with a focus on quality of life, and the necessity of adequate staffing to achieve this level of care. Furthermore, there was a clear appetite for change in the LTC sector. The participants concur that, to make any collective action successful, they need greater societal recognition of their work. One participant states: ‘But just because we have professional conscience doesn’t mean we should forget about our sense of boundaries, because it’s not one-way. That is to say there should be a reward [for our efforts]. Show recognition.’ Another says: ‘We also need to get the word out, our demands really need to get out there, and we need to unite and speak up.’ These quotes highlight the mood among participants that recognition and building alliances amongst workers and society are critical.

As the participants describe their strategies and express their desire for change, one participant comments, ‘you can’t give up hope’. Some still have a sense of hope that changes (initiated from above) will occur, and that things cannot continue as they are; others disagree, arguing that collective action is necessary. The discussions reveal different outlooks, providing a nuanced perspective on the loyalty that drives the workers.

Discussion

Our study has explored how care workers in Swiss nursing homes navigate the tensions between their commitment to the profession as a use value (rooted in an understanding of care as socially meaningful work) and the increasing standardisation and intensification of the labour process that reflect a growing focus on exchange value. We have revealed how these workers actively strive to sustain the use value of their work despite the personal toll and in the absence of serious prospects of institutional reforms. We suggest an extension of Hirschman’s (1970) theory by arguing that worker loyalty founded on commitment to use value can become a trap when voice is silenced, limiting prospects for change.

Use value as an anchor for loyalty

The shared commitment to the use value of care work is a central theme throughout the group discussions. The participants describe their work as a vocational mission, emphasising the importance of dignity for residents. These attitudes align with Nies’ (2021) analysis, whereby the value of labour of care workers is not derived from efficiency or measured outputs (related to exchange value), but from the ability to meet the human needs of residents, which embody the use value of care. Building on Nies, we find that the workers are frustrated because they are unable to do the work as they feel they ought to. This has, in their opinion, a negative impact on society as it undermines the care that people need.

Despite the pressures participants experience under a standardised and ill-suited labour process, they still derive meaningful moments of vocational fulfilment that develop the core of their professional identity. This use value is rooted in a commitment to providing life with dignity for residents, in contrast to the prevailing systemic logic premised on medical-technical indicators and cost effectiveness.

Clash between care logics

While the participants demonstrate a strong commitment to providing the best possible care, they highlight that their ability to do so is being systematically eroded through standardisation and efficiency metrics; the pursuit of exchange value clashes with and undermines the realisation of use values. Managerial diktats (responding to systemic constraints) reduce the ability to actualise the logic of care in the responsive manner that characterises it (Mol, 2008). This clash in the labour process has probably always existed in formal care work, as understaffing and stress are not a new phenomenon, but the influence of NPM has exacerbated it and made the work demands and stress increasingly unbearable for workers (Newman and Lawler, 2009).

The overreliance on measurement tools such as RAI and their associated documentation practices have not only transformed the labour process but also redefined what ‘care’ means from an organisational perspective. While, on the surface, the painstaking characterisation of certain care tasks has rendered the work more visible, it has concomitantly concealed a crucial part of it – the nurturing of relationships with residents and collaboration with colleagues – thus undermining the collective dimension of care.

Furthermore, increased standardisation has contributed to turning loyalty into a trap as it has imposed a sense of constrained autonomy in daily work, exacerbating the tendency to feel individually responsible for collective or systemic failures, in a way that ignores workers’ voice.

The trap: Loyalty without voice

Our findings challenge Hirschman’s assumption that loyalty ‘holds exit at bay and activates voice’ (1970: 78), thereby enabling organisational improvement. Instead, loyalty, rooted in nursing home workers’ professional identity and focused on actualising the use value of care, can simultaneously silence voice and prevent exit, due to ethical considerations. Without any activation of voice, loyalty can thus entrench care workers within dysfunctional environments. However, the participants in our study did not appear to remain loyal due to optimism that they would be able to exercise voice, but rather because of a strong commitment to residents and to the social meaning of care.

This commitment is not only the result of an idiosyncratic professional identity, but of changes in the organisation of the labour process. As Whitfield (2021: 345–346) notes in her research on English social care workers, ‘restructuring . . . has individualised responsibility for care quality’, leading workers to ‘perceive strikes as a moral failing in the context of care’. Unlike in Whitfield’s research, however, union members who participated in our group discussions were not primarily dissatisfied due to pay issues but shared with other workers the concern that the transformation of the caring labour process was adversely impacting residents. Both groups felt that this was an unsustainable evolution for carers and the cared for alike, although there was a difference in response: union members argued that accepting a flawed system harmed the residents, and that challenging it was in fact necessary. Non-union members, however, make up the majority of care workers in Switzerland.

We call this paralysis of voice the ‘loyalty trap’; it reveals how the participants internalise the responsibility for the well-being and dignity of residents, even though the labour process makes it increasingly difficult to provide care as use value. The trap stems from the workers recognising that only systemic change would alleviate the tension inherent in their work but seeing no way to develop a suitable strategy for change that would validate their strong commitment to the residents. One possible reason for this impasse is suggested by Béroud (2025), who highlights, in relation to the home care sector in France, that the organisation of the labour process is regulated not by the direct employers (whether individual beneficiaries or care home managers) but by the policy framework regulating the financing of senior care. The implication of that serpentine regulation is that, ‘unlike what can be observed in industrial firms, the capital/labour opposition is not central [in long-term care]: it takes indirect routes in which public authorities, through their choices regarding the financing of social policies, play a central role’ ⁸ (Béroud, 2025: 92).

