S t o c kh o l m Un i v e rs i ty D i ss e rt a t i on S e ri es Anna Essén Tec hnology
as
an
extension
of
the
human
body
E x p l o r i n g
t h e
p ot e n t i al
r o l e
o f
t ec h n o l o g y
i n
a n
e l d e r l y
h om e
c a r e
s et t i n g
© Anna Essén, Stockholm 2008 ISSN 978-91-7155-626-4 ISBN (XX-XXXX-XXXX) Printed in Sweden by US-AB, Stockholm 2008 Distributor: Företagsekonomiska institutionen
Stockholm University
Abstract
The present thesis explores the potential role and implications of technology in elderly care, as perceived by its users. This exploration is undertaken in terms of five empirical studies of a telehealth project, and a meta-analysis of their contributions. An important insight emerging from this work is the need to rethink the human subject as a body rather than a mere mind using technology. The thesis draws on phenomenology to re-conceptualize the user of technology, and to on this basis theorize about the potential role and implications of technology in care. It concludes that, in combination with humans who integrate technology with their other sensory and emotional capacities, technology can produce affect. The findings indicate that technology can contribute to seniors feeling safe, cared for, and thereby less isolated. The findings further demonstrate that, thanks to the perceptual capacity gained from technology, the workers become aware of new health problems that urgently call for their sensory and emotional responsiveness. On this ground, the thesis challenges the determinist view that technology threatens the essentially ‘human’. It rather concludes that feeling and other bodily resources are fundamental in the use of technology. Indeed, technology activates such ‘human’ capabilities. Hence, the technology studied plays a role as a complement rather than as a replacement to care workers. It increases their work burden by informing them about new needs. This may improve care quality but to an increased cost, which is relevant from a practical perspective. At a more general level, the thesis challenges the dualist legacies in mainstream management research, which have sought to divorce mind form the body, nature from culture and reason from emotion. It can thereby contribute to broader theoretical developments and fuel existing debates beyond the care setting. Keywords: care, telehealth, information technology, physicality, materiality, Merleau-Ponty, body, emotion, routines, variability, surveillance, privacy, service evaluation, service innovation, emergence, learning. © Anna Essén, Stockholm 2008 ISSN XXXX-XXXX ISBN (XX-XXXX-XXXX) Printed in Sweden by Printers name, City 2008 Distributor: Name of distributor (usually the department)
To Korris
Contents Stockholm University Dissertation Series ...........................................................i Anna Essén...........................................................................................................i NEW SERIES (if any).................................Fel! Bokmärket är inte definierat. XX (number of series) ................................Fel! Bokmärket är inte definierat. Abstract ............................................................................................................... iii Contents ..............................................................................................................iv Contents ...............................................................................................................v Preface and acknowledgements ..................................................................... 10 PART ONE........................................................................................................ 13 Introduction ....................................................................................................... 14 Highlighting weaknesses in dominant approaches to human-technology relationships ...................................................................................................... 17 Research ignoring the human context - seeking the effects of technology itself (determinism).............................................................................................................. 17 Viewing humans and technology as social facts (constructivism) ............................... 19 Equating humans and technology – viewing both as semiotic constructs (technoscience) .......................................................................................................... 20 The need for alternative approaches .......................................................................... 21
Suggesting a phenomenological approach .................................................... 23 Introducing the work of Merleau-Ponty ....................................................................... 23 Rethinking the user of technology............................................................................... 24 Uniting mind and the physical body ....................................................................... 24 Connecting the active body to the world................................................................ 25 Linking emotion, body and rationality .................................................................... 27 Re-conceptualizing the relationship between humans and technology.................. 27 Methodological reflection ............................................................................................ 29
The potential role and implications of technology in elderly care – the user perspective ........................................................................................................ 31 Viewing technology in use as an extension of the human body .................................. 31 Bodies emotionalizing and contextualizing technology .......................................... 33 Thinking of the implications of technology as capacity and feeling inside the body..... 34 Bodies selectively incorporating the micro and macro context.................................... 36 Studying the perceived reveals the perceiver ............................................................. 37
Conclusion ........................................................................................................ 38
Theoretical implications and future research directions ................................ 40 Practical implications........................................................................................ 43 References ........................................................................................................ 47 PART TWO ....................................................................................................... 54 Introducing the studies ..................................................................................... 55 1. The Role of Emotion in Service Evaluation: Senior Citizens’ Assessments of Long-term Care Services ............................................................................. 59 Abstract ...................................................................................................................... 59 Introduction................................................................................................................. 61 Literature review and theoretical framework ............................................................... 62 The role of emotions in evaluation processes........................................................ 62 Service dimensions ............................................................................................... 63 Interpretation variables.......................................................................................... 65 Methodology ............................................................................................................... 65 Data collection....................................................................................................... 66 Data analysis......................................................................................................... 66 Findings...................................................................................................................... 66 OUTCOME DIMENSIONS .................................................................................... 67 Independence and freedom................................................................................... 67 Technical outcome (physical health status) ........................................................... 67 PROCESS DIMENSIONS ..................................................................................... 68 Reliability............................................................................................................... 68 Responsiveness .................................................................................................... 69 Security ................................................................................................................. 69 Communication ..................................................................................................... 70 Competent personnel ............................................................................................ 70 Warm and caring attitude ...................................................................................... 71 Individualised service ............................................................................................ 71 Holistic care........................................................................................................... 72 Continuity of service .............................................................................................. 72 Dimension of physical environment and tangibles ................................................. 72 Summary of findings ................................................................................................... 73 Conclusions, implications, and future research........................................................... 74 Major conclusions.................................................................................................. 74 Theoretical implications ......................................................................................... 75 Practical implications............................................................................................. 76 Limitations and suggestions for further research ................................................... 76
References ........................................................................................................ 78
2. Variability as a Source of Stability: Studying Routines in the Elderly Home Care setting....................................................................................................... 82 Author: Essén, Anna ........................................................................................ 82 Abstract ...................................................................................................................... 82 Introduction................................................................................................................. 83 Method ....................................................................................................................... 84 Research setting ................................................................................................... 85 Data generation..................................................................................................... 85 Data analysis......................................................................................................... 86 Literature review and theoretical framework ............................................................... 86 Empirical material ....................................................................................................... 90 Artifacts ................................................................................................................. 90 The ostensive aspect – agreed on patterns........................................................... 92 The performative aspect........................................................................................ 94 Conclusion.................................................................................................................. 97 The role of and internal relationship between the parts of the routine.................... 97 Sources of variability in the home-help delivery routine......................................... 98 Theoretical implications ......................................................................................... 99 Managerial implications ....................................................................................... 101 Limitations and further research .......................................................................... 102 References ............................................................................................................... 103
Hodgson, G.M. Economics and evolution. Cambridge: Polity Press, 1993 104 3. The Emergence of Technology-based Service Systems: a Case Study of a Telehealth Project in Sweden..................................................................... 106 Author: Essén, Anna ...................................................................................... 106 Wordcount: 234 .............................................................................................. 106 Introduction............................................................................................................... 107 The innovation of technology-based services ........................................................... 109 Bricolage and technological drift.......................................................................... 110 Proposing a framework for studying the emergence of new technology-based services............................................................................................................... 112
Take in figure one about here........................................................................ 112 Method ..................................................................................................................... 113 Data generation................................................................................................... 114 Data analysis....................................................................................................... 114 The case ............................................................................................................. 115 Findings.................................................................................................................... 116 An injection of energy: Introducing a new technological resource without a clear end in sight.......................................................................................................... 116 Making do: “Creating” the resources needed to innovate services ...................... 117
Feedback mechanisms during the use of the new technology............................. 118 Redefining the automated alarms triggered by the new technology .................... 118 Redefining the patient data continuously provided by the technology.................. 119 Institutional constraints and stabilizing mechanisms............................................ 120 Interactions.......................................................................................................... 122 Drift: redefining the new technological resource – unexpected services emerging ............................................................................................................................ 123 Conclusion, implications and further research .......................................................... 123 Managerial implications ....................................................................................... 124 Theoretical implications, limitations and future research directions ..................... 126
References ...................................................................................................... 128 4. The Two Facets of Electronic Care Surveillance: Exploring the Elderly Caretaker’s View............................................................................................. 133 Introduction............................................................................................................... 133 Defining privacy ........................................................................................................ 135 Care surveillance as a potential privacy harm .......................................................... 136 Method ..................................................................................................................... 138 Empirical findings ..................................................................................................... 141 Care surveillance as enabling – feeling cared for ................................................ 141
And Ingrid states that ..................................................................................... 141 Care surveillance as constraining – feeling as if under suspicion ........................ 144 Discussion ................................................................................................................ 145 Conclusion................................................................................................................ 147 Limitations ........................................................................................................... 148 Research suggestions......................................................................................... 148 References ............................................................................................................... 149
5. The corporeality of learning in everyday practice .................................... 154 5. The corporeality of learning in everyday practice .................................... 154 Abstract .................................................................................................................... 154 Introduction............................................................................................................... 155 Practice-Based Learning Theory: A Critique............................................................. 156 The primacy of the perceptual .................................................................................. 158 Purposeful learning but without a conscious purpose ............................................... 159 Method ..................................................................................................................... 162 Data generation................................................................................................... 162 Mode of analysis ................................................................................................. 163 Findings.................................................................................................................... 164 The centrality of the body in learning how to perform daily tasks......................... 164 Technological artifacts as extension of bodily skills .................................................. 167 Discussions, concluding remarks and implications ................................................... 171
Theoretical implications and future research suggestions ................................... 172 References ............................................................................................................... 174
Preface and acknowledgements
This thesis would have looked completely different had I written it alone. Dear reader, You should have seen the first drafts of each paper! They asked different questions, used other theories and reached conclusions far from those outlined here. The papers were overall much longer. I realized – rather late— that research is not a matter of providing detailed and objective accounts of “the state of affairs” of things. To perform research is rather to participate in an academic debate by providing an argument that supports or contradicts others’ arguments. It is all about claiming something, and to do this in a convincing and trustworthy way. Being a researcher implies making decisions about what – of so many things that one reads and observes – to include, and about which conclusion – among numerous possible ones– to draw. This thesis is the result of various such subjective decisions about what to leave out and thereby hide. Dear Reader, please keep this in mind. But also recognize that the present thesis is not only the result of one person’s (my) subjective decisions. While never objective, it is the result of the choices made by numerous peer researchers, including many anonymous reviewers. In general, I believe that this thesis represents a pragmatic effort. The papers make this explicit, including not the most “true” theories but rather the most “useful” ones. Useful as they elucidate something that other theories do not. And, I have to admit, useful in the sense that they helped me to position my research and suited the interests of some Journal Editors (who considered the theories “timely” and “relevant”). Hence, the thesis should be seen as a pragmatic but serious attempt, made by a collective of scholars, to provide insights about how we can think about technology, care and human relationships and thereby contribute to theory and to society. I would like to thank some of you who have helped me during the process of writing this thesis. The names are NOT ordered according to Your importance. Solveig: In spite of your great knowledge and experience, you are extremely humble and generous with compliments. Thank you for inspiring me–when I have needed it the most (your timing has been amazing!). Thank you equally for always providing a critical eye towards eloquent but pretentious and useless theorizing. Thank you for asking: OK so what does that fancy concept really mean? What does it contribute with?
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Ali: You’ve tought me more about academic research than anyone else. Thank you for having the courage and energy to really criticizing my texts. Thank you for expecting much of me; for telling me: this is not good enough! Your belief in high quality science is unusual but contagious. Stockholm University should be very happy to have you. You have such high ideals. Don’t abandon them. The academic world has made me disappointed and disillusioned, as people’s ambition to gain power and publish a quantity rather than quality of articles often play too large a role in what gets done. But academics have also impressed me. Thank you my colleagues/friends at Stockholm University: Sara, Daniel, Torkild, Clara, Johanna, Robert, Eva & Dick for supporting me and for being devoted researchers. Your genuine interest in contributing to society or to theory has inspired me. Thank you my colleagues/friends at Harvard: Jeremy Nobel, David Satin, Juergen Bludau, Richard Bohmer, Norman Daniels, for letting me in your community, truly wishing to exchange healthcare research experiences. You showed me how exciting but tough research life can be. This thesis would not have been written at all if it weren’t for my sister and my parents. To Linda, my dear sister who encouraged me to become a Doctoral Candidate: You have always seen me as far more intelligent than I actually am – which has made me stronger! And Apricot & Pippi: A 30-year old feeling that ‘something’s missing’ after 2 days of work without mom and dad in the background – is that normal? Well, Yes. With you as parents it is. There is no room for me to thank you here. Suffice it to say that you are my best friends and you are fantastic role models. I could not have done this without you. I also want to thank my old friends Åsa Ö, Linda U, Pernilla, Åsa A and Sofia for being patient with me during these years! Åsa Ö: thank you especially for sharing your impressive knowledge about and experience of elderly care with me! Finally, this thesis might have been written: but I would have been a freak had you not been by my side, Christian. Writing a Ph D can make one fascinated by new theories that say absolutely no more— only with different words— than what most people already know. Thank you for reducing that tendency in me. And, thank you for telling me: “How beautiful you are” when I have actually looked like a wreck, in my dirty sweatpants, bad breath and mouth-full-of-half-eaten-cookies, sitting in front of the computer hour after hour…day after day… Getting married to you is the most emotional and best thing that has ever happened to me!
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PART ONE
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Introduction
Long-term elderly care constitutes a particular kind of service. Intimacy, relationship building and “humaneness” are frequently referred to as key aspects of such care services and the practice of nursing has historically been based on the assumption that direct human interaction has a therapeutic effect (Ford & McCormack, 2000; Glen, 1998; Gunter & Alligood, 2002; May & Ellis, 2001; Strauss et al., 1982). Introducing technology-mediated, remote services is bound to problematize such conventional assumptions. Certainly, the idea of computerized care is a controversial issue. Especially so in the context of elderly long-term care, in relation to which it has generated a polarized debate with information technology (IT) advocates and IT critics. Many scholars, practitioners and politicians foresee how IT-based home care services could enhance care quality and ultimately lead to an increased quality of life for the caretaker. It is also asserted that IT – a low cost resource – could replace humans in performing certain tasks and thereby enhance the effectiveness of care (Bashshur et al., 2005; Committee on Quality of Health Care, 2001; Demiris, 2004; Herbert et al., 2006; Korhonen et al., 2003; Teknisk Framsyn, 1999; SOU, 2002). Critics on the other hand, express concern about how technology may impose an instrumental rationality on care work that would serve the interests of managers rather than care personnel and elderly caretakers. They foresee how IT-based care services will replace proximal care services and argue that this could lead to the elderly becoming isolated from social structures, and to a mechanization and dehumanization of care more generally (Bauer, 2002; Dewsbury et al., 2002; Dunn, 2000; Dutta-Bergman, 2003; Hagberg, 2003; Stanberry, 2000; Williams et al., 1998; Taylor, 2001). While there are far-reaching visions as well as fears attached to the introduction of IT-based care services in the public as well as scholarly debate, it is yet largely unknown what could be the role of new technology and what implications it could actually generate in the elderly care setting. An important reason for this uncertainty is the narrow focus characterizing the academic discourse on IT and care. A large share of the current literature aims to investigate the ‘effects’ of IT in care. The outcome measures used are however limited to medical and clinical parameters such as blood sugar values and number of hospital readmissions (Bashshur et al., 2005; Hailey et al., 2002; 2004a; 2004b; Heinzelmann et al., 2005; Roine et al., 2001). It is further difficult to interpret the various (contradictory) results reported as most studies omit to explicate the 14
role the technology is assigned in the study setting, implicitly attributing the reported results to the technology itself. Studies arguing that “contextual” factors, beyond the specific technology in focus, influence the implications of IT in care are emerging (Ash & Berg, 2003; Kaplan & Shaw, 2002; Mohd et al., 2007; Schabetsberger et al., 2006). However, by focusing almost exclusively on how “managerial issues” often lead to the make or break of ITimplementations, this body of research, too, escapes some of the most basic and critical issues in the IT and care debate. Indeed, the idea of using new technology in care raises classical philosophical questions about the role and implications of technology in human life more generally (cf. Sharff & Dusek, 2003)—questions that has not been treated sufficiently in the current literature. I am referring to matters such as: Should we understand technology as antithetical to the emotionality and intimacy of human relationships? Is technology a force that leads to a mechanical execution of services and to a standardized human interaction? In short, will technology dehumanize care? Addressing these “thorny” issues requires an exploration of how humans (caretakers and caregivers) engage with new technology in actual, everyday situations. It seems reasonable to argue that care consumers’ and care workers’ experience of new technology is a fundamental question to investigate to bring the IT and care debate forward. Their views determine how the technology is used, what role the technology is assigned and hence the consequences the technology can contribute to. However, as indicated above, little attention has been paid to such basic but fundamental topics in academic research about IT and care. As a result, unfounded scenarios have gained foothold in the debate and in practice. Negative predictions have been particularly influential in the elderly care setting. Skepticism towards technology is widespread among care providers and the diffusion of technology in elderly care is slow (Essén, 2003). Many view technology as a threat to ‘genuine’ care giving work, while in fact; no one has really studied if this is the case. Against this background, the present thesis explores the potential role and implications of new technology in care service production and consumption. As opposed to the contemporary research on IT and care, the thesis acknowledges and brings to the fore the contextual, concrete and nonmechanical aspects of care, articulating the physicality and emotionality of care, and from there asks: how can technology contribute in this setting? The thesis has two parts. Part two includes five studies, based on two cases from the elderly care sector in Sweden where an in-home health monitoring system is used. Each study deals with a separate sub-question, uses unique theoretical frameworks and provides stand-alone theoretical contributions. Part one on the other hand, provides a meta-analysis and synthesis of
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the common themes emerging from the five studies at more general level.1 Using a phenomenological approach (primarily Merleau-Ponty (1962)), this overarching analysis departs from the studied care workers’ and care takers’ experience of technology. It assumes that the locus of this experience is the human body with its sensory and emotional intelligence, a body that is closely intertwined with the existing local setting and prevailing culture. What emerges from the overarching analysis is a new way of conceptualizing technology as an extension of the human body, including its material and ideational dimensions. The proposed way of theorizing about humans’ engagement with technology has several implications. It helps us to in new ways think about the potential role of technology in care from a user’s perspective and in general, about how technology can generate value in a setting such as care. In this way—by opening up perspectives rather than coming to a closure—the thesis contributes to the contemporary understanding of the potential role of new technology not only in care, but also in organizational life more generally. Part one of the thesis proceeds with a critical review of the dominant frameworks used in the IT in care literature, a presentation of an alternative theoretical framework used in the overarching analysis, its conclusion, major implications and suggestions for further research. The studies are presented in part two.
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Note that the studies include several important themes relating to care, technology, organization, innovation, learning and work that the overall introduction does not cover. 16
Highlighting weaknesses in dominant approaches to human-technology relationships
In this section I briefly account for the extant literature about IT and care services. The meta-analysis of the five studies in this thesis made me aware of the limitations in this body of research. While acknowledging its accomplishments, I shall argue that it often builds on assumptions that neglect important aspects of humans’ engagement with technology. As noted in the end of this section, this weakness can be traced back to a narrow-minded view of the human subject in social science research at general level.
Research ignoring the human context - seeking the effects of technology itself (determinism) Research about IT in care is mostly undertaken in computer science, informatics and medical disciplines and published in advanced engineering, telehealth, health informatics and e-health journals. Most studies are technology or medically-oriented and deal with either 1) describing prototype development and demonstrating technical possibilities, or 2) evaluating the clinical effects of new telehealth technologies. A large part of the latter category of IT and care research is rooted in health economic theory, seeking to compare the outcomes of IT-based care services with the outcomes of a previous nontechnological alternative. The results vary. While some studies conclude that telehealth can produce improved intermediate health-outcomes and reduce hospital readmissions, other studies report negative results (e.g Bashshur et al., 2005; Chan et al., 1998; Heinzelman et al, 2005; Hersh et al., 2002; Louis et al., 2003; Mair & Whitten, 2000). This literature is informative about the functional properties of technology but less so as regards how these functions are used. Indeed, “telehealth” reviews exclusively include studies employing health economic methods (randomized controlled trials) that focus on inputs (technological artifacts) and outputs (quantified clinical outcomes) while black-boxing the process of using technology. Reviews often exclude evaluations that focus on e.g. user, organizational, or other context-specific issues (see e.g. Roine et al., 2001; 17
Hailey et al., 2002; 2004a; 2004b; Taylor, 1998). This stems from the ambition to produce decontextualized, objective and generalizable results. Paradoxically, the result is often the opposite. Indeed, while there is an eagerness among healthcare researchers to evaluate exactly to what extent IT is ‘The Answer’ to the contemporary healthcare problems, their conclusions do not provide an answer to this question. An important reason for this is that authors neglect implications in areas beyond the strictly medical (patients’ physiological values) or clinical (hospital readmissions). The quantitative measures used say little about how care consumers or care workers experience the new technologies in their everyday life. In general, studies focusing on the objective functionality of technology and its quantitative effects do not provide much theoretical input to discussions about how technology will make patients feel when being provided with “IT-based care services”, about how care workers will use technology in their everyday work, or about how we can understand the role of technology in relation to human labor, that is, how humans engage with technology and how this affects their engagement with each other and the world. An explanation for the neglect of these issues is that studies adopting health economic models tend to view technology as given and attribute observed consequences to the technology itself, that is, implicitly provide a deterministic view of technology (cf. Collingridge 1980, Latour, 1992). A deterministic view also underlies the polarized positions in the popular debate and in practice (see introduction) in predictions suggesting that technology in general, and in itself, will lead to certain effects. Technological determinism is the thesis that technology is an autonomous force that constitutes a fundamental cause of change in society (Sharff & Dusek, 2003). This view essentially suggests that technology, once created and put in place, takes on a life of its own, follows a line of development almost contextless and thereby inevitably produces certain results. Discussing technology and society at general level, optimistic technological determinists have celebrated technology for its modernizing features, viewing technology as a revolutionary solution to social and economic problems (cf. Castells, 1996; Sharff & Dusek, 2003; Toffler, 1981). Pessimistic determinists on the other hand, have argued that modern technology (in general) threatens “the natural” and essentially human (Ellul, 1964; Heidegger, 1927/1962; Jonas, 1979; Marcuse, 1964/2003). This by taking over previous biological, perceptual and creative functions of human beings, producing a discontinuous and fragmented perception and by displacing human labor power in favor of automated technological production (Kellner 1999; Virilio 1994; 1995; 1997; 1999). Obviously, these philosophical utopian and dystopian views have reappeared in the care debate, in the visions concerning how IT itself represents a “technological fix” to the quality problems of care and
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in the argument that technology in itself will lead to a dehumanization and mechanization of care (see introduction). In summary, a large part of the IT and care literature and public debate is implicitly based on technological determinism. This is a problem. As noted by numerous authors, it is irrelevant to study or even discuss the effects of IT-applications themselves (Bijker et al., 1987; Feenberg 1992/2003; Kellner, 1999; Scharff & Dusek, 2003). Such an approach neglects the possibility of human users to make choices as regards how to use the technology. And as demonstrated in the studies here, such choices significantly shape the consequences of technology. I will return to this point.
Viewing humans and technology as social facts (constructivism) As a response and alternative to the deterministic view of technology, a view of technology as socially constructed emerged in social studies of science in the 1980s. This body of research suggests that what technologies are and become depend on the continuous reshaping of the technology by its users (e.g. Bijker et al, 1987; Bijker & Law, 1992). Similar perspectives have recently appeared in IT and care research. A growing number of studies depart from an interpretive and qualitative approach, studying the use of telehealth in specific settings. These studies show that a variety of healthcare information systems are little used, even though their technological accuracy have been demonstrated. It is argued that these results are due to organizational conflicts and other context-specific reasons, rather than the technology itself (e.g. Berg, 1999; 2001; Forsythe, 2001; Kaplan & Shaw, 2002; May et al., 2003; Mohd et al., 2007; Nicolini, 2006). The social constructivist influence on IT and care research has brought to the fore that technologies cannot be understood independently from how they are used in the actual context. This is an important contribution. However, authors have limited their attention to ‘organizational’ and managerial’ problems, at the expense of individual care workers’ and caretakers’ experience of new technology in their work or everyday life. In general, social constructivism can be criticized for suggesting “there is nothing but the social” (cf. Feenberg, 2003; Ihde, 1990). This is problematic because, as suggested by the studies in this thesis, concrete material aspects such as the physical attributes of technology and the physical capacities of human users influence how humans deploy technology, which in turn influences its implications.
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Equating humans and technology – viewing both as semiotic constructs (technoscience) It is finally relevant to mention that theories highlighting that the material dimensions of technology can influence its implications have appeared in the technoscience literature. The actor-network theory (Latour, 1987) suggests that technology and humans do not occupy separate domains or operate according to separate logics, nor does their relationship develop in some unilinear way (the former ‘causing change’ in the latter or vice versa). Work practices consist of various human and non-human elements and what comes to be the application and impact of technology is emergent, determined by the unpredictable interplay of these elements in each situation. It is argued that humans and non-humans should not be viewed as discrete entities; they constitute a sociotechnical assembly that should be dealt with as a whole (Latour, 1987; 1993). Haraway, (1991: 149, 152) writes that: “Cyborgs [are] creatures simultaneously animal and machine...” and that the “leaky distinction is between animal-human (organism) and machine”. These theories of technoscience have only begun to emerge in the IT and care/services research. For example, Nicolini (2007) observes how unexpected changes in care processes follow the introduction of IT in the studied care setting. He argues that the effects are unpredictable and emerge only when human and technological actants interact in situ. Hence studies need to explore unexpected effects, Nicolini concludes, and refrain from focusing ex-ante on some specific phenomenon (cf. Berg 1999; 2001; Constantinides & Baret, 2006). Technoscience theory has contributed to IT and care research by underlining the unpredictable aspects of technology use. However, while attempting to bring forth ‘the material’ in addition to the social, physical aspects of the human body such as emotion is left out in this literature. Indeed, technoscience research tends to portray humans and nonhumans as rather abstract ‘actants’, between which there is a symmetrical interaction. Latour takes the strongest stance, suggesting an interchangeability of humans and nonhumans. He writes that in sociotechnical collectives: “…there is no plausible sense in which artifacts, corporate body, and subject can be distinguished” (Latour, 1993: 197). This is close to the hybrid-cyborg figures of Haraway (1991). Both theories seek to blur the boundaries between subjects, artifacts and society, based upon semiotic principles. They describe human and nonhuman actors as textual constructs, operating on equal terms, merely according to different codes or ‘programs’. My observations certainly inspired me to criticize this view of “the worldas-text”. It obscures crucial ontological differences between humans and machines by producing non-situated and disembodied accounts of humans’ engagement with technology, and of organizational and social life in general. The studies included in this thesis demonstrate that the world includes more 20
dimensions than those that can be expressed in ‘programs’ or language. And, is the world nothing but emergent – are there not relatively stable structures – history – that influence human action and experience? I am not alone in raising these questions (see Ihde, 2002; Scharff, 2006). As others have argued, humans and artefacts can be made equivalent semiotically; but in practice they are not (Pickering, 1995). Humans are bodily, emotional and moral beings that are situated in a historical time in a way that technology in itself is not (Ihde, 2002). This should not be ignored in IT and care research.
The need for alternative approaches In summary, the extant IT and care services literature provides different views of technology and its users. Some studies implicitly draw on technological determinism and tend to ignore aspects related to human users completely; other studies provide a social constructivist view and can be criticized for reducing humans and technology to social facts. A limited number of studies use the actor network theory to acknowledge the mutual influence of the social and material. However, they do not discriminate between technology and humans, viewing them merely as abstract, semiotic constructs. This seems counterintuitive, especially in the long-term elderly care setting. As noted above, the importance of emotional sensitivity, intimacy and physical touch is well established in the care service setting literature. This was also clear to me in my effort to synthesize the findings of the studies included here. I repeatedly returned to the users’ perceptual capacity and emotionality when trying to understand the role of the technology in the cases studied. These issues seemed to hold as much explanatory power as the technology itself. Hence, the need for approaches that would help me take into account non-discursive, concrete, “human” aspects in the study of technology became obvious to me. Finding such a theoretical platform was however easier said than done. Indeed, not only the IT and care services literature, but also the organizational-, management- and sociological literature at more general provides a limited treatment of the human body and its emotions. Organization and management research has traditionally focused on human agents as rational decision-making agents, viewing rationality as a calculative, analytic and non-emotional capacity residing in the human mind (see e.g. Simon, 1976). Implicitly or explicitly, emotions have been dismissed as irrational, inner sensations and desires in need to be ‘tamed’ harnessed or driven out by the steady hand of reason (Brandth et al., 2005; Knights & Thanem, 2005; Nussbaum, 2001; Williams & Bendelow, 1998: 25) and the body has been treated like a non-intelligent and rather uninteresting physical container (Dale, 2001; Thanem, 2004; Turner, 1991; 1992; 1996; Shilling, 1993; 1997a, 1997b; 1997c). While there has in recent decades been a resurge in 21
interest in bodily matters in social science, theorizing is still limited and onesided. In relation to technology, scholars have primarily focused on the physicality of the body as constraining, discussing how technology may conquer such limitations, freeing subjects from their bodies (e.g. Balsamo, 1995; Featherstone & Burrows, 1995; Waldby, 1997; Williams, 1997, cf. Dale, 2001). In general, most studies discuss how social forces shape the construction of the body, thereby emphasizing the view of the body as passive, as an object of control and as acted upon 2 (Dale, 2001; Shilling, 1993; 1997a; 1997b; 1997c). Research on the body has further been disconnected from research about emotions and vice versa; the limited research that does exist about emotions tends to view emotions as mental rather than bodily3 (Knights & Thanem, 2005; Williams & Bendelow, 1998). This situation within social science research reflects the powerful legacy of the mind/body dualism of e.g. Cartesian philosophy. Scholars’ eagerness to turn away from biological determinism is most likely another reason for the prioritization of the ‘social’ and ‘mental’ at the expense of the physical (Knights & Thanem, 2005; Shilling, 1993; 1997; Turner, 1992). Given the state of the contemporary literature, I concluded that neither IT and care literature nor the mainstream social science literature could help me to frame the findings in my five studies. These findings do not highlight human ‘minds’ experiencing and reacting to the technology, based on factbased, calculative evaluation procedures. Rather, they point at active human bodies, with enabling physical capacities, using technology. Emotions further play various positive roles in the users’ experiences in ways that I could not categorize as purely mental or irrational. Hence, I could only agree with scholars who criticize the contemporary literature for neglecting that 1) the body should not only be viewed as acted upon but also as an active and enabling force, and 2) emotions are part of human physicality, expressivity and intelligence (Damasio, 1994; Hassard et al., 2000; Knights & Thanem, 2005; Nussbaum, 2001).
2
The prevalence of accounts of “docile bodies as faceless objects” (McNay, 2000) in the organizational literature is often explained with the influence of Foucault. However, as noted by Crossley (1996), Foucault does view the body as both active and acted upon. But he tends to be weaker on seeing the active body, and he does not provide a coherent theory of embodied agency (McNay, 2000), which may have led to the focus on the inscribed body rather than the lived body in Foucauldian organizational literature (Crossley, 1996). 3
This research has largely built on Hoschild’s (1983) notion of emotional labor. While providing significant insights, Hoschilds theorizing about emotions does not emphasize bodily, physical aspects (Knights & Thanem, 2005). It also runs into problems of micro and macro linkages (Williams & Bendelow, 1998; Wouters, 1989). I will return to this point. 22
Suggesting a phenomenological approach
Looking for an alternative philosophical ground that would help me explicate the insights emerging from the studies included here, I turned to the phenomenological literature. I found that Merleau-Ponty’s (1962, 1965, 1968) work provides a fruitful platform for highlighting the physical and emotional aspects of human experience, without returning to biological determinism.
Introducing the work of Merleau-Ponty Phenomenology is the study of human experience from the first-person point of view. That is, phenomenology is interested how humans perceive the world and its objects rather than in whether or not the objects ontologically exist in any objective sense.4 Merleau-Ponty entered the phenomenological field in the 1950s, introducing the notion of the body-subject as the source of human experience. Other phenomenologists had prepared the ground for this view. Husserl (1970[1936]) emphasized that “the life-world”, i.e. humans’ subjective perception of the world is the basis of their existence. Heidegger (1962[1927]) also emphasized the every-day experience in the world, talking about how “being-in-the-world” is what makes humans know things about the world (Yakhlef, 2008). Now, while Merleau-Ponty (1962; 1965; 1968) extended he also diverged from these ideas. Merleau-Ponty criticized Husserl’s understanding of human perception and experience as conscious acts occurring in the mind, viewing instead human experience as involving the whole body – in action, and intertwined with the world.5 In general, Mer4
Phenomenology includes several sub-branches, see e.g. Embree et al (1997).
5
It is important to clarify that Husserl understood human experience as constituted by a transcendental, inner, meaning-giving realm. Husserl sought to lay bare the essential structure of this deeper realm of subjectivity and consciousness. Husserl was uninterested in any reality beyond the lifeworld, “bracketing” the question of the independent existence of the natural world around us. Heidegger argued that we should not study our activities by “bracketing” the world, rather we should interpret the meaning things have for us by looking to our contextual relations to things in the world. Heidegger resisted Husserl’s Cartesian emphasis on consciousness, arguing that Husserl’s transcendental subject was too subjective in the sense that it loses the world, leading to a philosophy of consciousness that emphasizes a solitary, disembodied cogito. Heidegger suggested that our ways of relating to things are in practical activities like hammering, in a context of equipment and in being with others. Merleau-Ponty ex23
leau-Ponty saw the central phenomenological task as one of re-establishing ‘the roots of the mind in its body and in its world’ (Merleau-Ponty, 1965). In these terms, Merleau-Ponty challenged classic phenomenology, where that which thinks is separate from the material world and the body, and where our experience is directed toward things only through concepts and ideas (Dreyfus, 1979; Ihde, 1993; Merleau-Ponty, 1962; Stanford Encyclopedia, 2004; Williams & Bendelow, 1998). This perspective helped me to rethink and thereby better understand the experience of the studied care workers and care takers. My intention is to here present to you the re-conceptualization of “the user” of technology that emerged as a result of a parallel re-reading of the five studies and a gradual understanding of Merleau-Ponty’s philosophy.
