Introduction
Staying active and independent in old age has been an unquestionable ideal in Western welfare states for several decades (Lamb, Robbins-Ruszkowski and Corwin Reference Lamb, Robbins-Ruszkowski, Corwin and Lamb2017; Martinson and Berridge Reference Martinson and Berridge2015). More recently, this ‘successful ageing’ paradigm (Rowe and Kahn Reference Rowe and Kahn1997) has been supplemented by a strong political focus on mobilising the potentials of older people. In relation to the 2012 initiative ‘The European Year for Active Ageing and Solidarity Between Generations’, the European Commission stated: ‘Demographic change can be successfully tackled through a positive approach that focuses on the potentials of the older age groups’ (European Commission 2012: 3). Similarly, the World Health Organization (2002: 12), in their policy paper on active ageing, celebrates that the active ageing ideal ‘allows people to realise their potential for physical, social, and mental wellbeing throughout the life course and to participate in society’.
Focusing on potentiality, however, is not merely a rhetorical manoeuvre, but has manifested itself in concrete elder-care policies that have as their aim to mobilise the potentials of older people. One such policy is the Danish home care policy on reablement. Reablement, also referred to as enabling care, restorative care or everyday rehabilitation,Footnote 1 is a particular approach to home care for older people and is committed to substituting long-term home care arrangements for short-term home-based training programmes. During reablement programmes older people receive guidance, support and in-home training in order to regain lost capabilities, such as maintaining personal hygiene, doing housework or grocery shopping. The Danish policy on reablement states: ‘The municipalities must offer a time-limited reablement programme to persons who receive or apply for home care and in those cases where the citizen has the resources and potential to improve their functional capacity’ (Ministry of Children, Gender Equality, Integration and Social Affairs 2014b: 5, author's translation).Footnote 2 In this perspective, elder-care is not to be based on older people's current capabilities, but rather on their possible future capabilities. As such, reablement can be characterised as a new elder-care paradigm focused on maximising older people's bodily potentials (Meldgaard Hansen and Kamp Reference Meldgaard Hansen and Kamp2018). This paradigm thus relies heavily on and at the same time extends the expectations to older people imposed by the successful ageing paradigm. Not only are older people expected to use their capabilities for staying active and independent, they are also expected to engage in efforts to regain lost capacities, regardless of age or diagnosis. While successful ageing has received substantial criticism from the field of critical gerontology for placing the sole responsibility of ageing successfully on the individual (Dillaway and Byrnes Reference Dillaway and Byrnes2009; Holstein and Minkler Reference Holstein and Minkler2003; Katz Reference Katz2000), reablement, on the other hand, has so far largely escaped such criticisms. Despite – or perhaps due to – the scarcity of research on reablement, the widespread optimism among policy makers as well as professionals seems to persist. As a recent overview of the literature concludes: ‘Although the evidence is still emerging, reablement seems simply ‘the right thing to do’ – not trying to support people back to optimal independence would be bad for the individual as well as a poor use of scarce resources’ (Aspinal et al. Reference Aspinal, Glasby, Rostgaard, Tuntland and Westendorp2016: 577).
The aim of this paper is to explore how the rather abstract notion of potentiality is translated into a ‘workable’ principle by which elder-care professionals can allocate and provide home care for older people. For the professionals, the obligation to mobilise older people's potentials involves fundamentally new practices and judgements, such as how to identify potential future capabilities, how to assess whether or not a person's potential can be realised and, if so, by which concrete means and at what costs? I explore how these judgements are made by drawing on Annemarie Mol's (Reference Mol2008) term logic of care. I use this term to denote the different professional care rationales and practices of caring that are at play in the field of reablement. I identify a logic of reablement that encapsulates ideals of active ageing and continuing development throughout life. I contrast this with a logic of retirement, which in contrast holds that older people at the very last stage of life should be allowed to retreat and spend their remaining time and energy on enjoyable activities. I argue that elder-care professionals demonstrate both of these logics, and that an important part of practising reablement is to balance them in order to live up to policy obligations while at the same time complying with professional moral standards of good care.
In the following, I provide a description of the introduction of reablement in a Danish and international context and give an overview of the existing literature. I then outline the analytical approach of this paper. First, I highlight two analytical insights that can be drawn from the existing literature on potentiality. Second, I describe the paper's use of the term ‘logic of care’.
The policy and science of reablement
In the face of population ageing, mobilising the hidden potentials of older people constitutes an attractive policy solution towards minimising elder-care expenditures, while at the same time improving the quality of life of older people. Several high-income countries have implemented reablement in elder-care, including Denmark (Meldgaard Hansen Reference Meldgaard Hansen2016), Norway (Birkeland et al. Reference Birkeland, Tuntland, Førland, Jakobsen and Langeland2017), Sweden (Randström et al. Reference Randström, Wengler, Asplund and Svedlund2014), England (Wilde and Glendinning Reference Wilde and Glendinning2012), New Zealand (King et al. Reference King, Parsons, Robinson and Jörgensen2012) and Australia (Lewin, Alfonson and Alan Reference Lewin, Alfonso and Alan2013). It is characteristic across these countries that reablement is not merely seen as an additional or elective service, but as a cornerstone of the services available to older people (Aspinal et al. Reference Aspinal, Glasby, Rostgaard, Tuntland and Westendorp2016).
