S t o c kh o l m Un i v e rs i ty D i ss e rt a t i on S e ri es

Anna Essén
Tec hnology
as
an
extension
of
the
human
body 

E x p l o r i n g
 t h e 
 p ot e n t i al 
 r o l e
 o f 
 t ec h n o l o g y 
 i n 
 a n
 e l d e r l y 
 h om e 
 c a r e 
 s et t i n g 

© Anna Essén, Stockholm 2008

ISSN 978-91-7155-626-4
ISBN (XX-XXXX-XXXX)

Printed in Sweden by US-AB, Stockholm 2008

Distributor: Företagsekonomiska institutionen

Stockholm University
Abstract

The present thesis explores the potential role and implications of technology
in elderly care, as perceived by its users. This exploration is undertaken in
terms of five empirical studies of a telehealth project, and a meta-analysis of
their contributions. An important insight emerging from this work is the
need to rethink the human subject as a body rather than a mere mind using
technology. The thesis draws on phenomenology to re-conceptualize the user
of technology, and to on this basis theorize about the potential role and im-
plications of technology in care. It concludes that, in combination with hu-
mans who integrate technology with their other sensory and emotional ca-
pacities, technology can produce affect. The findings indicate that technol-
ogy can contribute to seniors feeling safe, cared for, and thereby less iso-
lated. The findings further demonstrate that, thanks to the perceptual
capacity gained from technology, the workers become aware of new health
problems that urgently call for their sensory and emotional responsiveness.
On this ground, the thesis challenges the determinist view that technology
threatens the essentially ‘human’. It rather concludes that feeling and other
bodily resources are fundamental in the use of technology. Indeed, technol-
ogy activates such ‘human’ capabilities.
Hence, the technology studied plays a role as a complement rather than as
a replacement to care workers. It increases their work burden by informing
them about new needs. This may improve care quality but to an increased
cost, which is relevant from a practical perspective. At a more general level,
the thesis challenges the dualist legacies in mainstream management re-
search, which have sought to divorce mind form the body, nature from cul-
ture and reason from emotion. It can thereby contribute to broader theoreti-
cal developments and fuel existing debates beyond the care setting.
Keywords: care, telehealth, information technology, physicality, materiality,
Merleau-Ponty, body, emotion, routines, variability, surveillance, privacy,
service evaluation, service innovation, emergence, learning.

© Anna Essén, Stockholm 2008

ISSN XXXX-XXXX
ISBN (XX-XXXX-XXXX)

Printed in Sweden by Printers name, City 2008

Distributor: Name of distributor (usually the department)
To Korris
Contents
Stockholm University Dissertation Series ...........................................................i

Anna Essén...........................................................................................................i

NEW SERIES (if any).................................Fel! Bokmärket är inte definierat.

XX (number of series) ................................Fel! Bokmärket är inte definierat.

Abstract ............................................................................................................... iii

Contents ..............................................................................................................iv

Contents ...............................................................................................................v

Preface and acknowledgements ..................................................................... 10

PART ONE........................................................................................................ 13

Introduction ....................................................................................................... 14

Highlighting weaknesses in dominant approaches to human-technology

relationships ...................................................................................................... 17
Research ignoring the human context - seeking the effects of technology itself
(determinism).............................................................................................................. 17
Viewing humans and technology as social facts (constructivism) ............................... 19
Equating humans and technology – viewing both as semiotic constructs
(technoscience) .......................................................................................................... 20
The need for alternative approaches .......................................................................... 21

Suggesting a phenomenological approach .................................................... 23

Introducing the work of Merleau-Ponty ....................................................................... 23
Rethinking the user of technology............................................................................... 24
Uniting mind and the physical body ....................................................................... 24
Connecting the active body to the world................................................................ 25
Linking emotion, body and rationality .................................................................... 27
Re-conceptualizing the relationship between humans and technology.................. 27
Methodological reflection ............................................................................................ 29

The potential role and implications of technology in elderly care – the user
perspective ........................................................................................................ 31
Viewing technology in use as an extension of the human body .................................. 31
Bodies emotionalizing and contextualizing technology .......................................... 33
Thinking of the implications of technology as capacity and feeling inside the body..... 34
Bodies selectively incorporating the micro and macro context.................................... 36
Studying the perceived reveals the perceiver ............................................................. 37

Conclusion ........................................................................................................ 38
Theoretical implications and future research directions ................................ 40

Practical implications........................................................................................ 43

References ........................................................................................................ 47

PART TWO ....................................................................................................... 54

Introducing the studies ..................................................................................... 55

1. The Role of Emotion in Service Evaluation: Senior Citizens’ Assessments

of Long-term Care Services ............................................................................. 59
Abstract ...................................................................................................................... 59
Introduction................................................................................................................. 61
Literature review and theoretical framework ............................................................... 62
The role of emotions in evaluation processes........................................................ 62
Service dimensions ............................................................................................... 63
Interpretation variables.......................................................................................... 65
Methodology ............................................................................................................... 65
Data collection....................................................................................................... 66
Data analysis......................................................................................................... 66
Findings...................................................................................................................... 66
OUTCOME DIMENSIONS .................................................................................... 67
Independence and freedom................................................................................... 67
Technical outcome (physical health status) ........................................................... 67
PROCESS DIMENSIONS ..................................................................................... 68
Reliability............................................................................................................... 68
Responsiveness .................................................................................................... 69
Security ................................................................................................................. 69
Communication ..................................................................................................... 70
Competent personnel ............................................................................................ 70
Warm and caring attitude ...................................................................................... 71
Individualised service ............................................................................................ 71
Holistic care........................................................................................................... 72
Continuity of service .............................................................................................. 72
Dimension of physical environment and tangibles ................................................. 72
Summary of findings ................................................................................................... 73
Conclusions, implications, and future research........................................................... 74
Major conclusions.................................................................................................. 74
Theoretical implications ......................................................................................... 75
Practical implications............................................................................................. 76
Limitations and suggestions for further research ................................................... 76

References ........................................................................................................ 78
2. Variability as a Source of Stability: Studying Routines in the Elderly Home
Care setting....................................................................................................... 82

Author: Essén, Anna ........................................................................................ 82

Abstract ...................................................................................................................... 82
Introduction................................................................................................................. 83
Method ....................................................................................................................... 84
Research setting ................................................................................................... 85
Data generation..................................................................................................... 85
Data analysis......................................................................................................... 86
Literature review and theoretical framework ............................................................... 86
Empirical material ....................................................................................................... 90
Artifacts ................................................................................................................. 90
The ostensive aspect – agreed on patterns........................................................... 92
The performative aspect........................................................................................ 94
Conclusion.................................................................................................................. 97
The role of and internal relationship between the parts of the routine.................... 97
Sources of variability in the home-help delivery routine......................................... 98
Theoretical implications ......................................................................................... 99
Managerial implications ....................................................................................... 101
Limitations and further research .......................................................................... 102
References ............................................................................................................... 103

Hodgson, G.M. Economics and evolution. Cambridge: Polity Press, 1993 104

3. The Emergence of Technology-based Service Systems: a Case Study of

a Telehealth Project in Sweden..................................................................... 106

Author: Essén, Anna ...................................................................................... 106

Wordcount: 234 .............................................................................................. 106

Introduction............................................................................................................... 107
The innovation of technology-based services ........................................................... 109
Bricolage and technological drift.......................................................................... 110
Proposing a framework for studying the emergence of new technology-based
services............................................................................................................... 112

Take in figure one about here........................................................................ 112

Method ..................................................................................................................... 113
Data generation................................................................................................... 114
Data analysis....................................................................................................... 114
The case ............................................................................................................. 115
Findings.................................................................................................................... 116
An injection of energy: Introducing a new technological resource without a clear
end in sight.......................................................................................................... 116
Making do: “Creating” the resources needed to innovate services ...................... 117
 Feedback mechanisms during the use of the new technology............................. 118
Redefining the automated alarms triggered by the new technology .................... 118
Redefining the patient data continuously provided by the technology.................. 119
Institutional constraints and stabilizing mechanisms............................................ 120
Interactions.......................................................................................................... 122
Drift: redefining the new technological resource – unexpected services emerging
............................................................................................................................ 123
Conclusion, implications and further research .......................................................... 123
Managerial implications ....................................................................................... 124
Theoretical implications, limitations and future research directions ..................... 126

References ...................................................................................................... 128

4. The Two Facets of Electronic Care Surveillance: Exploring the Elderly

Caretaker’s View............................................................................................. 133
Introduction............................................................................................................... 133
Defining privacy ........................................................................................................ 135
Care surveillance as a potential privacy harm .......................................................... 136
Method ..................................................................................................................... 138
Empirical findings ..................................................................................................... 141
Care surveillance as enabling – feeling cared for ................................................ 141

And Ingrid states that ..................................................................................... 141

Care surveillance as constraining – feeling as if under suspicion ........................ 144
Discussion ................................................................................................................ 145
Conclusion................................................................................................................ 147
Limitations ........................................................................................................... 148
Research suggestions......................................................................................... 148
References ............................................................................................................... 149

5. The corporeality of learning in everyday practice .................................... 154

5. The corporeality of learning in everyday practice .................................... 154

Abstract .................................................................................................................... 154
Introduction............................................................................................................... 155
Practice-Based Learning Theory: A Critique............................................................. 156
The primacy of the perceptual .................................................................................. 158
Purposeful learning but without a conscious purpose ............................................... 159
Method ..................................................................................................................... 162
Data generation................................................................................................... 162
Mode of analysis ................................................................................................. 163
Findings.................................................................................................................... 164
The centrality of the body in learning how to perform daily tasks......................... 164
Technological artifacts as extension of bodily skills .................................................. 167
Discussions, concluding remarks and implications ................................................... 171
 Theoretical implications and future research suggestions ................................... 172
References ............................................................................................................... 174
Preface and acknowledgements

This thesis would have looked completely different had I written it alone.
Dear reader, You should have seen the first drafts of each paper! They asked
different questions, used other theories and reached conclusions far from
those outlined here. The papers were overall much longer. I realized – rather
late— that research is not a matter of providing detailed and objective ac-
counts of “the state of affairs” of things. To perform research is rather to
participate in an academic debate by providing an argument that supports or
contradicts others’ arguments. It is all about claiming something, and to do
this in a convincing and trustworthy way. Being a researcher implies making
decisions about what – of so many things that one reads and observes – to
include, and about which conclusion – among numerous possible ones– to
draw. This thesis is the result of various such subjective decisions about
what to leave out and thereby hide. Dear Reader, please keep this in mind.
But also recognize that the present thesis is not only the result of one per-
son’s (my) subjective decisions. While never objective, it is the result of the
choices made by numerous peer researchers, including many anonymous
reviewers.
In general, I believe that this thesis represents a pragmatic effort. The pa-
pers make this explicit, including not the most “true” theories but rather the
most “useful” ones. Useful as they elucidate something that other theories do
not. And, I have to admit, useful in the sense that they helped me to position
my research and suited the interests of some Journal Editors (who considered
the theories “timely” and “relevant”).
Hence, the thesis should be seen as a pragmatic but serious attempt, made
by a collective of scholars, to provide insights about how we can think about
technology, care and human relationships and thereby contribute to theory
and to society. I would like to thank some of you who have helped me dur-
ing the process of writing this thesis. The names are NOT ordered according
to Your importance.
Solveig: In spite of your great knowledge and experience, you are ex-
tremely humble and generous with compliments. Thank you for inspiring
me–when I have needed it the most (your timing has been amazing!). Thank
you equally for always providing a critical eye towards eloquent but preten-
tious and useless theorizing. Thank you for asking: OK so what does that
fancy concept really mean? What does it contribute with?

10
 Ali: You’ve tought me more about academic research than anyone else.
Thank you for having the courage and energy to really criticizing my texts.
Thank you for expecting much of me; for telling me: this is not good
enough! Your belief in high quality science is unusual but contagious.
Stockholm University should be very happy to have you. You have such
high ideals. Don’t abandon them.
The academic world has made me disappointed and disillusioned, as peo-
ple’s ambition to gain power and publish a quantity rather than quality of
articles often play too large a role in what gets done. But academics have
also impressed me. Thank you my colleagues/friends at Stockholm Univer-
sity: Sara, Daniel, Torkild, Clara, Johanna, Robert, Eva & Dick for support-
ing me and for being devoted researchers. Your genuine interest in contribut-
ing to society or to theory has inspired me. Thank you my colleagues/friends
at Harvard: Jeremy Nobel, David Satin, Juergen Bludau, Richard Bohmer,
Norman Daniels, for letting me in your community, truly wishing to ex-
change healthcare research experiences. You showed me how exciting but
tough research life can be.
This thesis would not have been written at all if it weren’t for my sister
and my parents. To Linda, my dear sister who encouraged me to become a
Doctoral Candidate: You have always seen me as far more intelligent than I
actually am – which has made me stronger! And Apricot & Pippi: A 30-year
old feeling that ‘something’s missing’ after 2 days of work without mom and
dad in the background – is that normal? Well, Yes. With you as parents it is.
There is no room for me to thank you here. Suffice it to say that you are my
best friends and you are fantastic role models. I could not have done this
without you.
I also want to thank my old friends Åsa Ö, Linda U, Pernilla, Åsa A and
Sofia for being patient with me during these years! Åsa Ö: thank you espe-
cially for sharing your impressive knowledge about and experience of eld-
erly care with me!
Finally, this thesis might have been written: but I would have been a freak
had you not been by my side, Christian. Writing a Ph D can make one fasci-
nated by new theories that say absolutely no more— only with different
words— than what most people already know. Thank you for reducing that
tendency in me. And, thank you for telling me: “How beautiful you are”
when I have actually looked like a wreck, in my dirty sweatpants, bad breath
and mouth-full-of-half-eaten-cookies, sitting in front of the computer hour
after hour…day after day…
Getting married to you is the most emotional and best thing that has ever
happened to me!

11
12
PART ONE

13
Introduction

Long-term elderly care constitutes a particular kind of service. Intimacy,

relationship building and “humaneness” are frequently referred to as key
aspects of such care services and the practice of nursing has historically been
based on the assumption that direct human interaction has a therapeutic ef-
fect (Ford & McCormack, 2000; Glen, 1998; Gunter & Alligood, 2002; May
& Ellis, 2001; Strauss et al., 1982). Introducing technology-mediated, re-
mote services is bound to problematize such conventional assumptions.
Certainly, the idea of computerized care is a controversial issue. Espe-
cially so in the context of elderly long-term care, in relation to which it has
generated a polarized debate with information technology (IT) advocates and
IT critics. Many scholars, practitioners and politicians foresee how IT-based
home care services could enhance care quality and ultimately lead to an in-
creased quality of life for the caretaker. It is also asserted that IT – a low cost
resource – could replace humans in performing certain tasks and thereby
enhance the effectiveness of care (Bashshur et al., 2005; Committee on
Quality of Health Care, 2001; Demiris, 2004; Herbert et al., 2006; Korhonen
et al., 2003; Teknisk Framsyn, 1999; SOU, 2002). Critics on the other hand,
express concern about how technology may impose an instrumental rational-
ity on care work that would serve the interests of managers rather than care
personnel and elderly caretakers. They foresee how IT-based care services
will replace proximal care services and argue that this could lead to the eld-
erly becoming isolated from social structures, and to a mechanization and
dehumanization of care more generally (Bauer, 2002; Dewsbury et al., 2002;
Dunn, 2000; Dutta-Bergman, 2003; Hagberg, 2003; Stanberry, 2000; Wil-
liams et al., 1998; Taylor, 2001). While there are far-reaching visions as well
as fears attached to the introduction of IT-based care services in the public as
well as scholarly debate, it is yet largely unknown what could be the role of
new technology and what implications it could actually generate in the eld-
erly care setting. An important reason for this uncertainty is the narrow focus
characterizing the academic discourse on IT and care.
A large share of the current literature aims to investigate the ‘effects’ of
IT in care. The outcome measures used are however limited to medical and
clinical parameters such as blood sugar values and number of hospital read-
missions (Bashshur et al., 2005; Hailey et al., 2002; 2004a; 2004b; Heinzel-
mann et al., 2005; Roine et al., 2001). It is further difficult to interpret the
various (contradictory) results reported as most studies omit to explicate the

14
role the technology is assigned in the study setting, implicitly attributing the
reported results to the technology itself. Studies arguing that “contextual”
factors, beyond the specific technology in focus, influence the implications
of IT in care are emerging (Ash & Berg, 2003; Kaplan & Shaw, 2002; Mohd
et al., 2007; Schabetsberger et al., 2006). However, by focusing almost ex-
clusively on how “managerial issues” often lead to the make or break of IT-
implementations, this body of research, too, escapes some of the most basic
and critical issues in the IT and care debate.
Indeed, the idea of using new technology in care raises classical philoso-
phical questions about the role and implications of technology in human life
more generally (cf. Sharff & Dusek, 2003)—questions that has not been
treated sufficiently in the current literature. I am referring to matters such as:
Should we understand technology as antithetical to the emotionality and
intimacy of human relationships? Is technology a force that leads to a me-
chanical execution of services and to a standardized human interaction? In
short, will technology dehumanize care?
Addressing these “thorny” issues requires an exploration of how humans
(caretakers and caregivers) engage with new technology in actual, everyday
situations. It seems reasonable to argue that care consumers’ and care work-
ers’ experience of new technology is a fundamental question to investigate to
bring the IT and care debate forward. Their views determine how the tech-
nology is used, what role the technology is assigned and hence the conse-
quences the technology can contribute to. However, as indicated above, little
attention has been paid to such basic but fundamental topics in academic
research about IT and care. As a result, unfounded scenarios have gained
foothold in the debate and in practice. Negative predictions have been par-
ticularly influential in the elderly care setting. Skepticism towards technol-
ogy is widespread among care providers and the diffusion of technology in
elderly care is slow (Essén, 2003). Many view technology as a threat to
‘genuine’ care giving work, while in fact; no one has really studied if this is
the case.
Against this background, the present thesis explores the potential role and
implications of new technology in care service production and consumption.
As opposed to the contemporary research on IT and care, the thesis ac-
knowledges and brings to the fore the contextual, concrete and non-
mechanical aspects of care, articulating the physicality and emotionality of
care, and from there asks: how can technology contribute in this setting?
The thesis has two parts. Part two includes five studies, based on two
cases from the elderly care sector in Sweden where an in-home health moni-
toring system is used. Each study deals with a separate sub-question, uses
unique theoretical frameworks and provides stand-alone theoretical contribu-
tions. Part one on the other hand, provides a meta-analysis and synthesis of

15
the common themes emerging from the five studies at more general level.1
Using a phenomenological approach (primarily Merleau-Ponty (1962)), this
overarching analysis departs from the studied care workers’ and care takers’
experience of technology. It assumes that the locus of this experience is the
human body with its sensory and emotional intelligence, a body that is
closely intertwined with the existing local setting and prevailing culture.
What emerges from the overarching analysis is a new way of conceptualiz-
ing technology as an extension of the human body, including its material and
ideational dimensions. The proposed way of theorizing about humans’ en-
gagement with technology has several implications. It helps us to in new
ways think about the potential role of technology in care from a user’s per-
spective and in general, about how technology can generate value in a setting
such as care. In this way—by opening up perspectives rather than coming to
a closure—the thesis contributes to the contemporary understanding of the
potential role of new technology not only in care, but also in organizational
life more generally.
Part one of the thesis proceeds with a critical review of the dominant
frameworks used in the IT in care literature, a presentation of an alternative
theoretical framework used in the overarching analysis, its conclusion, major
implications and suggestions for further research. The studies are presented
in part two.

1
Note that the studies include several important themes relating to care, technology, organiza-
tion, innovation, learning and work that the overall introduction does not cover.

16
Highlighting weaknesses in dominant
approaches to human-technology
relationships

In this section I briefly account for the extant literature about IT and care
services. The meta-analysis of the five studies in this thesis made me aware
of the limitations in this body of research. While acknowledging its accom-
plishments, I shall argue that it often builds on assumptions that neglect im-
portant aspects of humans’ engagement with technology. As noted in the end
of this section, this weakness can be traced back to a narrow-minded view of
the human subject in social science research at general level.