Rethinking the user of technology Uniting mind and the physical body I saw human bodies rather than mere ‘minds’ experiencing the technology (and other objects/events) when analyzing the five studies in this thesis (Study 1, The role of emotion in service evaluation: senior citizens’ assessment of long-term care services; Study 2, Variability as a source of stability: studying routines in the elderly home care setting; Study 3, The emergence of technology-based service systems: a case study of a telehealth project in Sweden; Study 4, The two facets of electronic care surveillance: exploring the elderly caretaker’s view and Study 5, The corporeality of learning in everyday practice). The care workers and caretakers further evaluated the technology not only based on fact-based, calculative processes, but using their bodily emotions. By reading Merleau-Ponty’s claim that “human subjectivity is a bodily subjectivity” and that “the body is who we are; it is our consciousness, intelligence and intentionality”, it struck me that what these findings pointed at, was simply that the user is a body. Merleau-Ponty further underlined the primordial intention of the human body to be in equilibrium in the world. He saw this as a pre-reflective intentionality, bound to and realized only in the bodily performance itself (Vassleu, 1998). From my view, Merleau-Ponty hence talks about a bodily intelligence that helps us to act ‘smoothly’ in the world. This kind of bodily tendency was obvious primarily in the experience of the care workers studtended these ideas, claiming that the human subject is not a transcendental subject but a subject that emerges form nature. Hence, as noted by Bernet (1993), in Husserl’s work, there is a reduction of natural life, while it is in the work of Merleau-Ponty a reduction to natural life.
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ied here. Their basic, pre-reflective intention to acclimatize to their local and cultural environment clearly influenced their use and evaluation of the technology. (e.g. Study 3, 5). Now, the care workers and caretakers studied did not only engage with the technology in sub-conscious, non-discursive ways. As the interview transcripts reveal, the studied users also reflected about how to use the technology, and about its actual and potential contributions (Study 3, 4). Similarly, Merleau-Ponty did not deny the so-called reflective, mental, rational or discursive aspects of human life. What he did want to suggest was that such aspects are inseparable from our bodily, physical nature. He argued that discourse is far from a disembodied process, it is a fleshy process; it is produced though the work of the body. In short, there is no choice between discourse and fleshiness, according to Merleau-Ponty’s theory. They belong to each other “as do legs and walking”. 6 This seemed to me a fruitful view as I could not clearly separate the studied users’ conscious and sub-conscious, brain-related and body-related, factbased and emotion-related perception of the technology, they rather seemed intertwined, and equally important. Hence, the present conceptualization of “the user of technology” draws on Merleau-Ponty to suggest that the body is neither solely a discursive object (as suggested in pure constructivist views) or solely flesh and bone (the naturalistic view). The body rather provides a physical basis for all its discursive processes. In short, the ideational and the material are intertwined. This notion of intertwining also concerns the relationship between subject and object or between the perceiver and the perceived.
Connecting the active body to the world Merleau-Ponty argued that perception is not a matter of our body passively receiving sensory data form the world that our isolated mind later on interprets. Rather, perception should be understood as our body actively but prereflectively interrogating the world. Perception is about our body interpreting the world in relation to our practical engagement in the world, i.e. the projects we are involved in. My findings support Merleau-Ponty’s rejection of the idea that perception is an ‘inner’ representation of an ‘outer’ world of given objects (MerleauPonty 1962; 1968). 7 The studied care workers and care takers clearly per6
Indeed, despite Merleau-Ponty’s emphasis on our ‘primordial union with the world’, he made it clear that one never returns to immediate experience. Reason has a role in our ways of living, but it is based in the phenomenological exigencies of the subject and their life-world. 7 Merleau-Ponty argued that perception is not merely the result of the functioning of individual organs, but also a subjective human act in which each of the senses informs the others in virtue of their common behavioral project. As noted by Barral (1965: 94), Merleau-Ponty’s 25
ceived the technology (and other objects/events in the world) in relation to their concrete day-to-day interests (Study 1-5). They further perceived the technology from somewhere. Merleau-Ponty argued that our perception is contingent on our bodily position and tangible presence in a specific physical situation (Mallin, 1979). He also underlined that our perception is situated in an historical situation and is influenced by social, economic, political and cultural forces. This does not mean that Merleau-Ponty advocated a view of human bodies as passive or as mere social constructs. According to my interpretation, his theory opens up for a view where our bodies incorporate the micro and macro structures in which they are situated, an incorporation that is selective, influenced by the physicality of the body itself. In general, Merleau-Ponty’s theory emphasizes the lived, active body-subject rather than the body as an inert matter that is acted upon (Dale, 2001; Grosz, 1994; Williams & Bendelow, 1998). This resonates well with the findings in my studies. For example, I would not describe the care workers’ bodies as mere recipients or mediums of social structures. Sure, they incorporated values in society but they did this selectively, thereby selectively reproducing – renewing— structures. Hence, the present conceptualization builds on the premise that the human body is shaped by, but also agentic and active in relation to prevailing structures.8 (E.g. Study 3, 4). The conceptualization of the user suggested here further assumes that this mutual influence also applies to the human body and objects in the local, physical setting. Merleau-Ponty provides an example of a patient that experiences an absent limb (hand) as a correlate of those aspects of the world that ”speak to” the hand, e.g. the piano to be played, or the doorknob to be opened. When the patient restructures her/his world in such as manner that the things no longer beckon to the lost limb, then the experiences of the limb vanishes. To me, this example illustrates how our experience of ourselves (our ideational and material subjectivity) is influenced by the objects in our surroundings, and how we perceive objects on basis of our own, enabling and constraining, physicality. As Merleau-Ponty made clear, "whenever I try to understand myself, the whole fabric of the perceptible world comes too (Merleau-Ponty, 1964:15). He insisted that: "man is a network of relations" (1962: 456) and maintained that these relations are not something that we can unravel. The interdependence of the network is what gives humanity its very qualities, and by dissecting it, we risk losing the very thing that establishes us as human.
theory suggests that "if we attempt to localize and sectionalize the various activities which manifest themselves at the bodily level, we lose the signification of the action itself”. 8 As indicated by Schmidt (1983), Merleau-Ponty’s view may have inspired Giddens later structuration theory (1979; 1984), which recognizes that social structures produce but are also selectively re-produced (and thereby potentially renewed) by individual agents 26
Linking emotion, body and rationality In Merleau-Ponty’s theory, the mutual encroachment of the subject and the world and the ideational and material also explain human emotion. MerleauPonty refused to describe emotions as private and purely ‘mental’. According to his philosophy, emotions are essentially communicative, and intersubjective, constituted as physical and cultural dispositions through techniques of the body (Crossley, 1995a; 1995b; Williams & Bendelow, 1998). As noted in the Stanford Encyclopedia (2004), the view of emotions as physical (residing in the individual’s body) as well as cultural implies a certain ambiguity at the heart of our experience. Trying to discern what is an authentic emotion of the self, which is not induced by the demands of one's society, is infinitely difficult. Merleau-Ponty refused to use the concept of authenticity for his entire career “because of its overtones of an unattainable individualism” (Stanford Encyclopedia, 2004). He would not want to say that coming to terms with one’s own situation in an empowering way is impossible, rather that we cannot transcend of our environment. Merleau-Ponty's suggestion is that “circumstances point us to, and that they allow us to find a way” (Merleau-Ponty, 1962:456; Stanford Encyclopedia, 2004). Overall, Merleau-Ponty’s view of emotion is far from a ready-applicable package. Nonetheless, in combination with other, newer emotion theories (Crossley, 1997; Damasio, 1994; Nussbaum, 2001), his philosophy helped me to articulate what my studies hinted at: that emotions are bodily communicative capacities that help us to behave effectively and reach our goals. Emotions advised the studied care workers and care takers in how to in, if not rational, at least not irrational ways perform actions and make judgments (Study 1-5). On this ground, the present conceptualization assumes that as all our bodily capacities, emotions are forthcoming in actual situations, when our body performs actions in the world; and as with all our knowledge, emotions are shaped (enabled and constrained) by the physicality of the body as well as by culture. That is, emotions are ideational and material and they include prereflective as well reflective dimensions.
Re-conceptualizing the relationship between humans and technology The studies did not point at care workers and caretakers focusing on technology. They rather exhibited users engaging with each other through technology. Merleau-Ponty similarly argued that we often perceive the environment though intermediary objects without being explicitly aware of the intermediary object. For example, he referred to the blind person who is accustomed to using a stick and senses where he is "through his stick". The blind man is not aware of the stick but the objects he attempts to navigate about: it 27
is actually the other objects that make him aware of the stick. Further, we “know” how to turn a corner with our bike almost as if the bike was our own body. We think from the point of view of the bike. Thus, Merleau-Ponty’s theory suggests that we can incorporate instruments into our own body schema. This knowledge is not necessarily reflective or discursive; it is practical, embodied know-how and mastery (Crossley, 1995a; 1995b; 1996). This argument can be traced back to Heidegger’s (1927/1962) “ready-tohand” e.g. the hammer functioning as an extension of the arm’s capabilities (Selinger, 2006). Ihde (1990) develops the idea of humans reaching the world through technology. He maintains that the intentionality of bodily action goes beyond one’s bodily limits and he argues that technologies must be understood as existing in relation with humans rather than as discrete objects (Idhe, 1993). Ihde provides a useful conceptualization of human-technology relationships in this context. He writes about embodiment relations, where we humans take technological artefacts into their experiencing. In embodiment relations technologies constitute and approximate the status of a ‘quasi me’, as e.g. eyeglasses, and we perceive the world through technology. The technology withdraws to such a degree that it becomes the means and not the object of our perception. This is obviously similar to Merleau-Ponty’s discussion of the blind man’s cane serving as an extension of his perception. In hermeneutic relations the artefact is not transparent, but provides a representation of the world. In such relations readable, interpretable technologies make the world accessible to us in ways impossible for naked perception. In such relations, the perceptual focus is on the text of the artefact. Finally, alterity relations refer to relations where humans focus attention upon the technology itself and perceive the technology itself a quasi “other”, to which we relate, as e.g. in playing video games (Ihde, 1990). I will use this conceptualization to analyze the studied care workers’ and care takers’ engagement with technology in the next section. Suffice it here to say that in embodiment and hermeneutic relations, technology can be understood as an extension of the human body and perception. This implies that the technology can expand the human body’s ability to perceive affordances, i.e. opportunities for action. It is difficult to determine whether or not this extended perception resides inside the human body, or if it is external, residing in the technological ‘object’. This resonates with MerleauPonty’s problematization of the separation of the subject/object. Against this background, this thesis does not attempt to draw a strict border between the human user and the technology used (between the ideational and material) but assumes that there is a continuous relationship between these two.
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Methodological reflection Drawing on the phenomenological approach described above, the present thesis departs from the human subjective experience when analyzing the potential role and implications of technology in care. It assumes that the situated human body (with it’s reflective and pre-reflective capacities) is the locus of this experience. This has methodological implications. It suggests that the researcher needs to study not only that which can be expressed in words, but also non-discursive aspects. A challenge indeed. The thesis is based on empirical material generated by means of observations, in-depth interviews and field-work (see further the method section in the studies and appendix 2). While this fieldwork provided access to non-discursive elements, it is difficult to in the format of an academic thesis, i.e. with text, provide a portrayal of emotional, pre-reflective and tacit aspects of human action (cf. Knights & Thanem, 2005). This thesis should however be understood as an attempt to bring such aspects to the fore. The thesis does talk about the human body on the one hand, and technology as something “perceived” on the other. This may appear contradictory to Merleau-Ponty’s phenomenology, which resists any strict border between subject and object, inside and outside, perceiver and perceived. However, as noted by Merleau-Ponty himself, it may be useful, in a particular situation, to conceive of a seer and a seen, a subject and an object - provided that the terms of such dualities are recognized as relationally constituted. 9 In the spirit of phenomenology, I further want to highlight how my own body and its situatedness have influenced the present work. This thesis is written from the perspective of an eager-to-publish Ms Sc in computer science. With a passion for elderly care. And with an essentially positive attitude to technology. I am not claiming that the cases I have studied have presented themselves to me in any absolute manner, from all their angles. My observations and the findings presented in the studies are not the result of my eyes and ears ‘neutrally’ and passively receiving sensory data and my mind later interpreting this. My observations have rather been linked to my situated ambitions, to find something publishable inter alia. Encouraged by trends in the academic literature (primarily in management- and organization science) and the theoretical interests of peers at my institution, my body has selectively perceived certain events and not others, in pre-conscious and conscious ways. The physicality of my body has shaped the writing of the present text, which is not the result of a merely calculative, fact based reasoning in my mind. The text is also shaped by pre-reflective and emotional, i.e. bodily 9
Merleau-Ponty did not want to deny the possibility of cognitive relations between subject and object. In his theory, the seer and the seen condition one another. Our capacity for seeing is different from the capacity for being seen.
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aspects. In some ways, such aspects may have led me in arbitrary directions. The fact that certain “complicated” theories have made me feel excited (rather than them being more useful or ‘true’ than other theories) have most likely led me to use them rather than other alternatives. My use of certain theories rather than others may further be related to me being well rested, sitting in a comfortable chair, satisfied food-wise (hunger tends to make me more critical) when reading these theories, and in an opposite physical condition when reading other potential theories. Overall, I however feel that my body including its emotions has constituted an important resource in my work, leading me towards relevant paths. I have seldom had a clear formulation in my head before writing a paper. Rather, my intention has been to “write my way to” an idea or conclusion. Indeed, I could not have asked someone else to “write down my thoughts” as most of my conclusions have been forthcoming through the bodily effort of writing. In a sense, my hands have drawn conclusions as much as my brain. As regards emotions, I agree with Jaggar, who argues that emotion is necessary to producing reliable knowledge (1989). For instance, my efforts to not only draw publishable, but also “fair” conclusions and to provide “honest” accounts of the methods used are not the result of any calculative fact-based reasoning. My emotions rather forced me to - I would feel uneasy and guilty if I had not. I do not attempt to determine to what extent these enabling and constraining emotions and moral convictions are ‘my own’ or constructed by society. Suffice it to say that these bodily forces have exerted concrete (I have felt them) influence on this work in a way that I refuse to call irrational.
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The potential role and implications of technology in elderly care – the user perspective
The re-conceptualization of the user outlined above makes it possible to in a new way view the encounter between individuals and technology (compare with the deterministic, constructivist and technoscience approach in section two). Assuming that ‘the user is a body’, with all that it implies, I will in this section begin to tentatively conceptualize the potential role and implications of technology in care, based on themes that emerge from the five studies in this thesis.
Viewing technology in use as an extension of the human body The studies in this thesis suggest that humans use technology if they feel that it provides them with relevant capacities. Given that this is the case, they think of and use the new ‘extended’ or ‘technology-mediated’ capacity just as any of their other ‘naked’ bodily capacities. That is, they incorporate the technology into their own body. For example, Study 4, The two facets of electronic care surveillance: exploring the elderly caretaker’s view, highlights that one of the seniors studied here did not perceive that the technology expanded her bodily capacities, rather the opposite. She perceived the technology as an opponent rather than a component of her own body. She engaged in an alterity relation (Ihde, 1990), experiencing the monitoring technology as some foreign and intruding “other”, constraining her possibility of action. As a result, she rejected the technology (interrupted the service). The reaction can be understood as an illustration of how the human body rejects technology if it feels that the technology creates tensions (deviations from some ‘optimal bodyenvironment relation) rather than facilitates a smooth functioning in the world (Merleau-Ponty, 1962). Just like the human would reject an organ implant if it created conflicts with other organs. The example further illustrates how the emotion of the body can be constraining, impeding certain uses and hence preventing certain implications. 31
The majority of the caretakers studied however embodied (Ihde, 1990) the technology deployed. The technology itself is not the object of these seniors’ attention; the technology becomes transparent and withdraws. From the seniors’ perspective, the technology is merely a means through which information about their health status is delivered to the care workers. Indeed, just like a musician can produce new sounds and make herself heard through a music instrument, the seniors perceive that, through technology, they can make themselves ‘heard’ and ‘seen’ in expanded ways. As a result, the technology makes the seniors feel safe. What makes the seniors feel safe is however their belief that they, through the technology, can be ‘seen’ by other human caregivers, that is by other familiar individuals (cf. Study 4). Hence, the senior caretakers do not view the technology as an isolated, external object. Rather, the seniors perceive the technology as an extension of their own and others’ human body. The care workers used the system studied differently from the seniors. They looked at “activity curves” on a computer screen. The studies (see Study 2, Variability as a source of stability: studying routines in the elderly home care setting; Study 3, The emergence of technology-based service systems: a case study of a telehealth project in Sweden, and Study 5, The corporeality of learning in everyday practice, cf. Essén, 2008; Essén & Conrick, 2007; Essén & Conrick, 2008) illustrate that the care workers perceive that each activity curve refers to a senior’s activity status in her/his home. Hence, the care workers engage in a hermeneutic relation (Ihde, 1990) with the technology; the screen-data becomes their object of perception while simultaneously referring beyond itself. The seniors behavior and activity status become present to the care workers through the technology (digital activity curves) (cf. Study 2, 3). That is, the workers gradually started thinking from the point of view of the technology, and, rather than thinking about the technology, they started to perceive their environment in a different way (Crossley, 1995a; 1995b). The care workers’ use of the technology makes obvious their integration of technology-generated and their ‘naked’ capabilities. Inspired by MerleauPonty, I interpret this as an illustration of the human bodily motivation to avoid tensions with the environment. The care workers avoid such tensions by compensating for the limitations of the technology-mediated capability in various pre-reflective and reflective ways. (Just as they would compensate for a bad eye with their other eye).10 I will discuss this further below.
10
This compensatory capability underlines the argument that technology should be viewed as an extension of, and not a replacement for or equal to the human body. It also illustrates how the physicality of the body can be enabling, making implications happen. 32
Bodies emotionalizing and contextualizing technology What is indicated by the studies taken together is that while the technology amplifies the care workers awareness of the variability in (one aspect) the seniors’ condition, the technology cannot advice the care workers about how to act on the information (Study 2, 3, 5). The technology itself has no experience of individual seniors’ preferences concerning care delivery and it cannot foresee how individual seniors will react to different measures. What’s more, the technology cannot relate the problems it detects to other problems in the actual context. These limitations could potentially create tensions. However, the care workers prevent this by using their ‘naked’ bodily capability in several pre-reflective and reflective ways. In a sense, it is somewhat off the subject to speak of the de-contextualized and narrow-minded operation of the technology itself, as this is not what the care workers incorporate or use. The workers cannot but integrate the capability of the technology with their other perceptual and responsive bodily capabilities and emotions (Study 2, 3, 5). Hence, in the hands of the care workers, the technology becomes ‘contextualized’ and ‘emotionalized’. For example, the workers use their bodily knowledge stemming from long-term relationships with seniors when deciding how to approach individual seniors based on the new information. This enables the workers to act on the technology generated affordances in a way adjusted to the senior and the situation. The workers also relate the needs detected by the technology to other competing needs and aims in each situation. In the setting studied, it is often necessary to partly address several needs, rather than to completely solve one problem and ignore others. Aims are not ordered in any clear predefined hierarchy but rather form a heterarchy of aims (cf. Waerness, 1984). For example, neither the ambition to spend time on seniors in need, financial aims nor the objective to maintain fairness can be completely ignored in a situation. As revealed in study 2, 3, 5, the care workers use their body (its pre-reflective as well as reflective capability) in order to cope with such situations. Their emotion-ethical values represent particularly important resources (indeed a kind of knowledge) to them when they need to compromise between competing needs. A theme running through study 2, 3, 5 is further that the technology extends the care workers’ perception in a very delimited area when considering their overall day-to-day work. The care workers need to detect and respond to variability in many areas beyond seniors’ activity level to avoid tensions. Study 2, 3, 5 show that the workers’ ‘naked’ sensory and emotional bodily perception helps them in this context. The way in which their body receives and responds to calls from the environment and thereby “takes care of” many problems without the workers needing to reflect consciously on this is truly extraordinary. It is hard to conceive of a technology performing this activity, which is often pre-reflective and non-discursive. 33
In general, the studies illustrate how workers’ bodies often spontaneously express emotions when interacting with seniors. To understand this, it needs to be clarified that care workers are urged to act not only by self-interest, but also by emotional compassion for the seniors. That is, affective– and I believe: somatic — states serve as an important drive force in their work. This motivates their perception to ‘open up’ to emotional needs among seniors and to add to the work they perform the element of “emotional expression”, carefully adjusted to the senior in question, without being paid for this. For example, they touch seniors to show compassion and joke with the seniors simply to make the seniors feel good, although there is no economic incentive for them to perform such acts. (Most of) the care workers care about the seniors and want the seniors to feel good (cf. Study 3). Their perception and bodily response are directed towards this aim. As a result, the boundary of their area of attention is diffuse and indeed negotiable. Inspired by MerleauPonty, I do not attempt to determine to what extent these emotions are authentic or genuine. Suffice it to say that they are bodily, physical, prereflective, manifested in performance, and represent important resources to the care workers when doing their job. Indeed, the workers emotions represent to them a kind of intelligence that guides them in their actions and decisions, helping them to behave ‘effectively’ and I dare say, rationally in specific situation. It is important to note that the workers saw the technology in relation to these, their own, naked bodily capacities. Without these capabilities and tendencies of the workers’ body, the new technology-mediated perception would be worth little.11
Thinking of the implications of technology as capacity and feeling inside the body It should have appeared by now that the users studied here evaluated the technology on basis of the opportunities of action it afforded them and the 11
Now, it may be argued that the incapability of technology to be emotional, embodied and distracted should be highlighted as an advantage. The emotional relationships between care workers and seniors can produce an emotional bias and unfairness, as the workers’ attachment is presumably not evenly distributed across the seniors (see study 3) and that technology thereby could contribute to a more ‘fair’ perception. If viewing technology as a stand-alone actor, one could argue that it is never in a bad mood and it does not dislike anyone. It operates in a reliable and unbiased way. Further, one could argue that humans could not collect the information in an as focused way as the technology as their bodily capability to work towards several aims simultaneously makes them distracted. However, this thesis suggests that while technology may contribute with new data in a non-negotiable, de-contextualized and nonemotional way, this technological capability is ‘emotionalized’ and ‘contextualized’, i.e. related to other problems, as it is used by the workers. It is consequently only possible to, to a limited extent reduce e.g. emotional bias. 34
emotions it generated inside of them. And, they used their emotions in various ways when performing this evaluation of the technology. The influence of emotion is most evident as regards the seniors’ reaction to the technology. As noted above, one of the seniors did not value the new technology (cf. Study 4). This was somewhat unexpected as she was more anxious and frail than the other seniors, and one could, from an ‘objective’ or ‘fact-based’ point of view, have predicted that she would appreciate being watched more than the others. However, her reaction was not the result of some fact-based, calculative reasoning process. It rather followed an emotional line of thought; this woman was negative to the technology as it created certain undesirable feelings inside of her. Being electronically monitored made her feel ‘watched’, almost guilty and ‘constrained’. The majority of the senior caretakers, on the other hand, valued the technology as the perceived that it contributed to them reaching certain desirable emotional-states, namely the feeling of being cared for, safe, and thereby free. The seniors also thought about the technology as a service that can help them avoid moving to a nursing home and thereby escape significant privacy intrusions. Hence, the positive seniors, too, evaluated the technology in an emotional way, and on basis of what they felt that it enabled them to do. The care workers also appreciated/valued the technology as they felt that it could enhance their capacity to provide care services more attuned to the needs of the seniors (see Study 2, 3, 5; cf. Essén, 2008; Essén & Conrick, 2007; Essén & Conrick, 2008). Indeed, given the care workers’ hermeneutic engagement with the technology, they are provided with new information about seniors’ health problems. The information collected by the technology is information that the seniors cannot give, neither could the workers collect this information with their mere bodily senses. Hence the technology becomes to the workers an extended "area of sensitivity" (Merleau-Ponty, 1962:143). The care workers evaluate the technology in terms of this extended perceptual capability they gain through the technology. The care workers and care takers’ engagement with technology problematizes the view of technology as an external object that humans analytically evaluate. As argued by Merleau-Ponty (1962: 90), an object "is an object only insofar as it can be moved away from me ". Now, what do the care workers and caretakers think of when asked to assess the technology? It is not the ‘objective’ attributes of the technology.12 It is rather the extended bodily capability that they experience through the technology. These capabilities and emotional states (which I would not call purely mental or brainrelated) can be understood as a part of the users’ bodies rather than a part of 12
Drawing on Merleau-Ponty, I believe that even if the users would want to, they could not see the technology as simply the sum of its technical functionality, color, shape etc. The whole background apparatus of what technology in general means for them, what the specific technology has been/could be used for and by whom, comes with their perception of it.
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the technology as an external object. On this background, it seems more fruitful to analyze what human bodies, extended by technology, can accomplish, than focusing on where the border between humans and technology occur. Note however, that I am not advocating a view where humans and technology are equal ontologically. What I am suggesting is that the encounter between technology and humans can create new capabilities and emotions that are human in the sense that they are felt inside the human body.
Bodies selectively incorporating the micro and macro context The conceptualization of the user as a situated body encourages a consideration of how the historical context influenced the studied caretakers’ and care workers’ experience of the technology (Ihde, 2002; Merleau-Ponty, 1962). Study 1, The role of emotion in service evaluation: senior citizens’ assessment of long-term care services, exhibit that the seniors are aware of the financial constraints in elderly care. Their incorporation of this aspect of the historical context can partly explain why any “new”, additional service makes them feel grateful. Further, the seniors associate technology with improvement. Most likely, as they have experienced technological advancements in their life (cf. Essén & Wikström, 2005; Östlund, 1995). Finally, it appears reasonable to assume that the seniors’ desire for privacy, independence and freedom is related to values in the contemporary society. Discussing to what extent the seniors, in having these desires, are influenced by others (e.g. children wishing the seniors to be independent) is beyond the scope of this paper. What I want to note here is that social, political and economical structures influence the seniors’ reason-based as well as emotional experience of the technology and thereby its implications. It is similarly helpful to take into account that workers bodies are situated in specific situations, a larger service context, and in a historical and cultural time (Study 2, 3, 5). Study 3 shows how pre-existing structures and norms influence how workers’ bodies make use of the new technology. For example, as care workers incorporated and were attentive to the value attached to privacy, autonomy and pluralism in the contemporary society, they restricted their use of the technology in conscious as well as pre-conscious ways (cf. Essén, 2008; Essén & Conrick, 2007). The deeply rooted view of elderly care as a matter of human contact further contributed to individual workers’ emotional conviction that technology would never replace face-to-face visits (cf. Study 2, 3). In sum, the situatedness of the users’ bodies influences their perception of and physical engagement with technology. There is however scope for an 36
agentic body in the view I propose. Users choose to incorporate, enact and thereby reproduce certain structures and not others. For example, while the seniors seem to have incorporated the widespread rhetoric about technology’s potential to ‘increase quality, effectiveness and safety’; the workers have not fully embodied the view that technology represents a ‘panacea’ to healthcare problems. The workers’ rather appear to have embraced the established argument that the role of technology is very limited in care, as face-toface contact is crucial in this setting. Of course, the users’ selective incorporation of structures is related to their individual experience of specific situations. That is to say, there is an interaction between the influence of forces at micro- and macro level, which makes their total influence unpredictable (cf. study 3).
Studying the perceived reveals the perceiver In summary, an exploration of the technology as perceived by care workers and care takers reveals quite a lot about these humans. For example, the analysis above exposes care workers’ and caretakers’ naked bodily resources, showing that emotionality and sensory physicality can be enabling and constraining. It suggests that the users’ mind is clearly rooted in their lived body: the way they think about the technology appear closely intertwined with how their body uses the technology, which is closely related to their interests in everyday life. The users further think about the technology in a way that is both emotional and reason-based, and it is often difficult to separate these two. Indeed, emotion and reason seem closely intertwined, and emotionality seems closer to rationality than to irrationality. The analysis further begins to portray the care workers and caretakers’ view is linked to their selective incorporation of social structures. This supports MerleauPonty’s argument that a study of the perceived always ends up revealing the subject perceiving. As he wrote, this is the paradoxical condition of all human subjectivity: “we are both a part of the world and coextensive with it, constituting but also constituted” (Merleau-Ponty, 1962: 453).
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Conclusion
The present thesis has explored the potential role and implications of technology in care, as perceived by its users. An important insight emerging from this work was the need to rethink the human subject as a user of technology. The exploration consistently pointed at how the experience of the studied users was related not only to their mind but to their whole body. That is, their physical capacity and emotionality influenced their perception and use of technology and thereby the implications it generated. The human body is rarely mentioned in the contemporary literature on IT and care (neither in information systems research). Studies have rather tried to understand the implications of technology initiatives by investigating the influence of: technological functionality and design; managerial issues or social structures; and emergent inter-actions at a discursive level (see chapter two). While providing important insights, the extant research has hence been able neither to support nor reject the dramatic predictions that circulate in the IT and care debate, e.g. revolving around how technology may mechanize and dehumanize care or isolate seniors from social structures. The present thesis argues that the phenomenological tradition can help us to better address these issues. It uses Merleau-Ponty’s (1962; 1968) phenomenology to re-conceptualize the user of technology as a body. And to on this basis theorize about the potential role and implications of technology in care. The thesis concludes that the caretakers and care workers studied do not experience technology as an external object with ‘absolute’ or ‘objective’ qualities. They rather engage with technology as an extension of their own (physical and ideational) body. And they evaluate technology in terms of the bodily capacities and emotional states that it creates inside of them. These insights challenge the view of technology as an object external to the human body, with which the human user inter-acts, a view that is implied in one way or another in widespread frameworks of human-technology relationships in the extant literature (see section two). The findings rather suggest that human-technology relationships involve intra-actions between the ‘naked’ and the technology-mediated perception and capacity of the human body. Given this perspective, it is irrelevant to discuss whether or not technology in itself is non-emotional, de-contextualized, and inexperienced, and it is unhelpful to ask whether or not a technological device can engage in emotional relationships on its own. The gist of the thesis is that when used in 38
existing emotional relationships between humans, technology can contribute to such relationships. In combination with humans who contextualize the technical possibilities, incorporating the technology and integrating it with their other sensory and emotional capacities, technology can produce affect. The thesis shows how technology can contribute to seniors feeling safe and cared for, and to them feeling closer to the care personnel and thereby less isolated. These findings resonate with early studies of telephone technology, showing that technology can enable an experience of “intimacy at a distance” (Rosenmayr & Kockeis, 1963). However, this view is not widespread in the extant literature. In general, the thesis provides a counter example to the heretofore influential argument that technology diminishes the role of the situation-specific and ‘personal’ aspects of care. In the setting studied here, workers do not start acting in a detached, spiritless, machine-like manner when using technology. Their emotions do not play less a central role when they start using technology. On the contrary, thanks to the perceptual capacity gained from technology, the workers become aware of new situations that urgently call for their sensory and emotional responsiveness. On this ground, the thesis challenges the determinist view that technology threatens the essentially ‘human’ (Ellul, 1994; Heiddegger, 1949[1993]; Virilio, 1994; see discussion in Dewsbury et al., 2001; Dutta-Bergman, 2003; Dunn, 2000; Hagberg, 2003; Stanberry, 2000; Williams et al., 1998). It rather concludes that feeling and other bodily resources are fundamental in the use of technology. Indeed, technology activates such ‘human’ capabilities.
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Theoretical implications and future research directions
The present thesis insists that the pre-reflective intentionality and emotionality of the human body (rather than merely the reflective, calculative capacities of the conscious mind) influence how individuals use and evaluate technology and hence its potential implications. This view complements the contemporary literature on IT and care (and on information systems more generally), where the human body is typically not mentioned at all. This remarkable neglect of the body in the extant literature can partly be explained by the nature of the dominant frameworks used. Health economic, social constructivist and actor-network theory models encourage other foci, such as technology itself and social structures (see chapter two). As an alternative, the framework provided in this thesis inspires to theorizing that departs form individuals’ concrete engagement with the technology at micro level, asking what technology can do to human physicality and emotionality. The thesis argues that this is in fact one of the most fundamental questions to ask in order to understand the potential role and implications of technology in care and in social life in general. The majority of the users studied here experienced the technology as an extension of their human body. This supports Merleau-Ponty’s (1962; 1968) thesis that there is a continuity rather than discontinuity between the materiality (flesh) of human bodies and technology (the flesh of the world). This implies that research should refrain from studying technology in-itself (as is commonly done in the IT and care literature) and instead direct attention to how technology can be integrated with the ‘naked’ resources of our body (cf. Ihde, 2002). We here need to widen our perspectives and investigate not only how technology can extend our reflective, mental capacity to manipulate symbols, but also how technology can extend the pre-reflective physicality and emotionality of the human body. The insights of this thesis further relate to the general organizational and sociologist discourse about new technology in relation to the human body. This discussion has primarily revolved around the potential of new technology to “free” subjects (read: minds) from their constraining, material bodies. Authors speak of “post-bodied and post-human forms of existence” (Feath-
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erstone and Burrows, 1995: 2; Lupton, 1995; cf. Can der Ploeg 2002; Stone, 1991) and write that when we enter cyberspace we “leave behind our animal-shaped, emotional, intuitive, situated, vulnerable, embodied selves” (Dreyfus, 2001: 6). In contrast to these visions, this thesis argues, inspired by e.g. Dale (2001), Ihde (2002), Merleau-Ponty (1962), Knights & Thanem (2005), and Williams & Bendelow (1998), that while humans perceive the world through technology, we still perceive from somewhere. We perceive from our body with its pre-reflective intentionality and emotionality; from our body, which is situated in particular settings and relationships. Hence, the thesis rejects the idea that technology makes humans “disembodied” (if anything, humans make technology embodied). Indeed, we cannot free our mind from our bodies. This, I however believe is fortunate, as our bodily physicality not only constrains us. 13 The extraordinary emotional and preconscious capacity of the human body also enables us to realize the potential of technological capacity. At a more general level, the thesis says something about human knowledge, agency and materiality. By supporting Merleau-Ponty’s philosophy of human subjectivity, the thesis challenges the separation of mind from body, nature from culture and reason from emotion, which as noted by Willams & Bendelow (1998:250) “has been a consistent theme in Western though, dating as far back as Plato’s deliberations in the Phaedo, Aristotle’s musings in De Anima, and exemplified par excellence in Descartes famous Cogito ergo sum”. The dualistic legacy is certainly reflected in mainstream organizational research where the body is ”rarely seen as being relevant to the development of knowledge about organizations” (Dale, 2001:8) and where there has been a tendency to define the rational, objective, detached and disembodied human mind as the seat of truth and knowledge (Ihde, 2002; Turner, 1991; 1996; Williams & Bendelow, 1998). The present thesis can be positioned within the nascent literature that challenges these traditional views. It underlines the need to further rethink the biological in non-reductionist terms. Merleau-Ponty’s philosophy represents one such alternative, viewing human bodies as both physical and cultural beings, as both active and as acted upon.14 Future research further extending this view or developing other 13
Hence, this thesis extends the view of e.g. Dale (2001), who, while arguing that will never be able to escape our physicality, still portrays it as constraining. For example, Dale (2001: 41) writes that: ”in many ways, the dream of escape from the physical body turns out to be an illusion. The lived body resists and reminds the would-be transcendental ego of its constant and inevitable presence. While the mind is surfing the Net, finding its transcendental ego identity in cyberspace, the physical body develops eyestrain, injury…”. 14 Feminist writers have criticized Merleau-Ponty for producing non-gendered bodies by ignoring that there are multiple bodies and that bodies are socially constituted, thereby positing the body as the transcendental “being for itself”, the place Husserl previously reserved for consciousness. I find this unfair, as Merleau-Ponty does write about the situatedness of bodily perception and action. For those interested in this criticism, see further Butler, 1990; Dale, 2001; Irigaray, 1993; Young, 1980. 41
ways of connecting social constructivism and materialism is certainly warranted. To say the least. I would like to particularly encourage researchers to theorize in new ways about emotionality. The (limited) organizational and management research on emotions has from my view not been radical enough. It has been dominated by Hoschild’s (1983) theory of emotional labor, which talks about emotions in cognitive terms and not as embodied experiences (Knights & Thanem, 2005). The theory of emotional labor further makes a clear distinction between ‘authentic’ and ‘fabricated’ emotions. This has produced research discussing the negative consequences generated by workers’ expression of fabricated, ‘imposed’ emotions (see discussion in Lopez, 2006). The present thesis approaches human emotion from a very different perspective, highlighting the intelligent role emotion – as a bodily capacity— plays in human experience (cf. Fineman, 2000; 2003; Nussbaum, 2001;Sturdy, 2003). The thesis suggests that emotions can be viewed as enabling resources that allow individuals to perceive and respond effectively to circumstances in their surroundings. The thesis further questions the strict separation between ‘genuine’ and fabricated emotions (cf. Fineman, 2000; 2003; Wouters, 1989). Drawing on Merleau-Ponty (1962), it argues that emotions are never completely ‘private’, shaped only by the individuals’ inner, authentic, subjectivity. Emotions always incorporate the context – that is – emotions are always partly ‘fabricated’ or ‘imposed’. But this does not preclude them representing necessary and crucial resources in human action. Future research needs to acknowledge this and investigate the various ‘rational’, ‘effective’ enabling and necessary roles emotion plays in human practice. This would help us to further challenge the reason/emotion duality.
