Public and Private Spaces in Residential Care for Older People

Abstract

This chapter presents analyzed evidence of care workers’ fine-grained verbal and nonverbal management of private vs. public space in residential care facilities for older people in Sweden. Using conversation analysis and ethnographic observations, the chapter accounts for the methods that care workers adopt to order space in a way that maintains a sense of privacy and dignity for the residents with whom they work. The analyses demonstrate how they negotiate the private and public ambiguity of space in the resident’s bathroom and in the common living room. The findings suggest that despite unavoidable clashes between private and public spheres, care workers possess methods to manage these clashes. These methods are presented in a summary of practical highlights. Mutual orientation to the neutral parts of the body, and casting the care activity as a moment of shared amusement stand out as prominent strategies that dispel potential aspects of embarrassment.

Learning Objectives

By the end of this chapter, you will be able to:

• Identify the challenges associated with the ambiguity of the private and public spaces in residential care facilities;

• Recognize methods by which care workers and others can manage these challenges.

Introduction

Disability can necessitate care that involves transgressing customary social rules concerning privacy. In particular, when disability calls for a move to a residential facility, the individual’s private territory becomes the workplace of another. While the home bathroom is one place where private matters such as bathing, washing, and bodily excreting are accomplished and in a person’s ordinary home are commonly done alone; and, while one’s living room is a public place within a home, it still has symbols, like decorations, that indicate privacy in terms of residents’ right to control this space. In a residential care center, boundaries between private and public—of both the bathroom and living room—become unclear.

In this chapter, I present observations on care workers’ and residents’ negotiating public and private spheres in residential care facilities for older people in Sweden. I focus on the private bathroom and the common living room to shed light on the complexity and diversity of the residential care facility as a semi-public environment, a place both for institutional care and personal life. The ambiguity of these two spaces and the associated challenges has been emphasized in the research literature on care work (Hauge & Heggen, 2008; Twigg, 1999, 2000). Using conversation analysis (Sidnell & Stivers, 2013) and ethnographic observations (Hammersley & Atkinson, 2007), I investigate how care staff and residents more or less successfully manage the dual nature of the residential care facility as private and public space (Fig. 11.1).

Fig. 11.1

(Source Author)

Anna hangs towel

Extract 1 illustrates the ambiguity to which this chapter is devoted. It is taken from a conversation between a resident (R) Siri and a care worker (CW) Anna during a morning care session at a dementia unit in a Swedish residential care facility. The care activity takes place in the resident’s private bathroom. Siri has been toileting and is at present standing at the basin washing her hands. Anna is assisting the resident with small tasks. In line 1, Anna takes a towel and hands it to Siri.

Extract 1: Ambiguity in the residential care environment

01.	Anna: (CW)	varsågod here you are + hands over a towel to Siri +
02.	Siri: (R)	tack thank you
03.		(2.0)
04.	Siri:	va söta dom här handdukarna e how pretty these towels are
05.	Anna:	javisst e’rom gulliga yes they are cute aren’t they
06.	Siri:	såna här skulle ja behö- (.) kan du köpa nåra I could use some of the-  (.) could you buy some
07.		såna här till min bo- (.) privata bostad I need that at my ho- (.) private home
08.	Anna:	ja de kan vi göra yes we can do that
09.	Siri:	dom var jättesöta tycker ja they are super pretty I think * holds the towel in her hands ------->
10.	Anna:	m:m (0.5) jättefin färg e’re m:m (0.5) a super nice color
	siri:	--------------------------------->
11.	Siri:	(xxx) ja dom e söta (xxx) yes they are pretty ----------------------------*
12.	Anna:	ja↑: yes
13.		+ hangs the towel on the towel dryer ---> #fig.11.1
14.	Siri:	de kan du skaffa till mej you can buy those for me
	Anna:	--------------------------- -->
15.	Anna:	de kan ja skaffa till dej (.) om inte du vill följa I can buy them for you         (.) if you don’t want to come ------------------------------+
		me å handla with me and go shopping

This extract exemplifies care staff and residents managing the ambiguous boundaries between public and private spheres in a care facility. Siri in Extract 1, who is diagnosed with dementia, needs help with her daily hygiene in her private bathroom space that is simultaneously Anna’s workspace. While asking for and receiving help, Siri and Anna talk about towels (line 04). Talking about something other than the body, such as a physical object in the surrounding environment, in the current case a towel, takes away the focus from the care activity (Ridell, 2008) and the breach between private and public space.

What is noteworthy is not only the use of language as distraction, but also the way the resident refers to her presently living at the care facility as temporary, with the towels as alien objects that do not belong to her. The towels have been purchased by the care staff and paid for with the resident’s money. As such, they are meant to be seen as the resident’s belongings. In the sequence above, Anna and Siri praise the towels, but the towels are portrayed as no one’s private possession. The fact that Siri asks the care worker to buy this specific kind of towel for her private home (lines 06–07) supports the notion that home is someplace else, and that her place at the residential care facility is not home. In line 14, Siri asks Anna to buy those towels for her ‘real’ home: ‘de kan du skaffa till mej’ (you can buy those for me). Anna’s reply, ‘de kan jag skaffa till dej’ (I can buy them for you) contributes to the portrayal of the towels as semi-public objects, detached from personal ownership, and something one can observe and admire from a distance, something Siri admires and would like to have as her own.

