The clash between standardisation and engagement

The Authors

Anne Gerdes, University of Southern Denmark, Kolding, Denmark

Abstract

Purpose – The purpose of this paper is to analyse how standardisation influences home care work practice.

Design/methodology/approach – The paper presents a qualitative interview-based case study from the elderly care sector in a Danish council. The interviews reveal care workers and administrative staffs' interpretation of how the implementation of IT and standards affects their work situation. Findings from the case study are supported by a large-scale quantitative study regarding organisational transformations in the elderly care sector.

Findings – The paper discusses how standardisation, in the form of implementation of IT-systems and categorization tools, influences the potential for development of competencies. The findings show that an engaged practice is difficult to maintain when working under circumstances characterized by lack of time and a requirement for standardisation and documentation.

Originality/value – The study provides insight into the divergence between standards and the importance of relying on experience-based knowledge and value rational skills in relation to care work. The paper stresses the point that standards are necessary to coordinate workflow activities and support decision making. Nevertheless, it is shown that when reification dominates, the degree of standardisation will lend itself to an instrumental practice not supportive of growing competencies within the field of care giving.

Article Type:

Case study

Keyword(s):

Experience; Elder care; Standards; Home care; Surveillance; Denmark.

Journal:

Journal of Information, Communication & Ethics in Society

Volume:

Number:

Year:

2008

pp:

46-59

Copyright ©

Emerald Group Publishing Limited

ISSN:

1477-996X

1 The unfolding of competencies in a practice of control

Public service care for the elderly in Denmark has been undergoing change during the past decade in an attempt at quality control in key areas such as the planning of care, time for the individual client, better management of resources and quality assurance of services provided. Tools have been developed alongside concepts of quality, particularly related to practice, with the aim of supporting knowledge gathering and the assurance of quality in this area. These initiatives have at the same time brought about an increase in standardisation in the description of job functions with a view to establishing a uniform basis of comparison for quality assessments.

The majority of the councils in the country have introduced “Fælles Sprog” or “Common Language” (The Councils' National Assembly, 1998), which consists of a catalogue supporting an undifferentiated categorisation of the needs of the clients in relation to an assessment of the help required and to the means by which that should be effected. The staff involved is required to develop a common conceptual apparatus using Common Language. In this way, councils are attempting to establish an indiscriminate starting point for the service provided in the area of care for the elderly. Staff can, for instance, have different views of what the notion of “cleaning” covers and this can bring about variations in the quality of the service provided. Using common language as a point of reference provides a tool both for quality control and for the gathering of professional knowledge on a systematic basis. In conjunction with common language, most councils have introduced IT care systems, which are supposed to optimise opportunities to realise good intentions relating to quality development, coordination of workflow, knowledge management and decision support at the political level. However, the use of these systems raises a series of problems, which I am going to flesh out in what follows. It is of course, important to stress the fact that it is the use context rather than the systems in themselves that creates problems. This is also mentioned in a report of evaluation regarding Common Language, carried out by Hansen and Vedung (2005). Here, the authors summarise views regarding Common Language as pointed out by the Danish elderly interest group. On one hand, the elderly interest group of Denmark is worried that the tool might be used to promote economy and standardisation. On the other hand, the interest group is also positive towards the view that a reasonable use of the system might bring about improvement in the sector of care for the elderly. Olav Felbo, the Political Coordinator of the elderly interest group of Denmark is quoted for the following statement:

We have seen some examples where Common Language is used very schematically, but used in the right way Common Language II[1] forces the individual visitor to collect information in many areas. Thereby we hope that some of the examinations that have been carried out too hastily will be caught. On the other hand, the danger with Common Language is that it continuously will be the technical matters that overshadow the overall examination (Hansen and Vedung, 2005, p. 266 (My translation from Danish: AG)).