This complex governance structure makes it difficult to apportion blame for problems and identify exploitation, as it ‘combines financial extraction . . . with an imperative to save money and depress government spending’ (Whitfield, 2021: 346, emphasis in original). It exacerbates the tendency for workers to take individual responsibility for the results of their caring activities rather than ‘recognising that there are agencies responsible for valuing their labour’ (p. 346). In short, loyalty is a trap in long-term care because it obfuscates the relationships of (exchange) value production and exploitation, concealing them behind an individualised sense of responsibility for outcomes over which workers have, in effect, far less control than they believe.

A key question is, then, how might workers mobilise and achieve participation in the organisation of their work? This organisational aspect is an increasingly accepted goal in nursing science research for improving quality of care (Forde-Johnston and Stoermer, 2022; Fulton, 2022). ⁹ Greater staff participation is necessary because, while care should be planned and organised, it ought to respond to the needs and aspirations of workers and residents, which cannot be fully determined a priori. In this regard, Lopez (2006) analyses an alternative model of care in Michigan, which he refers to as ‘organised emotional care’. He argues that providing good care hinges on a collective effort, which can respond to the complex needs of each resident and reduce pressures on workers while promoting autonomy. Succinctly, standards are followed but autonomy exists for workers, specifically for relational tasks in the labour process.

While we argue that workers remain caught in the loyalty trap due to their vocational commitment to the well-being of residents, we also acknowledge the possibility that some could forgo exit because they struggle to find alternative labour market opportunities. The desire to ‘escape’ the pressures of LTC work and take up what is perceived as less stressful employment has been documented in other contexts, for instance Japan (Broadbent, 2014). This could be a limitation of our study, as the conversation in group discussions did not engage with alternative job opportunities, nor did we have questions related to this concept. Further research could provide insights into this issue for LTC workers in Switzerland, given the widespread frustration with working conditions.

Given the current organisation of the labour process in Swiss care homes, characterised by false autonomy in an increasingly standardised context, it seems unlikely that more participatory practices can emerge without workers exercising voice and actively pushing for transformations. In other words, their ability to fulfil the use value in care work is contingent on overcoming the contradictory tendencies that have turned loyalty into a trap.

Conclusion

In this article, we have shown that nursing home workers are committed to the use value of caring for residents in a dignified manner, which depends on trusting relationships. The restructuring of the labour process, rooted in the production of exchange values, seeks to increase efficiency through standardisation, causing much frustration among workers in the process. The fact that many of them remain in their roles does not mean they are more satisfied than those who leave, but rather that they are willing to suffer for the sake of residents, as they value person-centred care. The result of this situation is a clash for workers in the provision of care that burdens them with processes and objectives they resent. They remain committed, but their loyalty is not helping strengthen their voice, as it inhibits collective organisation: this is what we call the ‘loyalty trap’. This inability to articulate voice is linked to the individualisation of responsibility for caring, which has been exacerbated by NPM reforms, and reinforced by the complex governance and financing structures of long-term care. The latter disperse responsibility and hide the relations of exploitation that put the responsibility for care outcomes on workers.

Our findings therefore support Nies’ (2021: 44) claim that workers

pursue subjective interests in executing their work activity [which is] always based on certain perceptions of what their work is or should be about . . . Subjective interests . . . depend on the way in which one’s work activity impacts on others: colleagues, customers, clients or even society as a whole. Subjective work interests . . . revolve . . . around perceptions of use value.

As we have shown, workers thus resent and resist the pressures linked to valorisation (for exchange). While an increasing number of them decide to leave, an even greater number remain, confirming Hirschman’s insight that loyalty delays exit. In our case of Swiss care workers, however, it does not stimulate voice. Many workers remain loyal because they hope that their contribution will ultimately be recognised and that fundamental change will occur. While they bemoan the damaging impact of the labour process on their own welfare, they appear mostly concerned with ways to improve care for residents. Yet, their loyalty to the latter is unacknowledged by an organisation of care that appears to pursue different objectives.

Our argument has implications for policy as well as for the collective organisation of care workers. Exit is not an adequate indicator of the severity of the crisis of long-term care in Switzerland. Hence, policy responses that focus on the search for an ‘exit fix’ could make things worse if systemic solutions are sidelined. For example, when the fix entails recruiting new workers, many decide to leave as they realise how dysfunctional the sector is. The workers that remain experience heightened pressure as a result, with the added burden of feeling individually responsible for the negative impacts of short staffing on residents. It is therefore crucial to pay more attention to the ways that standardisation reduces the ability to deliver resident-centred care. Policy should address the underlying systemic issues in long-term care, with the active participation of workers. Yet, this seems unlikely if workers are unable to exercise voice to guide reform.

While the negative impact of NPM on quality of care and worker frustration has received much attention, less has been paid to collective action in care (Zarska et al., 2021), and to the role that worker voice may play to overcome the clash between contradictory care logics. For trade unions, organising LTC workers requires not only improving working conditions but supporting them to transform the labour process (Abraham-Aggarwal et al., 2024; Murphy and O’Sullivan, 2021). There are signs that society would support such mobilisation; in Switzerland, the Nursing Care Referendum of 2021, which demanded better wages and working conditions, passed with widespread support despite opposition from the authorities (Federal Council, 2021) – a rare occurrence for bottom-up initiatives. Frustration has however been mounting with the slow pace of its implementation by the state, which has focused on proposals regarding training but dragged its feet on working conditions and staffing rules. This has prompted the emergence of a coalition of unions and other organisations (including the nurses’ association SBK) who accuse the government of prioritising cost concerns over quality of care and threaten to organise a strike in 2027 (Ley et al., 2026).

Our article suggests that there is a role for class-based organising of care workers to support voice, escape the loyalty trap and transform care. Addressing this gap is therefore crucial for improving working conditions and ensuring better quality of life and care for residents.