Viewing one’s place at the residential care facility as only temporary is a common strategy used among residents to create a sense of control and belonging (Falk, Wijk, & Falk, 2012). Despite the fact that Siri has lived at the care facility for several years, and will probably do so for the rest of her life, her old residence would always be her home. Even though Anna did her best to personalize Siri’s room (e.g., towels), Siri’s sense of ‘home’ lies outside the institution.

Over the last decades, the negative effects of institutionalized care have become better understood; from this, the recognition of older people’s need for and right to privacy has developed. As a consequence, attempts have been made to profile residential care facilities as real homes. One measure has been to arrange common living rooms with elements that can be seen as typical symbols that mark a living room in a home. Another has been to design small-scale environments with single rooms and private bathrooms that make room for residents’ personal belongings. Despite these attempts, research indicates that problems associated with the institutionalization of older people’s care, such as loss of privacy, remain (Heinemann, 2011; Jansson, 2016), and residents are limited in maintaining privacy or exerting control (Hauge & Heggen, 2008)—all of which are key characteristics of a home according to social anthropologists (e.g., Douglas, 1991). The effects of such loss can be the cause of both physical and mental decline (Williams, 2011). In line with this argumentation, Falk et al. (2012, p. 1006) advocate for a clearer demarcation between the public and private, which would provide less ambiguous signals to care staff and residents.

In prior ethnographic research, residential care has often been described as negative (Allan & Crow, 1989; Goffman, 1961; Grainger, 1993; I. Higgins, 1998; J. Higgins, 1989; Lee-Treweek, 1994, 1998; Makoni & Grainger, 2002; Nussbaum, 1993; Twigg, 2000). In Goffman’s (1961) terms, the residential home is a ‘total institution’, a stigmatized world where the person is made subject to collective regimes. The literature on residential care accounts for a world where private space such as bathrooms ‘become some of the most public rooms where personal territory and dignity are frequently invaded’ (J. Higgins, 1989, p. 145), and where residents ‘have few personal possessions with which to maintain their sense of self’ (Twigg, 2000, p. 134). It is particularly the absence of privacy, the power to shut the door and exclude the public world outside, that is described as one of the most disliked aspects of living in residential homes (Allan & Crow, 1989). In contrast to previously reported negative aspects of life in residential homes, this chapter highlights the brighter side of institutional care. The purpose of the chapter is to account for methods that care workers adopt to order space in a way that maintains a sense of privacy and dignity for the resident.

After discussing the data, the analysis is divided into two sections. In section “The Ambiguous Space of the Bathroom” (Extracts 2–5), I demonstrate how care workers negotiate their presence in the resident’s private bathroom during morning care, and how they manage the body as spatially arranged according to gradations of privacy (cf. Twigg, 1999). The setting in section “The Ambiguous Space of the Common Living Room” (Extracts 6–7) is the common living room. I describe the strategies by which a resident creates a sense of home and privacy in the common living room and demonstrate how this leads to problematic situations that the care staff has to manage. Finally, I give a short summary of the practical highlights of the study.

Data

Data are drawn from two larger projects on communicative practices in older people’s care in Sweden headed by the author of this chapter (Jansson & Nikolaidou, 2013; Jansson, Wadensjö, & Plejert, 2017). Ethnographic fieldwork was conducted in six residential care facilities for older persons in Sweden, several hours each week, during day and evening shifts, between January 2010 and June 2011, and from May 2014 to June 2015. A combination of participant observation and video-recordings was used to generate comprehensive insight into the overall routines per setting. For this chapter, field notes and audio-/video-recordings at three care units in two residential care facilities are used. One is a somatic unit hosting residents—the primary challenges lie in the area of mobility (dementia symptoms for some develop after admission). Two are dementia units hosting residents with neurological challenges. The observations presented in this chapter are based on 72 diaries of field notes and approximately 30 hours of video documentation of staff-resident interaction.

Participants who figure in the examples analyzed are four residents in their eighties (three females and one male under the pseudonyms Adila, Minna, Siri, and Ove), and five care workers (under the pseudonyms Medina, Stina, Anna, Moa, and Ivan). Minna, Siri, and Ove are diagnosed with Alzheimer’s disease and are residents at dementia units. They are in the intermediate stages of the disease and receive help with their daily hygiene. Minna and Siri walk with trolleys (i.e., walkers), while Ove walks without an aiding device. Adila, who is wheelchair bound, is an Arabic-speaking resident living at a somatic unit. She immigrated to Sweden from Syria during old age. Whereas Adila and Siri have lived at the care facility for several years, Minna and Ove are rather new admittances.