The large-scale study, Den danske ældrepleje under forandring – En kontrolleret, randomiseret interventionsundersøgelse i 36 kommuner (Danish Elderly Care in Transformation – A Controlled, Randomised Intervention Study in 36 Councils) (Schultz-Larsen et al., 2004), throws light on processes of organisational adaptation in the area of care for the elderly over a three-year period (from 2000 to 2003)[2]. The dominant processes of change during this period were marked by a change to so-called “central examination” the introduction of IT as a tool in relation to examination, and the implementation of Common Language – the first ever set of standards for elderly care in Denmark. These are all initiatives designed to ensure quality development and common forms of documentation. The organisational procedure associated with the distribution of help means that the need for provision is laid down in the framework of Common Language and is expressed in a service contract with a specification of the areas which help is to cover. Using this contract as a basis, so-called “visiting notes” are regularly written, which care staff then use as a basis for action when they visit the clients. These visiting notes act as a memo or a set of guidelines for the care or practical help, which has to be provided for the individual client. The degree of detail in the visiting notes is often extensive with detailed guidelines. For example, instead of “help in the event of circulatory disturbance” there might be a detailed description of what action should be taken. At this directed level, the employees own assessment of the actual situation is not brought into play. We might imagine on the face of it that working under conditions in which personal involvement in the performance of a task is restricted by having to follow a standardised list might give rise to frustration. However, employees have, in fact, been found to request more thorough specifications, if the visiting note is written in general terms with a view to allowing room for the employee's own professionalism and to motivating an independent execution of professional judgement. This is underlined in the statements below, which originate from my own qualitative case study[3] in Fredericia Council, which supplement the large-scale study described above. Throughout this paper, I will use quotations from the case study for illustrative purposes:

1410 employees use the system, and they receive suggested guidelines, but would like to have rules […]. We can produce guidelines, which cover 90% of eventualities, but the remainder has to depend on the employee's own experience (Employee A: Administrative staff member in Fredericia Council).

The overriding desire for directive job descriptions might partly be explained by the fact that employees experience lack of time for dialogue about their work, as is pointed out below:

[…] In the earlier days [ed.: approximately 15 years ago] we used to have 3 meetings during daytime alone. Here, people talked about what they were doing and what was going on with our clients. Now we have visiting notes and, of course, we could use them as a background for a discussion of our views of care, but there is no time for this kind of activity. Also, if I get a visiting note written by the clients' primary contact person, I prefer a specific description in order to be able to carry out the work in a way similar to the way the usual contact person carries out the work. Therefore, I'm dependent on detailed visiting notes. Earlier, when we were more employees there was always somebody around who knew what to do, now we are very dependent on the visiting notes. For instance, at night shifts, we run a tight schedule with few people who cannot possibly know the needs of all the different clients in detail. Therefore, we follow the visiting notes very strictly – they are our guarantee that we do what has to be done, without visiting notes, we would be lost (Employee B: Social health care assistant).

The desire for detailed visiting notes also emphasises the adoption of the burgeoning documentation and surveillance culture in elderly care, where the ability to provide documentation for the fact that one has performed the duties one was contractually obliged to undertake is to an ever greater extent regarded as a necessity, not least with a view to countering complaints from users and politicians as financially responsible agents.

Such a situation is explained in Foucault (1979, p. 203) with reference to the constant presence in the individual of the consciousness of surveillance, so that surveillance itself need not, in fact, take place (Vuokko, 2008). Individuals assume henceforth, of their own volition, behaviour appropriate to the acceptance of control. The consciousness of the individual employee of being potentially under surveillance comes then to regulate behaviour:

[…] Employees know that as long as they carry out their work to the standard required, they cannot be criticised […]. If it comes to a dispute, there is a desire to be able to assess at what point an action deviated from the course agreed upon (Employee A: Administrative staff member in Fredericia Council).

I'm not going like “Big Brother is watching you” but of course, they might use it when I feed information to the system. Often we don't have time for it, so the information doesn't give an exact picture of what is going on … I often end up feeding the system after work, since I'm too busy during work. But, okay: If we can document a new need, they listen to us most of the time (Employee C: Social health care assistant).

The large-scale study of the 36 Danish councils demonstrates a similar general tendency for employees to accept registration and standardisation as positive factors. The study suggests that the original “housewife culture” is seen to be under attack from a burgeoning “medical/bureaucratic” culture (Schultz-Larsen et al., 2004, pp. 9, 112). In that context, Common Language is regarded as a positive initiative insofar as with this tool councils are sending a clear message about standards of quality in the organisation. This establishes the chance for transparency and clear management in the home care sector. As a result, employees perceive a much greater degree of clarity in the connection between the organisation's underlying set of values and its practice. At the same time, however, an opposing tendency can be sensed in their assessment of IT, in that employees do not feel that IT always leads to an equitable distribution of service provision to the public. In the study, it is noted that IT solutions and Common Language are not always developed “hand in hand” as planned, but rather “side by side” in particular in cases where the introduction of IT systems is not sufficiently supplemented by professional dialogue. In this way these systems fail to become meaningful for employees and become detached from practice, or at worst become scapegoats when organisational procedures break down.

