7.2 Construction of Caring Identities in the New Work Order

Zoe Nikolaidou and Anna-Malin Karlsson

Södertörn University

In the last ten years, the elder care sector in Sweden has undergone significant changes. Following a general pattern in the market, nursing and retirement homes have changed from being administered by local authorities to becoming private institutions. In private care facilities, the elderly and their relatives have become customers selecting a care provider from a large number of competitors. As a result, elder care has become a marketable product and new practices have been introduced to assist this transformation.

Documentation has emerged as a useful tool for ensuring the quality of services and is given a dominant role within care facilities. In line with the social welfare law (SoL) in Sweden, caregivers and assistant nurses document the elders’ lives, focusing on the social aspects of their lives. The digitalization of documentation has raised concerns about issues of computer literacy, staff education and allocation of time. Whether documenting electronically or on paper, documentation is often experienced as external and imposed. According to a report from the Stockholm Gerontology Research Center, documentation is considered time-consuming and unrelated to the practice and ideals of caring (Norrman & Hedberg, 2010, p. 44).

We understand these practices as a result of socio-economic changes, new technologies, and new workplace ideologies, which form part of the “new work order.” In this article we examine, first, how new institutional documentation practices influence the care-workers’ identity construction and, second, how the care-workers negotiate these new practices. Relevant for this study is the new role given to workers as individuals with great responsibility at work and the dominant role of texts. Extended workplace documentation and its impact on workers’ social practices and identities has been an ongoing issue in a number of workplace ethnographies (e.g. Iedema & Scheeres, 2003; Karlsson, 2009; Searle, 2002). A number of these ethnographies are concerned with literacy practices within medical care (Alexander, 2000) and elder care (Cuban, 2009; Wyse & Casarotto, 2004). Such studies have shown that documentation demands have partly resulted in genres such as checklists. However, the directive from the social welfare law to document “actual circumstances and meaningful events” calls for additional genres, where a less patterned kind of writing is required. In this article, we focus on one such genre: the resident’s journal. By discussing the care-workers’ attitudes to the content and language of the journal, we show how the different kinds of knowledge and work-identities are handled and formed in connection with documentation practices.

The project participants¹ are caregivers and assistant nurses in a retirement home and a nursing home. The retirement home is run by the local authorities and is organised in two large wards. In total, it hosts 94 apartments, with staff offices on the ground floor. The care-workers visit each resident daily, providing care according to the resident’s care-plan. The nursing home is a privately owned institution with a total of 96 rooms divided into ten smaller wards. In each ward, there are seven to nine residents and approximately seven staff members working in shifts. Most care-workers work in the same ward and with the same residents for many years.

In this ethnographic study of the care-workers’ literacy practices, data collection methods include participant observation and individual and group interviews. The research participants were chosen randomly, based on their availability and interest in the project. Out of the total 24 research participants, 20 were born outside of Sweden and Swedish is their second or third language. This selection is representative of the working population in Swedish nursing homes. Similarly, the majority of the participants were women, with only two men participating in the study. The gender distribution of the population reflects older views of the care profession as a traditionally female one and a development from earlier phases when women were doing similar unpaid work at home (Törnquist, 2004). All care-workers started working as caregivers, a work role that until recently demanded no special training. Some of them later registered in vocational courses and advanced to assistant nurse, a more demanding role that calls for specialized knowledge. However, in both research sites, caregivers and assistant nurses shared the same work roles and tasks.