Audio data have been transcribed according to conversation analytical principles (Ochs, Schegloff, & Thompson, 1996). Drawings illustrate bodily conduct. Embodied actions are transcribed according to conventions developed by Mondada (2014), see annotations presented in Chapter 1. Conversational video-recorded data in Arabic have been transcribed and then translated into Swedish by a proficient Arabic speaker. Translations from Swedish into English were made by the researcher and proofread by a Swedish-speaking, English native speaker. Each Swedish utterance is given an English translation in italics beneath it. Translations of Swedish into English are meant to be comprehensible, albeit not always altogether idiomatic.

Ethical Considerations

Data were collected in accordance with ethical guidelines established by the Swedish Research Council, and approved by a Regional Committee for Research Ethics (Dnr 2009-2003-31; Dnr 2013/2211-31). All care workers and residents in the study gave consent to participate. The staff, residents, and their relatives were informed about the aims of the study and about their rights as participants by means of a letter and in personal encounters with the researchers who conducted the data collection. The Arabic-speaking resident received information about the project in her language. During the observations and recordings, researchers were on alert for any signs of the residents’ unwillingness to be observed or recorded. All names have been changed to pseudonyms in the transcripts.

The Ambiguous Space of the Bathroom

While Extract 1 casts light on the unclear boundary between public and private that signifies the very nature of the care facility, in this section, I focus specifically on bathroom interactions, through which care workers negotiate their presence in this ambiguous space. The bathroom, whether in a person’s ordinary home or in a resident’s room at a care facility, is a place associated with intimacy and the primary care of bodies. It is a dedicated space relatively hidden from strangers, where private matters such as bathing, washing, and bodily excreting are accomplished. In a person’s home, these activities are commonly done alone or in the company of close intimates (cf. Twigg, 1999, 2000). Any disability necessitating intimate care involves transgressing customary social rules concerning privacy. Within the care unit, the private territory of the individual then becomes the workplace of another; thus, trespassing on and reordering the divisions between public and private.

In a residential care facility, the bathroom is the place where the basic work of washing bodies takes place. As noted by Twigg (2000, p. 145) and demonstrated in ethnographic studies (Grainger, 1993; Jansson & Plejert, 2014; Plejert, Jansson, & Yazdanpanah, 2014), bodywork in care may involve embarrassing or painful procedures. Lee-Treweek (1994) shows how these aspects of care have to be managed spatially by being confined to the privacy of back bedrooms and bathrooms of the institution in order to present older persons clean and dressed in communal areas.

Examples analyzed in this section are drawn from morning care sessions at two different dementia units. In all examples, residents receive help with intimate care of the body (e.g., undressing, showering and massaging the body with lotion). Previous studies have highlighted some of the potential challenges associated with the task of assisting residents with intimate care and report on methods that can be used to minimize residents’ opposition (Heinemann, 2009; Jansson & Plejert, 2014; Plejert et al., 2014; Yazdanpanah & Plejert, 2017). The role of humor (Heinemann, 2009) and body movement has been emphasized as crucial resources (Yazdanpanah & Plejert, 2017). The extracts below attend to care workers’ use of bodily conduct to maintain an aspect of spatial privacy for residents during these care activities.

Maintaining Spatial Privacy

Care workers in Twigg’s (1999) study report they would deliberately exit the bathroom and wait in the hall while clients bathed. This way of consciously maintaining an aspect of spatial privacy for the client does not occur in my data. One reason could be that the residents in my study, due to physical and cognitive impairment, require more assistance with the care activity. One reason might be that showering is a more ‘advanced’ activity to perform compared to sitting in a bath. While residents were put in shower chairs, the risk that they might fall remained. Additionally, maneuvering the shower tube (e.g., hose) requires finely tuned, coordinated movements, a procedure that was rarely left to residents.

Since care workers in my study could only leave residents out of sight momentarily, they only had at their disposal the area of the bathroom itself and, in many cases, the shower cabin to maintain a certain degree of privacy for residents. One strategy commonly observed among the care workers was to hand over the soap to residents and encourage them to wash their own bodies. During which, the care worker handled the maneuvering of the shower tube while keeping a certain corporeal distance from the resident, thus allowing the resident to retain some of the sense of being alone. Extract 2 exemplifies such a strategy. The extract involves a male resident (R) Ove and a female care worker (CW) Moa. Ove was sometimes perceived by the care workers as a ‘difficult’ resident, particularly when it came to showering. They reported that he often refused to shower or reacted with challenging behavior. In this particular case, the resident knew the care worker and, as will be shown, the two got along rather well. The camera is directed toward the care worker. The resident, who is hidden behind the shower curtain, is out of camera shot. The curtain is half open, so it is possible to see the care worker’s actions. The extract begins a few minutes into the shower when Moa is rinsing shampoo from Ove’s hair.