Research ignoring the human context - seeking the

effects of technology itself (determinism)
Research about IT in care is mostly undertaken in computer science, infor-
matics and medical disciplines and published in advanced engineering, tele-
health, health informatics and e-health journals. Most studies are technology
or medically-oriented and deal with either 1) describing prototype develop-
ment and demonstrating technical possibilities, or 2) evaluating the clinical
effects of new telehealth technologies. A large part of the latter category of
IT and care research is rooted in health economic theory, seeking to compare
the outcomes of IT-based care services with the outcomes of a previous non-
technological alternative. The results vary. While some studies conclude that
telehealth can produce improved intermediate health-outcomes and reduce
hospital readmissions, other studies report negative results (e.g Bashshur et
al., 2005; Chan et al., 1998; Heinzelman et al, 2005; Hersh et al., 2002;
Louis et al., 2003; Mair & Whitten, 2000).
This literature is informative about the functional properties of technology
but less so as regards how these functions are used. Indeed, “telehealth” re-
views exclusively include studies employing health economic methods (ran-
domized controlled trials) that focus on inputs (technological artifacts) and
outputs (quantified clinical outcomes) while black-boxing the process of
using technology. Reviews often exclude evaluations that focus on e.g. user,
organizational, or other context-specific issues (see e.g. Roine et al., 2001;

17
Hailey et al., 2002; 2004a; 2004b; Taylor, 1998). This stems from the ambi-
tion to produce decontextualized, objective and generalizable results. Para-
doxically, the result is often the opposite.
Indeed, while there is an eagerness among healthcare researchers to
evaluate exactly to what extent IT is ‘The Answer’ to the contemporary
healthcare problems, their conclusions do not provide an answer to this ques-
tion. An important reason for this is that authors neglect implications in areas
beyond the strictly medical (patients’ physiological values) or clinical (hos-
pital readmissions). The quantitative measures used say little about how care
consumers or care workers experience the new technologies in their every-
day life. In general, studies focusing on the objective functionality of tech-
nology and its quantitative effects do not provide much theoretical input to
discussions about how technology will make patients feel when being pro-
vided with “IT-based care services”, about how care workers will use tech-
nology in their everyday work, or about how we can understand the role of
technology in relation to human labor, that is, how humans engage with
technology and how this affects their engagement with each other and the
world.
An explanation for the neglect of these issues is that studies adopting
health economic models tend to view technology as given and attribute ob-
served consequences to the technology itself, that is, implicitly provide a
deterministic view of technology (cf. Collingridge 1980, Latour, 1992). A
deterministic view also underlies the polarized positions in the popular de-
bate and in practice (see introduction) in predictions suggesting that technol-
ogy in general, and in itself, will lead to certain effects.
Technological determinism is the thesis that technology is an autonomous
force that constitutes a fundamental cause of change in society (Sharff &
Dusek, 2003). This view essentially suggests that technology, once created
and put in place, takes on a life of its own, follows a line of development
almost contextless and thereby inevitably produces certain results. Discuss-
ing technology and society at general level, optimistic technological deter-
minists have celebrated technology for its modernizing features, viewing
technology as a revolutionary solution to social and economic problems (cf.
Castells, 1996; Sharff & Dusek, 2003; Toffler, 1981). Pessimistic determi-
nists on the other hand, have argued that modern technology (in general)
threatens “the natural” and essentially human (Ellul, 1964; Heidegger,
1927/1962; Jonas, 1979; Marcuse, 1964/2003). This by taking over previous
biological, perceptual and creative functions of human beings, producing a
discontinuous and fragmented perception and by displacing human labor
power in favor of automated technological production (Kellner 1999; Virilio
1994; 1995; 1997; 1999). Obviously, these philosophical utopian and dysto-
pian views have reappeared in the care debate, in the visions concerning how
IT itself represents a “technological fix” to the quality problems of care and

18
in the argument that technology in itself will lead to a dehumanization and
mechanization of care (see introduction).
In summary, a large part of the IT and care literature and public debate is
implicitly based on technological determinism. This is a problem. As noted
by numerous authors, it is irrelevant to study or even discuss the effects of
IT-applications themselves (Bijker et al., 1987; Feenberg 1992/2003; Kell-
ner, 1999; Scharff & Dusek, 2003). Such an approach neglects the possibil-
ity of human users to make choices as regards how to use the technology.
And as demonstrated in the studies here, such choices significantly shape the
consequences of technology. I will return to this point.

Viewing humans and technology as social facts

(constructivism)
As a response and alternative to the deterministic view of technology, a view
of technology as socially constructed emerged in social studies of science in
the 1980s. This body of research suggests that what technologies are and
become depend on the continuous reshaping of the technology by its users
(e.g. Bijker et al, 1987; Bijker & Law, 1992). Similar perspectives have re-
cently appeared in IT and care research. A growing number of studies depart
from an interpretive and qualitative approach, studying the use of telehealth
in specific settings. These studies show that a variety of healthcare informa-
tion systems are little used, even though their technological accuracy have
been demonstrated. It is argued that these results are due to organizational
conflicts and other context-specific reasons, rather than the technology itself
(e.g. Berg, 1999; 2001; Forsythe, 2001; Kaplan & Shaw, 2002; May et al.,
2003; Mohd et al., 2007; Nicolini, 2006).
The social constructivist influence on IT and care research has brought to
the fore that technologies cannot be understood independently from how
they are used in the actual context. This is an important contribution. How-
ever, authors have limited their attention to ‘organizational’ and managerial’
problems, at the expense of individual care workers’ and caretakers’ experi-
ence of new technology in their work or everyday life. In general, social
constructivism can be criticized for suggesting “there is nothing but the so-
cial” (cf. Feenberg, 2003; Ihde, 1990). This is problematic because, as sug-
gested by the studies in this thesis, concrete material aspects such as the
physical attributes of technology and the physical capacities of human users
influence how humans deploy technology, which in turn influences its
implications.

19
Equating humans and technology – viewing both as
semiotic constructs (technoscience)
It is finally relevant to mention that theories highlighting that the material
dimensions of technology can influence its implications have appeared in the
technoscience literature. The actor-network theory (Latour, 1987) suggests
that technology and humans do not occupy separate domains or operate ac-
cording to separate logics, nor does their relationship develop in some uni-
linear way (the former ‘causing change’ in the latter or vice versa). Work
practices consist of various human and non-human elements and what comes
to be the application and impact of technology is emergent, determined by
the unpredictable interplay of these elements in each situation. It is argued
that humans and non-humans should not be viewed as discrete entities; they
constitute a sociotechnical assembly that should be dealt with as a whole
(Latour, 1987; 1993). Haraway, (1991: 149, 152) writes that: “Cyborgs [are]
creatures simultaneously animal and machine...” and that the “leaky distinc-
tion is between animal-human (organism) and machine”.
These theories of technoscience have only begun to emerge in the IT and
care/services research. For example, Nicolini (2007) observes how unex-
pected changes in care processes follow the introduction of IT in the studied
care setting. He argues that the effects are unpredictable and emerge only
when human and technological actants interact in situ. Hence studies need to
explore unexpected effects, Nicolini concludes, and refrain from focusing
ex-ante on some specific phenomenon (cf. Berg 1999; 2001; Constantinides
& Baret, 2006).
Technoscience theory has contributed to IT and care research by underlin-
ing the unpredictable aspects of technology use. However, while attempting
to bring forth ‘the material’ in addition to the social, physical aspects of the
human body such as emotion is left out in this literature. Indeed, techno-
science research tends to portray humans and nonhumans as rather abstract
‘actants’, between which there is a symmetrical interaction. Latour takes the
strongest stance, suggesting an interchangeability of humans and nonhu-
mans. He writes that in sociotechnical collectives: “…there is no plausible
sense in which artifacts, corporate body, and subject can be distinguished”
(Latour, 1993: 197). This is close to the hybrid-cyborg figures of Haraway
(1991). Both theories seek to blur the boundaries between subjects, artifacts
and society, based upon semiotic principles. They describe human and non-
human actors as textual constructs, operating on equal terms, merely accord-
ing to different codes or ‘programs’.
My observations certainly inspired me to criticize this view of “the world-
as-text”. It obscures crucial ontological differences between humans and
machines by producing non-situated and disembodied accounts of humans’
engagement with technology, and of organizational and social life in general.
The studies included in this thesis demonstrate that the world includes more

20
dimensions than those that can be expressed in ‘programs’ or language. And,
is the world nothing but emergent – are there not relatively stable structures
– history – that influence human action and experience? I am not alone in
raising these questions (see Ihde, 2002; Scharff, 2006). As others have ar-
gued, humans and artefacts can be made equivalent semiotically; but in prac-
tice they are not (Pickering, 1995). Humans are bodily, emotional and moral
beings that are situated in a historical time in a way that technology in itself
is not (Ihde, 2002). This should not be ignored in IT and care research.

The need for alternative approaches

In summary, the extant IT and care services literature provides different
views of technology and its users. Some studies implicitly draw on techno-
logical determinism and tend to ignore aspects related to human users com-
pletely; other studies provide a social constructivist view and can be criti-
cized for reducing humans and technology to social facts. A limited number
of studies use the actor network theory to acknowledge the mutual influence
of the social and material. However, they do not discriminate between tech-
nology and humans, viewing them merely as abstract, semiotic constructs.
This seems counterintuitive, especially in the long-term elderly care setting.
As noted above, the importance of emotional sensitivity, intimacy and
physical touch is well established in the care service setting literature. This
was also clear to me in my effort to synthesize the findings of the studies
included here. I repeatedly returned to the users’ perceptual capacity and
emotionality when trying to understand the role of the technology in the
cases studied. These issues seemed to hold as much explanatory power as the
technology itself. Hence, the need for approaches that would help me take
into account non-discursive, concrete, “human” aspects in the study of tech-
nology became obvious to me. Finding such a theoretical platform was how-
ever easier said than done.
Indeed, not only the IT and care services literature, but also the organiza-
tional-, management- and sociological literature at more general provides a
limited treatment of the human body and its emotions. Organization and
management research has traditionally focused on human agents as rational
decision-making agents, viewing rationality as a calculative, analytic and
non-emotional capacity residing in the human mind (see e.g. Simon, 1976).
Implicitly or explicitly, emotions have been dismissed as irrational, inner
sensations and desires in need to be ‘tamed’ harnessed or driven out by the
steady hand of reason (Brandth et al., 2005; Knights & Thanem, 2005;
Nussbaum, 2001; Williams & Bendelow, 1998: 25) and the body has been
treated like a non-intelligent and rather uninteresting physical container
(Dale, 2001; Thanem, 2004; Turner, 1991; 1992; 1996; Shilling, 1993;
1997a, 1997b; 1997c). While there has in recent decades been a resurge in

21
interest in bodily matters in social science, theorizing is still limited and one-
sided. In relation to technology, scholars have primarily focused on the
physicality of the body as constraining, discussing how technology may
conquer such limitations, freeing subjects from their bodies (e.g. Balsamo,
1995; Featherstone & Burrows, 1995; Waldby, 1997; Williams, 1997, cf.
Dale, 2001). In general, most studies discuss how social forces shape the
construction of the body, thereby emphasizing the view of the body as pas-
sive, as an object of control and as acted upon 2 (Dale, 2001; Shilling, 1993;
1997a; 1997b; 1997c). Research on the body has further been disconnected
from research about emotions and vice versa; the limited research that does
exist about emotions tends to view emotions as mental rather than bodily3
(Knights & Thanem, 2005; Williams & Bendelow, 1998). This situation
within social science research reflects the powerful legacy of the mind/body
dualism of e.g. Cartesian philosophy. Scholars’ eagerness to turn away from
biological determinism is most likely another reason for the prioritization of
the ‘social’ and ‘mental’ at the expense of the physical (Knights & Thanem,
2005; Shilling, 1993; 1997; Turner, 1992).
Given the state of the contemporary literature, I concluded that neither IT
and care literature nor the mainstream social science literature could help me
to frame the findings in my five studies. These findings do not highlight
human ‘minds’ experiencing and reacting to the technology, based on fact-
based, calculative evaluation procedures. Rather, they point at active human
bodies, with enabling physical capacities, using technology. Emotions fur-
ther play various positive roles in the users’ experiences in ways that I could
not categorize as purely mental or irrational. Hence, I could only agree with
scholars who criticize the contemporary literature for neglecting that 1) the
body should not only be viewed as acted upon but also as an active and ena-
bling force, and 2) emotions are part of human physicality, expressivity and
intelligence (Damasio, 1994; Hassard et al., 2000; Knights & Thanem, 2005;
Nussbaum, 2001).

2
The prevalence of accounts of “docile bodies as faceless objects” (McNay, 2000) in the
organizational literature is often explained with the influence of Foucault. However, as noted
by Crossley (1996), Foucault does view the body as both active and acted upon. But he tends
to be weaker on seeing the active body, and he does not provide a coherent theory of embod-
ied agency (McNay, 2000), which may have led to the focus on the inscribed body rather than
the lived body in Foucauldian organizational literature (Crossley, 1996).
3
This research has largely built on Hoschild’s (1983) notion of emotional labor. While pro-
viding significant insights, Hoschilds theorizing about emotions does not emphasize bodily,
physical aspects (Knights & Thanem, 2005). It also runs into problems of micro and macro
linkages (Williams & Bendelow, 1998; Wouters, 1989). I will return to this point.

22
Suggesting a phenomenological approach

Looking for an alternative philosophical ground that would help me expli-

cate the insights emerging from the studies included here, I turned to the
phenomenological literature. I found that Merleau-Ponty’s (1962, 1965,
1968) work provides a fruitful platform for highlighting the physical and
emotional aspects of human experience, without returning to biological de-
terminism.

Introducing the work of Merleau-Ponty

Phenomenology is the study of human experience from the first-person point
of view. That is, phenomenology is interested how humans perceive the
world and its objects rather than in whether or not the objects ontologically
exist in any objective sense.4 Merleau-Ponty entered the phenomenological
field in the 1950s, introducing the notion of the body-subject as the source of
human experience. Other phenomenologists had prepared the ground for this
view. Husserl (1970[1936]) emphasized that “the life-world”, i.e. humans’
subjective perception of the world is the basis of their existence. Heidegger
(1962[1927]) also emphasized the every-day experience in the world, talking
about how “being-in-the-world” is what makes humans know things about
the world (Yakhlef, 2008). Now, while Merleau-Ponty (1962; 1965; 1968)
extended he also diverged from these ideas. Merleau-Ponty criticized
Husserl’s understanding of human perception and experience as conscious
acts occurring in the mind, viewing instead human experience as involving
the whole body – in action, and intertwined with the world.5 In general, Mer-
4
Phenomenology includes several sub-branches, see e.g. Embree et al (1997).
5
It is important to clarify that Husserl understood human experience as constituted by a tran-
scendental, inner, meaning-giving realm. Husserl sought to lay bare the essential structure of
this deeper realm of subjectivity and consciousness. Husserl was uninterested in any reality
beyond the lifeworld, “bracketing” the question of the independent existence of the natural
world around us. Heidegger argued that we should not study our activities by “bracketing” the
world, rather we should interpret the meaning things have for us by looking to our contextual
relations to things in the world. Heidegger resisted Husserl’s Cartesian emphasis on con-
sciousness, arguing that Husserl’s transcendental subject was too subjective in the sense that it
loses the world, leading to a philosophy of consciousness that emphasizes a solitary, disem-
bodied cogito. Heidegger suggested that our ways of relating to things are in practical activi-
ties like hammering, in a context of equipment and in being with others. Merleau-Ponty ex-

23
leau-Ponty saw the central phenomenological task as one of re-establishing
‘the roots of the mind in its body and in its world’ (Merleau-Ponty, 1965). In
these terms, Merleau-Ponty challenged classic phenomenology, where that
which thinks is separate from the material world and the body, and where
our experience is directed toward things only through concepts and ideas
(Dreyfus, 1979; Ihde, 1993; Merleau-Ponty, 1962; Stanford Encyclopedia,
2004; Williams & Bendelow, 1998).
This perspective helped me to rethink and thereby better understand the
experience of the studied care workers and care takers. My intention is to
here present to you the re-conceptualization of “the user” of technology that
emerged as a result of a parallel re-reading of the five studies and a gradual
understanding of Merleau-Ponty’s philosophy.

Rethinking the user of technology

Uniting mind and the physical body

I saw human bodies rather than mere ‘minds’ experiencing the technology
(and other objects/events) when analyzing the five studies in this thesis
(Study 1, The role of emotion in service evaluation: senior citizens’ assess-
ment of long-term care services; Study 2, Variability as a source of stability:
studying routines in the elderly home care setting; Study 3, The emergence
of technology-based service systems: a case study of a telehealth project in
Sweden; Study 4, The two facets of electronic care surveillance: exploring
the elderly caretaker’s view and Study 5, The corporeality of learning in
everyday practice). The care workers and caretakers further evaluated the
technology not only based on fact-based, calculative processes, but using
their bodily emotions. By reading Merleau-Ponty’s claim that “human sub-
jectivity is a bodily subjectivity” and that “the body is who we are; it is our
consciousness, intelligence and intentionality”, it struck me that what these
findings pointed at, was simply that the user is a body.
Merleau-Ponty further underlined the primordial intention of the human
body to be in equilibrium in the world. He saw this as a pre-reflective inten-
tionality, bound to and realized only in the bodily performance itself (Vas-
sleu, 1998). From my view, Merleau-Ponty hence talks about a bodily intel-
ligence that helps us to act ‘smoothly’ in the world. This kind of bodily
tendency was obvious primarily in the experience of the care workers stud-

tended these ideas, claiming that the human subject is not a transcendental subject but a sub-
ject that emerges form nature. Hence, as noted by Bernet (1993), in Husserl’s work, there is a
reduction of natural life, while it is in the work of Merleau-Ponty a reduction to natural life.

24
ied here. Their basic, pre-reflective intention to acclimatize to their local and
cultural environment clearly influenced their use and evaluation of the tech-
nology. (e.g. Study 3, 5).
Now, the care workers and caretakers studied did not only engage with
the technology in sub-conscious, non-discursive ways. As the interview tran-
scripts reveal, the studied users also reflected about how to use the technol-
ogy, and about its actual and potential contributions (Study 3, 4). Similarly,
Merleau-Ponty did not deny the so-called reflective, mental, rational or dis-
cursive aspects of human life. What he did want to suggest was that such
aspects are inseparable from our bodily, physical nature. He argued that dis-
course is far from a disembodied process, it is a fleshy process; it is pro-
duced though the work of the body. In short, there is no choice between dis-
course and fleshiness, according to Merleau-Ponty’s theory. They belong to
each other “as do legs and walking”. 6
This seemed to me a fruitful view as I could not clearly separate the stud-
ied users’ conscious and sub-conscious, brain-related and body-related, fact-
based and emotion-related perception of the technology, they rather seemed
intertwined, and equally important. Hence, the present conceptualization of
“the user of technology” draws on Merleau-Ponty to suggest that the body is
neither solely a discursive object (as suggested in pure constructivist views)
or solely flesh and bone (the naturalistic view). The body rather provides a
physical basis for all its discursive processes. In short, the ideational and the
material are intertwined. This notion of intertwining also concerns the rela-
tionship between subject and object or between the perceiver and the per-
ceived.

Connecting the active body to the world

Merleau-Ponty argued that perception is not a matter of our body passively
receiving sensory data form the world that our isolated mind later on inter-
prets. Rather, perception should be understood as our body actively but pre-
reflectively interrogating the world. Perception is about our body interpret-
ing the world in relation to our practical engagement in the world, i.e. the
projects we are involved in.
My findings support Merleau-Ponty’s rejection of the idea that perception
is an ‘inner’ representation of an ‘outer’ world of given objects (Merleau-
Ponty 1962; 1968). 7 The studied care workers and care takers clearly per-

6
Indeed, despite Merleau-Ponty’s emphasis on our ‘primordial union with the world’, he
made it clear that one never returns to immediate experience. Reason has a role in our ways of
living, but it is based in the phenomenological exigencies of the subject and their life-world.
7
Merleau-Ponty argued that perception is not merely the result of the functioning of individ-
ual organs, but also a subjective human act in which each of the senses informs the others in
virtue of their common behavioral project. As noted by Barral (1965: 94), Merleau-Ponty’s

25
ceived the technology (and other objects/events in the world) in relation to
their concrete day-to-day interests (Study 1-5).
They further perceived the technology from somewhere. Merleau-Ponty
argued that our perception is contingent on our bodily position and tangible
presence in a specific physical situation (Mallin, 1979). He also underlined
that our perception is situated in an historical situation and is influenced by
social, economic, political and cultural forces. This does not mean that Mer-
leau-Ponty advocated a view of human bodies as passive or as mere social
constructs. According to my interpretation, his theory opens up for a view
where our bodies incorporate the micro and macro structures in which they
are situated, an incorporation that is selective, influenced by the physicality
of the body itself. In general, Merleau-Ponty’s theory emphasizes the lived,
active body-subject rather than the body as an inert matter that is acted upon
(Dale, 2001; Grosz, 1994; Williams & Bendelow, 1998). This resonates well
with the findings in my studies. For example, I would not describe the care
workers’ bodies as mere recipients or mediums of social structures. Sure,
they incorporated values in society but they did this selectively, thereby se-
lectively reproducing – renewing— structures. Hence, the present conceptu-
alization builds on the premise that the human body is shaped by, but also
agentic and active in relation to prevailing structures.8 (E.g. Study 3, 4).
The conceptualization of the user suggested here further assumes that this
mutual influence also applies to the human body and objects in the local,
physical setting. Merleau-Ponty provides an example of a patient that expe-
riences an absent limb (hand) as a correlate of those aspects of the world that
”speak to” the hand, e.g. the piano to be played, or the doorknob to be
opened. When the patient restructures her/his world in such as manner that
the things no longer beckon to the lost limb, then the experiences of the limb
vanishes. To me, this example illustrates how our experience of ourselves
(our ideational and material subjectivity) is influenced by the objects in our
surroundings, and how we perceive objects on basis of our own, enabling
and constraining, physicality. As Merleau-Ponty made clear, "whenever I try
to understand myself, the whole fabric of the perceptible world comes too
(Merleau-Ponty, 1964:15). He insisted that: "man is a network of relations"
(1962: 456) and maintained that these relations are not something that we
can unravel. The interdependence of the network is what gives humanity its
very qualities, and by dissecting it, we risk losing the very thing that estab-
lishes us as human.

theory suggests that "if we attempt to localize and sectionalize the various activities which
manifest themselves at the bodily level, we lose the signification of the action itself”.
8
As indicated by Schmidt (1983), Merleau-Ponty’s view may have inspired Giddens later
structuration theory (1979; 1984), which recognizes that social structures produce but are also
selectively re-produced (and thereby potentially renewed) by individual agents

26
Linking emotion, body and rationality
In Merleau-Ponty’s theory, the mutual encroachment of the subject and the
world and the ideational and material also explain human emotion. Merleau-
Ponty refused to describe emotions as private and purely ‘mental’. Accord-
ing to his philosophy, emotions are essentially communicative, and intersub-
jective, constituted as physical and cultural dispositions through techniques
of the body (Crossley, 1995a; 1995b; Williams & Bendelow, 1998). As
noted in the Stanford Encyclopedia (2004), the view of emotions as physical
(residing in the individual’s body) as well as cultural implies a certain ambi-
guity at the heart of our experience. Trying to discern what is an authentic
emotion of the self, which is not induced by the demands of one's society, is
infinitely difficult. Merleau-Ponty refused to use the concept of authenticity
for his entire career “because of its overtones of an unattainable individual-
ism” (Stanford Encyclopedia, 2004). He would not want to say that coming
to terms with one’s own situation in an empowering way is impossible,
rather that we cannot transcend of our environment. Merleau-Ponty's sugges-
tion is that “circumstances point us to, and that they allow us to find a way”
(Merleau-Ponty, 1962:456; Stanford Encyclopedia, 2004).
Overall, Merleau-Ponty’s view of emotion is far from a ready-applicable
package. Nonetheless, in combination with other, newer emotion theories
(Crossley, 1997; Damasio, 1994; Nussbaum, 2001), his philosophy helped
me to articulate what my studies hinted at: that emotions are bodily commu-
nicative capacities that help us to behave effectively and reach our goals.
Emotions advised the studied care workers and care takers in how to in, if
not rational, at least not irrational ways perform actions and make judgments
(Study 1-5).
On this ground, the present conceptualization assumes that as all our bod-
ily capacities, emotions are forthcoming in actual situations, when our body
performs actions in the world; and as with all our knowledge, emotions are
shaped (enabled and constrained) by the physicality of the body as well as by
culture. That is, emotions are ideational and material and they include pre-
reflective as well reflective dimensions.