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Practical implications
“The elderly” have traditionally been associated with a negative attitude to new technology. To start with, the present thesis criticizes this generalization of ‘the elderly’. The thesis further challenges the view of elderly as technofobians by providing an example of elderly caretakers reacting differently, but overall very positive to new technology. The majority of the studied seniors feel safer and more cared for thanks to the new technology, which indicates that new technology can be marketed as providing emotions and social contact. It is however important to note that the studied setting is characterized by most of the seniors being satisfied with the care services they receive, partly as they enjoy a good relationship with the care personnel (cf Study 1). The seniors’ uncritical attitude to the new technology is presumably linked to their conviction that the familiar care personnel, who they trust, use the technology. This suggests that new technologies may rather easily be accepted among senior consumers, given that they are associated with ‘trusted’ personnel (cf. Essén & Wikström, 2005). 15 Note however, that this kind of uncritical attitude and trust in personnel could easily be misused. The studied care workers were also positive to the new technology. The technology used is far from sensational and this most likely led to more modest changes in the cases studied. The workers however gradually learned about the new technology and saw how it could potentially create value in their work. This is relevant to point out as the elderly care setting is far from computerized and there is a widespread belief about the negative attitude among home-help personnel toward technology. Indeed, there are strong doubts about the possibility of using high-tech in “the high-touch care setting” in general. This thesis suggests that this encounter may be fruitful, and that technology does not threaten ‘genuine’ or personal care. However, generating value is difficult and it will require a lot of work (cf. Essén & Conrick, 2007). The findings here particularly illustrate how organizational and structural factors impede the care workers’ exploration and exploitation of the new functionality. For example, as noted in Study 3, there is no “innovation climate” in the Swedish public elderly care setting (cf. Essén, 2008). 15
The seniors in this study were not interested in knowing any details about the new functionality of the new technology. This reaction may be related to the specific generation and cohort (elderly born 1910-1930) studied. Future elderly caretakers, born 1940 and later may be more interested in technology itself and may be more inclined to critically evaluating new technology. 43
The financial and hierarchical structure of the Swedish healthcare system impedes innovative long-term investments as well as the realization of innovations emerging at grass root level. This is nothing new to care managers but needs to be recognized by policy makers. Especially considering the rhetoric about how ‘there is promise in new technology’ in political reports (e.g. IT-strategy, 2006; SOU, 2002). As regards the relationship between new technology and cost-savings, I can only modestly discuss what my observations indicate.16 What emerges from the studies is that new technology implies additional costs rather than cost-savings. The studies suggest that technology can extend care workers’ perception, and thereby enable them to notice more problems and needs among seniors, which in turn increases their need to visit the seniors. This implies an increased work burden and rising rather than falling service production costs. Of course, the findings reported here are tied to the specific technology used: a monitoring system that generates new data about a new aspect of the caretakers’ health. Many new technologies however provide this kind of ‘service’ and functionality. As related to this, the thesis suggests that technology does not necessarily reduce variability in care practice; it rather increases variability (see study 2). This runs counter to the vision that telehealth will reduce (undesirable) variability in terms of exceptions and errors, as is often claimed by telehealth enthusiasts. It similarly contradicts the fear that technology will contribute to a more standardized, in terms of a more mechanized and non-adjusted care. This thesis suggests that technology can contribute to a more personadjusted care as it provides more nuanced information about the patient. This in turn, creates a more complex work environment where new ambiguous problems and exceptions occur. It should not be neglected that this leads to a situation where care workers need more authority and new types of competence, which may be associated with increased wage and educational costs. Overall, this thesis suggests that technology should not be viewed as a replacement but as a complement to workers in today’s elderly care system (Varlander, 2007; Wikstrom et al., 2002 provide similar insights in other service settings). Given my observations, I strongly believe that it would be devastating to replace face-to-face visits with electronic surveillance. There 16
I would in this context like underline that studying the implications of new technology in elderly care is a challenge. To start with, it is difficult to find cases to study, as few public care givers use new technology. It is difficult to initiate projects, i.e. inspire providers to invest in new technology due to the financial constraints they suffer. This also implies that for those providers who do invest in new technology, there are few resources available for ongoing support and education of users. As a result, projects tend to be small-scale and the new technical functionality tends to be far from exploited, the technology is typically underused (as in the cases studied here). These circumstances impede the use of and value produced through new technology, which makes it difficult for researchers to draw conclusions about the consequences of technology. What remains for researchers is to be attentive to what these kinds of projects indicate. This is relevant for those engaged in research policy. 44
are simply no “unnecessary” visits to reduce. Seniors certainly need the few visits they do receive. And, I want to underline the fantastic job many homehelpers perform when paying these visits. Those who do make an effort to make seniors feel cared for and seen (and I believe most do) make such a difference! (See study 1 and 2). This should be highlighted and rewarded more than today in care practice. In sum, the present thesis indicates that new technology may increase the quality of care, as a complement to human labor and thereby, to an increased cost. The question is: who is willing to invest in new technology given these conditions? There are financial incentives for private care givers to introduce new technology to consumers willing to pay for its’ qualitative benefits. Public care organizations on the other hand, do not have the financial resources to provide “new” qualitative benefits to seniors if they cannot expect a financial return on the investment required (see study 3). Hence, the diffusion of new technology in the public elderly care setting is uncertain. This is relevant to note for care policy makers, who sometimes appear to rely on the potential of new technology when discussing the future of elderly care. Swedish politicians further tend to pursue a strategy where communities are left to “decide for themselves” and encouraged to be ‘innovative’. This is easier said than done as this thesis shows. Finally, claiming that the human body and its emotions are important is nothing new under the sun. Claiming that our intelligence and consciousness reside in our body, and that our emotions are rational, is less established. Think about it: don’t we all somehow think of emotion and physicality as the opposite of ‘rationality’? Questioning this opposition should inspire to change and innovation in various ways. For example, telehealth technologies are often criticized for not being user-friendly (e.g. Essén, 2003; Scandurra, 2008). Certainly, the intertwined nature of emotion and reason makes technology development appear more exciting but also more challenging. Technology-developers need to recognize that: to develop machines that truly contribute to human settings, we must ask not only how the human mind or intellect works (and try to copy this), but rather, to consider the various needs of and roles played by the our physicality and emotionality. How can we develop technology that extends our body, including its pre-reflective capacities, in valuable ways? For example: How can we develop technology that stimulates workers capacity to show human warmth to seniors? Rejecting the dualisms further suggests that managers need to encourage rather than try to “suppress” employees’ physicality and emotionality. In general, let’s ask how we can appeal to our emotional intelligence. How can we allow it to thrive? Perhaps new forms of education, e.g. incorporating more art and literature, can help us learn about our passionate rationality. Isn’t this what makes the world go around anyway?
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PART TWO
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Introducing the studies
As noted above, a re-reading of the five studies (papers) made me aware of how the encounter between individuals and objects in their environment is not one characterized only by analytic reflection. It is also a pragmatic, intuitive, physical and emotional engagement. In general, the studies urged me think of mind and body, body and world, reason and emotion and the material and ideational, as intertwined rather than opposites, and I shall here account for how. Paper 1, The Role of Emotion in Service Evaluation: Senior Citizen’s Assessments of Long-term Care Services, explores how seniors form an opinion about care services, including the assistive-technologies provided to them. The paper reveals that emotion plays a central role in their evaluations. Certain aspects of services contribute to the seniors reaching emotional-states, and this is what the seniors initially refer to when explaining their judgments. They primarily remember events that have evoked in them emotional reactions. Their emotions further steer their reflective attention to these aspects; they typically continue to justify their judgment of these aspects and emotional reactions with fact-based reasoning. Hence, the paper questions the argument that emotions are opposed to cognition, arguing instead that there is a close relation (indeed, co-operation) between reason-based (analytic, reflective) and more intuitive, emotional, subjective reasoning. In general, the seniors’ perception of care services suggests that they do not engage with the world as calculative, disembodied, mental subjects. Rather, they use their whole body, which is a feeling and living body that includes but is not limited to a mind. The paper further exhibits how the seniors’ own experience of who they are, their own subjectivity, is influenced by how others see them. This resonates with the notion that the body-subject and the world are intertwined. It is finally worth noting that the seniors’ subjective evaluations had commonalities. Most of them underline the importance of care personnel providing human warmth. Hearing someone else laugh at one’s jokes can make a day.
Paper 2, Variability as a Source of Stability: Studying Routines in the Elderly Home Care Setting, demonstrates the ‘messy’ environment that elderly care constitutes, and how workers use their body in various ways to respond to 55
the unpredictability of their everyday work. Indeed, the ‘resources’ used by workers are not merely brain-related. It is however difficult to localize their capabilities in any certain organ. It seems to be an integrated capability, where mind and body, senses and reflection and tacit emotion and discursive facts interact. The paper exhibits that there is variability in the performance of home-help services. For example, home-helpers notice different things depending on what they feel is within their responsibility, which is in turn contingent on their personal history, their “habitus” (Bourdieu, 1977). Inspired by Merleau-Ponty, one can understand this habitus as corporeal, including acquired knowledge, values, ethics and affective modes that is expressed through the body. The paper further shows that technology makes the workers aware of new dimensions of seniors’ health. This creates additional variability, as seniors’ condition is far from predictable. Hence, rather than making the care work environment more ordered, the technology studied makes it even more disordered or ‘messy’. In general, the paper highlights the ethical, emergent and informal aspects of care work. This is interesting in relation to technology as it demonstrates the remarkable but inevitable complexity of everyday care practice, and hence points at what technology would have to be able to address if it was to replace humans in this setting. Paper 3, The Emergence of Technology-based Service Systems: a Case Study of a Telehealth Project in Sweden, shows that the “potential” of a technology is impossible to determine on basis of its functionality and material attributes (cf. Vargo & Lush, 2004 for a similar discussion). Such factors do play a role, but only in interaction with the users’ body, and thereby in relation to various contextual factors. This paper highlights that the care workers’ perception of technology is not a matter of their sensory organs receiving data about the ‘objective’ qualities of the technology, their mind later interpreting this data in a reflective way, followed by the actual use of the technology as a final stage. Perception and action is more closely linked that this. The workers do things, which make them realize what they, by incorporating technology, can accomplish. In general, what the users see the technology as, depends on what they perceive that it enables them to do, and this in turn is linked to their own body (what it is knowledgeable of, what it feels, its incorporation and rejection of social values), and concrete factors such as the facilities and time resources available. Overall, the paper highlights the relevance of thinking of the body as simultaneously situated in a micro- and a macro context, showing how developments should not be understood as taking place at one level, e.g. the social level or the biological level. Instead, factors at macro- and micro level interact through the users’ bodies. As suggested by Merleau-Ponty’s theory, human action is not mental or physical or cultural. It is everything at once. 56
Paper 4, The Two Facets of Electronic Care Surveillance: Exploring the Elderly Caretaker’s View, highlights the relevance of investigating the role and implications of technology from the user perspective. The variability in the studied seniors’ experiences could not be predicted from an outside perspective as it is related to the seniors’ emotional reactions to the technology. And the paper reveals that seniors’ emotions are related to their subconscious as well as conscious assumptions about their own condition, what is normal, what is private, what one should hide and about the interests of care providers. The paper illustrates that seniors’ personal desires (e.g. to continue living in their own homes and fear of moving to a nursing home) and view of themselves (their own frailty) strongly shape their experience of the technology and thereby its implications. Their belief that they are in need of supervision, that technology can contribute to them being able to live in their own home and thereby prevent them from being placed at a nursing home strongly influence their experience. In short, it is not primarily the material properties of the technology but rather how the seniors feel about the technology that matters to them. These feelings are physical as well as mental. And they are in a sense helpful, guiding the seniors in their judgments. This in ways that are difficult to predict but very understandable and far from completely random if one looks at the whole context. Paper 5, The Corporeality of Learning in Everyday Practice, rejects the prevailing view that knowledge is something that resides in the mind, arguing that knowledge rather resides in our whole body. The paper challenges the superiority of humans’ analytic and reflective capability, claiming instead that pre-reflective know-how is what we should understand as expertise. It is maintained that to know is to be physically able to perform actions without reflecting on how. That is, humans know when their body remembers and ‘takes care of’ things, thereby eliminating the need for conscious reflection. For example, the paper illustrates that workers gradually learn to master technology by incorporating it into their body schema. The more they use the technology, the less they reflect on how to use it, integrating it’s capacity with their other emotional and sensory capabilities in a pre-reflective way. In general, the paper illustrates that care workers experience-based, bodily responsiveness to the environment plays a central role in the delivery of care services. What emerges from the paper is that care work is not primarily about generalization and deduction, but about understanding the individual and subjective. The workers’ bodily capability to pre-reflectively perceive and respond to such particular issues makes them possible to handle. Without this bodily competence, care work would be immensely complex and time consuming.
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1. The Role of Emotion in Service Evaluation: Senior Citizens’ Assessments of Long-term Care Services 17
Authors: Essén, Anna & Wikström, Solveig
Abstract Purpose: This paper explores the role of emotions in consumers’ evaluations of service quality. Design/methodology/approach: The study uses empirical qualitative data from in-depth interviews with 26 senior citizens who are consumers of longterm residential care services in a Swedish rural community. The empirical findings are analysed inductively in terms of dimensions derived from the literature on the role of emotions in consumers’ evaluations of service quality. Findings: When explaining their overall evaluations of service quality, the respondents referred exclusively to service dimensions that had evoked emotional reactions. However, although these service dimensions were the only ones to influence the consumers’ perceptions of service quality, respondents tended to reflect about these dimensions in a cognitive manner. The remaining service dimensions, which did not evoke any emotional memories, did not influence the respondents’ perceptions of the overall quality of services rendered. Research implications: Emotional reactions can direct the attention of consumers to certain service dimensions, and subsequently trigger cognitive evaluations of these dimensions. The emotional and cognitive responses of consumers to services are thus interrelated. More research is needed into the mechanism of this interaction. Practical implications: Service providers should recognise that consumers’ emotional and cognitive reactions are intertwined. For providers of agedcare services, this study suggests certain service dimensions that are worthy of further attention in seeking positive evaluations of services from users.
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This paper is published in Managing Service Quality. Vol. 18 No. 2, 2008, pp. 147-162. 59
Originality/value: Previous research has tended to distinguish between emotional and cognitive evaluations of services. This study challenges this distinction by demonstrating that dimensions that have traditionally been viewed as ‘non-emotional’ can be influenced by ‘emotional’ reactions. Thus, the study shows that ‘emotional bias’ can lead to some dimensions having a disproportionate influence on overall evaluations of service.
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Introduction The evaluation of service by consumers has received considerable attention in the services literature over recent decades (Cronin and Taylor, 1994; Grönroos, 2001; Gummesson, 2004; Oliver, 1977). As noted by Edvardsson (2005), most of this research has posited consumer satisfaction as a cognitive process, whereby consumers compare their expectations of service with the actual service outcome (Oliver, 1977; Parasuraman et al., 1985). More recently, this focus on the purely cognitive aspects of consumers’ evaluations has been criticised (Dubé & Menon, 2000; Edvardsson, 2005; Liljander & Strandvik, 1997) as an increasing number of studies have shown that emotions also influence consumers’ evaluations of services (Erevelles, 1998; Jian & Lu Wang, 2006; Richins, 1997; Westbrook & Oliver, 1991; Wong, 2004). However, most studies of the role of emotions in evaluations of service quality have drawn sharp distinctions between cognitive functions and emotional functions (Darden & Babin, 1994; Groth & Dye, 1999; Strauss, 2002; Yu & Dean, 2001). For example, Jian and Lu Wang (2006, p. 215) observed that: … traditional measures of service quality, such as reliability, empathy, assurance, and responsiveness may only measure the cognitive evaluations of service quality, and may not be applicable in emotional-intensive service settings, where consumers use other criteria to evaluate service quality.
In making this distinction, Jiang and Lu Wang (2006) categorised various services as being ‘emotional’, as opposed to ‘non-emotional’. In the first (‘emotional’) category, these authors included so-called ‘hedonic services’, which produce certain emotions (such as excitement and playfulness) and which consumers are said to evaluate emotionally. In the second (‘nonemotional’) category, the authors included so-called ‘utilitarian services’ (such as car repairing, tax return filing, banking, and health care), which consumers are said to evaluate cognitively on the basis of the functional utilities that these services provide. The difficulty with this approach is that the multidisciplinary literature on emotion suggests that emotion and cognition are not distinctive functions; indeed, there is evidence to suggest that the two are rather closely related and can be considered as two sides of the same coin (Armon-Jones, 1991; Damasio, 1994, 2002). These multidisciplinary insights into the link between the emotional and cognitive components of evaluation have been largely neglected in the extant service-quality literature. The present study addresses this oversight by exploring the intertwined nature of consumers’ emotional and cognitive reactions to services in the setting of long-term residential care for the elderly. This is a setting in which the provision of both ‘utilitarian’ services and ‘emotional’ services is impor-
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tant; indeed, in residential aged care, emotional care is an essential aspect of the service itself (Strauss et al., 1982). Moreover, it has been suggested that the consumers have a greater emotional response to services that last longer and take place in more intimate proxemic spaces (Price et al. 1995). It is therefore likely that an examination of services in such a setting will yield valuable insights into the role played by emotions in consumers’ evaluations of service quality. The rest of this paper is organised as follows. Following this introduction, the paper presents a review of the literature on: (i) the role of emotion in consumers’ evaluations; (ii) service dimensions of particular interest in this respect; and (iii) so-called ‘interpretation variables’ (‘attribution’ and ‘expectations’). This is followed by accounts of the methodology and findings of an empirical study of the perceptions of 26 Swedish senior citizens regarding the services they receive in residential care. Finally, the paper summarises the major findings, the theoretical and practical implications of the study, its limitations, and suggestions for further research
Literature review and theoretical framework The role of emotions in evaluation processes According to Scherer (1984), emotions can be broadly defined as distinct patterns of processes that include antecedent events, physiological and neurological responses to these events, and the appraisal activity brought to bear on these events. Emotions, mood, and attitudes are all elements within the general category of mental processes that is often referred to as ‘affect’ (Bagozzi et al., 1999). The present study draws on various multidisciplinary findings about the nature of ‘emotions’ and ‘cognition’. According to Damasio (1994, 2002), human reasoning and rational decisions are not derived from logic alone, but require the support of affect. Similar ideas are incorporated in the theory of ‘affect-as-information’ (Schwarz 1990; Schwarz and Clore 1988; 1996). According to this theory, people rely on their feelings when making judgments about a target (for example, a service) because they perceive that these feelings contain valuable judgmental information. Schwarz and Clore (1996) contended that affect comes into such overall judgments through a controlled inferential process. A typical affect-based inference is the heuristic question: ‘How do I feel about it?’ In addressing this question, people infer liking/disliking or satisfaction/dissatisfaction from the valence of their feelings (Schwarz and Clore, 1988). These ‘feeling-inputs’, which are subjective experiences of affective states and which include sensory or bodily components (Schwarz and Clore, 1996), can be produced in two ways: (i) inte62
grally, which refers to a perception of the object being evaluated (for example, by looking directly at the object); or (ii) incidentally, which refers to a feeling induced from a source that is independent of the object being evaluated (for example, a consumer being in a ‘bad mood’ before being exposed to the target) (Schwarz and Clore 1988; Pham et al., 2001). Studies applying the theory of ‘affect-as-information’ have shown that feelings are experienced immediately upon exposure to a target. Once experienced, these feelings frame subsequent thought generation by triggering ‘feeling-consistent cognitions’ that help to explain the initial feeling response (LeDoux 2000; Pham et al., 2001). A review of neuro-physiological evidence has led Damasio (1994, p. 198) to a similar conclusion: Somatic states [including emotion], negative or positive, caused by the appearance of a given representation, operate not only as a marker for the value of what is represented, but also as a booster for continued working memory and attention.
In contrast, non-emotional and reason-based assessments are only weakly related to spontaneous thought generation. Indeed, according to Pham et al. (2001), some reason-based assessments can simply result in a ‘dead end’— because there is no reason to explore them further. In summary, ‘affect-as-information’ research shows that people form overall cognitive evaluations based on their feelings with respect to the target; moreover, they appear to do so in an informed, deliberate manner. This has obvious relevance to how consumers use feelings-as-information when evaluating service dimensions that have, in the past, been categorised as purely ‘cognitive’ (Jian & Lu Wang, 2006).
Service dimensions For convenience, the service dimensions that consumers assess when they evaluate healthcare services can be divided into three broad categories: (i) outcome quality; (ii) process quality; and (iii) physical environment quality (Brady & Cronin, 2001; Rust and Oliver, 1994). Each of these is discussed below. The services-management literature has traditionally treated outcome quality as that which the customer is left with when the production process is finished (Grönroos, 2001; Gummesson, 2004). In the healthcare context, ‘outcome’ is assessed in terms of a patient’s health status as a result of the treatment received—including such factors as pain relief (Larrabee and Bolden, 2001) and the therapeutic efficacy of the treatment (Piette, 1999). Process quality, which has also been described as ‘functional quality’ (Grönroos, 2001) or ‘relational quality’ (Gummesson, 2004), refers to the consumers’ subjective experiences of how the service is delivered. Accord63
ing to both the services-management literature and the healthcare literature, consumers consider the following to be important dimensions of process quality: • •
•
•
•
•
•
•
•
reliability: whether services are performed dependably, as promised (Grönroos, 2001; Parasuraman et al., 1985); responsiveness and access: whether services are provided at convenient times and places and delivered on timely basis (Parasuraman et al. 1985; 1988) with minimal waiting times (Vukmir, 2006); security: whether services are delivered in a manner that is free from danger, risk, and doubt (Parasuraman et al., 1985); whether patient integrity and safety are preserved (Irurita, 1999); communication: whether consumers perceive that they are kept informed and that the services are explained (Parasuraman et al. 1985); whether patients are given accurate and adequate information (Irurita, 1999); competence: the perceived expertise of professionals (Grönroos, 2001; Parasuraman et al. 1985); the technical performance of care personnel (Arora et al. 2004). attitude: whether healthcare professionals have a respectful and friendly demeanour (Parasuraman et al., 1985); whether they treat patients pleasantly (Vukmir, 2006); individualised service: whether the specific requirements of individual consumers are understood and attended to (Parasuraman et al., 1985); whether the ‘voice’ of the patient is heard and understood (Suhonen et al., 2005). holistic care: whether care is delivered with a view to caring for the various needs of the ‘whole person’ (Gunther and Alligood, 2002). continuity: whether ongoing care of health problems is provided in an appropriate fashion that takes account of previous treatments and/or treating personnel (Woodward et al., 2004).
The physical environment includes tangibles (Parasuraman et al., 1985) and servicescape (Bitner, 1990). These dimensions refer to the extent to which the physical setting of the service is appealing to consumers. In the healthcare literature, this includes such variables as the ward environment and cleanliness (Larrabee and Bolden, 2001).
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Interpretation variables According to the services-management literature, certain ‘interpretation variables’ influence consumers’ evaluations of the dimensions noted above. Although most service-management scholars have used these variables to interpret consumers ‘cognitive’ evaluations, the present study contends that they also have relevance to the ‘emotional’ evaluations made by consumers. These ‘interpretation variables’ can be considered in two categories: (i) attribution; and (ii) expectations. According to attribution theory (Kelley, 1973), consumers react differently to services depending on their identification of the causes of particular service features. Similarly, in terms of emotional experiences during consumption, it has been argued that consumers’ attributions of who or what caused an emotional experience influence the impact of that consumption emotion on service evaluations (Dubé et al., 1996; Oliver, 1993). For example, Schwarz and Clore (1988) demonstrated that feelings cease to influence consumers’ judgments if they doubt that the feelings were elicited by the object being evaluated. With regard to expectations, it has long been contended that perceived service quality represents the gap between the expected level of service quality and the consumer’s perception of the service quality actually received (Oliver, 1977; 1993; Parasuraman et al. 1985). Although various aspects of this model have been criticised (Cronin and Taylor, 1994), it is important to note that the critics do not deny any role for expectations in the formation of consumer judgments (Brady and Cronin, 2001). The present study contends that expectations are relevant in the context of residential aged care—a view that finds support in the healthcare literature (Cheng Lim and Tang, 2000).
Methodology This qualitative empirical study, which was performed in March 2005, was based on in-depth interviews with 26 senior citizens living in the rural municipality of Heby (Sweden). The interviews were conducted in a conversational manner to create an intimate and trusting atmosphere in which the respondents felt free to express their feelings. Several authors have noted that there is a need for qualitative research of this type to complement the quantitative methods that have traditionally been used to investigate patients’ evaluation of care services (Avis et al. 1997; O’Connor and Shewchuk, 2003). The 26 respondents were chosen as a convenience sample (Patton, 2002) by municipal social workers from among the 270 senior citizens served by social services in the Heby region. The inclusion criteria were: (i) that the
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respondents lived alone; (ii) that they were physically impaired; and (iii) that they were frequent and experienced consumers of aged-care services. The sample consisted of 15 females and 11 males, of whom 16 were aged greater than 80 years and 10 were aged less than 80 years. The respondents suffered from a variety of health conditions. Initially, 28 potential respondents received an introductory letter, before being contacted by telephone by social workers. Two potential respondents rejected, leaving a final sample of 26.
Data collection One of the present authors performed all the interviews, which took place in the respondents’ homes. Each interview, which lasted approximately 90 minutes, began with an explanation that the purpose of the interview was to understand the respondent’s perception of the care services he or she received, including hospital and homecare services. All respondents were encouraged to speak freely about issues of service evaluation that were important to them. The semi-structured interviews proceeded as an informal discussion, with a checklist ensuring that all important issues were covered (Patton, 2002).
Data analysis The interviewing author transcribed the interviews, and both the present authors analysed the transcripts. Recurrent themes in the data were identified and categorised into a list of key words (Spiggle, 1994; Strauss and Corbin 1990). The authors then independently identified combinations of keywords on the basis of quality dimensions from the literature. Any discrepancies between the authors’ classifications were resolved. A final list of influential service dimensions emerged, with each having a specific meaning in terms of the respondents’ expressions. Findings with respect to these dimensions were made in terms of: (i) affective states (affect-as-information); (ii) the interpretation variable of ‘attribution’; and (iii) the interpretation variable of ‘expectations’.
Findings The majority of the respondents (22 of 26) stated that they were, on an overall assessment, quite ‘content’ with the quality care that they received. A minority (4 of 26) were more critical and could be described, overall, as ‘discontented’.
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In accordance with the conceptual framework outlined above, the respondents’ evaluations of the service dimensions are presented in three categories: (i) outcome; (ii) process; and (iii) physical environment and tangibles.
OUTCOME DIMENSIONS Independence and freedom The notion of ‘affect-as-information’ played a significant role in the respondents’ evaluations of services that impinged upon their independence and freedom. Many of the respondents reported negative affective states—such as feeling lonely and anxious in everyday life. These respondents were therefore grateful for ‘home help’ visits, which gave them ‘courage’ to live alone in their own homes. As one respondent observed: I’m often anxious … a bit worried. It’s hard being lonely all the time … I am very grateful for receiving this good service … I really need it to manage … one gets weaker and weaker.
Another respondent commented on the home-help visitors in the following terms: They’re great, the girls … I don’t know what I would do without them. I [certainly] could not live here.
Many respondents explained that their overall positive evaluation of the services they received was essentially based on the feeling of independence they enjoyed as a result of the care services they received. One of the respondents drew attention to the role played by technological and transport services in promoting her feeling of independence: Thanks to the assistive technologies I can do quite a lot myself … and with transport services it is possible for me to continue taking care of myself … I am happy that I don’t have to ask my son to give me a ride … it makes me feel more free.
Technical outcome (physical health status) ‘Affect-as-information’ was not significant in the respondents’ assessments of the technical outcomes of the services they received. None of the respondents explained their overall evaluations by referring to the extent to which healthcare services had improved their physical health status. Indeed, many had low expectations regarding the care system’s ability to ‘solve’ all their health-problems. As one respondent observed: 67
I’m sure they’ve done all they possibly can.
Although many of the respondents had experienced failed surgery or incorrect diagnoses, they did not interpret these problems as indicative of poor service quality. Rather, they often attributed their unresolved health problems to their previous lifestyle, age, or the natural history of disease itself. Similarly, the respondents seldom referred to the technical results of home-help services; indeed, they appeared to be rather uninterested in discussing this aspect of the services.
PROCESS DIMENSIONS Reliability It was apparent that ‘affect-as-information’ played a significant role in the respondents’ evaluations of the dimension of reliability. All of the respondents explicitly stated that they were physically vulnerable and that they worried about accidents (such as falls). As one respondent observed: I know I could fall, I’m not stable … but I trust [the home-helpers] completely, they are good, reliable girls … they always come immediately when I press the [safety alarm].
All of the four ‘discontented’ respondents had experienced delayed service (or no service at all), and all had reacted strongly and emotionally to these experiences. For example, one respondent stated: Nine months have passed since the last visit and I have yet to receive notice … I worry about this … I feel ignored … I don’t understand why he doesn’t call me ... if he is busy he can still call me just to say that he needs to postpone our meeting.
Another respondent said: You can’t count on them … Once one of the girls said that she would check on me in the evening again, but she didn’t … she just wanted to get home as soon as possible I guess … and that’s just one example … and this [made] me really sad, disappointed, even humiliated sometimes.
It was apparent that the discontented respondents usually blamed the personnel for the negative emotions they had experienced as a result of unreliability.
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Responsiveness Evaluations of the dimension of responsiveness were not especially influenced by ‘affect-as-information’; indeed, the respondents did not spontaneously refer to ‘responsiveness’. When specifically asked about this dimension, the respondents explained that they did not expect a high level of responsiveness. For example: Of course, my doctor can rarely see me exactly when I call … instead we set up a time … this is not [the doctor’s] fault, there are many names on the waiting list.
Another respondent even blamed herself for a lack of responsiveness when she waited all night for help after falling in the bathroom: I have only myself to blame … I wasn’t wearing my safety alarm and could not call for help.
In general, it was apparent from the interviews that reliability was more important than responsiveness; in other words, waiting was acceptable provided that the respondents knew how long they would be waiting.
Security In contrast to the preceding dimension, evaluations of the dimension of security were significantly influenced by ‘affect-as-information’. Several of the discontented respondents explained their overall negative evaluations by referring to experiences of feeling unsafe. For example, one respondent related how he felt unsafe while being transported to and from hospital: I cannot believe they didn’t get me an ambulance … going in an ordinary taxi for hours is the worst if you don’t feel well … I was actually afraid I wouldn’t make it to the hospital.
Two other discontented respondents had also felt unsafe during taxi transport to the hospital: I’m sure they can afford ambulances in such rare emergency cases … Indeed, this has to do with sheer arrogance.
It was apparent that the respondents felt strongly about feeling unsafe, and that such memories continued to cause them significant emotional upset.
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Communication Evaluations of the dimension of communication were also influenced by ‘affect-as-information’. The respondents wanted to be informed about such matters as changes in the service delivery. They felt betrayed, and even abandoned, when given insufficient information. For example, one respondent was visited by a male home-helper without having been informed that this would occur: I was very upset, when Jessica did not come. Instead, a boy stood at my door … she hadn’t told me about this … I cannot find a good reason for her not telling me about this.
This episode was a major cause of this respondent’s overall discontentment with the services she received. In contrast to this experience, the interviews with other respondents indicated that effective communication ameliorated negative emotional responses to other service failures. For example, one respondent had initially been placed in an isolation ward in hospital when health professionals thought he had a contagious disease, but he was eventually released from isolation when it was realised that he was actually suffering from an allergy. Despite the inconvenience, the respondent was satisfied with his care because communication had been good: They seemed to care about me … They were careful to explain everything to me. I didn’t feel that they treated me badly … they were just worried.
Competent personnel Evaluations in the dimension of competent personnel were not influenced by ‘affect-as-information’. Indeed, the respondents did not refer spontaneously to the education and expertise of their carers when discussing the quality of care; nor did they say much about the issue of competence when specifically encouraged to discuss it. Although some of the home-helpers were perceived as ‘young’ or ‘not very skilled’, the respondents did not react emotionally to the young helpers relative lack of experience and competence: They don’t have to make my bed perfectly as [staff do] in an hotel … As long my bed gets made … and they are nice.