The need to ensure across-the-board documentation satisfies the desire to coordinate activities, establish control and manage resources in elderly care. However, this takes place at the expense of insight into tacit knowledge based on experience. Within the field of knowledge management ( Nonake and Tacheuchi, 1995; Davenport and Pruskak, 1998) it is observed that despite the boom in IT systems that might support knowledge building, most tools do not facilitate knowledge building but instead tend to emphasise the importance of effectively managing context-free information ( Nonake et al., 2001). Futhermore, it is well known from organisation science ( Lipsky, 1980; March and Simon, 1958) that implementation of standards in order to ensure documentation will downplay aspects of work practice that are impalpable. The explicit tasks mentioned on the visiting note will be the ones prioritized unless management puts explicit focus on the impalpable aspects of the work:

[…] 10-20% can be seen here, but I have so many consultancy tasks – indirect nursing – which are not reflected in CARE [IT system] (Employee D: Nurse).

The service has to be the same no matter who visits the citizen (Employee E: Planner in Fredericia Council).

Standardisation of work processes is of course, necessary to a certain extent. This point is stressed in the work on learning in communities of practice done by Wenger (1998). According to Wenger, our existence rests on our being in practice and living through taking part in communities of practice. Thereby practice is about meaning as an experience of everyday life (Wenger, 1998, p. 52). Communities of practice are formed by dimensions of mutual engagement (who are we?), joint enterprise (where are we heading?) and shared repertoire (how do we talk about matters that matter?). Our being in the world is about constructing meaning by negotiating meaning through a dual process of participation and reification. In this sense, reification shapes and organises knowledge construction and thereby functions as a platform for our participation in negotiation of meaning.

In order to avoid chaos, any community of practice rests on products of reification in the form of reflections of practice translated into procedures, abstractions and different kinds of tools allowing us to navigate and participate in practice. Therefore, Common Language and IT systems have great impacts on activities regarding coordination and communication among organisational units (Hansen and Vedung, 2005, p. 219). Timmermans and Berg (1997) also point this out in a case study dealing with standardisation in action. Here, they present two cases involving a cardio pulmonary resuscitation protocol that is used as a worldwide standard, and an oncology research protocol. They illustrate how these protocols are the product of negotiation among networks consisting of actors, technological development, experience from practice as well as theoretical knowledge. Thereby these protocols are seen as techno-scientific scripts, which manage to bring together and transform different trajectories in setting up a framework for coordinated actions (Timmermans and Berg, 1997, p. 276). In a Kuhnian sense, they note that the development of a protocol is an open-ended process implying an ongoing struggle between many different parties (Timmermans and Berg, 1997, p. 287). They explain how such protocols manage to provide for so-called “local universality” in different settings, pointing out that local universality depends on how standards manage the tensions among transforming work practices while simultaneously being grounded in those practices (Timmermans and Berg, 1997, p. 298). They argue that protocols can be viewed as reifications, which influence the work of medical practitioners, and at the same time, these protocols are transformed themselves.

It is important to stress the point that standards have to be seen to be also in flux and as part of practice. On the other hand, if the balance tips over and reification dominates, the degree of formalisation will evidently lend itself to the development of an instrumental practice (Wenger, 1998, p. 65). In the elderly care case, where reification is maintained through a high degree of standardisation followed by little overlap to participation, knowledge production therefore falls short of capturing much of the knowledge embedded in care giving relationships and in practice these systems live their own lives:

[…] Well, about CARE [IT system] we went on a course two years ago this summer […] Common Language? Here I have to admit, it is this little silly catalogue”? … well it is still lying in my locker, and right now they are being collected because they have to be revised or whatever it is they have to be … But I don't use it, really I don't. We should of course, and I can't speak on behalf of all my colleagues, but they look as they did when we got them. Interviewer: But they are connected to the criteria for central visitation of the needs of the elderly. Are you familiar with these criteria? Yeah, well some of them one knows, I guess … but then, they are suddenly changed, and then it is suddenly called a “C2 service pack” and so on … But I don't feel that this has been properly explained to us. It is possible that it has been explained once I was off work, but I don't think that we have that much off, so in a way it just goes over the heads of us … and when we experience that, Mrs. Jensen has become weaker, then we request for more help further on in the system, and then it goes from a C2 to a C3 or the other way round. I have to admit, it doesn't interest me. What interests me is that the clients get what they have the right to get, then they can call it whatever they will (Employee F: Social health care assistant).

