Variability as a source of stability: studying routines in the elderly home care setting

8/7/2019 Variability as a source of stability: studying routines in the elderly home care setting

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Variability as a source of stability:

Studying routines in the elderly homecare setting

Anna Essn

A B S T R A C T While it is agreed that there can be a difference between the routine

as inscribed in artefacts, the ostensive aspect of the routine and its

performative aspect, little is known about the relationship between

these parts of the routine. Further, while authors acknowledge that

there is variability in routines as performed, the contemporary litera-

ture says less about the sources of this variability. Using empirical data

from the Swedish community care setting, the present article

explores the workings of and relationship between the different

aspects of the home-help delivery routine. The article also explores

the sources of variability in workers execution of this routine in situ.

The article provides rich illustrations of the differences between the

routine as inscribed in artefacts, as articulated patterns and the

workers performance of the routine in specific situations. In contrast

to the argument that alignment between these aspects contributes

to stability in the routine, this article claims that divergences between

them promote stability. The article highlights how factors in the local

context, including exceptions created by technology, constitute

sources of variability in the routine. It further shows how values in

the contemporary society, adopted by individuals as emotional-

ethical principles, shape individuals performance of the routine and

thereby generate variability in the routine. In general, the article

underlines the importance of considering the cultural context in

which the routine is situated, at micro- and macro-level, when

analysing its operation. Indeed, factors beyond the routine influence

individuals conception of and execution of the routine.

1 6 1 7

Human Relations

DOI: 10.1177/0018726708096640

Volume 61(11): 16171644

Copyright 2008

The Tavistock Institute

SAGE Publications

Los Angeles, London,

New Delhi, Singapore

http://hum.sagepub.com

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KE YWORDS artefact elderly care emotional labour healthcare

organizations public management routines

Introduction

Routines have attracted the interest of scholars for more than half a century

(see e.g. March & Simon, 1958; Simon, 1945; Stene, 1940, for early

examples) and significant contributions to our understanding of routines

have been made. However, as noted in the review by Becker (2004), many

ambiguities and inconsistencies prevail in the routine literature. In particu-lar, as regards the role of subjective choice and variability in routines. Indeed,

It is remarkable that attempts at actually specifying how routines are varied,

selected, and retained, are very few still (Becker, 2004: 62).

This becomes evident when considering the role of routines in the

Swedish elderly home help setting. Home-help services are tax-financed in

Sweden and national directives underline the importance of fairness and

equality in access to these services (Social Ministry, 2005). This implies a

need to reduce local variations in the way these services are granted and

delivered. Centralized service plans pre-specify workers day-to-day service

delivery at minute level. On the other hand, elderly care is characterized by

high variability (frequent exceptions) in needs encountered by workers

(Perrow, 1967). Fall accidents, sudden anxiety outbursts and other un-predictable problems are common.

How can routines operate in such a setting? Clearly, workers execution

of the home-help routine cannot only be a matter of executing the pre-

specified tasks in the service plans. There must be additional efforts to respond

to the unpredictable changes in seniors needs. What shapes these additional

efforts? And, how are these efforts related to the overall routine do they

threaten its stability and survival? The contemporary literature does not

provide an answer these questions.

Recent work suggests that there can be a difference between the routine

as inscribed in artefacts, that is, written rules or technology code; the

ostensive aspect of routine, that is, the routine as agreed on activitypatterns; and the performative aspect, that is, the routine as enacted by indi-

vidual workers in specific situations (Pentland & Feldman, 2005). There is,

however, a lack of understanding of the roles of and relationship between

these parts of the routine (Pentland & Feldman, 2005). Further, while

authors acknowledge that contextual contingencies contribute to variability

in the performance of routines (Birnholtz et al., 2007; Feldman, 2000;

Human Relations 61(11)1 6 1 8

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Tsoukas, 1996; Tsoukas & Chia, 2002), the contemporary literature says less

about how humans face such contingencies (Tsoukas & Chia, 2002). This

weakness in the literature is important as it impedes our understanding of

what routines are, how routines remain stable and/or change and what effect

they have on organizations (Becker, 2005; Collinson & Wilson, 2006;

Pentland & Feldman, 2005).

Given this gap in the literature, the present article explores the workings

of and relationship between the artefact, ostensive and performative level of

the home-help delivery routine, focusing on how these dimensions can

constitute sources of stability and variability. Assuming that the routine at

artefact and ostensive level does not cover the efforts made by workers whenperforming the routine in actual situations, the article also investigates what

other factors shape these efforts.

The article uses qualitative empirical data from two cases in the

Swedish community care setting. The findings suggest that the home-help

delivery routine incorporates an intriguing mix of efforts to reduce and

respond to variability. Drawing on Pentland and Feldman (2005), the article

provides rich illustrations of the differences between the routine as inscribed

in artefacts, as articulated patterns and the workers performance of the

routine in situ. It is the claim of the article that this divergence contributes

to the stability of the routine. To further explain these differences, the article

uses the framework of Mouzelis (1995) and Tsoukas (1996) to show how

social norm, individuals values (disposition) and situational-interactive

dimensions influence ostensive patterns and how workers enact the routine

in situ. These dimensions contribute to the understanding of the variability

inherent in the ostensive and performative aspect. The article further shows

how technological artefacts can play an intrusive role in this context, adding

variability to the performance of routines.

In general, the article underlines the importance of considering the

cultural context in which the routine is situated when analysing its operation.

Indeed, factors beyond the routine at artefact and ostensive level influence

individuals conception of and execution of the routine. The article particu-

larly highlights how values in the contemporary society and adopted by indi-

viduals as emotional-ethical principles shape their performance of the routine.This raises several questions that warrant further research.

The article commences with a brief presentation of contemporary views

on routines. Next, a framework for studying routines is presented. Empirical

material from a study of the Swedish elderly care setting follows. The article

ends with conclusions, implications, study limitations and suggestions for

further research.

