Breaking New Ground in Home Care Encounters : Shared Transformative Agency between Home Care Workers and their Elderly Clients
Year: 2020
Type: dissertation
Abstract: Physical mobility is a central factor in elderly people’s agency in the twilight of life. The loss of elderly people’s physical mobility presents a major challenge for modern society. To address this challenge, a group of practitioners and experts in the field of elderly care in Helsinki designed and implemented a tool, the Mobility Agreement, to cultivate agency and promote elderly people’s physical capability and mobility. The framework for the Mobility Agreement was developed from 2006 to 2009 as part of a co-operative research and development project on promising practices in home care, funded by the City of Helsinki and led by researchers from CRADLE at University of Helsinki. The Mobility Agreement provides structured support for the elderly in everyday life during home care visits. It is a plan jointly prepared by the home care client and his or her home care worker to promote day-to-day exercise. The home care worker provides assistance by selecting and monitoring the exercises. When necessary, a physiotherapist or an occupational therapist may be involved. With the introduction of the Mobility Agreement, the focus of the home care staff shifts: less time is spent managing home care duties on behalf of the elderly person, and more time is spent guiding and encouraging the client to exercise regularly. My study focuses on the encounters of home care clients and workers and the working methods associated with the Mobility Agreement, used to support the clients’ functional capacity and physical mobility. The practical underlying philosophy (Jones, 2007) is to move from doing to people, to doing on behalf of people and eventually to doing with people, in such a way that that the elderly client has more opportunity to be in charge and do things him- or herself, but with assistance rather than care. Qualitative data were collected from two developmental research projects in Helsinki over a six-year period (2006–2012) through observations, video-recordings during the home care encounters, and interviews of home care workers and their elderly clients. I used ethnographic observation, analyzed the dialogues, and tracked indications of the emergence of transformative agency among the participants. This analysis allowed me to conceptualize the adoption of the Mobility Agreement practice as a transformation in which home care workers could recognize and support their elderly clients’ transformative agency, as well as that of their own. This study also addresses the restrictive factors that may prevent the formation of agency. This dissertation is an empirical, ethnographic and longitudinal formative interventionist study, based on the cultural-historical activity theory (CHAT). Its aim is to generate and support a cycle of expansive learning (Engeström, 2015). The dissertation consists of four empirical articles and a summary that brings them together to present a picture for learning opportunities to break new ground in home care encounters. The study addresses three research questions: 1. What prevents the formation of shared agency in home care? The results of this study show that defensive learning cycles arise from home care workers’ fear of additional work and new competence demands, and from home care clients’ quest for safety, often crystallized in fear of falling. The formation of shared agency is hampered if the contradiction between the efficiency of the home care worker (doing his or her job) and the potential effectiveness of the home care service (maintaining the functional capacity and reducing social exclusion among elderly people) is not expansively worked out. The introduction of the Mobility Agreement thus becomes a source of frustration rather than a developmental process mediated by a useful tool promoting physical mobility exercises in home care visits. 2. What kinds of learning take place when an agency-fostering new practice is introduced in home care encounters? Expansive learning takes place when such a new practice triggers the development of an expanded shared object, which allows the home care client and the home care worker to construct shared goals, plans and practices concerning the clients’ functional capacity and physical mobility. This in turn requires new kinds of dialogue and cooperation, as well as reflective interaction between the two separate yet intertwined processes of the home care client’s learning and the home care worker’s learning. In other words, the client and the worker need to understand and commit to an idea of embodied and discursive co-configuration, which includes continuous negotiation between these two parties, and eventually also with other actors who contribute to the client’s overall home care service and wellbeing. 3. What main insights are needed to accomplish a sustainable, agentive transformation process in home care and change the home care script? These insights require co-configuration work that maintains and supports the elderly person’s functional capacity, postpones frailty, and reduces the risk of social exclusion. The planned and professionally initiated use of the Mobility Agreement succeeds when it connects and merges with client-initiated and incidental uses of artifacts as second stimuli. The expansive use of artifacts is of crucial importance for the quality and continuity of future-making in critical encounters. The answers given above summarize the findings of my four research articles (Articles I–IV). These articles also illustrate four perspectives of agency and their implications for home care. Article I introduces a perspective on agency as co-configuration in home care, with new forms of agency generated with the help of the Mobility Agreement. In article II, the key notion is “germ cell.” In supporting physical mobility among the elderly, getting up from a chair emerges as the germ cell, shaped and articulated primarily by means of bodily movements. The new collective concept of sustainable mobility emerges by expansion from the germ cell of the simple movement of getting up from a chair. This new concept has the potential to transcend and overcome the contradiction between safety and autonomy, and to generate a new kind of shared transformative agency. The meaning of the artifacts (Article III) emerges during critical encounters in which two or more relevant actors come together to deal with a problem that represents both a potentially shared object and a conflict of motives. Artifacts can be used both restrictively, to avoid engaging in the implementation of the Mobility Agreement; and expansively, to initiate and support actions that implement the Mobility Agreement. Article IV identifies the importance of learning cycles as a perspective on shared transformative agency. Learning emerges as interplay, movement between the expansive and defensive learning actions of the home care client and the worker. Home care encounters have an in-built asymmetry between the potentially powerful practitioner and potentially powerless elderly client. When the learning challenge requires reorientation of both parties, the power relations seem to become much more open-ended and mutable. When the home care worker and the client engage in either a predominantly defensive or a predominantly expansive learning cycle, in many cases it is not at all simple to determine who is teaching or leading, or who is guiding whom. Shared transformative agency is a key quality of expansive learning. It requires volitional actions from both participants. Mutual volition is at the core of shared transformative agency, defined as breaking away from a given frame of action and taking the initiative to transform it. Co-configuration requires flexible knotworking in which no single actor has the sole, fixed authority. New forms of work organization in the social and health sector require further research on negotiated knotworking across boundaries in the care of elderly people living at home. Keywords: Home Care, Mobility Agreement, Shared Transformative Agency, Double Stimulation, Expansive learning, Germ Cell
Source: Työväentutkimus Vuosikirja
Author: Jaana Nummijoki
Language: English
Subfield: Life-span and Life-course Studies
Field: Social Sciences
Domain: Social Sciences
Open Access status: green
OpenAlex ID: W3034405210