Extract 2: Moa is rinsing the shampoo from Ove’s hair with the shower tube

01.	Ove: (R)	ho ho ho ho
02.	Moa: (CW)	∆ bends down; rinses the shampoo from O’s hair -----> #fig. 11.2
03.	Moa:	du ser ut som en riktig sportdykare you look like a real sport diver ------------------------------------------
04.		(10.0) (( M rinses the shampoo ))
05.	Moa:	varsågod Ove      (.) nu får du tvätta dej here you go Ove       (.) now you can wash yourself ---------------------------------------------∆
06.		så sköter jag vattnet I will take care of the water then ∆ raises body --------∆ #fig.11.3
07.	Ove:	(ja)ha well yes
08.	Moa:	m:↑m m:↑m
09.		(4.5) (( showering goes on ))
10.	Moa:	∆ takes a step aside; gazes downward ---------------------------------->> #fig. 11.4
11.		(2.0) (( showering goes on ))
12.	Moa:	kan man se som lite morrongymnastik samtidigt (.) you can regard this as some morning exercise at the same (.)
13.		eller h↑u:r. time can’t you
14.	Ove :	ja [man får göra de ja    (.) (man) får stå på h(h)änderna yes you may do that yea (.) (you) may stand on your hands
15.	Moa:	[j¿:a      [y:ea
16.		he he      [he he he (( laughter ))
17.	Ove:	[hi hi hi hi .h he he he he .h (.) ja:a                            ((laughter))                  (.) ye:a

In line 02, Moa bends down and rinses shampoo from the resident’s hair (Fig. 11.2). She is now inside the shower cabinet and close to the resident’s body. At this moment, when the water is raining down from Ove’s head, Moa likens him to a sport diver. This is a delicate moment in the shower activity as something is being done to the resident (Jansson & Plejert, 2014; Twigg, 2000). The care worker controls this task; the resident is not allocated any active part of the task. Still, the way the resident is portrayed as a sport diver invokes a masculine and vigorous identity, and dispels any potential unpleasant or threatening experience of the hair wash. Having finished the hair wash, Moa leaves the washing of the body to the resident (lines 05–06), ‘varsågod Ove (.) nu får du tvätta dej så sköter jag vattnet’ (here you go Ove (.) now you can wash yourself I will take care of the water then). She raises, withdraws her left hand, and maneuvers the shower tube with her right hand (Fig. 11.3). In line 10, she takes a step aside in an outward direction from the cabinet area (Fig. 11.4), withdrawing herself physically from the resident. Half her body is now outside the shower cabin, her left arm touching the basin behind her. Her gaze is directed downwards. Through this change of body posture and gaze, Moa distances herself from the resident and the act of washing, both with her body and with her gaze, thus establishing a sense of integrity and privacy for the resident. Now partly out of sight for the resident, only the care worker’s face and her right arm with which she maneuvers the shower tube is in Ove’s sight. Moa remains in this posture throughout the washing. After seven seconds only the sound of running water, the care worker introduces a joke (lines 12–13), ‘kan man se som lite morrongymnastik samtidigt (.) eller h↑u:r’ (you can regard this as some morning exercise at the same time (.) can’t you). Ove responds with laughter in his voice, conveying amusement (line 14), ‘ja [man får göra de ja (.) (man) får stå på h(h)änderna’ (yes you may do that yea (.) (you) may stand on your hands). This response indicates that Ove endorses the care worker’s jocular categorization of the shower as morning exercise. Moa starts laughing, and Ove overlaps with laughter resulting in joint laughter (lines 16–17).

Fig. 11.2

(Source Author)

Ove behind shower curtain; Moa rinses shampoo from Ove’s hair

Fig. 11.3

(Source Author)

Moa attending to water

Fig. 11.4

(Source Author)

Moa stepping aside

In Extract 2, body posture and gaze direction stand out as prominent resources for the management of spatial privacy. The jocular tone dispels potential aspects of embarrassment invoked by physical exposure. The washing of the body, a private matter accomplished in the presence of another, is thereby cast as a moment of shared amusement. All this contributes to preserving some sense of autonomy for the resident.

Managing the Spatial Ordering of the Body

Help with the shower task represents not only the intrusion of professional care into the most private territory of the resident’s apartment, the bathroom, it also involves transgressing customary social rules concerning the exposure of the body, which is itself spatially ordered according to gradations of privacy (Jourard, 1966; Jourard & Rubin, 1968; Twigg, 1999). This has implications for the care encounter, which is discussed in the analysis of Extracts 3–5. The willingness of persons to allow others to physically contact their bodies via sight and touch is a function of the closeness of the relationship. Extracts 3–5 illustrate how care workers manage this spatial ordering of the body during intimate care.

Thinking Points

• 1. Maintaining physical and visual distance during private activities may contribute to a sense of autonomy, control, and dignity to the resident or care recipient.

• 2. Using humor during assistance within private spaces may also relieve stress and help establish a congenial rapport between caregiver and care receiver.

In Extract 3, the care worker (Moa) and the resident (Ove) become involved in a small talk sequence that starts with Moa complimenting the resident’s feet. The compliment breaks a longer silence while Ove washes his body (line 18). During this silence, the care worker’s gaze is directed downwards.