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Literature review and theoretical framework

Early work defined routines as a fixed pattern of activity in response to a

defined stimulus accompanied by the absence of search (March & Simon,

1958; Nelson & Winter, 1982; Winter, 1986). Scholars associated the routine

with activity performed without explicitly selecting it over alternative ways

of acting (Ashforth & Fried, 1988; Cyert & March, 1963; Gersick &

Hackman, 1990; March & Simon, 1958; Simon, 1945; Stene, 1940; Weiss

& Ilgen, 1985). Routines have further traditionally been understood as

storing knowledge (Cohen & Bacdayan, 1994; Hodgson, 1998; Nelson &

Winter, 1982). As related to this, it has been argued that routines result in

economizing on the limited information processing and decision-makingcapacity of agents (Cyert & March, 1963; Dosi et al., 1999; Gersick &

Hackman, 1990; Hodgson, 1997; Reason, 1984; Simon, 1945; Weiss &

Ilgen, 1985; Winter, 1986). Scholars have further maintained that routines

are means for coordination and control (Cohen et al., 1996; Dosi et al., 1999;

March, 1991; March & Simon, 1958; Merton, 1940; Nelson & Winter,

1982; Stene, 1940) by making many simultaneous activities mutually consist-

ent (March & Olsen, 1989), establishing a truce (Nelson & Winter, 1982)

and by being easier to monitor and measure than non-routine behaviour. As

noted by Becker (2004): The more standardized, the easier to compare. The

easier to compare, the easier to control (p. 655). In general, routines have

traditionally been associated with stability (Hodgson, 1993; Nelson, 1994;Nelson & Winter, 1982) and with a reduction of uncertainty, for example,

through their ability to establish a certain level of predictability and expec-

tations for members of the organization (Becker & Knudsen, 2005; Cyert &

March, 1963; Nelson & Winter, 1982).

This optimistic view of routines has come to be the target of criticism.

It has been argued that the stability effects of routines can be negative,

leading to organizational inertia. The strength of habits may further lull indi-

viduals into executing well-known routines even when external stimuli vary

(Gersick & Hackman, 1990; Reason, 1984; Weick, 1979). Hence, scholars

have maintained that routines may lead to deskilling (Leidner, 1993; May,

1985), demotivation (Ilgen & Hollenbeck, 1991), mindlessness (Ashforth &

Fried, 1988) and that routines may be in conflict with individualization inservice delivery (Berg, 1997; Hanlon et al., 2005; Leidner, 1993).

Neither of these views could explain the multiple roles played by the

routine studied here. Hence, the present study draws on an alternative way

of theorizing routines that has recently emerged in the organizational/

management literature. I will primarily refer to Feldman and Pentland (2003)

and Pentland and Feldman (2005), although several works have contributed

to the framework they present (e.g. Feldman, 2000; Giddens, 1984; Latour,


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1986; Pentland & Reuter, 1994). Feldman and Pentland (2003: 95) define

routines as: repetitive, recognizable patterns of interdependent actions

carried out by multiple actors. In Pentland and Feldman (2005) they suggest

that routines have three dimensions. Artefacts refer to the routine as

inscribed in, for example, written rules and technology. This article assumes

that humans can delegate tasks to artefacts, which in turn can prescribe

activity of humans (Akrich, 1992; Latour, 1992). The ostensive aspect

(Latour, 1986) denotes participants account of the routine. It is important

to note that participants may have different understandings of what they

really do and that these understandings may be different from the routine

inscribed in artefacts. Theperformative aspect(Latour, 1986) consists of theroutine executed by particular individuals in particular places and times; the

routine in practice. Feldman and Pentland (2003) argue that artefacts and

the ostensive aspect of a routine can only serve as a template for behaviour;

people always need to improvise to respond to unexpected conditions and

contextual contingencies when they enact routines (Feldman, 2000;

Suchman, 1987; Weick, 1993).

Against this background, the performance of routines should be viewed

as an effortful accomplishment rather than automatic behaviour (Pentland

& Reuter, 1994). As noted by Giddens (1984):

. . . it is a major error to suppose that these phenomena [routines] . . .

are simply repetitive forms of behaviour carried out mindlessly. Onthe contrary . . . the routinized character of most social activity is

something that has to be worked at continually by those who sustain

in their day-to-day conduct.

(Giddens, 1984: 86)

In short, recent research suggests that routines incorporate several dimen-

sions that can operate in different ways. Importantly, the performative

dimension acknowledges that there are contextual contingencies in any

situation (Tsoukas, 1996; Tsoukas & Chia, 2002). Alas, the contemporary

literature does not quite answer what shapes how humans improvise when

facing such contextual contingencies (Tsoukas & Chia, 2002). It seems

reasonable to assume that there is an immense variability in individuals

responses to such unpredictable issues. What shapes this variability in human

performance? And, how is this variability related to the ostensive and artefact

aspects of the routine? As noted by Pentland and Feldman (2005), these

questions remain largely unexplored in the contemporary literature.

A few studies have discussed factors that shape individuals perform-

ance of routines. For example, Cohen and Bacdayan (1994) nicely illustrate

how individuals remember parts of routines in their procedural memory, that


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is, a relatively inarticulate memory for how to do things (typically discussed

in terms of habits or skills). Individuals are not always consciously aware of

this skill, but it tends to persist. Thus routines reside partially in an organiz-

ational unconscious, it is argued. Birnholtz et al. (2007) also write about the

role of habitual dispositions stored in individuals procedural memory. They

ask: how can such individual dispositions be turned into collective patterns

of behaviour? They find that this can occur via transfer of individual dispo-

sitions from experienced to new organizational members. To what extent

individual dispositions are generalized however depends on several factors

including: the domain credibility (rather than formal authority) of the indi-

vidual actor, the visibility of the action and the degree of external standard-ization of the action. Some dispositions and improvisations may be

incompatible with other dispositions and will therefore not take hold at

organizational level.

This research importantly highlights that response tendencies stored

in individuals hard-to-access procedural memory can influence the per-

formative and in turn the ostensive aspect of routines. However, it does not

conceptualize where these response tendencies come from. The research

further primarily talks about how such response tendencies contribute to

stability and continuity in individuals enactment of routine. This raises

questions about the sources of variability in individuals performance of

routines. In general, contemporary research does not quite explicate what

makes some individuals consciously work at the routine in certain ways,

others work at it in other ways, and others still ignore this fine-tuning

completely.

