Tinkering with care values in public and private organizations

Citation

Oute, J. and Rudge, T. (2019), "Tinkering with care values in public and private organizations", Journal of Organizational Ethnography, Vol. 8 No. 3, pp. 245-252. https://doi.org/10.1108/JOE-10-2019-077

Tinkering with care values in public and private organizations

This special issue develops from discussions and papers presented at the Annual Ethnography Symposium in 2017 and aims to gather ethnographies on how care values intersect with service organizations, welfare policy and varying views of good professional practice in private and welfare institutions. It zooms in on the growing cross-disciplinary interest in the values of care for the ill, unwell and unhealthy or disabled in industrialized societies. The issue takes up the well-known but far from trivial debates about how bureaucrats, professionals, students, users and families often represent and face competing requirements and approaches to care in organizations informed by different values and ideologies. Yet, the ideological or value-laden underpinnings of care in organizations often remain less clear in organizational studies, nursing research and in social studies in medicine and social work. Questions of value lie at the heart of debates about the organization of current welfare systems, provision of care services and the architecture of future societies. This transpires, for example, in recent contributions to Journal of Organizational Ethnography on meaning making in acute nursing care practices (Lake et al., 2015), in studies of health care reform and patient and public involvement (PPI) (Glasdam and Oute, 2019) and in studies of volunteering and ethnographic conduct (Garthwaite, 2016).

Values are embedded in the contemporary calculus of health and social care provision in many different forms (Rose, 1999, 2007): the financial value of contracts for health or social care services; consumerist values and the commercialization of help seekers (Mol, 2008; Mol et al., 2010), ethical values located in standards and guidelines which regulate clinical practice (Huniche, 2011), and moral values, through which dilemmas and discrepancies are experienced by professionals (Mattingly, 2014, 1998). Albeit invisible and/or taken-for-granted these kinds of different orders of worth are not only deeply rooted in the political requirements that underpin care in organizations, such orders also shape reform and the very organization of welfare services. Moreover, the entanglement of different sets of values also form a background for professional-user relations, recruitment of staff, care education and professionals’ feelings and at times limit users’ access to services at street level. In response, we need ethnographic work that disentangles what care values “do” in care organizations and bring to light how they are made to work, negotiated and resisted by actors in everyday practice. The issue thus aims to elucidate such themes that are often hidden in the intersections between ethnographic, organizational and health care journals. The issue focuses on the taken-for-granted values, ideals and ideologies located in the practical realities of care giving and receiving across a range of contexts.

Organizational ethnographies on care values

This issue features six international ethnographies from comparable contexts such as the USA, UK, Canada and Denmark. The papers rely on a variety of analytical gazes such as a Foucauldian notion of discourse and knowledge (Foucault, 1992), Mol’s (2008) concept of logics of care, Latour’s (1999) Actor–Network theory (ANT), Hochschild’s (2012) work on emotional labor and Lipsky’s (2013) work on street-level bureaucracy. Empirically, the papers are based on fieldwork in a number of both private and public organizations. As featured, these varying empirical contexts include cancer support businesses, care for older persons with potential for functional decline, daily social work, mental health-, employment- and drug treatment systems, nursing recruitment at universities and clinical education in hospitals. However, one could argue that the papers consider a remarkably homogenous issue. In spite of their vast analytical and empirical differences, they cast light on the tensions, collisions and negotiations of incommensurate care values in organizations and their social effects.

The article entitled “Making work visible in a cancer support business” (Anderson and Jorgensen, 2019) sheds light on the work that breast cancer support staff perform in the USA. Based on open-ended interviews and observation of staff-customer interaction, store activity and the physical setting, the study illuminates how individuals whose work is located in the nexus of business and medicine negotiate potential contradictions and how this positions them within professional hierarchies. Anderson and Jorgensen analyse how staff balance image enhancement with comforting care in a non-medical space. In conclusion, the authors argue that cancer support businesses represent a kind of medical-commercial organization that constitutes certain challenges for staff members and patient-customers. In this setting, the paper recommends the development of more comprehensive care for surgical patients within, as well as outside, comparable health care systems in the USA and beyond.

In the paper entitled “Logics of care in clinical education” (Lehn-Christiansen and Holen, 2019), the authors discuss how contemporary Danish health care is grounded in different values. The authors use Mol’s work on logics of care and the notion of tinkering to disentangle the fluid and value-laden practices that constitute care in the Danish health care system. They assert how nursing students, or at least their educational practices and professional identities, are shaped by different logics of care when acquiring competencies to provide care in clinical placements. The paper is based on observational- and interview data drawn from a large scale qualitative study where they follow 40 nursing students throughout all clinical elements of their study program. In the analysis, the authors identify three overall logics of care: the logic of relational care, the logic of care education and the logic of care production. Whereas the logic of production and the educational logic seem to be dominant and mutually reinforce each other, the logic of relational care remains subordinate in daily educational practice. On this backdrop, the authors argue that the struggle over the very idea of good care reflects a case of the overall struggle over care values in Danish health care systems. They argue that it forms a background for future challenges in nursing and health care more generally. In conclusion, the paper suggests that this ideological struggle and subordination of relational care in the education setting brings about an inhibition of future recruitment of nurses, make it increasingly difficult to keep nurses in the health care workforce and slowly devalue non-specialized, basic and person-centered care.