Re-conceptualizing the relationship between humans and

technology
The studies did not point at care workers and caretakers focusing on tech-
nology. They rather exhibited users engaging with each other through tech-
nology. Merleau-Ponty similarly argued that we often perceive the environ-
ment though intermediary objects without being explicitly aware of the in-
termediary object. For example, he referred to the blind person who is accus-
tomed to using a stick and senses where he is "through his stick". The blind
man is not aware of the stick but the objects he attempts to navigate about: it

27
is actually the other objects that make him aware of the stick. Further, we
“know” how to turn a corner with our bike almost as if the bike was our own
body. We think from the point of view of the bike. Thus, Merleau-Ponty’s
theory suggests that we can incorporate instruments into our own body
schema. This knowledge is not necessarily reflective or discursive; it is prac-
tical, embodied know-how and mastery (Crossley, 1995a; 1995b; 1996).
This argument can be traced back to Heidegger’s (1927/1962) “ready-to-
hand” e.g. the hammer functioning as an extension of the arm’s capabilities
(Selinger, 2006).
Ihde (1990) develops the idea of humans reaching the world through
technology. He maintains that the intentionality of bodily action goes beyond
one’s bodily limits and he argues that technologies must be understood as
existing in relation with humans rather than as discrete objects (Idhe, 1993).
Ihde provides a useful conceptualization of human-technology relationships
in this context. He writes about embodiment relations, where we humans
take technological artefacts into their experiencing. In embodiment relations
technologies constitute and approximate the status of a ‘quasi me’, as e.g.
eyeglasses, and we perceive the world through technology. The technology
withdraws to such a degree that it becomes the means and not the object of
our perception. This is obviously similar to Merleau-Ponty’s discussion of
the blind man’s cane serving as an extension of his perception. In hermeneu-
tic relations the artefact is not transparent, but provides a representation of
the world. In such relations readable, interpretable technologies make the
world accessible to us in ways impossible for naked perception. In such rela-
tions, the perceptual focus is on the text of the artefact. Finally, alterity rela-
tions refer to relations where humans focus attention upon the technology
itself and perceive the technology itself a quasi “other”, to which we relate,
as e.g. in playing video games (Ihde, 1990).
I will use this conceptualization to analyze the studied care workers’ and
care takers’ engagement with technology in the next section. Suffice it here
to say that in embodiment and hermeneutic relations, technology can be un-
derstood as an extension of the human body and perception. This implies
that the technology can expand the human body’s ability to perceive affor-
dances, i.e. opportunities for action. It is difficult to determine whether or
not this extended perception resides inside the human body, or if it is exter-
nal, residing in the technological ‘object’. This resonates with Merleau-
Ponty’s problematization of the separation of the subject/object. Against this
background, this thesis does not attempt to draw a strict border between the
human user and the technology used (between the ideational and material)
but assumes that there is a continuous relationship between these two.

28
Methodological reflection
Drawing on the phenomenological approach described above, the present
thesis departs from the human subjective experience when analyzing the
potential role and implications of technology in care. It assumes that the
situated human body (with it’s reflective and pre-reflective capacities) is the
locus of this experience. This has methodological implications. It suggests
that the researcher needs to study not only that which can be expressed in
words, but also non-discursive aspects. A challenge indeed. The thesis is
based on empirical material generated by means of observations, in-depth
interviews and field-work (see further the method section in the studies and
appendix 2). While this fieldwork provided access to non-discursive ele-
ments, it is difficult to in the format of an academic thesis, i.e. with text,
provide a portrayal of emotional, pre-reflective and tacit aspects of human
action (cf. Knights & Thanem, 2005). This thesis should however be under-
stood as an attempt to bring such aspects to the fore.
The thesis does talk about the human body on the one hand, and technol-
ogy as something “perceived” on the other. This may appear contradictory to
Merleau-Ponty’s phenomenology, which resists any strict border between
subject and object, inside and outside, perceiver and perceived. However, as
noted by Merleau-Ponty himself, it may be useful, in a particular situation, to
conceive of a seer and a seen, a subject and an object - provided that the
terms of such dualities are recognized as relationally constituted. 9
In the spirit of phenomenology, I further want to highlight how my own
body and its situatedness have influenced the present work. This thesis is
written from the perspective of an eager-to-publish Ms Sc in computer sci-
ence. With a passion for elderly care. And with an essentially positive atti-
tude to technology. I am not claiming that the cases I have studied have pre-
sented themselves to me in any absolute manner, from all their angles. My
observations and the findings presented in the studies are not the result of my
eyes and ears ‘neutrally’ and passively receiving sensory data and my mind
later interpreting this. My observations have rather been linked to my situ-
ated ambitions, to find something publishable inter alia. Encouraged by
trends in the academic literature (primarily in management- and organization
science) and the theoretical interests of peers at my institution, my body has
selectively perceived certain events and not others, in pre-conscious and
conscious ways.
The physicality of my body has shaped the writing of the present text,
which is not the result of a merely calculative, fact based reasoning in my
mind. The text is also shaped by pre-reflective and emotional, i.e. bodily

9
Merleau-Ponty did not want to deny the possibility of cognitive relations between subject
and object. In his theory, the seer and the seen condition one another. Our capacity for seeing
is different from the capacity for being seen.

29
aspects. In some ways, such aspects may have led me in arbitrary directions.
The fact that certain “complicated” theories have made me feel excited
(rather than them being more useful or ‘true’ than other theories) have most
likely led me to use them rather than other alternatives. My use of certain
theories rather than others may further be related to me being well rested,
sitting in a comfortable chair, satisfied food-wise (hunger tends to make me
more critical) when reading these theories, and in an opposite physical con-
dition when reading other potential theories.
Overall, I however feel that my body including its emotions has consti-
tuted an important resource in my work, leading me towards relevant paths. I
have seldom had a clear formulation in my head before writing a paper.
Rather, my intention has been to “write my way to” an idea or conclusion.
Indeed, I could not have asked someone else to “write down my thoughts” as
most of my conclusions have been forthcoming through the bodily effort of
writing. In a sense, my hands have drawn conclusions as much as my brain.
As regards emotions, I agree with Jaggar, who argues that emotion is neces-
sary to producing reliable knowledge (1989). For instance, my efforts to not
only draw publishable, but also “fair” conclusions and to provide “honest”
accounts of the methods used are not the result of any calculative fact-based
reasoning. My emotions rather forced me to - I would feel uneasy and guilty
if I had not. I do not attempt to determine to what extent these enabling and
constraining emotions and moral convictions are ‘my own’ or constructed by
society. Suffice it to say that these bodily forces have exerted concrete (I
have felt them) influence on this work in a way that I refuse to call irrational.

30
The potential role and implications of
technology in elderly care – the user
perspective

The re-conceptualization of the user outlined above makes it possible to in a

new way view the encounter between individuals and technology (compare
with the deterministic, constructivist and technoscience approach in section
two). Assuming that ‘the user is a body’, with all that it implies, I will in this
section begin to tentatively conceptualize the potential role and implications
of technology in care, based on themes that emerge from the five studies in
this thesis.

Viewing technology in use as an extension of the

human body
The studies in this thesis suggest that humans use technology if they feel that
it provides them with relevant capacities. Given that this is the case, they
think of and use the new ‘extended’ or ‘technology-mediated’ capacity just
as any of their other ‘naked’ bodily capacities. That is, they incorporate the
technology into their own body.
For example, Study 4, The two facets of electronic care surveillance: ex-
ploring the elderly caretaker’s view, highlights that one of the seniors stud-
ied here did not perceive that the technology expanded her bodily capacities,
rather the opposite. She perceived the technology as an opponent rather than
a component of her own body. She engaged in an alterity relation (Ihde,
1990), experiencing the monitoring technology as some foreign and intrud-
ing “other”, constraining her possibility of action. As a result, she rejected
the technology (interrupted the service). The reaction can be understood as
an illustration of how the human body rejects technology if it feels that the
technology creates tensions (deviations from some ‘optimal body-
environment relation) rather than facilitates a smooth functioning in the
world (Merleau-Ponty, 1962). Just like the human would reject an organ
implant if it created conflicts with other organs. The example further illus-
trates how the emotion of the body can be constraining, impeding certain
uses and hence preventing certain implications.

31
 The majority of the caretakers studied however embodied (Ihde, 1990) the
technology deployed. The technology itself is not the object of these seniors’
attention; the technology becomes transparent and withdraws. From the sen-
iors’ perspective, the technology is merely a means through which informa-
tion about their health status is delivered to the care workers. Indeed, just
like a musician can produce new sounds and make herself heard through a
music instrument, the seniors perceive that, through technology, they can
make themselves ‘heard’ and ‘seen’ in expanded ways. As a result, the
technology makes the seniors feel safe. What makes the seniors feel safe is
however their belief that they, through the technology, can be ‘seen’ by other
human caregivers, that is by other familiar individuals (cf. Study 4). Hence,
the senior caretakers do not view the technology as an isolated, external ob-
ject. Rather, the seniors perceive the technology as an extension of their own
and others’ human body.
The care workers used the system studied differently from the seniors.
They looked at “activity curves” on a computer screen. The studies (see
Study 2, Variability as a source of stability: studying routines in the elderly
home care setting; Study 3, The emergence of technology-based service sys-
tems: a case study of a telehealth project in Sweden, and Study 5, The cor-
poreality of learning in everyday practice, cf. Essén, 2008; Essén & Conrick,
2007; Essén & Conrick, 2008) illustrate that the care workers perceive that
each activity curve refers to a senior’s activity status in her/his home. Hence,
the care workers engage in a hermeneutic relation (Ihde, 1990) with the
technology; the screen-data becomes their object of perception while simul-
taneously referring beyond itself. The seniors behavior and activity status
become present to the care workers through the technology (digital activity
curves) (cf. Study 2, 3). That is, the workers gradually started thinking from
the point of view of the technology, and, rather than thinking about the tech-
nology, they started to perceive their environment in a different way
(Crossley, 1995a; 1995b).
The care workers’ use of the technology makes obvious their integration
of technology-generated and their ‘naked’ capabilities. Inspired by Merleau-
Ponty, I interpret this as an illustration of the human bodily motivation to
avoid tensions with the environment. The care workers avoid such tensions
by compensating for the limitations of the technology-mediated capability in
various pre-reflective and reflective ways. (Just as they would compensate
for a bad eye with their other eye).10 I will discuss this further below.

10
This compensatory capability underlines the argument that technology should be viewed as
an extension of, and not a replacement for or equal to the human body. It also illustrates how
the physicality of the body can be enabling, making implications happen.

32
Bodies emotionalizing and contextualizing technology
What is indicated by the studies taken together is that while the technology
amplifies the care workers awareness of the variability in (one aspect) the
seniors’ condition, the technology cannot advice the care workers about how
to act on the information (Study 2, 3, 5). The technology itself has no experi-
ence of individual seniors’ preferences concerning care delivery and it can-
not foresee how individual seniors will react to different measures. What’s
more, the technology cannot relate the problems it detects to other problems
in the actual context. These limitations could potentially create tensions.
However, the care workers prevent this by using their ‘naked’ bodily capa-
bility in several pre-reflective and reflective ways. In a sense, it is somewhat
off the subject to speak of the de-contextualized and narrow-minded opera-
tion of the technology itself, as this is not what the care workers incorporate
or use. The workers cannot but integrate the capability of the technology
with their other perceptual and responsive bodily capabilities and emotions
(Study 2, 3, 5). Hence, in the hands of the care workers, the technology be-
comes ‘contextualized’ and ‘emotionalized’.
For example, the workers use their bodily knowledge stemming from
long-term relationships with seniors when deciding how to approach indi-
vidual seniors based on the new information. This enables the workers to act
on the technology generated affordances in a way adjusted to the senior and
the situation. The workers also relate the needs detected by the technology to
other competing needs and aims in each situation. In the setting studied, it is
often necessary to partly address several needs, rather than to completely
solve one problem and ignore others. Aims are not ordered in any clear pre-
defined hierarchy but rather form a heterarchy of aims (cf. Waerness, 1984).
For example, neither the ambition to spend time on seniors in need, financial
aims nor the objective to maintain fairness can be completely ignored in a
situation. As revealed in study 2, 3, 5, the care workers use their body (its
pre-reflective as well as reflective capability) in order to cope with such
situations. Their emotion-ethical values represent particularly important re-
sources (indeed a kind of knowledge) to them when they need to compro-
mise between competing needs.
A theme running through study 2, 3, 5 is further that the technology ex-
tends the care workers’ perception in a very delimited area when considering
their overall day-to-day work. The care workers need to detect and respond
to variability in many areas beyond seniors’ activity level to avoid tensions.
Study 2, 3, 5 show that the workers’ ‘naked’ sensory and emotional bodily
perception helps them in this context. The way in which their body receives
and responds to calls from the environment and thereby “takes care of”
many problems without the workers needing to reflect consciously on this is
truly extraordinary. It is hard to conceive of a technology performing this
activity, which is often pre-reflective and non-discursive.

33
 In general, the studies illustrate how workers’ bodies often spontaneously
express emotions when interacting with seniors. To understand this, it needs
to be clarified that care workers are urged to act not only by self-interest, but
also by emotional compassion for the seniors. That is, affective– and I be-
lieve: somatic — states serve as an important drive force in their work. This
motivates their perception to ‘open up’ to emotional needs among seniors
and to add to the work they perform the element of “emotional expression”,
carefully adjusted to the senior in question, without being paid for this. For
example, they touch seniors to show compassion and joke with the seniors
simply to make the seniors feel good, although there is no economic incen-
tive for them to perform such acts. (Most of) the care workers care about the
seniors and want the seniors to feel good (cf. Study 3). Their perception and
bodily response are directed towards this aim. As a result, the boundary of
their area of attention is diffuse and indeed negotiable. Inspired by Merleau-
Ponty, I do not attempt to determine to what extent these emotions are
authentic or genuine. Suffice it to say that they are bodily, physical, pre-
reflective, manifested in performance, and represent important resources to
the care workers when doing their job. Indeed, the workers emotions repre-
sent to them a kind of intelligence that guides them in their actions and deci-
sions, helping them to behave ‘effectively’ and I dare say, rationally in spe-
cific situation.
It is important to note that the workers saw the technology in relation to
these, their own, naked bodily capacities. Without these capabilities and
tendencies of the workers’ body, the new technology-mediated perception
would be worth little.11

Thinking of the implications of technology as capacity

and feeling inside the body
It should have appeared by now that the users studied here evaluated the
technology on basis of the opportunities of action it afforded them and the

11
Now, it may be argued that the incapability of technology to be emotional, embodied and
distracted should be highlighted as an advantage. The emotional relationships between care
workers and seniors can produce an emotional bias and unfairness, as the workers’ attachment
is presumably not evenly distributed across the seniors (see study 3) and that technology
thereby could contribute to a more ‘fair’ perception. If viewing technology as a stand-alone
actor, one could argue that it is never in a bad mood and it does not dislike anyone. It operates
in a reliable and unbiased way. Further, one could argue that humans could not collect the
information in an as focused way as the technology as their bodily capability to work towards
several aims simultaneously makes them distracted. However, this thesis suggests that while
technology may contribute with new data in a non-negotiable, de-contextualized and non-
emotional way, this technological capability is ‘emotionalized’ and ‘contextualized’, i.e.
related to other problems, as it is used by the workers. It is consequently only possible to, to a
limited extent reduce e.g. emotional bias.

34
emotions it generated inside of them. And, they used their emotions in vari-
ous ways when performing this evaluation of the technology.
The influence of emotion is most evident as regards the seniors’ reaction
to the technology. As noted above, one of the seniors did not value the new
technology (cf. Study 4). This was somewhat unexpected as she was more
anxious and frail than the other seniors, and one could, from an ‘objective’
or ‘fact-based’ point of view, have predicted that she would appreciate being
watched more than the others. However, her reaction was not the result of
some fact-based, calculative reasoning process. It rather followed an emo-
tional line of thought; this woman was negative to the technology as it cre-
ated certain undesirable feelings inside of her. Being electronically moni-
tored made her feel ‘watched’, almost guilty and ‘constrained’. The majority
of the senior caretakers, on the other hand, valued the technology as the per-
ceived that it contributed to them reaching certain desirable emotional-states,
namely the feeling of being cared for, safe, and thereby free. The seniors
also thought about the technology as a service that can help them avoid mov-
ing to a nursing home and thereby escape significant privacy intrusions.
Hence, the positive seniors, too, evaluated the technology in an emotional
way, and on basis of what they felt that it enabled them to do.
The care workers also appreciated/valued the technology as they felt that
it could enhance their capacity to provide care services more attuned to the
needs of the seniors (see Study 2, 3, 5; cf. Essén, 2008; Essén & Conrick,
2007; Essén & Conrick, 2008). Indeed, given the care workers’ hermeneutic
engagement with the technology, they are provided with new information
about seniors’ health problems. The information collected by the technology
is information that the seniors cannot give, neither could the workers collect
this information with their mere bodily senses. Hence the technology be-
comes to the workers an extended "area of sensitivity" (Merleau-Ponty,
1962:143). The care workers evaluate the technology in terms of this ex-
tended perceptual capability they gain through the technology.
The care workers and care takers’ engagement with technology problema-
tizes the view of technology as an external object that humans analytically
evaluate. As argued by Merleau-Ponty (1962: 90), an object "is an object
only insofar as it can be moved away from me ". Now, what do the care
workers and caretakers think of when asked to assess the technology? It is
not the ‘objective’ attributes of the technology.12 It is rather the extended
bodily capability that they experience through the technology. These capa-
bilities and emotional states (which I would not call purely mental or brain-
related) can be understood as a part of the users’ bodies rather than a part of

12
Drawing on Merleau-Ponty, I believe that even if the users would want to, they could not
see the technology as simply the sum of its technical functionality, color, shape etc. The
whole background apparatus of what technology in general means for them, what the specific
technology has been/could be used for and by whom, comes with their perception of it.

35
the technology as an external object. On this background, it seems more
fruitful to analyze what human bodies, extended by technology, can accom-
plish, than focusing on where the border between humans and technology
occur.
Note however, that I am not advocating a view where humans and tech-
nology are equal ontologically. What I am suggesting is that the encounter
between technology and humans can create new capabilities and emotions
that are human in the sense that they are felt inside the human body.