Tsoukas (1996) (compare Mouzelis, 1995) provides a framework

elucidating social factors that influence individuals rule following, which is

helpful in this context. Tsoukas (1996) suggests that normative expectations

that are associated with a particular role influence how it is carried out. The

dispositional dimension refers to individuals background, the system of

mental patterns of perception, appreciation, and action, which has been

acquired by an individual via past socializations and is brought to bear on

a particular situation (Tsoukas, 1996: 17). It is the result of the diverse social

contexts individual workers have gone through during their lives (seeBourdieus 1990 notion of habitus). Finally, the interactive-situational

dimension refers to the concrete and particular sociotemporal setting in

which an act takes place (see Goffman, 1983, interaction order).

These three interrelated dimensions of social practices overlap with,

but also add to, the contemporary understanding of the factors that influ-

ence how humans view and enact routines. Tsoukas/Mouzeliss model

acknowledges that the here and now (the interactive-situational dimension)


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influences action. This resonates with Latours (1986) and Feldman and

Pentlands (2003) idea of the performative aspect. However, while Latour

(1986) posits that the performative aspect is all about the emergent what

is here and now (Cooren et al., 2006; Latour, 1992)1 Tsoukas/Mouzeliss

model highlights that normative expectations and individuals background

influence how individuals respond to the here and now. This idea can be

used to make explicit the influence of value structures and of the past

(embodied, internalized by individuals as personal values) in the articulation

(ostensive aspect) and enactment (performative aspect) of routines.

Drawing on the above, this article assumes that the performance of a

routine is guided and constrained by the routine as pre-inscribed in artefactsand as articulated patterns (the ostensive aspect). Emergent issues in the

local, physical setting in which the routine is performed further plays an

important role (the interactive-situational dimension). How workers perform

a routine is finally influenced by factors beyond the routine and the local

situation, namely: prevailing expectations (cultural norms) and workers

disposition (personal values) (Mouzelis, 1995; Pentland & Feldman, 2005;

Tsoukas, 1996). The article presupposes that these intertwined factors

contribute both to 1) individuals inarticulate habitual dispositions and rela-

tively subconscious execution of routines (see Birnholtz et al., 2007; Cohen

& Bacdayan, 1995) and 2) individuals more reflective, conscious responses

to exceptional cases, that is, their effort to make the routine work.

Method

A case study approach was deemed appropriate as it would enable the

researcher to acquire a holistic view of the routine in all its dimensions, in

its organizational context and over time. This approach further allowed the

researcher to use various data generation methods, which was important as

this study aimed at generating rich data about individuals account of the

routine versus their actual performance (Denzin & Lincoln, 2000; Patton,

2004; Weick, 2007). The article triangulates different methods (Brewer &

Hunter, 1989) to provide a credible and trustworthy portrayal of routines.

Research setting

The article uses empirical material from the Swedish community-based

elderly care (home-help) setting. It focuses on a routine that is central in this

setting, namely the repeated delivery of granted home-help services to

seniors. This article seeks to give a broad account of this the home-help


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delivery routine but it is not given where it starts and where it ends.

Numerous artefacts further enable and constrain the execution of this

routine. The article discusses the service plan document that specifies the

services each senior is granted, and a technical artefact that plays an import-

ant role in the execution of this routine, namely monitoring alarms.

Data generation

This article is part of a larger ongoing longitudinal research program on tech-

nology and care. The article builds on data generated from the study of two

Swedish home-help providers: A and B. Care providers A and B were chosenas they have implemented a new telehealth technology and could therefore

provide rich data about this (purposeful sampling; Patton, 2004). These

providers both operate under the same laws and national health system

structure and they can be viewed as units of an organization. Several data

generation methods have been used. The author has participated at 20

sessions (McGall & Simmons, 1969; Patton, 2004) at informal and formal

personnel meetings at providers A and B during May to September 2003 and

during 200407. Field notes were taken on these occasions. Further, 38 more

focused, in-depth interviews (McCracken, 1988) with home-help managers

at different levels (n = 15), home-helpers (n = 20) at providers A and B, and

municipal care managers/gatekeepers (n = 3) in the two related munici-

palities have been conducted. The interviewed managers and home-helpers

have been employed five to 15 years. The author performed the interviews

face-to-face (30); via phone (8) on two occasions: during May to

September 2003 and during December to January 2005. Interviews started

with the author asking informants to describe the delivery of home-help

services at a general level. The author proceeded more explicitly focused on

issues related to variability and agency. Typical questions to home-helpers/

managers were: in what situations do you always perform tasks/do you

encourage tasks always being performed/ in the same way? How? Why?

When do you execute tasks differently in order to adjust to specific situations

or specific caretakers? Do you think your way of acting differs from your

colleagues way of acting? How? Why? Questions were asked in an open-ended fashion and were not specified in detail prior to the interviews,

allowing the interviewer to word questions spontaneously (Patton, 2004).

More structured methods would leave little room for unexpected issues to

emerge. Face-to-face interviews lasted for 90120 minutes; phone interviews

about 30 minutes. The author transcribed and translated (from Swedish to

English) the audio-recorded answers. The author further studied documen-

tation such as laws and service plans describing the home-help delivery.


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Finally, the author performed participant observations on eight occasions, by

joining three home-helpers at A and 1 at B during two half-days each, during

their visits to senior households. This was relevant as routines are partially

tacit (Cohen & Bacdayan, 1996). Field notes were taken from these

occasions.

Data analysis

Thematic content analysis, an interpretative process where the researcher

takes the context into consideration (Mason, 2002), was performed. First,

all transcripts and observational notes were read through to obtain a senseof the whole. Meaning units, a word, a sentence or a whole paragraph that

described the idea or execution of the home-help delivery routine were

marked. The meaning units were condensed into a description of their

content. Themes, that is, threads of meaning running through the descrip-

tions (Mason, 2002) were abstracted. During this coding process, the author

departed from the tentative, emerging theoretical framework, while at the

same time being open for unexpected issues to emerge (Patton, 2004). The

theoretical framework and thematization presented here is a result of an

iterative process, including several rounds of interpreting the empirical

material and reviewing the literature (Denzin & Lincoln, 2000). The quotes

presented below represent frequently mentioned examples encountered

during interviews/observations. On a few occasions, informants were called

during the analysis phase in order to ensure that the interpretation presented

is in accordance with their view. Further, the analysis and conclusions have

been discussed repeatedly with peer-researchers (Patton, 2004).