It was apparent that some of the home-helpers were certainly not ‘experts’; nevertheless, this does not cause the respondents to be discontented. With respect to health care professionals, the respondents did have high expectations regarding education and expertise; however, they did not bother to evaluate whether this is the case. A typical response was: 70
I take this for granted.
Warm and caring attitude Evaluations in the dimension of a warm and caring attitude were significantly influenced by ‘affect-as-information’. In making their overall evaluations, the contented respondents often referred to their positive affective responses to the attitudes of personnel. For example: My former doctor wasn’t good; he had a very harsh tone … [but my new doctor] is very good. He is so soft and gentle towards me … and he makes me confident that things will be OK.
Another respondent made the following observation about a home-helper: She can put me in quite a jolly mood … she jokes a lot with me… She looks at me with her brown eyes in such a nice way … and sometimes she pats my hand when she feels that I am ‘down’ or anxious … she is so compassionate. We get a long really well; I think she would say that too.
Similarly, the discontented respondents attributed negative affective states to the unsatisfactory attitudes of certain personnel; moreover, they related this to their perceptions of poor service quality. For example: I don’t like going to the doctor … I don’t think he likes me. He probably sees me as a tiring elderly hag … I’m always uncomfortable in his office.
In general, the respondents were quite intolerant of personnel who did not treat them nicely: It doesn’t cost them anything to be nice.
Individualised service There was little evidence that affective responses played a significant role in evaluations of individualised service. The respondents did not spontaneously talk about individualised service. When they were probed about this, their answers indicated that many would have liked to receive services that reflected their personal preferences; however, they did not necessarily expect this. A respondent who reported overall contentment with the system made the following observation: … you can’t get your personal dreams fulfilled in this [publicly financed] system.
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In general, the respondents ascribed a lack of individualised services to the well-publicised lack of resources in the public health system.
Holistic care Evaluations in the dimension of holistic care were not influenced by ‘affectas-information’. By and large, the respondents appeared to tolerate the delivery of fragmented care, which they attributed to the specialised and decentralised nature of the healthcare system. One respondent summarised this attitude in the following terms: My different doctors know different things … but nobody really knows about all my problems … but, that’s how the system works.
Continuity of service Evaluations in the dimension of a continuity of service were significantly influenced by ‘affect-as-information’. Most of the contented respondents stated that they were glad to have known the home-helpers (whom they referred to as ‘friends’) for a long time. Some of the respondents had also been treated by the same general practitioner (doctor) for more than 20 years. The respondents felt safe and comfortable in the knowledge that care personnel were aware of their medical history and personal preferences. This knowledge made a significant contribution to their overall positive evaluations. Conversely, a lack of continuity caused negative emotional reactions. For example, one respondent complained about a lack of communication between successive home-helpers: I understand that some of them quit and new persons get employed … but I wonder why they don’t have some routine for telling the new personnel about me … They could save time on this, as it takes me a long time to explain my problems … Indeed, it makes me even more upset when I think about this.
Dimension of physical environment and tangibles Evaluations in the dimension of a physical environment and tangibles were significantly affected by ‘affect-as-information’. Familiar surroundings were important to the respondents. They especially appreciated being treated in their own homes, which made them feel safe. For example, one respondent described her negative reaction to the prospect of being moved to a hospital: I don’t feel comfortable there! I don’t know what to do or where to go … I can only lie there and wait … I was so happy when they arranged for a doctor to come and visit me at home instead. I felt much better ... They didn’t need to do that. That’s what I call ‘good service’. 72
A few respondents mentioned emotional reactions to tangibles when explaining their overall evaluations. For example, one respondent described how a large breathing aid inhibited social participation: This ‘thing’ [the breathing aid] is so big … I can’t go away with it … I would be embarrassed … sleeping at someone else’s house is out of the question.
In contrast, some of the seniors had positive emotional responses to tangibles; in particular, they appreciated unobtrusive technical aids that they were able to wear beneath clothes.
Summary of findings The respondents referred to only some of the service dimensions spontaneously. These were the dimensions that were most obviously associated with affective states and emotional experiences. These included: • • •
outcome dimensions: ‘independence and freedom’; process dimensions: ‘reliability’; ‘security’; ‘communication’; ‘warm and caring attitude’; ‘continuity of service’; and physical environment and tangibles.
Although emotional experiences appeared to direct the seniors’ attention to these dimensions, it was noteworthy that the respondents often subsequently explained their evaluations of these dimensions in cognitive terms; indeed, in some cases it was difficult to distinguish between the emotional aspects and the cognitive aspects. The comments of respondents contained reference to ‘facts’ as well as to emotional states. This was particularly obvious in the case of the discontented respondents in their attempts to explain their negative emotional experiences. The remaining dimensions were not especially affected by ‘affect-asinformation’. These included: • •
outcome dimensions: ‘technical outcome (physical healthstatus)’; and process dimensions: ‘responsiveness’; ‘competent personnel’; ‘individualised service’; ‘holistic care’.
When probed about these dimensions, it was clear that the respondents could see insufficiencies but that these deficiencies did not create emotional reactions and did not influence their evaluations of the overall service quality. They attributed these problems to external factors beyond the control of the service personnel and thus had low expectations. 73
Conclusions, implications, and future research Major conclusions The aim of this paper has been to explore the role of emotion in consumers’ evaluations of service in the context of long-term residential care services for the elderly. The most important finding of the present study is that most of the senior citizens interviewed in the study claimed that they were ‘content’ with the overall services rendered—despite some negative experiences and the fact that certain aspects of the services deviated from their ideal desires. Similar findings have been found in previous studies in the healthcare literature (Avis et al., 1997; Staniszewska and Ahmed, 1999). It is the contention of the present paper that the theory of ‘affect-as-information’ (Schwartz & Clore, 1988; 1996) can help to explain these somewhat anomalous positive evaluations in the face of negative experiences. The study also indicates that pre-existing emotional states played an important role in the respondents’ overall positive evaluations. Such preexisting feelings have been previously described in the literature as ‘incidental’ (as opposed to ‘integral’) feelings about an object (Schwartz & Clore, 1988; Pham et al., 2001). The senior citizens studied here were physically vulnerable, and they often feel anxious and sad. These ‘incidental’ negative affective states contributed to the respondents’ positive overall evaluations of the services they received because they felt dependent on (and grateful for) the services provided. In some cases, these ‘incidental’ feelings caused respondents with low self-esteem to blame themselves for service malfunctions, rather than blaming the personnel. These findings support previous research that has demonstrated a direct relationship between negative selfattributed emotions (such as of anxiety, shame, and guilt) and high levels of satisfaction with services rendered (Dubé et al., 1996; Dubé & Ménon, 2000). The present study also suggests that consumers use affect-as-information with regard to ‘integral feelings’ in their evaluation of certain dimensions. These ‘integral’ feelings, which refer to affective states that are produced by the consumers’ direct perception of the service dimension (Schwartz & Clore, 1988), can also be described as ‘consumption emotions’ (Bagozzi et al., 1999). In the present study, the following dimensions appeared to fall into this category: ‘independence and freedom’; ‘reliability’; ‘security’; ‘communication’; ‘warm and caring attitude’; ‘continuity of service’; and ‘physical environment and tangibles’. Moreover, it seemed that the respondents spontaneously remembered (and cared about) only these dimensions, which they associated with emotional experiences. Drawing on Johnston and Clark (2001) and Damasio (1994; 2002), it would seem that an emotional 74
‘memory bias’ was operating in these evaluations. However, it is important to note that once the respondents had recalled an emotional experience related to a service dimension, they often then began to undertake further reflections on that dimension in a relatively non-emotional way—that is, by referring to perceived ‘facts’ about the service, rather than emotional experiences. Mechanisms such as ‘attribution’ (Kelley, 1973) and ‘expectations’ (Oliver, 1977; 1993; Parasuraman et al., 1985) were thus used cognitively to explain their emotional reactions. Moreover, this cognitive reasoning appeared to fortify the initial emotional reactions in a reiterative process of consolidation. In conclusion, the present study finds that consumers’ ‘emotional’ evaluations of services (and specific service dimensions) should not be conceptualised as being completely separate from their ‘non-emotional’ (reason-based) assessments. On the contrary, the two are interrelated—it is apparent that feelings can direct consumers’ attention to certain aspects of services and trigger further reason-based assessments of these aspects.
Theoretical implications This study underlines the importance of consumers’ emotional reactions in their service evaluations. As such, the study contributes to the services literature which, as noted by Edvardsson (2005) among others, has been dominated by research that characterises the service-evaluation process as a nonemotional, reason-based assessment. In particular, the study illustrates how initial emotional responses can direct the attention of consumers to certain service dimensions, and thus trigger cognitive (‘fact-based’) evaluations of these dimensions. This supports the notion that emotions can frame subsequent thought generation (LeDoux, 2000; Pham et al., 2001). By demonstrating that emotions can thus play an important role in customers’ assessments of service types and dimensions that have previously been categorised as ‘non-emotional’ by the use of such labels as “utility services” (Jian & Lu Wang, 2006), “pure utility variables” (Groth & Dye, 1999), “cold facts” (Strauss, 2002) and “functional” (Darden & Babin, 1994), the present study thus challenges the notion of a clear distinction between consumers’ evaluations of so-called ‘emotional services’ (or service dimensions) and their evaluations of so-called ‘non-emotional’ services (or service dimensions). In contrast to this presumed distinction, the present study argues that the ‘emotional’ and the ‘cognitive’ are mutually related. Finally, it has often been argued that consumers care more about the service process (that is, how the service is delivered) than the result of the service (that is, the outcome) (Grönroos, 2001); moreover, it has been argued that this outcome is a technical matter that is evaluated in a relatively objective manner (Brady & Cronin, 2001). In contrast, the present study provides a context (the long-term care of the elderly) in which the service outcome is 75
fundamental to the consumers’ evaluations; moreover, this outcome is an affective state that is attributed by the consumers to the service being provided. In general, the present study contends that the relative importance accorded to various service dimensions in consumers’ overall evaluations depends on the extent to which the dimensions evoke emotional experiences; this, in turn, is likely to be context dependent.
Practical implications The present study underscores the need for service providers to recognise consumption emotions in order to influence consumers’ service perceptions. In the case of service providers of aged-care services, attention should be directed to the emotional aspects of the dimensions that have been identified in the present study as being especially relevant in terms of ‘affect-asemotion’. These include: • • •
outcome dimensions: ‘independence and freedom’; process dimensions: ‘reliability’; ‘security’; ‘communication’; ‘warm and caring attitude’; ‘continuity of service’; and physical environment and tangibles.
The seniors have low expectations about the other dimensions, which explain why the seniors did not explicitly evaluate them. In this context of elderly care, full technical outcome (physical health-status) is not attainable any longer and thus not a relevant dimension. The other dimensions can be improved and can thus add to the service quality. These dimensions should thereby not be neglected.
Limitations and suggestions for further research This study is only an initial step in the ongoing exploration of the links between emotions and cognition in consumers’ evaluations of service. Largerscale studies of consumers in other contexts are needed to verify the findings of the present study, which was conducted in one particular service context. More specifically, it would be interesting to explore whether consumers in general attach little importance to (and therefore tend to neglect) service dimensions that they do not associate with emotional experiences. This is a crucial question to be addressed in future investigations of the role of emotions in consumers’ evaluations of services.
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2. Variability as a Source of Stability: Studying Routines in the Elderly Home Care setting 18
Author: Essén, Anna
Abstract While it is agreed that there can be a difference between the routine as inscribed in artifacts, the ostensive aspect of the routine and its performative aspect, little is known about the relationship between these parts of the routine. Further, while authors acknowledge that there is variability in routines as performed, the contemporary literature says less about the sources of this variability. Using empirical data from the Swedish community care setting, the present paper explores the workings of and relationship between the different aspects of “the home-help delivery routine”. The paper also explores the sources of variability in workers’ execution of this routine in situ. The paper provides rich illustrations of the differences between the routine as inscribed in artifacts, as “agreed on patterns” and the workers’ performance of the routine in specific situations. It is the claim of the paper that these differences contribute to the stability of the routine. The paper highlights how factors in the local context, including exceptions created by technology, constitute sources of variability in the routine. It further shows how values in the contemporary society, adopted by individuals as emotional-ethical principles, shape individuals’ performance of the routine and thereby generate variability in the routine. In general, the paper underlines the importance of considering the cultural context in which the routine is situated, at micro and macro level, when analyzing its operation. Indeed, factors beyond the routine influence individuals’ conception of and execution of the routine.
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This paper is published in Human Relations. Vol. 61, No 11, pp 1617-1644. It has also been presented at the Academy of Management Meeting in Atlanta, 2007. 82
Introduction Routines have attracted the interest of scholars for more than half a century (see e.g. Stene, 1940; Simon, 1947; March & Simon, 1958 for early examples) and significant contributions to our understanding of routines have been made. However, as noted in the review by Becker (2004), many ambiguities and inconsistencies prevail in the routine literature. In particular as regards the role of subjective choice and variability in routines. Indeed, “It is remarkable that attempts at actually specifying how routines are varied, selected, and retained, are very few still“ (Becker, 2004: 62). This becomes evident when considering the role of routines in the Swedish elderly home help setting. Home-help services are tax-financed in Sweden and national directives underline the importance of fairness and equality in access to these services (Social ministry, 2005). This implies a need to reduce local variations in the way these services are granted and delivered. Centralized service plans pre-specify workers’ day-to-day service delivery at minute level. On the other hand, elderly care is characterized by high variability (frequent exceptions) in needs encountered by workers (Perrow, 1967). Fall accidents, sudden anxiety outbursts and other unpredictable problems are common. How can routines operate in such a setting? Clearly, workers’ execution of the home-help routine cannot only be a matter of executing the prespecified tasks in the service plans. There must be additional efforts to respond to the unpredictable changes in seniors needs. What shapes these additional efforts? And, how are these efforts related to the overall routine – do they threaten its stability and survival? The contemporary literature does not provide an answer these questions. Recent work suggests that there can be a difference between the routine as inscribed in artifacts, i.e. written rules or technology code; the ostensive aspect of routine, i.e. the routine as “agreed on” activity patterns; and the performative aspect, i.e. the routine as enacted by individual workers in specific situations (Pentland & Feldman, 2005). There is however a lack of understanding of the roles of and relationship between these parts of the routine (Pentland & Feldman, 2005). Further, while authors acknowledge that contextual contingencies contribute to variability in the performance of routines (Birnholtz et al., 2007; Feldman, 2000; Tsoukas, 1996; Tsoukas & Chia, 2002), the contemporary literature says less about how humans face such contingencies (Tsoukas & Chia, 2002). This weakness in the literature is important as it impedes our understanding of what routines are, how routines remain stable and/or change and what effect they have on organizations (Becker, 2005; Collinson and Wilson, 2006; Pentland & Feldman, 2005). Given this gap in the literature, the present paper explores the workings of and relationship between the artifact, ostensive and performative level of “the home-help delivery routine”, focusing on how these dimensions can 83
constitute sources of stability and variability. Assuming that the routine at artifact and ostensive level does not cover the efforts made by workers when performing the routine in actual situations, the paper also investigates what other factors shape these efforts. The paper uses qualitative empirical data from two cases in the Swedish community care setting. The findings suggest that the home-help delivery routine incorporates an intriguing mix of efforts to reduce and respond to variability. Drawing on Pentland and Feldman (2005), the paper provides rich illustrations of the differences between the routine as inscribed in artifacts, as “agreed on patterns” and the workers’ performance of the routine in situ. It is the claim of the paper that this divergence contributes to the stability of the routine. To further explain these differences, the paper uses the framework of Tsoukas (1996) and Mouzelis (1995) to show how social norm, individuals’ values (disposition) and situational-interactive dimensions influence how workers enact the routine in situ. These dimensions contribute to the understanding of the variability inherent in the performative aspect. The paper further shows how technological artifacts can play an intrusive role in this context, adding variability to the performance of routines. In general, the paper underlines the importance of considering the cultural context in which the routine is situated when analyzing its operation. Indeed, factors beyond the routine at artifact and ostensive level influence individuals’ conception of and execution of the routine. The paper particularly highlights how values in the contemporary society and adopted by individuals as emotional-ethical principles shape their performance of the routine. This raises several questions that warrant further research. The paper commences with a brief presentation of contemporary views on routines. Next, a framework for studying routines is presented. Empirical material from a study of the Swedish elderly care setting follows. The paper ends with conclusions, implications, study limitations and suggestions for further research.
Method A case study approach was deemed appropriate as it would enable the researcher to acquire a holistic view of the routine in all its dimensions, in its organizational context, and over time. This approach further allowed the researcher to use various data generation methods, which was important as this study aimed at generating rich data about individuals’ account of the routine versus their actual performance (Denzin & Lincoln, 2000; Patton, 2004; Weick, 2007). The paper triangulates different methods (Bruwer & Hunter, 1989) to provide a credible and trustworthy portrayal of routines.
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Research setting The paper uses empirical material from the Swedish community-based elderly care (home-help) setting. It focuses on a routine that is central in this setting, namely the repeated delivery of granted home-help services to seniors. This paper seeks to give a broad account of this “the home-help delivery routine” but it is not given where it starts and where it ends. Numerous artifacts further enable and constrain the execution of this routine. The paper discusses the service plan document that specifies the services each senior is granted, and a technical artifact that plays an important role in the execution of this routine, namely monitoring alarms.
Data generation This paper is part of a larger ongoing longitudinal research program on technology and care. The paper builds on data generated from the study of two Swedish home-help providers: A and B. Care provider A and B were chosen as they have implemented a new telehealth technology and could therefore provide rich data about this (purposeful sampling (Patton, 2004)). These providers operate under the same laws and national health system structure and they can be viewed as units of an organization. Several data generation methods have been used. The author has participated at 20 sessions (McGall & Simmons, 1969; Patton, 2004) at informal and formal personnel meetings at provider A and B during May-Sept 2003 and during 2004-2007. Field notes were taken on these occasions. Further, 38 more focused, in-depth interviews (McCracken, 1988) with home-help managers at different levels (n=15), home-helpers (n=20) at provider A and B, and municipal care managers/gatekeepers (n=3) in the two related municipalities have been conducted. The interviewed managers and home-helpers have been employed 515 years. The author performed the interviews, face-to-face (30), via phone (8) on two occasions: during May–September 2003 and during DecemberJanuary 2005. Interviews started with the author asking informants to describe the delivery of home-help services at a general level. The author proceeded more explicitly focused on issues related to variability and agency. Typical questions to home-helpers/managers were:” in what situations do you always perform tasks/do you encourage tasks always being performed/ in the same way? How? Why? When do you execute tasks differently in order to adjust to specific situations or specific caretakers? Do you think your way of acting differs from your colleagues’ way of acting? How? Why? Questions were asked in an open-ended fashion and were not specified in detail prior to the interviews, allowing the interviewer to word questions spontaneously (Patton, 2004). More structured methods would leave little room for unexpected issues to emerge. F-2-F interviews lasted for 90-120 minutes, phone interviews about 30 minutes. The author transcribed and 85
translated (from Swedish to English) the audio-recorded answers. The author further studied documentation such as laws and service plans describing the home-help delivery. Finally, the author performed participant observations at 8 occasions, by joining 3 home-helpers at A and 1 at B during two half-days each, during their visits to senior households. This was relevant as routines are partially tacit (Cohen & Bacdayan 1996). Field notes were taken from these occasions.
Data analysis Thematic content analysis, an interpretative process where the researcher takes the context into consideration (Mason, 2002), was performed. First, all transcripts and observational notes were read through to obtain a sense of the whole. Meaning units, a word, a sentence or a whole paragraph that described the idea or execution of the home-help delivery routine were marked. The meaning units were condensed into a description of their content. Themes, i.e. threads of meaning running through the descriptions (Mason, 2002) were abstracted. During this coding process, the author departed from the tentative, emerging theoretical framework, while at the same time being open for unexpected issues to emerge (Patton, 2004). The theoretical framework and thematization presented here is a result of an iterative process, including several rounds of interpreting the empirical material and reviewing the literature (Denzin & Lincoln, 2000). The quotes presented below represent frequently mentioned examples encountered during interviews/observations. On a few occasions, informants were called during the analysis phase in order to ensure that the interpretation presented is in accordance with their view. Further, the analysis and conclusions have been discussed repeatedly with peer-researchers (Patton, 2004).
Literature review and theoretical framework Early work defined routines as a fixed pattern of activity in response to a defined stimulus accompanied by the absence of search (March & Simon, 1958; Nelson & Winter, 1982; Winter, 1986). Scholars associated the routine with activity performed without explicitly selecting it over alternative ways of acting (Simon, 1945; Stene, 1940; Weiss & Ilgen, 1985; Ashforth & Fried, 1988; Cyert & March, 1963; Gersick & Hackman, 1990; March & Simon, 1958). Routines have further traditionally been understood as storing knowledge (Cohen & Bacdayan, 1994; Hodgson, 1998; Nelson & Winter, 1982). As related to this, it has been argued that routines result in economizing on the limited information processing and decision-making capacity of agents (Gersick & Hackman, 1990; Hodgson, 1997; Simon, 1947; Winter, 1986; Cyert & March, 1963; Dosi et al., 1999; Gersick & Hackman, 1990; 86
Reason, 1990; Simon, 1947; Weiss & Ilgen, 1985). Scholars have further maintained that routines are means for coordination and control (Cohen et al 1996; Dosi et al., 1999; March, 1991; March & Simon, 1958; Merton, 1940; Nelson & Winter 1982; Stene, 1940) by making many simultaneous activities mutually consistent (March & Olsen, 1989) establishing a truce (Nelson & Winter, 1982) and by being easier to monitor and measure than nonroutine behavior. As noted by Becker (2004): “The more standardized, the easier to compare. The easier to compare, the easier to control” (pp. 655). In general, routines have traditionally been associated with stability (Hodgson, 1993; Nelson, 1994; Nelson & Winter 1982) and with a reduction of uncertainty, e.g. through their ability to establish a certain level of predictability and expectations for members of the organization (Becker & Knudsen, 2004; Cyert & March, 1963; Nelson & Winter, 1982). This optimistic view of routines has come to be the target of criticism. It has been argued that the stability effects of routines can be negative, leading to organizational inertia. The strength of habits may further lull individuals into executing well-known routines even when external stimuli vary (Gersick & Hackman, 1990; Reason, 1984; Weick, 1979). Hence, scholars have maintained that routines may lead to deskilling (Leidner, 1993; May, 1985), demotivation (Ilgen & Hollenbeck, 1991) mindlessness (Ashforth & Fried, 1988) and that routines may be in conflict with individualization in service delivery (Leidner, 1993; Berg, 1997; Hanlon et al., 2005). Neither of these views could explain the multiple roles played by the routine studied here. Hence, the present study draws on an alternative way of theorizing routines that has recently emerged in the organizational/management literature. I will primarily refer to Feldman and Pentland (2003) and Pentland and Feldman (2005), although several works have contributed to the framework they present (e.g. Feldman, 2000; Giddens, 1984; Latour, 1986; Pentland & Reuter, 1994). Feldman and Pentland (2003:95) define routines as: “repetitive, recognizable patterns of interdependent actions carried out by multiple actors”. In Pentland and Feldman (2005) they suggest that routines have three dimensions. Artifacts refer to the routine as inscribed in e.g. written rules and technology. The present paper assumes that humans can delegate tasks to artifacts, which in turn can prescribe activity of humans (Akrich, 1992; Latour, 1992). The ostensive aspect (Latour, 1986) denotes participants’ account of the routine. It is important to note that participants’ may have different understandings of what they ‘really’ do and that these understandings may be different from the routine inscribed in artifacts. The performative aspect (Latour, 1986) consists of the routine executed by particular individuals in particular places and times; the routine in practice. Feldman and Pentland (2003) argue that artifacts and the ostensive aspect of a routine can only serve as a template for behavior; people always need to improvise to respond to unexpected conditions and contextual con-
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tingencies when they enact routines (Feldman, 2000; Suchman, 1987; Weick, 1993). Against this background, the performance of routines should be viewed as an effortful accomplishment rather than automatic behavior (Pentland & Reuter, 1994). As noted by Giddens (1984): …it is a major error to suppose that these phenomena [routines]…are simply repetitive forms of behavior carried out ‘mindlessly’. On the contrary…the routinized character of most social activity is something that has to be ‘worked at’ continually by those who sustain in their day-to-day conduct (Giddens, 1984:86). In short, recent research suggests that routines incorporate several dimensions that can operate in different ways. Importantly, the performative dimension acknowledges that there are contextual contingencies in any situation (Tsoukas, 1996; Tsoukas & Chia, 2002). Alas, the contemporary literature does not quite answer what shapes how humans improvise when facing such contextual contingencies (Tsoukas & Chia, 2002). It seems reasonable to assume that there is an immense variability in individuals’ responses to such unpredictable issues. What shapes this variability in human performance? And, how is this variability related to the ostensive and artifact aspects of the routine? As noted by Pentland and Feldman (2005), these questions remain largely unexplored in the contemporary literature. A few studies have discussed factors that shape individuals’ performance of routines. For example, Cohen and Bacdayan (1994) nicely illustrate how individuals remember parts of routines in their procedural memory, i.e. a relatively inarticulate memory for ”how to” do things (typically discussed in terms of habits or skills). Individuals are not always consciously aware of this skill, but it tends to persist. Thus routines reside partially in an "organizational unconscious", it is argued. Birnholtz et al. (2007) also write about the role of habitual dispositions stored in individuals’ procedural memory. They ask: how can such individual dispositions be turned into collective patterns of behavior? They find that this can occur via transfer of individual dispositions from experienced to new organizational members. To what extent individual dispositions are generalized however depends on several factors including: the domain credibility (rather than formal authority) of the individual actor, the visibility of the action and the degree of external standardization of the action. Some dispositions and improvisations may be incompatible with other dispositions and will therefore not take hold at organizational level. This research importantly highlights that response tendencies stored in individuals’ hard-to-access procedural memory can influence the performative and in turn the ostensive aspect of routines. However, it does not conceptualize where these response tendencies come from. The research further primarily talks about how such response tendencies contribute to stability and continuity in individuals’ enactment of routine. This raises questions about the sources of variability in individuals’ performance of routines. In general, 88
contemporary research does not quite explicate what makes some individuals consciously “work at” the routine in certain ways, others “work at” it in other ways, and others still ignore this fine-tuning completely. Tsoukas (1996) (cf. Mouzelis, 1995) provides a framework elucidating social factors that influence individuals’ rule following, which is helpful in this context. Tsoukas (1996) suggests that normative expectations that are associated with a particular role influence how it is carried out. The dispositional dimension refers to individuals’ background, “the system of mental patterns of perception, appreciation, and action, which has been acquired by an individual via past socializations and is brought to bear on a particular situation” (Tsoukas, 1996, pp.17). It is the result of the diverse social contexts individual workers have gone through during their lives (cf. Bourdieu’s (1990) notion of “habitus”). Finally, the interactive-situational dimension refers to the concrete and particular sociotemporal setting in which an act takes place (cf. Goffman (1983), interaction order). These three interrelated dimensions of social practices overlap with but also add to the contemporary understanding of the factors that influence how humans enact routines. Tsoukas/Mouzelis’ model acknowledges that the ‘here and now’ (the interactive-situational dimension) influences action. This resonates with Latour's (1986) and Feldman and Pentland’s (2003) idea of the performative aspect. However, while Latour (1986) posit that the performative aspect is all about the emergent, what is ‘here and now’ (Latour, 1992; Cooren et al., 2006),19 Tsoukas/Mouzelis’ model highlights that normative expectations and individuals’ background influence how individuals respond to “the here and now”. This idea can be used to make explicit the influence of value structures and of “the past” (embodied, internalized by individuals as personal values) in the enactment of routines. Drawing on the above, this paper assumes that the performance of a routine is guided and constrained by the routine as pre-inscribed in artifacts and as agreed on patterns (the ostensive aspect). Emergent issues in the local, physical setting in which the routine is performed further plays an important role (the interactive-situational dimension). How workers perform a routine is finally influenced by factors beyond the routine and the local situation, namely: prevailing expectations (cultural norms) and workers’ disposition (personal values) (Mouzelis, 1995; Pentland & Feldman, 2005; Tsoukas, 1996). The paper presupposes that these intertwined factors contribute both to 1) individuals’ inarticulate habitual dispositions and relatively subconscious execution of routines (cf. Cohen & Bacdayan, 1995; Birnholtz et al., 2007 and 2) individuals’ more reflective, conscious responses to exceptional cases, i.e. their effort to “make the routine work”.
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Latour views structure as a result (explanandum) rather than as a cause (explanans) (Latour, 1992; Cooren et al., 2006). 89
Empirical material This section accounts for the day-to-day delivery of home-help services to seniors in Sweden, which I refer to as “the home-help delivery routine”. This routine stems from the Swedish social services law, which declares that all citizens have a right to a certain level of quality of life and security (SFS 2001:453). The social services law underlines several principles that should guide the provision of public services including: ensuring the individual’s dignity, autonomy and ensuring that the individual has the same living conditions as all others, i.e. normalization. These paragraphs and national ambitions have remained over time and political shifts in Sweden. They reflect welfare and equity principles that are deeply rooted in the Swedish society (Social ministry, 2005).
Artifacts Inscriptions in service plan documents
Many of the home-helpers have never seen the paragraphs in the social services law. Its abstract aims have been operationalized in terms of various predefined “home-help services” such as help with: making the bed; getting up from/to bed; doing dishes; grocery shopping; overall cleaning; washing and ironing clothes; personal hygiene e.g. showering; moving around in the appt/house; preparing breakfast/basic evening meal); hair care; dressing/undressing; general supervision/check up visit; outdoor walk. Care coordinators, employed as ‘gate-keepers’ in each municipality, decide what service seniors in the community are to receive. The final decision, i.e. list of granted services, is documented in individual service plans, which are executed by home-helpers. The service plans consist of rather detailed instructions, as in the following typical example: “…Name: Aina […]. Condition/Need: Chronic Obstructive Pulmonary Disease, is anxious […]. Granted service: Daily: Help with getting up from bed, getting dressed, hygiene, making the bed, preparing breakfast, at 8.30 a.m. 20 minutes. Food delivery at 12.30. Help with preparing meal, 16.30. 15 minutes. Help with getting undressed, hygiene, go to bed. at 22.00. 15 minutes. Once a week: Help with shower 30 minutes …” (Service plan document).
In many cases, the service plans remain unchanged for several years. Hence, the service plans prescribe patterns of actions that are to be repeated by home-helpers during long-periods of time. The home-helpers cannot make
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changes in the service plans. If the home-helpers note that a senior’s needs have changed, they have to request that the care coordinator visit the senior again and thereafter make a change in the service plans. This entails an undesirable delay between the request and actual changes in the service plans according to home-helpers. Still, the home-helpers appreciate the centralized decisional order as it ensures a fair distribution of scarce public resources: “…I think it is for the best. I mean, if we were to decide, we would perhaps be tempted to grant ‘cute’ seniors more services than the more grumpy ones...” (home-helper).
Interviews further suggest that the service plans relieve the home-helpers of some decision-making troubles: “…it’s nice to have something to depart from, that someone else has decided, one has to make decisions all the time when out on the field anyway…” Inscriptions in technology code
Municipalities are to ensure the safety of seniors, which implies a need to somehow incorporate the detection and response to unpredictable emergencies in the home-help delivery routine. This task is inscribed in and partly executed by the newly implemented telemonitoring technology. This technology continuously collects information about each senior’s activity level (via alarm devices with sensors that seniors wear on the wrist). It automatically triggers alarms every time a significant change in activity level is detected, as this can indicate an emergency. Seniors can also activate alarms manually by pressing a button on the device. The system transmits automatic and manual alarms to care workers. The monitoring system always performs these tasks in the same predefined way, without interruptions (except in case of technical failure) and without variability. A manager asserts that this consistency is valuable from a fairness point of view: “…The technology is always in the same mood and it does not have any favorites…it triggers alarms if a divergences occurs, period. … in theory, it also compensates for differences between seniors in asking for help, some seniors never demand medical service...until they’re close to death...” (Manager).
Hence, the work of detecting emergencies has in part been delegated to the technology. However, the technology does in turn prescribe activity of the home-helpers: encouraging personnel to respond to the alarms that it triggers. I will return to this point.
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The ostensive aspect – agreed on patterns The care managers and many of the home-helpers agree that the delivery of home-help service incorporates more dimensions that those inscribed in artifacts. Patterns stemming from cultural values
Many home-helpers assert that it is their responsibility to provide ‘human contact’ while executing the service plans. This self-imposed responsibility resonates with human right, welfare and equity principles that are well established in the Swedish society: “…When you think about it, the service plans are merely a “cover”. This is not only what our work is about… I mean, many times, “getting help with breakfast preparation” is not what actually means something to the senior. This is not what makes him able to keep on living alone. I’m not saying that our work is NOT about delivering these services [in the service plans], but, I mean, the oldies would not be OK if a robot did all the food, etc. They need the energy that meeting another person generates… But it would look a bit silly to write that in the service plan, ‘human contact, 10 minutes’ …[…]…of course, everyone in Sweden has a right to not be completely isolated when getting old…”. (home-helper).
The interviewed care managers and group leaders share this view of the home-help delivery routine. They refer more explicitly to the social services law in this context. A manager at provider B talks about how he expects personnel to show warmth and act friendly when visiting seniors: “…you have to genuinely like elderly people to be able to perform this job…[…]…I try to think about that when I recruit new people. This has to do with maintaining the dignity of each senior, they are vulnerable and homehelpers that serve them without showing them ‘a human face’, without ‘being present’, without recognizing them as individual persons can cause a lot of harm…I mean, our [as community care provider] commitment is to ensure the elderly a certain level of quality of life and that includes being seen as a person…” (Manager). “…I mean, in former times, children took care of their old parents. That’s not how it works today. That’s why there is social services, I mean, it is a very Swedish thing…You know how the politicians keep saying ‘in Sweden we take care of our elderly’. I think there are even laws about the need to treat the elderly with respect…” (Group leader). Patterns stemming from individuals’ practical experience, i.e. from the performative aspect
The home-helpers also account for activity patterns emanating from their practical experience when describing the home-help delivery routine. When home-helpers perform the service plans during long periods of time, they 92
gradually learn about each senior’s individual but rather stable preferences. This knowledge is shared at morning meetings and it thereby gives rise to collective behavioral patterns. Many of the home-helpers argue that this is an important part of the routine and there are peer-to-peer expectations in this context: “… A lot of the small – but important - things we do, we do each time…for example, during the wintertime, we always lit up the candle on Ruth’s kitchen table when preparing her breakfast, turn up the heat, then turn on the radio and put the morning paper on the table…That’s how she likes it…every single day. I know the others do it too. We don’t have to ask her anymore, this is what she has preferred for ages…I know some [of the home-helpers] may ignore such things but that makes me real mad…” (Home-helper). “… we’ve learned that Bror cares about details concerning the shower. He wants rather cold water first, and then gradually warmer … and we have learned to be VERY careful with the shampoo when helping Bror in the shower...[…]…This type of knowledge is very important to share…we talk about such issues at the morning meetings…”(Home-helper). Patterns stemming from the powerful prescription of technology artifacts
The home-helpers’ schedules are filled with the tasks specified in the service plans. No time is formally allocated to alarm “turn-outs”. Hence, there is a conflict between the activity prescribed by the technology-generated alarms on the one hand, and by the service plans on the other hand. There is an “agreed on” way of coping with this conflict, namely by prioritizing the alarms: “…If there is an alarm, everything changes. We have to leave the service plans aside then. The alarms have priority. One or ideally two of us [on duty that day] have to interrupt whatever we are doing, take the car and visit the senior in question... “ (Home-helper).