Despite widespread political and professional optimism, however, there is substantial scientific uncertainty with regards to the effects of reablement. While one recent review finds evidence that reablement has positive effects in terms of functional capacity, service utilisation and quality of life (Tessier et al. Reference Tessier, Beaulieu, Mcginn and Latulippe2016), others point to the lack of a clear theoretical and conceptual basis for reablement, and argue that the low quality of the existing evidence constitutes a significant barrier to considering reablement interventions in unity (Cochrane et al. Reference Cochrane, Furlong, McGilloway, Molloy, Stevenson and Donnelly2016; Legg et al. Reference Legg, Gladman, Drummond and Davidson2016; Whitehead et al. Reference Whitehead, Worthington, Parry, Walker and Drummond2015). In accordance with this, I argue that in order to explore the mechanisms through which the effects – or the lack thereof – happen, there is a need for qualitative studies that focus on how specific varieties of reablement work in local contexts. Some of the existing qualitative studies of reablement focus on finding success criteria or solutions that can make reablement more effective and argue that improved interdisciplinary collaboration (Birkeland et al. Reference Birkeland, Tuntland, Førland, Jakobsen and Langeland2017; Moe and Brataas Reference Moe and Brataas2016) or increased psycho-social skills among professionals (Randström et al. Reference Randström, Wengler, Asplund and Svedlund2014) could improve the outcomes of reablement. As such, these studies do not question the desirability or unintended implications of reablement and thus also fall short in uncovering the practical and moral aspects of mobilising older people's potentials. This is done better by studies that take a more open approach in studying how reablement emerges as a practice in the everyday work practices of elder-care professionals who are to translate the potentiality paradigm into a workable principle. Studies that apply such a practice-oriented perspective reveal that reablement challenges existing professional identities and logics (Dahl, Eskelinen and Hansen Reference Dahl, Eskelinen and Hansen2015; Meldgaard Hansen and Kamp Reference Meldgaard Hansen and Kamp2018) and that professionals face significant challenges in engaging older people in reablement (Dahl, Eskelinen and Hansen Reference Dahl, Eskelinen and Hansen2015; Meldgaard Hansen Reference Meldgaard Hansen2016; Moe, Ingstad and Brataas Reference Moe, Ingstad and Brataas2017; Rabiee and Glendinning Reference Rabiee and Glendinning2011). These studies thus help uncover some of the reasons for the discrepancies between policy ambitions, on the one hand, and the current evidence on the effects of reablement, on the other. In order to build on this research by studying reablement as the representation of a certain elder-care paradigm – the potentiality paradigm – this study sets out to explore how the notion of potentiality is made to work by elder-care professionals working in a Danish municipality.
In Denmark, the first municipality started working with reablement in 2008. After achieving positive results in the form of high satisfaction among older people and professionals (Kjellberg Reference Kjellberg2010), as well as significant reductions in elder-care expenditures (Kjellberg and Ibsen Reference Kjellberg and Ibsen2010), reablement was disseminated to other municipalities. In 2013, 94 per cent of municipalities had formalised work practices around reablement (Kjellberg et al. Reference Kjellberg, Hauge-Helgestad, Madsen and Rasmussen2013), and as of 1 January 2015, a new legal provision was added to the Act on Social Services. According to the law, municipal elder-care providers must offer a time-limited reablement programme to home care applicants over the age of 65, who are thought to have the potential to improve their functional capacity, thereby reducing their need for traditional elder-care services (Ministry of Children, Gender Equality, Integration and Social Affairs 2014a). Due to Denmark being characterised by a particularly high degree of social benefits, including universal elder-care, it provides us with a strong case for exploring how welfare states respond politically to the increasing pressures created by population ageing and how these responses are translated into practice.
Exploring potentiality through a lens of logics
Potentiality
The notion of potentiality seems to have a broad appeal in academia as well as in everyday life. This may be due to its ability to articulate abstract matter – that which does not currently exist, but may come into being in the future – and at the same time encapsulate positive notions of progress, development, hopes and dreams. Potentiality thus serves as a useful term to fill the imaginative gap between what is and what could be (Taussig, Hoeyer and Helmreich Reference Taussig, Hoeyer and Helmreich2013). Relating the present to the future, however, is not what makes the notion of potentiality unique. This has also been done using concepts such as promises (Thompson Reference Thompson2007), hopes (Good Reference Good2001; Mattingly Reference Mattingly2010) and expectations (Brown Reference Brown2003; Tutton Reference Tutton2011). What makes potentiality unique is its ability to mobilise action. Whereas promises, hopes and expectations seem to direct our attention towards the person making or having them, potentiality directs our attention towards those who are to realise the potential. In other words, speaking in terms of potentiality makes moral claims on others to act (Taussig, Hoeyer and Helmreich Reference Taussig, Hoeyer and Helmreich2013). Potentiality thus emerges as a highly politically and morally laden concept that demands action towards realising specific potentials.
In recognising the uniqueness of studying potentiality, in 2013 a special issue of Current Anthropology was dedicated to the study of potentiality in biomedicine. In the following, I highlight two analytical insights from here that are relevant for the purpose of my analysis of reablement. The first relates to the process of mobilising potentials: that practices of potentialisation are inextricably bound up with practices of care. The second deals with the implications of this process: that efforts to realise potentials often result in effects other than those expected.