Empirical material

This section accounts for the day-to-day delivery of home-help services to

seniors in Sweden, which I refer to as the home-help delivery routine. This

routine stems from the Swedish social services law, which declares that all

citizens have a right to a certain level of quality of life and security (SFS,

2001:453). The social services law underlines several principles that shouldguide the provision of public services including: ensuring the individuals

dignity, autonomy and ensuring that the individual has the same living

conditions as all others, that is, normalization. These paragraphs and

national ambitions have remained over time and political shifts in Sweden.

They reflect welfare and equity principles that are deeply rooted in the

Swedish society (Social Ministry, 2005).


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Artefacts

Inscriptions in service plan documents

Many of the home-helpers have never seen the paragraphs in the social

services law. Its abstract aims have been operationalized in terms of various

predefined home-help services such as help with: making the bed; getting

up from/to bed; doing dishes; grocery shopping; overall cleaning; washing

and ironing clothes; personal hygiene, for example, showering; moving

around in the apartment/house; preparing breakfast/basic evening meal; hair

care; dressing/undressing; general supervision/check up visit; outdoor walk.

Care coordinators, employed as gate-keepers in each municipality, decidewhat service seniors in the community are to receive. The final decision, that

is, list of granted services, is documented in individual service plans, which

are executed by home-helpers. The service plans consist of rather detailed

instructions, as in the following typical example:

. . . Name: Aina [. . .]. Condition/Need: Chronic Obstructive Pulmonary

Disease, is anxious [. . .]. Granted service: Daily: Help with getting up

from bed, getting dressed, hygiene, making the bed, preparing break-

fast, at 8.30 a.m. 20 minutes. Food delivery at 12.30. Help with

preparing meal, 16.30. 15 minutes. Help with getting undressed,

hygiene, go to bed. at 22.00. 15 minutes. Once a week: Help withshower 30 minutes . . .

(Service plan document)

In many cases, the service plans remain unchanged for several years. Hence,

the service plans prescribe patterns of actions that are to be repeated by

home-helpers during long-periods of time. The home-helpers cannot make

changes in the service plans. If the home-helpers note that a seniors needs

have changed, they have to request that the care coordinator visit the senior

again and thereafter make a change in the service plans. This entails an

undesirable delay between the request and actual changes in the service

plans according to home-helpers. Still, the home-helpers appreciate the

centralized decisional order as it ensures a fair distribution of scarce publicresources:

. . . I think it is for the best. I mean, if we were to decide, we would

perhaps be tempted to grant cute seniors more services than the more

grumpy ones . . .

(Home-helper)


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Interviews further suggest that the service plans relieve the home-helpers of

some decision-making troubles:

. . . its nice to have something to depart from, that someone else has

decided, one has to make decisions all the time when out on the field

anyway . . .

Inscriptions in technology code

Municipalities are to ensure the safety of seniors, which implies a need to

somehow incorporate the detection and response to unpredictable emerg-encies in the home-help delivery routine. This task is inscribed in and partly

executed by the newly implemented telemonitoring technology. This tech-

nology continuously collects information about each seniors activity level

(via alarm devices with sensors that seniors wear on the wrist). It auto-

matically triggers alarms every time a significant change in activity level is

detected, as this can indicate an emergency. Seniors can also activate alarms

manually by pressing a button on the device. The system transmits automatic

and manual alarms to care workers.

The monitoring system always performs these tasks in the same pre-

defined way, without interruptions (except in case of technical failure) and

without variability. A manager asserts that this consistency is valuable from

a fairness point of view:

. . . The technology is always in the same mood and it does not have

any favourites . . . it triggers alarms if a divergences occurs, period . . .

in theory, it also compensates for differences between seniors in asking

for help, some seniors never demand medical service . . . until theyre

close to death . . .

(Manager)

Hence, the work of detecting emergencies has in part been delegated to the

technology. However, the technology does in turn prescribe activity of the

home-helpers: encouraging personnel to respond to the alarms that ittriggers. I will return to this point.

The ostensive aspect articulated patterns

The care managers and many of the home-helpers agree that the delivery of

home-help service incorporates more dimensions that those inscribed in


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artefacts. There is, however, variation in the informants articulated view of

what these added dimensions of the routine actually involve.

Patterns stemming from cultural values

Many home-helpers assert that it is their responsibility to provide human

contact while executing the service plans. This self-imposed responsibility

resonates with human right, welfare and equity principles that are well

established in the Swedish society:

. . . When you think about it, the service plans are merely a cover.This is not only what our work is about . . . I mean, many times,

getting help with breakfast preparation is not what actually means

something to the senior. This is not what makes him able to keep on

living alone. Im not saying that our work is NOT about delivering

these services [in the service plans], but, I mean, the oldies would not

be OK if a robot did all the food, etc. They need the energy that meeting

another person generates . . . But it would look a bit silly to write that

in the service plan, human contact, 10 minutes . . . [. . .] . . . of course,

everyone in Sweden has a right to not be completely isolated when

getting old . . .

(Home-helper)

The interviewed care managers and group leaders share this view of the

home-help delivery routine. They refer more explicitly to the social services

law in this context. A manager at provider B talks about how he expects

personnel to show warmth and act friendly when visiting seniors:

. . . you have to genuinely like elderly people to be able to perform this

job . . . [. . .] . . . I try to think about that when I recruit new people.

This has to do with maintaining the dignity of each senior, they are

vulnerable and home-helpers that serve them without showing them a

human face, without being present, without recognizing them as indi-

vidual persons can cause a lot of harm . . . I mean, our [as communitycare provider] commitment is to ensure the elderly a certain level of

quality of life and that includes being seen as a person . . .

(Manager)

. . . I mean, in former times, children took care of their old parents.

Thats not how it works today. Thats why there is social services, I

mean, it is a very Swedish thing . . . You know how the politicians keep


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saying in Sweden we take care of our elderly. I think there are even

laws about the need to treat the elderly with respect . . .