A manager talks about the power of the alarms to alter the performances of the home-help delivery routine: “…Of course, we have to prioritize to respond to the alarms…we can’t just ‘leave the turn-outs for later’. We have to act immediately on emergency alarms. Otherwise, there may be legal sanctions…Fortunately it is easy for new girls to understand this prioritization, it’s pretty intuitive, I mean, normal people feel that there is an urgent need to act if there is an ALARM...it’s in ones backbone…” (Manager).
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The performative aspect It is clear that the interviewees’ account of the ‘way they work’ does not cover the variability inherent in the home-help delivery routine. Situational-interactive aspects
Observations were particularly helpful to reveal how each instance of performing the home-help delivery routine varies with the senior’s mood, condition and the relationship between the senior and the home-helper, i.e. situation-specific aspects. Accompanying a home-helper when she performed the instruction <
Many of the home-helpers ‘check on’ all the seniors they visit, while they e.g. prepare food or make the bed. Even if this is not specified in the service plans. How they do this varies. A home-helper explains how she focuses her attention on different aspects depending on the situation: “…of course, you check on them even if this is not specified on the list. For instance, sometimes you note a strange smell when you open the door…I also hear on seniors voice, if they sound unusually weak or start mumbling…Kurt, I usually touch his hand at one time or another when I visit him, I remember recently, his hand was very cold when I patted it. This was an indicator… I commented on this, but I didn’t do anything about it, but I think he felt relieved that I noted it…” (home-helper).
Situation specific factors influence how the agreed on need to provide “human contact” is realized. I observed how one and the same home-helper switched the tone of voice, tempo and body language when talking to different seniors, while delivering the same service “on paper”. A home-helper talks about this:
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“For example, Helena, she had a stroke and it’s difficult to hear what she says. You really have to listen carefully and…she takes small breaks between the words. In the beginning, I thought she had finished her sentences and I started to fill in, but that was detrimental, she needs to get the chance to speak up for her self. I’ve learned now to be more patient… With Anton on the other hand [I act differently.] …Anton has always seen himself as a funny guy I think. I understand his jokes and I really try to show him that I appreciate his jokes. … I think our laughs are crucial to his well-being and health… yes, Anton and I, we have developed our own sense of humor…I really like to joke with him…I think it makes him feel like he is still in the game…[…]…of course, if he has a bad day [Anton suffers from chronic back pain] I might not joke a lot, I may not give him a BIG SMILE… I may rather tell him something to get his mind off his pain…”(home-helper). Individuals’ personal views and emotional-ethical values
The quotations above show that many home-helpers “add” to the home-help routine efforts to respond to situation-specific issues. This work is not documented. Why do they do this? Because they view this as part of their job – and as part of their human responsibility to ‘help fellow beings in need’. Indeed, many of the home-helpers are driven by altruistic ideals to care for the needy: “…This job is rewarding as you really feel that you do something for people in need. That’s what keeps me going during the days...and I mean, I really care for many of the seniors…so it’s natural for me to do what I can to make them feel good while I’m there. I’m there anyway right? So I might as well use my time effectively…” (home-helper).
Now, all home-helpers do not share this view and this creates variability in the enactment of the service plans. Some home-helpers make no effort to “add” personalized dimensions to the routine. Some only do that (or less than that), which is specified in the service plans without being friendly or showing any warmth. The findings suggest that this variability in individual performance is influenced by the diversity in home-helpers’ personal views and emotional-ethical values: “…I think there is a difference between the girls who find pride in their work on the one hand, and those who see it as dirty work and wish they were somewhere else on the other hand. If you do not like your situation…you will not go that extra mile, like trying to put a smile on the senior’s face by joking a bit…[…]…For example, some of them really try to do the dishes very quickly to get the time to sit down and chat with the senior…others do not make this effort…in general, I know there are ‘nicer’ and less nice girls [home-helpers]…but there is nothing we can do about that. One has to accept that…” (Manager). “…Lisa was typical, she was arrogant toward seniors. I talked to her. She told me that her brother was a doctor and her sister some kind of lawyer. She felt 95
pressured to start studying and get a ‘real’ job...she viewed this job as simple…”(Manager). “…I think we have different ideals…different goals with our home- visits. Some may only aim to ‘get them done’. I always try to chat with the seniors… I’m brought up with that, to treat people with respect. And further, to do whatever you do with your whole heart…[…]… You know, even if I’m in a bad mood, I am always friendly to the seniors. It usually makes me in a very good mood! …of course, I have to confess that I talk a little extra with my favorites, like David…”(Home-helper).
Individual views are in turn related to the cultural and historical context in which they are situated. The general ambivalent social status of “elderly care work” is identified as an important factor influencing the variability in home-helpers emotion-ethical values and behavior: “…this is not a well paid job. That sends signals to the home-helpers as well as everyone else. Of course it affects the status of the job. On the other hand, elderly care work does have some status in the sense that it is seen as meaningful and important. People working with the elderly are seen as “nice people”…” (Group leader) “…This has generally been seen as a job ‘anyone’ could take without any formal education. But of course, anyone cannot do this job - well. You need to be committed and have experience to do it well. That should have the same status as formal education if you ask me, but it doesn’t in today’s society…” (Manager). Exceptions: highlighting the influence of personal values
The influence of the workers’ diverse emotional-ethical values is highlighted in situations with competing rationalities. For example, seniors sometimes refuse the services that they are granted. Complying with the wishes expressed by the senior in such cases implies a divergence from the service plans. The home-helpers act differently in such cases, illustrated by the following quotes: “… I really try to listen to the senior. I don’t want to force them, say… to eat for example. I think it’s wrong to treat another human as if she knows nothing. It’s against my personal principles. They have a right to autonomy…And who am I to claim that I know better than they do… “(homehelper). “…Olle sometimes says he doesn’t want a shower or says ‘oh, I’ve already taken a shower!’ when it is obvious that he hasn’t. I try to make the shower less intimidating to him in such cases and I usually manage to make him willing to let me shower him… It is a matter of their dignity!…I remember when my mom was old and senile…she often said no when the home-helpers told her they were to shower her. And they just left, can you believe that!? Happy 96
to leave I guess... Hence, I found her smelling sweat and I felt so humiliated on her behalf. I often showered her myself…”( home-helper).
Another example is when the monitoring technology triggers alarms. The home-helpers do prioritize the alarms as is “agreed on”. But they respond differently to the alarms, depending on their view of what is “an urgent need” and what they feel is “fair”: ”…Alarms can be caused by any reason…the senior may have had a heart attack …but there are also more diffuse cases, where a senior has pressed the button because he is lonely and anxious. Then it is difficult to know how long you should stay with the senior…I have a hard time leaving the senior in such cases, I’m that type. And I believe that one can urgently need company if one is anxious…it [problems of depression and anxiety] runs in the family… I know others are more ‘rigid’, and only stay if there has been a physical accident…of course they just try to be fair to the others who are waiting… “ (home-helper).
In sum, the performative aspect of the home-help delivery routine exhibits more variability than the ostensive and artifact aspects. The workers’ diverse emotional-ethical values, which are in turn inextricably linked to the micro (family values) and macro (values established in the contemporary society) context in which the workers are situated, constitute an important source of variability here.
Conclusion The findings presented above suggest that “the home-help delivery routine” incorporates various dimensions that operate in variability reducing and variability enhancing ways.
The role of and internal relationship between the parts of the routine The power over the routine as inscribed in artifacts (service plans and technology) is centralized and the routine as inscribed is a source of consistency in the setting studied. The service plans represents a default way of operating that the workers can return to after making ‘detours’ called for in specific situations. The routine as inscribed in technology artifacts further operates in a stable manner. In general, the routine as inscribed in artifacts is inflexible and the routine may therefore seem static from an outside perspective. The present exploration however shows that the routine would not survive would it consist merely of these inscriptions.
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The ostensive aspect of the routine, i.e. the content of the routine as agreed on by the workers, has a complementary role in this respect. It mediates between the routine at artifact and performative level. The ostensive aspect incorporates agreed on solutions to conflicts between the prescriptions made by artifacts. It is further shaped both by individuals’ practical experience of executing the routine and by prevailing cultural views. These micro and macro forces influence individuals’ understanding of the role of the routine. Hence, the ostensive aspect of the routine recognizes and responds to more variability than artifacts. The performative aspect of the routine incorporates yet more variability. It is sensitive to several more influences than those “invited” to directly shape the routine at artifact and ostensive level. I will return to this point. What I want readers to note here is that the technology artifact is a source of variability at the performative level. It creates situations with competing concerns. As neither service plans nor agreed on rules covers such situations, many home-helpers apply personal rules, originating in “what they feel is right” in such cases. In general, many of the home-helpers complement or diverge from the routine as inscribed in the service plan to “make it work” in actual situations. The variability generated by this effort could impossibly be covered by the routine at artifact or ostensive level. Nonetheless, it is a desirable variability. Indeed: thanks to many of the home-helpers’ efforts to compensate for the inflexibility of the routine as inscribed in service plans, these rules can remain unchanged– and the routine overall can survive. Now, this overall argument does not mean that all the variability in the performative aspect should be embraced. I shall discuss this below.
Sources of variability in the home-help delivery routine As indicated above, contextual contingencies (interactive-situational aspects, Tsoukas (1996)) constitute one source of inevitable variability in the performative aspect of the routine studied here. Now, this study suggests that difference in workers’ personal values (disposition, Tsoukas, 1996) creates another layer of variability in the performative aspect. Altruistic convictions, acquired during the previous life history, motivate many workers to consciously add work to the routine to respond to contextual contingencies in situ. Other home-helpers, who view home-help as a degrading and lowstatus job often omit to fine-tune the routine in this way. Indeed, negative emotional convictions even drive some home-helpers to do less than what is inscribed or agreed on when executing the routine in situ. Hence, the diversity in individuals’ personal emotional-ethical values constitutes an important source of undesirable variability in the routine. The salient influence of emotion-ethical values should be understood in relation to the high frequency of exceptions (emergencies) and the resource scarcity prevailing in the elderly care setting. These conditions create an 98
environment characterized by unpredictable and competing needs and a constant call for reflective judgment about what is “the right” (or least bad) thing to do. It is further crucial to note that the workers’ personal values are inseparable from (produced by and reproducing) the contrasting prevailing cultural values and norms in the contemporary society (Tsoukas, 1996) as well as the workers’ diverse private backgrounds (habitus, Bourdieu (1990)). The gist of all this is that the performance of routines is shaped by factors beyond the routine itself, and beyond the organization in question. As a result, the performance is difficult to predict and control.
Theoretical implications Previous research has recognized that there are differences between the dimensions of a routine. It is agreed that there is an immense variability inherent in the performative aspect of the routine as opposed to the routine as inscribed in artifacts (Pentland & Feldman, 2005). The present paper extends these arguments in several ways. The close look at the internal dynamics of the home-help delivery routine shows that its survival is dependent on the fact that workers depart from and return to, but often override the routine at artifact level. The managers interviewed accept this. Hence, this study suggests an alternative to the view that differences between the routine at artifact, ostensive and performative level indicate disagreement between labor and management (e.g. Callaghan & Thompson, 2001; Deery et al., 2004; Hanlon et al., 2005; Taylor et al., 2002) or that divergence between the parts of a routine may indicate “resistance or serious misunderstandings about what it takes to do the work …[or] a template that is outdated” (Pentland & Feldman (2005) pp. 806). In contrast, the present study argues that the survival of the routine is dependent on the differences between its aspects. It suggests that the routine at artifact level can remain stable just because the ostensive and the performative aspect differ (complement and diverge) from it. Hence, the study supports the argument made by Toukas & Chia (2002) who write about stability and change in general: “… the statement "the acrobat maintains her balance" is true, as is also true the statement "the acrobat constantly adjusts her posture…[…]… The apparent stability of the acrobat does not preclude change; on the contrary it presupposes it.” (pp. 572). (cf. Birnholtz et al., 2007). In general, this study underlines the need for theory acknowledging that variability reduction is not only the aim of managers and that it is not the only aim of managers (as is implicitly suggested in Callaghan & Thompson, 2001; Deery et al., 2004; Hanlon et al., 2005; Taylor et al., 2002). The findings suggest that managers, workers and consumers recognize the simultaneous need to: 1) reduce internal variability (Harvey et al. 1997) stemming from e.g. favoritism and other bias to ensure fairness and 2) respond to (the inevitable) external variability (Harvey et al. 1997) in consumer needs. This 99
implies that variability reduction and variability response efforts should not be portrayed as antithetical, or as generalized categories. Rather there is a need for nuanced accounts of variability management in relation to routines. This study further starts to demystify the variability in the performative aspect of routine. It supports the notion that situational contingencies exist in any situation, discussing this in terms of interactive situational issues (Tsoukas, 1996). However, it adds the insight that individuals’ personal values (dispositions, previous life experiences or ‘habitus’, Bourdieu, 1990; Mouzelis, 1995; Tsoukas, 1996) shape how individuals respond to such contingencies. More specifically, it shows that workers’ emotional-ethical principles can constitute rules for how to execute a routine, in particular in situations where there are competing concerns, and that this creates variability in the performance of the routine. This contributes to the literature. Previous research suggests that individuals’ inarticulate and subconscious response tendencies (Birnholtz et al 2007; Cohen & Bacdayan, 1994) influence their behavior. However, as noted by Birnholtz et al (2007) reflection (based on individuals’ declarative knowledge) also plays an important role when individuals decide how to act in new, unknown situations (Birnholtz et al. 2007). The present study extends this argument by highlighting how emotionalethical values influence individuals’ conscious efforts to “make the routine work” in situ. Of course, emotional-ethical values are presumably partly stored in individuals’ procedural memory as inarticulate and subconscious response tendencies. However, the frequency of exceptions (Perrow, 1967) and competing needs in the setting studied activates these values and forces workers to apply them in a more conscious way. Hence, the notion of the dispositional dimension (Tsoukas, 1996) should not only be understood as the as a subconscious force that steer individuals’ behavior, but also as a standpoint that individuals can articulate and depart from when they need to reflect on alternative ways to act. Finally, the study highlights that technology artifacts can constitute a source of variability and unpredictability in routines. This insight complements the literature that tends to equate technology with variability reduction. Indeed, authors have referred to the variability reducing consequences of “protocol-laden technology” without specifying if this refers to the inscribed, agreed on or performed patterns of the routine (e.g. Hanlon et al., 2005). Further, routine studies have primarily discussed the indirect enabling and constraining role of artifacts in terms of written rules, checklists etc (Cyert & March, 1963; Miner, 1991; Miner & Estler, 1985; Howard-Grenville, 2005; Pentland & Feldman, 2005). The present paper suggests that artifacts can be active participants in retaining and varying the routine by executing and powerfully prescribing activity, playing an intrusive role. In sum, the present paper adds to the contemporary understanding of the internal dynamics of the routine. It further highlights that emergent factors in the local context, including exceptions generated by technology artifacts; 100
individuals’ personal values and structures in the larger social context represent sources of variability in the performance of routine. Hence, the present paper situates individuals’ enactment of the routine in a cultural and historical context, at micro and macro level (cf. Narduzzo et al., 2000; HowardGrenville, 2005).
Managerial implications There is today a tendency among politicians to overestimate the importance of routines encoded in artifacts. For example, national care quality is increasingly equated with thorough documentation of routines. Electronic work logs are also gaining attention (see e.g. Social ministry, 2005). The purpose of such tools is ultimately to detect divergences between the routine as inscribed and as performed, by measuring e.g. minutes spent on each task. However, this study suggests that additions or divergences from routines as inscribed are often necessary in the care setting. Indeed, the smooth operation of routine studied (and the care system of which it is a part) in fact implicitly builds on the “added” work performed by many home-helpers (but not others). The ostensive aspect incorporates the normative expectation that home-helpers will be “givers”, that they will – presumably driven by their own emotional-ethical conviction - “voluntarily” perform many tasks to respond to various undocumented needs among seniors that nobody but the senior notices.20 This needs to be brought to the fore in quality discussions. Workers emotional-ethical values should be the target of improvement efforts and quality discussions in addition to documentation issues. I am not suggesting more written rules, but a much more frequent articulation of the need to reach a certain degree of consistency in how workers approach and adjust to seniors. One such way is to standardize inputs (Mintzberg, 1979), i.e. by educating personnel and ensuring shared values. Frequent meetings and technologies supporting real-time communication between front-line workers who work isolated out on the field is an extension of this. In general, there is a need to look at the result rather than the process, e.g. by asking seniors about their satisfaction with the care they receive. Of course, the undesirable variability illustrated in this paper partly stems from the low status of elderly care work in today’s society, which in turn is rooted in wage structures, the contemporary view of body work and of theoretical versus practical knowledge. Clearly, coming to grips with these issues 20
To understand this situation, we need to consider that the growing number of seniors in Sweden has not been accompanied by a corresponding increase in community care providers’ budget. As a result, public resources are allocated to the most obvious (read: physical) needs rather than more subtle, emotional needs related to loneliness. This makes the workers’ efforts to strain-and-stretch the routine (e.g. by rushing through tasks to release time to chat with seniors) crucially important. 101
not only requires other measures than more rigid rules, it requires structural changes.
Limitations and further research The present work does not set out to make generalizations but endeavors to provide a set of propositions to be further investigated by future research. By unpacking the routine, this study reveals organizational power structures. The power of the routine as inscribed in artifacts is centralized in the studied setting. However, the differences between the artifact, ostensive and performative aspect of the routine indicate that there is a significant degree of decentralized decision-making. This is partly related to the fact that workers are ”out alone on the field” when performing the routine. Researchers could investigate other settings where workers’ are informally allowed to make decisions in situ to “make the routine work” but where this discretion is not formally recognized, i.e. not accompanied by status or power of the routine as inscribed in artifacts. Further, this study illustrates a setting where workers express emotion to satisfy seniors needs, use their emotions to detect (“feel”) what the consumers need, and use their emotions as a guide when making difficult decisions. Emotions clearly play various roles that cannot be covered by the notion of emotional labor (Hoschild, 1983). This is however beyond the scope of this paper and an avenue for future research. Finally, this study can be positioned within an emergent stream of studies that are starting to look at the interplay rather than conflict between rules and creativity, stability and change, reducing and responding to variability etc. (Birnholtz et al., 2007; Gilson et al., 2005; Pentland & Reuter, 1994; Tsoukas & Chia, 2002). Research further conceptualizing such relationships is warranted.
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3. The Emergence of Technology-based Service Systems: a Case Study of a Telehealth Project in Sweden 21
Author: Essén, Anna Abstract: Purpose. This paper is concerned with the process of innovating technologybased service systems. Research has recently elucidated how bricolage, i.e., individuals’ “making do” with the means available can trigger innovation. However, the concept of bricolage essentially remains a black box. This paper attempts to flesh out the concept of bricolage and thereby elucidate the innovation of technology-based services as an emergent process. Methodology/Approach. The paper uses case study data from the Swedish elderly homecare setting. Findings. The findings illustrate how the emergence of technology-based care services can be triggered by an injection of energy in terms of a new technological resource being made available in an organization, proceeding as a continuous interaction between personnel repurposing and recombining resources at hand, positive and negative feedback dynamics, institutional regulations and culture-related stabilizing mechanisms. Research limitations/implications. New services can arise as a result of a number of efforts and events that in isolation appear non-significant. Taken together, and interacting with enabling and constraining forces that promote the emergence of certain new services and prevent others, such acts and events generate unpredictable outcomes. The result may be incremental but by no means trivial innovations. Originality/value of paper. The paper suggests an approach to innovation that complements conventional thinking in the new service development literature. The proposed framework can help to explain how and why certain new service emerge, and others not, in unexpected and unpredictable ways. Wordcount: 234
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This paper is published in Journal of Service Management. 2009, Vol 20/1, pp 98 – 121.
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Introduction Knowledge about the service innovation process is important for our understanding of the transformation of offerings, organizations and sectors over time. However, it is still an underexposed area in the literature (e.g. de Jong and Vermeulen, 2003; Syson and Perks, 2004), in particular the process of innovating technology-based service systems (Menor et al., 2002; Van Riel, 2005). Scholars have recently pointed at the complexity related to this kind of service innovation, arguing that it involves not only technological but also organizational development (e.g. Magli et al., 2006; Piccoli et al., 2004). It has further been suggested that the technology-based service innovation process encompasses many informal and iterative elements, and that it is influenced by extra-organizational factors, such as the prevailing policies and cultural values (e.g. Barlow et al., 2006). These insights indicate that students of technology-based service innovation should take on a broad perspective. Alas, the nascent technology-based service innovation literature does not quite respond to this call. Existing studies largely approach this area from a technology-oriented perspective, either attempting to 1) model the systematic sides of technology-based service innovation or 2) investigate to what extent certain technology-based services respond to certain consumers’ needs (Chircu et al., 2001; Dabholkar et al., 2003; Lanseng and Andreassen, 2007; Massey et al., 2007; Mørch et al., 2004; Slater and Mohr, 2006; SungEui, 2005; Walker et al., 2002). This tends to produce studies incapable of capturing the complexity of technology-based service innovation. Indeed, the prevailing practice-oriented approach tends to generate studies that neglect the informal and unpredictable dimensions of the technology-based service innovation process and it’s sensitivity to the influence of extraorganizational factors. This weakness applies to the New Service Development literature in general. It is dominated by studies depicting service innovation as a well-planned, formal process, starting with a managerial vision and ending with full-scale launch (Cooper et al., 1994; Johne and Storey, 1998; Menor et al., 2002). While scholars have criticized these models for obscuring the iterative and bottom-up sides of service innovation (Edvardsson et al., 1995, Dolfsma, 2004; Steven and Dimitriadis, 2004) alternative models are hard to find. In summary, the new service development literature (including studies focusing on technology-based service innovation) mainly theorizes about the formal, linear and predictable facets of the innovation process. This in spite of observations suggesting that many innovation processes are cyclical and that they involve unexpected, informal interactions between factors at individual-, organizational-and societal level. The lack of theoretical understanding of the latter aspects has implications in practice. Such aspects are not considered in cost analyses or supported with tools or technologies (Maglio et al., 2006). As a result, informal mechanisms and ideas are not caught up, 107
potential innovations go unnoticed, and many extra-organizational forces that exert positive or negative influence on the innovation process are not dealt with, leading ultimately to a reduced financial performance. The present paper seeks to address the imbalance in the extant literature by proposing a framework for studying the process of technology-based service system innovation from a broad perspective, using an approach that elucidates the non-linear facets of this process. The paper draws on LévyStrauss’s (1966) concept of bricolage, which implies that individuals’ ‘making do with resources at hand’, as opposed to managerial visions, can trigger innovation. To flesh out this concept, illustrating how it is influenced by certain institutions, resources and events, the present paper integrates it with the notion of technological drift (Ciborra et al., 2000) and with a model of emergentism (Chiles et al., 2004; Prigogine and Stengers, 1984). The paper illustrates the proposed framework using empirical data about the first phase of developing technology-based elderly care services. Hence, the paper responds to calls for innovation research in settings other than the financial sector, which has received a disproportional amount of attention in the development literature to date (Smith and Fischbacher, 2005; Stevens and Dimitriadis, 2004). The care setting is relevant as increased healthcare spending and possibly unsustainable healthcare funding models motivate many care providers to develop existing care services by using information technology (IT) or ”telehealth ” applications (Koch, 2006; Lanseng and Andreassen 2007; OECD, 2004). Service development in this area is however immature. Indeed, there are internationally few examples of telehealth services offered in routine care service delivery (Barlow et al., 2006). This situation and the public healthcare sector in general, have received surprisingly little attention in the service innovation literature (Smith and Fischbacher, 2005). Drawing on the proposed emergentism framework the paper describes the beginning of an innovation process, which is triggered by a new technological resource being made available in a care organization and proceeding as a continuous interaction between repurposing mechanisms, feedback mechanisms, institutional regulations and stabilization mechanisms. This way of understanding the service development process extends the concepts of bricolage and drift, by revealing the enabling and constraining dynamics that reinforce the emergence of certain services and prevent others from realizing. The applicability of these insights go well beyond the care setting. They are relevant to students of innovation processes in general. Overall, the paper opens up avenues for research studying how new services can arise, actualize, materialize in a non-linear and rather unpredictable way, and it thereby complements the new service development and service innovation literature, which to date has been dominated by studies outlining “success factors” and emphasizing the importance of systematic innovation processes (Åstebro and
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Michela, 2005; Atuahene-Gima, 1996; Avlonitis et al., 2001; de Brentani, 2001). The paper begins with a selective literature review and a presentation of the proposed theoretical framework, integrating insights from bricolage (Lévi-Strauss, 1966), technological drift (Ciborra et al., 2000) and emergentism (e.g. Chiles et al., 2004; Prigogine and Stengers, 1984). Case study findings from a telehealth project conducted by a public elderly care provider in Sweden follow. The paper proceeds with conclusions, implications and suggestions for further research.
The innovation of technology-based services The concern of this paper is the process of innovating new technology-based service systems.22 The “new service development” literature has paid little attention to such innovation processes (e.g. Menor et al., 2002). A review of the nascent technology-based service innovation literature reveals that it largely attempts to shed light on the systematic, ordered facets of the development process (cf. Chircu et al., 2001; Palmer and Griffith 1998; Passerini et al., 2007; Sung-Eui, 2005; van Riel et al., 2004). For example, Piccoli et al. (2004) conceptualize the development of technology-based services as a migration from one discrete phase to the next, which follows a predictable pattern determined by the firm’s overarching goal of maximizing its return on its technology investment. Many service development studies further focus on consumers’ adoption of technological innovations (e.g. Dabholkar et al., 2003; Lanseng and Andreassen, 2007; Massey et al., 2007; Slater and Mohr, 2006; Walker et al., 2002; Vrechopoulos et al., 2001). This research produces important insights, but tends to produce an understanding of the innovation process as predictable and possible to control. Now, a few recent studies have suggested that the process of innovating technology-based services is more complex than this. Barlow et al (2006) highlight that this process involves integration between the technological innovation and the service provision system (including authority structures). They also argue that the policy context, contemporary values and cultural norms can influence the innovation process.23 In general, they point at a mishmash of factors, at various levels, that can play important roles in the process of innovating technology-based services. Maglio et al., (2006) similarly suggest that technology-based service innovation involves not only 22
Innovation can broadly be described as an idea, artifact, or behavior that is new to or perceived as new by the organization adopting it (Daft, 1978; Zaltman et al., 1973). This paper deals with the process that generates such ‘outcomes’. 23 Barlow et al (2006) write about “implementing” a technological innovation, but I believe that it is more appropriate to talk about service innovation. The overall discourse needs to shift focus from technology implementation to service innovation. 109
technological, but also organizational and individual relationships, i.e. that it should be understood as a matter of developing new service systems. Their examination of IT- service delivery systems suggests that such systems comprise a large share of non-planned tasks and negotiations performed by individuals and that other ‘fuzzy’ factors, which are beyond the manager’s direct control, influence the development of such systems. These latter study examples indicate that the technology-based service innovation process 1) involves more than the ordered implementation of a new technology; is 2) cyclical rather than linear and that it is 3) influenced by informal and unpredictable factors, among which many are beyond the organization’s control. As noted above, such aspects have however not seen much light in the new service development literature. It is however important to note that recent research on innovation systems more generally is increasingly underlining that innovation can occur through other pathways than well managed and systematic processes. Indeed, observations suggest that innovation trajectories are often informal, ad hoc and unpredictable and that they should be understood as cyclical, including various feedback loops and evolving through complex – often unexpected and even accidental – events (Consoli, 2005; Gadrey et al., 1995; Jensen et al., 2007; Metcalfe et al., 2005; Rothschild and Darr, 2005). However, few models elucidating how these factors interact have been suggested. Hence, there appears to be a need for a more comprehensive framework that allow for a multi-level analysis of the dynamics between micro processes at individual and organizational level on the one hand, and structures at societal level on the other hand, in the innovation process. In the next section I shall try to present such a framework. I will start by introducing the notion of bricolage (LéviStrauss, 1966) and technological drift.
Bricolage and technological drift The concept of “bricolage” often referred to as making do with “whatever is at hand” (Lévi-Strauss, 1966: 17; Miner et al., 2001; Weick, 1993) helped to describe and understand the innovation process observed in this study. This paper draws on Baker and Nelson (2005) who define bricolage as “making do by applying combinations of the resources at hand to new problems and opportunities” (pp. 333). Resources at hand refer to a set of pre-existing ‘odds and ends’ (Lévi-Strauss, 1966:18) e.g. available materials (Lanzara, 1999), coping mechanisms (Hatton, 1989) and skills and ideas (Baker and Nelson, 2005). Bricolage implies that such resources-at-hand are reused for different applications than those for which they were originally intended or used (Garud and Karnoe, 2003; Miner et al., 2001). In other words, bricolage is the repurposing and refashioning of the old in making something new (Weick, 1993) and it involves recombining existing elements rather than fabricating them from scratch (Baker and Nelson, 2005). 110
Bricolage contradicts the rational model of innovation as seeking means to reach a given end. In bricolage, the ends are not clearly known at the outset and the “reasoning” process does not use logical deduction but is more of a spontaneous process (Innes and Booher, 1999). Indeed, bricolage is related to improvisation. To paraphrase Miner et al. (2001: 314): “…as improvisation permits no temporal gap between the design and execution of activities, improvisers have little opportunity to seek resources beyond those already at hand, and they therefore typically engage in bricolage”. Hence, in contrast to conventional views on innovation, bricolage suggests that innovation can be understood as actors departing from the means and gradually learning what aims are possible. It is difficult to foresee the result of such practices. Bricolage is associated with unexpected outcomes that are half-realized, hybrid and imperfect, but which do their job and can be improved (Lanzara, 1999; Miner et al., 2001). As this paper deals with technology-based services, insights about the unpredictability of outcomes in the information systems (IS) literature are relevant to consider here. The IS literature discusses this in terms of technological drift (Ciborra et al. 2000), i.e. the tendency of technologies to deviate from their planned purpose for a variety of reasons (pp. 4). Technology often performs in unexpected ways and it tends to produce unintended side effects when implemented. As a result, users often have to revise goals and intentions or try to find ways to alter or work around the technological properties over time (Ciborra et al., 2000; Pickering, 1995). The affordance (Gibson, 1979) of technology, i.e., users’ perception of what action is possible with the technology, is further highly contextual. This shapes the consequences of IS implementations in unpredictable ways (Orlikowski, 1992 cf. Feenberg, 1999; Murata, 2003). Summing up, the concepts of bricolage and technological drift complement each other, suggesting that the innovation of technology-based services can be triggered by individuals making do with resources at hand, and that the outcomes of such practices, i.e. the new technology-based services that actually emerge, may be different from what was initially envisaged by technology designers or the user organization. These insights were valuable when analyzing the innovation process studied here. However, it soon became clear that there was more to the process studied than actors “making do with resources at hand”. Further, neither bricolage nor technological drift could sufficiently explain why certain technology-based services came to be while others were prevented from being realized. Why did outcomes “drift” in one direction and not another?
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Proposing a framework for studying the emergence of new technology-based services Indeed, while the literature applying bricolage and technological drift do shed light on the triggering and outcome related elements of the innovation process, the bricolage process has essentially remained a black box. To open this black box, i.e. unpack the intermediate dimension of the innovation process, this paper uses insights from complexity theory (cf. McKelvey, 1999). Complexity theory is suitable for the study of how new services can come to be as it focuses on emergence, on “becoming rather than being” and on “process rather than state” (Gleick, 1987: 5). It can be used to explain how and why a phenomenon evolves from the interaction of myriad events, small and large, spontaneous and deliberate, and at multiple levels (Chiles et al., 2004). The idea that emergent properties amount to more than the sums of the properties of their parts is central in emergentism theory (Gleick, 1987). This paper draws on the dissipative structures model (Prigogine and Stengers, 1984; cf. Chiles et al., 2004), which posits four interacting mechanisms of emergence24: 1) ‘fluctuation’ refers to injections of energy represented by new activities, events or resources that interrupt the existing order and catalyze the emergence of a new order; 2) ‘feedback dynamics’ amplify the initial fluctuations, helping the new order to take hold and gain momentum; 3) ‘stabilization dynamics’ are deep structures that shape novelties and guides choices in a way consistent with the systems accumulated history and learning, preserving the systems identity and core behavioral patterns; and 4) ‘recombination dynamics’ refers to how the system’s existing elements are reused, rearranged, reconstructed, re-leveraged, and re-created. Hence, the dissipative structures model overlaps with bricolage but it also extends this concept by elucidating the forces that enable and constrain what individuals can make of the technological resources at hand. While organizational students have used the dissipative structures model to explain how the evolution of organizational systems proceed from a “punctuated emergency” to the next, i.e. from one order to another over time (Chiles et al., 2004; Leifner, 1989), this paper draws on it to explain the first phase in a service development process, i.e. the emergence of a new service, which can be understood as the evolution of one new order. Figure 1. A framework for unpacking the concept of bricolage in the context of the innovation of technology-based services. Take in figure one about here
24 This version of the dissipative structures model is simplified to suit the purpose of this paper. See further Prigogine and Stengers (1984).
