From Carers to Trainers: Professional Identity and Body Work in Rehabilitative Eldercare

Caring for elderly substance users: Challenges, dilemmas and recommendations

Aim: To investigate the challenges and barriers in Danish care professionals' work in relation to elderly citizens who use substances. Method: The study draws on data from a "going along" study of care professionals' encounters with citizens as well as interviews with professionals. This was conducted in two smaller, rural municipalities in Denmark. Findings: Providing adequate care for elderly citizens who use substances can be highly challenging. This is due to a multitude of factors, especially (1) the complexity of their health conditions, (2) contradictory logics of care (autonomy vs. healthy living), (3) citizens often unpredictable behaviours, (4) lack of cooperation between welfare systems and, not least, (5) lack of knowledge and education among healthcare professionals. Conclusions: There is a need for more specialised procedures locally, the appointment of local "experts", better cooperation between sectors and easier accessible training and information on the group on a national level.

Training the ageing bodies: New knowledge paradigms and professional practices in elderly care

In the Scandinavian countries, reablement has become a principle permeating all parts of elderly care, hence potentially transforming care and care work. This article explores the advent of new knowledge paradigms and practices of physiotherapists and occupational therapists transforming reabling care in particular ways, leading to what we term a logic of training emerging in the field. These professional groups have obtained a dominant position as reablement specialists in Norway and Denmark, where our extensive fieldwork was performed as part of a 3-year research project. Taking inspiration from Annemarie Mol's concept of logic, we study how professional practices are organised and infused with specific values, meanings and ideals in situated contexts. We hence explore the logic of training, its abstracted image of the body and rational goal-oriented model for progress measurement and its ramifications when addressing ageing bodies in a complex field marked by the unpredictabilities of the social and lived bodies, administrative rules and temporalities and the quest for empowering and involving clients. The paper concludes by pointing at new contradictions arising when practicing reabling care and particularly points out the tensions arising in care relations, where ambitions on empowering and disciplining the client and the elderly body may collide.

'Where do we come from and where are we going?' A study about the transformation of knowledge related to long-term care

The care crisis manifests the tensions and profound changes which are taking place in contemporary long-term care systems, leading to new care views and modalities in society. Through 26 interviews conducted with caregivers, family members and elderly people with care needs, this study aims to make visible the transformation in the conceptions of care in the Basque Country. First, the results show the displacement of familiarist ideas and values. Second, we describe the daily management of the social and moral tensions associated with outsourcing and the meaning of care work. Third, the findings indicate the emergence of new perspectives on the modalities of care. The contribution of cognitive polyphasia towards analysing the management and integration of new knowledge associated with care in a specific socio-cultural context is discussed. Finally, we consider the applicability of our findings in terms of relevant solutions for care management and innovation in this field.

Boundary work in task-shifting practices - a qualitative study of reablement teams

BACKGROUND

Health services worldwide have provided incentives for establishing teams to accommodate complex health care tasks, enhance patient outcomes and organizational efficiency, and compensate for shortages of health care professionals. Parallel to and partly due to the increased focus on teamwork, task shifting has become a health policy. Task shifting involves new tasks and responsibilities, which may result in social negotiations about occupational boundaries.

OBJECTIVE

The aim of this study was to explore how the division of tasks, responsibilities, and roles in reablement practices can appear as boundary work between physiotherapists (PTs) and home trainers (HTs).

METHODS

The study drew on data from fieldwork with seven Norwegian reablement teams, including observations and individual interviews with PTs and HTs. We conducted thematic analysis informed by a theoretical framework on professional boundaries.

RESULTS

We identified two different practices, which we labeled as: i) "The engine and the assistant" and ii) "The symbiotic team." We drew on these practices and theory of boundary making and boundary blurring to interpret the results.

CONCLUSION

The findings indicate that boundary-making processes may generate asymmetric power relations that may constrain autonomous work and job satisfaction in teams, whereas boundary-blurring processes may promote collaborative practices that enhance holistic approaches and mutual learning on reablement teams.

Tinkering with (in)visibilities: Caring for older people with surveillance technologies

New surveillance technologies have in later years been introduced in care for older people as part of a broader policy agenda of 'sustainable' welfare state retrenchment, promoting ideals of self-sufficiency and empowerment of older people 'ageing in place'. Drawing on newer approaches to surveillance studies, this article explores care workers' active labour in creating (in)visibility in a complex and ongoing process of tinkering, while negotiating political rationales of empowerment and professional accountability. Hence, visibilities are conceived as coded, reflecting different ideals and rationales. Based on extensive fieldwork in Danish eldercare, we analyse two forms of surveillance: virtual homecare and sensor-flooring, where clients are involved and positioned in different ways in accomplishing surveillance. We illuminate how the process of accomplishing (in)visibility does not only involve tinkering with technology, but also with spatial arrangements in the client's home, and with clients' behaviour. Consequently, we underscore how tinkering may turn out to be a difficult and even conflictual task of negotiating professional authority and accountability in ways that resonate with clients' sense of autonomy and policy ideals of empowerment. Our studies underline how the power dynamics of surveillance in care should not be overlooked, even though they are continuously negotiated in care practices.