Bodies selectively incorporating the micro and macro

context
The conceptualization of the user as a situated body encourages a considera-
tion of how the historical context influenced the studied caretakers’ and care
workers’ experience of the technology (Ihde, 2002; Merleau-Ponty, 1962).
Study 1, The role of emotion in service evaluation: senior citizens’ assess-
ment of long-term care services, exhibit that the seniors are aware of the
financial constraints in elderly care. Their incorporation of this aspect of the
historical context can partly explain why any “new”, additional service
makes them feel grateful. Further, the seniors associate technology with im-
provement. Most likely, as they have experienced technological advance-
ments in their life (cf. Essén & Wikström, 2005; Östlund, 1995). Finally, it
appears reasonable to assume that the seniors’ desire for privacy, independ-
ence and freedom is related to values in the contemporary society. Discuss-
ing to what extent the seniors, in having these desires, are influenced by
others (e.g. children wishing the seniors to be independent) is beyond the
scope of this paper. What I want to note here is that social, political and eco-
nomical structures influence the seniors’ reason-based as well as emotional
experience of the technology and thereby its implications.
It is similarly helpful to take into account that workers bodies are situated
in specific situations, a larger service context, and in a historical and cultural
time (Study 2, 3, 5). Study 3 shows how pre-existing structures and norms
influence how workers’ bodies make use of the new technology. For exam-
ple, as care workers incorporated and were attentive to the value attached to
privacy, autonomy and pluralism in the contemporary society, they restricted
their use of the technology in conscious as well as pre-conscious ways (cf.
Essén, 2008; Essén & Conrick, 2007). The deeply rooted view of elderly
care as a matter of human contact further contributed to individual workers’
emotional conviction that technology would never replace face-to-face visits
(cf. Study 2, 3).
In sum, the situatedness of the users’ bodies influences their perception of
and physical engagement with technology. There is however scope for an

36
agentic body in the view I propose. Users choose to incorporate, enact and
thereby reproduce certain structures and not others. For example, while the
seniors seem to have incorporated the widespread rhetoric about technol-
ogy’s potential to ‘increase quality, effectiveness and safety’; the workers
have not fully embodied the view that technology represents a ‘panacea’ to
healthcare problems. The workers’ rather appear to have embraced the estab-
lished argument that the role of technology is very limited in care, as face-to-
face contact is crucial in this setting. Of course, the users’ selective incorpo-
ration of structures is related to their individual experience of specific situa-
tions. That is to say, there is an interaction between the influence of forces at
micro- and macro level, which makes their total influence unpredictable (cf.
study 3).

Studying the perceived reveals the perceiver

In summary, an exploration of the technology as perceived by care workers
and care takers reveals quite a lot about these humans. For example, the
analysis above exposes care workers’ and caretakers’ naked bodily re-
sources, showing that emotionality and sensory physicality can be enabling
and constraining. It suggests that the users’ mind is clearly rooted in their
lived body: the way they think about the technology appear closely inter-
twined with how their body uses the technology, which is closely related to
their interests in everyday life. The users further think about the technology
in a way that is both emotional and reason-based, and it is often difficult to
separate these two. Indeed, emotion and reason seem closely intertwined,
and emotionality seems closer to rationality than to irrationality. The analy-
sis further begins to portray the care workers and caretakers’ view is linked
to their selective incorporation of social structures. This supports Merleau-
Ponty’s argument that a study of the perceived always ends up revealing the
subject perceiving. As he wrote, this is the paradoxical condition of all hu-
man subjectivity: “we are both a part of the world and coextensive with it,
constituting but also constituted” (Merleau-Ponty, 1962: 453).

37
Conclusion

The present thesis has explored the potential role and implications of tech-
nology in care, as perceived by its users. An important insight emerging
from this work was the need to rethink the human subject as a user of tech-
nology. The exploration consistently pointed at how the experience of the
studied users was related not only to their mind but to their whole body. That
is, their physical capacity and emotionality influenced their perception and
use of technology and thereby the implications it generated.
The human body is rarely mentioned in the contemporary literature on IT
and care (neither in information systems research). Studies have rather tried
to understand the implications of technology initiatives by investigating the
influence of: technological functionality and design; managerial issues or
social structures; and emergent inter-actions at a discursive level (see chapter
two). While providing important insights, the extant research has hence been
able neither to support nor reject the dramatic predictions that circulate in the
IT and care debate, e.g. revolving around how technology may mechanize
and dehumanize care or isolate seniors from social structures.
The present thesis argues that the phenomenological tradition can help us
to better address these issues. It uses Merleau-Ponty’s (1962; 1968) phe-
nomenology to re-conceptualize the user of technology as a body. And to on
this basis theorize about the potential role and implications of technology in
care. The thesis concludes that the caretakers and care workers studied do
not experience technology as an external object with ‘absolute’ or ‘objec-
tive’ qualities. They rather engage with technology as an extension of their
own (physical and ideational) body. And they evaluate technology in terms
of the bodily capacities and emotional states that it creates inside of them.
These insights challenge the view of technology as an object external to the
human body, with which the human user inter-acts, a view that is implied in
one way or another in widespread frameworks of human-technology rela-
tionships in the extant literature (see section two). The findings rather sug-
gest that human-technology relationships involve intra-actions between the
‘naked’ and the technology-mediated perception and capacity of the human
body.
Given this perspective, it is irrelevant to discuss whether or not technol-
ogy in itself is non-emotional, de-contextualized, and inexperienced, and it is
unhelpful to ask whether or not a technological device can engage in emo-
tional relationships on its own. The gist of the thesis is that when used in

38
existing emotional relationships between humans, technology can contribute
to such relationships. In combination with humans who contextualize the
technical possibilities, incorporating the technology and integrating it with
their other sensory and emotional capacities, technology can produce affect.
The thesis shows how technology can contribute to seniors feeling safe and
cared for, and to them feeling closer to the care personnel and thereby less
isolated. These findings resonate with early studies of telephone technology,
showing that technology can enable an experience of “intimacy at a dis-
tance” (Rosenmayr & Kockeis, 1963). However, this view is not widespread
in the extant literature.
In general, the thesis provides a counter example to the heretofore influ-
ential argument that technology diminishes the role of the situation-specific
and ‘personal’ aspects of care. In the setting studied here, workers do not
start acting in a detached, spiritless, machine-like manner when using tech-
nology. Their emotions do not play less a central role when they start using
technology. On the contrary, thanks to the perceptual capacity gained from
technology, the workers become aware of new situations that urgently call
for their sensory and emotional responsiveness. On this ground, the thesis
challenges the determinist view that technology threatens the essentially
‘human’ (Ellul, 1994; Heiddegger, 1949[1993]; Virilio, 1994; see discussion
in Dewsbury et al., 2001; Dutta-Bergman, 2003; Dunn, 2000; Hagberg,
2003; Stanberry, 2000; Williams et al., 1998). It rather concludes that feeling
and other bodily resources are fundamental in the use of technology. Indeed,
technology activates such ‘human’ capabilities.

39
Theoretical implications and future research
directions

The present thesis insists that the pre-reflective intentionality and emotional-
ity of the human body (rather than merely the reflective, calculative capaci-
ties of the conscious mind) influence how individuals use and evaluate tech-
nology and hence its potential implications. This view complements the con-
temporary literature on IT and care (and on information systems more gener-
ally), where the human body is typically not mentioned at all. This
remarkable neglect of the body in the extant literature can partly be ex-
plained by the nature of the dominant frameworks used. Health economic,
social constructivist and actor-network theory models encourage other foci,
such as technology itself and social structures (see chapter two). As an alter-
native, the framework provided in this thesis inspires to theorizing that de-
parts form individuals’ concrete engagement with the technology at micro
level, asking what technology can do to human physicality and emotionality.
The thesis argues that this is in fact one of the most fundamental questions to
ask in order to understand the potential role and implications of technology
in care and in social life in general.
The majority of the users studied here experienced the technology as an
extension of their human body. This supports Merleau-Ponty’s (1962; 1968)
thesis that there is a continuity rather than discontinuity between the materi-
ality (flesh) of human bodies and technology (the flesh of the world). This
implies that research should refrain from studying technology in-itself (as is
commonly done in the IT and care literature) and instead direct attention to
how technology can be integrated with the ‘naked’ resources of our body (cf.
Ihde, 2002). We here need to widen our perspectives and investigate not
only how technology can extend our reflective, mental capacity to manipu-
late symbols, but also how technology can extend the pre-reflective physical-
ity and emotionality of the human body.
The insights of this thesis further relate to the general organizational and
sociologist discourse about new technology in relation to the human body.
This discussion has primarily revolved around the potential of new technol-
ogy to “free” subjects (read: minds) from their constraining, material bodies.
Authors speak of “post-bodied and post-human forms of existence” (Feath-

40
erstone and Burrows, 1995: 2; Lupton, 1995; cf. Can der Ploeg 2002; Stone,
1991) and write that when we enter cyberspace we “leave behind our ani-
mal-shaped, emotional, intuitive, situated, vulnerable, embodied selves”
(Dreyfus, 2001: 6). In contrast to these visions, this thesis argues, inspired by
e.g. Dale (2001), Ihde (2002), Merleau-Ponty (1962), Knights & Thanem
(2005), and Williams & Bendelow (1998), that while humans perceive the
world through technology, we still perceive from somewhere. We perceive
from our body with its pre-reflective intentionality and emotionality; from
our body, which is situated in particular settings and relationships. Hence,
the thesis rejects the idea that technology makes humans “disembodied” (if
anything, humans make technology embodied). Indeed, we cannot free our
mind from our bodies. This, I however believe is fortunate, as our bodily
physicality not only constrains us. 13 The extraordinary emotional and pre-
conscious capacity of the human body also enables us to realize the potential
of technological capacity.
At a more general level, the thesis says something about human knowl-
edge, agency and materiality. By supporting Merleau-Ponty’s philosophy of
human subjectivity, the thesis challenges the separation of mind from body,
nature from culture and reason from emotion, which as noted by Willams &
Bendelow (1998:250) “has been a consistent theme in Western though, dat-
ing as far back as Plato’s deliberations in the Phaedo, Aristotle’s musings in
De Anima, and exemplified par excellence in Descartes famous Cogito ergo
sum”. The dualistic legacy is certainly reflected in mainstream organiza-
tional research where the body is ”rarely seen as being relevant to the devel-
opment of knowledge about organizations” (Dale, 2001:8) and where there
has been a tendency to define the rational, objective, detached and disem-
bodied human mind as the seat of truth and knowledge (Ihde, 2002; Turner,
1991; 1996; Williams & Bendelow, 1998). The present thesis can be posi-
tioned within the nascent literature that challenges these traditional views. It
underlines the need to further rethink the biological in non-reductionist
terms. Merleau-Ponty’s philosophy represents one such alternative, viewing
human bodies as both physical and cultural beings, as both active and as
acted upon.14 Future research further extending this view or developing other

13
Hence, this thesis extends the view of e.g. Dale (2001), who, while arguing that will never
be able to escape our physicality, still portrays it as constraining. For example, Dale (2001:
41) writes that: ”in many ways, the dream of escape from the physical body turns out to be an
illusion. The lived body resists and reminds the would-be transcendental ego of its constant
and inevitable presence. While the mind is surfing the Net, finding its transcendental ego
identity in cyberspace, the physical body develops eyestrain, injury…”.
14
Feminist writers have criticized Merleau-Ponty for producing non-gendered bodies by
ignoring that there are multiple bodies and that bodies are socially constituted, thereby posit-
ing the body as the transcendental “being for itself”, the place Husserl previously reserved for
consciousness. I find this unfair, as Merleau-Ponty does write about the situatedness of bodily
perception and action. For those interested in this criticism, see further Butler, 1990; Dale,
2001; Irigaray, 1993; Young, 1980.

41
ways of connecting social constructivism and materialism is certainly war-
ranted. To say the least.
I would like to particularly encourage researchers to theorize in new ways
about emotionality. The (limited) organizational and management research
on emotions has from my view not been radical enough. It has been domi-
nated by Hoschild’s (1983) theory of emotional labor, which talks about
emotions in cognitive terms and not as embodied experiences (Knights &
Thanem, 2005). The theory of emotional labor further makes a clear distinc-
tion between ‘authentic’ and ‘fabricated’ emotions. This has produced re-
search discussing the negative consequences generated by workers’ expres-
sion of fabricated, ‘imposed’ emotions (see discussion in Lopez, 2006). The
present thesis approaches human emotion from a very different perspec-
tive, highlighting the intelligent role emotion – as a bodily capacity— plays
in human experience (cf. Fineman, 2000; 2003; Nussbaum, 2001;Sturdy,
2003). The thesis suggests that emotions can be viewed as enabling re-
sources that allow individuals to perceive and respond effectively to circum-
stances in their surroundings. The thesis further questions the strict separa-
tion between ‘genuine’ and fabricated emotions (cf. Fineman, 2000;
2003; Wouters, 1989). Drawing on Merleau-Ponty (1962), it argues that
emotions are never completely ‘private’, shaped only by the individu-
als’ inner, authentic, subjectivity. Emotions always incorporate the context –
that is – emotions are always partly ‘fabricated’ or ‘imposed’. But this does
not preclude them representing necessary and crucial resources in human
action. Future research needs to acknowledge this and investigate the various
‘rational’, ‘effective’ enabling and necessary roles emotion plays in hu-
man practice. This would help us to further challenge the reason/emotion
duality.

42
Practical implications

“The elderly” have traditionally been associated with a negative attitude to

new technology. To start with, the present thesis criticizes this generalization
of ‘the elderly’. The thesis further challenges the view of elderly as techno-
fobians by providing an example of elderly caretakers reacting differently,
but overall very positive to new technology. The majority of the studied
seniors feel safer and more cared for thanks to the new technology, which
indicates that new technology can be marketed as providing emotions and
social contact. It is however important to note that the studied setting is
characterized by most of the seniors being satisfied with the care services
they receive, partly as they enjoy a good relationship with the care personnel
(cf Study 1). The seniors’ uncritical attitude to the new technology is pre-
sumably linked to their conviction that the familiar care personnel, who they
trust, use the technology. This suggests that new technologies may rather
easily be accepted among senior consumers, given that they are associated
with ‘trusted’ personnel (cf. Essén & Wikström, 2005). 15 Note however, that
this kind of uncritical attitude and trust in personnel could easily be misused.
The studied care workers were also positive to the new technology. The
technology used is far from sensational and this most likely led to more
modest changes in the cases studied. The workers however gradually learned
about the new technology and saw how it could potentially create value in
their work. This is relevant to point out as the elderly care setting is far from
computerized and there is a widespread belief about the negative attitude
among home-help personnel toward technology. Indeed, there are strong
doubts about the possibility of using high-tech in “the high-touch care set-
ting” in general. This thesis suggests that this encounter may be fruitful, and
that technology does not threaten ‘genuine’ or personal care. However, gen-
erating value is difficult and it will require a lot of work (cf. Essén & Con-
rick, 2007). The findings here particularly illustrate how organizational and
structural factors impede the care workers’ exploration and exploitation of
the new functionality. For example, as noted in Study 3, there is no “innova-
tion climate” in the Swedish public elderly care setting (cf. Essén, 2008).

15
The seniors in this study were not interested in knowing any details about the new function-
ality of the new technology. This reaction may be related to the specific generation and cohort
(elderly born 1910-1930) studied. Future elderly caretakers, born 1940 and later may be more
interested in technology itself and may be more inclined to critically evaluating new technol-
ogy.

43
The financial and hierarchical structure of the Swedish healthcare system
impedes innovative long-term investments as well as the realization of inno-
vations emerging at grass root level. This is nothing new to care managers
but needs to be recognized by policy makers. Especially considering the
rhetoric about how ‘there is promise in new technology’ in political reports
(e.g. IT-strategy, 2006; SOU, 2002).
As regards the relationship between new technology and cost-savings, I
can only modestly discuss what my observations indicate.16 What emerges
from the studies is that new technology implies additional costs rather than
cost-savings. The studies suggest that technology can extend care workers’
perception, and thereby enable them to notice more problems and needs
among seniors, which in turn increases their need to visit the seniors. This
implies an increased work burden and rising rather than falling service pro-
duction costs. Of course, the findings reported here are tied to the specific
technology used: a monitoring system that generates new data about a new
aspect of the caretakers’ health. Many new technologies however provide
this kind of ‘service’ and functionality.
As related to this, the thesis suggests that technology does not necessarily
reduce variability in care practice; it rather increases variability (see study
2). This runs counter to the vision that telehealth will reduce (undesirable)
variability in terms of exceptions and errors, as is often claimed by telehealth
enthusiasts. It similarly contradicts the fear that technology will contribute to
a more standardized, in terms of a more mechanized and non-adjusted care.
This thesis suggests that technology can contribute to a more person-
adjusted care as it provides more nuanced information about the patient. This
in turn, creates a more complex work environment where new ambiguous
problems and exceptions occur. It should not be neglected that this leads to a
situation where care workers need more authority and new types of compe-
tence, which may be associated with increased wage and educational costs.
Overall, this thesis suggests that technology should not be viewed as a re-
placement but as a complement to workers in today’s elderly care system
(Varlander, 2007; Wikstrom et al., 2002 provide similar insights in other
service settings). Given my observations, I strongly believe that it would be
devastating to replace face-to-face visits with electronic surveillance. There

16
I would in this context like underline that studying the implications of new technology in
elderly care is a challenge. To start with, it is difficult to find cases to study, as few public
care givers use new technology. It is difficult to initiate projects, i.e. inspire providers to
invest in new technology due to the financial constraints they suffer. This also implies that for
those providers who do invest in new technology, there are few resources available for ongo-
ing support and education of users. As a result, projects tend to be small-scale and the new
technical functionality tends to be far from exploited, the technology is typically underused
(as in the cases studied here). These circumstances impede the use of and value produced
through new technology, which makes it difficult for researchers to draw conclusions about
the consequences of technology. What remains for researchers is to be attentive to what these
kinds of projects indicate. This is relevant for those engaged in research policy.

44
are simply no “unnecessary” visits to reduce. Seniors certainly need the few
visits they do receive. And, I want to underline the fantastic job many home-
helpers perform when paying these visits. Those who do make an effort to
make seniors feel cared for and seen (and I believe most do) make such a
difference! (See study 1 and 2). This should be highlighted and rewarded
more than today in care practice.
In sum, the present thesis indicates that new technology may increase the
quality of care, as a complement to human labor and thereby, to an increased
cost. The question is: who is willing to invest in new technology given these
conditions? There are financial incentives for private care givers to introduce
new technology to consumers willing to pay for its’ qualitative benefits.
Public care organizations on the other hand, do not have the financial re-
sources to provide “new” qualitative benefits to seniors if they cannot expect
a financial return on the investment required (see study 3). Hence, the diffu-
sion of new technology in the public elderly care setting is uncertain. This is
relevant to note for care policy makers, who sometimes appear to rely on the
potential of new technology when discussing the future of elderly care.
Swedish politicians further tend to pursue a strategy where communities are
left to “decide for themselves” and encouraged to be ‘innovative’. This is
easier said than done as this thesis shows.
Finally, claiming that the human body and its emotions are important is
nothing new under the sun. Claiming that our intelligence and consciousness
reside in our body, and that our emotions are rational, is less established.
Think about it: don’t we all somehow think of emotion and physicality as the
opposite of ‘rationality’? Questioning this opposition should inspire to
change and innovation in various ways. For example, telehealth technologies
are often criticized for not being user-friendly (e.g. Essén, 2003; Scandurra,
2008). Certainly, the intertwined nature of emotion and reason makes tech-
nology development appear more exciting but also more challenging. Tech-
nology-developers need to recognize that: to develop machines that truly
contribute to human settings, we must ask not only how the human mind or
intellect works (and try to copy this), but rather, to consider the various
needs of and roles played by the our physicality and emotionality. How can
we develop technology that extends our body, including its pre-reflective
capacities, in valuable ways? For example: How can we develop technology
that stimulates workers capacity to show human warmth to seniors? Reject-
ing the dualisms further suggests that managers need to encourage rather
than try to “suppress” employees’ physicality and emotionality. In general,
let’s ask how we can appeal to our emotional intelligence. How can we al-
low it to thrive? Perhaps new forms of education, e.g. incorporating more art
and literature, can help us learn about our passionate rationality. Isn’t this
what makes the world go around anyway?

45
46
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 PART TWO

54
Introducing the studies

As noted above, a re-reading of the five studies (papers) made me aware of

how the encounter between individuals and objects in their environment is
not one characterized only by analytic reflection. It is also a pragmatic, intui-
tive, physical and emotional engagement. In general, the studies urged me
think of mind and body, body and world, reason and emotion and the mate-
rial and ideational, as intertwined rather than opposites, and I shall here ac-
count for how.

Paper 1, The Role of Emotion in Service Evaluation: Senior Citizen’s As-

sessments of Long-term Care Services, explores how seniors form an opinion
about care services, including the assistive-technologies provided to them.
The paper reveals that emotion plays a central role in their evaluations. Cer-
tain aspects of services contribute to the seniors reaching emotional-states,
and this is what the seniors initially refer to when explaining their judg-
ments. They primarily remember events that have evoked in them emotional
reactions. Their emotions further steer their reflective attention to these as-
pects; they typically continue to justify their judgment of these aspects and
emotional reactions with fact-based reasoning. Hence, the paper questions
the argument that emotions are opposed to cognition, arguing instead that
there is a close relation (indeed, co-operation) between reason-based (ana-
lytic, reflective) and more intuitive, emotional, subjective reasoning. In gen-
eral, the seniors’ perception of care services suggests that they do not engage
with the world as calculative, disembodied, mental subjects. Rather, they use
their whole body, which is a feeling and living body that includes but is not
limited to a mind. The paper further exhibits how the seniors’ own experi-
ence of who they are, their own subjectivity, is influenced by how others see
them. This resonates with the notion that the body-subject and the world are
intertwined. It is finally worth noting that the seniors’ subjective evaluations
had commonalities. Most of them underline the importance of care personnel
providing human warmth. Hearing someone else laugh at one’s jokes can
make a day.