The Individual, the Professional, and the Institutional

Research has shown that the care-workers’ professional knowledge can be divided into education-based knowledge and experience-based competence (Törnquist, 2004). A significant part of the skills within care-work are associated with what might be called everyday knowledge. This could also be the reason why care-work has historically not been sufficiently valued as a profession (Törnquist, 2004, pp. 14-15). Experienced-based knowledge within care-work is, to a large extent, not verbally expressed. For example, in home care the careworkers work in solitude and have built up their knowledge without communicating it to someone else (Törnquist, 2004, p. 41). In the past, research on nurses’ work knowledge tended to use terms such as “tacit knowledge” or “language absence,” implying that a distinct, precise and scientifically-based register does not exist within the field (e.g., Josefsson, 1991, pp. 34-37). Today, being a nurse is an academic profession and nursing is an established scientific field. We believe, though, that the difficulties with creating and establishing a scientific language have moved downwards in the hierarchy and are now relevant to the work performed by care-workers. We choose not to talk about “language absence” in absolute terms. Instead, we suggest that care-work consists of various kinds of knowledge, discourses, and identities. Törnquist (2004) makes a distinction between three aspects of care-workers’ professional competence: the first is related to formal education, the second to professional skills and the third to individual competence. The three aspects represent different reference frameworks of knowledge, the most obvious being the one related to formal education. Professional skills are defined as the skills and knowledge considered necessary by the care-workers in order to accomplish their tasks (Törnquist, 2004, p. 208). Individual competence refers to the care-workers’ character and personal experiences (Törnquist, 2004, pp. 211–212). These categories can be compared to the institutional, professional and personal discourses, which are identified based on interactional grounds by Roberts and Sarangi (1999, 2003).

Theory, Method and Central Concepts

The project’s theoretical and methodological framework originates from the field of New Literacy Studies (Barton, 2007; Gee, 1996; Street, 1993), where reading and writing is considered as situated in specific contexts: in events and in practices. As a result, the focus is not placed upon individual competence, but on the frameworks, norms, roles and traditions of a literacy practice. The most important analytical tool when analyzing data from observations is the literacy event (Barton, 2007; Heath, 1983). Literacy events instantiate cultural conventions associated with the use of reading and writing or they instantiate literacy practices. These practices should be understood as abstract patterns that also include norms and evaluations.

The situated nature of literacy practices associates them with identity construction. This is particularly true when looking at identity as situated and manifested in our interaction with other people and social practices (Gee, 2001). In this chapter, parallel to institutional, professional and personal discourses, we are going to talk about institutional, professional and individual work-identities. The institutional identity is the one we adopt through our position in an institution. It can also be manifested discursively, for example, when expressing oneself according to institutional rules. A professional identity is constructed together with colleagues in the same workgroup. This identity can also be manifested discursively, through referencing the group’s norms and routines. The professional identity is, to a larger extent than the institutional identity, based on belonging and participation in a common practice. Finally, the individual identity is based upon personal experience, for example, on the manifestation of one’s individual qualities.

There is reason to believe that there is a differentiation between the institutional, the professional, and the individual identities of care-workers. The difference between the two latter is more obscure, since a part of the care-worker’s professional skills are based on individual experience. When analyzing the employees’ texts and interviews, we take into consideration the extent to which they refer to the group or to colleagues, as well as to their personal experiences and life outside the workplace. We consider those occasions when the individual and the professional are merged as an interesting result of our analysis.

The Problematic Journal

The resident journal is indeed one of the most problematic texts in the elder care facilities. The employees are asked to free-write about significant events in the resident’s life (though not on a daily basis). The care-workers do not often have a clear understanding of who will read these journals. Some of them believe that the journals are read only by staff, while others, like the employee in the following interview extract,² believe that the resident’s relatives, the supervisor, and the nurses can also read the journal:

Z: But it’s just your colleagues that read it, right?

Employee: No, the supervisor can read this, the relatives and then the nurse, they can read it, so it’s not just my colleagues, a lot of people are involved.

We will examine here how the journal as a genre offers possibilities for identity construction. The focus will be on the way the employees navigate between institutional, professional and individual discourses. We discuss the care-workers’ understanding of what should be written in the journal, and then continue to examine different ways of writing.

Deciding on What Should Be Documented

A first step in documentation is to distinguish between what is relevant and useful to be included in the journal. In a group interview, the care-workers discussed what it means to document only significant incidents. They argued that “significant” refers to events that deviate from the norm. This means that when reading the following entry, “She ate lunch with everyone else in the kitchen … she was in a good mood today,” the reader would assume that the resident usually eats food in her room and that she is often not in a good mood. For the same reason, the employees agree that they should not include in their writing routine events, such as showering—but they should write if someone refuses to have a shower. At the same time, they believe that there is value in writing down positive experiences, for example when a resident plays bingo. As one of the participants said: “it is about quality in their lives …, it’s not just eating, sitting, they also do activities.”