(Group leader)

Patterns stemming from individuals practical experience, that is,

from the performative aspect

Several home-helpers also account for activity patterns emanating from their

practical experience when describing the home-help delivery routine. When

home-helpers perform the service plans during long periods of time, they

gradually learn about each seniors individual but rather stable preferences.This knowledge is shared at morning meetings and it thereby gives rise to

collective behavioural patterns. Many of the home-helpers argue that this is

an important part of the routine and there are peer-to-peer expectations in

this context:

. . . weve learned that Bror cares about details concerning the shower.

He wants rather cold water first, and then gradually warmer . . . and

we have learned to be VERY careful with the shampoo when helping

Bror in the shower . . . [. . .] . . . This type of knowledge is very import-

ant to share . . . we talk about such issues at the morning meetings . . .

(Home-helper)

. . . A lot of the small but important things we do, we do each time

. . . for example, during the wintertime, we always lit up the candle on

Ruths kitchen table when preparing her breakfast, turn up the heat,

then turn on the radio and put the morning paper on the table . . .

Thats how she likes it . . . every single day. I know the others do it too.

We dont have to ask her anymore, this is what she has preferred for

ages . . . I know some [of the home-helpers] may ignore such things

but that makes me real mad . . .

(Home-helper)

The last quote illustrates that, while many workers agree on the need toincorporate senior adjusted elements in the routine, some workers have

divergent views.

Patterns stemming from the powerful prescription of technology artefacts

The home-helpers schedules are filled with the tasks specified in the service

plans. No time is formally allocated to alarm turn-outs. Hence, there is a


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conflict between the activity prescribed by the technology-generated alarms

on the one hand, and by the service plans on the other hand. There is an

undocumented, but articulated and largely agreed on, way of coping with

this conflict, namely by prioritizing the alarms:

. . . If there is an alarm, everything changes. We have to leave the

service plans aside then. The alarms have priority. One or ideally two

of us [on duty that day] have to interrupt whatever we are doing, take

the car and visit the senior in question . . .

(Home-helper)

A manager talks about the power of the alarms to alter the performances of

the home-help delivery routine:

. . . Of course, we have to prioritize to respond to the alarms . . . we

cant just leave the turn-outs for later. We have to act immediately

on emergency alarms. Otherwise, there may be legal sanctions . . .

Fortunately it is easy for new girls to understand this prioritization,

its pretty intuitive, I mean, normal people feel that there is an urgent

need to act if there is an ALARM . . . its in ones backbone . . .

(Manager)

The performative aspect

As noted above, workers do in some areas have different articulated views

of the patterns included in the home-help delivery routine. These differences

generate variability in the performance of the routine. There are, however,

additional sources of variability in the performative aspect. In general, it is

clear that the interviewees account of the way they work does not cover

the variability inherent in the home-help delivery routine. This is because

workers often enact a certain articulated pattern or treatment (e.g. provid-

ing human contact) differently depending on emergent, client-specific and

tacit factors.

Situational-interactive aspects

Observations were particularly helpful to reveal how each instance of

performing the home-help delivery routine varies with the seniors mood,

condition and the relationship between the senior and the home-helper, that

is, situation-specific aspects. Accompanying a home-helper when she

performed the instruction check up visit, 10 minutes at Sivs, I could only

observe her chat briefly with Siv, have a look to see that everything is OK,


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and then leave. I probed her if she could explain what work she actually

performed:

. . . I simply see if everything is OK . . . I really cant say exactly what

I check, it depends! [. . .] . . . I guess I check if the senior is dressed or

not. No, thats not true, Anton is always in his night robe . . . this work

is really about knowing the senior. I guess . . . what I look for is changes

from last time. Changes . . . I mean, I dont try to figure out if Kurt is

weak, he is always weak. I try to find out if he is unusually weak . . .

you have to know what is normal for each senior . . . Its very diffi-

cult to explain, I usually feel intuitively if something is wrong . . . Forexample, Ingrid is extremely tidy, and I may ask her if everything is

OK if I notice that her kitchen is not as tidy as usual . . . But at Ruths

I would react if there was NOT a mess. That is what it usually looks

like at her place . . .

(Home-helper)

Many of the home-helpers check on all the seniors they visit, while they,

for example, prepare food or make the bed. Even if this is not specified in

the service plans. How they do this varies. A home-helper explains how she

focuses her attention on different aspects depending on the situation:

. . . of course, you check on them even if this is not specified on the list.

For instance, sometimes you note a strange smell when you open the

door . . . I also hear on seniors voice, if they sound unusually weak or

start mumbling . . . Kurt, I usually touch his hand at one time or another

when I visit him, I remember recently, his hand was very cold when I

patted it. This was an indicator . . . I commented on this, but I didnt

do anything about it, but I think he felt relieved that I noted it . . .

(Home-helper)

Situation specific factors influence how the articulated and largely agreed on

need to provide human contact is realized. I observed how one and the same

home-helper switched the tone of voice, tempo and body language whentalking to different seniors, while delivering the same service on paper. A

home-helper talks about this:

For example, Helena, she had a stroke and its difficult to hear what

she says. You really have to listen carefully and . . . she takes small

breaks between the words. In the beginning, I thought she had finished

her sentences and I started to fill in, but that was detrimental, she needs

to get the chance to speak up for her self. Ive learned now to be more


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patient . . . With Anton on the other hand [I act differently.] . . . Anton

has always seen himself as a funny guy I think. I understand his jokes

and I really try to show him that I appreciate his jokes . . . I think our

laughs are crucial to his well-being and health . . . yes, Anton and I,

we have developed our own sense of humour . . . I really like to joke

with him . . . I think it makes him feel like he is still in the game . . .

[. . .] . . . of course, if he has a bad day [Anton suffers from chronic

back pain] I might not joke a lot, I may not give him a BIG SMILE . . .

I may rather tell him something to get his mind off his pain . . .

(Home-helper)

Hence, the articulated task of providing human contact is performed differ-

ently depending on the specific client and clientworker relationship.

Individuals personal views and emotional-ethical values

The quotations above show that many home-helpers add to the home-help

routine efforts to respond to situation-specific issues. This work is not docu-

mented. Why do they do this? Because they view this as part of their job

and as part of their human responsibility to help fellow beings in need.

Indeed, many of the home-helpers are driven by altruistic ideals to care for

the needy:

. . . This job is rewarding as you really feel that you do something for

people in need. Thats what keeps me going during the days . . . and I

mean, I really care for many of the seniors . . . so its natural for me to

do what I can to make them feel good while Im there. Im there

anyway right? So I might as well use my time effectively . . .