Extract 3: Moa and Ove continuation of shower

18.		(2.0) (( M holds the shower tube; gazes downwards ))
19.	Moa:	vilka fina fötter du har what nice feet you have ∆ looks down at O’s feet; turns body aside -----> #fig. 11.5
20.		(0.5)
21.	Ove:	ja verkligen yes really
	moa:	----------→
22.	Moa:	ja jättefina yes really nice --------------→
23.	Ove:	ja:a de var ju vänligt yeah that was really kind
	moa:	----------------------------∆
24.	Moa:	dom var  (xx) dom var snygga att titta på they are (xx) nice to look at #fig. 11.6
25.		(0.7)
26.	Ove:	he he he (( laughter ))
	moa:	----------∆
27.	Moa:	faktiskt really
	moa:	∆ bends her upper body down ------------>> #fig. 11.7
28.		(2.0) (( showering goes on ))
29.	Moa:	man ska vara rädd om fötterna you should take care of your feet
30.	Ove:	javisst ska man de yes indeed you should
31.	Moa:	m:: (.) dom ska bära en he:la livet m::  (.) they should carry you your whole life
32.	Ove:	oj oj oj oh oh oh
33.	Moa:	ja::↑a ye::a
34.	Ove:	å dom sparkar på en å and they kick you also
35.	Moa:	ja:::[de gö’rom ye::  [a they do
36.	Ove:	[he he he he he              ((laughter))

In line 19, Moa looks down and compliments Ove’s feet with a praise assessment (Fig. 11.5), ‘vilka fina fötter du har’ (what nice feet you have). Ove makes the same evaluation and agrees, ‘ja verkligen’ (yes really). In response, Moa proffers a second assessment, ‘ja jättefina’ (yes really nice). The resident shows appreciation for the compliment, ‘ja:a de var ju vänligt’ (yes that was really kind). In line 24, the care worker turns her body aside and withdraws the shower tube (Fig. 11.6), while offering more praise, ‘dom var snygga att titta på’ (they are nice to look at). The resident responds with amused laughter (line 26). In line 27, Moa bends down and asserts her positive evaluation, ‘faktiskt’ (really). She bends her upper body down so as to come closer to Ove’s feet with her gaze (Fig. 11.7). This reciprocal praising of the resident’s feet is followed by a small talk sequence focusing on feet in general (lines 29–35).

Fig. 11.5

(Source Author)

Moa gazes downward

Fig. 11.6

(Source Author)

Moa looking down

Fig. 11.7

(Source Author)

Moa gazing at Ove’s feet

As the interaction in this extract occurs during the washing of the body, the care worker, assisting the resident when needed, runs the risk of being cast into the role of an observer, a role that might be sensitive given the resident’s nakedness. The small talk sequence about Ove’s feet and about feet in general break a potentially embarrassing silence. As such, the reciprocal praising and the way the participants agree with one another help to create and reinforce social affiliation (Pomerantz, 1984). In addition, it helps the participants avoid focusing on sensitive parts of the body.

Thinking Points

• 1. Small talk during assistance in private spaces during private acts such as showering may alleviate the care receiver’s embarrassment or feelings of intrusion.

• 2. Through careful diversion of body and gaze, the caregiver may circumvent awkwardness that may occur in self and in the care receiver.

The next example (Extract 4) involves a male care worker Ivan and a female resident Minna. The example is drawn from an audio recording during a morning activity in the resident’s bathroom, as the resident is undressed and prepared to shower. In this example, the locus of shared attention is the resident’s shoes. From the care worker’s procedural talk preceding the extract, the task of undressing, except for the shoes, has been carried out when the extract begins.

Extract 4: Ivan and Minna focus on shoes

01.	Ivan: (CW)	så:    (.) nu får du sätta dej there    (.)now you can sit down
02.		(18.0)(( scratch sound ))
03.	Ivan:	vilka fina skor du har Minna what nice shoes you have Minna
04.	Minna: (R)	m:
05.	Ivan:	ja::. var har du köpte dom? yea where did you buy them
06.	Minna:	de var länge sen it was a long time ago
07.	Ivan:	de var       [länge sen it was a           [long time ago
08.	Minna:	[de vet ja’nte                              [I don’t know
09.	Ivan:	ja:::. men dom e jättefina ye:::a but they are really nice
10.	Minna:	ja de e’rom yes they are
11.		(3.0)
12.	Minna:	ja måste ha strumpor på mej I must have socks on
13.	Ivan:	ja de ska du få (.) men ja tänkte bara yes you will         (.) but I only thought
14.		ta av den hära         (.) d[å får du nya kläder I’d take off this one    (.) then you will have new clothes
15.	Minna:	[å: då fryser ja ihjäl ännu mera                [ oh then I will die of cold even more
16.	Ivan:	ja f[örstår de    (.) ja ska stänga dörren I understand that  (.) I will lock the door
17.	Minna:	[å va hemskt   [ oh how awful
18.		(2.0)
19.	Minna:	de e så kallt it’s so cold
20.	Ivan:	ja: yea
21.	Minna:	de e så kallt (.) å: de e som de var ute it’s so cold    (.) oh it’s as if we were outdoors

