This paper was presented to the 8th International Conference on Cultural Gerontology, April 10th 2014 in Galway University. For those who would like to learn more about this event, here is the program of the conference.
Negociating power relations and interactional order in a retirement home in France
Abstract : Concerns about elederly long term care-giving and nursing have been incrinsingly growing, leading to bring a normative focus on retirement homes. Such ‘substitutive homes’ have been largely described as total insitutions (Goffman, 1968), which was translated into a call for change in professionnal’s practices. Good practices guides, edited by several official agencies in France attempt to lower the total institution weight in a context where elederly are seen as vulnerable, and their protection stands as the one moral goal to aim to. Based on a qualitative enquiry that includes participant observation and formal interviews, our research as attempted to grasp the links between knowledge, normativity, and the (re)production of an interactional order within a retirement home. Where « there is nothing easier than observing the dominating institution » (Mallon, 2007), we intended to submit power relation within the long term home to a renewed analysis of power relations. Focusing on cognitive logics presiding to interactions, our research revealed three major issues of the social order in such homes nowadays. (1) In a relation of service, occupying a client’s role provides power leverage to residents who make an unequal use of it in the interactions; but other logics preserve in some ways the total functioning despite the efforts made to put it at large. (2) The development of professional guidelines and their contents set new norms that are contradictory, largely contributing to a tensed atmosphere within the retirement home. (3) The interest of the elderly being thought as opposed to the interests of professionals leads to shutter any form of professional contestation about working conditions as it will be seen as a moral deviancy failing to put the residents’ interests on top of any other consideration.
In France, when asked about what they would wish for their own future, old people – and also younger people – massively answer that they wish to remain healthy enough to stay away from the retirement/care home. I understand from what I’ve heard today that it might not be French-specific. As a matter of fact, nationally, the statistics speak for themselves: the majority of people living in such homes got there because they didn’t have any other choice left, mainly because of health issues. The average age and levels of dependency at entrance kept on rising through the years. Retirement/care homes carry a very poor image of themselves, both in common sense and in medias discourses. But this poor image has also been attested through scientific research. They have been described mainly under Erving Goffman’s concept of total institution from the 70’s throughout today. Researches have exposed how coercive these places could be, how people were treated – or whether mistreated -, how the collective care provided denied individuality or humanity to the elderly, and so on.
Concerns about elderly long term care-giving and nursing have been increasingly growing, leading to bring a normative focus on retirement homes. Poor images have been translated into a call for a change in professionals’ practices. Good practices guidelines, edited by several official agencies in France attempt to lower the total institution weight in a context where elderly are seen as vulnerable, and their protection stands as the one moral goal to aim to. Based on a qualitative enquiry that includes participant observation (a year and a half, including a month as a cleaning lady) and formal interviews, our research as attempted to grasp the practices along with the ongoing change.
Where « there is nothing easier than observing the dominating institution » (Mallon, 2007), we intended to submit power relations within the care home to a renewed analysis. Focusing on cognitive logics presiding to interactions, I will sketch out three outcomes of our analysis in this presentation. (1. Power relations and negotiated social order) First, different sets of logics rule practices, and each of them organises the social relations differently. These social relations and hierarchies are not independent from contexts and can’t be set once and for all ; (2. Control staff through moral education) Secondly, we can witness that the goal of the institution is now also to control, teach, and keep a constant watch on its staff, whose interests are thought as opposed to the residents’ ; (3. Contradictory norms and working conditions) And thirdly, the promoted norms of practice are highly contradictory, which leads to having to choose which one to break when acting, and a really tensed atmosphere in such homes.
1. Power relations and negotiated social order
Several logics are used to organise practice. The three major of them are industrial logics ; domestic logics, but also merchant/civic logics. Each of them organises the social hierarchies in a particular way. Staff’s work is mainly organised under industrial logics. In there, the residents stand for the passive objects of the production. They basically don’t exist as actors in this area. At the same time, domestic logics are presiding to making a “almost home”. The domestic logics are more ambiguous in terms of positioning the residents on the social ladder. One the one hand, these logics are referring to the idea of the residence as a whole, as a family, leading to more symmetrical forms of relationships between staff members and residents. But on the other hand, these logics can also lead the staff members to describe the resident’s demands as childish draws of attention – they do so when they turn down demands saying “you are not alone”, positioning them at the very bottom of the ladder. But finally, the third logics, merchant or civic ones are providing the residents with the role of the client, which is at the very top of the ladder. In a relation of service, occupying a client’s role (or a person with civic rights – the promotion of civic rights for the residents of care homes in France was pretty much inspired by the client’s figure) provides power leverage to residents : they have to ask for services, and some of them actually put a great deal at stating their needs, ordering for a due quite harshly. If it is regarded as legitimate by anyone in the home, the manners of doing so can be socially violent, despiteful, particularly regarding the cleaning ladies. Hence, positions on the social ladder can vary a lot, are subject to negociation, and one couldn’t state once and for all nowadays that grasping residents at the bottom of the ladder fully covers the meanings of the situations. Power relations allow negotiations of this social order, and some language and power leverage are performing for the residents.