Potentiality appears as a highly performative construct. Humans, animals or technologies do not have potentials, but are imbued with potential through social processes of potentialisation. It then becomes interesting to explore the practical work carried out by frontline workers assigned to mobilise potentials. In Svendsen and Koch's (Reference Svendsen and Koch2013) paper on the use of piglets in experimental neonatal research, they demonstrate how laboratory workers, in their efforts to realise piglets’ potentials and produce scientific knowledge, are deeply committed to caring for the piglets. Similarly, in Friese's (Reference Friese2013) study on the use of animal models in experimental research, she demonstrates that laboratory workers’ care for the animals is an integral part of their work. In both of the studied fields, however, care is generally repressed as an unscientific practice that can interfere with ideals of standardisation. Although dealing with animals in laboratories and not older people in their homes, these studies nicely illustrate the constitutive role that care plays in realising potentiality. It brings attention to the subtle co-operation between the potentialised entities and those assigned to realise their potential. As Friese (Reference Friese2013: S130) puts it: ‘the everyday idiom of potential denotes the idea that a kernel of ability or talent must be nurtured, or cared for, if it is to be actualized in practice’.
Bringing care into the equation thus also points to the fragility of potentiality. In order to realise something that resides, not in oneself, but in another entity, and not in the present, but only in a potential future, care must be taken. If not, the potentiality will not be realised. Care, in other words, is not only a means to realising potentiality – care is in itself a potentialising practice (Friese Reference Friese2013).
The second analytical insight is that although potentialities are often formulated in quite specific terms with regards to their expected outcomes, these are often not realised in practice. Since the realisation of potentiality depends on the (care) interactions between frontline workers and those imbued with potentiality, and due to the relational and situated nature of care, the outcomes of such processes are unpredictable. Timmermans and Buchbinder (Reference Timmermans and Buchbinder2013) demonstrate that despite grand promises of preventing metabolic conditions among newborns by means of screening, this practice emerges as ambiguous due to diagnostic uncertainty. Kaufman (Reference Kaufman2013), in her study on kidney transplantation, argues that transplantation does not only involve new possibilities, but also carries with it a ‘tyranny of potential’ as transplantation forces new moral obligations upon all of the actors involved. Finally, Svendsen (Reference Svendsen2011) illustrates how human embryonic stem cell research entails a new understanding of waste embryos as valuable, making it immoral to discard them. Summarising, these studies illustrate that efforts to realise certain potentials force new – and often deeply moral – dilemmas upon humans. As entities are potentialised, we are faced not only with new possibilities, but also new obligations, prioritisations and uncertainties. In this way, potentiality actualises new moral horizons (Svendsen Reference Svendsen2011).
Logics of care
In order to explore how elder-care professionals translate a policy of potentiality into a workable practice, this paper draws on Annemarie Mol's term the logic of care. In her book The Logic of Care: Health and the Problem of Patient Choice (Mol Reference Mol2008), she uses the term to denote two contrasting ways of conceiving patients in Western health care. In distinguishing the term from similar concepts she elaborates:
It asks for something that one might also call style. It invites the exploration of what is appropriate or logical to do in some site or situation, and what is not. It seeks a local, fragile and yet pertinent coherence. This coherence it not necessarily obvious to the people involved. It need not even be verbally available to them. It may be implicit: embedded in practices, buildings, habits and machines. (Mol Reference Mol2008: 8)
Thus, although the term logic suggests an interest in ways of thinking or reasoning, it has to do with the practices that characterise a certain field. Mol recognises that the practices of a field, although diverse, messy and unexpected, are characterised by a certain degree of coherence. The glue that holds these practices together is constituted by logics. I draw on this term in order to identify how the underlying rationales of working in reablement unfold in the practical encounters between older people and elder-care professionals. As with Mol's empirical case, it is exactly in times of change that it is particularly interesting to uncover logics of care, since it then becomes possible to see multiple logics play out in the same arena and thus be rendered visible through the friction they create. Exploring how professionals translate the abstract notion of potentiality into concrete work practices through a lens of logics enables the uncovering of the practical work involved when a new care paradigm is introduced into a field characterised by existing professional practices and rationales.
Methods
The study applies three main kinds of ethnographic method: document analysis, participant observations and semi-structured interviews. Initially, a document search was conducted to identify policies, reports, work descriptions, and so on, at the Danish Parliament's document archive, and on websites of key policy institutions. During fieldwork, additional documents, including work descriptions, guidelines and educational material for elder-care professionals, were collected. Participant observations were carried out between April 2015 and February 2016 in two out of the five geographical and administrative elder-care units that make up Copenhagen's municipal elder-care services. Observations focused on the various encounters that take place between older people and elder-care professionals during a reablement programme, including telephone conversations between older people requesting elder-care services and staff at the municipal reception units, assessment meetings, planning, halfway and finalising meetings between the older person and elder-care professionals; as well as the actual reablement training carried out in the older persons’ homes. In total, more than 150 hours of observations were carried out. These involved more than 50 elder-care professionals, including assessors, therapists, nurses, and health and social care assistants (hereafter care assistants), as well as 31 older people. Since the majority of these older people were not thought to have reablement potential or for various other reasons were not enrolled in a reablement programme, only seven ended up going through reablement. I observed six of these older persons throughout their reablement programme, as well as two additional older persons who, with the help of assessors and therapists, I recruited after their enrolment in a reablement programme. Each of the persons who went through reablement was observed on three to eight occasions during assessment, planning, half-way and finalising meetings, as well as during reablement training. Reablement participants, six females and two males, were between 67 and 94 years of age.
Finally, semi-structured interviews were carried out with five assessors, three therapists, two nurses and three care assistants. Interviews served two purposes. One was to enquire into elder-care professionals’ reflections and opinions on reablement, and the other was to supplement observations, i.e. to clarify questions that had occurred during observations. Interviews were transcribed verbatim, and the extracts from these quoted in this paper were translated into English by the author.