Ivan begins by asking the resident to sit down on the shower chair. Minna has just been undressed, her nightdress and her trousers taken off. The vulnerable parts of the resident’s body are thus exposed; only the feet are covered. The compliment in line 3 breaks a rather long silence, when Ivan then takes off the resident’s shoes. The small talk about Minna’s shoes helps the care worker defuse tensions and mitigate the experience of being exposed. In addition, it helps the care worker avoid talking about the more private parts of the body. In line 12, Minna objects to having her socks taken off, the only clothing sheltering her body. When Ivan suggests removing the socks, despite Minna’s expressed desire to have them on, ‘men ja tänkte bara ta av den hära’ (but I only thought I’d take off this one), the resident escalates her opposition with an extreme case formulation (Pomerantz, 1986), ‘å: då fryser ja ihjäl ännu mera’ (oh then I will die of cold even more [emphasis added]). Despite Ivan’s negotiations, the continuation of the interaction, marked by opposition and complaining, embodies the vulnerability that frames the care encounter.

Thinking Points

• 1. Complaints by care recipient may, indeed, be diversions from the discomfort of the loss of privacy.

• 2. Co-participants may consider acknowledging such complaints as a way to maintain the care recipient’s dignity and relieve tensions arising from the necessity of occupying the care recipient’s private space.

In Extract 5, which involves Siri and Anna, neutral areas of the body—the back and the hands (Jourard, 1966)—are emphasized. Siri has had a shower and is presently sitting in a chair in the hall outside the bathroom (see Fig. 11.8). Prior to this extract, Anna has towel dried the resident’s back.

Fig. 11.8

(Source Author)

Anna focuses on Siri’s hand

Extract 5: Siri and Anna focus on neutral areas of the body

01.	Anna: (CW)	(2.0)+ massages Siri’s back with lotion ------>
02.	Siri: (R) anna:	å va skönt de va på ryggen oh that felt good     on my back ----------------------------------+
03.	Anna:	m:m (.) ˚ja ska ta˚ m:m  (.) I’ll take + moves hand to Siri’s arm +
04.		(1.5) (( A massages Siri’s left underarm with lotion ))
05.	Anna:	va fin du e på arm- händerna nu your arm- hands look really nice now + massages Siri’s left hand; caresses it with her index finger -------------------+ #fig.11.8
06.	Anna:	+ massages Siri’s hand ----->
07.	Siri: anna:	Ja yes ---+
08.	Anna:	nu e’ru inte alls så där narig som du var ett tag now you are not at all as chapped as you were + massages Siri’s left arm ----------------------->
09.		------+(0.5)
10.	Siri:	ja ja   (.) jo ja e rädd om de för att ja [spe- yea yea  (.) well I take care of them since I pla-
	anna:	+ massages Siri’s left hand ------------------>
11.	Anna:	[ja:                                                                                                  [ye:a
12.	Siri:	spelar ju så att play so
13.	anna:	----------------+(0.5)
14.	Siri:	[man kan [ one can
	anna:	+ massages Siri’s left arm ---->
15.	Anna:	[man måste va rädd om dej [ someone needs to take care of you ------------------------>
16.	Siri:	använda händerna till de use your hands for that
	anna:	-----------------------+
17.	Anna:	precis exactly + moves her hand to Siri’s back ----->>

Anna is applying lotion to Siri’s body with gentle massaging movements, sheltering Siri’s back with a towel (line 01). The resident assesses this as comfortable and nice (line 02). Anna continues rubbing the resident’s left arm, and when she arrives at Siri’s hand, she bends her upper body down so as to come closer to the resident’s hand with her gaze (Fig. 11.8). While caressing Siri’s left hand, she compliments the quality of her hands. Anna then moves to Siri’s arm. She holds the resident’s hand as she massages the arm with lotion, remarking that her hands are no longer chapped (lines 08–09). Anna’s compliment opens up a conversation about Siri’s hands and the role of hands. As Anna continues massaging the resident’s hands and arms (lines 10–17), Siri indicates that she takes care of her hands, emphasizing she plays the piano, which Anna approves.

By highlighting Siri’s hand—focusing her gaze and complimenting it—the care worker minimizes attention to the resident’s more private parts of the body. In compliance, the resident makes her hand accessible to visual and tactual contact. This mutual orientation of the participants’ bodies toward the region of the resident’s body they are discussing and working with creates a public focus of attention, allowing the private to remain private.

Thinking Point

Diverting talk and attention to neutral areas of the body such as feet, hands, or back during assistance in private spaces such as the bathroom may mitigate the stress and awkwardness the care receiver may experience during these times.

The Ambiguous Space of the Common Living Room

In this section, I use an example from a somatic unit that illustrates the clashes between private and public in the ambiguous space of the common living room. I demonstrate how care workers manage these clashes that emanate from unclear boundaries. The example is divided into two extracts, 6 and 7.