The paper entitled “Ethnographic reflections on access to care services” (Oute and Bjerge, 2019) takes its empirical point of departure in a multisited ethnographic field study of the management of citizens with complex problems in Danish welfare systems. Using Lipsky’s work on bureaucratic service regulation as an analytical lens, the authors investigate how gatekeepers’ ways of regulating the researchers’ access to knowledge in/about care services reflect the systemic and interpersonal values that inform Danish welfare systems’ daily workings. Moreover, they explore how the authors’ methodological experiences mirror or compare to the value-informed regulatory strategies that professionals and users experience in their daily encounters in the same local practices that the authors have studied. By doing so, the authors analyze how their own and informants’ experiences reflect three sets of value-informed strategies used to regulate access to care in care organization: “Gatekeepers’ sympathy and creaming,” “Queuing and delay,” and “Withdrawal of consent and ‘no resources.’” The analysis suggests that trust, shared goals and sympathy seem to be key to the process of getting access and elucidates the political-professional conditionality of access to care services. Although seeming trivial, this insight begs the question whether or how the professionals’ informal values and personal preferences can outweigh political requirements and users’ legal rights to services in care organizations.

In the article on “How care values as discursive practices effect the ethics of a care-setting”, Moreau and Rudge (2018) examine how care values permeate, legitimize and authorize hospitalized-older-adults’ care, technologies and practices in order to put on display how values establish certain orders of worth with significant effect on the ethics of the care-setting. Drawing on a Foucauldian notion of discourse and knowledge, the authors analyze data from participant observation, interviews, chart reviews and reviewed literature to understand how values frame care situations for older-adult-patients classified with a potential for functional decline. The analysis reveals how value-laden articulations of measurement, efficiency, economics, risk and functional decline as equivalent to loss of capacity for independent living pervade care technologies and practices. The authors show how these practices subjugate older adults’ bodies to governmental techniques and how these technologies turn older patients into measurable objects of knowledge. As such, the paper reveals how dominant care values inform technologies and practices that aim to govern hospitalized older patients as a population that elide the possibility for professionals and those in need of care to engage in person-centered care.

The paper entitled “The practice of selecting for values in nursing” (Klingenberg and Pelletier, 2019) is based on observations of a selection events at three UK universities and interviews with academic staff, administrators and service users and carers. It investigates the range of methodological resources available for research on values-based selection by examining how selection processes play out in practice. In order to analyze how interactions and negotiations between the selectors, applicants and various materials deployed during the interview processes bring certain “personal values” in selection of nursing students into effect, the authors draw upon principles from ANT. In the analysis, the paper unfolds how informants talk about heroism and exclusivity and how selectors articulate applicants when talking about themselves and their relation to the socio-material backdrop of selection for values in recruitment. The presentation of the themes puts on display how care values are not static but extra-individual products of the processes of ever-changing interactions between actors in the field. This insight begs the question of recent political attempts to develop a “quick fix” to the problem of professional culture in nursing by highlighting the need to re-introduce the complexities delineated in the dominant discourse on values-based recruitment.

Based on observations, interviews and professionals’ written accounts derived from an ethnographic fieldwork at an English social work department, the paper entitled “Bring yourself to work”: Rewriting the feeling rules in “personalised’ social work” Whitaker (2019) investigates how feeling rules are constructed, experienced and contested in daily social work practice. Concentrating on the “backstage” of the organization, the author considers how the management seek to shape practitioners towards certain forms of emotional display in increasingly market-oriented conditions and on how professionals respond. In bringing Hochschild’s work on emotional labor to the analysis, the author suggests how the notion of bringing yourself to work reflects a value-laden talismanic figure for the organization which emerges through the processes of personalization as rupture, disciplining and auditing the feeling rules and frontline staff members’ responses to such a belief system. The paper displays the emergence of tensions between traditional bureaucratic function, the incursions of the market and feeling rules of relatability, commitment and creativity. With this analytical background, the paper concludes by considering how relational and interactive exchange in practice is not only commodified but that affective connections seem ready-made for audit, managerial assessment and regulation.

