Abstract
This PhD thesis examines how body care of older care dependent people is constituted in research and practice in various settings in the Danish healthcare system.
The background to this is that body care is a mundane everyday practice most people perform without needing help. However, due to illness or decreased functioning which potentially comes with old age, some older people might need assistance with body care in an institutionalized healthcare setting. Thus, a daily practice like body care is also the older people’s encounter with the Danish Welfare state. In recent decades, in healthcare- and polices there has been an increased focus on evidence-based- and person-centered care, active aging, and a de-institutionalization of old age. Moreover, reablement has become a dominating paradigm in eldercare, changing the focus from passive care to a care aiming at maintaining, regaining, or developing functions.
In the last decade within nursing, which traditionally is grounded in the care of the body, nationally and internationally, there has been an increased focus on fundamental care needs. This includes e.g. assisting care- dependent people keeping their bodies clean, bathe, or assist with the elimination of bodily wastes (defecation and urination). Nursing research demonstrates that older care-dependent people do not receive high quality nurs-ing care, leading to increased morbidity and mortality. Therefore, it is argued that nursing should be based on evidence and centered on the relationship between the person needing care and the care worker providing care.
The thesis explores the body care practices of older people and how this care is shaped by the institutional context, for example health policy ambitions, different knowledge forms regarding the body, care, and aging, as well as materiality. Moreover, the thesis explores how the body care practices have implications for the older people’s subjectivity. The thesis aims to contribute with new knowledge on how body care of older people is constituted in practice in the Danish healthcare system and in nursing research. With this background the overarching research question of the thesis is:
How is body care of older people constituted in research and practice in different institutional contexts in the healthcare system?
The research question is divided into the three following sub-questions:
•What is problematized in nursing research literature on body care of older peo-ple?
•How is body care practiced in different contexts in the Danish healthcare system, and how do institutional, bodily and material conditions shape the practices?
•What are the possibilities for subjectification in the body care practices for the older people?
The thesis is carried out within a critical humanistic and social science health research tradition and is informed by poststructuralist research traditions. Thus, attention is directed towards body care for older people as practices emerging in a complex network of multiple constitutive forces. Body care for older people is not seen as a stable phenomenon but as something that is constituted and practiced in daily practices in different institutionalized contexts.
The empirical data was generated from December 2020 to January 2022 through ethnographic fieldwork in a hospital ward, two nursing homes, and two home care teams. Data generation consists of participant observations of body care situations, individual interviews with the older people, and focus group interviews with staff.
The analysis in the thesis consists of three parts which are presented in the form of three articles.
The first article, "Body care of older people in different institutionalized settings: A systematic mapping review of international nursing research from a Scandinavian perspective", examines international nursing research literature on body care of older people from 2010-2020 to explore how body care of older people is constituted in the nursing research field. The article is a systematic mapping review aiming to identify the characteristics of the research literature. Furthermore, a problematization analysis perspective is applied to examine how body care of older people is constituted through problematizations. The review shows that the included articles predominantly adopt a biomedical research approach focusing on evidencebased care. Another part of the literature is based on humanistic approaches focusing on subjective experiences and person-centered care practices. The article reveals that body care of older people is constituted as a practice that should be evidence-based as well as focus on the relationship between the two subjects in the care relationship. The article also illuminates how dualisms between the body as an object and the body as experienced as well as between subjects and objects, are reproduced. The article points to how nursing research on body care of older people is embedded in power-knowledge relations where biomedical knowledge forms seem to be dominating.
The second article, "The choreographies of the elimination of faeces: An ethnographic study of the institutionalized body care practices of older people in different health care settings", explores how care is choreographed to ensure that the elimination of feces as part of body care does not become matter out of place. The article draws on an understanding of care as ongoing socio-material practices as well as it draws on the anthropologist Mary Douglas' concept of dirt as ‘matter out of place’. The article illuminates how bodies, materialities, tech-nologies, different ethical ideals and professional knowledge on hygiene and the digestive system are dominating actors in the choreographies, which are negotiated, ordered and distributed spatially and temporally. Matter out of place varies across the contexts and is closely linked to the knowledge forms, ethical ideals, and materiality present in the different contexts. Moreover, the article demonstrates how care is choreographed differently in the different institutionalized settings. The article concludes that the assistance with the elimination of faeces are complex and deeply institutionalized practices, where the institutionalized context of care plays an active role in shaping body care practices.