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The framework (see fig. 1) suggests that the development of new services can be triggered by the injection of energy in terms of a new technology resource being made available in an organization. The organizational members will engage in bricolage (Lévi-Strauss, 1966) by making do with the new resource, i.e. they will repurpose it and recombine it with old resources and as a result, they will learn what the technology affords in context. The individual members’ acts of making do should however not be confused with boundless freedom and endless creativity. Positive and negative feedback mechanisms shape their acts of making do. That is, the immediate responses the personnel encounter when using the new resource will amplify certain uses and prevent others from being repeated. The (unexpected) performance of the new technology, when implemented, will also actuate responses and developments in certain directions rather than others. These responses contribute to the definition of the boundaries of the emerging service. The emergence of new ways of using the new resource, i.e. the birth of new technology-based services, is further influenced by more permanent institutional constraints and stabilizing mechanisms such as organizational structure, regulations and cultural values (Chiles et al. 2004; Prigogine and Stengers, 1984). The innovation process will unfold as a continuous interaction between these enabling and constraining mechanisms and it will produce results that may drift from the original intention of technology designers and the user organization (Ciborra et al., 2000). In general, is difficult for any single actor to control the outcome of this process as it is shaped by participants and forces at various levels and at different points of time. This view of the innovation process has emerged during the process of writing this paper, see method section, and it has guided the analysis and presentation of the findings.
Method The present paper explores how the mechanisms depicted in figure 1 operate in a particular context such as technology-based care service innovation. That is, the purpose is to develop rather than to test theory. The study is based on a single case. This case was chosen for theoretical reasons, i.e. as it could reveal an unusual phenomenon (technology-based care service innovation) and support the elaboration of the emergent theory (theoretical rather than representational sampling (Yin, 1984)). Studying the single case during over 3 years (2004-2007)25 allowed the researcher (author) to follow the informal, gradual processes of service development over time in its realworld context and to use various information sources (Yin, 1984). In gen25
This study is part of an ongoing research program investigating the infusion of information technology (IT) into elderly care. 113
eral, the case study approach is suitable for longitudinal research seeking to unravel the underlying dynamics of phenomena that play out over time (Siggelkow, 2007).
Data generation A telehealth project conducted by the community care organization in Heby in Sweden constitutes the case studied. Heby is today one of few elderly care providers engaged in the development of IT-based services in Sweden. The author has participated in a large number of formal and informal meetings in Heby during 2004-2007. Field notes have been taken from these observations. Home-helpers’ service documentation has further been scrutinized and summarized in field notes. In 2006, 12 un-structured interviews were performed with home-help and managerial personnel within the Heby community care organization. The interviews revolved around visions about the telehealth technology and the actual use and development of services on basis of this technology (see appendix). The longitudinal study allowed the researcher to ask follow up questions such as, why did you not exploit that function, etc. see how one thing led to another (interactions). Interviews were performed at the nursing home where personnel gather before they deliver home-help services. The interviews included open-ended questions in order to allow for unexpected issues to emerge and lasted about 90 minutes each. The interviews were recorded, transcribed and translated (Swedish to English) by the author.
Data analysis Following the pattern for inductive research (Denzin and Lincoln, 1998; Miles and Huberman, 1994), the author worked recursively between the interview transcripts, field notes and the theory being developed. Field notes and interview transcripts were analyzed at two levels. The author first focused on building detailed descriptions of particular acts where the individuals involved in the telehealth project created new ways to use the new technology. These descriptions were then coded tentatively, using key words emerging from the empirical data (Miles and Huberman, 1994). When documenting patterns in the data, tentative theoretical explanations were constructed based on an initial framework. The individual-level, pragmatic, ad hoc and bottom-up tendencies ran across interview transcripts as well as observational notes. Similarly, the role of forces at structural level were evident in several sources. The author discussed uncertainties in the data with two of the home-helpers at several occasions. Several working papers that attempted to explain regularities in the data were written. These papers were 114
presented to peer scholars and critical feedback was received. During the repeated process of interrogating the data, revising the theory, and returning to the data, Lévi-Strauss’s concept of bricolage was discovered as a good characterization of the behaviors observed in the case. However, it became obvious that this concept did not explain the process alone. The dissipative structures model emerged as relevant after some modification. And after several rounds of experimental coding, the themes reported in the present paper eventually emerged (Denzin and Lincoln, 2000). In the presentation of the results, illustrative examples of the data from which the author drew inferences are provided (Miles and Huberman, 1994). When quotes are used, the names of the informants are coded.
The case The study focused on a sub-unit of the Heby community care organization (as this unit implemented the new technology). This sub-unit employed 18 home-helpers at the moment. The municipality director of Heby is ultimately in charge of the care delivered by these home-helpers. There are also regional managers, heading over group leaders, who in turn lead groups of home-helpers. In 2003/2004, the Heby municipality director and regional manager decided to invest in an activity monitoring technology. At this time, Heby was suffering from financial constraints (budget deficit). The managers used money from a temporary municipal development fund to cover the investment. The new technology has similarities with “traditional safety alarms” that are provided to seniors in the community. The monitoring units are wrist-worn and include a button that seniors can manually press when they are in an emergency situation. The new monitoring units however also include functionality that differs radically from the traditional alarms. Embedded sensors continuously monitor seniors’ activity level, transmit this information to service providers, and present it in the form of graphical activity curves displayed on a computer screen. The monitoring system also sends automatic alarms to personnel if significant changes in activity level are detected, e.g. if a senior is completely inactive as this can indicate an emergency. Hence, the system provides information about subtle changes in activity patterns over time, i.e. non-emergency information, but also about drastic changes in activity levels via automatic inactivity alarms, i.e. emergency information. The Heby managers bought 23 end-user monitoring units. The technology was installed in 23 elderly households located in a sub-region of Heby. They also purchased a PC with a certain application installed, which was needed in order for personnel to be able to analyze the patient activity information (graphical activity curves) generated by the system.
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Findings The development process studied was characterized by a continuous interaction between the mechanisms in the proposed theoretical framework. The mechanisms are illustrated with examples from situations where they were salient.
An injection of energy: Introducing a new technological resource without a clear end in sight A group of managers in the Heby community care organization initiated the development process studied. They envisioned that new technology-based services could contribute to a more cost-effective care service production and they decided to invest in a telemonitoring system. There were numerous new care technologies available on the market, but few targeted the elderly homecare sector. Hence, the managers pragmatically “settled” with a technology that seemed to hold some promise. An important reason for the managers paying attention to this particular technology was an informal relationship between key actors (as opposed to a systematic scanning of all technologies available). Serendipitous events such as people being seated next to each other at a grand dinner played a role here. The vendor marketed the monitoring system as a tool for ensuring the safety of seniors living in single households. “…The message was that the monitoring system would enhance our capacity to detect emergencies...And the extended information about the senior patient’s ‘general status’ would enable us to ‘know’ our seniors better...” (Birgitta, Manager).
While the managers were animated by such claims, they were uncertain about what benefits the use of the technology could produce at a more concrete level. “We found it difficult to predict…At this stage, our belief was that the advantages of the monitoring technology in practice would emerge along with the staff members starting to use it” (Anna, Manager).
Indeed, it was difficult for the managers to formulate a new service concept at this stage as they were unsure of what the new technology, in the hands of the home-helpers, could do.
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Making do: “Creating” the resources needed to innovate services The managers saw to that the new hardware and software was paid for. Their engagement was however limited to the purchase of the new technology. Hence, the front-line employees (home-helpers and their group-leader) faced the challenge of installing, configuring, and using the new technology without any new resources formally being allocated to this. The empirical material revealed that the personnel, “out of nothing”, created resources that, taken together made it possible for the technology to be used and the innovation of new services to begin. Take for example the issue of finding a place for the new PC (to which the monitoring information would be sent). The home-helpers don’t have an “office” as they are always out visiting seniors. The home-helpers however meet every morning at one of the community nursing homes for demented patients. The group-leader repurposed a room that was not occupied by any senior to create space for using the technology. “This room is rarely used, and it can be locked, which is important as the elderly [nursing home residents suffering from dementia] may otherwise wander through the door and start playing with the computer” (Liv, group-leader).
There was further a need to “find” time to install the new monitoring devices in the elderly households. The group-leader managed this by reallocating time from other tasks that could wait. As this was not always possible, the installation was sporadic and spanned over a long period of time. Moreover, the personnel were forced to “create” technical support, as there were no formal resources allocated to this. The group-leader took advantage of her good relationship with an employee at the technology vendor in this context. “There were a lot of unexpected problems in the beginning. I can tell you that… so I called Fredrik [employed at the technology firm] and told him that we just had to make the monitoring devices work again...Poor Fredrik I called him often, but he was always willing to help me. He has a hard time saying no, he is that type of guy… Fredrik really wants us to like the new technology…so that we can spread the gospel I guess […] we don’t pay for this…” (Eva, group-leader).
Finally, there was a need to innovate some rules for how to respond to the new alarms generated by the new technology. The personnel reused existing routines in this context. They decided to respond to the new inactivity alarms in exactly the same way as when they are notified about the traditional manual alarms: two home-helpers working shift at the nursing home take a community car and drive immediately to the senior in question to check on him/her.
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“…we were not sure of what kind of events would actually trigger inactivity alarms, I mean, these automatic alarms are totally different from the other alarms [manually triggered alarms], but it seemed reasonable to use our existing routines…that we are all familiar with” (Jenny, home-helper).
Hence, by making do with the resources at hand the front-line employees created a platform that enabled them to start using and innovating services on the basis of the new technology.
Feedback mechanisms during the use of the new technology As the personnel started using the new technology, feedback mechanisms reinforced certain features and affordances and impeded others. An important feedback link was that from the monitored senior consumers. Most of the seniors appreciated being provided with new, “modern” alarms with monitoring functionality. This encouraged the personnel to keep on using and learning about the new technology. However, some of the seniors started to rely too much on the technology. “…Jim told me he had felt really bad before my visit. But he didn’t call on us as he thought the technology would notice this anyway. You could see this on the computer, couldn’t you, he said…but we couldn’t…“(Jessica, homehelper).
This feedback taught personnel what the monitoring technology was not, i.e. a general health monitor, as they had initially envisaged. The personnel rather started to define it as a complementary source of information, which reflected a single and very specific aspect of seniors’ health.
Redefining the automated alarms triggered by the new technology As opposed to what was initially expected by the vendor and the care providers, none of the automatic inactivity alarms triggered was caused by emergencies.26 The home-helpers’ alarm documentation revealed that the automatic alarms were rather caused by various rather subtle changes in activity. For example, one note said: The alarm was presumably triggered by Jeff lying still most of the day. He was tired, recently discharged from hospital. I gave Jeff a sandwich when I arrived. He appreciated this.
Another example: 26
There were also a large number of “false” alarms that were triggered by seniors sleeping unusually deep during the study period. 118
Lillian confirmed she was just tired and a bit sad when I arrived. We talked for a few minutes. This made her happy. I told her I would call back in half an hour.
The personnel learned that the monitoring system could detect and notify them about situations when seniors were “unusually weak”. New services emerged as the personnel responded to such situations. They paid the seniors, from whom alarms were automatically triggered, extra “support visits”. The content of these visits was deemed highly contingent on the senior and necessary to innovate in situ. A home-helper explains: “you have to feel what is right in these moments. The automatic alarms can be triggered by various reasons. Perhaps the seniors are weak and just need you to sit next to them, hold their hand for a minute. In other cases, making them laugh may be the recipe to make them feel better…” (Joni, homehelper).
The seniors’ responses suggested that the new customized support visits could produce feelings of safety and reduce anxiety among the seniors. “…Essentially, I think these visits make the seniors feel watched over and cared for…” (Hannah, home-helper).
Interviewees also claim that the new support services have preventive value: “…Visiting a senior who is merely feeling a bit tired and sad may prevent him/her from getting really anxious and completely passive…[…] and if seniors feel safe at home, this may prevent them from applying for placement at a nursing home…” (Gunilla, group-leader).
Redefining the patient data continuously provided by the technology The monitoring technology also generates real-time information about the seniors’ activity level over time, displayed as graphical activity curves on a computer screen. The personnel realized that this activity information allowed them to see whether or not the seniors wear their alarm. This is important as many seniors forget to wear their alarms and are hence unable to call for help in emergencies. “… I realized that I can see if seniors are wearing their alarm or not on the screen…if the line is straight this means there is no signal, [that] the senior is not wearing the alarm…we didn’t think of this in the beginning…”(Ulla, home-helper).
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The personnel started to remind the seniors (who according to the activity data was not wearing their alarm) to wear their alarms. That is, a “makingsure-that-seniors-wear-their-alarms” service started to take shape. As there were no pre-existing routines to copy in this context, the personnel improvised when reminding the seniors about the alarms, combining the new patient data with their “old” consumer knowledge. For example, Jenny says: “We saw on the screen that Siv never wears her alarm during the night … I did not really know how to talk to her about this though. I didn’t want to say that we “can see” if she wears it or not...Siv would find this privacy threatening, I know her. I ended up not talking about the monitoring system at all. Instead, I talked about the risk of falling… and I think it worked…” (Jenny, home-helper).
This way of using the new patient data generated the desired results. “…We have seen an effect on the curves. When we tell them specifically about this, more or less directly, they tend to start using their alarm. Hence, they can call on us when in danger. This provides the seniors and their relatives with a greater sense of safety…they’ve told us this…” (Maria, homehelper).
Institutional constraints and stabilizing mechanisms The personnel assert that they could use the monitoring system in a number of preventive ways beyond what has been mentioned above. “…We could use it [the new patient data] to identify seniors who appear to be extremely passive daytime or suffer from insomnia at night and help them become more active during the day for example… introducing targeted daily activity services could prevent a lot of sleeping disorders from getting worse. This could prevent fall accidents, which are more common among tired seniors…” (Maria, home-helper).
However, the home-helpers don’t have the authority to make any major changes in the services they deliver. “…The home-helpers have to stick to the service plans, they cannot just add new services…We would need to create a new role structure, where frontline employees could adjust the content of the services they deliver on basis of real-time information generated by technologies like this…” (Anna, manager).
In general, the data revealed that the reimbursement system and organization of the national care system constrained the care providing organization’s possibilities to realize service innovations that respond to “new” needs.
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“Addressing seniors sleeping disorders or irregular activity patterns in preventive purpose … is beyond our public commitment…we would have to bear such production costs without being reimbursed by the government for this…sure this could generate long-term health improvements and thereby cost-savings…but there is no evidence of this. And who knows if I will ever get any return on such investments, political shifts may change my budget totally…” (Karin, manager).
Privacy concerns further hampered more extended customized prevention services from being realized. The monitoring technology actually provides a lot of information about the seniors. When they leave the house, when they sleep, how deep they sleep, and it is possible to infer quite a lot on basis of their general activity level. The home-helpers could use this information to, in a preventive purpose, intervene in the seniors’ behavior. However, the home-helpers did not use the data in this way. Eva explains: “…I mean sure, we can see if the senior leaves the house and at what time. I can see that Elov leaves the house every day at about the same time and that he returns after 15 minutes. I knew this before; he likes to take a morning walk every day. But if I would see that he didn’t leave the house one day I wouldn’t call him and tell him to take a walk – even if it is good for his health. This would invade on his privacy! But if he would stop performing this daily routine of his completely, I would perhaps tell the girls to check on him a bit extra, during their regular visits…” (Liv, group-leader).
Similarly, Jessica says: “If an activity curve indicate that something is not OK, you feel like asking the senior about this... But we cannot say to a senior that ‘we have seen on the curves that you are very inactive during the days’. This might make the seniors feel watched in a negative sense… ” (Jessica, home-helper).
Interestingly, the data also indicated that the value attached to principles such as autonomy and pluralism impeded certain services to emerge. “…Unless there is an alarm, we rarely do anything about the changes in activity level we see on the screen. .. I mean, how long is it normal to have a ‘low activity’ level? In some cases low activity level can be a sign of depression or a signal that something is wrong health-wise… something that could get worse if we do nothing about it…but, seniors may simply need a lot of rest some days…and who are we to decide what’s ‘normal’ and not?...” (Eva, group-leader). “…It is a scary thought, that we would use this to control that everyone has a perfectly regular pattern, sleeping during the night and being active during the day. We know that sleeping patterns change when one ages. It is important to allow variation here. Some elderly may enjoy staying up until 3 am,
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sleeping until 6 am and sleeping in the afternoon instead…” (Birgitta, Manager).
Scepticism toward “high-tech business” further discouraged the personnel to exploit the functionality of the new technology. The monitoring system can be set to trigger various alarms, e.g. if the senior leaves the apartment etc. The home-helpers however decided to keep such alarm functions latent. “We decided to only activate the inactivity emergency alarms, in this first stage of use…using all the new functions seemed too demanding and complicated…We are not in a high-tech business. We are not high-tech people…” (Jenny, home-helper).
Finally, the data indicated that the deeply rooted view of elderly care as a matter of human (read: face-to-face) contact contributed to personnel using the new information as a complement rather than as a replacement to faceto-face visits. “…We would never collect information about our elderly merely via computers instead of visiting them. This would be out of the question, care is about human contact…” (Ulla, home-helper).
Interactions There were numerous interactions between the mechanisms. For example, stabilization mechanisms influenced the “energy-injection mechanism” as financial constraints encouraged the managers to choose a relatively lowcost technology and the prevailing healthcare culture made them inclined to not choose a too radical technology (e.g. robotics). Stabilization mechanisms in terms of prevailing values further influenced the “feedback mechanism” in terms of the positive reaction among seniors (via their high belief in the reliability of modern technology). Prevailing values also influenced how the workers interpreted the feedback signals from the seniors and how the workers, as a result, redefined the purpose of the technology. There were also interactions between the stabilization mechanisms and “making-do mechanisms” (operational employees’ acts of bricolage). Workers were forced to make do with available resources due to institutional constraints such as a limited budget and the rigid financial structure. Cultural values further constrained their use of the technology. Hence, stabilization mechanisms influenced how workers made do with the technology, and this of course influenced how seniors reacted to the new technology, which in turn also influenced how workers continued to make do with the technology. These examples illustrate the cyclical nature of the emergence of new technology-based services in the case studied.
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Drift: redefining the new technological resource – unexpected services emerging In summary, as a result of the implementation of the monitoring technology, new technology-generated patient data entered the work-life of personnel. The new data unexpectedly brought to the fore the fact that seniors often forget to wear their alarms and it occurred to the personnel that they could use the technology to detect and respond to this problem. The personnel also understood that the technology could notify them when seniors were “weak” and thereby provided them with an opportunity to address such more subtle health changes. Overall, the personnel gradually learned that the new technology primarily enabled various preventive services. This view differed from the technology vendor’s claims and the managers’ initial expectations of the new technology, which revolved more around its role as an emergency-detector. The personnel redefined the new technological resource, increasingly referring to it as a complementary decision support and an “early warning” tool. On the basis of this contextualized understanding of the technological resource, the personnel started to provide seniors with new “extra support visits” and “alarm-usage control services”, carefully adjusted to the senior and the situation. Neither the vendor nor the managers had anticipated the emergence of these new services. The services are still in a nascent stage. The personnel and managers however assert that they will continue to use the technology to further learn what it enables them to do for their senior consumers.
Conclusion, implications and further research This paper proposes a theoretical framework for studying technology-based service system innovation as a non-linear and emergent process. The framework extends the notion of bricolage by drawing on ideas from emergentism (the dissipative structures model, which originates in complexity theory (Prigogine and Stengers, 1984)) and technological drift (Ciborra et al., 2000). The paper has shown the relevance of the enabling and constraining dynamics incorporated in this framework in the study of service innovation. More specifically, the paper has described the emergence of new technology-based services as a continuous interaction between the injection of energy in terms of a new technological resource, personnel making do with resources at hand, feedback dynamics, and stabilizing mechanisms. These dynamics helped to explain how and why certain new services emerged, and others not, in the case studied. For example, the personnel started to tinker with the new technological resource in the actual context, combining it with existing resources, and various unexpected actions made possible by the technology, i.e. new “service affordances” emerged. The personnel’s realiza123
tion of these possibilities were influenced by feedback mechanisms that attenuated certain acts and others not. There were also more permanent stabilizing forces that prevented the personnel from even starting to carry out certain ideas that emerged. The applicability of these insights go well beyond the care setting. The framework suggested can be used by students of technology-based/service system innovation more generally. In particularly by researchers seeking models allowing a broad analysis of the innovation process, including its non-linear, informal and unpredictable facets. The framework can also inspire researchers seeking models encouraging an exploration of the influence of individual factors and of extra-organizational dimensions at societal level. In general, this paper suggests an approach that complements established thinking on service innovation. Much of the service innovation literature to date appears primarily interested in identifying success factors in innovation projects, underlining the importance of allocating resources to multifunctional, autonomous development teams, engaging external parties such as consumers, suppliers, competitors and other stakeholders in all stages of the process, creating an innovation-friendly climate, etc (Alam and Perry, 2002; Åstebro and Michela, 2005; de Brentani, 2001; de Jong and Vermeulen, 2003; Johne and Storey, 1998; Kelley and Storey, 1999; Matear et al., 2004; Ottenbacher et al., 2006). In contrast, the present paper reports about “trivial” acts and events, which taken together led to the emergence of new service ideas and to the provision of a few new services. There is reason to believe that “mundane” development processes and results such as those reported in this paper are no less common than innovation processes that are aligned with the recommendations in the new service development literature. As noted by Sundbo (1997), service industries seldom have R & D departments. Hence, to understand how new services emerge, we need to acknowledge that services may sometimes emerge as a result of fluctuations, i.e. injections of energy, spontaneous or deliberate, that trigger more or less unexpected responses and in an ad-hoc manner lead to incremental changes. This too is innovation in services.
Managerial implications This paper does not set out to provide managerial recipes for how to conduct optimal innovation processes. It is descriptive rather than prescriptive. However, the findings do provide insights about issues that managers should recognize in their decisions about how to plan for and how to support the innovation process. To start with, this paper reports about how a service innovation process can unfold in the absence of a clear strategy, that is, without much managerial planning. In the case studied, the managers simply made a new technological resource available to front-line personnel and their idea was to see what new care services could emerge as a result. This is in 124
contrast to innovation processes beginning with the managerial definition of a “service objective” and proceeding with the formal allocation of the resources necessary to achieve this objective, as has been proposed (Alam and Perry, 2002; Cooper et al., 1994; Edgett, 1994). In the case studied, the new technology was the only resource formally allocated to the service development project. There was no “development team” or “development budget” devoted to the service innovation as is often recommended in service innovation literature (de Jong and Vermeulen, 2003; Edvardsson and Olsson, 1996; Johne and Storey, 1998; Kelley and Storey, 1999; Stevens and Dimitriadis, 2004; Syson and Perks, 2004). The present study however shows that this did not prevent innovation from happening. It rather forced front-line personnel to make do with the resources at hand, i.e., to engage in bricolage (Lévi-Strauss, 1966). In creating the prerequisites for employing the new technology, i.e. creating space for service innovation, they reallocated time from activities that could wait and repurposed resources at hand, such as abandoned facilities, social relationships and private experiences. Indeed, the absence of any formal allocation of resources to the innovation process studied may have had positive implications. For example, hidden and seemingly unrelated resources had perhaps not been put to any productive application if a development budget had been available. As it were, bricolage sometime created value without withdrawing resources from any current use. Further, as the operational personnel could not delegate tasks to some “development team”, they were forced to infuse the new technology into their work life without disrupting their day-to-day work. As a result, the technology was fairly integrated in the organization. However, most likely, lack of “new” resources and the reliance on resources at hand made the personnel strive for a workable rather than a breakthrough solution. The absence of an innovation strategy further led to ad hoc choices that tended toward the option requiring the least cognitive effort and time (Douglas, 1987). As a result, the personnel were inclined to choose paths that avoided dramatic changes. These factors contribute to the fact that incremental rather than radical or disruptive (Christensen, 1997) innovations were produced. In general, the creative use of bits and pieces has produced a “bits and pieces” innovation, a half-realized innovation. Elements that are vital to the development of a sustainable service are still lacking. As noted by Baker and Nelson (2005), “coaxing”, a large degree of ad hoc responses and improvisation can be anathema to the establishment of reliable impersonal routines. The provision of the new service is dependent on the employees’ capability to create space to use the new technology as no formal roles or responsibilities have been created. Further, the vendor will not provide “free” support forever. It needs to be noted though that the process is far from finished. More formalized processes and roles will most likely emerge over time.
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In general, the findings presented here are relevant to managers not only in the care setting but in service settings in general. Indeed, this study highlights the complexity related to the innovation of technology-based service systems, and the many forces that managers need to take into account before and during such innovation processes. Although it is difficult for managers to control the mechanisms involved, such as individual workers improvisations, pragmatic acts of ‘making do’, institutional constraints and reactions among consumers, managers need to be aware of the significance of such forces. They should establish support systems for, in terms of e.g. rewards or other incentives to support and encourage workers tinkering with the resources at hand. They should also engage in continuous follow up meetings to catch up emergent, incremental ideas. And they should try to reflect on how institutional regulations and cultural values may influence the innovation process. In summary, the present study suggest that while innovation processes may be difficult to predict and control, it is possible to distinguish patterns and to in advance ‘prepare for’ certain interactions. The findings elucidate how individuals’ engagement in bricolage is not merely a matter of arbitrarily departing from the means available; it is also shaped by attenuating and reducing feedback mechanisms. Outcomes do not drift randomly, but as a result of structural and cultural factors. Institutional constraints had particular significance in the context studied. The personnel could not innovate new services merely on basis of what was technically afforded and what could produce values to their senior caretakers. They rather had to keep their public commitment in mind, i.e. what needs they are and are not reimbursed for responding to. Deeply rooted values such as maintaining privacy, autonomy and the prevailing healthcare culture with the view of care as a matter of human (face-to-face) contact also influenced the emergence of new services by disallowing more radical uses of the new technology.
Theoretical implications, limitations and future research directions The present exploratory study is based on a single case. And the public home-help setting studied is idiosyncratic in many ways. However, the purpose was to develop rather than to test theory (Eisenhardt and Graebner, 2007). As noted by Siggelkow (2007), single cases can serve as counterexamples, thereby enabling the development of existing theory by pointing to gaps and beginning to fill them. The present study can be viewed as an attempt to, if not ’falsify’ then at least challenge the prevailing tendency to speak of technology-based service innovation as a predictable, systematic process that is contingent on managerial decisions. The present study has hopefully illustrated that as an alternative, the concepts of bricolage, techno-
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logical drift and complexity theory can sensitize researchers to important cyclical dynamics inherent in the emergence of new technology-based service systems. Of course, further research needs to validate and refine the proposed framework (figure 1) in other settings. Explorations of how organizations can make use of new technologies (e.g. digital and nanotechnologies) to provide new services in complex settings such as health care are particularly warranted. Such innovations indeed occur in interfirm modularity settings (Staudenmeyer et al., 2005) where it is difficult for a single actor to develop all parts of the final offering as this requires deep insight in 1) what is technologically feasible as well as insight in 2) the specific service delivery processes in question. Longitudinal studies, using multiple cases, covering various actors (not only the service provider but also technology vendors etc) and combining qualitative and quantitative data generation methods would benefit the further development of the framework suggested here. Also, this paper studied the early stage of a single service innovation process. Research focusing on later phases in such emergent processes would further our understanding of how new services are legitimized and actually become available to consumers. Paying attention to the differences between private and public actors in this context is relevant. In general, the purpose of this explorative study was to begin to outline a new direction in new service development research, one that goes beyond the interest of providing managers with unrealistic recipes for how to create optimal innovation processes, but instead takes on a multilevel analysis and considers the influence of forces at individual as well as societal level to describe how new services actually come to be. Complexity theory (cf. McKelvey, 1999) provides opportunities for learning more about how new services can emerge in this context. The service innovation literature would benefit from this theory being applied to elucidate how single events at micro level can trigger changes at macro levels, leading to the emergence of new orders and paradigm shifts in the services industry, i.e. multilevel analysis (Chiles et al., 2004).
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4. The Two Facets of Electronic Care Surveillance: Exploring the Elderly Caretaker’s View 27
Abstract: Scholars are increasingly questioning the notion that electronic surveillance merely constrains individuals’ liberty and privacy. However, illustrations of alternative perspectives are few and there is a need for empirical research exploring the actual experience of surveilled subjects. This study, carried out in Sweden, seeks to offer a nuanced account of how elderly caretakers experience electronic care surveillance in relation to their privacy. It is based on in-depth interviews with 17 seniors who have participated in a telemonitoring project and who have experience of being continuously activity monitored in their own homes. The findings suggest that elderly caretakers can perceive electronic care surveillance as freeing and as protecting their privacy, as it enables them to continue living in their own home rather than moving to a nursing home. One individual however experienced a privacy violation and the surveillance service was interrupted at her request. This illustrates the importance of built-in possibilities for subjects to exit such services. In general, the study highlights that e-surveillance can be not only constraining but also enabling. Hence, it supports the view of the dual nature of surveillance. The study also illustrates the agency of the surveilled subject, extending the argument that various agents actually participate in the construction of surveillance practices. It analyzes the indirect role and responsibility of the surveilled subject, and thereby questions the traditional roles ascribed to the agents and targets of surveillance.
Introduction Academics have worried about the threats to privacy associated with electronic surveillance (e-surveillance) for decades (e.g. Davies, 1992; Flaherty, 1989; Floridi, 2006; Garson, 1988; Goodwin, 1991; Lyon, 2001; 2002; Lyon 27
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& Zureik, 1996; Mason, 1986; Ogura, 2006; Parenti, 2001; Solove, 2006; Weckert, 2001). However, as noted by a large number of scholars (e.g. Wood, 2003; Lyon, 2006; 2007; Haggerty, 2006; Haggerty and Ericson, 2000; Hier, 2003; Rössler, 2005; Solove, 2001; Vaz & Bruno, 2003), the extant surveillance literature is overly dominated by the Big Brother (Orwell, 1949) and Panopticon metaphors (Bentham, 1969; Foucault, 1977), which inspire one-sided and dystopic views on surveillance. To paraphrase Lianos (2003), contemporary e-surveillance studies routinely refer to the erosion of privacy and liberties by sinister and totalitarian forces, which “is damaging as it is superficial and analytically unfounded, and it pre-empts the feelings and opinions of the public, usually with great inaccuracy” (Lianos, 2003: 414). Similarly, Haggerty and Ericson (2000) argue that “far from the negative connotations that tend to be attached to surveillance, many surveillance practices today are not only supported but encouraged by those who serve as the primary targets of data gathering systems” (pp. 401). Indeed, the widespread assumption in the surveillance literature that subjects are surveilled against their will is now being questioned (Lyon, 2007; Pecora, 2002). Few studies have actually explored the experience of surveilled subjects (Haggerty, 2006; Lyon, 2006). In general, the contemporary surveillance literature tends to analyze surveillance technology in isolation, as given and as inevitably producing certain effects in a predictable fashion (Ball, 2002; Haggerty and Ericson 2000; Hier, 2003; Haggerty, 2006). It therefore fails to give balanced accounts of how users interact with surveillance technologies in practice. Recently, studies taking the locality and particularity of e-surveillance applications and the agency of surveilled subjects into account have however emerged (Dubbeld, 2006; Koskela, 2006; Fotel & Thomsen, 2004). Drawing on insights from the field of science and technology (e.g. Latour, 1987; Bijker, Hughes & Pinch, 1989), these studies highlight that the operation of surveillance technology is by no means given, but rather contingent on the user-context. It is also argued that e-surveillance should not only be understood as constraining but also as enabling (Bogard, 2006; Lyon, 2007). These insights have however not been used to explore the relation between e-surveillance and privacy. In general, this perspective is underdeveloped and more research is asked for, in particular as regards the view of the surveilled subject (e.g. Lyon, 2006; 2007). Given these weaknesses in the surveillance literature, the present paper attempts to provide a nuanced account of individual subjects’ experience of electronic care surveillance in relation to their privacy. Care surveillance has received little attention in the surveillance literature (Lyon, 2001; 2006; 2007; Vaz & Bruno, 2003; Dubbeld, 2006; Wood, 2003). As noted by Vaz & Bruno (2003), this neglect may partly be due to the challenge related to studying e-care surveillance in a critical fashion. Surveillance and control are integral parts of care and it is difficult to separate these elements. Neverthe134
less, electronic care surveillance technologies such as in-home telemonitoring are emerging and authors have underlined the pertinence of taking the issue of privacy into account when evaluating such technologies (Bauer, 2002; Hensel, Demiris & Courtney, 2006; Von Tigerstrom, 2000). Responding to these calls, the paper uses empirical data from the Swedish elderly care setting, exploring how care takers perceive that being continuously activity monitored in their own home affects their privacy. As this is a fairly unexplored area, the paper also asks more broadly how we can understand esurveillance and privacy in this context. The findings highlight that electronic care surveillance can be perceived as enabling by surveilled subjects. The majority of the seniors in this study feel that electronic care surveillance can indirectly protect their privacy by enabling them to continue living in their own homes rather than moving to a nursing home. In general, care surveillance makes the majority of the seniors interviewed feel cared for and safe rather than constrained. What makes them feel safe is however the fact that certain familiar care workers watch over them. The technology merely becomes a link between themselves and the care workers. The study also highlights the importance of built-in possibilities for subjects to exit from the service. One individual experienced a privacy violation and felt constrained when monitored. The surveillance service was interrupted at her request. The article begins with a definition of privacy. Next, widespread assumptions in the surveillance literature are problematized in relation to care surveillance and privacy. Alternative perspectives are outlined. Findings from the in-depth interviews with 17 seniors follow. The article ends with discussion, conclusions, implications and limitations, which suggest further research avenues.
Defining privacy28 Warren & Brandeis (1890) defined privacy as the right to be let alone. This definition has since been extended and includes various multi-dimensional conceptualizations (cf. e.g. Altman, 1976; DeCew, 1997; Gavison, 1995; Inness, 1992; Westin, 1967). Rössler (2005) recently provided a comprehensive definition, outlining three interrelated aspects of “the private sphere”: 1) Informational privacy (protection against unwanted access to personal information about us); 2) Decisional privacy (protection against unwanted interference in our decisions); and 3) Local (physical) privacy (protection against the unwanted admission of other people to personal spaces or areas).
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There has been a debate regarding whether or not a “right to privacy” exists and even if there is a unified concept of privacy (cf. Friedlander, 1982; Schoeman, 1984). 135
Empirical studies of patients’ perception of privacy focus on hospital or nursing home settings (e.g. Damschroder, Pritts, Neblo, Kalarickal, Creswell & Hayward, 2007; Parrott, Burgoon, Burgoon & LePoire, 1989). This literature suggests that hospital patients experience a loss of privacy when they cannot withdraw or find a personal, private space, e.g. when they have to share room with other patients (Barron, 1990; Marini, 1999; Mattiasson & Hemberg, 1998; Woogara, 2005). What also emerges from this literature is that patients experience privacy violations if they have to witness other patients’ problems (Sidenvall, Fjellstrom & Ek, 1994). This aspect of privacy, which has been neglected in the surveillance literature, is in this paper referred to as freedom from observing and reacting to others. What emerges from the privacy and care literature is that patients primarily desire privacy in relation to other patients rather than in relation to care professionals. It seems reasonable to assume that patients are relatively inclined to willingly disclose personal, health-related information to care personnel if they believe that this is relevant for the care services to be provided. I will return to this point below.