Taken together, the conclusions and considerations raised in this issue represent a number of interconnected themes. The papers illustrate that the study of care values is not limited to certain professional practices, such as nursing, drug treatment or social work. The papers also highlight that care values “do” something in practice despite often playing an unacknowledged role in daily care practices. It implies that values tend to shape how some actions can be seen as meaningful while also other actions are considered less meaningful. Another theme emerging throughout the selection of papers is concerned with the overlaps, exchanges, tensions or conflicts between different and at times antagonistic value-laden care practices. The theme emerges through the papers’ illustrations of the, often, strained relationship between incommensurable sets of values. On the one hand, the papers reveal how commercial, productions-oriented-, bureaucratic- and political notions of good care play a pivotal role in daily care practices. On the other, the papers show that despite the previous emphases, professionals and user or customers often, if not always, view relational and humanistic forms of care as a cornerstone in care organizations. This also touches upon a further theme reflected in the papers concerned with the dominance of practices informed by commercial-economical rather than humanistic-relational values in care organization. Finally, the papers are concerned with the effects of value-laden technologies and practices and in particular, the kinds of limitations these relations bring into effect for actors in the field. The analyses of the processes of personalization and emotional labor, responsibilization, de-legitimization of basic care and devaluation of person-centeredness in care organizations point to a similar effect. They illustrate how the technologies and practices that combine economically or politically driven care with humanistic-relational values tend to blur the lines between the state/organization and the individual/personal as well as lessening the difference between the commercial and private in favor of the state or the business.

Conceptualizing value-informed practices in care organizations

These themes point to how care values are ambiguous concepts. The very notion of value often refers to cost-effectiveness or how the idea of value is applied purposefully (Moreau and Rudge, 2018; Wegner, 2016). However, values need not be explicit or strategic. Rather they are often articulated rhetorically or discursively. They are embedded in how problems, purposes and solutions are talked about, used in practice and represented in policy (Bacchi, 2009; Oute and Bjerge, 2019). Across the different contexts and situations that have been scrutinized in this issue, values emerge through competing discourses, logics, managerial technologies, policies and regulatory strategies that structure experience and frame care practices in both private and public organizations. This implies that bureaucrats, academics, administrators, professionals, drug users and students might intentionally or un-intentionally articulate and legitimize certain ideological and value-laden practices through their talk, writing and action that have a significant impact on their possibilities to care (Mol, 2008; Laclau and Mouffe, 2014; Glasdam and Oute, 2019). Rather than care being a matter of actors’ personal choice, value-informed care is thus socially (ideologically, politically, professionally, etc.) contingent. The intentional or unintentional emphasis of specific ideologies and care values has powerful effects on the transformation or continuation of care practices in organizations in line with those conditions of care.

On a critical note, one could argue that this is hardly breaking news. The social contingency and transformative potential of values in and outside of care organizations is already well established in, for example, Mol’s (2008) work on logics of care, Foucault’s (1992) work on discourse, knowledge and subjectivity, Rose’s (1999) work on rationalities and Laclau’s and Mouffe’s (2014) work on ideology and radical democracy. This literature tends to emphasize that values and ideologies are not individual. They are extra-individual. In this overarching perspective, the different value-laden articulations of care and the value-informed care practices described in this issue suggest that care is normative per se.

However, that insight does not really add many new insights either. To name a few, political and medical anthropologists (Però et al., 2011; Shore and Wright, 1997; Mattingly, 2014; Kleinman, 1991), micro-sociologists (Goffman, 2007) and political scientists (Lipsky, 2013) have also made the observation that values and political ideology permeate care practices, service provision at street level and caring in the everyday lives of persons and families suffering from health issues. But despite providing novel and important insights into the complex relations between material, symbolic and political underpinnings of practices embedded in care, the literature tends to downplay the particular significance of the values of care. This suggests that less is known about bureaucrats, professionals, administrators, users and family members, at times, creative ways of interrupting different requirements and their ways of tinkering with different values and concerns in care organizations. This insight echoes Vohnsen’s (2015) recent critique of conventional views of street level work as relatively coherent practices being guided by distinct sets of value-laden concerns belonging to certain professional groups. Resembling the analysis of the interplay between different sets of values throughout this issue, Vohnsen (2015) argues that the street-level workers’ planning and implementation practices in welfare organizations are informed by different vectors of concern for the citizen, for system’s ability to manage the workload and for the validity of the project. These analytical insights also bear some resemblance with recent research on the black box of service change (Bjerge and Rowe, 2017) but proceeds to elaborate this area in the literature on care organizations by casting light on what seems like a black box of the processual and shifty nature of value-informed practices in care organizations sui generis. Thus, the selection of papers featured in this issue might not offer anything epistemologically or analytically new to the field. But it provides an opportunity for the reader to deepen his or her understanding of the nature of how care values underpin, inform and bring into effect a range of matters of concern that need to be dealt with in care organizations. This issue is not an exhaustive catalogue of all value-laden vectors of concerns in care organizations and the ways actors resist political requirements of cost-effective practice, interrupt implementation of evidence-based methods, navigate ideological antagonisms in practice and handle value-conflicts between actors. Rather, this special issue considers how the value-laden underpinnings and characteristics of caring in organizations are processual, and ever-changing rather than clear cut representations and enactments of certain ethics, policies or ideologies. It does so by elaborating how care values and their often messy practical expressions and effects are available to be described empirically and analyzed in depth to show how state or organizationally derived values can be tinkered with to negotiate other ways of providing care. As well, the papers in this issue locate where the constraints of care values may reside.

