How Professionals Tinker With Ethical Tensions Collectively When Fostering Service User Autonomy: An Ethnographic Study In Long-term Care

Abstract

Background: The value of patient autonomy has become central in healthcare. However, care practices involve a plurality of possibly conflicting values. These values often transgress the borders of the individual professional-client relationship as they involve family members, other professionals and community organizations. Good care should acknowledge this complexity, which requires a collective handling of the tensions between values. To better understand this process, we draw on Mol (2008, 2010) by developing the notion of collective tinkering. Methods: Through ethnographic study in two teams in community housing services for people with intellectual disability and serious mental illness, we analyze how professionals tinker collectively. This research design enables in-depth analysis of care practices as they unfold in their situated context. Data were gathered by means of participant observation, interviews and focus groups with professionals, service users, peer support workers and family members. Results: Collective tinkering is analyzed 1) within teams of professionals working together with family members; 2) between professionals from different organizations providing care for the same client; and 3) in organizing practices for a collective of clients. Collective tinkering involves assembling values into a care practice, attentively experimenting with these care practices and adjusting care accordingly within a collective of those involved in care for a particular client or collective of clients. When collective tinkering does not occur, the stakeholders excluded from the tinkering (e.g. clients or family members) may experience poor quality of care.Conclusion: Collective tinkering differs from ‘individual’ tinkering between professionals and clients in several ways. First, by including stakeholders involved with the client, collective tinkering adds values and ontologies important in dealing with the situation and aids the creative process of inventing and experimenting with the care practices that assemble these values. Second, collective tinkering needs organizational structures beyond direct professional-client contacts. Structures that provide the time and space for the wider collective involved in care to come together, reflect and co-design care practices. The results also show that collective tinkering runs the risk of excluding clients in negotiating value tensions. Including clients should be carefully considered when structuring collective tinkering.

Different views on collaboration between older persons, informal caregivers and care professionals

“…For T A B L E 2 Main connections between the senses and the views. 42,43 As such, the intricate relationships underscore the potential for conflicts, emphasizing the complexity that partners face in navigating collaboration in care triads.…”

“…Also, each care triad may comprise different care professionals and informal caregivers, making it even more challenging for partners in the care triad to assume a role that acknowledges and accommodates all views involved. Previous studies revealed that beneath these different needs and experiences often lie diverse values and that these values may come into conflict 42,43 . As such, the intricate relationships underscore the potential for conflicts, emphasizing the complexity that partners face in navigating collaboration in care triads.…”

“…Our study highlights the importance of recognizing the complexity of relationships within care. This complexity receives insufficient attention in policy documents that shape the work of care professionals, encompassing competency profiles and quality frameworks 43 . A policy stance that is overly rigid in defining collaboration, solely focusing on one viewpoint, may therefore obstruct the alignment between various viewpoints and potentially cause friction in the collaborative effort.…”

“…This complexity receives insufficient attention in policy documents that shape the work of care professionals, encompassing competency profiles and quality frameworks. 43 A policy stance that is overly rigid in defining collaboration, solely focusing on one viewpoint, may therefore obstruct the alignment between various viewpoints and potentially cause friction in the collaborative effort. Hence, policy frameworks should be designed to foster adaptive efforts in establishing collaborative relationships with various partners in the care triad who can hold different views.…”