Paper 2, Variability as a Source of Stability: Studying Routines in the Elderly

Home Care Setting, demonstrates the ‘messy’ environment that elderly care
constitutes, and how workers use their body in various ways to respond to

55
the unpredictability of their everyday work. Indeed, the ‘resources’ used by
workers are not merely brain-related. It is however difficult to localize their
capabilities in any certain organ. It seems to be an integrated capability,
where mind and body, senses and reflection and tacit emotion and discursive
facts interact. The paper exhibits that there is variability in the performance
of home-help services. For example, home-helpers notice different things
depending on what they feel is within their responsibility, which is in turn
contingent on their personal history, their “habitus” (Bourdieu, 1977). In-
spired by Merleau-Ponty, one can understand this habitus as corporeal, in-
cluding acquired knowledge, values, ethics and affective modes that is ex-
pressed through the body. The paper further shows that technology makes
the workers aware of new dimensions of seniors’ health. This creates addi-
tional variability, as seniors’ condition is far from predictable. Hence, rather
than making the care work environment more ordered, the technology stud-
ied makes it even more disordered or ‘messy’. In general, the paper high-
lights the ethical, emergent and informal aspects of care work. This is inter-
esting in relation to technology as it demonstrates the remarkable but inevi-
table complexity of everyday care practice, and hence points at what tech-
nology would have to be able to address if it was to replace humans in this
setting.

Paper 3, The Emergence of Technology-based Service Systems: a Case Study

of a Telehealth Project in Sweden, shows that the “potential” of a technology
is impossible to determine on basis of its functionality and material attributes
(cf. Vargo & Lush, 2004 for a similar discussion). Such factors do play a
role, but only in interaction with the users’ body, and thereby in relation to
various contextual factors. This paper highlights that the care workers’ per-
ception of technology is not a matter of their sensory organs receiving data
about the ‘objective’ qualities of the technology, their mind later interpreting
this data in a reflective way, followed by the actual use of the technology as
a final stage. Perception and action is more closely linked that this. The
workers do things, which make them realize what they, by incorporating
technology, can accomplish. In general, what the users see the technology
as, depends on what they perceive that it enables them to do, and this in turn
is linked to their own body (what it is knowledgeable of, what it feels, its
incorporation and rejection of social values), and concrete factors such as the
facilities and time resources available. Overall, the paper highlights the rele-
vance of thinking of the body as simultaneously situated in a micro- and a
macro context, showing how developments should not be understood as
taking place at one level, e.g. the social level or the biological level. Instead,
factors at macro- and micro level interact through the users’ bodies. As sug-
gested by Merleau-Ponty’s theory, human action is not mental or physical or
cultural. It is everything at once.

56
Paper 4, The Two Facets of Electronic Care Surveillance: Exploring the
Elderly Caretaker’s View, highlights the relevance of investigating the role
and implications of technology from the user perspective. The variability in
the studied seniors’ experiences could not be predicted from an outside per-
spective as it is related to the seniors’ emotional reactions to the technology.
And the paper reveals that seniors’ emotions are related to their sub-
conscious as well as conscious assumptions about their own condition, what
is normal, what is private, what one should hide and about the interests of
care providers. The paper illustrates that seniors’ personal desires (e.g. to
continue living in their own homes and fear of moving to a nursing home)
and view of themselves (their own frailty) strongly shape their experience of
the technology and thereby its implications. Their belief that they are in need
of supervision, that technology can contribute to them being able to live in
their own home and thereby prevent them from being placed at a nursing
home strongly influence their experience. In short, it is not primarily the
material properties of the technology but rather how the seniors feel about
the technology that matters to them. These feelings are physical as well as
mental. And they are in a sense helpful, guiding the seniors in their judg-
ments. This in ways that are difficult to predict but very understandable and
far from completely random if one looks at the whole context.

Paper 5, The Corporeality of Learning in Everyday Practice, rejects the pre-

vailing view that knowledge is something that resides in the mind, arguing
that knowledge rather resides in our whole body. The paper challenges the
superiority of humans’ analytic and reflective capability, claiming instead
that pre-reflective know-how is what we should understand as expertise. It is
maintained that to know is to be physically able to perform actions without
reflecting on how. That is, humans know when their body remembers and
‘takes care of’ things, thereby eliminating the need for conscious reflection.
For example, the paper illustrates that workers gradually learn to master
technology by incorporating it into their body schema. The more they use
the technology, the less they reflect on how to use it, integrating it’s capacity
with their other emotional and sensory capabilities in a pre-reflective way. In
general, the paper illustrates that care workers experience-based, bodily re-
sponsiveness to the environment plays a central role in the delivery of care
services. What emerges from the paper is that care work is not primarily
about generalization and deduction, but about understanding the individual
and subjective. The workers’ bodily capability to pre-reflectively perceive
and respond to such particular issues makes them possible to handle. With-
out this bodily competence, care work would be immensely complex and
time consuming.

57
58
1. The Role of Emotion in Service
Evaluation: Senior Citizens’ Assessments of
Long-term Care Services 17

Authors: Essén, Anna & Wikström, Solveig

Abstract
Purpose: This paper explores the role of emotions in consumers’ evaluations
of service quality.
Design/methodology/approach: The study uses empirical qualitative data
from in-depth interviews with 26 senior citizens who are consumers of long-
term residential care services in a Swedish rural community. The empirical
findings are analysed inductively in terms of dimensions derived from the
literature on the role of emotions in consumers’ evaluations of service qual-
ity.
Findings: When explaining their overall evaluations of service quality, the
respondents referred exclusively to service dimensions that had evoked emo-
tional reactions. However, although these service dimensions were the only
ones to influence the consumers’ perceptions of service quality, respondents
tended to reflect about these dimensions in a cognitive manner. The remain-
ing service dimensions, which did not evoke any emotional memories, did
not influence the respondents’ perceptions of the overall quality of services
rendered.
Research implications: Emotional reactions can direct the attention of con-
sumers to certain service dimensions, and subsequently trigger cognitive
evaluations of these dimensions. The emotional and cognitive responses of
consumers to services are thus interrelated. More research is needed into the
mechanism of this interaction.
Practical implications: Service providers should recognise that consumers’
emotional and cognitive reactions are intertwined. For providers of aged-
care services, this study suggests certain service dimensions that are worthy
of further attention in seeking positive evaluations of services from users.

17
This paper is published in Managing Service Quality. Vol. 18 No. 2, 2008, pp. 147-162.

59
Originality/value: Previous research has tended to distinguish between emo-
tional and cognitive evaluations of services. This study challenges this dis-
tinction by demonstrating that dimensions that have traditionally been
viewed as ‘non-emotional’ can be influenced by ‘emotional’ reactions. Thus,
the study shows that ‘emotional bias’ can lead to some dimensions having a
disproportionate influence on overall evaluations of service.

60
Introduction
The evaluation of service by consumers has received considerable attention
in the services literature over recent decades (Cronin and Taylor, 1994;
Grönroos, 2001; Gummesson, 2004; Oliver, 1977). As noted by Edvardsson
(2005), most of this research has posited consumer satisfaction as a cognitive
process, whereby consumers compare their expectations of service with the
actual service outcome (Oliver, 1977; Parasuraman et al., 1985). More re-
cently, this focus on the purely cognitive aspects of consumers’ evaluations
has been criticised (Dubé & Menon, 2000; Edvardsson, 2005; Liljander &
Strandvik, 1997) as an increasing number of studies have shown that emo-
tions also influence consumers’ evaluations of services (Erevelles, 1998;
Jian & Lu Wang, 2006; Richins, 1997; Westbrook & Oliver, 1991; Wong,
2004). However, most studies of the role of emotions in evaluations of serv-
ice quality have drawn sharp distinctions between cognitive functions and
emotional functions (Darden & Babin, 1994; Groth & Dye, 1999; Strauss,
2002; Yu & Dean, 2001). For example, Jian and Lu Wang (2006, p. 215)
observed that:

… traditional measures of service quality, such as reliability, empathy, assur-

ance, and responsiveness may only measure the cognitive evaluations of
service quality, and may not be applicable in emotional-intensive service set-
tings, where consumers use other criteria to evaluate service quality.

In making this distinction, Jiang and Lu Wang (2006) categorised various

services as being ‘emotional’, as opposed to ‘non-emotional’. In the first
(‘emotional’) category, these authors included so-called ‘hedonic services’,
which produce certain emotions (such as excitement and playfulness) and
which consumers are said to evaluate emotionally. In the second (‘non-
emotional’) category, the authors included so-called ‘utilitarian services’
(such as car repairing, tax return filing, banking, and health care), which
consumers are said to evaluate cognitively on the basis of the functional
utilities that these services provide.
The difficulty with this approach is that the multidisciplinary literature on
emotion suggests that emotion and cognition are not distinctive functions;
indeed, there is evidence to suggest that the two are rather closely related
and can be considered as two sides of the same coin (Armon-Jones, 1991;
Damasio, 1994, 2002). These multidisciplinary insights into the link between
the emotional and cognitive components of evaluation have been largely
neglected in the extant service-quality literature.
The present study addresses this oversight by exploring the intertwined
nature of consumers’ emotional and cognitive reactions to services in the
setting of long-term residential care for the elderly. This is a setting in which
the provision of both ‘utilitarian’ services and ‘emotional’ services is impor-

61
tant; indeed, in residential aged care, emotional care is an essential aspect of
the service itself (Strauss et al., 1982). Moreover, it has been suggested that
the consumers have a greater emotional response to services that last longer
and take place in more intimate proxemic spaces (Price et al. 1995). It is
therefore likely that an examination of services in such a setting will yield
valuable insights into the role played by emotions in consumers’ evaluations
of service quality.
The rest of this paper is organised as follows. Following this introduction,
the paper presents a review of the literature on: (i) the role of emotion in
consumers’ evaluations; (ii) service dimensions of particular interest in this
respect; and (iii) so-called ‘interpretation variables’ (‘attribution’ and ‘ex-
pectations’). This is followed by accounts of the methodology and findings
of an empirical study of the perceptions of 26 Swedish senior citizens re-
garding the services they receive in residential care. Finally, the paper sum-
marises the major findings, the theoretical and practical implications of the
study, its limitations, and suggestions for further research

Literature review and theoretical framework

The role of emotions in evaluation processes

According to Scherer (1984), emotions can be broadly defined as distinct
patterns of processes that include antecedent events, physiological and neu-
rological responses to these events, and the appraisal activity brought to bear
on these events. Emotions, mood, and attitudes are all elements within the
general category of mental processes that is often referred to as ‘affect’
(Bagozzi et al., 1999).
The present study draws on various multidisciplinary findings about the
nature of ‘emotions’ and ‘cognition’. According to Damasio (1994, 2002),
human reasoning and rational decisions are not derived from logic alone, but
require the support of affect. Similar ideas are incorporated in the theory of
‘affect-as-information’ (Schwarz 1990; Schwarz and Clore 1988; 1996).
According to this theory, people rely on their feelings when making judg-
ments about a target (for example, a service) because they perceive that these
feelings contain valuable judgmental information. Schwarz and Clore (1996)
contended that affect comes into such overall judgments through a controlled
inferential process. A typical affect-based inference is the heuristic question:
‘How do I feel about it?’ In addressing this question, people infer lik-
ing/disliking or satisfaction/dissatisfaction from the valence of their feelings
(Schwarz and Clore, 1988). These ‘feeling-inputs’, which are subjective
experiences of affective states and which include sensory or bodily compo-
nents (Schwarz and Clore, 1996), can be produced in two ways: (i) inte-

62
grally, which refers to a perception of the object being evaluated (for exam-
ple, by looking directly at the object); or (ii) incidentally, which refers to a
feeling induced from a source that is independent of the object being evalu-
ated (for example, a consumer being in a ‘bad mood’ before being exposed
to the target) (Schwarz and Clore 1988; Pham et al., 2001).
Studies applying the theory of ‘affect-as-information’ have shown that
feelings are experienced immediately upon exposure to a target. Once expe-
rienced, these feelings frame subsequent thought generation by triggering
‘feeling-consistent cognitions’ that help to explain the initial feeling re-
sponse (LeDoux 2000; Pham et al., 2001). A review of neuro-physiological
evidence has led Damasio (1994, p. 198) to a similar conclusion:

Somatic states [including emotion], negative or positive, caused by the ap-

pearance of a given representation, operate not only as a marker for the value
of what is represented, but also as a booster for continued working memory
and attention.

In contrast, non-emotional and reason-based assessments are only weakly

related to spontaneous thought generation. Indeed, according to Pham et al.
(2001), some reason-based assessments can simply result in a ‘dead end’—
because there is no reason to explore them further.
In summary, ‘affect-as-information’ research shows that people form
overall cognitive evaluations based on their feelings with respect to the tar-
get; moreover, they appear to do so in an informed, deliberate manner. This
has obvious relevance to how consumers use feelings-as-information when
evaluating service dimensions that have, in the past, been categorised as
purely ‘cognitive’ (Jian & Lu Wang, 2006).

Service dimensions
For convenience, the service dimensions that consumers assess when they
evaluate healthcare services can be divided into three broad categories: (i)
outcome quality; (ii) process quality; and (iii) physical environment quality
(Brady & Cronin, 2001; Rust and Oliver, 1994). Each of these is discussed
below.
The services-management literature has traditionally treated outcome
quality as that which the customer is left with when the production process is
finished (Grönroos, 2001; Gummesson, 2004). In the healthcare context,
‘outcome’ is assessed in terms of a patient’s health status as a result of the
treatment received—including such factors as pain relief (Larrabee and
Bolden, 2001) and the therapeutic efficacy of the treatment (Piette, 1999).
Process quality, which has also been described as ‘functional quality’
(Grönroos, 2001) or ‘relational quality’ (Gummesson, 2004), refers to the
consumers’ subjective experiences of how the service is delivered. Accord-

63
ing to both the services-management literature and the healthcare literature,
consumers consider the following to be important dimensions of process
quality:

• reliability: whether services are performed dependably, as

promised (Grönroos, 2001; Parasuraman et al., 1985);
• responsiveness and access: whether services are provided at
convenient times and places and delivered on timely basis
(Parasuraman et al. 1985; 1988) with minimal waiting times
(Vukmir, 2006);
• security: whether services are delivered in a manner that is
free from danger, risk, and doubt (Parasuraman et al., 1985);
whether patient integrity and safety are preserved (Irurita,
1999);
• communication: whether consumers perceive that they are
kept informed and that the services are explained (Parasura-
man et al. 1985); whether patients are given accurate and
adequate information (Irurita, 1999);
• competence: the perceived expertise of professionals (Grön-
roos, 2001; Parasuraman et al. 1985); the technical perform-
ance of care personnel (Arora et al. 2004).
• attitude: whether healthcare professionals have a respectful
and friendly demeanour (Parasuraman et al., 1985); whether
they treat patients pleasantly (Vukmir, 2006);
• individualised service: whether the specific requirements of
individual consumers are understood and attended to
(Parasuraman et al., 1985); whether the ‘voice’ of the patient
is heard and understood (Suhonen et al., 2005).
• holistic care: whether care is delivered with a view to caring
for the various needs of the ‘whole person’ (Gunther and Al-
ligood, 2002).
• continuity: whether ongoing care of health problems is pro-
vided in an appropriate fashion that takes account of previ-
ous treatments and/or treating personnel (Woodward et al.,
2004).

The physical environment includes tangibles (Parasuraman et al., 1985) and

servicescape (Bitner, 1990). These dimensions refer to the extent to which
the physical setting of the service is appealing to consumers. In the
healthcare literature, this includes such variables as the ward environment
and cleanliness (Larrabee and Bolden, 2001).

64
Interpretation variables
According to the services-management literature, certain ‘interpretation
variables’ influence consumers’ evaluations of the dimensions noted above.
Although most service-management scholars have used these variables to
interpret consumers ‘cognitive’ evaluations, the present study contends that
they also have relevance to the ‘emotional’ evaluations made by consumers.
These ‘interpretation variables’ can be considered in two categories: (i) attri-
bution; and (ii) expectations.
According to attribution theory (Kelley, 1973), consumers react differ-
ently to services depending on their identification of the causes of particular
service features. Similarly, in terms of emotional experiences during con-
sumption, it has been argued that consumers’ attributions of who or what
caused an emotional experience influence the impact of that consumption
emotion on service evaluations (Dubé et al., 1996; Oliver, 1993). For exam-
ple, Schwarz and Clore (1988) demonstrated that feelings cease to influence
consumers’ judgments if they doubt that the feelings were elicited by the
object being evaluated.
With regard to expectations, it has long been contended that perceived
service quality represents the gap between the expected level of service qual-
ity and the consumer’s perception of the service quality actually received
(Oliver, 1977; 1993; Parasuraman et al. 1985). Although various aspects of
this model have been criticised (Cronin and Taylor, 1994), it is important to
note that the critics do not deny any role for expectations in the formation of
consumer judgments (Brady and Cronin, 2001). The present study contends
that expectations are relevant in the context of residential aged care—a view
that finds support in the healthcare literature (Cheng Lim and Tang, 2000).

Methodology
This qualitative empirical study, which was performed in March 2005, was
based on in-depth interviews with 26 senior citizens living in the rural mu-
nicipality of Heby (Sweden). The interviews were conducted in a conversa-
tional manner to create an intimate and trusting atmosphere in which the
respondents felt free to express their feelings. Several authors have noted
that there is a need for qualitative research of this type to complement the
quantitative methods that have traditionally been used to investigate patients’
evaluation of care services (Avis et al. 1997; O’Connor and Shewchuk,
2003).
The 26 respondents were chosen as a convenience sample (Patton, 2002)
by municipal social workers from among the 270 senior citizens served by
social services in the Heby region. The inclusion criteria were: (i) that the

65
respondents lived alone; (ii) that they were physically impaired; and (iii) that
they were frequent and experienced consumers of aged-care services.
The sample consisted of 15 females and 11 males, of whom 16 were aged
greater than 80 years and 10 were aged less than 80 years. The respondents
suffered from a variety of health conditions. Initially, 28 potential respon-
dents received an introductory letter, before being contacted by telephone by
social workers. Two potential respondents rejected, leaving a final sample of
26.

Data collection
One of the present authors performed all the interviews, which took place in
the respondents’ homes. Each interview, which lasted approximately 90
minutes, began with an explanation that the purpose of the interview was to
understand the respondent’s perception of the care services he or she re-
ceived, including hospital and homecare services. All respondents were en-
couraged to speak freely about issues of service evaluation that were impor-
tant to them. The semi-structured interviews proceeded as an informal dis-
cussion, with a checklist ensuring that all important issues were covered
(Patton, 2002).

Data analysis
The interviewing author transcribed the interviews, and both the present
authors analysed the transcripts. Recurrent themes in the data were identified
and categorised into a list of key words (Spiggle, 1994; Strauss and Corbin
1990). The authors then independently identified combinations of keywords
on the basis of quality dimensions from the literature. Any discrepancies
between the authors’ classifications were resolved.
A final list of influential service dimensions emerged, with each having a
specific meaning in terms of the respondents’ expressions. Findings with
respect to these dimensions were made in terms of: (i) affective states (af-
fect-as-information); (ii) the interpretation variable of ‘attribution’; and (iii)
the interpretation variable of ‘expectations’.

Findings
The majority of the respondents (22 of 26) stated that they were, on an over-
all assessment, quite ‘content’ with the quality care that they received. A
minority (4 of 26) were more critical and could be described, overall, as
‘discontented’.

66
 In accordance with the conceptual framework outlined above, the respon-
dents’ evaluations of the service dimensions are presented in three catego-
ries: (i) outcome; (ii) process; and (iii) physical environment and tangibles.

OUTCOME DIMENSIONS

Independence and freedom

The notion of ‘affect-as-information’ played a significant role in the respon-
dents’ evaluations of services that impinged upon their independence and
freedom. Many of the respondents reported negative affective states—such
as feeling lonely and anxious in everyday life. These respondents were there-
fore grateful for ‘home help’ visits, which gave them ‘courage’ to live alone
in their own homes. As one respondent observed:

I’m often anxious … a bit worried. It’s hard being lonely all the time … I am
very grateful for receiving this good service … I really need it to manage …
one gets weaker and weaker.

Another respondent commented on the home-help visitors in the following

terms:

They’re great, the girls … I don’t know what I would do without them. I [cer-
tainly] could not live here.

Many respondents explained that their overall positive evaluation of the

services they received was essentially based on the feeling of independence
they enjoyed as a result of the care services they received. One of the re-
spondents drew attention to the role played by technological and transport
services in promoting her feeling of independence:

Thanks to the assistive technologies I can do quite a lot myself … and with
transport services it is possible for me to continue taking care of myself … I
am happy that I don’t have to ask my son to give me a ride … it makes me
feel more free.

Technical outcome (physical health status)

‘Affect-as-information’ was not significant in the respondents’ assessments
of the technical outcomes of the services they received. None of the respon-
dents explained their overall evaluations by referring to the extent to which
healthcare services had improved their physical health status. Indeed, many
had low expectations regarding the care system’s ability to ‘solve’ all their
health-problems. As one respondent observed:

67
 I’m sure they’ve done all they possibly can.

Although many of the respondents had experienced failed surgery or incor-

rect diagnoses, they did not interpret these problems as indicative of poor
service quality. Rather, they often attributed their unresolved health prob-
lems to their previous lifestyle, age, or the natural history of disease itself.
Similarly, the respondents seldom referred to the technical results of
home-help services; indeed, they appeared to be rather uninterested in dis-
cussing this aspect of the services.