The idea of value-informed care being a precarious and messy affair is well illustrated by Klingenberg and Pelletier’s (2019) use of a Latourian notion of practice as an interactional process as compared to practice being static and unchanging. The processual and messy character of caring in organizations is also illustrated in Christiansen and Holen’s (2019) paper. Echoing studies from medical anthropology, their analysis also relies on Mol’s and others’ definition of care as a processual practice (Mol, 2008). In line with the rest of this issue, they point to how caring processes are neither bound to particular contexts nor limited to certain professional practices or health care institutions. Such a view asserts the messy process of practicing care that encompasses the multiplicity of “doings” in the midst of competing political requirements, commercial concerns, professional discourses or humanistic views of what is at stake and needs to be done in any care organization. As presented by Mol and others (2010), tinkering is well-suited to capture the process of how professionals actively balance competing value-laden concerns in private and welfare organizations in order to understand the interactional characteristics of caring and the dynamics of value-informed care practices in the context of medical treatment, private care organizations, casework, nursing and social work. By relying on Vohnsen (2015), Mol’s (2008) and Mol’s et al. (2010) work, Nygaard-Christensen et al. (2018) analyze how tinkering covers a continuous and non-linear process. They point to how the process encompasses different ways of articulating good or fitting solutions to citizens’ problems through a circular process of getting an overview of all possible services, weighing up different interpretations of citizens’ problems and considering how certain interpretations of the services would best help the citizen. The study of tinkering thus highlights the processual and messy character of professionals’ ways of tinkering with service construction and weighing up different kinds of value-informed care. They argue that the concept can be utilized “to capture and describe a style of working that, although not a formally recognized method, might be recognizable to many caseworkers in the welfare system” (Nygaard-Christensen et al., 2018, p. 57). Given that tinkering stems from studies of care-work and seems to capture the socially contingent care practices illuminated in this issue (Mol et al., 2010; Lydahl, 2017), the analysis of casework tinkering seems to go far beyond social work. In this light, this special issue offers another and perhaps more important insight. It adds to the literature by theorizing the characteristics of care practices in organizations by paying attention to how care is characterized by different actors’ ways of tinkering with what matters to them and what needs to be done in accordance with a personal, professional, organizational or governmental set of values. Taken together, the included papers suggest that social workers’, students’, administrators’ and customers’ or users’ value-informed practices and their ways of balancing different values of care reflect empirically different but homogenous cases of tinkering.

Conclusion

As stated above, the purpose of this issue is to elucidate the taken-for-granted values, ideals and ideologies located in the practical realities of care giving and receiving across a range of contexts. The issue envelops a range of organizational ethnographies on care values suggesting that care practice is characterized by tinkering and creativity. This suggests that the daily realities of care organizations are constituted by the messy daily processes of exploring opportunities, weighing up what matters and balancing personal needs, political requirements and organizational values in order to make ends meet. However, tinkering processes need not only be a generic trait of practice in care organizations. As suggested by Vohnsen (2015) and Nygaard-Christensen et al. (2018), tinkering might also be a necessity to the maintenance of care organizations and their ability to function over time. In fact, tinkering might be key to the maintenance of social organizations in society per se (Graham and Thrift, 2007). This suggests that social organizations’ ability to continue to provide coherent, ethical and fitting care that weigh up many different concerns would stop functioning if practitioners stop working creatively to make the organizations work, maintain them and improve their ability to provide care. From this perspective, one can only imagine what would happen in/to care organizations in real life if professionals stopped tinkering and simply stuck to strict sets of laws, regulations, ethical standards and/or managerial protocols (Graham and Thrift, 2007)? How would care organizations, and especially those facing tensions between street-level practices vs organizational/governmental protocols, do without creative maintenance and what consequences would the absence of creativity and tinkering have (Graham and Thrift, 2007)? Given that this issue was never methodologically or analytically set up to directly address questions of the effects of organizational abidance and/or organizational decay, its perhaps most important contribution lies in raising them.