Care surveillance as a potential privacy harm As noted above, much of the surveillance literature builds on the concept of the panopticon society (Bentham 1969; Foucault, 1977; Boyne 2000), suggesting that e- surveillance can violate individuals’ privacy by intruding on their informational and decisional privacy (e.g. Gandy, 1993; Lyon & Zureik, 1996; Floridi, 2006; Michelfelder, 2001; Nagel, 1998; Rössler, 2005; Solove, 2006; Udo, 2001). It is argued that the harm of surveillance is that, if unsure about whether one is watched or not, one must constantly present oneself as though one were being observed. The result is inhibition and selfcensorship, i.e. a loss of autonomy in terms of the authenticity of one’s behavior, which is turned into behavior “as if”. This view provides significant insights. However, it highlights certain aspects of surveillance while ignoring others. Importantly, studies bringing this view of surveillance to the fore build on certain presumptions. For one, elites with malign intentions to discipline and exert social control are the assumed agents of surveillance. Second, the intention to control is understood as an ambition to constrain the behavior of the targets of surveillance. Third, the targets of surveillance are depicted as passive victims. And fourth, the surveillance technology itself is viewed as the source of negative effects (cf Bogard, 2006; Dubbeld, 2006; Haggerty, 2006; Lyon, 2007). I will argue below that these four assumptions are not easily generalized to the care surveillance setting. What makes care surveillance a complex subject of study is the intertwined relation between control and care (Dubbeld, 2006; Lyon, 2006; Vaz 136
& Bruno, 2003). The work of Lianos (2003) can provide some clarification here. Lianos (2003) highlights that institutional control is integral to specific surveillance activities, but that “It would be reductive and unjustified to see such activities as relating exclusively or principally to control”. He gives an example: “One could look at a CCTV system which monitors the traffic on a road network; is this dispositif about repressive surveillance (traffic offences), detective surveillance (stolen vehicles)…accident prevention or the improvement of access times for emergency services…?” (pp. 415). He answers that the system is about everything at once. This is indeed applicable to the care surveillance setting. The intention behind care surveillance includes but cannot be reduced to a malign ambition to control (cf Lyon, 2007). In this respect, the general definitions of e-surveillance do not quite capture the meaning of care surveillance. E-surveillance is often referred to as the systematic observation and recording of acts of compliance and deviance in order to manage or influence behaviors by means of information technology (Clarke, 1988; Lyon, 2001). Dictionaries further define surveillance as: “to watch over; supervision or superintendence; close observation of a person or group… especially one under suspicion e.g. a prisoner, or the like (usually by the police)” (dictionary.com 2007). While the first definition says little about the intention behind surveillance, the latter highlights that surveillance is associated with observation of “suspected” individuals and is understood as something that is done for the sake of others rather than the surveilled. Can we not watch over others because we care about them, then? Of course, we can suggest this is so (cf. Lyon, 2007). Consider the meaning of care: dictionary definitions of care include: “Watchful oversight; charge or supervision; to be concerned; have thought or regard; to make provision or look out for someone in need…providing treatment for or attending to; have a special preference for; to have inclination, liking, fondness or affection for…” (dictionary.com, 2007). Major caring constructs in the nursing literature are compassion, empathy, nurturance, succorance, comfort and support (Cloyes, 2002; Jecker & Self, 1991; Kreuter, 1957; Lavoie, De Koninck, & Blondeau, 2006; Leininger, 1977). Hence, care is, just like any type of surveillance, associated with supervision and “watching over”. However, care also refers to the concern about and feelings directed to a person - a person in need. An act of care is generally thought of as performed “for one’s own sake”, i.e. to maintain or improve the surveilled subjects’ health or safety. Hence, in studies of care surveillance it is important to consider that care surveillance includes but cannot be reduced to an ambition to control. It can also incorporate an intention to maintain or improve the patients’ health. Let us return to Lianos (2003): he also maintains that institutional control is often perceived as beneficial “and sometimes even liberating as much as constraining” (pp. 415). Others have recognized the dual function of surveillance (Lyon 1994, 2001, cf. Giddens, 1984). For example, Bogard (2006) 137
refers to surveillance both as capture (fixing a flow, surveillance as determination) and as flight (releasing a flow, surveillance as resistance). Bogard (2006) argues that to surveil means to guard and he writes: “guardianship is not a simple constraint, but an art of control that makes it safe for something to move freely…” (Bogard, 2006: 98). From this view, surveillance practices can in a sense be viewed as freeing. Drawing on these arguments, this paper assumes that care surveillance can be perceived as both enabling and constraining from the viewpoint of individuals. Finally, the surveillance literature tends to discuss the effects of surveillance technologies without considering that the consequences of a certain technology are by no means given (Ball, 2002; Dubbeld, 2006). The present paper assumes that while a certain technology facilitates certain behaviours and impedes others, there are also opportunities for people to choose how to use and not use the technology (Berg, 1997; Bijker et al. 1989; Latour, 1987; Oudshoorn & Pinch, 2003). This perspective makes clear that users are not necessarily victims passively subjugated to technological domination or disciplinary surveillance. It allows for a consideration of the potential resistance from users (Ball, 2002; 2006; Dubbeld, 2006; Wood, 2003). In summary, scholars have begun to suggest alternatives to the dystopic and deterministic principles traditionally applied in the surveillance literature. There are however no empirical studies illustrating how these principles work in relation to privacy, in actual empirical settings and from the perspective of the surveilled subject. This paper seeks to address this gap in the literature by exploring individuals’ experience of being surveilled in relation to their sense of privacy. Privacy is here defined as 1) the freedom to escape being observed or accessed when desired. This implies protection from unwanted access to personal information about us, i.e. informational privacy; unwanted interference in our decisions, i.e. decisional privacy; and unwanted admission of others to personal spaces or areas, i.e. local/physical privacy (Rössler, 2005). Privacy also refers to 2) the freedom to escape observing and reacting to others (Sidenvall, Fjellstrom & Ek, 1994). The question of concern is: how do individuals experience care surveillance as enabling and/or constraining in relation to their privacy? The premise is that a surveillance technology needs to be understood in relation to how it is used and not used in the actual context, i.e. how the care surveillance practice is constructed. The surveilled subjects are viewed as participating in this construction.
Method The purpose of this paper is to understand not only if, but also why seniors feel that electronic care surveillance (telemonitoring) does or does not violate their privacy. The paper further attempts to illicit not only expected, but 138
also unexpected, privacy issues arising from the viewpoint of elderly individuals. Hence, an open-ended, in-depth interview approach was deemed appropriate. As noted by McRobb & Rogerson (2004), quantitative instruments may be too blunt and may obscure more than they reveal, as our understanding of consumers’ privacy conceptions is as yet limited. Research setting. In 2006, a public long-term care provider in the municipality of Heby, Sweden, decided to introduce a new telemonitoring service in their community. The new e-service was seen as a potential replacement to traditional manual alarms that were currently in use. The monitoring service requires that the user wear a monitoring device on the wrist. Sensors embedded in the monitoring device continuously collect “activity data” about the user. This data is transmitted to the care center. Care personnel can access the data, which is presented in graphical format as activity curves on a computer screen. The activity curves provide information about the user’s sleeping patterns (e.g. how many sleeping interruptions and sleeping periods per day and night, how many times the user gets out of bed during the night), when the user leaves the house and takes off the wrist worn unit, among other things. The activity curves can be analyzed over time in order to detect changing activity patterns, which can indicate emerging health problems. During the first two days of use, the monitoring system registers each user’s “normal” activity pattern. Thereafter, automatic alarms are generated when the sensors detect that the user’s activity diverges from her/his normal pattern, e.g. in cases where the activity level is unusually low due to the senior having fallen and turned unconscious. Users can also activate alarms manually by pushing a button on the device, just like with “traditional” pendant safety alarms. The alarms are also transmitted to the care center. The Heby managers decided to provide the new service to 20 seniors, as a first step, before expanding the use of the new monitoring technology. Two social workers recruited 20 seniors that were: 1) living alone in their own home; 2) vulnerable and exposed to health risks in their home and therefore provided with manual safety alarms; 3) capable of being interviewed. 3 of the seniors could not use the devices due to allergies etc. The seniors were informed about the monitoring service via letters and were given the opportunity to ask further questions in follow up telephone calls. They were told that that their activity level would be monitored, that automatic alarms could be triggered if there would be a radical change in activity level and that this was performed to ensure their safety. It’s worth noting that the personnel did not see any radical healthproblems on basis of the surveillance data during the study period, but rather that the seniors were sometimes not wearing their alarms and that they were not sleeping well. The personnel were “discrete” when acting on this kind of information. They did not say “we have seen on the data that you did not sleep well” for example. They tried to embed questions and reminders, e.g. about to wear alarms in their regular conversations with the seniors. 139
Data generation. This study is based on in depth interviews with 17 of the seniors (68-96 years old, 9 female and 8 male) that accepted the use of the monitoring service. This purposeful sampling strategy can be called extreme case sampling, i.e. selecting cases that are information rich because they are special in some way (Alvesson & Sköldberg, 1994). At the time of the interviews (September 2006), the 17 seniors had been monitored for 6-7 months. The seniors were somewhat familiar with the interviewer (author) who had visited all the seniors to perform interviews once before, and who had chatted with the seniors at least twice on the phone. The interviews lasted 90-120 minutes, were performed face-to-face and within the homes of the seniors. Interviews were very informal, unstructured, including open-ended questions in order to allow for unexpected issues to emerge (Patton 2004). The interviewer (author) began by asking the seniors how they experienced the new monitoring alarms, discussing this at a general level for a while before bringing the issue of privacy explicitly to the fore. Interviews typically proceeded with a discussion about privacy and privacy threats. Other topics were also covered, as this study is part of a larger research program. Interviews were recorded, transcribed and translated (Swedish to English) by the author. Notes were taken on nonverbal cues, such as general appearance, anxiety etc. (Patton, 2004). Data analysis. The content analysis was performed in several steps. First, all transcripts and observational notes were read through to obtain a sense of the whole. Meaning units, a word, a sentence or a whole paragraph that answered questions of why and how the seniors perceived or did not perceive privacy violations, were marked. As privacy perceptions are often covert and expressed “between the lines” (Bates, 1964), the author tried to be sensitive to observational notes on non-verbal cues. The meaning units were condensed into a description of their manifest content and an interpretation of their latent content. Themes, i.e. threads of meaning running through the descriptions and interpretations (Baxter, 1991) were abstracted. The transcripts were thereafter compared with the aim of detecting patterns across participants (Moustakas, 1994). Next, the themes were compared and analyzed based on the assumptions presented in the theoretical framework. Hence, a combined inductive and deductive approach was used (Alvesson & Sköldberg, 1994). In order to improve the credibility of the interpretation, the author presented the themes to peer scholars at research seminars (Leininger, 1994). The thematization as presented in this paper is a result of an iterative process of culling the empirical data, modifying the sub-themes and refining the theoretical framework. The themes are presented below, illuminated by extracts and quotations. The names are pseudonyms. The Stockholm University Ethics committee gave approval to the study.
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Empirical findings The interviews suggested that the seniors had divergent experiences of the new monitoring alarms. Two contrasting perspectives are presented below.
Care surveillance as enabling – feeling cared for The majority of the seniors (16 out of 17) expressed positive views about being surveilled. Interviews suggest that these seniors believe that the monitoring service serves their own interest to get help in case of accidents. For example, Kurt says: I think it’s great that they do this for us…they must be very expensive, these new alarms…they told me it would be safer than the old one [which does not include any monitoring functionality]…so I feel safe. It must be safer; it is newer so it should be better, more reliable. And I mean, in this way they can keep a track of me even when they are not here, which is good because I’m alone here in my house…
Further, Sonja maintains that: It is good that they know, it is good thing to be surveilled! I mean the more they know, the better they can understand my problems …I really trust them, the girls. Very reliable girls…You know, they are like my friends…of course I want them to see if something is wrong, I might not be able to press the button and if I am lying on the floor dying …
And Ingrid states that ”…It is a safety thing… you never know when you will fall. When you least expect it…”
When asked what he would say if his GP would want to access the information, Bror says: Of course he could do that!…I only see him when something is VERY wrong...and that is not very often so he does not keep much track of me…I’m glad if he takes the time to think about my condition! But I have to confess that I am also glad if I don’t have to go to the doctor.
These seniors clearly want care personnel to know as much as possible about them and they appreciate that the care providers are interested in gathering data about them; they see it as a privilege. The seniors also appreciate it if the care personnel exert influence on their behaviour or intervene, on basis of the surveillance data. For example Lilly explains:
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they can see if I wear the new alarm, and that’s good, because I tended to forget to wear the old alarm. They remind me if they see that I’m not wearing the new alarm. They do it in a nice way of course… Now I always use the alarm, and that’s good… …And my children think its great…
The seniors also believed that being surveilled contributes (in combination with other home-help services) to them being able to stay safely in their own homes instead of moving to nursing homes. Henning maintains that: Sometimes I can feel a bit lonely here living alone. I think, what if something would happen to me? I mean, no one knows what’s going on here. I think they have bought these things [surveillance devices] for this reason, they cannot call me every minute, but I guess they can get some information now…and of course that’s important if I am to remain here in my own house [as opposed to being moved to a nursing home]. I really hope I can live here until I die…so that’s good because its nice if someone else knows if I’m OK or not OK. Of course, my kids call me now and then, but they may not be lucky enough to call at the right time so to speak
Further, Ulf says: “I think we need more things like this, like this new thing, so that they can keep an eye on us at home rather than moving us to nursing homes…”.
Privacy concerns make many of the seniors reluctant to move to a nursing home. They mention two aspects of privacy in this context. First, they express a desire for freedom to escape being observed and intruded on by others: It is important that you can go home, leave others when you feel tired…and I like to do just whatever I feel like… without anyone looking at me… here [in my own home] I can walk around in my two day old socks sometimes, if they are not dirty…I try to not wash too often… (Elov). If I would move to a nursing home they would see me walking up during the night… …I wouldn’t want to meet anyone when I get up during the night when I cannot sleep. Maybe they would force me to take sleeping pills then! (Anna).
Second, the seniors underline the importance of privacy in terms of being able to escape observing and being close to others. In other words, the seniors are not only concerned about others watching them, but also about themselves being forced to watch others, illustrated by the following quotes: I don’t want company by those I don’t know…I wouldn’t like to sit with other oldies when I eat…I don’t want to see them eat with trembling hands…listen to their memories…it would make me feel older I think (Lennart);
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Last time I was hospitalized it really struck me that there is nothing worse than being forced to watch people that cannot manage themselves. And I had to sit next to some of them who had really bad breaths due to heavy medication I believe…[…] …and I like the peace and quiet in my own home…being by myself is not too bad. I like being by myself too, you see…even if it is lonely” (Bror). I don’t want to sit and stare at others sitting in their chairs like me…meeting people in the mornings in the corridor…hearing them speaking on the phone with their children…seems crowded…It’s easier to spend the days here, where I know what to do. Thanks to my daily routines the days pass rather quickly…” (Bo).
The seniors consider surveillance to be a service that can help them avoid moving to a nursing home and thereby escape such intrusions. The seniors who viewed surveillance as a positive service did not mention any feelings of “being watched” or feeling intruded on due to the monitoring services spontaneously. When asked specifically if they have ever felt uncomfortable by being monitored they clearly reject this idea. They seem surprised at this question. For example, Bror says: “…I never think about it!…I really don’t…I hardly feel it. I never take it off…”
Other seniors expressed similar views, illustrated by the following quotes: “… [giggles]… I never think about it!!! …Actually never…”(Jim); “…No, I haven’t thought about it at all. I don’t go around reflecting on what the alarm does…it feels very natural for me to wear it…[…] who cares if they see when I get up in the night and go to the toilet…they’ve seen me naked…” (Elov). “…On the contrary, no! I feel safer now…” (Sonja).
These seniors understand that information about them is collected and transferred to the care providers. They also know that care providers can see if they are wearing the alarm or not and that automatic alarms can be triggered. But none of them completely understand what the sensors monitor, or how the technology analyses this information. They believe they have received sufficient information however. Consider Lilly for example. She was obviously not very knowledgeable about the data collected about her. I started explaining a bit more in detail how the new technology operates to her. She seemed very uninterested, even uncomfortable, and says: “That I do not understand…”.
When I ask Lilly if she wishes she had received more information about how the technology works, she says no.
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“Oh I think I’ve been sufficiently informed. I don’t need to know everything about that apparatus …that’s their job, the girls…and I trust them so…”.
This is typical. Indeed, the seniors trust the care providers and are happy to delegate the task of understanding the new technology to them. It is however important to note that while the seniors know little about the workings of the technology, they do not feel that they have no control over the service. The seniors do not feel that the alarms are forced upon them, or that they have no possibility to exit this service. On the contrary, they feel that they can interrupt the monitoring service at any time, as illustrated by the following quotes: I believe I can get my old alarm back any time, sure. I’d just tell them if that was the case. (Bror). You bet I could let them have this new alarm back…I think it’s much more expensive than the old alarm. And it’s modern technology. So I wouldn’t trade it against the old alarm! (Linnea).
Care surveillance as constraining – feeling as if under suspicion One of the interviewed seniors, Siv, experienced a privacy violation. Siv claimed her personal space right from the start. She agreed to meet me when I called her to book an interview, but with a reluctant tone of voice. When I arrive, she opens the door with her dog Toy in her arms. “ You better not touch me, Toy might get mad then”,
she says and smiles nervously. Siv is anxious, and suffers from an apparent lack of self-esteem. She worries about her health a lot. She is frank about this: “I am a very anxious person…always have been…I worry about everything…anything…the smallest things…”.
Siv says—before I have asked—that she wishes to get her old alarm back. “ I don’t like it, the new alarm. I don’t like being surveilled. I want my old alarm back…[…]…it doesn’t matter who looks at the information. The fact that someone can look is enough…”.
Siv explains her dislike with feelings of being observed. She thinks that her sleeping pattern is sensitive information. She says “I don’t want people to know when I take a nap…when Toy [her dog] and I are lazy…that’s only between him and I…they know enough about me. I want to spare them my strange habits…” 144
It is also clear that being monitored influences Siv’s decisions: “It hits me, when I lay down late in the mornings that this is monitored…also, at times when I can’t sleep and get up in the middle of the night I sometimes think that this might be seen…which makes me reluctant to do so!”
Siv cannot see that the monitoring service adds anything beyond the service she already receives. The community care personnel deliver food to her at noon, and conduct a check up visit in the evenings. She says. They check on me twice a day already, I think this is enough…I mean, it is different at a hospital, but in my own home I don’t want people to watch me all the time…It feels a bit strange, this idea, to monitor people in their own homes. Your home is your own place; they can’t start turning it into a technicality. You have to let people alone in their own homes. No, that’s going too far.
During my visit, a home-helper came by to give Siv her old alarm back, which made her happy.
Discussion This study explored senior care-takers’ experience of being e-surveilled in relation to their privacy. The majority of the seniors in this study (16 out of 17) have a positive experience of being surveilled. This has to do with how the care surveillance technology was used and not used in the particular setting studied but also with the specificity of care surveillance. This paper initially argued that care surveillance includes but cannot be reduced to an ambition to control. It can also be understood as incorporating an intention to provide for individuals in need. This view of surveillance resonates with the view of e-surveillance expressed by the positive seniors in this study. These seniors are aware of their frailty and they feel that they need to be watched over in one way or another. Hence, these seniors do not experience any violation of their information privacy (Rössler, 2005) when monitored because they do not want to hide the information collected from care personnel. The seniors further appreciate that care personnel can acquire digital information about and influence their behavior. They view it as a benefit to be reminded to behave in certain ways as this can enhance their own safety. In other words, they do not perceive that e-care surveillance intrudes on their decisional privacy (Rössler, 2005). Interviews make clear that the seniors do desire to physically withdraw from care personnel. They do not however perceive any local/physical privacy (Rössler, 2005) invasion due to the monitoring service as they feel that they are “let alone” (Warren & Brandeis, 145
1890), even if they are electronically monitored. Indeed, the monitoring service can indirectly protect informational, decisional and local privacy from the viewpoint of these seniors. It strengthens their possibilities to continue living in their own homes rather than moving to nursing homes, where they expect significant threats to their privacy, both in terms of a reduction in the freedom to escape being observed but also in terms of a declined freedom to escape being exposed to information about other caretakers. These latter points highlight that surveillance can be liberating rather than constraining. In general, these seniors’ reported experience of care surveillance involves the thought of “a friendly eye in the sky” (Solove, 2001) rather than of a “Big Brother” watching (Orwell, 1949). It is however important to note that the conceived of “friendly eye” is not anonymous. The seniors rather think of certain care workers, who deliver other services to them, as being “the watchers on the other side”. Being surveilled by the care personnel who they trust makes the seniors feel safe. Indeed, it makes them feel more cared for. The seniors do not reflect much about the surveillance technology itself, it withdraws and merely becomes a link between themselves and the care workers. This suggests that the technological artifact is far from central in surveillance practices. What is important to consider is rather how the surveillance service is introduced to the subjects in the actual setting. An important aspect in this context was the opportunity for seniors to exit the surveillance service. As we discussed above, one of the seniors used this possibility and opted out of the service. This woman was more concerned about her public appearance than the others and she had a lower threshold regarding the amount of data she was willing to disclose to the care personnel. The possibility that someone may look at the data collected about her, and the possibility that her data may not look “normal” bothered this woman. Indeed, e-monitoring intrudes on her informational privacy and it threatens her decisional privacy (Rössler, 2005) as the fact that she is monitored influences – or at least crosses her mind when making— decisions about how to behave. E-surveillance further invades on her local/physical privacy as she perceived the surveillance service as a physical intrusion in her home. This woman was however not forced to continue and the monitoring was interrupted at her request. This illustrates that surveilled subjects can exert resistance. Hence, the widespread assumption that malign intentions lie behind surveillance practices is not quite valid in the care surveillance context. The care surveillance practice studied here involves control but this is not perceived as constraining by the majority of the surveilled seniors. On the contrary, the seniors appreciate the fact that the care providers collect information about and intervene in their health. They feel that someone else takes responsibility for their well-being and this makes them feel free rather than constrained. 146
Conclusion This study suggests that care surveillance practices can be constructed in ways that make the surveilled subjects feel cared for and liberated. It thereby challenges the widespread deterministic view of e-surveillance as involving the destruction of privacy and liberty by sinister forces (see further e.g. Haggerty, 2006; Hier et al., 2006; Dubbeld, 2006). The majority of the seniors in this study viewed care-surveillance as a means to protect their privacy in terms of freedom to escape being observed and observing others face-toface, as they compare being e-surveilled to moving to a nursing home. (cf. Rössler, 2005; Lyon, 2001; 2002). Hence, the study illustrates the dual side of surveillance in relation to privacy, arguing that surveillance is not necessarily constraining but can also be enabling (Bogard, 2006; Lyon, 2001; 2006; 2007). It is however important to note that one senior in this study perceived the care surveillance service as constraining. The experience of being surveilled is subjective and it should be expected to vary across individuals. Of importance here is a built in possibility for individuals to exert resistance. One could argue that the care surveillance practice studied here involves an element of seduction (see Bauman, 1992; Hier, 2003; Rössler, 2005). The majority of the seniors studied here are indeed attracted by the rewards they associate with being surveilled (individualized care) and rather uncritically accept the surveillance service. However, describing the subjects as victims seduced and manipulated by the care providers would be to oversimplify the situation and would merely reproduce the view of the surveilled subject as passive and subject to totalizing powers. We can learn more by broadening the perspective and analyze the surveilled’s indirect participation and responsibility for the development of surveillance practices of the kind studied here. As noted above, the seniors studied here wish to age in their own homes, rather than at institutions. This is partly because of their desire for privacy in terms of freedom to withdraw physically from others. In general, citizens’ wish to “age in place” due to the independence and freedom this entails has contributed to the emergence of various in-home care surveillance technologies (e.g. Barlow & Venables, 2004). These technologies also emerge as a result of the governmental desire to reduce costs of nursing homes and the technology-providers’ strive to make profit. Against this background, the care surveillance practice studied here may be considered as predicated on and in the service of a certain type of liberty, namely the freedom to age in one’s own home and manage everyday life without being constantly intruded on. This suggests that surveillance can cultivate and protect certain types of freedom desired by care consumers in today’s society (Lyon, 2002; Rose, 1999 cf. Nock, 1993).
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Limitations The findings reported here concern elderly care, which is a very specific setting. Elderly care takers are generally frail and aware of their need to be “checked on” regularly. The rural Swedish community studied is further characterized by a low turn over of care personnel and satisfied elderly care takers. Also, the seniors in this study are grateful for being provided with new, modern and expensive monitoring alarms and participating in a development project. This may lead to overly positive attitudes. There is also the risk of the elderly seeking to please the home-helpers and the interviewer by expressing positive views. The author tried to reduce this risk by establishing a relationship with the seniors and by creating an open and informal atmosphere during interviews.
Research suggestions This study challenges the argument that e-surveillance de-humanizes activities (e.g. Los, 2006; Ogura, 2006) by showing that care surveillance can make individuals feel cared for rather than “reduced to digital data”. In the case studied, e-surveillance complemented rather than substituted face-toface visits. More research is warranted about how e-surveillance can be integrated with face-to-face services in order to avoid dehumanizing practices. While the enabling capacity of e-surveillance deserves more attention in general, so does its constraining potential. We need critical studies of surveillance practices rooted in good intentions – at what point do they develop into unacceptable forms of control? This issue is relevant considering the development toward IT-based preventive health assessment in healthcare systems internationally. Rising wage costs and reducing costs of technology will create more instances of e-surveillance. Indeed, Armstrong’s (1995) argument that we are heading toward “surveillance medicine” is highly pertinent. Further, this study highlighted the agency of the surveilled individuals in terms of their possibility to exit surveillance services. The alternatives provided to such individuals warrant further research. Will their resistance imply that they are excluded from certain benefits? This study further opens up avenues for research problematizing the border between the targets and agents of e-surveillance. As noted by Lyon (2007), people today increasingly desire public services that require surveillance. We need to study at multiple levels who initiates e-surveillance practices? Finally, this paper highlights that privacy does not only refer to the possibility to limit what others know about us. Privacy also refers to the possibility to limit what information we are exposed to. Further research about how this privacy aspect, concerning the information flow from the external envi-
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ronment to us, operates is relevant considering the vast amount of health information and advice that is transferred to consumers in today’s society.
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5. The corporeality of learning in everyday practice 29
Authors: Essén, Anna & Yakhlef, Ali.
Abstract Although it recognizes the practical, spontaneous nature of learning and knowing the practice-based learning theory remains silent on the role of the body, overlooking the point that it is the locus of ‘meaningful’ action and ‘knowing’. The present paper seeks to address this deficiency by suggesting a corporeal approach to learning, drawing on Merleau-Ponty’s (1962) work. Drawing on interview material elicited from a group of home care givers, as well as observation notes, we show the centrality of the workers’ body in understanding and carrying out the practices of providing seniors with care and help. While the practice-based learning theory still considers reflection as a requirement for learning, our material suggests that reflection can upset the workers’ skilful action and ‘smooth operation’. The spontaneous and open nature of their practices does not admit of explicit thinking and cogitating. Implications of the suggested view for the theory and practice of learning are drawn. Keywords Practices; Learning; Reflection; Body; Non-reflective; Perception; Bodily skills.
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This paper has been submitted to the Academy of Management Meeting in Las Vegas, 2008. 154
Introduction It is increasingly argued that knowledge and learning are the outcome of social structures and interests (Brown & Duguid, 1991; Gherardi, 1999; Longino, 2002). The significance of the physical environment, objects and artifacts in the acquisition of knowledge, dissemination and the codification of knowledge has also been recognized. Material agency and the role of ‘non-humans’ as sources of knowledge have become common foci in contemporary studies (Latour & Woolgar, 1996; Pickering, 1995; Tsoukas, 1996; Hutchins 1996). This emphasis on the role of artifacts represents an important complement to the view of knowledge and learning as merely social phenomena. Nevertheless, the focus on “post-human” (e.g. Hayles, 1999) and “distributed” cognitive environments (e.g. Hutchins & Klaussen, 1996; Normann, 1993) in the organization and management literatures has obscured other ‘human’ aspects of learning such as the role of the body in the process of learning and acquisition of knowledge. Although there has recently been, within the area of social sciences, an interest in the role of the body in general (e.g. Howson, 2004; Wolkowitz, 2002; Morgan et al., 2005), in most such studies the body tends to be either reified as a thing-in-itself or treated as an infinitely malleable phenomenon which simply reflects social and cultural forces (Shilling, 2005). The recent ‘embodied’ turn in social sciences has tended to produce sociologies about the body, being mainly concerned with questions of how the body is disciplined, dieted, gendered , and abjected (Cregan, 2006; Trethewey, 1999; Balsamo, 1996; Bordo, 1989; Young, 1990) through different discourses and forms of institutionalization. This view of the body as an object overlooks the body’s potential to ‘know’ and ‘act’ in ways that go beyond social rules, norms and discourses (Bourdieu, 1977; Dreyfus, 1996; Merleay-Ponty, 1962; 1965; 1968; Wacquant, 2005). The body is regarded as the object of representation, control and knowledge, rather than the source of knowledge (Bourdieu, 1977) and meaningful ‘action’. Taking a phenomenological approach, the present study seeks to redress this imbalance by suggesting a bodily practice-based learning theory in which the body is treated as a subject (‘body-subject’, as Merleau-Ponty (1962) calls it). Rather than an object, it is argued that the body (including the mind) is the locus of all meaningful action and learning and that it is through our bodily senses that we gain access to the world (Merleau-Ponty, 1962). Learning requires bodily efforts and movement in space – or forms of embodiment – which also include cognitive efforts. On this count, body and mind form a body-mind complex whereby the mind is given a body and the body is given a mind. The link between this body-mind complex and the practical world is not dis-attached reflection, but spontaneous engagement with the world, through ‘doing’ things, ‘acting’ and direct experience. Such doing is only possible through bodily efforts and movements in a specific 155
space and an environment. As an illustration of this approach, we focus on the elderly care services context to show how care givers acquire knowledge about, and respond to, the needs of the elderly seniors. We believe that in this context learning (understood as the acquisition of knowledge) through the human body is fundamental for accomplishing various care-giving tasks. Although workers are supplied with instructions as to how to behave with regard to the seniors, workers are often challenged to spontaneously respond to emerging situations and to act in a pre-reflexive way, relying more on their perceptual, bodily skills than on written instructions. We begin with a discussion of the practice-based learning theory with a view to showing some weaknesses which are due to its negligence of the human body. Next we present a phenomenological approach that recognizes the centrality of the body in learning and knowing. Subsequently, we present the method, drawing on field work (observations and interviews) to illustrate some of the proposed ideas. Finally, discussions of the empirical material and theoretical implications for further studies are drawn.
Practice-Based Learning Theory: A Critique The recent practice turn in social sciences has captured the interest and the imagination of organization theorists (Brown and Duguid 1991; Lave and Wenger 1991; Blackler, 1993; Wenger, 1998; Fox, 2000; Contu and Willmott, 2003; Roberts, 2006; Handley et al , 2006; Whittington, 2006, etc). Within this approach, it is increasingly argued that knowledge and learning are the outcome of social structures and interests, rather than that of cognitive thinking of individuals (Brown & Duguid, 1991; Gherardi, 1999; Longino, 2002). However, what the practice-based learning theory (PBLT) actually does is displace learning from the individual’s mind to what it calls ‘shared social practices’ (Tsoukas, 1996; Ghirardi, 2000), a kind of public, super-individual, relational, interactional level (Fox, 2000), rather than overcoming the mind-body dualism to which it initially rightly objects. The bedrock assumption of the PBLT is that learning is situated or localized, not in the mind of the individual, but in the community of practitioners as they work and innovate (Becker 1953; Brown and Duguid 1991; Lave 1988; Lave and Wenger 1991; Harding, 1986; Haraway, 1991; Mol 1999; Latour 1987; Knorr-Cetina, 1981). As an illustration, it is regarded that “the human agent’s understanding resides, first and foremost, in the practice in which he [sic] participates. It is shared in rules in such a way as the locus of the agent’s knowing how to follow a rule is not in his head but in the practice” (Tsoukas, 1996: 16). Learning is not something that people passively undergo, or have but rather it is “something they do” (Blackler, 1995: 1023) and can be acquired only through participation in their everyday practices and activities (Brown and Duguid, 1991; Lave and Wenger, 1991; Nicolini 156
and Meznar, 1995; Elkjaer, 2003; Contu and Willmott, 2003; Roberts, 2006; Handley et al., 2006). In other words, being in the world is not enough, we need to do something in the world – rightly or wrongly – in order for us to learn. As Winograd & Flores (1986: 78) insist, “knowledge and understanding (in both the cognitive and linguistic senses) do not result from formal operations on mental representations of an objectively existing worlds…[but] from the individual’s committed participation in …[collective action that is] embedded in a socially shared background of concerns, action, and beliefs’”. However, despite this emphasis on participation, reflection still pervades most theorizing. This reflection, or ‘turning back on ourselves’ (Maturana & Varela, 1998: 24) is assumed to offer a chance to learn how we learn, to know how we know, and ‘to discover our blindness (pp. 24). It is further assumed that this reflective learning does not represent any final stage or end state (Thelen & Smith, 1994), but it offers the capacity of a continuing refined modesty, perhaps, that may keep us sufficiently aware of our blind spots. Most often, the reflective mode is articulated in language: “language is the constitutive and antipoetic social medium through which we become aware of others and ourselves” (Winograd & Flores 1986 page number). In a similar fashion, Gherardi and Nicolini (2001: 51) claim that reflection is necessary for learning because, they assume, it provides ways to “move learning outcome into the verbal and conscious area, which make[s] it possible to share with others”. Elkjaer (2003: 48) concurs: “If people want to learn from their experience, however, they must get them out of the physical and non-discursive field and turn them into acknowledged and conscious experience”. By reducing learning to a matter of conscious thinking, it fails to do justice to the body’s potential to learning. As a consequence, the practice-based learning is still beholden to the reflective mode of being. Reflection militates against our spontaneous bodily participation in everyday practices. Practices involve the pre-conscious, automatic mode of operation underlying a community (Bourdieu 1977; Lash 2002). They are related to non-acting and non-thinking entities. Practices are supra-individual; foregrounding the pre/unconscious (Lash 2002), ruled more by the habitus, rather than the by intellectus (Bourdieu, 1977). Practices are the outcome of learning processes through which players know without knowing the practical sense of doing things—of how things are done or happen (Bourdieu, 1977). Practices are open-ended, intention-free and pre-cognitive processes. The practice-based learning theory is unable to bridge the gap between ‘unthinking’ individuals and their spontaneous practices, or their practical engagement with the world. Although the body is the medium of practices, it has been deferred from discussion. Bracketing out the body rests on a mistaken assumption that the body is an object of, if not the obstacle to, knowledge and representation, rather that the source of knowledge (Bourdieu, 1977). Merleau-Ponty’s works provide a new connection between body and 157
action without falling prey to the mind-body dualism. Merleau-Ponty (1962) regards the body, including the mind, (through various forms of embodiment) as our access to the world, insisting that ‘consciousness’ is not located in the mind but in the body. For him, embodiments are a sine qua non for learning and knowing, and the process of learning is not necessarily a conscious one.