One theme evolving from the empirical data in the study of Hauge and Heggen (2008, p. 464) was the lack of social relationships between the residents: ‘[T]he residents live their everyday lives in a room with ambiguous boundaries and have hardly any social relationships among themselves’. Those residents who were mobile typically withdraw to their own rooms to maintain a degree of privacy. Adila, by contrast, has created for herself a private sphere in a corner of the common living room, spending up to 10 hours a day here, making it her habitual place. Adila usually sits in an armchair with a small table beside her where she has her afternoon coffee (see Fig. 11.9). On the table she has a bottle with water she uses for watering the potted plants. Consequently, the care staff also considered this corner Adila’s space.

Fig. 11.9

(Source Author)

Repotting activity

Extracts 6 and 7 are drawn from an episode in which a care worker (CW) Stina is engaged in repotting the plants in Adila’s habitual place (see Fig. 11.9). Elsa, a Swedish-speaking co-resident of Adila’s, is sitting in her wheelchair watching the activity. The repotting was scheduled by the care staff as a social activity set up for all residents at the care unit.

Notably, Adila regards the plants as her private belongings: she takes care of them and waters them daily. Some plants are from exotic fruit seeds that her son has bought for her. When Extract 6 begins, Adila and an Arabic-speaking care worker (CW) Medina are approaching. Adila, having napped for an hour in her room, has not been informed about the repotting activity. Upon viewing the mess of soil on the table, she becomes upset. The analysis focuses on the care workers’ practices in turning Adila’s indignation into amusement.

Extract 6: Indignation to amusement

01.	Stina: (CW)	hej Adila. hello Adila. ¤looks at Adila----->
02.		(0.5)(( Adila and Medina are approaching ))
03.	Medina: (CW) stina:	shoufi       [shou aam ya´amloulek bi look what they are doing with ----------------------------------------
04.	Stina:	[he::j.                               [hello                                -------¤
05.	Medina:	zara’tek shoufi your plants look
06.		(1.1) (( Stina leaves hold of the plant ;
07.		steps forward on the floor gazing at A ))
08.	Adila:	shou dakhalltili bi zar´ati
	(R)	what do you put in my plants *makes a hand point*
	stina:	¤ moves the tray with soil aside ---¤(0.5)
	medina:	+ smiles ------------------------+
09.	Medina:	hhhhh(.)£va g¿ö:r du me mi- he(h)nnes£ h[hhhhhhh what are you doing with m- her
	stina:	¤ smiles and looks at Adila -------------------->> #fig. 11.10

When Adila approaches, Stina looks up from the plant and greets her (line 01). In line 03, Medina bids for Adila’s attention with a smile, ‘shoufi shou[aam ya´amloulek bi zara’tek shoufi’ (look what they are doing with your plants look). The fact that Medina assesses the event as something remarkable is corroborated by the fact that she recycles the verb ‘shoufi’ (look) and refers to the plants as Adila’s by use of the Arabic possessive suffix /tek/(your) in ‘zara’tek’ (plants- your). Arriving where the repotting is occurring, Medina turns away from Adila and places her wheelchair in a position right in front of Stina, who is standing at the table with the plants. Stina also makes arrangements to create space for Adila and invites her to participate. She greets Adila, steps forward and moves aside a tray with soil. The care workers’ bid for attention encourages Adila to display emotion. In line 08, seeing her potted plants, the mess of soil, and empty pots on the table, she responds with indignation. Pointing with her hand and gazing at the plants on the table, she issues a question in Arabic with an indignant voice, ‘shou dakhalltili bi zar´ati’ (what do you put in my plants), thus assessing the local scene as an unexpected and accountable event (Fig. 11.10). Following Adila’s reaction, Medina starts laughing (line 09). She turns her gaze to Stina and voices Adila’s Arabic speech in Swedish for her. Medina’s rendition of Adila’s response cry (Goffman, 1981) is produced with a high pitch and within-speech laugh particles conveying a stance of amusement, ‘£va g¿ö:r du me mi- he(h)nnes£ h[hhhhhhh’ (what are you doing with m- her). This change of framing (Goffman, 1974) constitutes a shift in affective stance compared to Adila’s prior talk, a switch from serious indignation to agreeable surprise and amusement.

Fig. 11.10

(Source Author)

Repotting configuration of participants

In Extract 7, which follows eight seconds after Extract 6, the Arabic-speaking care workers explain to Adila what Stina is doing with her plants. I demonstrate how the care workers cast the complainable event, the repotting of Adila’s plants, as an activity worthy of praise and how Adila eventually aligns with this frame.