The third article, "'I'm not ill, I'm just old' - Negotiations of risk: An ethnographic study of the subjectification of older people in assisted body care practices in institutionalized homes", examines the subjectification processes in the body care practices in the context of home. The article draws on a Foucauldian understanding of discursive practices and subjectification. The analyses show how the older people are subjectified as being at -risk or not at- risk. The subjectification is not only dependent on biomedical and gerontological discourses. Hegemonic discourses of active aging and home and homeliness are interacting with these discourses destabilizing the subject positions. The article shows how the older people navigate and negotiate the subject positions offered in the body care practices in different ways. A rejection of the position as active and a rejection to engage in prevention of biomedical risks related to old age, seems to sediment a position as at-risk and thus non-agentic and problematic. The article concludes that the strong focus on active ageing and home paradoxically holds the potential to exclude the material processes of ageing as well as the subjective experiences of bodies and home.
Overall, the thesis shows that body care is constituted through complex processes, where the constitutive forces are multiple, and where both human and non-human actors interact. The thesis demonstrates how body care is embedded in powerful discourses about the body, aging, and home, which become constitutive of how body care is practiced and having thorough implications for the older people’s agency, longings and everyday life. Furthermore, the thesis points to how bodies, technologies, materiality, knowledge forms, and political and ethical ideals about aging and care are negotiated, distributed and ordered spatially and temporally, constituting body care in multiple ways. The dissertation concludes that the focus on evidence-based care in nursing and the political focus on reablement and active aging potentially silence important knowledge about body care practices and the older people's everyday bodily practices.
The background to this is that body care is a mundane everyday practice most people perform without needing help. However, due to illness or decreased functioning which potentially comes with old age, some older people might need assistance with body care in an institutionalized healthcare setting. Thus, a daily practice like body care is also the older people’s encounter with the Danish Welfare state. In recent decades, in healthcare- and polices there has been an increased focus on evidence-based- and person-centered care, active aging, and a de-institutionalization of old age. Moreover, reablement has become a dominating paradigm in eldercare, changing the focus from passive care to a care aiming at maintaining, regaining, or developing functions.
In the last decade within nursing, which traditionally is grounded in the care of the body, nationally and internationally, there has been an increased focus on fundamental care needs. This includes e.g. assisting care- dependent people keeping their bodies clean, bathe, or assist with the elimination of bodily wastes (defecation and urination). Nursing research demonstrates that older care-dependent people do not receive high quality nurs-ing care, leading to increased morbidity and mortality. Therefore, it is argued that nursing should be based on evidence and centered on the relationship between the person needing care and the care worker providing care.
The thesis explores the body care practices of older people and how this care is shaped by the institutional context, for example health policy ambitions, different knowledge forms regarding the body, care, and aging, as well as materiality. Moreover, the thesis explores how the body care practices have implications for the older people’s subjectivity. The thesis aims to contribute with new knowledge on how body care of older people is constituted in practice in the Danish healthcare system and in nursing research. With this background the overarching research question of the thesis is:
How is body care of older people constituted in research and practice in different institutional contexts in the healthcare system?
The research question is divided into the three following sub-questions:
•What is problematized in nursing research literature on body care of older peo-ple?
•How is body care practiced in different contexts in the Danish healthcare system, and how do institutional, bodily and material conditions shape the practices?
•What are the possibilities for subjectification in the body care practices for the older people?
The thesis is carried out within a critical humanistic and social science health research tradition and is informed by poststructuralist research traditions. Thus, attention is directed towards body care for older people as practices emerging in a complex network of multiple constitutive forces. Body care for older people is not seen as a stable phenomenon but as something that is constituted and practiced in daily practices in different institutionalized contexts.
The empirical data was generated from December 2020 to January 2022 through ethnographic fieldwork in a hospital ward, two nursing homes, and two home care teams. Data generation consists of participant observations of body care situations, individual interviews with the older people, and focus group interviews with staff.