After the collection of empirical material, all material was coded thematically using the software NVivo. Themes were developed using an abductive approach (Tavory and Timmermans Reference Tavory and Timmermans2014). This involves a creative engagement with the empirical material. The key is to lead the coding by the surprises that emerge in the material, i.e. by directing attention to the aspects in the material that existing theories fall short in explaining, instead of towards those that fit with existing theories or concepts. This was achieved by means of a recursive process in which collection of empirical material and development of themes took place simultaneously.
Making potentiality workable
In the following, I present my analysis of which logics unfold as potentiality is made workable by elder-care professionals working with reablement in the City of Copenhagen. This is done taking a chronological path through elder-care professionals’ efforts to identify, operationalise and realise potential in older people through the course of a reablement programme.
Identifying potentiality: the careful induction of motivation
When a request for elder-care services is made, the municipality to which the request is sent is obliged to assess the older person's potential to engage in reablement. This assessment takes place in the person's home at a meeting attended by an inter-disciplinary team consisting typically either of an assessor and a therapist, or a therapist and a nurse, and less frequently also by a care assistant.Footnote 3 Furthermore, relatives of the older person are often present at these meetings.
It was the municipality's stated goal that 80 per cent of first-time elder-care enquirers were referred to reablement. In practice, however, only 23 per cent were referred to reablement during the first six months after the law's commencement (City of Copenhagen, The Health and Care Committee 2015). Similarly, of the 31 people I observed being assessed for their reablement potential, only 13 were referred to reablement, and of those five opted out. Accordingly, the majority of the older people were exempt from reablement, i.e. were not thought to have a reablement potential. In the following, I explore the practical complexities of identifying potentiality.
According to an internal work description, only terminal cancer or progressed dementia would disqualify a person from reablement solely based on her or his diagnosis. In all other cases, it was then up to professionals’ judgement whether a person had reablement potential and, hence, should be referred to reablement, or not. During assessment meetings, it became clear that what determined the outcome of this judgement was universally articulated as ‘motivation’:
I'd say that there isn't potential if they are not motivated for it, so motivation, I'd say, is like paramount. The citizen has to be motivated for change in order for me to say that there is potential. If the citizen is not motivated, we might as well drop it. I can say, ‘You should have [motivation]’ … but if you have just given up everything and say, ‘I can't’, then you can't. (Therapist)
Thus, motivation was seen as the deciding factor. This viewpoint was shared by all of the interviewed professionals, and this has also been demonstrated in previous research (Meldgaard Hansen and Kamp Reference Meldgaard Hansen and Kamp2018; Rabiee and Glendinning Reference Rabiee and Glendinning2011). Thus, it was the general conception that it was not so much people's health condition that decided whether or not they had reablement potential, but rather their desire for reablement. However, as reflected in the relatively low number of people who were referred to reablement, many were simply ‘unmotivated’:
I had an idea that many people really really want to achieve some things by us helping them through reablement, and that is the case for many, but there are also many who just want to lean back in their chair and sometimes I think that that's fair enough (laughs). When they have become so old and then you have to tell them, ‘Yes, you may have a lot of pain in your back, but if you sat down and did your vacuuming, then you would be able to do it’. I think that it can be a bit tough sometimes telling people that we can't help them, although you want to help them. (Nurse)
As the nurse here expresses, she had been surprised by the number of older people who were not motivated. In her opinion, however, it is perfectly acceptable to ‘lean back’ at the last stage of life. Assessment meetings revealed that people who request elder-care and, hence, are assessed fortheir reablement potential are often characterised by progressed physical, mental and cognitive decline. Accordingly, many were exempt from reablement with reference to their health condition:
It doesn't make sense to set up a reablement programme if there is no reablement potential, I mean if they will never be able to manage cleaning in the long run, then it's better that we come in and help them with cleaning and then they are able to manage other things that give them more joy in their everyday life, so that they can maintain their quality of life instead of them spending a whole day on cleaning because they divide this task over several steps. (Nurse)
As the nurse here indicates, for those who were so impaired that they did not have the energy to both clean and engage in more enjoyable activities, lack of motivation was accepted.