The primacy of the perceptual By making no distinction between the bodily and the perceptual, cognitive, Merleau-Ponty (1962) transcends the Cartesian mind-body dualism: “It is through the body that we have access to the world. Perception hence involves the perceiving subject in a situation rather than positioning them as a spectacular who has somehow abstracted themselves from the situation. There is an inter-connection of action and perception: “every perceptually habituality is still a motor habit” (Merleau-Ponty 1962: 53). To the extent that being-in-the-world involves a lived body engaged in situated everyday practices, humans are defined in terms of the things they do in their life-world. However, what they do does not involve unmediated, bodily activities; rather these activities are mediated through perception, where perception is not viewed as passive receptivity, but rather as a creative and skilful capacity that shapes the activities and practices that it accompanies. Such perceptual, bodily activities are referred to by Merleau-Pony (1962) as embodiments. Embodiment involves bodily efforts (including cognitive ones) exerted with respect to the world. Implied in the notion of embodiment is the idea that cognition necessarily occurs through and within our bodily structures which are themselves coupled to biological and social contexts (Varela, 1991). For instance, “knowledge in the hands is forthcoming only when bodily effort is made, and cannot be formulated in detachment from that effort” (Merleau-Ponty 1962: 144). Knowledge is produced when physical efforts are made by our bodily faculties, such as seeing, hearing, touching, feeling, smelling, etc. It is only through such embodiments that individuals come to know their reality (Küpers, 1998: 339). Embodiment is thus two-fold: it involves physical, perceptual (cognitive) efforts and a world (consisting of humans and artifacts) that is perceived and acted upon. However, this world is neither (empirically) given, existing objectively, nor subjectively constructed by the perceiving subject. For Merleau-Ponty perception is construed to encompass practical action, therefore, when he talks about the primacy of perception he is also arguing for the primacy of spontaneous, practical action. Perception is responsive accommodation to circumstances beyond our control (Rouse, 2005: 43). To the extent that what the body perceives and receives (perceptual receptivity) is only possible thanks to its accumulated preceding movements and embodiments 158
Merleau-Ponty maintains that: “One could also say that the behavior is the first cause of all stimulations…[and that] it is the organism itself …which chooses the stimuli in the physical world to which it is sensitive” (1962: 441). What we see and perceive is thus reflected in the shape of the physical capacities of our body, in the sense that our body conditions what it perceives and does, but it is also conditioned by what is seen and done, for seeing presupposes being seen” (Merleau-Ponty, 1962). The body is the locus of this interactive dialogue between the ‘internal’ and ‘external’. Our consciousness is neither the outcome of private, cognitive processes, nor of objective stimuli imposed on us through sense data from an external environment. Rather, it is experienced in and through our body. Things exist for themselves (in a transcendental fashion) because they resist our knowing them with total certainty; but they exist for us (immanently) because we always experience them in relation to our own body and the forms of embodiment we have learned. For example, we attend to a chair in certain ways rather than others, because it allows for certain embodiments (such as sitting) while disallowing others (such as sleeping comfortably). In this sense, the chair is both transcendental and immanent and as given to experience it is an “in-itself-for-me”. It is in this way that Merleau-Ponty argues that our experiences are inter-connected with the world and the artifacts we use. Perceptual experience involves an openness to the world which is neither given, nor purely spontaneous (Rouse 2005: 44). The stress on the perceptual is meant to ground practical action in its situation, and to reinforce the point that “reflection should not feign ignorance of its origin in perceptual experience”, the point being that the “I can” precedes and conditions the possibility of the “I know” (Merleau-Ponty, 1962: 137). Hence learning is corporeal in the sense that “A movement is learned when the body has understood it, that is, when it has incorporated it into its ‘world’, and to move one’s body is to aim at things through it; it is to allow oneself to respond to their call, which is made upon it independently of any representation. Motility, then, is not, as it were, a handmaid of consciousness, transporting the body to that point in space of which we have formed a representation before-hand” (Merleau-Ponty, 1962: 139).
Purposeful learning but without a conscious purpose As noted, embodiment presupposes some kind of perception and some way to act in response to what is presented; in this response we are solicited or called to transform the presented situation. In this sense, the know-how acquired is reflected back to us in the solicitations of the situation correlative with our disposition to respond to them. Merleau-Ponty calls this tendency to respond to situational solicitations ‘skilful coping’, which he describes as activities that do not require a mental representation of their goals. This skil159
ful coping can be purposive without the agent entertaining a purpose. Our skilful embodiment enables us to respond to circumstances without requiring an explicitly formulated aim: “The life of consciousness – cognitive life, the life of desire or perceptual life – is subtended by an `intentional arc' which projects round about us our past, our future, our human setting, our physical, ideological and moral situation, or rather which results in our being situated in all these respects. It is this intentional arc which brings about the unity of the senses, of intelligence, of sensibility and motility” (Merleau-Ponty, 1962: 136) As Merleau-Ponty points out, the concept of ‘intentional arc’ implies a new account of the relation between perception and action. In contrast to conventional approaches that treat motivation in psychological terms, Merleau-Ponty provides a more primary form of motivation, arguing that once one has acquired a certain skill one is solicited to act without needing to have in mind a goal at all. Our everyday skilful coping, our activities are experienced as a steady flow of skilful activity in response to one’s sense of the situation. In our skilful coping, when we sense that our situation deviates from some optimal body-environment relationship, our motion takes us closer to that optimum and thereby reduces the “tension” resulting from the deviation. In this context, one's body is simply solicited by the situation to get into equilibrium with it. The intentional arc throws new light on how the human agent is led to act, know and learn – merely thanks to the body’s tendency to achieve an equilibrium which is preparatory and temporary, functioning as a springboard for the renewal of neediness, and as a ground for further exploration (Rouse, 2005: 44). Dreyfus (1996) says that as our skills are improved and refined to cope with more and more things and situations, things show up as soliciting our skilful responses. Hence, as we refine our skills, we encounter more and more differentiated solicitations to act. Referring to Gibson’s (1979) concept of ‘affordance’, Dreyfus notes that the “characteristics of the physical (perceptible) world – what affords walking on, squeezing through, reaching, etc – are correlative with our bodily capacities and acquired skills. Because mail boxes, for instance, afford mailing letters we do not reflect upon them objectively, but rather we consider them as part of our perceptual and practical field. In this way, we regularly integrate aspects of the world within our schema of bodily capacities. It is in this way that the intentional arc is constantly enhanced, without being goal-directed. For instance, when using equipment, tools typically are assimilated into our capacities for movement or physical functions. However, as Rouse (2005: 45) notices, “although tools can be put aside in a way that bodily members cannot, the bodily skills acquired in using them become a more permanent part of a bodily and personal repertoire. I set my bicycle aside when I arrive at a destination, but I do not set aside my ability to ride or the expanded mobility that it provides”. We do not relate to tools in terms of 160
‘subject’/object’, body/mind, or body/world. Rather, in this inter-connective way, our embodied skills are acquired through engaging with things and attending to situations. Our skilful embodiments determine how things and situations show up for us as requiring and soliciting our response. The more expert one is, the more one becomes solicited by its environment to respond. Experts can detect more features of the world and thus are more prompted or solicited to respond accordingly. Of course, all this does not mean that we cannot be motivated to learn, say to play tennis, but what is meant is that as we learn tennis we do not try consciously to discriminate more and more subtle tennis situations and pair them with more and more subtle responses (Dreyfus, 1996). Once we get involved in practicing, the body takes over and does the rest and learning proceeds outside the range of consciousness. Phenomenologists argue that the idea of purposive actions without purpose is not confined to brute, physical activities. Wacquant (2005) quotes Eliasoph (2005: 162) saying “boxing is not very different from other activities: differences in bodily training seamlessly slide into differences in emotions and cognition”. Wacquant (2005) insists that both cognition and emotion are incarnate responses that engage the trained faculties and proclivities of an indivisible “body-mind complex”. Even the most “mental” of activities, such as philosophy, mathematics, or playing chess are fully embodied, each in its different way. For, whether these involve the handling of certain objects or “’intellectual’ activities such as talking, reading or writing...All these bodily activities then include also routinized mental and emotional activities which are – on a certain level – bodily, as well” (Reckwitz, 2002: 251). Thinkers, from many fields – philosophy, cognitive linguistics, neuroscience, etc – have argued that thinking itself is a deeply corporeal activity (Ryle, 1949; Merleau-Pony, 1962; Damasio, 1999; Lakoff and Johnson, 1999). The phenomenological approach adopted in this paper provides an alternative to the practice-based learning theory. In these terms, learning is to take place when our behavior becomes spontaneous and a-theoretical, and when intuitive responses to an emergent situation replaces reasoning and thinking. The limitation of the practice-based learning theory lies mainly in its conception of learning as a thought process, being biased towards the logic of the ‘I think’, rather than that of the ‘I can’. From this phenomenological perspective, even the logic of the ‘I think’ is itself embodied and structured by what our body ‘can’. By dint of exercise, the body comes to coordinate a large range of muscular activities in an increasingly automatic way, until awareness retreats and recedes to the background. Similarly, in the use of equipment, tools typically become part of our integrated capacities for movement and practical skills. Because our practical, bodily skills are petrified in bodily habits, they become elusive to intellection and impervious to conscious transformation. Consequently, they have the power to define the boundaries within which conscious thought occurs (Hayles, 1999: 205) 161
and the way social rules and norms are conceived and enacted (Wacquant, 2005). Hence, rather than the social shaping our conceptions of what we do and learn; it is the body that does all these. In light of this phenomenological approach we want to illustrate that knowing and learning takes place through the human body in tandem with the artifacts that extend its corporeal capacities. In their skillful coping with their daily activities, workers providing health care services to elderly citizens use their bodies to understand and make sense of the situational requirements in routinized, non-reflective ways. In line with Dreyfus (1996), we will show that although workers are equipped with minute instructions as to how to go about delivering their services, learning and knowledge their tasks presuppose that they forget those instructions and instead, behave according to the emergent circumstance and situational affordances they are presented with in a spontaneous way.
Method This paper is based on a field study of care workers in two Swedish communities. Data was gathered during 2003-2007. Getting access to care workers’ behavior, including their pre-reflective bodily activities and gradual learning is difficult. Observations, in-depth interviews and the study of documentation (written rules and laws about public care service delivery) were used in this study. Observations and informal conversations perhaps gave us the most valuable access to the workers’ perceptions of their practices, in actual situations (Denzin & Lincoln, 2000). The observational notes provided particularly an important grasp of our informants’ embodiment and the use of various senses in exercising their tasks.
Data generation The first series of interviews took place in 2003, with 20 front-line employees (home-helpers) in community A. The duration of interviews ranged from 60 to 90 minutes. The topics of the interviews revolved around everyday home-help delivery services, focusing on how the home-helpers understand and respond to the seniors’ needs. Although the interviewing researchers/authors employed an interview guide, they tried to let the interviewees determine, to a large extent, the direction and flow of the conversation (Oakley, 1981). The limited coverage of the written instructions soon became clear. Workers spoke of the need to constantly adjust to the situation in ways difficult to articulate, when delivering services. To further understand the workers’ adjustment to each senior requirements and situation, one of the researchers (the interviewer) accompanied three different home-helpers when they visited senior households. Observations were performed on 6 162
occasions, lasting 4 hours each. Observation notes were taken immediately after in-home visits and refined in the evening (Bernard, 1998). Follow-up conversations conducted between each visit, while walking or driving from one household to the next. Notes were audio-recorded and later transcribed, thereby providing a valuable source of information. In particular, it allowed us to probe into the workers’ practices and behaviors. For instance, the conversation showed that the workers were not often aware of many of their daily activities, since these are carried out in a spontaneous way. A second series of interviews (10 interviews) with, and observations (8 hours in total) of, front-line workers employed in community B were performed in 2005, using similar approaches as during the first set. These interviews were more focused on learning and the mode in which tasks were executed. Follow-up phone calls (n=5) were conducted to clarify issues that were not clear enough for us. The participants were all front-line service employees, aged between 19 and 50 years, with an experience ranging between 5 months to 30 years. The majority (19 out of 30) of the participants, however, had a long experience (more than five years). To protect the participants’ anonymity, their names are not cited.
Mode of analysis For our present purposes, content analysis was performed in several stages (Mason, 2002). In stage one, verbatim transcripts from formal interviews and notes from observations and informal conversations were read through to obtain a sense of the whole. Themes, i.e. threads of meaning running through the descriptions (Mason, 2002) were abstracted. We analyzed the material for emergent themes that suggested how the workers use their bodily skills in performing their daily tasks (Creswell, 2003; Denzin & Lincoln, 2000). This iterative process was continued until data saturation was reached and no new themes were identified (Glaser & Strauss, 1967; Morse, 1994). The identified themes included workers’ increasing reliance on their bodily senses rather than formal instructions as they gained experience, and their body perceiving opportunities for action (rather than passively receiving data about the environment). Data analysis subsequently became an iterative process. We went back to the literature to help sensitize us to the potential meanings of the themes our material pointed at. We developed a preliminary coding framework, which evolved as we continued to discuss the field notes. In this way, this interpretive process was emergent rather than prefigured and set up in advance (Creswell, 2003).
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Findings The centrality of the body in learning how to perform daily tasks As noted above, a number of themes has emerged from the interview material and observation notes with regard to how care givers perform their practices of care giving. Most prominently, these home-helpers use their perceptual, bodily skills to spontaneously respond to emerging circumstances, without reflecting about what they do although they were provided with written and/or verbal instructions to guide their responses to the needs of the seniors. There are individual service plans that specify what services workers are to execute and how. One such service plan document looks like this: “…Name: Aina […]. Condition/Need: Chronic Obstructive Pulmonary Disease, is anxious […]. Granted service: Daily: Help with getting up from bed, getting dressed, hygiene, making the bed, preparing breakfast, at 8.30 a.m. 20 minutes. Food delivery at 12.30. Help with preparing meal, 16.30. 15 minutes. Help with getting undressed, hygiene, go to bed. at 22.00. 15 minutes. Once a week: Help with shower 30 minutes …” (Service plan document).
New care workers further receive verbally advice and tips from more experienced workers as regards how to deliver the specified care services. However, interviews suggest that much of the knowledge used in care work is difficult to learn by reading or following formal verbal instructions. Newcomers always walk beside and watch an experienced worker before going out on their own. However, watching is not enough. Interviewees maintain that to learn care work, one needs to actually perform the tasks oneself, using one’s own body. For example, Eva talks about this process: “… although I had listened to Sanna’s [experienced worker] advice and I had watched how she showered Edith, I felt far from sure about how to do it. Sure, I had watched her several times and I mean, I knew that by heart. Still, it was quite a different thing to do it myself. Now, I’ve had to find my way of doing it. I do what Sanna does basically, but I’m sure I do it differently than she does…. […]… Now I do not think of the advice or the service plan, I just work my way through it …” (Eva).
The interviewed care workers talked about how they, when they were new and inexperienced, explicitly concentrated on directing their 164
body to responding to seniors’ needs, but gradually and through practice, that conscious effort has disappeared: “…Sure, helping seniors shift side in bed or get out of bed requires certain bodily technique. When two of us [home-helpers] are required, we need to coordinate our efforts. It is hard to explain how you learn this... Rita taught me a lot of things about this…in the beginning she used to tell me to use my left arm to do that and to bend my knees to get more strength…and she used to keep reminding me not to be to concentrated while doing that...and so on… I had a hard time being friendly at the same time as concentrating on getting the moves right… Now I can do that. I don’t need to think about my moves at all. I just respond to seniors’ moves and adjust accordingly. Indeed, I usually see immediately if they don’t like what I’m doing. But I can talk to the seniors while doing this, and I can talk to Rita about other things. I don’t need to concentrate in the same way as in the beginning…” (Helena). “…I remember when I was new...I felt so clumsy… every single move was a major and challenging decision... It was like, Should I pat her hand now? Or will she find that offensive? Should I ask her how she is? Can I leave her already? Can I interrupt her now? And I was so self-conscious, thinking about how I looked or seemed, how my voice sounded weird… and I had sweaty hands and thought that seniors would notice this…Now, I seldom think about myself, I think about the senior instead, if she or he has problems or so…[…]…I guess I trust my intuition, I usually feel how to move around in the seniors’ houses. Actually, if I start thinking too much about how I behave, things tend to get difficult…” (Eva).
Hence, the interviewees even suggest that reflective thinking can impede the workers’ spontaneous responses, as it interferes with their body’s ability to take care of things ‘itself’, in a pre-reflective manner.
This form of learning is improved as the home-helpers meet and respond (using their body) to more and more nuanced situational requirements. Furthermore, this learning requires increased ability to perceive, recognize and select more features sophisticated features of a situation, as they interact with the seniors: “…Now I kind of know of know how hot the water should be. In the beginning, when she [a senior helped in the shower] said, could you turn the hot water on? I had NO clue how hot it should be ….So when I did that, she said aaoch that is too hot!!! Which was embarrassing…now I know her preference, and I can feel when the water is warm or cold for her…or at least, I notice when she thinks it is too hot, as I make sense of her facial expressions… in that way, I avoid her outbursts…which is a relief, it makes it so much easier…I don’t have to ask her …because you learn to know these things auto165
matically when you get to know the senior and when you’ve done it a few times…” (Jessica).
It seems that bodily learning in this context occurs without the care workers’ entertaining motivation or conscious intention. The workers cannot account for any explicit strategy regarding how they try to make their body discriminate between more subtle events. But as their body accumulates knowledge about how to interact with the seniors, i.e. incorporates more ‘moves’ into its body schema, it also seems to perceive more refined ‘calls’ to intervene in a given situation. Action and perception are closely interlinked. Indeed, the empirical material suggests that experienced home-helpers do not passively perceive sensory facts that they interpret and then transform into intentions about how to intervene or act. They rather selectively perceive problems or opportunities for action. To know in this context presupposes a bodily ability to perceive a situational call to interfere and skillfully respond to that call so as to redress the emerging tension between the body and the situation. For instance, olfactory, sonorous and tactile elements experienced during previous visits are stored in the body of the experienced workers without making conscious efforts to learn them and remember. Observations suggest that their bodies open up to relevant information without the workers explicitly instructing their body about what senses to use and what not to sense. For example, Hannah explains how nowadays (as opposed to when she was completely new), her bodily senses are activated and drawn to different aspects depending on the situation while visiting the seniors: “…for instance, sometimes I sense an unusual smell when I open the door…At other times, I may hear from the pitch of the seniors’ voice, whether they sound unusually weak or start mumbling…Kurt, I usually touch his hand at one time or another when I visit him, I remember recently, his hand was colder than usual when I patted him. This was an indicator …” (Hannah).
I ask Hannah whether she “plans” in advance what she would do every time she calls on the seniors and her answer was negative: “…I just do it. It is not like I first think that I’ve got to smell if something smells strange…then I have to go and pat her hand and feel if it is unusually cold…if I smell something strange smell I think my attention is drawn to this and I continue to smell and try to understand what it is…” (Hannah).
Further, Joni talks about what she actually does when performing her so called “check up” visits at seniors’ houses: “…I simply see whether everything is OK…I really can’t say exactly what I check, it depends! […]…this work is really about knowing the senior. […]… I mean, I don’t try to figure out whether Kurt is weak; I know he is always 166
weak. I try to find out if he is unusually weak…you have to know what is ‘normal’ for each senior… It’s very difficult to explain, I usually feel intuitively whether something is wrong… For example, Ingrid is extremely tidy, and I may ask her if everything is OK if I notice that her kitchen is not as tidy as usual…[…]…you know, there may be signs here and there…indicating that something is wrong…”(Joni).
In this case, Joni does not consciously direct her vision to focus on the kitchen she is just led to the kitchen ‘automatically’, relying on pertinent clues in the home of the senior. There is no in-advance plan to be followed or an intention behind each move the home-helpers make. For instance, from our observation notes, it was possible to notice how the workers’ bodies do not passively receive sensory data from the situations, but rather they selectively and creatively perceive object attributes depending on their bodily skills. For example, I joined Hanna one day and observed her while working. I noted that the senior’s garden was in need of tidying and watering, so I asked Hanna if she noted this. “Was it? Well, no… of course, I don’t pay attention to everything…I don’t even see if the senior has a computer break-down, that’s not my responsibility…I note problems that I can do something about…“ (Hanna).
Again, perception is a matter of creating meaning and a matter of perceiving opportunities for action that one has the bodily skill to act on. The experienced workers’ perception of situational features is hard to separate from their ability to respond to them. Indeed, their knowledge is manifested in their ability to respond to solicitations in a pre-conscious way. For example, accompanying a home-helper who visited a senior named Ruth, I observed the home-helper move very close to Ruth when talking to her one day but not the next. I asked Joni about this after the second visit. Her answer suggests that she performs this adjustment unconsciously: “I did that?...Well…a lot of things, one just does … I guess, as concerns Ruth, I’ve learned that some days she doesn’t hear well. Its really a day-today thing. I think this is related to how well she has slept…if she has slept well, she hears much better… So I guess I automatically move closer to her when I feel that she doesn’t hear when talking to her…I guess…I learned this as she rarely heard what I told her in the beginning…”
Technological artifacts as extension of bodily skills The care workers do not only use the body to perform their daily activities. Their work also relies on equipment and technological artifacts. Technological artifacts are used to extend their bodily capacity to perceive more refined features of the environment. Hence the introduction of new instruments and 167
equipment means that workers need to learn how to use them in the same way they learn how to develop bodily skills. And in the same way, learning to use instruments implies a shift away from the reflective to the nonreflection mode of interaction. For instance, the community we are studying opted for a new way of improving its services to the seniors by devising an in-home monitoring system. These wrist-worn monitoring devices, equipped with wireless sensors, continuously collect information about the seniors’ activity level. The information is captured into graphical activity curves and transmitted to the care center where it is displayed on a computer screen. For the care workers, such devices initially posed a challenge. They had to learn to absorb them into their own bodily capabilities: “…In the beginning, I thought much about how to move the mouse with my hand…[…]… I tried to understand the [software] program and the computer. How does this work?? I had a hard time opening new windows on the screen. I tried to remember what the technology provider told us about how to use it…Now, I care less about how it actually works, I don’t need to know that…” (home-helper).
Gradually, learning to use the technology implied forgetting the existence of that technology. Indeed, learning here implies increasingly incorporating the technical capacity into their own body and amplifying their own area of sensitivity to the seniors’ needs, being less preoccupied with looking at the dots on the screen. One of the workers, talked about how she was getting to learn to read the curves without the great amount of efforts and stress she used to have at the beginning. She does not look the curves in their details in order to make a diagnosis of the health of the seniors she is watching over. One of the authors observed home-helper use the instrument. She double-clicked on a specific activity curve. When asked why, she said “It [the activity curve] looked strange….It may be difficult to see for you, but I know that this senior’s curve should not look like this. It signals something wrong to me”.
Hence, it is almost as though the workers, equipped with the instrument, were able to ‘feel’ more about the state of the seniors than prior to learning the use of the instrument. The workers’ way of learning how to use the new technology also highlights how this involves the acquisition of a skill to perceive more subtle affordances. For example, the monitoring system categorizes seniors’ activity levels as within ‘normal’ range or as ‘deviant’, marking such levels as blue or red respectively. The workers talk about how they were merely able to discriminate between these two states (normal/deviant) when using the instrument in the beginning. Their accounts further suggest that they initially concentrated on looking at each curve in a 168
rather systematic way, trying to understand the system’s diagnosis of each of the seniors. With practice, they have learned to perceive/attend to the curves in a more selective way, becoming more and more able to perceive more and more nuanced solicitations prompting them to act. “…in the beginning, I reacted when it was indicated on the screen that the senior’s activity level was ‘divergent’ [the activity curve turns red if this is the case]…Now, I can see more things. I mean, that categorization is rather crude, normal or divergent...Now, I see more nuances…like, if a ‘normal’ activity curve is actually not normal for a certain senior…I mean, it may be ‘normal’ for some seniors to have divergent levels in periods during which they are ill… its like, I see when something unusual appears in the curves…[…]…like, if the senior’s pattern changes over time. I may notice that a senior starts becoming active a bit earlier than usual in the morning, even if this is’ within normal limits’. I may try to ask the senior about this between the lines when visiting him the next time. This is in a way preventive work, noticing subtle changes before the system categorizes it as’ divergent’ levels…” (home-helper).
Interviews suggest that learning how to use the instrument not only implies developing a more sophisticated perceptual ability to select more features of the situation, by using the instrument, but also a less conscious capacity to respond to the senior’s needs. For example, the technology gathers information about whether a senior is wearing an alarm or not (this generates a straight yellow line on the curve). A home-helper talks about how she has gradually learned to pre-reflectively use this information as an extension of her perceptual skill: “…The system marks this [a senior not wearing the device] as yellow, i.e. not normal. But it is not always that simple, or black and white. A senior may take off the device if he is about to take a bath or go to the store – that is OK of course. When should one react? Now I find it easier to determine when a senior has been without the alarm for ‘too long’…[…]… I don’t try to exactly count how many centimeters the yellow line is…but its like, I see when the yellow line looks ‘too long’. This depends on the senior. But I have somehow started to grasp for how long it is ‘normal’ for certain seniors to take it off…Agda never takes it off. Hence, I would automatically react if Agda’s line would be yellow for a long time. This would be unusual for her. This is something you learn with time. After a while you see it more intuitively. Which makes it easier, and I can go over the curves rather quickly now…” (home-helper).
Similarly, other workers find it hard to explain how they know when a senior does wear their alarm for too long. It appears as if their helpers’ body remembers the graphical appearance of a seniors curve. They don’t explicitly compare the curves (e.g. their length of passivity in cm), their body seems to have remembered the pervious ‘look of’ senior’s curves and hence, it automatically reacts when the patterns of curves change. Whether or not this 169
knowledge or information is ‘stored’ in the vision, brain or whole body is impossible to tell. But it is clear that it is not abstract reflective knowledge. Rather it, it is knowledge in the body, forthcoming only through bodily efforts. This bodily knowledge (extended capacity gained through using the instrument) is handy. Indeed, the workers can quickly scan a large number of curves as they ‘automatically’ see when something is unusual. They don’t have to concentrate explicitly on looking for deviant patterns. Their perception guides them to it. Their vision is drawn to the ‘right’ curve. What was also salient in the empirical material was that when becoming proficient in using the technology (incorporating it to their body schema), the workers combined their technology-enhanced perception with their other ‘naked’ perceptual capability in a pre-reflective manner. For example, one of the authors observed a home-helper scroll down the computer, over-viewing various activity curves. She stops at one specific senior’s activity curve, double clicks and then continues. When asked afterwards if she noted something unusual when analyzing the curves, she asserts that everything was OK. The researcher reminded her that she stopped at one curve. When forced to think about it, she says after a while: “oh that’s right, that was probably Anton’s curve. I visited him earlier today and he was not feeling well and he had to rest; I reacted as his curve suggested he was very active now! It did not make sense; it felt a bit odd. But then I remembered that his daughter was to visit him in the evening. So I went on to the next curve… You automatically relate what you see on the screen with what you’ve observed during visits of course...” (home-helper).
When having incorporated the instrument, the workers do not merely see activity curves, their bodily experience of a senior’s overall state comes with it. That is, they automatically combine their extended, technology-mediated perception, with their ‘naked’ perception, and can thereby make a proficient diagnosis of the senior’s need. Thanks to this intelligent but pre-reflective integration of perceptual capabilities, the care workers’ body can discriminate more features of the situation. “...When I look at the curves at the computer display, my attention is drawn to the sleeping patterns… I try to see how the seniors sleep [when looking at the curves]…[…]…I think we are inclined to look for sleeping disorders as there is a lot of fuzz about this today, a lot of articles in regular news papers…but also advertising in journals for care professionals… We receive a lot of information from the pharmaceutical companies about the medicine available for sleeping disorders and related problems like depression and restless legs…so we talk more about this…[…]...some years ago I would simply have said that elderly people often sleep badly, that it is a natural part of ageing…and I would not be interested in knowing exactly how they sleep. But now there is a point in noticing it…” .
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Discussions, concluding remarks and implications As noted above, care workers/home-helpers use their body in understanding and carrying out the practices of providing seniors with care and help. Our empirical material strongly suggests that as the care workers become knowledgeable, explicit verbal or written instructions recede to the background (Dreyfus, 1996). As they become more confident and experienced care workers rely much more on their bodily perception and pre-reflective adjustment when delivering care services than on formal instructions. The findings even suggest that reflection can disturb the workers’ skilful action and ‘smooth operation’. It is as if thinking about how to behave ‘crowds out’ their bodily attention away from its openness and spontaneous response to the situation. The care workers’ practices are not guided by conscious thinking, nor are they just per chance happening. Because they are not informed by predetermined, in-advance rules or specifications, they can be spontaneously open to new possibilities. Their spontaneous and open nature does not admit of explicit thinking and cogitating, as the practice-based learning theory tends to suggest when it makes reflection as a requirement for learning (Gherardi and Nicolini; Elkajaer). Workers sometimes find it awkward and counterproductive to follow the rules set up to them by regulators. Each situation has its own demands. Rather than taking place through abstract thinking, learning how to help the senior means that the workers have to deploy and use their bodies in different ways. It entails an increased perceptual, bodily ability to discriminate more and more refined features of the situation. This perceptual, bodily spontaneity is not a passive receptivity, but also a creative responsiveness. To the extent that practices imply an open space of indeterminacy, the body’s creative responsiveness is necessary to cope with indefinitely new challenges and new situations. This perpetual call to rise to emergent challenges is referred to by Merleau-Ponty (1962) as ‘coping’. . This everyday ‘coping’ can be understood as care workers’ body acting with an implicit ‘intention’ to orient themselves and strike a balance between their body’s dispositional skills and whatever challenge they confront. Driven by this primary ‘motivation’, the care workers’ bodies ‘automatically’ make various efforts to reduce tensions between themselves and the situations they encounter. The more perceptual skills they acquire to respond to situations, the 171
more their body accumulates and becomes habitualized to perceive more refined structures in the environment. Indeed, perceiving is an activity that is tightly linked to their responsive capability. Workers’ perceptual receptivity and responsive ability are constantly being altered (in however small a way), becoming a "flexible skill, a power of action and reaction" (Crossley, 1994: 12). In contrast to the PBLT that places learning at an inter-subjective, social level, it is suggested that the locus of learning lies in the bodily, perceptual skills. Indeed, the findings reject the idea that individuals learn by first passively perceiving sensory data, then interpreting and reflecting upon this data in their mind, and finally transforming this interpretation to instructions to their body. Rather, we show how learning takes place without the workers’ thinking explicitly about what they learn. In Merleau-Ponty’s (1962) words, we are dealing with "knowledge [that is] in the hands, which is forthcoming only when bodily effort is made, and cannot be formulated in detachment from that effort" (Merleau-Ponty, 1962: 144). Furthermore, the primacy of the pre-reflective in the learning process, and the shift away from the reflective to the pre-reflective, is also evident in leaning new technological artifacts. Care workers initially engage with the technology as an object but as they engage with it, they gradually incorporate it into their body schema, making the extended perception ‘their own’. Even, when they turn the computer off, the skill they have acquired is a more permanent part of their body. They gradually reach a state where they, through the instrument, perceive opportunities for action in an increasingly pre-reflective way. For example, rather than analyzing the technologygenerated patient data in a calculating, reflective, instrumental fashion, they ‘feel’ whether something is wrong or not. . While invoking reflection as a requirement for learning is redolent with the Cartesian, subject-object dualism, our approach suggests that our view of learning goes beyond the distinction between mind and body, as well as between (a thinking) subject and an object of that reflection.
Theoretical implications and future research suggestions The present work contributes to the discussion on the practice-based learning theory, suggesting an alternative view that brings the body to the center of human learning and knowledge. While the PBLT can be credited with dethroning the individual mind as the cognizing unit, it ignores the body’s ability to make meaningful action and knowledge. This has been the chief aim of the preset paper, namely, to argue for 172
the corporeality of learning. Learning does not reside in the social (be it rules, norms, or processes), as asserted by a large number of theorists (see e.g. Brown & Duguid, 1991; Lave & Wenger, 1991; Mol, 1999; Tsoukas, 1996). The present paper lends strength to the view that learning as associated with doing, but it takes full account of the concrete and physical nature of action and activities (Bourdieau, 1977; Lash, 2002). The present paper also casts doubt over the widespread assumption that learning occurs via reflection (e.g. Maturana & Varela, 1998; Gherardi & Nicolini, 2001; Elkjaer, 2003). Indeed, rather than assuming that to know is to be able to reflect on one’s actions, this paper suggests that to learn is to suppress thinking and reflecting. It is our argument that “being-in” and “thinking-about” the world do not make a person learn. Rather, she needs to use more than her brain, she needs to use her whole body in actual situations for her to remember and learn how to act. The PBLT has failed to show how this process occurs. Indeed, while many contemporary scholars allegedly reject the mind-body dualism, there is little theorizing that actually provides alternative conceptualizations. . Indeed, the mind-body dualism is still implicitly pervasive in the literature through its objectification of the body, its treatment as an auxiliary component. The view presented here paves the way for new research that challenges the mind-body dualism. We need to go beyond repeating the argument that learning is ruled by social structures and is a matter of embodying social structures. This work begins to outline a path for students of learning and knowledge, a path assuming and acknowledging the centrality of the physical capacity of the human body. It will
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hopefully stimulate a new direction, not only in learning and knowledge research but also in technology, management and organizational science more generally. On a more practical level, the view presented here has significant implications. Challenging the view of learning as guided by conscious reflection, by abstract mental operations, would imply that we need to focus more on-the-job training and less on formal training relying on instructions and books.
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