(Home-helper)

Now, all home-helpers do not share this articulated view (a disagreement

that is visible also at ostensive level) and this creates variability in the

enactment of the service plans. Some home-helpers make no effort to add

personalized dimensions to the routine. Some only do that (or less than that),which is specified in the service plans without being friendly or showing any

warmth. The findings suggest that this variability in individual performance

is influenced by the diversity in home-helpers personal views and emotional-

ethical values (and their thereby differing articulated view of what the routine

should incorporate):

. . . I think there is a difference between the girls who find pride in their

work on the one hand, and those who see it as dirty work and wish


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they were somewhere else on the other hand. If you do not like your

situation . . . you will not go that extra mile, like trying to put a smile

on the seniors face by joking a bit . . . [. . .] . . . For example, some of

them really try to do the dishes very quickly to get the time to sit down

and chat with the senior . . . others do not make this effort . . . in

general, I know there are nicer and less nice girls [home-helpers] . . .

but there is nothing we can do about that. One has to accept that . . .

(Manager)

. . . Lisa was typical, she was arrogant toward seniors. I talked to her.

She told me that her brother was a doctor and her sister some kind oflawyer. She felt pressured to start studying and get a real job . . . she

viewed this job as simple . . .

(Manager)

. . . I think we have different ideals . . . different goals with our home-

visits. Some may only aim to get them done. I always try to chat with

the seniors . . . Im brought up with that, to treat people with respect.

And further, to do whatever you do with your whole heart . . . [. . .]

. . . You know, even if Im in a bad mood, I am always friendly to the

seniors. It usually makes me in a very good mood! . . . of course, I have

to confess that I talk a little extra with my favourites, like David . . .

(Home-helper)

Individual views are in turn related to the cultural and historical context in

which they are situated. The general ambivalent social status of elderly care

work is identified as an important factor influencing the variability in home-

helpers emotion-ethical values and behaviour:

. . . this is not a well paid job. That sends signals to the home-helpers

as well as everyone else. Of course it affects the status of the job. On

the other hand, elderly care work does have some status in the sense

that it is seen as meaningful and important. People working with the

elderly are seen as nice people . . .(Group leader)

. . . This has generally been seen as a job anyone could take without

any formal education. But of course, anyone cannot do this job well.

You need to be committed and have experience to do it well. That

should have the same status as formal education if you ask me, but it

doesnt in todays society . . .

(Manager)


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Hence, as workers incorporate different cultural values, partly depending on

their private history, their articulated view of the routine (at the ostensive

level) differs. This creates variability in the performance of the routine a

variability that is attenuated by tacit, inarticulate, situational factors.

Exceptions: Highlighting the influence of personal values

The influence of the workers diverse emotional-ethical values is highlighted

in situations with competing rationalities. For example, seniors sometimes

refuse the services that they are granted. Complying with the wishes

expressed by the senior in such cases implies a divergence from the serviceplans. The home-helpers act differently in such cases, illustrated by the

following quotes:

. . . I really try to listen to the senior. I dont want to force them, say

. . . to eat for example. I think its wrong to treat another human as if

she knows nothing. Its against my personal principles. They have a

right to autonomy . . . And who am I to claim that I know better than

they do . . .

(Home-helper)

. . . Olle sometimes says he doesnt want a shower or says oh, Ive

already taken a shower! when it is obvious that he hasnt. I try to makethe shower less intimidating to him in such cases and I usually manage

to make him willing to let me shower him . . . It is a matter of their

dignity! . . . I remember when my mom was old and senile . . . she often

said no when the home-helpers told her they were to shower her. And

they just left, can you believe that!? Happy to leave I guess . . . Hence,

I found her smelling sweat and I felt so humiliated on her behalf. I often

showered her myself . . .

(Home-helper)

Another example is when the monitoring technology triggers alarms. The

home-helpers do prioritize the alarms as is agreed on. But they respond

differently to the alarms, depending on their view of what is an urgent needand what they feel is fair:

. . . Alarms can be caused by any reason . . . the senior may have had

a heart attack . . . but there are also more diffuse cases, where a senior

has pressed the button because he is lonely and anxious. Then it is diffi-

cult to know how long you should stay with the senior . . . I have a

hard time leaving the senior in such cases, Im that type. And I believe


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that one can urgently need company if one is anxious . . . it [problems

of depression and anxiety] runs in the family . . . I know others are

more rigid, and only stay if there has been a physical accident . . . of

course they just try to be fair to the others who are waiting . . .

(Home-helper)

In sum, this variability in performance can be traced back to variability in

the ostensive aspect, that is, in the workers articulated view of the patterns

that should be executed. As there is diversity in the articulated views, there

is variability in performance. The workers diverse emotional-ethical values,

which are in turn inextricably linked to the micro- (family values) and macro-(values established in the contemporary society) context in which the

workers are situated, constitute an important source of variability here.

However, there is also performative variability that cannot be explained by

ostensive differences. This variability stems from the fact that workers

execute a certain articulated/ostensive pattern differently depending on the

senior in question, and the situation. That is, differences at the ostensive level

interact with situation-interactional factors. As a result, the performative

aspect of the home-help delivery routine exhibits more variability than the

ostensive and artefact aspects.

Conclusion

The findings presented above suggest that the home-help delivery routine

incorporates various dimensions that operate in variability reducing and

variability enhancing ways.

The role of and internal relationship between the parts of the routine

The power over the routine as inscribed in artefacts (service plans and tech-

nology) is centralized and the routine as inscribed is a source of consistency

in the setting studied. The service plans represents a default way of operat-

ing that the workers can return to after making detours called for in specificsituations. The routine as inscribed in technology artefacts further operates

in a stable manner. In general, the routine as inscribed in artefacts is inflex-

ible and the routine may therefore seem static from an outside perspective.

The present exploration however shows that the routine would not survive

were it to consist merely of these inscriptions.