It feels as if bit-by-bit we have too many administrative tasks. I would like to sit by a computer if that was what I was supposed to do. But that wasn't the reason why I took this job in the first place. And if the people who figure out the plans are too far away from the people who have to use the system, then it turns into a kind of bureaucracy (Employee C: Social health care assistant).

2 Forms of knowledge and skills in the area of elderly care

Professional judgement plays a considerable role in all forms of elderly care and clinical reasoning. The ability to be able to cast a glance at an elderly person and assess what needs to be done is rooted in abilities, which have been exercised in practice, where an experience-based understanding of what it means to exercise care is developed in the practical part of a nursing course and later in professional work. In advance of this experience-based understanding lies an understanding of abstract concepts derived from formal education (in nursing or in the area of social or health work), teaching books and classification systems.

The relation between knowledge based on rules on the one hand and knowledge based on experience on the other is defined in the Dreyfus brothers' well-known five-stage model for skill acquisition (Dreyfus and Dreyfus, 1986, pp. 16-50). Here, the learner's movement towards the expert stage is described through various developmental stages, in which the introductory stages – novice, advanced beginner and competent – are, in brief, characterised by the learner at the outset using rules that are context-free, abstract and open to generalisation in order to understand a new area, and only later bringing himself into the picture. Competent practitioners, therefore, take abstract rules as their starting point but are at the same time capable of reaching an independent decision about which strategy it would be meaningful to pursue in a given situation. The higher levels of the skills model, proficient and expert, are marked by an ever-increasing level of involvement in a given situation, where development of expertise is characterised by the expert having a deep situational understanding of his area. This leads to him ceasing to make use of analytical principles and using instead tacit knowledge, when he is to translate knowledge into meaningful action in a given context. By means of experience-based knowledge, the expert is in a position to act intuitively and with concentrated focus when he is confronted with a problem. In the exercise of professional judgement the development of skills moves, therefore, from rule-based behaviour independent of context to situated behaviour dependent on context. From this point of view, conceptual understanding should ideally be subordinated to hands-on, experience-based understanding.

However, by focusing on standard descriptions for elderly care, the opportunity for forms of exchange of experience and of dialogue conducive to skills development, which would take their departure in concepts anchored in practice, is overridden[4]. In this way, the meaning of the narrative in a language, which determines situations, based on experience and practical use is eliminated. Instead, stress is placed on communication by means of instrumental conceptual systems, in which particular attention is paid to the general traits of specific situations. In Martinsen (2004, p.138), the distinguished philosopher in the area of nursing research, we find, for example, an interpretation of the significance of the narrative in the acquisition of skills in the care area, where she emphasises the importance of the open narrative as protection against “the formulaic language of rulebook morality” (My translation from Danish: AG). Through narratives, we are in a position to pass on hands-on understanding and to reflect on experiences without having to force them into a template, in which reality is submitted to abstract concepts. When rational and abstract conceptual systems are used as tools in resource management, quality control and knowledge-gathering, a barrier is placed in the way of the development of the kind of dialogue which might promote skills development in the area of elderly care.

2.1 Value-rational skills

An experience-based understanding is not captured by the language used for communication about one's profession and work in elderly care. If employees are encouraged to respond to the needs of those in their care on the basis of a standardised and across-the-board formula, which looks at the needs of the individual from a generalised viewpoint and without an eye to the encounter with the person in that unique context, there will be a worsening in the conditions needed for developing a differentiated working language necessary for the building of a culture whose principal values relate to care relations between people. When encounters with individuals have constantly to be assessed in relation to general, blanket registration, efforts are focused on dealing with the creation of data appropriate for documentation. To adopt the terminology of the Dreyfus brothers, we can say that what happens is that employees are restricted to the three lowest stages of the skills model, since the system to an overriding extent encourages the exercise of behaviour which is rule-based and independent of context. This problem is also raised in the article, online “Medical consultations: are we heading in the right direction?” Here the authors argue that the move from face-to-face communication towards form-filling online exercises in online medical practice in the long run might undermine the medical profession (George and Duquenoy, 2005).

