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Rättfärdigade prioriteringar - en kvalitativ analys av hur personal i äldreomsorgen hanterar motstridiga verksamhetslogiker
Jönköping University, School of Health and Welfare, HHJ. SALVE (Social challenges, Actors, Living conditions, reseach VEnue). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
2016 (Swedish)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Justified priorities – a qualitative analysis of how eldercare personnel handle contradictory logics of activity (English)
Abstract [sv]

Tidigare forskning visar att äldreomsorgspersonal kämpar med två typer av logiker: en ekonomisk logik och en omsorgslogik. Även om båda logikerna behövs för att skapa god omsorg så utmanar de varandra. Dessa utmaningar kommer till uttryck i omsorgspraktiken där personalen ställs in för val och måste göra prioriteringar.

Denna avhandling syftar till att förstå hur äldreomsorgspersonal beskriver att de arbetar för att finna balans mellan logikerna och hur de rättfärdigar sina prioriteringar i omsorgen om de äldre personerna. Frågeställningen för avhandlingen är att ta reda på hur personal och enhetschef vid ett kommunalt äldreboende förstår och hanterar interaktionen mellan de två logiker som styr omsorgsarbetet för att främja de äldre personernas välbefinnande. Syftet innehåller tre delsyften: 1) att analysera personalens erfarenheter av och meningsskapande kring de äldre personernas välbefinnande och deras reflektioner kring det omsorgsarbete de utför, 2) att belysa och problematiserade logiker som styr omsorgsarbetet samt 3) att analysera hur personalen rättfärdigar sina prioriteringar i rådande kontext och hur deras förklarbarhet påverkar deras professionella identiteter. Målet är att bidra med socialvetenskaplig kunskap om de överväganden personal gör när de ställs inför att göra prioriteringar i äldreomsorgens praktik.

Material samlades in genom 12 individuella intervjuer med personal vid ett kommunalt äldreboende, en intervju med personalens enhetschef och en uppföljande gruppintervju med tre personer ur personalgruppen. Materialet analyserades med tre analysmetoder: fenomenologisk analys, reflexiv analys och positioneringsanalys. Resultatet visar att personalen definierar de äldre personernas välbefinnande som ett behov av att känna sig existentiellt berörd. Denna känsla av existentiell beröring delas in i tre delar: känsla av valfrihet, känsla av njutning och känsla av närhet till någon eller något. Arbetet för att uppnå detta välbefinnande beskrivs innebära ett balanserande av tre tvetydigheter: att vilja värna om de äldre personernas valfrihet och samtidigt hantera institutionella begränsningar, de äldre personernas behov av aktivering å ena sidan och att de inte behöver aktiveras å andra sidan samt att förstå de äldre personernas behov av rutiner samtidigt som det är svårt att veta vilka behov de har. Tvetydigheterna kontextualiserades och de två logikerna som styr omsorgsarbetet analyserades. Analysen visar att enhetschefen skapar en hybrid av den ekonomiska logiken och omsorgslogiken; ekonomi är omsorg och vice versa. Denna hybrid möter motstånd från personalen som skiljer på de båda logikerna genom att tala om ”vård och det där andra”. Personalen upplever att den ekonomiska logiken begränsar deras möjligheter att utföra omsorg i linje med omsorgslogiken. Motsättningar mellan de båda logikerna leder till prioriteringar som rättfärdigas av personalen i syfte att behålla de professionella identiteterna.

Den teoretiska analysen bygger på teorier om institutionella logiker, förklarbarhet ochprofessionell identitet. Analyserna visar vikten av att väcka dialog mellan enhetschefer och personal där de diskuterar innebörder av olika värdeord som används på politisk nivå. Sådana diskussioner skulle kunna bidra till mindre motstånd och en högre överensstämmelse mellan verksamhetsmål och praktik. Avhandlingen visar även vikten av att förstå logiker som vertikala istället för horisontellt uppdelade. Alltså, att styrande verksamhetslogiker existerar uppifrån och ned i verksamheter (från politisk nivå till chefsnivå och till praktisk nivå) och att de inte kan delas in i exempelvis en professionslogik och en styrningslogik. Den senare synen kan bidra till potentiella missförstånd eftersom det gör att konflikter kan tolkas existera mellan personal och chef, medan de egentligen existerar mellan olika motstridiga värderingssystem.