PROCESS DIMENSIONS

Reliability
It was apparent that ‘affect-as-information’ played a significant role in the
respondents’ evaluations of the dimension of reliability. All of the respon-
dents explicitly stated that they were physically vulnerable and that they
worried about accidents (such as falls). As one respondent observed:

I know I could fall, I’m not stable … but I trust [the home-helpers] com-
pletely, they are good, reliable girls … they always come immediately when I
press the [safety alarm].

All of the four ‘discontented’ respondents had experienced delayed service

(or no service at all), and all had reacted strongly and emotionally to these
experiences. For example, one respondent stated:

Nine months have passed since the last visit and I have yet to receive notice
… I worry about this … I feel ignored … I don’t understand why he doesn’t
call me ... if he is busy he can still call me just to say that he needs to post-
pone our meeting.
Another respondent said:

You can’t count on them … Once one of the girls said that she would check
on me in the evening again, but she didn’t … she just wanted to get home as
soon as possible I guess … and that’s just one example … and this [made]
me really sad, disappointed, even humiliated sometimes.

It was apparent that the discontented respondents usually blamed the person-
nel for the negative emotions they had experienced as a result of unreliabil-
ity.

68
Responsiveness
Evaluations of the dimension of responsiveness were not especially influ-
enced by ‘affect-as-information’; indeed, the respondents did not spontane-
ously refer to ‘responsiveness’. When specifically asked about this dimen-
sion, the respondents explained that they did not expect a high level of re-
sponsiveness. For example:

Of course, my doctor can rarely see me exactly when I call … instead we set
up a time … this is not [the doctor’s] fault, there are many names on the wait-
ing list.

Another respondent even blamed herself for a lack of responsiveness when

she waited all night for help after falling in the bathroom:

I have only myself to blame … I wasn’t wearing my safety alarm and could
not call for help.

In general, it was apparent from the interviews that reliability was more im-
portant than responsiveness; in other words, waiting was acceptable pro-
vided that the respondents knew how long they would be waiting.

Security
In contrast to the preceding dimension, evaluations of the dimension of secu-
rity were significantly influenced by ‘affect-as-information’. Several of the
discontented respondents explained their overall negative evaluations by
referring to experiences of feeling unsafe. For example, one respondent re-
lated how he felt unsafe while being transported to and from hospital:

I cannot believe they didn’t get me an ambulance … going in an ordinary taxi

for hours is the worst if you don’t feel well … I was actually afraid I
wouldn’t make it to the hospital.

Two other discontented respondents had also felt unsafe during taxi transport
to the hospital:

I’m sure they can afford ambulances in such rare emergency cases … Indeed,
this has to do with sheer arrogance.

It was apparent that the respondents felt strongly about feeling unsafe, and
that such memories continued to cause them significant emotional upset.

69
Communication
Evaluations of the dimension of communication were also influenced by
‘affect-as-information’. The respondents wanted to be informed about such
matters as changes in the service delivery. They felt betrayed, and even
abandoned, when given insufficient information. For example, one respon-
dent was visited by a male home-helper without having been informed that
this would occur:

I was very upset, when Jessica did not come. Instead, a boy stood at my door
… she hadn’t told me about this … I cannot find a good reason for her not
telling me about this.

This episode was a major cause of this respondent’s overall discontentment

with the services she received.
In contrast to this experience, the interviews with other respondents indi-
cated that effective communication ameliorated negative emotional re-
sponses to other service failures. For example, one respondent had initially
been placed in an isolation ward in hospital when health professionals
thought he had a contagious disease, but he was eventually released from
isolation when it was realised that he was actually suffering from an allergy.
Despite the inconvenience, the respondent was satisfied with his care be-
cause communication had been good:

They seemed to care about me … They were careful to explain everything to

me. I didn’t feel that they treated me badly … they were just worried.

Competent personnel
Evaluations in the dimension of competent personnel were not influenced by
‘affect-as-information’. Indeed, the respondents did not refer spontaneously
to the education and expertise of their carers when discussing the quality of
care; nor did they say much about the issue of competence when specifically
encouraged to discuss it. Although some of the home-helpers were perceived
as ‘young’ or ‘not very skilled’, the respondents did not react emotionally to
the young helpers relative lack of experience and competence:

They don’t have to make my bed perfectly as [staff do] in an hotel … As long
my bed gets made … and they are nice.

It was apparent that some of the home-helpers were certainly not ‘experts’;
nevertheless, this does not cause the respondents to be discontented.
With respect to health care professionals, the respondents did have high
expectations regarding education and expertise; however, they did not bother
to evaluate whether this is the case. A typical response was:

70
 I take this for granted.

Warm and caring attitude

Evaluations in the dimension of a warm and caring attitude were signifi-
cantly influenced by ‘affect-as-information’. In making their overall evalua-
tions, the contented respondents often referred to their positive affective
responses to the attitudes of personnel. For example:

My former doctor wasn’t good; he had a very harsh tone … [but my new
doctor] is very good. He is so soft and gentle towards me … and he makes
me confident that things will be OK.

Another respondent made the following observation about a home-helper:

She can put me in quite a jolly mood … she jokes a lot with me… She looks
at me with her brown eyes in such a nice way … and sometimes she pats my
hand when she feels that I am ‘down’ or anxious … she is so compassionate.
We get a long really well; I think she would say that too.

Similarly, the discontented respondents attributed negative affective states to

the unsatisfactory attitudes of certain personnel; moreover, they related this
to their perceptions of poor service quality. For example:

I don’t like going to the doctor … I don’t think he likes me. He probably sees
me as a tiring elderly hag … I’m always uncomfortable in his office.

In general, the respondents were quite intolerant of personnel who did not
treat them nicely:

It doesn’t cost them anything to be nice.

Individualised service
There was little evidence that affective responses played a significant role in
evaluations of individualised service. The respondents did not spontaneously
talk about individualised service. When they were probed about this, their
answers indicated that many would have liked to receive services that re-
flected their personal preferences; however, they did not necessarily expect
this. A respondent who reported overall contentment with the system made
the following observation:

… you can’t get your personal dreams fulfilled in this [publicly financed]
system.

71
In general, the respondents ascribed a lack of individualised services to the
well-publicised lack of resources in the public health system.

Holistic care
Evaluations in the dimension of holistic care were not influenced by ‘affect-
as-information’. By and large, the respondents appeared to tolerate the deliv-
ery of fragmented care, which they attributed to the specialised and decen-
tralised nature of the healthcare system. One respondent summarised this
attitude in the following terms:

My different doctors know different things … but nobody really knows about
all my problems … but, that’s how the system works.

Continuity of service
Evaluations in the dimension of a continuity of service were significantly
influenced by ‘affect-as-information’. Most of the contented respondents
stated that they were glad to have known the home-helpers (whom they re-
ferred to as ‘friends’) for a long time. Some of the respondents had also been
treated by the same general practitioner (doctor) for more than 20 years. The
respondents felt safe and comfortable in the knowledge that care personnel
were aware of their medical history and personal preferences. This knowl-
edge made a significant contribution to their overall positive evaluations.
Conversely, a lack of continuity caused negative emotional reactions. For
example, one respondent complained about a lack of communication be-
tween successive home-helpers:

I understand that some of them quit and new persons get employed … but I
wonder why they don’t have some routine for telling the new personnel about
me … They could save time on this, as it takes me a long time to explain my
problems … Indeed, it makes me even more upset when I think about this.

Dimension of physical environment and tangibles

Evaluations in the dimension of a physical environment and tangibles were
significantly affected by ‘affect-as-information’. Familiar surroundings were
important to the respondents. They especially appreciated being treated in
their own homes, which made them feel safe. For example, one respondent
described her negative reaction to the prospect of being moved to a hospital:

I don’t feel comfortable there! I don’t know what to do or where to go … I

can only lie there and wait … I was so happy when they arranged for a doctor
to come and visit me at home instead. I felt much better ... They didn’t need
to do that. That’s what I call ‘good service’.

72
A few respondents mentioned emotional reactions to tangibles when explain-
ing their overall evaluations. For example, one respondent described how a
large breathing aid inhibited social participation:

This ‘thing’ [the breathing aid] is so big … I can’t go away with it … I would
be embarrassed … sleeping at someone else’s house is out of the question.

In contrast, some of the seniors had positive emotional responses to tangi-

bles; in particular, they appreciated unobtrusive technical aids that they were
able to wear beneath clothes.

Summary of findings
The respondents referred to only some of the service dimensions spontane-
ously. These were the dimensions that were most obviously associated with
affective states and emotional experiences. These included:

• outcome dimensions: ‘independence and freedom’;

• process dimensions: ‘reliability’; ‘security’; ‘communica-
tion’; ‘warm and caring attitude’; ‘continuity of service’; and
• physical environment and tangibles.

Although emotional experiences appeared to direct the seniors’ attention to

these dimensions, it was noteworthy that the respondents often subsequently
explained their evaluations of these dimensions in cognitive terms; indeed, in
some cases it was difficult to distinguish between the emotional aspects and
the cognitive aspects. The comments of respondents contained reference to
‘facts’ as well as to emotional states. This was particularly obvious in the
case of the discontented respondents in their attempts to explain their nega-
tive emotional experiences.
The remaining dimensions were not especially affected by ‘affect-as-
information’. These included:

• outcome dimensions: ‘technical outcome (physical health-

status)’; and
• process dimensions: ‘responsiveness’; ‘competent person-
nel’; ‘individualised service’; ‘holistic care’.

When probed about these dimensions, it was clear that the respondents could
see insufficiencies but that these deficiencies did not create emotional reac-
tions and did not influence their evaluations of the overall service quality.
They attributed these problems to external factors beyond the control of the
service personnel and thus had low expectations.

73
Conclusions, implications, and future research

Major conclusions
The aim of this paper has been to explore the role of emotion in consumers’
evaluations of service in the context of long-term residential care services for
the elderly.
The most important finding of the present study is that most of the senior
citizens interviewed in the study claimed that they were ‘content’ with the
overall services rendered—despite some negative experiences and the fact
that certain aspects of the services deviated from their ideal desires. Similar
findings have been found in previous studies in the healthcare literature
(Avis et al., 1997; Staniszewska and Ahmed, 1999). It is the contention of
the present paper that the theory of ‘affect-as-information’ (Schwartz &
Clore, 1988; 1996) can help to explain these somewhat anomalous positive
evaluations in the face of negative experiences.
The study also indicates that pre-existing emotional states played an im-
portant role in the respondents’ overall positive evaluations. Such pre-
existing feelings have been previously described in the literature as ‘inciden-
tal’ (as opposed to ‘integral’) feelings about an object (Schwartz & Clore,
1988; Pham et al., 2001). The senior citizens studied here were physically
vulnerable, and they often feel anxious and sad. These ‘incidental’ negative
affective states contributed to the respondents’ positive overall evaluations
of the services they received because they felt dependent on (and grateful
for) the services provided. In some cases, these ‘incidental’ feelings caused
respondents with low self-esteem to blame themselves for service malfunc-
tions, rather than blaming the personnel. These findings support previous
research that has demonstrated a direct relationship between negative self-
attributed emotions (such as of anxiety, shame, and guilt) and high levels of
satisfaction with services rendered (Dubé et al., 1996; Dubé & Ménon,
2000).
The present study also suggests that consumers use affect-as-information
with regard to ‘integral feelings’ in their evaluation of certain dimensions.
These ‘integral’ feelings, which refer to affective states that are produced by
the consumers’ direct perception of the service dimension (Schwartz &
Clore, 1988), can also be described as ‘consumption emotions’ (Bagozzi et
al., 1999). In the present study, the following dimensions appeared to fall
into this category: ‘independence and freedom’; ‘reliability’; ‘security’;
‘communication’; ‘warm and caring attitude’; ‘continuity of service’; and
‘physical environment and tangibles’. Moreover, it seemed that the respon-
dents spontaneously remembered (and cared about) only these dimensions,
which they associated with emotional experiences. Drawing on Johnston and
Clark (2001) and Damasio (1994; 2002), it would seem that an emotional

74
‘memory bias’ was operating in these evaluations. However, it is important
to note that once the respondents had recalled an emotional experience re-
lated to a service dimension, they often then began to undertake further re-
flections on that dimension in a relatively non-emotional way—that is, by
referring to perceived ‘facts’ about the service, rather than emotional experi-
ences. Mechanisms such as ‘attribution’ (Kelley, 1973) and ‘expectations’
(Oliver, 1977; 1993; Parasuraman et al., 1985) were thus used cognitively to
explain their emotional reactions. Moreover, this cognitive reasoning ap-
peared to fortify the initial emotional reactions in a reiterative process of
consolidation.
In conclusion, the present study finds that consumers’ ‘emotional’ evalua-
tions of services (and specific service dimensions) should not be conceptual-
ised as being completely separate from their ‘non-emotional’ (reason-based)
assessments. On the contrary, the two are interrelated—it is apparent that
feelings can direct consumers’ attention to certain aspects of services and
trigger further reason-based assessments of these aspects.

Theoretical implications
This study underlines the importance of consumers’ emotional reactions in
their service evaluations. As such, the study contributes to the services litera-
ture which, as noted by Edvardsson (2005) among others, has been domi-
nated by research that characterises the service-evaluation process as a non-
emotional, reason-based assessment. In particular, the study illustrates how
initial emotional responses can direct the attention of consumers to certain
service dimensions, and thus trigger cognitive (‘fact-based’) evaluations of
these dimensions. This supports the notion that emotions can frame subse-
quent thought generation (LeDoux, 2000; Pham et al., 2001).
By demonstrating that emotions can thus play an important role in cus-
tomers’ assessments of service types and dimensions that have previously
been categorised as ‘non-emotional’ by the use of such labels as “utility
services” (Jian & Lu Wang, 2006), “pure utility variables” (Groth & Dye,
1999), “cold facts” (Strauss, 2002) and “functional” (Darden & Babin,
1994), the present study thus challenges the notion of a clear distinction be-
tween consumers’ evaluations of so-called ‘emotional services’ (or service
dimensions) and their evaluations of so-called ‘non-emotional’ services (or
service dimensions). In contrast to this presumed distinction, the present
study argues that the ‘emotional’ and the ‘cognitive’ are mutually related.
Finally, it has often been argued that consumers care more about the serv-
ice process (that is, how the service is delivered) than the result of the serv-
ice (that is, the outcome) (Grönroos, 2001); moreover, it has been argued
that this outcome is a technical matter that is evaluated in a relatively objec-
tive manner (Brady & Cronin, 2001). In contrast, the present study provides
a context (the long-term care of the elderly) in which the service outcome is

75
fundamental to the consumers’ evaluations; moreover, this outcome is an
affective state that is attributed by the consumers to the service being pro-
vided. In general, the present study contends that the relative importance
accorded to various service dimensions in consumers’ overall evaluations
depends on the extent to which the dimensions evoke emotional experiences;
this, in turn, is likely to be context dependent.

Practical implications
The present study underscores the need for service providers to recognise
consumption emotions in order to influence consumers’ service perceptions.
In the case of service providers of aged-care services, attention should be
directed to the emotional aspects of the dimensions that have been identified
in the present study as being especially relevant in terms of ‘affect-as-
emotion’. These include:

• outcome dimensions: ‘independence and freedom’;

• process dimensions: ‘reliability’; ‘security’; ‘communica-
tion’; ‘warm and caring attitude’; ‘continuity of service’; and
• physical environment and tangibles.

The seniors have low expectations about the other dimensions, which ex-
plain why the seniors did not explicitly evaluate them. In this context of eld-
erly care, full technical outcome (physical health-status) is not attainable any
longer and thus not a relevant dimension. The other dimensions can be im-
proved and can thus add to the service quality. These dimensions should
thereby not be neglected.

Limitations and suggestions for further research

This study is only an initial step in the ongoing exploration of the links be-
tween emotions and cognition in consumers’ evaluations of service. Larger-
scale studies of consumers in other contexts are needed to verify the findings
of the present study, which was conducted in one particular service context.
More specifically, it would be interesting to explore whether consumers in
general attach little importance to (and therefore tend to neglect) service
dimensions that they do not associate with emotional experiences. This is a
crucial question to be addressed in future investigations of the role of emo-
tions in consumers’ evaluations of services.

76
77
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81
2. Variability as a Source of Stability:
Studying Routines in the Elderly Home Care
setting 18

Author: Essén, Anna

Abstract
While it is agreed that there can be a difference between the routine as in-
scribed in artifacts, the ostensive aspect of the routine and its performative
aspect, little is known about the relationship between these parts of the rou-
tine. Further, while authors acknowledge that there is variability in routines
as performed, the contemporary literature says less about the sources of this
variability. Using empirical data from the Swedish community care setting,
the present paper explores the workings of and relationship between the dif-
ferent aspects of “the home-help delivery routine”. The paper also explores
the sources of variability in workers’ execution of this routine in situ. The
paper provides rich illustrations of the differences between the routine as
inscribed in artifacts, as “agreed on patterns” and the workers’ performance
of the routine in specific situations. It is the claim of the paper that these
differences contribute to the stability of the routine. The paper highlights
how factors in the local context, including exceptions created by technology,
constitute sources of variability in the routine. It further shows how values in
the contemporary society, adopted by individuals as emotional-ethical prin-
ciples, shape individuals’ performance of the routine and thereby generate
variability in the routine. In general, the paper underlines the importance of
considering the cultural context in which the routine is situated, at micro and
macro level, when analyzing its operation. Indeed, factors beyond the routine
influence individuals’ conception of and execution of the routine.

18
This paper is published in Human Relations. Vol. 61, No 11, pp 1617-1644. It has also been
presented at the Academy of Management Meeting in Atlanta, 2007.

82
Introduction
Routines have attracted the interest of scholars for more than half a century
(see e.g. Stene, 1940; Simon, 1947; March & Simon, 1958 for early exam-
ples) and significant contributions to our understanding of routines have
been made. However, as noted in the review by Becker (2004), many ambi-
guities and inconsistencies prevail in the routine literature. In particular as
regards the role of subjective choice and variability in routines. Indeed, “It is
remarkable that attempts at actually specifying how routines are varied, se-
lected, and retained, are very few still“ (Becker, 2004: 62).
This becomes evident when considering the role of routines in the Swed-
ish elderly home help setting. Home-help services are tax-financed in Swe-
den and national directives underline the importance of fairness and equality
in access to these services (Social ministry, 2005). This implies a need to
reduce local variations in the way these services are granted and delivered.
Centralized service plans pre-specify workers’ day-to-day service delivery at
minute level. On the other hand, elderly care is characterized by high vari-
ability (frequent exceptions) in needs encountered by workers (Perrow,
1967). Fall accidents, sudden anxiety outbursts and other unpredictable prob-
lems are common.
How can routines operate in such a setting? Clearly, workers’ execution
of the home-help routine cannot only be a matter of executing the pre-
specified tasks in the service plans. There must be additional efforts to re-
spond to the unpredictable changes in seniors needs. What shapes these addi-
tional efforts? And, how are these efforts related to the overall routine – do
they threaten its stability and survival? The contemporary literature does not
provide an answer these questions.
Recent work suggests that there can be a difference between the routine as
inscribed in artifacts, i.e. written rules or technology code; the ostensive
aspect of routine, i.e. the routine as “agreed on” activity patterns; and the
performative aspect, i.e. the routine as enacted by individual workers in spe-
cific situations (Pentland & Feldman, 2005). There is however a lack of un-
derstanding of the roles of and relationship between these parts of the routine
(Pentland & Feldman, 2005). Further, while authors acknowledge that con-
textual contingencies contribute to variability in the performance of routines
(Birnholtz et al., 2007; Feldman, 2000; Tsoukas, 1996; Tsoukas & Chia,
2002), the contemporary literature says less about how humans face such
contingencies (Tsoukas & Chia, 2002). This weakness in the literature is
important as it impedes our understanding of what routines are, how routines
remain stable and/or change and what effect they have on organizations
(Becker, 2005; Collinson and Wilson, 2006; Pentland & Feldman, 2005).
Given this gap in the literature, the present paper explores the workings of
and relationship between the artifact, ostensive and performative level of
“the home-help delivery routine”, focusing on how these dimensions can

83
constitute sources of stability and variability. Assuming that the routine at
artifact and ostensive level does not cover the efforts made by workers when
performing the routine in actual situations, the paper also investigates what
other factors shape these efforts.
The paper uses qualitative empirical data from two cases in the Swedish
community care setting. The findings suggest that the home-help delivery
routine incorporates an intriguing mix of efforts to reduce and respond to
variability. Drawing on Pentland and Feldman (2005), the paper provides
rich illustrations of the differences between the routine as inscribed in arti-
facts, as “agreed on patterns” and the workers’ performance of the routine in
situ. It is the claim of the paper that this divergence contributes to the stabil-
ity of the routine. To further explain these differences, the paper uses the
framework of Tsoukas (1996) and Mouzelis (1995) to show how social
norm, individuals’ values (disposition) and situational-interactive dimen-
sions influence how workers enact the routine in situ. These dimensions
contribute to the understanding of the variability inherent in the performative
aspect. The paper further shows how technological artifacts can play an in-
trusive role in this context, adding variability to the performance of routines.
In general, the paper underlines the importance of considering the cultural
context in which the routine is situated when analyzing its operation. Indeed,
factors beyond the routine at artifact and ostensive level influence individu-
als’ conception of and execution of the routine. The paper particularly high-
lights how values in the contemporary society and adopted by individuals as
emotional-ethical principles shape their performance of the routine. This
raises several questions that warrant further research.
The paper commences with a brief presentation of contemporary views on
routines. Next, a framework for studying routines is presented. Empirical
material from a study of the Swedish elderly care setting follows. The paper
ends with conclusions, implications, study limitations and suggestions for
further research.