The ostensive aspect of the routine, that is, the content of the routine

as articulated by the workers, has a complementary role in this respect. It


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mediates between the routine at artefact and performative level. The

ostensive aspect incorporates articulated solutions to conflicts between the

prescriptions made by artefacts. The ostensive aspect is further shaped both

by individuals practical experience of executing the routine and by prevail-

ing cultural views. These micro- and macro-forces influence individuals

understanding of the role of the routine, however in different ways depend-

ing on the individual. That is, all articulated ostensive patterns are not

agreed on. Hence, the ostensive aspect of the routine recognizes and

responds to more variability than artefacts.

The performative aspect of the routine incorporates yet more

variability. It is sensitive to several more influences than those invited todirectly shape the routine at artefact and ostensive level. While differences

in the ostensive aspect generate variability in the performative aspect, there

are also other sources of variability in the performative aspect. I will return

to this point. What I want readers to note here is that the technology artefact

is a source of variability at the performative level. It creates situations with

competing concerns. As service plans do not cover such situations, many

home-helpers apply personal rules, originating in what they feel is right in

such cases. In general, many of the home-helpers complement or diverge

from the routine as inscribed in the service plan to make it work in actual

situations. The variability generated by this effort could not possibly be

covered by the routine at artefact level. Neither can it be explained merely

by variability at the ostensive level, as it is the result of an interaction between

the workers articulated view of the routine and situation-specific aspects,

including tacit, client-related and emergent issues. Nonetheless, it is a desir-

able variability. Indeed: thanks to many of the home-helpers efforts to

compensate for the inflexibility of the routine as inscribed in service plans,

these rules can remain unchanged and the routine overall can survive.

Now, this overall argument does not mean that all the variability in

the performative aspect should be embraced. I shall discuss this below.

Sources of variability in the home-help delivery routine

As indicated above, contextual contingencies (interactive-situationalaspects;Tsoukas, 1996) constitute one source of inevitable variability in the

performative aspect of the routine studied here. Now, this study suggests that

difference in workers personal values (disposition, Tsoukas, 1996) creates

another layer of variability in the (ostensive and) performative aspect. Altru-

istic convictions, acquired during the previous life history, shape workers

views of what the routine should comprise and thereby motivate many

workers to consciously addwork to the routine to respond to contextual


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contingencies in situ. Other home-helpers, who view home-help as a degrad-

ing and low-status job, often omit to fine-tune the routine in this way. Indeed,

negative emotional convictions even drive some home-helpers to do less than

what is inscribed or agreed on when executing the routine in situ. Hence, the

diversity in individuals personal emotional-ethical values constitutes an

important source of undesirable variability in the performative aspect of the

routine, which can partly be traced to variability at the ostensive level.

The salient influence of emotion-ethical values should be understood

in relation to the high frequency of exceptions (emergencies) and the resource

scarcity prevailing in the elderly care setting. These conditions create an

environment characterized by unpredictable and competing needs and aconstant call for reflective judgment about what is the right (or least bad)

thing to do. It is further crucial to note that the workers personal values are

inseparable from (produced by and reproducing) the contrasting prevailing

cultural values and norms in the contemporary society (Tsoukas, 1996) as

well as the workers diverse private backgrounds (habitus; Bourdieu, 1990).

The gist of all this is that the performance of routines is shaped by

factors beyond the routine itself, and beyond the organization in question

(see Feldman, 2003; Howard-Grenville, 2005). As a result, the performance

is difficult to predict and control.

Limitations and further researchThe present work does not set out to make generalizations but endeavours

to provide a set of propositions to be further investigated by future research.

By unpacking the routine, this study reveals organizational power

structures. The power of the routine as inscribed in artefacts is centralized

in the studied setting. However, the differences between the artefact, osten-

sive and performative aspect of the routine indicate that there is a significant

degree of decentralized decision-making. This is partly related to the fact that

workers are out alone on the field when performing the routine. Researchers

could investigate other settings where workers are informally allowed to

make decisions in situ to make the routine work but where this discretion

is not formally recognized, that is, not accompanied by status or power ofthe routine as inscribed in artefacts.

Further, this study illustrates a setting where workers express emotion

to satisfy seniors needs, use their emotions to detect (feel) what the

consumers need, and use their emotions as a guide when making difficult

decisions. Emotions clearly play various roles that cannot be covered by the

notion of emotional labour (Hochschild, 1983). This is, however, beyond the

scope of this paper and an avenue for future research.


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Finally, this study can be positioned within an emergent stream of

studies that are starting to look at the interplay rather than conflict between

rules and creativity, stability and change, reducing and responding to vari-

ability, etc. (Birnholtz et al., 2007; Gilson et al., 2005; Pentland & Reuter,

1994; Tsoukas & Chia, 2002). Research further conceptualizing such

relationships is warranted.

Theoretical implications

Previous research has recognized that there are differences between the

dimensions of a routine. It is agreed that there is an immense variabilityinherent in the performative aspect of the routine as opposed to the routine

as inscribed in artefacts (Pentland & Feldman, 2005). This article extends

these arguments in several ways.

The close look at the internal dynamics of the home-help delivery

routine shows that its survival is dependent on the fact that workers depart

from and return to, but often override the routine at artefact level. The

managers interviewed accept this. Hence, this study suggests an alternative

to the view that differences between the routine at artefact, ostensive and

performative level indicate disagreement between labour and management

(e.g. Callaghan & Thompson, 2001; Deery et al., 2004; Hanlon et al., 2005;

Taylor et al., 2002) or that divergence between the parts of a routine may

indicate resistance or serious misunderstandings about what it takes to do

the work . . . [or] a template that is outdated (Pentland & Feldman, 2005:

806). In contrast, the present study argues that the survival of the routine is

dependent on the differences between its aspects. It suggests that the routine

at artefact level can remain stable just because the ostensive and the

performative aspect differ (complement and diverge) from it. Hence, the

study supports the argument made by Toukas and Chia (2002) who write

about stability and change in general: . . . the statement the acrobat main-

tains her balance is true, as is also true the statement the acrobat

constantly adjusts her posture . . . [. . .] . . . The apparent stability of the

acrobat does not preclude change; on the contrary it presupposes it (p. 572)

(see Birnholtz et al., 2007).In general, this study underlines the need for theory acknowledging

that variability reduction is not only the aim of managers and that it is not

the only aim of managers (as is implicitly suggested in Callaghan &

Thompson, 2001; Deery et al., 2004; Hanlon et al., 2005; Taylor et al.,

2002). The findings suggest that managers, workers and consumers recog-

nize the simultaneous need to: 1) reduce internal variability (Harvey et al.,

1997) stemming from, for example, favouritism and other bias to ensure


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fairness; and 2) respond to (the inevitable) external variability (Harvey et al.,

1997) in consumer needs. This implies that variability reduction and vari-

ability response efforts should not be portrayed as antithetical, or as gener-

alized categories. Rather there is a need for nuanced accounts of variability

management in relation to routines.