Slutsatsen är att de båda logikerna behövs för att stödja äldre personers välbefinnande. Ibland är logikerna samspelta och ibland är de i konflikt med varandra. När logikerna ställs mot varandra är det av vikt att komma ihåg att den ekonomiska logiken är lika förhandlingsbar som omsorgslogiken. De två logikerna existerar i samspel och om deras motstridigheter inte belyses finns risk att omsorgspraktiken inte stödjer de äldre personernas välbefinnande.

Abstract [en]

This dissertation aims at contributing to social scientific knowledge about prevailing prioritizations in eldercare practice by looking at an economic and a caring logic, and how these logics are overlapping, contradictory or come in conflict with each other. A more concrete aim is to understand how the personnel describe their work with or for balance between the logics and their justifications prioritizations made in the care of older persons. The research question is: How do personnel and care unit manager at a public nursing home understand and handle the two logics that govern care work for facilitating wellbeing of the residents. The aim and research question led to three sub-aims: 1) to analyze the personnel’s experiences of and meaning making about the care work they carry out, 2) to illuminate and problematize the two logics above, and 3) to analyze how the personnel justify their prioritizations in prevailing context, and how their accountability have an effect on their professional identities.

Empirical material was gathered through 13 individual interviews with care personnel and their care unit manager at a public nursing home in Sweden. These interviews were complemented by a group interview. The material was analyzed by the use of three methods: phenomenology (Paper I and II), reflexive analysis (Paper III), and a positioning analysis (Paper IV). Paper I found that the personnel understands the residents’ well-being as being characterized by feeling of being existentially touched. This essence is constituted by feeling freedom of choice, pleasure, and closeness to someone or something. In Paper II, the work for facilitating this kind of wellbeing was characterized by three ambiguities: (i) freedom of choice for the older persons vs. institutional constraints, (ii) the residents' need for activation vs. wanting not to be activated, and (iii) the residents' need for routine vs. the eldercarers' not being able to know what the residents need. Paper III showed that the care unit manager created a hybrid of the two logics (economy is care and vice versa) and that the personnel oppose this hybrid. The opposition is shaped as the personnel divides their work in care and “those other things”. These findings showed how interaction between the logics expresses itself in practice and that it is the personnel who has to handle contradictions between the logics in their everyday care work. The positioning analysis in Paper IV had three levels. The first level showed how the carers align with their peers and that they find the organizational frame, within which they have agency, changed due to increased workload. This change led to an order of priorities. The second level showed that the carers relate to three aspects when making accounts: the care itself, the older persons, and the media. The third level showed that the carers share a view of administration, cleaning, serving meals, and filling up supplies, as not being parts of caring.

The dissertation’s theoretical framework focused on theories on logics, accountability, and professional identity. The conclusion is that both logics are needed in order to facilitate the well-being of the older persons. The relationships between the two logics are not always clear and if their contradictions are not illuminated, there is a risk for a care practice that does not facilitate the well-being of their residents. An important theoretical contribution is that logics of activities should be understood vertically (form political, through management, and down to the level of practice) instead of horizontally. The practical implications emphasize the importance of supporting the personnel’s professional identity on the one hand, and discussing the logics on the other. By understanding differences between definitions on management-level and practice level, a homogeneity can be reached.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2016. , 74 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 76
Keyword [en]
Eldercare, personnel, logics, accounts, professional identity, qualitative method
National Category
Health Sciences
Identifiers
URN: urn:nbn:se:hj:diva-34198ISBN: 978-91-85835-75-1 (print)OAI: oai:DiVA.org:hj-34198DiVA: diva2:1052284
Public defence
2017-01-13, Insikten, Portalen, School of Health and Education, Skövde, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-12-15 Created: 2016-12-06 Last updated: 2016-12-06Bibliographically approved
List of papers
1. Feeling existentially touched - A phenomenological notion of the well-being of elderly living in special housing accommodation from the perspective of care professionals
Open this publication in new window or tab >>Feeling existentially touched - A phenomenological notion of the well-being of elderly living in special housing accommodation from the perspective of care professionals
2013 (English)In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 8, 20587Article in journal (Refereed) Published
Abstract [en]

This article presents a phenomenological analysis of interview material, in which 12 care professionals in elderly care reflect on the elderly's well-being within the frame of special housing accommodation. The perspective of the care professionals is of special interest. The findings show that the well-being is characterized as the elderly's feelings of being existentially touched. The well-being is an existential experience of being acknowledged as a human being and is an approach that classifies the elderly's needs as those of having, loving, and being. The meaning of the phenomenon is elucidated by the constituents: (1) to feel the freedom of choice, (2) to feel pleasure, and (3) to feel closeness to someone or something. The findings contribute new understanding of well-being in the elderly care by its existential dimension of the well-being as "just being'' and of doing things in order to experience meaningfulness. Accordingly, the well-being of the elderly as it is seen from the perspective of the care professionals involves both carers' subjectivity and intersubjectivity between the care professional and the elderly. An implication for promoting elderly's well-being is to develop awareness of these existential dimensions.