Extract 7: Working towards alignment

20.		(( 8 seconds of recording; Adila displays indignation ))
21.	Medina:	aam behoutollon trab ahmar they are putting red soil into them + points at the table with pot plants +
22.		>ja sa dom [behöver< jo::rd I said they need soil +gazes at Stina-------------+
23.	Stina:	[ny: j¿o::rd.                            [new soil                           ¤gesticulates; looks at Adila¤
24.	Stina:	ja::a (.) ja::   (.) (xx) yea       (.) yea          (.) (xx) ¤ looks at Adila --------->>                          ∆smiles; tilts head aside∆
25.	Medina:	lazemlen trab       ahmar       jd¿id, (.)hadjeh. they need new red soil lady + points at the tray with soil on the floor +
26.	Adila:	bra[: good * nods and smiles * øgazes at Stina--------->>
27.	Stina:	[hon tycker de e henne     [s blommor     [she thinks that they’re       [her flowers
28.	Medina:	[bra:vo (.)                                                                  [bravo (.)
	adila:	*smiles----->>
29	Medina:	hon                         [tycker bra:↑vo she                             [thinks bravo
30.	Stina:	[hhhhahahhahahaha[hahahahahahaha                                       ((laughter))
31.	Medina:	[hahahaha                                ((laughter))

Medina explains to Adila in Arabic that they are adding fresh soil, ‘aam behoutollon trab ahmar’ (they are putting red soil into them). By emphasizing the initial syllable while making an extended hand pointing at the table with potted plants, she describes the event as something worthy of attention. She then turns to Stina and reports in Swedish what she just said in Arabic to Adila (line 22), ‘>ja sa dom behöver < jo::rd’ (I said they need soil). Stina looks at Adila and highlights the material, the new soil, in Swedish, ‘[ny: j¿o::rd’. (new soil). While pointing at the tray with soil on the floor, Medina rephrases in Arabic the information about new soil that they have collectively emphasized in the preceding talk in Swedish, ‘lezemlen trab ahmar jd¿id, (.) hadjeh’. (they need new red soil lady). In response, Adila evaluates the repotting as worthy of appreciation with the assessment term ‘bra:’ (good) in Swedish. She holds her gaze on Stina while smiling and nodding. In line 27, Stina emphatically aligns with Adila’s display of indignation in previous turns by confirming the fact that Adila regards the plants as hers, ‘hon tycker de e henne[s blommor’ (she thinks that they’re her flowers). In overlap, Medina rephrases Adila’s assessment turn in Swedish with an upgrade, ‘bravo’ (bravo) that she subsequently recycles, ‘hon tycker bra:↑vo’ (she thinks bravo). Stina responds with a stream of laughter (line 30) and Medina overlaps with further laughter resulting in laughing together.

The grounds for Adila’s indignation in this example may appear unresolvable. It may well be the case that Adila’s having a specific habitual place in the common living room has created a sense of home for her and an ‘attachment to space’ (cf. Falk et al., 2012, p. 1003). As viewed from an institutional perspective, the corner where Adila has her habitual place is a public space and hence no one’s private sphere. Even though Adila takes care of the potted plants as if they were hers, they are no one’s private belongings. Most have been bought by the institution as part of the public decoration of the care facility. Potted plants can, however, be seen as typical symbols that mark a private living room. In her challenging question to the care workers (Extract 6, line 08), ‘shou dakhalltili bi zar´ati’ (what do you put in my plants), Adila refers to the plants as hers. Also the care workers refer to the plants as Adila’s (see Extract 6, line 05 and Extract 7, line 27). This is their way of aligning with Alina’s ownership of the plants and the possible transgression she experienced when not informed about the repotting of her plants.

Summary

In this chapter, I have presented observations on care workers’ and residents’ negotiation of public and private in residential care facilities for older people in Sweden. From the data, I account for the methods that care workers adopt to order space in a way that maintains a sense of privacy and dignity for the resident. I demonstrate (1) how care workers negotiate their presence in the ambiguous space of bathrooms; (2) how they manage the resident’s body according to gradations of privacy. I show that body posture, gaze direction, and reciprocal praising stand out as prominent resources for this management. The analysis attests to how the participants mutually orient to the neutral parts of the body, such as the feet and the hands. Focus on the neutral regions of the body (or with accessories such as the shoes in Extract 4) allows both care workers to avoid contact with more private parts and all participants to avoid naming these parts with direct language, strategies that work to negotiate body taboos. Extracts 6 and 7 focus on the clashes between private and public in the ambiguous space of the common living room and how care workers manage these clashes, largely by emphatically aligning with the residents’ views.

Practical Implications

The findings suggest that despite unavoidable clashes between private and public spheres in the ambiguous space of care facilities, care workers possess methods to manage these clashes. What particularly stands out in all data extracts is the way the care workers cast an embarrassing situation as a moment of amusement through affect-regulating practices. Additional ways to negotiate the private and public ambiguity of space required in all caregiving settings are presented in the Practical Highlights section below.

Practical Highlights

• 1. Fine-grained verbal and nonverbal interactional moves work to negotiate privacy boundaries—physical and visual.

• 2. Bodily posture and gaze direction are prominent resources for the management of spatial privacy in the private territory of the resident’s bathroom.

• 3. Casting potential breaches into private spaces or activities as a moment of shared amusement dispels potential aspects of embarrassment.

• 4. Mutual orientation to the neutral parts of the body, such as the resident’s feet, hands, and back may help maintain customary social rules concerning the exposure of the body.

• 5. Small talk, gaze direction, and reciprocal praise are examples of methods.

• 6. Unavoidable clashes between public and private in the ambiguous space can be managed through affect-regulating practices (e.g., shared laughter, a jocular tone) and through emphatically aligning with the resident’s view.