Alledaagse omgang tussen zorgprofessionals en zorgontvangers als vindplaats voor goede (LVB) zorg

Day-to-day contact between care professionals and care recipients as a finding place for good MID care

The idea of good care for young people with a mild mental disability, who are often categorized as “difficult” (Teeuwen, 2012), is subject to dominant ethics from “outside”. The vision and mission of organizations, the current social paradigm, scientific insights, methodologies, protocols and quality systems are all normatively loaded (Baart & Vosman, 2015) and bring with them notions of “desired effects”. In this research, we take a radically different perspective. We show how we can find what works well in the everyday routine. Our approach is so different from the usual approach taken, that different theories and methodology are required to demonstrate what we mean.

First of all, we consider concern ethics as a perspective (Gilligan, 1982, Noddings, 1984; Tronto, 1993, 2013; Barnes, 2012; Laugier, 2014, 2016), and we follow Baart and Timmerman (2016) in the empirically grounded care ethics that we use. We argue for a variant of grounded theory, in which theory is used not as “an a priori or a posteriori explanation”, but in a heuristic manner (Vosman, Den Bakker & Weenink, 2016). When choosing theoretical concepts, it is important that the concepts chosen reveal where moral orientation arises in day-to-day contact within institutional contexts, such as “everyday life” (Dorfman, 2014), “concern” (Sayer, 2011), “emergent goods” (Laugier, 2014, 2016), and “forms of life” (Jaeggi, 2014). We have already discussed these concepts in a previous contribution to JSI (Kolen, Vosman & Timmerman, 2016b). This article reports on our empirical research. In addition to empirically grounded care ethics, we used institutional ethnography (DeVault, 2013; Prodinger & Turner, 2013; Smith, 2006) in our attempt to identify institutional influences and in doing so, we have developed an “underwater screen” that is able to identify such influences in observation reports (Kolen, Timmerman & Vosman, 2015, 2016).

Between September 2011 and December 2012, we followed 19 young people with a mild intellectual disability (IQ 50 – 85) in their day-to-day contact with care professionals in the context of three different care organizations. Each of these young people was followed for the duration of one day. The observation reports were open-coded using tools such as the “underwater screen”. This gave us an initial impression of what is at stake for young people and for care givers in their day-to-day contact, and which institutional influences on everyday contact can be identified. We then developed a coding system. This was the first step towards understanding the dynamic that is present in day-to-day contact. In doing this, we viewed the actions of care givers, residents, and the institutional context in a praxeological manner, as doing, leaving, and undergoing (Nicolini, 2012; Schmidt, 2012; Schatzki, 2002; Schäfer, 2016; Vosman et al., 2016). The results of the coding system were processed in an extended data matrix (Miles, Huberman & Saldaña, 2013) in which the day-to-day contact between the three actors was described on the basis of scenes (Woo, Rennie & Poyntz, 2015) from the empirical material. We subsequently developed a “densified matrix” in order to identify characteristics that would make it possible to compare the scenes with each other. This resulted in three main characteristics: the actions of the resident, the actions of the care giver, and the actions of the institutional context. These three characteristics of scenes are the three dimensions of the “characteristics space” (Lazarsfeld, 1937), in which we searched for a moral orientation that manifests itself in everyday contact. We did this by analysing a series of scenes, leading us to the concept of “attending to” (Kolen, Vosman & Timmerman, 2016b). This concept is based on Hannah Arendt’s concept of power. She sees power as a space between actors in day-to-day contact, in which scope can be created to speak meaningfully and to let others speak meaningfully.

In order to bring the empirical insights and theoretical notions together and to lift them to a higher level, we used the metaphor (Semino & Demjén, 2017) of a football training session in which participants are taught to “play together”. We use “game” to mean everyday contact, which is determined by the three players: the care giver, the resident, and the institutional context. “The playing field” is ordinariness itself. “The ball” stands for the issue, under which lies the concealed matter at stake. “Possession of the ball” means that the player who is in possession contributes to determining the moral orientation (the direction) of the game.

Using this metaphor of a football training session, we ultimately arrive at the description of a typology of day-to-day contact in which we distinguish three types. In the first type, which we call “broken game”, the actors initiate moves primarily on the basis of their own intentions, but do not anticipate the moves of the other actors. The second type of day-to-day contact we call “regular game”. In this variant, the game of everyday contact is played in accordance with the rules (the institutional context regards this as good care). We call the third type of day-to-day contact “new game”. In all three variants of everyday contact, the three actors are attending to what is at stake for them.

Finally, we also ask how we can determine whether day-to-day contact in question is good. To answer this question, we take the German philosopher Rahel Jaeggi’s (2014) theory of forms of life. Jaeggi does not start with external ideological norms or work on the basis of professional ethics, but takes the problem-solving capacity of day-to-day contact as her guiding principle. It is this dynamic of solution, the capacity to create a space in which problems do not disappear but where opportunities for dealing with these problems arise, that constitutes the assessment criterion.

SAMENVATTING

Alledaagse omgang tussen zorgprofessionals en zorgontvangers als vindplaats voor goede (LVB) zorg

In een zorgethisch georiënteerd, conceptueel en kwalitatief empirisch onderzoek naar de zorgpraktijk van professionals en jongeren met een licht verstandelijke beperking (lvb-jongeren) zijn we nagegaan hoe de alledaagse omgang tussen hen verloopt en welke morele oriëntaties daarbinnen werkzaam zijn. Die alledaagse omgang is geen “tussentijd”, tijd tussen de momenten van echte zorg, therapie, behandeling, maar is juist vindplaats van goede zorg. We tonen aan hoe die alledaagse omgang doordrongen wordt van “institutioneel gewenste effecten” die van buiten komen. Ons punt is dat de omgang ook van binnenuit morele mogelijkheden in zich draagt te ontdekken wat de jongere goed blijkt te doen. Om goed te kunnen waarnemen wat er aan de orde is, introduceren we een aantal theoretische concepten die daarbij helpen. Het blijkt dat de jongeren en hun begeleiders in de alledaagse omgang ruimte creëren, met elkaar een welbepaalde dynamiek aangaan en daarin ontdekken wat het goede is dat gedaan moet worden. De resultaten van ons onderzoek presenteren we in een typologie. Zo leggen we de alledaagse omgang in moreel opzicht open. De mogelijkheden worden zichtbaar die alledaagse omgang voor goede zorg biedt. Het zijn mogelijkheden die momenteel in de zorg nauwelijks worden onderkend. De morele oriëntaties blijken niet perse van buitenaf geïmporteerd te hoeven worden.