If we turn to look at “visiting notes” we could easily find instances in which employees in the course of time would become so well drilled that they did no longer need to consult the visiting notes but took decisions themselves based on earlier experiences of similar situations and visiting notes. However, here we cannot speak of training directed at expertise in the area, but rather of training in routines, in which the employee has gone through a process of being drilled within the framework of a rigid realm of standards. Employees have, then, received a tool, or a template, for categorising the environment with which they are confronted in their work. In itself, this does not stimulate the form of involvement or commitment required to develop expertise, since it becomes difficult to establish commitment in a specific situation when it constantly has to be assessed in relation to a demand for abstract documentation. In this way, the rhythm of care work is fragmented and relations to the person in care are depersonalised in the formal demands of the visiting note. By breaking the flow in work rhythm, which might otherwise promote involvement in the situation, “break-down situations” are set up, in which employees are forced to step outside the situation and take on the role of observer, monitoring their own performance from a distance instead of being active and reflecting participants in the specific context[5]. By this means, a new situation is created in which the performance of care work causes employees to objectify their relation to the person in their care. A relation which no longer presents itself as an aim in itself but which is instead regarded as a means to achieve an overriding aim, which concerns the ability to deliver general results capable of being documented – and assessed:

[…] I was shocked once an inspector called because a client was discharged from hospital. The big problem was that the bed wasn't ready … So could we find time to go and fix the bed clothes? I said, of course, we will find time for that. Then she went: “Yes, fine, It also only takes 5 minutes.” I said: “I'm not walking in there just doing the bed in a new home. I also present myself, talk to the client, who just arrived home back from hospital, and maybe fells a little confused about it all”…The inspector has to do the measurement of time, but reality is often different from that (Employee G: Social health care assistant).

The development of expertise and the ability to exercise professional judgement in elderly care could be promoted by encouraging the opportunity to exercise the form of knowledge, which in Aristotle's (2002) The Nicomachean Ethics is referred to as phronesis. In contrast to episteme, which relates to unchanging rational knowledge independent of context[6] (know that), and techne, which is directed towards the productive rational capacity (know how), Aristotle highlights phronesis as the form of wisdom relating to that practical and moral astuteness in action which is associated with learning incorporated into practice. This form of proficiency is not neutral but moral in its being, since it mirrors a form of reflection grounded in practice and cultivated by the employee's ability to be involved and to take a stance in any specific situation. Rather than being concerned with whether “one has done as one ought” the employee is committed to the situation and takes decisions against a background which not only involves conceptually abstract knowledge, but also draws upon experiences from previous situations. As mentioned earlier, what the Dreyfus brothers stressed as significant elements in the movement towards expertise was precisely an increasing involvement and commitment of this kind. The conceptual, fact-oriented form of knowledge, which attaches itself to the use of IT systems and visiting notes in the area of elderly care, minimises opportunities to develop skills which are rooted in practice and value-rational.

3 How standardisation challenges care giving – an ethical perspective

Our enlightenment quest to be fair through abstraction and disengagement may lead us to be unwise in our practice (Benner, 2000, p. 305).

In order to elaborate further on the interrelatedness of engagement and professional care giving, I would like to bring in moral philosophical reflection. Hereby, we can establish the foundation for a more profound insight into what it means to relate ethically to the circumstances in which we find ourselves, and how this might affect our ability to exercise engaged moral practical reasoning in particular cases. The philosophical starting point for a description of what, ethically speaking, comes into play in such relations is taken principally from The Ethical Demand (Løgstrup, 1997). Here, Løgstrup presents a moral philosophical standpoint, which implies that ethics should not be regarded as an abstract theoretical project, which removes ethics from the concrete relations and situations in which ethics in fact is rooted. Instead, ethics depends on the ethical demand, which derives from the basic fact that we, to use Løgstrup's (1997, p. 5) own words, are entangled with each other. In our striving after the good (or the bad) we are mutually dependent on each other – we live in a state of surrender to each other[7]. This fundamental precondition – with which everyone is actually familiar – forms the central point in the formulation of ethics[8] by Løgstrup. He sees ethics from the viewpoint of phenomenological metaphysics, in that we cannot arrive at ethics through thought but are, so to speak, born into it, which makes its basic attributes appear self-evident. Løgstrup (1997, p. 16) expresses this himself as follows: “it is a common philosophical observation that the most elementary phenomena of our existence are the ones we are least aware of.”