In other cases, however, professionals would make a great effort to motivate the unmotivated. Indeed, professionals saw it as their professional obligation to engage in ‘motivational work’ (Meldgaard Hansen Reference Meldgaard Hansen2016) in order to ‘find the person's motivation’, as it was often framed. An important part of professionals’ training for working with reablement includes training in ‘motivational interviewing’, a method evolving from treatment of alcoholism based on ‘a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence’ (Rollnick and Miller Reference Rollnick and Miller1995: 326). During observations, however, it became clear that motivational work involved much more profound practices than simply finding motivation. Rather, motivational work involved actively inducing motivation through subtle tactical manoeuvres. One tactic was to try to convince people that it was in their own interest to participate in reablement:
Well, sometimes I will try to stress how important it is to handle one's daily activities … The more activities you can handle, the better are your chances of maintaining a high functional level. And then I inform them that there are actually studies that show that the more self-reliant people are, the better health you actually have, so keeping the help away is actually really healthy in relation to staying fit and healthy. (Therapist)
The therapist here illustrates how she tries to appeal to people's reason by pointing their attention towards the beneficial health effects of reablement. Another commonly used tactic was to ask people what they enjoyed doing in their leisure time or what they would like to change in their lives. Although often confused and even suspicious when asked these types of questions, most older people would eventually buy in to the idea and mention leisure activities that they enjoyed (Hjelle et al. Reference Hjelle, Tuntland, Førland and Alvsvåg2017), such as going for a walk, being confident in taking the bus, going to the beach, visiting friends or attending a music café. The logic behind this manoeuvre is described in the following:
We have to consider their whole life … Before, when they applied for cleaning, then it was only cleaning we focused on … whereas now, we instead see, well can training rub off on other things? Like could you be better at taking the bus or a train? If that makes sense to you, then that's what we have to do. And then you hope that it will rub off on them, so that if you can handle a bus and train then you might become more confident and then you might be able to handle cleaning. (Assessor)
According to the assessor, it is the hope that a reablement programme focusing on a ‘fun’ activity will rub off on the person's capability to carry out household activities. It also appeared that professionals, often assessors and therapists, would use certain tactics to ensure that motivation for leisure activities was transformed into motivation for household tasks. This was referred to as presenting the older person with a ‘carrot’ or ‘appetiser’ and could happen as described below:
If, for instance, the citizen wants to go outside and go to Tivoli [an amusement park and pleasure garden] again, then one could actually grant some time for a care worker to go to Tivoli as an appetiser, something like, ‘Okay this is what you want, but first we have to do some other things. First you have to go through some … training so that you can take the bus or something like that … The art is to … make some suggestions that the citizen wants to do. So with cleaning you can say that that's a tough nut to crack. There aren't many who shout with joy at the thought of cleaning, right? So that is a tough one to sell, right? There are other things that are easier to sell, right? But that's the thing about motivation. The citizen wants to go to Tivoli, but can't be bothered to clean, so it's on the cards that that's what the citizen wants, that's where their motivation is, right? (Assessor)
The assessor here describes her work with motivation as similar to both that of a salesman and an artist; she has to sell her product – reablement – which at times requires the artful presentation of the product in order to make it more appealing. In this way, it was not uncommon to ‘trick’ people into participating (Dahl, Eskelinen and Hansen Reference Dahl, Eskelinen and Hansen2015). Another tactic was to grant unmotivated older people temporary home care in the hope that they would become motivated for reablement when they experienced that their home carer stopped coming. A therapist reluctantly described this practice as ‘playing confidence tricks’ on the older people. Finally, professionals recounted how they occasionally, as a last resort, would try to persuade people into accepting reablement by saying that they would not be granted home care if they did not agree to participate in reablement, thus making reablement an offer that could not be refused (Meldgaard Hansen Reference Meldgaard Hansen2016). Although several professionals mentioned this practice, I never witnessed it during my observations. This might indicate that professionals were in practice more yielding towards ‘unmotivated’ older people than they were willing to admit. As a result, out of those 18 I observed being exempt from reablement, only one was not granted any home care, because professionals did not think that she had the need, whereas the remaining 1715 were granted the home care services they had requested.
What I have demonstrated in this section is that reablement is not only a political manoeuvre, but involves profoundly new practices and rationales (Meldgaard Hansen and Kamp Reference Meldgaard Hansen and Kamp2018) – a new logic of care (Dahl, Eskelinen and Hansen Reference Dahl, Eskelinen and Hansen2015). I term this the logic of reablement, according to which anything is possible as long as a person is motivated for development. Accordingly, professionals’ main task during assessment meetings was to carry out motivational work. This involved carefully – and sometimes artfully – tinkering with (Mol, Moser and Pols Reference Mol, Moser and Pols2010) the older people's preferences and wishes. Although some were reluctant to talk about these practices, they were generally justified as means to achieve the higher aim of helping people reach their unutilised potential. In contrast to this logic, I identify the logic of retirement. According to this logic, people at the very last stage of life, characterised by progressed physical, mental or cognitive decline, should be allowed to sit back and enjoy life. Although this logic was rarely verbalised in interviews, elder-care professionals’ practices revealed that they would accept some older people's preference for spending their remaining time and energy on activities that they enjoy. Thus, rather than a clear-cut shift from one logic to another, what is the case here therefore seems to be better framed as a co-existence of logics.
Operationalising potential: negotiating goals
For those older people who are thought to have a reablement potential, the next step of the reablement programme is to operationalise this potential. In accordance with the stated policy principle that reablement must be individualised and goal-oriented, elder-care professionals in the City of Copenhagen are required to set up specific goals for each reablement programme in collaboration with the reablement recipient. This is done at the end of the assessment meeting by the assessor or therapist using the Patient-Specific Functional Scale (PSFS) (see Figure 1), which is a scale used to list activities that the person wants to improve during their reablement programme. Each of the listed activities is given a number from 0 to 10 indicating the degree to which the person is currently able to perform the activities. The idea is then to repeat the PSFS measurement at the end of the reablement programme in order to assess the effect.
Figure 1. Patient-Specific Functional Scale.
However simple goal-setting and scoring of current functional abilities on a scale of 0–10 might seem, using the PSFS emerged as an ambiguous task in practice. Often difficulties with the PSFS were related to the quantification of the older people's current abilities. One woman objected that she was not very comfortable with numbers, and another was offended by being asked how well she was able to clean her apartment, which made her object to the assessor and therapist: ‘That is the stupidest scale! Do you also get one where you have to say how good you are at [reablement]?’ It seemed that the idea of even setting up goals was considered nonsense by the majority of the older people, as expressed by an assessor:
it is often hard to get the citizen to formulate that kind of thing because it's the citizen's goals right? It's not my goals and it's, yeah … It's something I find hard because many citizens will consider it to be very abstract, ‘Well, why is she asking that, I just want help, that's my goal’ right (laughs), no but really. So it just becomes something abstract, so unfortunately often you put the words in their mouth, you know, because you know that you in your documentation have to set up a goal. (Assessor)
As indicated here, setting up goals is an abstract endeavour for those whose wish is simply to get the help they have requested. In support of this, the excerpt below, from the completing of the PSFS at 94-year-old Walter's assessment meeting, demonstrates the abstract nature of setting up reablement goals:
At the end of the meeting, the assessor finds the PSFS and explains that Walter on a scale of 0–10 must indicate how well he is mastering the different everyday activities that he wants to improve. He is silent for a while before the daughter suggests the activity ‘washing himself’, which he currently receives home care for. The assessor: ‘How well are you doing that now?’ Walter: ‘Ten.’ The assessor looks sceptical and says, ‘But you've just said that you can't do it.’ Walter replies, ‘But I used to.’ Assessor: ‘But we're focusing on what you can do now.’ Walter: ‘But I can't do it at all now. Someone is doing it for me.’ Assessor: ‘Sure, but you have to imagine if you were to do it yourself, how well would you then be able to do it?’ Walter looks puzzled and goes silent again. Assessor: ‘Can we agree on seven?’ Walter: ‘Okay.’