2. Control staff through moral education
Preventing the total institution to arise has been translated into an attempt to empower the residents, more or less effectively as we saw it. But more largely, the whole logics intended to put their interest and its preservation on top of any other consideration. Their interest is, in this model, being thought as opposed to the interests of staff members whose power and will appear as structural threats to the residents’. As the guidelines state it, the problem is being thought as arising from professionals’ culture, which is to be changed through life-long learning. Their practices and beliefs are pointed out as the cause and source of mistreatment, which leads to constant watch and surveillance over them. Empower the residents is then developed through un-power the staff members, as the two populations are thought as separate and opposed.
For instance, if residents can complain about the treatment they receive, staff members can’t. Staffs’ violence is called mistreatment and can lead to legal pursue, while the “violence” of the residents is barely acknowledged in guidelines, although it is no less violence – for example, a professional in my home had her nose broken being punched by one of the residents. It was called a work injury, making the relational cause disappear, but failing to make the fear go away. One of the direct consequences of this is that strong medication can be given to some residents to respond to staff fear of them. Although it is also conceived a mistreatment, medical treatment is one of the few leverages left to the staff members.
In this system, any form of professional contestation about working conditions can be seen as a moral deviancy because it would sound as self-interested statement, that is failing to put residents interests on top. It is not enough understanding, or even already being mistreating them. This logic holds the possibility of harsh managing lines to the professionals, although their positions are already very difficult in terms of physical and health issues, but also in terms of social recognition and rewarding. As a consequence, retirement homes actually struggle to fill the jobs they have to offer. On a national basis, the turn over is massive : only one third of the medical staff stays more than a year in a retirement home ; absenteeism also constitutes a daily problem to face. The job is known to be really hard, and the difficulties are mainly understood as derived from a lack of human resources. But our analysis has shown it to be more deeply rooted inside the on-going change plus the contradictory logics organising work.
3. Contradictory norms and working conditions
The development of professional guidelines and their contents set new norms that are contradictory, largely contributing to a tensed atmosphere within the retirement home. For instance, the industrial rhythmic shifts of the staff members are not easily combining with the necessity of creating a home for the residents. No dead time is allowed to them, which makes very difficult not to appear being in rush as they have to create a smooth and joyful atmosphere. The tranquillity of the residents is highly contrasting with the staff members rhythm, who constantly have to go back and forth between these two injunctions : on the one hand look concerned by the amount of work, and be sure not to be spotted as a lazy professional, but at the same time don’t show the rush your in, slow down and look relaxed for the benefit of the residents.
Here is another example of these contradictions, which is a bit tricky because it relays on a specificity of the French language : saying “tu” or “vous” when addressing elder people, which can basically be translated into the use of the first name or the last name preceded by “miss” or “mister”. The norms promote to use the last name whenever addressing a resident. But such ways of addressing people showed to hold several possible meanings. On the one hand, saying “tu” or calling them by their first name is perceived, according to the prescription, as disrespect, mainly by the workers who have a degree and had a specific education. But on the other hand, some cleaning ladies – who didn’t have a specific education – consider saying “vous” or calling them by their last name a way to put the elderly at large, a way to prevent creating links and to look down at them. Whereas “tu” or first names, when asked for, allow for a more symmetrical form of relation. I say “When asked for”, because some residents actually feel more comfortable being called by their first name as for them too, it sets a more familiar environment. They ask for it because it is a way for them to actually feel home. So some cleaning ladies do so, only when no manager or family member can hear them, as it is strictly forbidden by the local and national norms. But within norms, it is also promoted to adapt to the residents wishes in order to allow them to appropriate their new home. Professionals then have to choose which rule to break: the calling or the adapting.
These are just two examples, but an awful lot of gestures and actions are normed under such contradictions, which makes possible for the staff to be caught on the wrong foot at any time, resulting in a really tensed atmosphere. I think though that the majority of them arise from creating individual treatment thorough standardized norms of practice, and knowledge. This standardization relays on the categorisation of age and elderly as a coherent whole, a specific field of knowledge.
« Is the retirement home a Hotel, Prison, or Hospital ? » was one of the questions raised by the call for paper. We can attest that to its residents, it stands for the three at the same time. But to me, this question can’t be separated anymore from the workers conditions point of view, as one of the retirement home new central goal is to control them mainly by outweighing their power leverages, leaving them defenceless in contexts were they also can be mistreated. But also because talking about residents treatments is talking about professional’s practices. I believe that research shouldn’t separate these two parts as they are the two sides of a same coin.
Readers, please feel free to make any comment !