The decision of what information to include in the journal is an overarching dilemma. Resistance to documenting the routine events can be connected to an institutional discourse where the focus lies on communicating information effectively and avoiding documenting unnecessary data. At the same time, the care-workers express a wish to document activities related to the quality of the residents’ lives. This can be connected to a more individual discourse, but it can also be interpreted as a part of the employees’ professional conduct.

In the group interview, it was stated that care-workers are not responsible for writing down medical information. The sentence “coughs a lot and sounds wheezy,” found in a resident’s journal, is considered by an interviewee to be an acceptable comment, since it deals with what the care-workers can see and hear and is not a medical interpretation. Interestingly, some care-workers do include medical details in their journal entries. We interpret this as the result of a new or extended professional identity construction, mainly from the assistant nurses, who possess medical knowledge and find it unprofessional to omit writing significant medical observations.

Not making interpretations is in line with a restrictive stance that is often expressed by the care-workers. They talk about “not writing what one thinks” and “not painting a picture” of what they can only guess. An example discussed in the group interview was a resident who had a fight with his son. The participants agreed that such events should not be included in documentation. “I know nothing about their situation,” says one of the care-workers. Any problems between the residents and their families lie outside of the care-workers’ responsibilities and any concerns should be discussed with the nurse.

In the above examples, the care-workers assume an institutional identity. They place themselves in a hierarchical position where they have limited responsibilities and authority. When in doubt, it is better not to write at all. In the interviews, this is explicitly mentioned as a problem more than once. One of the assistant nurses says: “Honestly, it is stupid not to be able to write what has really happened.”

What should be included in documentation is also connected to a division of functions between oral and written form. Information that cannot be written can be orally reported in a report meeting or in the corridor between colleagues. In the case of oral reporting, the institutional restrictions are fewer and, therefore, this type of communication is experienced as more effective. It can be argued that in the report meetings, the care-workers construct mainly their professional identity. For instance, during a report meeting, a caregiver describes an encounter with the resident’s angry daughter and the negative impact of this encounter on the resident. This kind of information is not included in the resident’s journal. Even though it would be useful information for all the care-workers to know, including it would violate the restrictions around written documentation.

In some instances, the care-workers choose to discursively construct their professional identity in the journal. They write entries where they relate to their colleagues and document what they consider as important information, regardless of the institutional guidelines. The following extracts are taken from journals and they include information of what, according to some participants, should not be included in official documentation:

She fights a lot when given care.

He was very disagreeable, threatening and screamed really loud.

He spread poo all over the place on the bed, toilet, clothes, on the body.

This contradiction suggests that the institutional and the professional workidentities are, in a way, opposing each other. It is also clear that the individual identity is rarely manifested in written documentation. Writing about feelings and individual experiences with the residents is unthinkable. In one of our observations, a caregiver comes back from a resident and is very upset because of a racist comment. The caregiver chooses not to document the incident and does not report it in any other way. In similar cases, the employees claim that they should not be insulted by the residents’ behavior, since it can be justified by their health circumstances. The employees’ individual needs are repudiated in favor of their decision to maintain a professional stance, and the choice not to write, based on their professionalism, overlaps with the institutional instructions.

When the residents’ feelings are in focus, the individual and the professional identity of the care-workers overlap. In the group interview, the participants discussed whether they should write down a resident’s weight. One resident had privately asked the care-worker, after being weighed, not to include her weight gain on the documentation form. The care-worker followed the resident’s wish, but she orally informed her colleagues and the nurse. The choice not to write is based upon her individual aspect of identity, in an effort to show solidarity with the resident. The fact that the care-worker later informed her colleagues is related partly to the professional and partly to the institutional aspect of her identity. One of the interviewees confirmed the professional aspect by saying that they need to report completion of each task so that their colleagues will not have to repeat it. The institutional aspect is expressed by reporting back to the nurse.

Different understandings of the journals’ potential readers play an important role in the employees’ choices of what to document. The idea that the relatives may read the journal is often a reason for restrictions in writing. One assistant nurse believes that the journals do not depict reality. She argues: “If they want us to lie, then we will lie.” With “they,” she refers to the institution; the employee here shows how she adjusts to the institutional demands. The word “lie” indicates what she really believes about the situation. Another care-worker says that they often choose not to document some incidents because it is difficult to abide by the institutional demands, that is, to write with “fine words.”