Place, publisher, year, edition, pages
CoAction Publishing, 2013
Keyword
Well-being, phenomenology, elderly care, lifeworld, lived experience, existentially touched
National Category
Social Sciences
Research subject
Humanities and Social sciences
Identifiers
urn:nbn:se:hj:diva-34192 (URN)10.3402/qhw.v8i0.20587 (DOI)000317964600001 ()23601762 (PubMedID)2-s2.0-84878910405 (Scopus ID)
Available from: 2013-10-24 Created: 2016-12-06 Last updated: 2017-11-29Bibliographically approved
2. Witnessing presence: Swedish care professionals' experiences of supporting resident's well-being processes within the frame of residential care homes (RCH)
Open this publication in new window or tab >>Witnessing presence: Swedish care professionals' experiences of supporting resident's well-being processes within the frame of residential care homes (RCH)
2016 (English)In: Journal of Aging Studies, ISSN 0890-4065, E-ISSN 1879-193X, Vol. 37, 1-9 p.Article in journal (Refereed) Published
Abstract [en]

The purpose of this article is to analyse the phenomenon of supportive care for older persons' well-being. The phenomenon is seen from the eldercarers' meaning-making through their lifeworld perspective at a residential care home. Based on primary empirical interview material with twelve professionals in the context of Swedish eldercare, a phenomenological analysis was undertaken. The result shows that the phenomenon of supportive care for older persons' well-being creates certain ambiguities in the professionals' meaning-making. In practice, it balances between the older persons' (from hereon called residents) needs and the conditions of the eldercare organization. The ambiguities (the what) is made up by three constituents: (i) freedom of choice for the older persons vs. institutional constraints, (ii) the residents' need for activation vs. wanting not to be activated, and (iii) the residents' need for routine vs. the eldercarers' not being able to know what the residents need. The conclusions drawn are that this ambiguity has consequences for the eldercarers' choice of handling supportive care for older persons' well-being (the how). They have to navigate between the support for authenticity, dwelling and mobility, and their own presence and time. In performing supportive care for older persons' well-being, the eldercarers have to consider aspects concerning the resident's lifeworld, the social setting of the eldercare ward, and the institutional demands of the organization. The practical implications for supporting well-being in the care of older residents are manifested in the importance of 'the little things', and the eldercarer's ability to give receptive attention, which requires presence.

Place, publisher, year, edition, pages
Elsevier, 2016
Keyword
Supportive care, Well-being, Lived experience, Care professionals, Residential care home
National Category
Health Sciences
Identifiers
urn:nbn:se:hj:diva-34193 (URN)10.1016/j.jaging.2016.01.001 (DOI)000376704700001 ()27131273 (PubMedID)2-s2.0-84960873221 (Scopus ID)
Available from: 2016-06-27 Created: 2016-12-06 Last updated: 2017-11-29Bibliographically approved
3. Economizing care – Governing institutionalized logics at a public nursing home
Open this publication in new window or tab >>Economizing care – Governing institutionalized logics at a public nursing home
(English)Manuscript (preprint) (Other academic)
National Category
Health Sciences
Identifiers
urn:nbn:se:hj:diva-34194 (URN)
Available from: 2016-12-06 Created: 2016-12-06 Last updated: 2016-12-06
4. To do or not to do: Problematizing accounts made by carers (not) prioritizing care tasks as the work load increases
Open this publication in new window or tab >>To do or not to do: Problematizing accounts made by carers (not) prioritizing care tasks as the work load increases
(English)Manuscript (preprint) (Other academic)
Keyword
Social work, narrative approaches, self, positioning, dominant cultural storylines
National Category
Health Sciences
Identifiers
urn:nbn:se:hj:diva-34196 (URN)
Available from: 2016-12-06 Created: 2016-12-06 Last updated: 2016-12-06

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