Method
A case study approach was deemed appropriate as it would enable the re-
searcher to acquire a holistic view of the routine in all its dimensions, in its
organizational context, and over time. This approach further allowed the
researcher to use various data generation methods, which was important as
this study aimed at generating rich data about individuals’ account of the
routine versus their actual performance (Denzin & Lincoln, 2000; Patton,
2004; Weick, 2007). The paper triangulates different methods (Bruwer &
Hunter, 1989) to provide a credible and trustworthy portrayal of routines.

84
Research setting
The paper uses empirical material from the Swedish community-based eld-
erly care (home-help) setting. It focuses on a routine that is central in this
setting, namely the repeated delivery of granted home-help services to sen-
iors. This paper seeks to give a broad account of this “the home-help deliv-
ery routine” but it is not given where it starts and where it ends. Numerous
artifacts further enable and constrain the execution of this routine. The paper
discusses the service plan document that specifies the services each senior is
granted, and a technical artifact that plays an important role in the execution
of this routine, namely monitoring alarms.

Data generation
This paper is part of a larger ongoing longitudinal research program on tech-
nology and care. The paper builds on data generated from the study of two
Swedish home-help providers: A and B. Care provider A and B were chosen
as they have implemented a new telehealth technology and could therefore
provide rich data about this (purposeful sampling (Patton, 2004)). These
providers operate under the same laws and national health system structure
and they can be viewed as units of an organization. Several data generation
methods have been used. The author has participated at 20 sessions (McGall
& Simmons, 1969; Patton, 2004) at informal and formal personnel meetings
at provider A and B during May-Sept 2003 and during 2004-2007. Field
notes were taken on these occasions. Further, 38 more focused, in-depth
interviews (McCracken, 1988) with home-help managers at different levels
(n=15), home-helpers (n=20) at provider A and B, and municipal care man-
agers/gatekeepers (n=3) in the two related municipalities have been con-
ducted. The interviewed managers and home-helpers have been employed 5-
15 years. The author performed the interviews, face-to-face (30), via phone
(8) on two occasions: during May–September 2003 and during December-
January 2005. Interviews started with the author asking informants to de-
scribe the delivery of home-help services at a general level. The author pro-
ceeded more explicitly focused on issues related to variability and agency.
Typical questions to home-helpers/managers were:” in what situations do
you always perform tasks/do you encourage tasks always being performed/
in the same way? How? Why? When do you execute tasks differently in
order to adjust to specific situations or specific caretakers? Do you think
your way of acting differs from your colleagues’ way of acting? How? Why?
Questions were asked in an open-ended fashion and were not specified in
detail prior to the interviews, allowing the interviewer to word questions
spontaneously (Patton, 2004). More structured methods would leave little
room for unexpected issues to emerge. F-2-F interviews lasted for 90-120
minutes, phone interviews about 30 minutes. The author transcribed and

85
translated (from Swedish to English) the audio-recorded answers. The author
further studied documentation such as laws and service plans describing the
home-help delivery. Finally, the author performed participant observations at
8 occasions, by joining 3 home-helpers at A and 1 at B during two half-days
each, during their visits to senior households. This was relevant as routines
are partially tacit (Cohen & Bacdayan 1996). Field notes were taken from
these occasions.

Data analysis
Thematic content analysis, an interpretative process where the researcher
takes the context into consideration (Mason, 2002), was performed. First, all
transcripts and observational notes were read through to obtain a sense of the
whole. Meaning units, a word, a sentence or a whole paragraph that de-
scribed the idea or execution of the home-help delivery routine were marked.
The meaning units were condensed into a description of their content.
Themes, i.e. threads of meaning running through the descriptions (Mason,
2002) were abstracted. During this coding process, the author departed from
the tentative, emerging theoretical framework, while at the same time being
open for unexpected issues to emerge (Patton, 2004). The theoretical frame-
work and thematization presented here is a result of an iterative process,
including several rounds of interpreting the empirical material and reviewing
the literature (Denzin & Lincoln, 2000). The quotes presented below repre-
sent frequently mentioned examples encountered during inter-
views/observations. On a few occasions, informants were called during the
analysis phase in order to ensure that the interpretation presented is in accor-
dance with their view. Further, the analysis and conclusions have been dis-
cussed repeatedly with peer-researchers (Patton, 2004).

Literature review and theoretical framework

Early work defined routines as a fixed pattern of activity in response to a
defined stimulus accompanied by the absence of search (March & Simon,
1958; Nelson & Winter, 1982; Winter, 1986). Scholars associated the routine
with activity performed without explicitly selecting it over alternative ways
of acting (Simon, 1945; Stene, 1940; Weiss & Ilgen, 1985; Ashforth &
Fried, 1988; Cyert & March, 1963; Gersick & Hackman, 1990; March &
Simon, 1958). Routines have further traditionally been understood as storing
knowledge (Cohen & Bacdayan, 1994; Hodgson, 1998; Nelson & Winter,
1982). As related to this, it has been argued that routines result in economiz-
ing on the limited information processing and decision-making capacity of
agents (Gersick & Hackman, 1990; Hodgson, 1997; Simon, 1947; Winter,
1986; Cyert & March, 1963; Dosi et al., 1999; Gersick & Hackman, 1990;

86
Reason, 1990; Simon, 1947; Weiss & Ilgen, 1985). Scholars have further
maintained that routines are means for coordination and control (Cohen et al
1996; Dosi et al., 1999; March, 1991; March & Simon, 1958; Merton, 1940;
Nelson & Winter 1982; Stene, 1940) by making many simultaneous activi-
ties mutually consistent (March & Olsen, 1989) establishing a truce (Nelson
& Winter, 1982) and by being easier to monitor and measure than non-
routine behavior. As noted by Becker (2004): “The more standardized, the
easier to compare. The easier to compare, the easier to control” (pp. 655). In
general, routines have traditionally been associated with stability (Hodgson,
1993; Nelson, 1994; Nelson & Winter 1982) and with a reduction of uncer-
tainty, e.g. through their ability to establish a certain level of predictability
and expectations for members of the organization (Becker & Knudsen, 2004;
Cyert & March, 1963; Nelson & Winter, 1982).
This optimistic view of routines has come to be the target of criticism. It
has been argued that the stability effects of routines can be negative, leading
to organizational inertia. The strength of habits may further lull individuals
into executing well-known routines even when external stimuli vary (Ger-
sick & Hackman, 1990; Reason, 1984; Weick, 1979). Hence, scholars have
maintained that routines may lead to deskilling (Leidner, 1993; May, 1985),
demotivation (Ilgen & Hollenbeck, 1991) mindlessness (Ashforth & Fried,
1988) and that routines may be in conflict with individualization in service
delivery (Leidner, 1993; Berg, 1997; Hanlon et al., 2005).
Neither of these views could explain the multiple roles played by the rou-
tine studied here. Hence, the present study draws on an alternative way of
theorizing routines that has recently emerged in the organiza-
tional/management literature. I will primarily refer to Feldman and Pentland
(2003) and Pentland and Feldman (2005), although several works have con-
tributed to the framework they present (e.g. Feldman, 2000; Giddens, 1984;
Latour, 1986; Pentland & Reuter, 1994). Feldman and Pentland (2003:95)
define routines as: “repetitive, recognizable patterns of interdependent ac-
tions carried out by multiple actors”. In Pentland and Feldman (2005) they
suggest that routines have three dimensions. Artifacts refer to the routine as
inscribed in e.g. written rules and technology. The present paper assumes
that humans can delegate tasks to artifacts, which in turn can prescribe activ-
ity of humans (Akrich, 1992; Latour, 1992). The ostensive aspect (Latour,
1986) denotes participants’ account of the routine. It is important to note that
participants’ may have different understandings of what they ‘really’ do and
that these understandings may be different from the routine inscribed in arti-
facts. The performative aspect (Latour, 1986) consists of the routine exe-
cuted by particular individuals in particular places and times; the routine in
practice. Feldman and Pentland (2003) argue that artifacts and the ostensive
aspect of a routine can only serve as a template for behavior; people always
need to improvise to respond to unexpected conditions and contextual con-

87
tingencies when they enact routines (Feldman, 2000; Suchman, 1987;
Weick, 1993).
Against this background, the performance of routines should be viewed as
an effortful accomplishment rather than automatic behavior (Pentland &
Reuter, 1994). As noted by Giddens (1984): …it is a major error to suppose
that these phenomena [routines]…are simply repetitive forms of behavior
carried out ‘mindlessly’. On the contrary…the routinized character of most
social activity is something that has to be ‘worked at’ continually by those
who sustain in their day-to-day conduct (Giddens, 1984:86).
In short, recent research suggests that routines incorporate several dimen-
sions that can operate in different ways. Importantly, the performative di-
mension acknowledges that there are contextual contingencies in any situa-
tion (Tsoukas, 1996; Tsoukas & Chia, 2002). Alas, the contemporary litera-
ture does not quite answer what shapes how humans improvise when facing
such contextual contingencies (Tsoukas & Chia, 2002). It seems reasonable
to assume that there is an immense variability in individuals’ responses to
such unpredictable issues. What shapes this variability in human perform-
ance? And, how is this variability related to the ostensive and artifact aspects
of the routine? As noted by Pentland and Feldman (2005), these questions
remain largely unexplored in the contemporary literature.
A few studies have discussed factors that shape individuals’ performance
of routines. For example, Cohen and Bacdayan (1994) nicely illustrate how
individuals remember parts of routines in their procedural memory, i.e. a
relatively inarticulate memory for ”how to” do things (typically discussed in
terms of habits or skills). Individuals are not always consciously aware of
this skill, but it tends to persist. Thus routines reside partially in an "organi-
zational unconscious", it is argued. Birnholtz et al. (2007) also write about
the role of habitual dispositions stored in individuals’ procedural memory.
They ask: how can such individual dispositions be turned into collective
patterns of behavior? They find that this can occur via transfer of individual
dispositions from experienced to new organizational members. To what ex-
tent individual dispositions are generalized however depends on several fac-
tors including: the domain credibility (rather than formal authority) of the
individual actor, the visibility of the action and the degree of external stan-
dardization of the action. Some dispositions and improvisations may be in-
compatible with other dispositions and will therefore not take hold at organi-
zational level.
This research importantly highlights that response tendencies stored in in-
dividuals’ hard-to-access procedural memory can influence the performative
and in turn the ostensive aspect of routines. However, it does not conceptual-
ize where these response tendencies come from. The research further primar-
ily talks about how such response tendencies contribute to stability and con-
tinuity in individuals’ enactment of routine. This raises questions about the
sources of variability in individuals’ performance of routines. In general,

88
contemporary research does not quite explicate what makes some individuals
consciously “work at” the routine in certain ways, others “work at” it in
other ways, and others still ignore this fine-tuning completely.
Tsoukas (1996) (cf. Mouzelis, 1995) provides a framework elucidating
social factors that influence individuals’ rule following, which is helpful in
this context. Tsoukas (1996) suggests that normative expectations that are
associated with a particular role influence how it is carried out. The disposi-
tional dimension refers to individuals’ background, “the system of mental
patterns of perception, appreciation, and action, which has been acquired by
an individual via past socializations and is brought to bear on a particular
situation” (Tsoukas, 1996, pp.17). It is the result of the diverse social con-
texts individual workers have gone through during their lives (cf. Bourdieu’s
(1990) notion of “habitus”). Finally, the interactive-situational dimension
refers to the concrete and particular sociotemporal setting in which an act
takes place (cf. Goffman (1983), interaction order).
These three interrelated dimensions of social practices overlap with but
also add to the contemporary understanding of the factors that influence how
humans enact routines. Tsoukas/Mouzelis’ model acknowledges that the
‘here and now’ (the interactive-situational dimension) influences action. This
resonates with Latour's (1986) and Feldman and Pentland’s (2003) idea of
the performative aspect. However, while Latour (1986) posit that the per-
formative aspect is all about the emergent, what is ‘here and now’ (Latour,
1992; Cooren et al., 2006),19 Tsoukas/Mouzelis’ model highlights that nor-
mative expectations and individuals’ background influence how individuals
respond to “the here and now”. This idea can be used to make explicit the
influence of value structures and of “the past” (embodied, internalized by
individuals as personal values) in the enactment of routines.
Drawing on the above, this paper assumes that the performance of a rou-
tine is guided and constrained by the routine as pre-inscribed in artifacts and
as agreed on patterns (the ostensive aspect). Emergent issues in the local,
physical setting in which the routine is performed further plays an important
role (the interactive-situational dimension). How workers perform a routine
is finally influenced by factors beyond the routine and the local situation,
namely: prevailing expectations (cultural norms) and workers’ disposition
(personal values) (Mouzelis, 1995; Pentland & Feldman, 2005; Tsoukas,
1996). The paper presupposes that these intertwined factors contribute both
to 1) individuals’ inarticulate habitual dispositions and relatively subcon-
scious execution of routines (cf. Cohen & Bacdayan, 1995; Birnholtz et al.,
2007 and 2) individuals’ more reflective, conscious responses to exceptional
cases, i.e. their effort to “make the routine work”.

19
Latour views structure as a result (explanandum) rather than as a cause (explanans) (Latour,
1992; Cooren et al., 2006).

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Empirical material
This section accounts for the day-to-day delivery of home-help services to
seniors in Sweden, which I refer to as “the home-help delivery routine”. This
routine stems from the Swedish social services law, which declares that all
citizens have a right to a certain level of quality of life and security (SFS
2001:453). The social services law underlines several principles that should
guide the provision of public services including: ensuring the individual’s
dignity, autonomy and ensuring that the individual has the same living con-
ditions as all others, i.e. normalization. These paragraphs and national ambi-
tions have remained over time and political shifts in Sweden. They reflect
welfare and equity principles that are deeply rooted in the Swedish society
(Social ministry, 2005).

Artifacts

Inscriptions in service plan documents

Many of the home-helpers have never seen the paragraphs in the social serv-
ices law. Its abstract aims have been operationalized in terms of various pre-
defined “home-help services” such as help with: making the bed; getting up
from/to bed; doing dishes; grocery shopping; overall cleaning; washing and
ironing clothes; personal hygiene e.g. showering; moving around in the
appt/house; preparing breakfast/basic evening meal); hair care; dress-
ing/undressing; general supervision/check up visit; outdoor walk. Care coor-
dinators, employed as ‘gate-keepers’ in each municipality, decide what serv-
ice seniors in the community are to receive. The final decision, i.e. list of
granted services, is documented in individual service plans, which are exe-
cuted by home-helpers. The service plans consist of rather detailed instruc-
tions, as in the following typical example:

“…Name: Aina […]. Condition/Need: Chronic Obstructive Pulmonary Dis-

ease, is anxious […]. Granted service: Daily: Help with getting up from bed,
getting dressed, hygiene, making the bed, preparing breakfast, at 8.30 a.m. 20
minutes. Food delivery at 12.30. Help with preparing meal, 16.30. 15 min-
utes. Help with getting undressed, hygiene, go to bed. at 22.00. 15 minutes.
Once a week: Help with shower 30 minutes …” (Service plan document).

In many cases, the service plans remain unchanged for several years. Hence,
the service plans prescribe patterns of actions that are to be repeated by
home-helpers during long-periods of time. The home-helpers cannot make

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changes in the service plans. If the home-helpers note that a senior’s needs
have changed, they have to request that the care coordinator visit the senior
again and thereafter make a change in the service plans. This entails an un-
desirable delay between the request and actual changes in the service plans
according to home-helpers. Still, the home-helpers appreciate the centralized
decisional order as it ensures a fair distribution of scarce public resources:

“…I think it is for the best. I mean, if we were to decide, we would perhaps
be tempted to grant ‘cute’ seniors more services than the more grumpy
ones...” (home-helper).

Interviews further suggest that the service plans relieve the home-helpers of
some decision-making troubles:

“…it’s nice to have something to depart from, that someone else has decided,
one has to make decisions all the time when out on the field anyway…”

Inscriptions in technology code

Municipalities are to ensure the safety of seniors, which implies a need to
somehow incorporate the detection and response to unpredictable emergen-
cies in the home-help delivery routine. This task is inscribed in and partly
executed by the newly implemented telemonitoring technology. This tech-
nology continuously collects information about each senior’s activity level
(via alarm devices with sensors that seniors wear on the wrist). It automati-
cally triggers alarms every time a significant change in activity level is de-
tected, as this can indicate an emergency. Seniors can also activate alarms
manually by pressing a button on the device. The system transmits automatic
and manual alarms to care workers.
The monitoring system always performs these tasks in the same pre-
defined way, without interruptions (except in case of technical failure) and
without variability. A manager asserts that this consistency is valuable from
a fairness point of view:

“…The technology is always in the same mood and it does not have any fa-
vorites…it triggers alarms if a divergences occurs, period. … in theory, it
also compensates for differences between seniors in asking for help, some
seniors never demand medical service...until they’re close to death...” (Man-
ager).

Hence, the work of detecting emergencies has in part been delegated to the
technology. However, the technology does in turn prescribe activity of the
home-helpers: encouraging personnel to respond to the alarms that it trig-
gers. I will return to this point.

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The ostensive aspect – agreed on patterns
The care managers and many of the home-helpers agree that the delivery of
home-help service incorporates more dimensions that those inscribed in arti-
facts.

Patterns stemming from cultural values

Many home-helpers assert that it is their responsibility to provide ‘human
contact’ while executing the service plans. This self-imposed responsibility
resonates with human right, welfare and equity principles that are well estab-
lished in the Swedish society:

“…When you think about it, the service plans are merely a “cover”. This is
not only what our work is about… I mean, many times, “getting help with
breakfast preparation” is not what actually means something to the senior.
This is not what makes him able to keep on living alone. I’m not saying that
our work is NOT about delivering these services [in the service plans], but, I
mean, the oldies would not be OK if a robot did all the food, etc. They need
the energy that meeting another person generates… But it would look a bit
silly to write that in the service plan, ‘human contact, 10 minutes’ …[…]…of
course, everyone in Sweden has a right to not be completely isolated when
getting old…”. (home-helper).

The interviewed care managers and group leaders share this view of the
home-help delivery routine. They refer more explicitly to the social services
law in this context. A manager at provider B talks about how he expects
personnel to show warmth and act friendly when visiting seniors:

“…you have to genuinely like elderly people to be able to perform this

job…[…]…I try to think about that when I recruit new people. This has to do
with maintaining the dignity of each senior, they are vulnerable and home-
helpers that serve them without showing them ‘a human face’, without ‘being
present’, without recognizing them as individual persons can cause a lot of
harm…I mean, our [as community care provider] commitment is to ensure
the elderly a certain level of quality of life and that includes being seen as a
person…” (Manager).

“…I mean, in former times, children took care of their old parents. That’s not
how it works today. That’s why there is social services, I mean, it is a very
Swedish thing…You know how the politicians keep saying ‘in Sweden we
take care of our elderly’. I think there are even laws about the need to treat
the elderly with respect…” (Group leader).

Patterns stemming from individuals’ practical experience, i.e. from the

performative aspect
The home-helpers also account for activity patterns emanating from their
practical experience when describing the home-help delivery routine. When
home-helpers perform the service plans during long periods of time, they

92
gradually learn about each senior’s individual but rather stable preferences.
This knowledge is shared at morning meetings and it thereby gives rise to
collective behavioral patterns. Many of the home-helpers argue that this is an
important part of the routine and there are peer-to-peer expectations in this
context:

“… A lot of the small – but important - things we do, we do each time…for

example, during the wintertime, we always lit up the candle on Ruth’s
kitchen table when preparing her breakfast, turn up the heat, then turn on the
radio and put the morning paper on the table…That’s how she likes it…every
single day. I know the others do it too. We don’t have to ask her anymore,
this is what she has preferred for ages…I know some [of the home-helpers]
may ignore such things but that makes me real mad…” (Home-helper).

“… we’ve learned that Bror cares about details concerning the shower. He
wants rather cold water first, and then gradually warmer … and we have
learned to be VERY careful with the shampoo when helping Bror in the
shower...[…]…This type of knowledge is very important to share…we talk
about such issues at the morning meetings…”(Home-helper).

Patterns stemming from the powerful prescription of technology

artifacts
The home-helpers’ schedules are filled with the tasks specified in the service
plans. No time is formally allocated to alarm “turn-outs”. Hence, there is a
conflict between the activity prescribed by the technology-generated alarms
on the one hand, and by the service plans on the other hand. There is an
“agreed on” way of coping with this conflict, namely by prioritizing the
alarms:

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

plans aside then. The alarms have priority. One or ideally two of us [on duty
that day] have to interrupt whatever we are doing, take the car and visit the
senior in question... “ (Home-helper).

A manager talks about the power of the alarms to alter the performances of
the home-help delivery routine:

“…Of course, we have to prioritize to respond to the alarms…we can’t just

‘leave the turn-outs for later’. We have to act immediately on emergency
alarms. Otherwise, there may be legal sanctions…Fortunately it is easy for
new girls to understand this prioritization, it’s pretty intuitive, I mean, normal
people feel that there is an urgent need to act if there is an ALARM...it’s in
ones backbone…” (Manager).