The Correct Way of Writing

“Sometimes it is difficult to find fine words in order to describe a situation. We don’t know what we should write.” This is how a care-worker describes the problem of correct writing. In the interviews, the employees argue repeatedly that they must document with respect for the residents. Using “fine words” can be linked to the social welfare law (SoL), which clearly states that documentation should protect the individual’s integrity. Respect and integrity are also emphasized during documentation training, as well as in language courses for staff in Swedish as a second language. Thus, the main problems faced when writing journal entries have to do with finding the correct language and perspective. The care-workers discuss in the interviews, as well as amongst themselves, the balance between the individual and the professional experience, between the human truth and the respectful distance:

Employee: It is not possible to write how as stupidly as one wants. “Poo” or I don’t know what, there should also be some finesse and this is the hardest part. We should write but it should not be derogatory, it should be a nice documentation.

Z.: So when you say finesse do you mean which words you should use?

Employee: Yes, that we cannot just write, like I said, “very angry” or those unnecessary, strange, I don’t know how to say it … as I said finesse … it will not be derogatory for the resident, it is them we work for so it’s difficult when it comes to language because it is important to describe events exactly as they happened.

In another interview, an assistant nurse talks about the struggle to find a professional language that is relevant to his job. He looks for this professional language in the medical world, where it is possible to use specialized vocabulary:

Z.: I have heard from other colleagues … that you cannot use everyday words. Is that also a problem?

Employee: Yes, exactly. Because each work area has its own language. I’ve seen how they document at the hospital. They don’t need to write like a story, it should be short and concise and then comes the next person who will read it and they understand exactly what it’s about. But here it’s very mixed. People who have had a bit more education, others who haven’t, so it can be difficult. For example, if someone wants to write “blood pressure,” they can write BP and an upwards arrow and this means high blood pressure. There are people who have difficulties understanding this.

The same person discusses the issue of correct language in relation to time and effectiveness. He does not refer to the institutional frameworks, but to himself as a professional and the way he wants to see documentation develop according to the work needs. Brevity and conciseness are ideals related to collegiality and, by talking about them, the care-worker expresses the professional aspect of his identity:

Z.: Does it take a lot of time?

Employee: Sometimes. Not much time but it can be good to think that it’s not just me reading this, so I should formulate it as good as I can. To try, you know, to find words that are easy to understand and then try to limit my documentation as much as possible, because if it’s long then it can be boring, so you need to be short and concise.

A clear pattern here is that some assistant nurses (as opposed to the caregivers) instantiate discursively a professional identity that leans towards the medical direction. One assistant nurse continuously writes down medical details in the journal:

I discovered that she had two plasters of 25mg matrifen on the right shoulder and one on the left side of the upper back.

She is given penicillin Kåvepenin …

These assistant nurses anchor their professional skills to their formal education, both in their (discursive) practices and in the interviews. The opposite happens when a caregiver discusses her professional skills as based on her individual experience. Here, she answers a question about her previous education:

Employee: The usual education and I had, how can I say, classes at school, on needlework, women’s manual work, painting.

Z.: For how long?

Employee: All my life, we are a big family and we work together and we learn from each other and then pass it on to the children.

Z.: So it’s more experience than education?

Employee: Yes, yes, exactly.

The same caregiver has different ideas regarding writing in a short and concise manner. She would rather write longer and more complete journal entries, but language restricts her:

It is very important for me to write exactly as it is, not just short words, cohesive stories I can’t do that, I cannot write many stories because they are very wrong. It just doesn’t work.

The caregivers and the assistant nurses belong to the same staff group and have similar tasks, while at the same time they orientate towards somewhat different identities. This indicates the complex nature of care-work and shows that a professional care identity can be related to both formal education and everyday experience. In both cases the care-workers’ feelings and integrity do not play a central role when the professional identity is manifested in writing. We witnessed no journal entry describing a resident’s cruelty or a care-worker’s degradation. This may explain why it is not allowed to include expressions like “aggressive” in social documentation, since the word describes the employee’s experience and interpretation and is therefore not an objective comment.