Here it is obvious that goal-setting requires Walter to think in abstract terms. Not only does he, at the age of 94, have to say what he would like to improve in the future, he also has to imagine how well he would be able to carry out tasks that he is not currently carrying out. Since he finds this confusing and challenging, both assessor and relatives contribute significantly to the goal-setting. Resulting, four goals are set up: being able to do grocery shopping, prepare food, wash himself and go for a walk. Goals were therefore not only informed by the older people's wishes, as otherwise intended politically, but rather emerged through negotiations between older people, relatives and professionals (Moe, Ingstad and Brataas Reference Moe, Ingstad and Brataas2017).
There were also indications that PSFS could be an insensitive tool:
You can identify some activity problems, but maybe it doesn't make sense to put a number on it, because there is no need to rub salt into the wound, if it is someone who is really upset about not be able to do something. (Therapist)
In this case, the therapists demonstrate that the PSFS could conflict with her logic of care, because the quantification of one's capabilities, or rather incapabilities, could inflict pain on the older person. Hence, due to the aforementioned difficulties in using the PSFS, professionals were generally uncomfortable using it. Sometimes they omitted to fill out the PSFS, in which case they had to make up goals to cite in the electronic documentation system as they returned to their office. Although the older people thus resist the rational subjectivity imbedded in these kinds of measurements (Abrams and Gibson Reference Abrams and Gibson2017), professionals only do this partly. Although professionals largely acknowledge that goals, due to the cognitive and emotional difficulties involved in quantifying one's capabilities, are not accurate accounts of reality, they comply with their obligation to document goals in the electronic documentation system. The resulting data are therefore to some extent manipulated (Hoeyer Reference Hoeyer2010).
A further complexity appeared when professionals had used leisure activities as ‘carrots’ as described in the previous section. Although it was accepted by assessors and therapists that reablement programmes focused on leisure activities, it became clear that in order to fit with the PSFS format, at least some of the goals had to be formulated in terms of activities that were likely to lead to reduced need for elder-care services. Ida, who was 83 years old, managed, with some help from the assessor, the therapist and her daughter, to mention three goals for her reablement programme: prepare meals, go to her friend's house to play bridge and go for a walk. In order to make the latter goal correspond with a specific elder-care service, the assessor suggested that Ida could train by walking towards the supermarket to buy groceries. This was agreed upon and written into the documentation system. This way, there would sometimes be a mix of leisure and household tasks listed as goals.
In those cases where the PSFS had been filled out by an assessor, it occasionally happened at the subsequent planning meeting, which was only attended by the therapist, care assistant and older person, that the formulated goals were modified. The therapist would sometimes decide to focus only on some of the goals set up in the PSFS and thereby scale down the ambitions. For instance, in Ida's case, the therapist decided to focus only on the walks, since she did not think that Ida seemed motivated to prepare meals and because she saw going for a walk as an intermediate goal to going to her friend's house to play bridge. For Walter, described previously, the four formulated goals were reduced to only one goal of going for a walk, as the therapist thought this was more realistic. When asked about his case, she explained:
You can say, sometimes when you visit a citizen and for instance there is [a goal] about ‘I have to be able to cook’ or something, and then you can see that we are so far from that goal, and then you can get the idea that, ‘Are you sure that you said this?’ … and then sometimes I get the feeling that the assessor has taken something up that the citizen has maybe not felt like doing, but then because they have talked about it [the assessor says], ‘Well that would be nice to be able to do, right? Please?’, and then some goal is put down, which is not really the citizen's, but it has been an ambitious assessor, who thought it was a good idea. (Therapist)
The therapist here indicates that she takes on the role of Walter's advocate in trying to modify the ascribed goals so that they reflect his true goals better. Furthermore, the above quotation reflects that the operationalisation of potentiality sometimes happened through subtle negotiations of reablement goals by professionals with contrasting logics of care. Although assessors had the formal authority to document reablement goals, the therapists, as those who were to instruct the care assistants in the reablement training, in practice had the last word.
What I have demonstrated in this section is that operationalising potentiality was an ambiguous task, often characterised by negotiations between older people, relatives and professionals. In order to spare the older people from having to go through the abstract, confusing and sometimes upsetting scoring of their own capabilities and formulation of long-term goals, the filling out of the PSFS was often omitted or done, basically, by putting words in their mouths. Moreover, goals would sometimes be scaled down at the planning meeting. Professionals in this way managed to fulfil their obligation to quantify and document reablement goals, but without complying with the logic of reablement that these should be accurate accounts of reality; not because they did not want to, but because it was practically, and sometimes morally, unfeasible. Instead, professionals seemed to draw more on a logic of retirement, where older people should be protected from scoring themselves on a scale from 0 to 10 and going through a reablement programme with over-ambitious goals. It appears, then, that the closer the professionals were to the actual realisation of potentiality, the harder it was to stay loyal to the logic of reablement.