Through an analysis of the concept of trust, Løgstrup illustrates the mutual dependency between people, while at the same time pointing out that the other's self-surrender to me equally demands that I am always unilaterally under obligation to the person I meet. It is only I who can determine whether I will accept or reject the other, or, as Løgstrup (1997, p. 25) expresses it: “A person never has something to do with another person without also having some degree of control over him or her.” It is, then, not a question of the ethics of trust in a sentimental sense. The ethical demand made of the other is not a matter of care but represents a fundamental precondition of being human consisting of self-surrender. The importance of avoiding sentimentalising the concept of trust cannot be exaggerated:

Regardless of how varied the communication between persons may be, it always involves the risk of one person daring to lay him or herself open to the other in the hope of a response. This is the essence of communication and it is the fundamental phenomenon of ethical life (Løgstrup, 1997, p. 17).

At the same time, it is not a question here of a concept of trust, which stands or falls on whether or not it is honoured. It is a matter of the simple form of trust expressed by the fact that we cannot avoid surrendering to each other. Regardless of whether we like each other or not, we cannot live without referring to each other and to the community. Trust lies, therefore, in the nature of that reference – and by extension self-surrender – as a common characteristic of all co-existence. Despite the fact that in concrete historical contexts trust can be realised under more or less favourable conditions, the self-surrendering is always the underlying factor.

The ethical demand can only be honoured spontaneously, as soon as we begin to think about whether we are really acting as we ought, the focus moves to ourselves and away from the essence: to act exclusively in relation to the other person. From an ideal perspective, we do not act ethically in such situations and might end up in self-justification and moralizing behaviour. The demand is, furthermore, unfulfilled since we do not have universal knowledge, we can never know to what extent the help we proffer the other is the help, which, from an ethical point of view, best fulfils the unspoken need for help. In this way, the demand is also unspoken since we approach the other because we are aware of the other's need, not because of an explicit request for help[9].

As an ideal consideration, Løgstrup maintains the radical nature of the demand and the impossibility of fulfilling it. At the same time, he is conscious of the fact that the ideal is often only realised in an approximate version, since life as lived requires compromises, when we consider a situation before acting, or when we end up acting out of duty, because we know it is expected of us. This is, however, in reality better than not helping at all, even though from an ideal viewpoint it cannot be regarded as an ethically correct action, since the action does not answer to the radicality of the demand to act exclusively for the sake of the other person. This means, then, that in the course of the process towards arriving at the execution of a helping action, a slippage has taken place, so that an egoistic element has crept in, as our thought has been more in relation to ourselves than to the other.

The fundamental condition demands that we are receptive to the other. It is, however, also the case that we would be in an unbearably extreme position if we had not equipped ourselves with norms, which could protect us from direct confrontation with the ethical demand to take care of the life of the other. Even though co-existence rests on a basic assumption of trust, we surrender our existence by showing each other a conditional trust, which spares us from unbearable exposure. We are forced, so to speak, to trivialise the basic prerequisite of life by giving it a form, which makes existence bearable and practicable. Existence is given shape, then, by the conventional norms with which we surround ourselves in order to preserve a smooth and functional co-existence – “Without the protection of the conventional norms, association with other people would be unbearable” (Løgstrup, 1997, p. 19). In that context the norms are wedged in like a neutralising instrument, which provides a space for action in which we do not need to relate to the fundamental, radical alternatives of human existence every time we come into contact with one another – that which is not unconditional care for the other's life is destruction thereof. Løgstrup (1997, p. 20) notes that it is the child who does not manage to bear the comfortable mantle of convention, but encounters the world with trust and without reservations:

The child, being yet outside of convention, still stands in the power of the given alternative. If he or she fails to encounter love, his or her future possibilities are destroyed – as psychology and psychiatry have amply shown.