Final Discussion

The overarching question in this chapter has been how a traditionally practical profession, based, to a large extent, on experience-based skills, is influenced by the introduction of new work practices and by the increasing role of literacy. A question related to this is how different aspects of nursing knowledge are shaped and reshaped through the employees’ writing practices. We have set out to answer these questions by studying the care-workers’ everyday work and literacy practices. This has given us ground to talk about different work-identities that are related to different uses of writing.

Based on earlier research on care work (Törnquist, 2004) and on discourses in medical care (Roberts & Sarangi, 1999, 2003), we have introduced three aspects of work-identity: institutional, professional and individual. The demand to document at the workplace has promoted an institutional expression of identity. At the same time, the journal as a genre has a free form and allows for a possible inscription of other identity aspects.

The institutional aspect is dominant, mainly in relation to the individual. Writing personal reflections is not allowed, and it should be noted that there is no genre in the social documentation system where the care-workers’ experiences can be included. Thus the institutional aspect appears to dominate over the professional. This leads employees to turn to oral communication when passing on collegial knowledge.

In our understanding, this inherent conflict explains many of the difficulties that the care-workers in this study experience: the social in the care sector appears to have elements of the “language absence” discussed by Josefson (1991). We argue, therefore, that it is difficult to write the social within the framework of documentation. This is tied up with institutional literacy’s demand for objectivity, neutrality and (relative) context-independence. There are many possible readers and many possible interpretations. The need for writing in a “fine,” respectful way is, in the worst case, restrictive. The fact that the care-workers avoid writing, or choose to “lie,” points to a constraint in developing a functional professional literacy, a literacy that would actually serve to facilitate their colleagues’ work.

In the new work order, even traditionally public services are exposed to competition and various types of evaluation and comparison. The minor role of the individual aspect of writing can be interpreted as an attempt to standardize the employees’ language and the content of their documentation. By restricting social documentation by restricting the use of certain words and phrases and by not permitting any input of a personal nature, it is possible to ensure that all entries in the logbook are similar to each other and do not deviate from the norm. Indeed, a large number of the entries in the texts we have analyzed are repetitive and sometimes even identical. This is in contrast to the more general philosophy behind social documentation, which asks for personalized documentation.

Such standardization processes are in line with quality assurance measures, found today in the private sector, which demand documenting compliance and standard operating processes (e.g., Defoe, 2004; Jackson, 2000). The fact that the eldercare sector follows such a policy line is not a surprise, since one of the two nursing homes in our research has recently been privatized. In this facility, the future aim of social documentation is that the residents’ relatives will have online access to their relatives’ journals. It is possible, therefore, that the nursing home’s management must make sure that all documentation entries are standardized and more importantly, that all entries testify to the elder’s well-being and quality of life in the specific home, just as initially advertised. It is important, therefore, that the care-workers document efficiently, present a positive image of life in the nursing home, and place emphasis upon the resident rather than upon themselves and their own experiences.

Taking all this into consideration, one must ask whether it is possible to marry the social care ideal with the ambition to be marketable. It becomes obvious that one of the two factors needs to be sacrificed for the sake of the other. The impact that such a sacrifice has had for the development of workplace literacy practices is significant. In the past, literacy was a useful tool in the hands of care-workers; they could effectively communicate and construct a common professional identity through it. Now, however, literacy events are of an institutional nature and are often restricting the employees’ work practices. Whereas workplace texts had an internal and temporary character, and were generally disregarded by institutional regulations, they are now put in the service of marketing and are therefore given a dominant role. The texts are no longer written in the intimate professional or personal discourse, but are underpinned by an imposed language of an institutional nature. The care-workers are forced to change their old practices and follow the new discourse, making sacrifices with regard to the content and the quality of the services they provide. What remains to be seen is whether the new private sector will detect the possible inefficiency of the documentation system and therefore introduce new practices, or whether the care-workers will adjust their work practices even more to meet the existing demands.

Notes

1. The study described here is part of a larger project under the name “Care work as language work: Affordances and restrictions with Swedish as a second language in the new work order.” The project is formed by two parts, one focusing upon oral interaction and the other upon written communication within the elder care sector. This chapter reports on the initial phase within the written communication study.
2. All interview extracts and examples have been translated from Swedish.

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