Silence Agreements in Danish Elderly Care: Phantasmatic Asymmetry between Care Managers and Self-Appointed Helpers with a Muslim Immigrant Background

This paper explores the composite of elderly immigrants, self-appointed helpers (selvudpegede hjælpere) and care managers (visitatorer) in Danish municipalities. Free elderly care is a common good in the Danish welfare state. Instead of using the homecare service provided by the municipality, many elderly citizens with a Muslim immigrant background prefer to have a family member contracted as their self-appointed helper. The self-appointed helper is often a spouse, daughter or daughter-in-law, who ends up having the dual role as both a caring, loving family member and a professional care worker. Due to the special setup with self-appointed helpers working in their private homes, it is difficult for the care managers to follow standard rules and procedures. Instead, it seems to be a public secret that there is a gap between what we are supposed to do (according to the law) and what we actually do. We suggest seeing this gap as a silence agreement, where care managers, self-appointed helpers and elderly citizens refrain from asking all the critical questions (regarding the provision of care, the quality of care, working conditions, etc.) that no one wants to know the answers to. However, when the silence agreement from time to time breaks down, the relationship between the self-appointed helper and the care manager is haunted by a widespread phantasm where Muslim immigrants are cast as welfare scroungers. Basically, we argue that care managers and self-appointed helpers share a silent agreement but when it is neglected or violated, the latter end up in a vulnerable and marginalized position. The dynamic highlights the ambiguous intimate belonging of Muslim immigrant families and questions to what extent they were seen as legitimate subjects under the state in the first place.

Dignity equals distance? Pursuing dignity in care for older adults

This paper explores how dignity is articulated and pursued by care workers in two currently prominent policy initiatives seeking to reform Danish care services for older people. Based on ethnographic case studies of ‘reablement’ practices and the use of ‘welfare technologies’, the paper shows how these attempts to create dignified care services transform interactions between care recipients and care workers. The analysis is inspired by a socio-material perspective on dignity as ‘crafted’ and ‘co-laboured’ in daily practices, in an interplay between multiple human and non-human actors. In the cases studied, dignity is articulated as closely related to older people's increasing autonomy and independence of formal care, and is pursued through enhancing care recipients’ self-care ability, and through technological automation of care tasks. However, these articulations and pursuits of dignity do not stand alone. When everyday care practices are closely examined, dignity is also pursued by care workers as increased co-operation and equality between care workers and care recipients, as de-objectification, and as promotion of enjoyment and quality of life. In these practices, care is ambivalently positioned as both a potential threat to dignity, and as a prerequisite to achieving it. The paper concludes by discussing the risks of policy agendas pursuing a narrow understanding of dignity as simply independence of care.

What constitutes 'good care' and 'good carers'? The normative implications of introducing reablement in Danish home care

As populations worldwide are ageing, Western welfare states are currently implementing welfare reforms aimed at curbing the rising need for social and healthcare services for ageing populations. A central element in home-care reforms in several welfare countries is reablement: short-term home-based training programmes aimed at re-enabling older people to live in their own homes independently of care. In this paper, we explore how transitioning from compensatory care to reablement care is not merely a practical process, but also a deeply normative one. Drawing on Annemarie Mol's concept of 'ontonorms' we analyse the normative dynamics involved in transitioning from one form of care to another as reflected in reablement professionals' practices and discourses. The paper draws on 10 months of multisited ethnographic fieldwork carried out from April 2015 to February 2016 in a Danish municipality, including participant observations of reablement practices as well as qualitative interviews with 13 professionals working with reablement. We demonstrate that professionals generally consider reablement to represent a desirable shift in home care from 'bad care' practices of making people passive through compensatory care, towards 'good care' practices of 'keeping people going' despite their limitations. Moreover, we demonstrate that while therapists are valued as 'good carers' due to their ability to focus on development and training, nurses and in particular home helpers are devalued as 'bad carers' due to their 'caring genes' and lack of technical and theoretical skills necessary for documentation work. Finally, we discuss the implications of these normative dynamics, which may risk stigmatising compensating care practices, although this form of care to a large extent continues to coexist with reablement practices. In conclusion, we argue for a more nuanced approach to care, recognising compensatory care and reablement as complementary forms of care, each doing good under different circumstances.

Potentiality made workable – exploring logics of care in reablement for older people

In the face of population ageing, Western health-care systems are currently demonstrating an immense interest in mobilising older people's potentials. With this agenda in mind, several countries have introduced reablement: a type of home care aimed at mobilising older people's potentials for independence by means of short-term training programmes. Based on extensive ethnographic fieldwork conducted in Denmark's home care sector, this paper explores how elder-care professionals translate the abstract notion of ‘potentiality’ into practice. Theoretically, the paper draws on Annemarie Mol's term ‘logic of care’. I demonstrate that professionals draw on two co-existing logics of care: a logic of reablement encapsulating ideals of successful ageing and life-long development; and a logic of retirement, which in contrast allows people at the end of life to retreat and engage in enjoyable activities. Professionals manage to balance these logics in order to live up to policy obligations while at the same time complying with moral standards of good care. However, very little is achieved in terms of increased independence. I argue that by narrowly focusing on bodily and quantifiable potentials, the ‘potentiality paradigm’ holds the risk of deeming older people to lack potential. In conclusion, I therefore encourage a more inclusive approach to elder-care and ageing that recognises the complexities of ageing, including older people's potentials for retreat and leisure.