The Ella narrative

The categorization of ‘Rehabilitation techniques’ and ‘Nurturing techniques’ emerged in tandem with a re-examination of the coexistence of the techniques in the dataset. In this process, the observa- tions and focus groups allowed for different analytical insights. The observations showed the situated ways in which the introduction of rehabilitation by higher status therapists to lower status care aides and older people lead to disagreement over the approach, which should guide and shape aspect of homecare work associated with stigma; care aides and older people emphasised nurturing, that conflicted with rehabilitation approaches. Hence, the observations were useful to identify how rehabilitation and nurturing techniques coexisted and continually generated dynamic negotiation over the roles, means and outcomes of homecare providing among the actors. In contrast, the focus groups were helpful, because they showed how workers shared their more abstract and general thoughts, reflections and feelings concerning the observed practice and disagreements. Hence, the focus groups were useful in identifying the ways in which higher status workers (occupational therapists and nurses) seemed to systematically value and promote rehabilitation techniques at the expense of nurturing techniques to resolve and justify the observed disagreements, and the ramifications for care aides.

how a rehabilitation programme was conducted. Those present in the home besides Ella and myself were Anne, the therapist, and Karen, the care aide.

I arrive at Ella’s detached house in a rural residential neighbourhood with Anne, an occupa- tional therapist. When the care aide Karen arrives, we ring the bell. We stand there for a while until Ella finally opens the door. She has white ruffled hair and is wearing a dressing gown. She is leaning on a walker. ‘You are a big crowd,’ she says and looks a little overwhelmed and confused. Anne explains that they talked about the visit on the phone. We all sit down in her living room. Anne begins by summarizing Ella’s situation: ‘So Ella, you recently fell off your bike and cracked your pelvis. You have also undergone two knee replacements and one hip replacement, but before the incident you did not get any help?’ Ella nods. Anne continues, ‘The aim of this meeting is to make you independent of your walker again, as we talked about on the phone.’ Ella smiles: ‘I would love to be able to walk in my garden again.’ Anne finds two sheets of paper in her bag, one sheet that says ‘work plan’ and another with a circle: ‘a citizen wheel’, she explains. It consists of squares with categories such as

‘Bathing’ and ‘Bedding’. Anne starts to go through it, filling out the categories step by step.

First, Anne asks Ella about her bathing routine. Ella does most of the bathing herself; as she says,

‘Karen helps me rinse my hair after I shampoo it because the soap makes me feel inse- cure.’ Anne replies, ‘This is something that we have to work on. We will put up a grip in the shower.’ ‘Yes, because otherwise it’s a little bit difficult to wash your behind — right?’ Karen explains with a smile. Ella nods.

Second, Anne asks about dressing. ‘Ella, I can tell you get help putting on your tights; why is that?’

Ella explains, ‘It’s the silly toes that are causing trouble.’ Anne and Karen discuss what aids they can use to overcome this problem. ‘I don’t think I can use such things [aids],’ Ella says with a concerned voice. Karen replies, ‘No, but that’s what we’re going to work on.’ Anne continues, ‘Karen, you can also try with the shoes. You have to remember to keep your hands behind your back, right?’ Karen looks at Ella and replies, ‘Yes, we have to think a little before we act.’ The third topic is vacuuming and mopping. Anne tells Karen that she is surprised how mobile Ella is despite her walker and her prosthesis. They discuss whether they can train Ella to do the tasks. Ella asks with a worried voice,

‘What are you talking about?’ Anne smiles: ‘I have incredibly good experience with training people to do the vacuuming again.’ ‘Will you come by and control me then?’ Ella asks. Anne replies, ‘Karen will help you, but I prefer the word collaboration over control, right?’ Ella nods. Bedding is the fourth

topic. Anne and Karen discuss whether Ella might be able to make the bed, change the duvet cover and put on the sheet herself; despite her walker, ‘Nothing is wrong with her arms,’ as one of them notes.

Ella says, ‘However, Karen has been nice enough to help me with the bedding.’ ‘Yes, but you can learn that fast, right Ella?’ Anne says with an encouraging voice. Ella replies, ‘If somebody is standing next to me, I will try.’

In the end, Karen and Anne discuss how many minutes Karen needs to train Ella in each task. Karen continuously argues that she needs more time than Anne suggests. ‘Alright, you still have to do some cleaning, so I’ll give you more time,’ Anne says. Karen replies, ‘Ella will most likely never be able to wash the toilet on the sides.’ Anne says: ‘Well, Ella can wash the toilet on the sides if she sits on the toilet.’ Karen looks sceptical: ‘Yes, I guess so.’ Anne shows Ella the coloured citizen wheel: ‘It describes your function levels concerning your everyday tasks.’ Ella nods in a disinterested way.

This narrative illustrates the ambiguous ways stigma is reshaped as Anne introduces rehabilitation and disrupts Ella’s and, to some extent, Karen’s alternative nurturing approach to the work. As a result, we see that rehabilitation and nurturing techniques emerge as two competing ways to discur- sively and materially (Ashforth and Kreiner, 1999; Wolkowitz, 2006) shape similar aspects of the work. As demonstrated above, Anne in a sense avoids focusing on bodily vulnerability, drawing on rehabilitation techniques that focus on Ella’s (hidden) physical potential and urging Karen to ‘think’,

‘train’ and use hands-off tools such as ability aids. In contrast, Ella draws on nurturing techniques that centre on her declining, insecure and infirm body (parts) and her need for Karen’s nurturing and physical contact (for an generalized overview of these two techniques, see Table 6). Finally, we see that Karen, inconsistently and dynamically, draws on both techniques. The competing techniques, and Karen’s indecisive use of them, show that techniques to shape stigma are not stable, undisputable or stratified (Twigg et al., 2011; Wainwright et al., 2011). Lower-status recipients and care aides draw on nurturing techniques to challenge self-care rehabilitation techniques. For example, Ella highlights that she not only needs Karen’s help due to her physical decline but also values her ‘nice’ behaviour.

Although the narrative demonstrates that the introduction of rehabilitation has stimulated disagreement about the appropriate motivations and outcomes guiding eldercare, it also shows that they are associated with the actors’ status-differentiated use of techniques. As with other higher status actors

with formal decision-making power, we see Anne attempting to make rehabilitation the dominant technique by patronising Ella and ignoring Ella’s (and Karen’s) points of view or by indicating that to obtain her acknowledgement, they had to dispense with their nurturing approach and adopt rehabilitation. In the next three sections, I will elaborate on the implications of these ambiguous ways of shaping stigma for the three core aspects of work that risk stigmatization (ageing bodies, tools and practices to undertake intimate work and care workers’ bodies; see Table 6). I will show the ways in which higher status nurses and therapists attempt to promote and entrench rehabilitation techniques at the expense of nurturing techniques.

7.10 Shaping the stigma of frail ageing bodies by redefining them as self-care