This study further starts to demystify the variability in the ostensive

and performative aspect of routine. It supports the notion that situational

contingencies exist in any situation, discussing this in terms of interactive

situational issues (Tsoukas, 1996). However, it adds the insight that indi-

viduals personal values (dispositions, previous life experiences or habitus;

Bourdieu, 1990; Mouzelis, 1995; Tsoukas, 1996) shape how individualsrespond to such contingencies. More specifically, it shows that workers

emotional-ethical principles can constitute rules for how to execute a routine,

in particular in situations where there are competing concerns, and that this

creates variability in the workers articulated views and thereby in their

performance of the routine. This contributes to the literature. Previous

research suggests that individuals inarticulate and subconscious response

tendencies (Birnholtz et al., 2007; Cohen & Bacdayan, 1994) influence their

behaviour. However, as noted by Birnholtz et al. (2007) reflection (based on

individuals declarative knowledge) also plays an important role when indi-

viduals decide how to act in new, unknown situations (Birnholtz et al., 2007).

The present study extends this argument by highlighting how emotional-

ethical values influence individuals conscious efforts to make the routine

work in situ. Of course, emotional-ethical values are presumably partly

stored in individuals procedural memory as inarticulate and subconscious

response tendencies. However, the frequency of exceptions (Perrow, 1967)

and competing needs in the setting studied activates these values and forces

workers to apply them in a more conscious way. Hence, the notion of the

dispositional dimension (Tsoukas, 1996) should not only be understood as

a subconscious force that steers individuals behaviour, but also as a stand-

point that individuals can articulate and depart from when they need to

reflect on alternative ways to act.

Finally, the study highlights that technology artefacts can constitute

a source of variability and unpredictability in routines. This insightcomplements the literature that tends to equate technology with variability

reduction. Indeed, authors have referred to the variability reducing conse-

quences of protocol-laden technology without specifying if this refers to the

inscribed, agreed or performed patterns of the routine (e.g. Hanlon et al.,

2005). Further, routine studies have primarily discussed the indirect enabling

and constraining role of artefacts in terms of written rules, checklist, etc.

(Cyert & March, 1963; Howard-Grenville, 2005; Miner, 1991; Miner &


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Estler, 1985; Pentland & Feldman, 2005). This article suggests that artefacts

can be active participants in retaining and varying the routine by executing

and powerfully prescribing activity, playing an intrusive role.

In sum, this article adds to the contemporary understanding of the

internal dynamics of the routine. It further highlights that emergent factors

in the local context, including exceptions generated by technology artefacts;

individuals personal values and structures in the larger social context repre-

sent sources of variability in the routine. Hence, the present article situates

individuals enactment of the routine in a cultural and historical context, at

the micro- and macro-level (see Feldman, 2003; Howard-Grenville, 2005;

Narduzzo et al., 2000).

Managerial implications

There is today a tendency among politicians to overestimate the importance

of routines encoded in artefacts. For example, national care quality is increas-

ingly equated with thorough documentation of routines. Electronic work

logs are also gaining attention (see e.g. Social Ministry, 2005). The purpose

of such tools is ultimately to detect divergences between the routine as

inscribed and as performed, by measuring, for example, minutes spent on

each task. However, this study suggests that additions or divergences from

routines as inscribed are often necessary in the care setting.

Indeed, the smooth operation of routine studied (and the care system

of which it is a part) in fact implicitly builds on the added work performed

by many home-helpers (but not others). The ostensive aspect incorporates

the normative expectation that home-helpers will be givers, that they will

presumably driven by their own emotional-ethical conviction volun-

tarily perform many tasks to respond to various undocumented needs

among seniors that nobody but the senior notices.2 This needs to be brought

to the fore in quality discussions.

Workers emotional-ethical values should be the target of improvement

efforts and quality discussions in addition to documentation issues. I am not

suggesting more written rules, but a much more frequent articulation of the

need to reach a certain degree of consistency in how workers approach andadjust to seniors. One such way is to standardize inputs (Mintzberg, 1979),

that is, by educating personnel and ensuring shared values. Frequent

meetings and technologies supporting real-time communication between

front-line workers who work isolated out on the field is an extension of this.

In general, there is a need to look at the result rather than the process, for

example, by asking seniors about their satisfaction with the care they receive.


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Of course, the undesirable variability illustrated in this article partly

stems from the low status of elderly care work in todays society, which in

turn is rooted in wage structures, the contemporary view of body work and

of theoretical versus practical knowledge. Clearly, coming to grips with these

issues not only requires other measures than more rigid rules, it requires

structural changes.

Acknowledgement

The author wishes to thank Ali Yakhlef at the Stockholm University School of

Business, for invaluable help and is also immensely grateful for the constructiveadvice and inspiration provided by two anonymous reviewers for HumanRelations.

Notes

1 Latour views structure as a result (explanandum) rather than as a cause (explanans)(Latour, 1992; also Cooren et al., 2006).

2 To understand this situation, we need to consider that the growing number of seniors

in Sweden has not been accompanied by a corresponding increase in community

care providers budget. As a result, public resources are allocated to the most

obvious (read: physical) needs rather than more subtle, emotional needs related to

loneliness. This makes the workers efforts to strain-and-stretch the routine (e.g. by

rushing through tasks to release time to chat with seniors) crucially important.

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Anna Essn is a doctoral candidate at the Stockholm University School

of Business.Her interests include technology-based care services,knowl-

edge, learning and the body. She has just finished her thesis: Technology

as an extension of the human body. Exploring the potential role of tech-

nology in an elderly care setting. She has published in journals including

Social Science & Medicine,Managing Service Qualityand International Journal

of Medical Informatics. See further [http://www.annaessen.blogspot.com/].

[E-mail: [email protected]]


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