The analysis in the thesis consists of three parts which are presented in the form of three articles.
The first article, "Body care of older people in different institutionalized settings: A systematic mapping review of international nursing research from a Scandinavian perspective", examines international nursing research literature on body care of older people from 2010-2020 to explore how body care of older people is constituted in the nursing research field. The article is a systematic mapping review aiming to identify the characteristics of the research literature. Furthermore, a problematization analysis perspective is applied to examine how body care of older people is constituted through problematizations. The review shows that the included articles predominantly adopt a biomedical research approach focusing on evidencebased care. Another part of the literature is based on humanistic approaches focusing on subjective experiences and person-centered care practices. The article reveals that body care of older people is constituted as a practice that should be evidence-based as well as focus on the relationship between the two subjects in the care relationship. The article also illuminates how dualisms between the body as an object and the body as experienced as well as between subjects and objects, are reproduced. The article points to how nursing research on body care of older people is embedded in power-knowledge relations where biomedical knowledge forms seem to be dominating.
The second article, "The choreographies of the elimination of faeces: An ethnographic study of the institutionalized body care practices of older people in different health care settings", explores how care is choreographed to ensure that the elimination of feces as part of body care does not become matter out of place. The article draws on an understanding of care as ongoing socio-material practices as well as it draws on the anthropologist Mary Douglas' concept of dirt as ‘matter out of place’. The article illuminates how bodies, materialities, tech-nologies, different ethical ideals and professional knowledge on hygiene and the digestive system are dominating actors in the choreographies, which are negotiated, ordered and distributed spatially and temporally. Matter out of place varies across the contexts and is closely linked to the knowledge forms, ethical ideals, and materiality present in the different contexts. Moreover, the article demonstrates how care is choreographed differently in the different institutionalized settings. The article concludes that the assistance with the elimination of faeces are complex and deeply institutionalized practices, where the institutionalized context of care plays an active role in shaping body care practices.
The third article, "'I'm not ill, I'm just old' - Negotiations of risk: An ethnographic study of the subjectification of older people in assisted body care practices in institutionalized homes", examines the subjectification processes in the body care practices in the context of home. The article draws on a Foucauldian understanding of discursive practices and subjectification. The analyses show how the older people are subjectified as being at -risk or not at- risk. The subjectification is not only dependent on biomedical and gerontological discourses. Hegemonic discourses of active aging and home and homeliness are interacting with these discourses destabilizing the subject positions. The article shows how the older people navigate and negotiate the subject positions offered in the body care practices in different ways. A rejection of the position as active and a rejection to engage in prevention of biomedical risks related to old age, seems to sediment a position as at-risk and thus non-agentic and problematic. The article concludes that the strong focus on active ageing and home paradoxically holds the potential to exclude the material processes of ageing as well as the subjective experiences of bodies and home.
Overall, the thesis shows that body care is constituted through complex processes, where the constitutive forces are multiple, and where both human and non-human actors interact. The thesis demonstrates how body care is embedded in powerful discourses about the body, aging, and home, which become constitutive of how body care is practiced and having thorough implications for the older people’s agency, longings and everyday life. Furthermore, the thesis points to how bodies, technologies, materiality, knowledge forms, and political and ethical ideals about aging and care are negotiated, distributed and ordered spatially and temporally, constituting body care in multiple ways. The dissertation concludes that the focus on evidence-based care in nursing and the political focus on reablement and active aging potentially silence important knowledge about body care practices and the older people's everyday bodily practices.
| Translated title of the contribution | Body care of older people: An ethnographic study of body care practices in different institutionalized settings in Danish healthcare |
|---|---|
| Original language | Danish |
| Place of Publication | Roskilde |
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| Publisher | Roskilde Universitet |
| Number of pages | 138 |
| ISBN (Print) | 9788791362651 |
| ISBN (Electronic) | 9788791362668 |
| Publication status | Published - 2024 |
| Series | Afhandlinger fra Ph.d.-skolen for Mennesker og Teknologi |
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Bibliographical note
Supervisor: Sine LehnCo-supervisor: Dorthe Overgaard