Furthermore, I have demonstrated that, in conflict with policy goals that reablement should reduce the need for elder-care services, reablement gave rise to new needs, since people were in effect given help – although only for a limited time – to engage in leisure activities, which is otherwise outside the municipal elder-care services’ responsibility. One might say that as reablement is unleashed (Pols and Willems Reference Pols and Willems2011) in practice, it carries with it a completely unexpected effect in the form of new needs.
Realising potentiality: managing the complexities of everyday life
After the operationalisation of potentiality, followed the actual realisation of potentiality. This was to happen through care assistants training the older people in reaching their reablement goals in accordance with the therapists’ instructions. As previously mentioned, only 13 out of 31 people I observed being assessed for their reablement were referred to reablement; and out of those, five decided to opt out (leaving them without any publicly funded home care at all), and one passed away before his reablement programme had started. Furthermore, two reablement programmes were disrupted and, hence, not finalised. One programme was cancelled because the person was admitted to hospital and the other because the person passed away. This resulted in only five out of the 31 people assessed for reablement potential (hence not including those two that were recruited after their referral to reablement) actually completing a full reablement programme. Besides reflecting the general level of physical impairment of people requesting elder-care, this also reflects some complexities encountered by professionals assigned to realising the potentials of older people. As reflected in the PSFS, reablement is expected to improve people's functional capacity in a linear progression, from one stable state to another through a systematic and intensive training programme. During reablement programmes, however, it appeared that regaining the capacity to carry out everyday activities was more complex than that. One significant challenge was that all of the older people who underwent reablement suffered from various medical conditions. This meant that they would often have to cancel training sessions due to hospital appointments or acute illness. For 67-year-old Anna, whose reablement programme focused on cleaning, it proved challenging to find available days in her calendar for reablement. She suffered from very severe chronic obstructive pulmonary disease and cataracts, had a coronary artery stent and an implantable cardioverter defibrillator, and had undergone surgery for two prolapsed intervertebral discs. Accordingly, it turned out to be a challenging task to find available days in her calendar to carry out reablement training between doctors’ appointments and her two-weekly bingo sessions, which was her main social activity, since she did not have any family. Ilse, who was 76 years old, had recently had a near-fatal stroke and therefore had an intensive eight-week rehabilitation programme at the local training centre, on Tuesdays. Hence when on Wednesdays she had her reablement training focusing on cleaning, this was hindered by sore muscles and low energy levels. The care assistant therefore struggled to get Ilse to participate in the cleaning as planned. Another complicating factor was care assistants’ holidays or days off, which often resulted in reablement programmes being suspended, since it was difficult for substituting care workers to take over a training programme in which they had not been instructed. These types of logistical challenges often made it impossible for care assistants to follow the agreed plan.
Another complexity in realising potentiality was that reablement goals were often stated rather simplistically, e.g. ‘doing the laundry’ or ‘showering’. For 79-year-old Ella, who used a walker and had a foot wound as well as a heart condition for which she had a pacemaker, the four stated goals of her reablement programme were to be able to clean her apartment, do her laundry, take a bath and go for a walk. As the care assistant trained Ella for the above, I observed how these tasks in practice involved several sub-tasks. At the first training session, the care assistant decided to skip the goal of doing laundry after trying to get Ella to balance the laundry basket on her walker, take the elevator to the ground level, walk outside along the building to the laundry at the other end of the building, walk on a ramp to the basement level where the laundry was placed, put the clothes in the washing machine and walk back to the apartment; only to repeat it all twice in order to first put the clothes from the washer to the dryer and then to pick up the dried clothes. They had only made it to the outside of the laundry when the care assistant said to Ella that she would let the therapist know that Ella could not do her laundry herself. Similarly, showering involved sub-tasks of putting out clothes to wear after the shower, covering the bandage on her foot wound, putting out the bathing bench, getting undressed, adjusting the water to the right temperature, applying soap, shampoo and conditioner, rinsing it out, drying her body, mopping the floor (since she did not have a separate shower cubicle) and getting dressed. After having gone through all these steps, the assistant evaluated that although Ella could manage the actual shower by herself, it was unrealistic that she could also mop the floor and get dressed, if there was to be any energy left for the rest of the day:
I don't think she would have energy and manage it all [the steps of bathing] and it would be too much to swallow for her if she had to do it all by herself and there wasn't anybody there. So Ella gets to do whatever Ella feels like on the particular day … What she manages to do on her own she gets to do, and then I'm just present and guide her and help her. (Care assistant)
As we see here, Ella's ability to take a bath was not stable, but rather something that varied from day to day, according to the degree to which she felt pain from her foot wound. What the care assistant describes is therefore how proper care needs to be sensitive to these fluctuations. Through this invisible work practice (Star and Strauss Reference Star and Strauss1999) of carefully adapting her level of care to Ella's needs on a daily basis, she carefully manages to care for Ella while at the same time ensuring her sense of independence. Since Ella was not always able to take a bath on any given day, it was decided at the finalising meeting to grant Ella home care for a bi-weekly bath as well as laundry service.