In the same way, the ideal of Florence Nightingale in working within the care sector is of course, not apt since care workers have to distance themselves in order act as professionals. If they do not manage to protect themselves as professionals, they become too emotionally involved in their work, which will not help the persons dependent on them as professional care workers. In dealing with care giving from a professional ethical perspective, we have to find a balance between:

care giving as fulfilling demands in standards (such as visiting notes) and nothing else; and
care giving as paying attention to the individual as an unique person.

However, how can we set of a framework for acting ethically without promoting yet another standard? In order to sort this out, my perspective is indebted to Lindseth (2002), who works with ethics in relation to the health care service. Lindseth's (2002, p. 67) thematic treatment of this situation emphasises that:

… The tendency always to answer the question about what we should do is powerful. If ethics in this way does not become downright unethical, it is reduced to an “ethical skill” which is to have a supplementary function in relation to professional skill.

At the same time, we must consider that situations which require ethical decision making are unique by virtue of the fact that they are embodied in a specific context. Even though rules and firm principles can be necessary for the management of ethical questions, we will never be able to establish a form of ethical preparedness, in which every situation is placed in a form capable of generalisation. For Løgstrup (1972, p. 36) the consequences of generalising reasoning often end in moralism, where morality comes into being for its own sake. Lindseth (2002, p. 72) mentions a curious case from the health care sector, in which a project was to investigate the effect of singing to patients with dementia, based on a hypothesis that this might possibly improve their condition. However, to sing for the sick only becomes a well-chosen ethical act in a given situation, when the singer spontaneously sings from excess of energy and good will, and if the sick person apparently values this contribution. Alternatively, the act can border on the embarrassing if it is forced from a sense that this is something that ought to be done in the situation, because this is stressed in the general plan of the given investigation. Lindseth (2002, p. 73) summarises the situation somewhat humorously with the words:

Here we also see what constitutes the difference between joy and horror: In the one instance the patient is met with and cared for, in the other made into an object which has to be dealt with.

In this sense, standardisation of care giving relations falls short of capturing what is really at stake in the practice of nursing.

Nevertheless, the abovementioned analytical clarification can inform practical organizational contexts. In the attempt to make the complexity of the relationship between philosophy and practice intelligible, we can follow Ayer (1969, pp. 245-6) in his article On the Analysis of Moral Judgements, and ask to what degree we can distinguish between:

… The activity of a moralist, who sets out to elaborate a moral code or to encourage its observance, and that of a moral philosopher, whose concern is not primarily to make moral judgments but to analyse their nature?

In this connection, Ayer claims that philosophy ought to concern itself with the clarification of concepts and that it's area of interest should consequently be kept separate from practice. Philosophy relates therefore to ways in which we are to understand moral concepts and over and above that, philosophy takes a neutral stance on behaviour in practice. Still, I would like to stress that, while “moralist” and philosopher do not have the same purposes and duties, this does not necessarily give occasion to regard their areas of interest as separate, let alone to maintain such a separation between understanding the morality in the world as against changing the morality in the world. However, this does not mean that moral philosophy is to be translated into effective guides for action at the level of a “do-it-yourself” manual. My point here has been to reveal how a philosophical understanding of the ethical world can be fruitful in a context in which we wish to establish room for reflection about ethical conditions in the real world.

4 Conclusion

This paper has focused on questions, which arise when IT systems used to handle knowledge and manage resources are employed in a context characterised by the demand for documentation. Under such circumstances opportunities for skills development in elderly care have from the outset little chance of success, since the development of the professionalism of employees is kept at a level of competence which does not motivate them to become involved. In the specific situations with which employees are confronted in practice, they have primarily to relate their own observations to a generalised care template, which specifies the demands made of them in the exercise of their duties. This focus on standards and classification results in a systematisation of the knowledge area in elderly care. In turn this involves the accumulation of data with the aim of passing on content material for statisticians, for resource management and for knowledge-gathering. However, no springboard is set up for the further development of skills, since the focus on standards and classification emphasises standard performance carried out in accordance with general specifications of requirements, with no eye for the value of the knowledge that lies in allowing space for reflection in practice. Furthermore, from an ethical point of view, it is shown that when reification is out of balance with participation, care giving relations fall short of capturing what is essentially involved in the practice of nursing.

References

Aristotle (2002), Nicomachean Ethics, Oxford University Press, Oxford, (translated by Christopher Rowe, S.), .