Similarly, for the aforementioned Ida, whose reablement programme was scaled down from having three goals to only having the one goal of going for a walk, I observed that the care assistant and Ida went for a walk in the courtyard instead of walking towards the supermarket, as planned. The care assistant explained that it was not possible to walk on the street, because there was no ramp to get Ida's walker from the building to the street and because the door-opener did not work. Consequently, although it might be possible for Ida to manage the actual walk, ‘going for a walk’ also included the sub-tasks of opening a very heavy door and carrying her walker down the step to the street. The care assistant saw this as an impossible task for Ida, who was 83 years of age and recovering from a stroke and resulting hemiplegia. The care worker thus further scaled down the goals, which reaffirms the aforementioned point that the closer to the practical realising potentiality that professionals work, the more inclined they are to lean towards the logic of retirement.
As this section illustrates, the rationale embedded in a logic of reablement that ‘self-reliance’ exists as a stable state, achievable by means of motivation, does not correspond with the complexities that care assistants encounter in their practical work. In order to perform good care, care assistants therefore draw on a logic of retirement according to which there are limits to what is physically possible for an older person to do regardless of how motivated they are. Interestingly, however, they do not disregard the logic of reablement, but stay loyal to this logic in letting the older persons do as much of the activities as they can manage – a practice several mentioned having always done – but taking into consideration the energy needed by the older people for the rest of the day's activities. By thus using their professional judgement, they managed to ensure carefully that older people were neither harmed by receiving too much care (Meldgaard Hansen and Kamp Reference Meldgaard Hansen and Kamp2018) nor harmed by an over-ambitious reablement programme, although this occasionally demanded their deliberate deviation from the agreed plan and goals.
Out of the reablement programmes which I followed, no older people were by the end of the programme categorised as ‘fully self-reliant’. They all ended up being granted all or some of the elder-care services they had requested – and in some cases more care services than they had initially requested.
Conclusion
Existing evidence on the effects of reablement has left largely unquestioned the assumption that reablement is a successful concept. In this paper, I have sought to unfold reablement by looking into the practical aspects of mobilising older people's potentials. By exploring which logics of care are at play as elder-care professionals translate the paradigm of potentiality into a workable principle, I have demonstrated that there are profound discrepancies between the political ambition to mobilise the hidden potential in older people, on the one hand, and the practical reality that elder-care professionals face in their meetings with older people, on the other – a reality which is characterised by complexities, negotiations and unexpected effects. In their endeavours to re-able older people, elder-care professionals carefully balance two different and sometimes contrasting logics of care in order to comply with policy obligations as well as professional moral standards of good care. Professionals draw on a logic of reablement as they optimistically assess all home care applicants for their potential for increased independence, set up ambitious goals and artfully try to induce motivation in the older people. However, the further along in the process and, hence, the closer to the realisation of potential that professionals work, the more inclined they are to lean towards a logic of retirement. Faced with older people at the last stage of life, often characterised by bodily and cognitive decline, professionals often allow older people to sit back or spend their remaining time on doing what they enjoy, which is rarely cleaning.
My point is not that the blame for the limited effects of reablement should be placed with elder-care professionals. On the contrary, as I hope to have demonstrated, this professionalism is crucial in ensuring that moral standards of good care are maintained in reablement. Instead, I argue that the reason for the difficulties in mobilising potentials in older people should be found in the mythical character of the idea that home care applicants possess large amounts of unutilised bodily potential which are possible for the state to mobilise in order to curb the pending welfare state crisis. As this study demonstrates, the majority of home care applicants, although often deemed to ‘lack potential’ or ‘be unmotivated’, have other kinds of potentials and motivations, usually directed towards retreat and leisure. Ironically then, although presented as an elder-care paradigm that offers a more inclusive approach to ageing that recognises older people's resources and potentials, the potentiality paradigm thus comes to do just the opposite. By insisting on a narrow focus on bodily and quantifiable potentials that can lead to reduced elder-care expenditures, the potentiality paradigm comes to portray the majority of older people as without potential. Although undoubtedly unintended, a focus on bodily potentials therefore reinforces dichotomies of active–passive, independent–dependent and successful–failed ageing also implied by much critical gerontology and, thus, falls into the trap of merely turning to the other side of the same judgemental coin (Martinson and Berridge Reference Martinson and Berridge2015). Since such dichotomous conceptions of ageing are often empirically untenable (Grøn Reference Grøn2016), it is necessary, in order to grasp the complexities of ageing, to pay attention to the everyday practices and insights of elder-care professionals, who translate policy into practice. By failing to take into account the challenges experienced by the experts of the field, and merely looking at the whether or not the anticipated effects are achieved, we miss the opportunity – or rather and necessity – to discuss the moral assumptions embedded in the paradigm of potentiality and whether these are desirable. As a concept that has penetrated local, national as well as international policy (Aspinal et al. Reference Aspinal, Glasby, Rostgaard, Tuntland and Westendorp2016), it is crucial to explore further the moral horizons actualised by reablement, e.g. how does an attention to potentiality constitute our understanding of ageing, how does it affect the conditions for a good senior life and how do older people respond to these new demands? As this study demonstrates, these deeply moral issues unfold when studying the practical aspect of introducing a new elder-care paradigm. Only by engaging in such ethnographic explorations can we open up the moral discussion of how elder-care and, more broadly, ageing is conceived of in the 21st century.
Acknowledgements
This research was supported by Nordea-fonden through the Center for Healthy Aging, University of Copenhagen. I thank my supervisors Henriette Langstrup and Ulla Christensen for their support and valuable feedback during the processes of conducting the fieldwork for, and writing up, this paper. A special thanks to the older people and elder-care professionals in the City of Copenhagen who, through their openness and willingness to let me gain insight into their engagements with reablement, made this study possible.