93
The performative aspect
It is clear that the interviewees’ account of the ‘way they work’ does not
cover the variability inherent in the home-help delivery routine.

Situational-interactive aspects
Observations were particularly helpful to reveal how each instance of per-
forming the home-help delivery routine varies with the senior’s mood, con-
dition and the relationship between the senior and the home-helper, i.e. situa-
tion-specific aspects. Accompanying a home-helper when she performed the
instruction <<check up visit, 10 minutes<< at Siv’s, I could only observe
her chat briefly with Siv, have a look “to see that everything is OK”, and
then leave. I probed her if she could explain what work she actually per-
formed:

“…I simply see if everything is OK…I really can’t say exactly what I check,
it depends! […]… I guess I check if the senior is dressed or not. No, that’s
not true, Anton is always in his night robe…this work is really about know-
ing the senior. I guess…what I look for is changes from last time. Changes…
I mean, I don’t try to figure out if Kurt is weak, he is always weak. I try to
find out if he is unusually weak…you have to know what is ‘normal’ for each
senior… It’s very difficult to explain, I usually feel intuitively if something is
wrong… For example, Ingrid is extremely tidy, and I may ask her if every-
thing is OK if I notice that her kitchen is not as tidy as usual…But at Ruth’s I
would react if there was NOT a mess. That is what it usually looks like at her
place…”(Home-helper).

Many of the home-helpers ‘check on’ all the seniors they visit, while they
e.g. prepare food or make the bed. Even if this is not specified in the service
plans. How they do this varies. A home-helper explains how she focuses her
attention on different aspects depending on the situation:

“…of course, you check on them even if this is not specified on the list. For
instance, sometimes you note a strange smell when you open the door…I also
hear on seniors voice, if they sound unusually weak or start mum-
bling…Kurt, I usually touch his hand at one time or another when I visit him,
I remember recently, his hand was very cold when I patted it. This was an in-
dicator… I commented on this, but I didn’t do anything about it, but I think
he felt relieved that I noted it…” (home-helper).

Situation specific factors influence how the agreed on need to provide “hu-
man contact” is realized. I observed how one and the same home-helper
switched the tone of voice, tempo and body language when talking to differ-
ent seniors, while delivering the same service “on paper”. A home-helper
talks about this:

94
 “For example, Helena, she had a stroke and it’s difficult to hear what she
says. You really have to listen carefully and…she takes small breaks between
the words. In the beginning, I thought she had finished her sentences and I
started to fill in, but that was detrimental, she needs to get the chance to
speak up for her self. I’ve learned now to be more patient… With Anton on
the other hand [I act differently.] …Anton has always seen himself as a funny
guy I think. I understand his jokes and I really try to show him that I appreci-
ate his jokes. … I think our laughs are crucial to his well-being and health…
yes, Anton and I, we have developed our own sense of humor…I really like
to joke with him…I think it makes him feel like he is still in the
game…[…]…of course, if he has a bad day [Anton suffers from chronic back
pain] I might not joke a lot, I may not give him a BIG SMILE… I may rather
tell him something to get his mind off his pain…”(home-helper).

Individuals’ personal views and emotional-ethical values

The quotations above show that many home-helpers “add” to the home-help
routine efforts to respond to situation-specific issues. This work is not
documented. Why do they do this? Because they view this as part of their
job – and as part of their human responsibility to ‘help fellow beings in
need’. Indeed, many of the home-helpers are driven by altruistic ideals to
care for the needy:

“…This job is rewarding as you really feel that you do something for people
in need. That’s what keeps me going during the days...and I mean, I really
care for many of the seniors…so it’s natural for me to do what I can to make
them feel good while I’m there. I’m there anyway right? So I might as well
use my time effectively…” (home-helper).

Now, all home-helpers do not share this view and this creates variability in
the enactment of the service plans. Some home-helpers make no effort to
“add” personalized dimensions to the routine. Some only do that (or less
than that), which is specified in the service plans without being friendly or
showing any warmth. The findings suggest that this variability in individual
performance is influenced by the diversity in home-helpers’ personal views
and emotional-ethical values:

“…I think there is a difference between the girls who find pride in their work
on the one hand, and those who see it as dirty work and wish they were
somewhere else on the other hand. If you do not like your situation…you will
not go that extra mile, like trying to put a smile on the senior’s face by joking
a bit…[…]…For example, some of them really try to do the dishes very
quickly to get the time to sit down and chat with the senior…others do not
make this effort…in general, I know there are ‘nicer’ and less nice girls
[home-helpers]…but there is nothing we can do about that. One has to accept
that…” (Manager).

“…Lisa was typical, she was arrogant toward seniors. I talked to her. She told
me that her brother was a doctor and her sister some kind of lawyer. She felt

95
 pressured to start studying and get a ‘real’ job...she viewed this job as sim-
ple…”(Manager).

“…I think we have different ideals…different goals with our home- visits.
Some may only aim to ‘get them done’. I always try to chat with the sen-
iors… I’m brought up with that, to treat people with respect. And further, to
do whatever you do with your whole heart…[…]… You know, even if I’m in
a bad mood, I am always friendly to the seniors. It usually makes me in a
very good mood! …of course, I have to confess that I talk a little extra with
my favorites, like David…”(Home-helper).

Individual views are in turn related to the cultural and historical context in
which they are situated. The general ambivalent social status of “elderly care
work” is identified as an important factor influencing the variability in
home-helpers emotion-ethical values and behavior:

“…this is not a well paid job. That sends signals to the home-helpers as well
as everyone else. Of course it affects the status of the job. On the other hand,
elderly care work does have some status in the sense that it is seen as mean-
ingful and important. People working with the elderly are seen as “nice peo-
ple”…” (Group leader)

“…This has generally been seen as a job ‘anyone’ could take without any
formal education. But of course, anyone cannot do this job - well. You need
to be committed and have experience to do it well. That should have the same
status as formal education if you ask me, but it doesn’t in today’s society…”
(Manager).

Exceptions: highlighting the influence of personal values

The influence of the workers’ diverse emotional-ethical values is highlighted
in situations with competing rationalities. For example, seniors sometimes
refuse the services that they are granted. Complying with the wishes ex-
pressed by the senior in such cases implies a divergence from the service
plans. The home-helpers act differently in such cases, illustrated by the fol-
lowing quotes:

“… I really try to listen to the senior. I don’t want to force them, say… to eat
for example. I think it’s wrong to treat another human as if she knows noth-
ing. It’s against my personal principles. They have a right to auton-
omy…And who am I to claim that I know better than they do… “(home-
helper).

“…Olle sometimes says he doesn’t want a shower or says ‘oh, I’ve already
taken a shower!’ when it is obvious that he hasn’t. I try to make the shower
less intimidating to him in such cases and I usually manage to make him will-
ing to let me shower him… It is a matter of their dignity!…I remember when
my mom was old and senile…she often said no when the home-helpers told
her they were to shower her. And they just left, can you believe that!? Happy

96
 to leave I guess... Hence, I found her smelling sweat and I felt so humiliated
on her behalf. I often showered her myself…”( home-helper).

Another example is when the monitoring technology triggers alarms. The

home-helpers do prioritize the alarms as is “agreed on”. But they respond
differently to the alarms, depending on their view of what is “an urgent
need” and what they feel is “fair”:

”…Alarms can be caused by any reason…the senior may have had a heart at-
tack …but there are also more diffuse cases, where a senior has pressed the
button because he is lonely and anxious. Then it is difficult to know how long
you should stay with the senior…I have a hard time leaving the senior in such
cases, I’m that type. And I believe that one can urgently need company if one
is anxious…it [problems of depression and anxiety] runs in the family… I
know others are more ‘rigid’, and only stay if there has been a physical acci-
dent…of course they just try to be fair to the others who are waiting… “
(home-helper).

In sum, the performative aspect of the home-help delivery routine exhibits

more variability than the ostensive and artifact aspects. The workers’ diverse
emotional-ethical values, which are in turn inextricably linked to the micro
(family values) and macro (values established in the contemporary society)
context in which the workers are situated, constitute an important source of
variability here.

Conclusion
The findings presented above suggest that “the home-help delivery routine”
incorporates various dimensions that operate in variability reducing and
variability enhancing ways.

The role of and internal relationship between the parts of the

routine
The power over the routine as inscribed in artifacts (service plans and tech-
nology) is centralized and the routine as inscribed is a source of consistency
in the setting studied. The service plans represents a default way of operating
that the workers can return to after making ‘detours’ called for in specific
situations. The routine as inscribed in technology artifacts further operates in
a stable manner. In general, the routine as inscribed in artifacts is inflexible
and the routine may therefore seem static from an outside perspective. The
present exploration however shows that the routine would not survive would
it consist merely of these inscriptions.

97
 The ostensive aspect of the routine, i.e. the content of the routine as
agreed on by the workers, has a complementary role in this respect. It medi-
ates between the routine at artifact and performative level. The ostensive
aspect incorporates agreed on solutions to conflicts between the prescriptions
made by artifacts. It is further shaped both by individuals’ practical experi-
ence of executing the routine and by prevailing cultural views. These micro
and macro forces influence individuals’ understanding of the role of the rou-
tine. Hence, the ostensive aspect of the routine recognizes and responds to
more variability than artifacts.
The performative aspect of the routine incorporates yet more variability.
It is sensitive to several more influences than those “invited” to directly
shape the routine at artifact and ostensive level. I will return to this point.
What I want readers to note here is that the technology artifact is a source of
variability at the performative level. It creates situations with competing
concerns. As neither service plans nor agreed on rules covers such situations,
many home-helpers apply personal rules, originating in “what they feel is
right” in such cases. In general, many of the home-helpers complement or
diverge from the routine as inscribed in the service plan to “make it work” in
actual situations. The variability generated by this effort could impossibly be
covered by the routine at artifact or ostensive level. Nonetheless, it is a de-
sirable variability. Indeed: thanks to many of the home-helpers’ efforts to
compensate for the inflexibility of the routine as inscribed in service plans,
these rules can remain unchanged– and the routine overall can survive.
Now, this overall argument does not mean that all the variability in the
performative aspect should be embraced. I shall discuss this below.

Sources of variability in the home-help delivery routine

As indicated above, contextual contingencies (interactive-situational as-
pects, Tsoukas (1996)) constitute one source of inevitable variability in the
performative aspect of the routine studied here. Now, this study suggests that
difference in workers’ personal values (disposition, Tsoukas, 1996) creates
another layer of variability in the performative aspect. Altruistic convictions,
acquired during the previous life history, motivate many workers to con-
sciously add work to the routine to respond to contextual contingencies in
situ. Other home-helpers, who view home-help as a degrading and low-
status job often omit to fine-tune the routine in this way. Indeed, negative
emotional convictions even drive some home-helpers to do less than what is
inscribed or agreed on when executing the routine in situ. Hence, the diver-
sity in individuals’ personal emotional-ethical values constitutes an impor-
tant source of undesirable variability in the routine.
The salient influence of emotion-ethical values should be understood in
relation to the high frequency of exceptions (emergencies) and the resource
scarcity prevailing in the elderly care setting. These conditions create an

98
environment characterized by unpredictable and competing needs and a con-
stant call for reflective judgment about what is “the right” (or least bad)
thing to do. It is further crucial to note that the workers’ personal values are
inseparable from (produced by and reproducing) the contrasting prevailing
cultural values and norms in the contemporary society (Tsoukas, 1996) as
well as the workers’ diverse private backgrounds (habitus, Bourdieu (1990)).
The gist of all this is that the performance of routines is shaped by factors
beyond the routine itself, and beyond the organization in question. As a re-
sult, the performance is difficult to predict and control.

Theoretical implications
Previous research has recognized that there are differences between the di-
mensions of a routine. It is agreed that there is an immense variability inher-
ent in the performative aspect of the routine as opposed to the routine as
inscribed in artifacts (Pentland & Feldman, 2005). The present paper extends
these arguments in several ways.
The close look at the internal dynamics of the home-help delivery routine
shows that its survival is dependent on the fact that workers depart from and
return to, but often override the routine at artifact level. The managers inter-
viewed accept this. Hence, this study suggests an alternative to the view that
differences between the routine at artifact, ostensive and performative level
indicate disagreement between labor and management (e.g. Callaghan &
Thompson, 2001; Deery et al., 2004; Hanlon et al., 2005; Taylor et al., 2002)
or that divergence between the parts of a routine may indicate “resistance or
serious misunderstandings about what it takes to do the work …[or] a tem-
plate that is outdated” (Pentland & Feldman (2005) pp. 806). In contrast, the
present study argues that the survival of the routine is dependent on the dif-
ferences between its aspects. It suggests that the routine at artifact level can
remain stable just because the ostensive and the performative aspect differ
(complement and diverge) from it. Hence, the study supports the argument
made by Toukas & Chia (2002) who write about stability and change in gen-
eral: “… the statement "the acrobat maintains her balance" is true, as is also
true the statement "the acrobat constantly adjusts her posture…[…]… The
apparent stability of the acrobat does not preclude change; on the contrary it
presupposes it.” (pp. 572). (cf. Birnholtz et al., 2007).
In general, this study underlines the need for theory acknowledging that
variability reduction is not only the aim of managers and that it is not the
only aim of managers (as is implicitly suggested in Callaghan & Thompson,
2001; Deery et al., 2004; Hanlon et al., 2005; Taylor et al., 2002). The find-
ings suggest that managers, workers and consumers recognize the simulta-
neous need to: 1) reduce internal variability (Harvey et al. 1997) stemming
from e.g. favoritism and other bias to ensure fairness and 2) respond to (the
inevitable) external variability (Harvey et al. 1997) in consumer needs. This

99
implies that variability reduction and variability response efforts should not
be portrayed as antithetical, or as generalized categories. Rather there is a
need for nuanced accounts of variability management in relation to routines.
This study further starts to demystify the variability in the performative
aspect of routine. It supports the notion that situational contingencies exist in
any situation, discussing this in terms of interactive situational issues (Tsou-
kas, 1996). However, it adds the insight that individuals’ personal values
(dispositions, previous life experiences or ‘habitus’, Bourdieu, 1990; Mouze-
lis, 1995; Tsoukas, 1996) shape how individuals respond to such contingen-
cies. More specifically, it shows that workers’ emotional-ethical principles
can constitute rules for how to execute a routine, in particular in situations
where there are competing concerns, and that this creates variability in the
performance of the routine. This contributes to the literature. Previous re-
search suggests that individuals’ inarticulate and subconscious response ten-
dencies (Birnholtz et al 2007; Cohen & Bacdayan, 1994) influence their
behavior. However, as noted by Birnholtz et al (2007) reflection (based on
individuals’ declarative knowledge) also plays an important role when indi-
viduals decide how to act in new, unknown situations (Birnholtz et al. 2007).
The present study extends this argument by highlighting how emotional-
ethical values influence individuals’ conscious efforts to “make the routine
work” in situ. Of course, emotional-ethical values are presumably partly
stored in individuals’ procedural memory as inarticulate and subconscious
response tendencies. However, the frequency of exceptions (Perrow, 1967)
and competing needs in the setting studied activates these values and forces
workers to apply them in a more conscious way. Hence, the notion of the
dispositional dimension (Tsoukas, 1996) should not only be understood as
the as a subconscious force that steer individuals’ behavior, but also as a
standpoint that individuals can articulate and depart from when they need to
reflect on alternative ways to act.
Finally, the study highlights that technology artifacts can constitute a
source of variability and unpredictability in routines. This insight comple-
ments the literature that tends to equate technology with variability reduc-
tion. Indeed, authors have referred to the variability reducing consequences
of “protocol-laden technology” without specifying if this refers to the in-
scribed, agreed on or performed patterns of the routine (e.g. Hanlon et al.,
2005). Further, routine studies have primarily discussed the indirect enabling
and constraining role of artifacts in terms of written rules, checklists etc (Cy-
ert & March, 1963; Miner, 1991; Miner & Estler, 1985; Howard-Grenville,
2005; Pentland & Feldman, 2005). The present paper suggests that artifacts
can be active participants in retaining and varying the routine by executing
and powerfully prescribing activity, playing an intrusive role.
In sum, the present paper adds to the contemporary understanding of the
internal dynamics of the routine. It further highlights that emergent factors in
the local context, including exceptions generated by technology artifacts;

100
individuals’ personal values and structures in the larger social context repre-
sent sources of variability in the performance of routine. Hence, the present
paper situates individuals’ enactment of the routine in a cultural and histori-
cal context, at micro and macro level (cf. Narduzzo et al., 2000; Howard-
Grenville, 2005).

Managerial implications
There is today a tendency among politicians to overestimate the importance
of routines encoded in artifacts. For example, national care quality is increas-
ingly equated with thorough documentation of routines. Electronic work logs
are also gaining attention (see e.g. Social ministry, 2005). The purpose of
such tools is ultimately to detect divergences between the routine as in-
scribed and as performed, by measuring e.g. minutes spent on each task.
However, this study suggests that additions or divergences from routines as
inscribed are often necessary in the care setting.
Indeed, the smooth operation of routine studied (and the care system of
which it is a part) in fact implicitly builds on the “added” work performed by
many home-helpers (but not others). The ostensive aspect incorporates the
normative expectation that home-helpers will be “givers”, that they will –
presumably driven by their own emotional-ethical conviction - “voluntarily”
perform many tasks to respond to various undocumented needs among sen-
iors that nobody but the senior notices.20 This needs to be brought to the fore
in quality discussions.
Workers emotional-ethical values should be the target of improvement ef-
forts and quality discussions in addition to documentation issues. I am not
suggesting more written rules, but a much more frequent articulation of the
need to reach a certain degree of consistency in how workers approach and
adjust to seniors. One such way is to standardize inputs (Mintzberg, 1979),
i.e. by educating personnel and ensuring shared values. Frequent meetings
and technologies supporting real-time communication between front-line
workers who work isolated out on the field is an extension of this. In gen-
eral, there is a need to look at the result rather than the process, e.g. by ask-
ing seniors about their satisfaction with the care they receive.
Of course, the undesirable variability illustrated in this paper partly stems
from the low status of elderly care work in today’s society, which in turn is
rooted in wage structures, the contemporary view of body work and of theo-
retical versus practical knowledge. Clearly, coming to grips with these issues

20
To understand this situation, we need to consider that the growing number of seniors in
Sweden has not been accompanied by a corresponding increase in community care providers’
budget. As a result, public resources are allocated to the most obvious (read: physical) needs
rather than more subtle, emotional needs related to loneliness. This makes the workers’ ef-
forts to strain-and-stretch the routine (e.g. by rushing through tasks to release time to chat
with seniors) crucially important.

101
not only requires other measures than more rigid rules, it requires structural
changes.

Limitations and further research

The present work does not set out to make generalizations but endeavors to
provide a set of propositions to be further investigated by future research.
By unpacking the routine, this study reveals organizational power struc-
tures. The power of the routine as inscribed in artifacts is centralized in the
studied setting. However, the differences between the artifact, ostensive and
performative aspect of the routine indicate that there is a significant degree
of decentralized decision-making. This is partly related to the fact that work-
ers are ”out alone on the field” when performing the routine. Researchers
could investigate other settings where workers’ are informally allowed to
make decisions in situ to “make the routine work” but where this discretion
is not formally recognized, i.e. not accompanied by status or power of the
routine as inscribed in artifacts.
Further, this study illustrates a setting where workers express emotion to
satisfy seniors needs, use their emotions to detect (“feel”) what the consum-
ers need, and use their emotions as a guide when making difficult decisions.
Emotions clearly play various roles that cannot be covered by the notion of
emotional labor (Hoschild, 1983). This is however beyond the scope of this
paper and an avenue for future research.
Finally, this study can be positioned within an emergent stream of studies
that are starting to look at the interplay rather than conflict between rules and
creativity, stability and change, reducing and responding to variability etc.
(Birnholtz et al., 2007; Gilson et al., 2005; Pentland & Reuter, 1994; Tsou-
kas & Chia, 2002). Research further conceptualizing such relationships is
warranted.

102
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3. The Emergence of Technology-based
Service Systems: a Case Study of a
Telehealth Project in Sweden 21

Author: Essén, Anna

Abstract:

Purpose. This paper is concerned with the process of innovating technology-

based service systems. Research has recently elucidated how bricolage, i.e.,
individuals’ “making do” with the means available can trigger innovation.
However, the concept of bricolage essentially remains a black box. This
paper attempts to flesh out the concept of bricolage and thereby elucidate the
innovation of technology-based services as an emergent process.
Methodology/Approach. The paper uses case study data from the Swedish
elderly homecare setting.
Findings. The findings illustrate how the emergence of technology-based
care services can be triggered by an injection of energy in terms of a new
technological resource being made available in an organization, proceeding
as a continuous interaction between personnel repurposing and recombining
resources at hand, positive and negative feedback dynamics, institutional
regulations and culture-related stabilizing mechanisms.
Research limitations/implications. New services can arise as a result of a
number of efforts and events that in isolation appear non-significant. Taken
together, and interacting with enabling and constraining forces that promote
the emergence of certain new services and prevent others, such acts and
events generate unpredictable outcomes. The result may be incremental but
by no means trivial innovations.
Originality/value of paper. The paper suggests an approach to innovation
that complements conventional thinking in the new service development
literature. The proposed framework can help to explain how and why certain
new service emerge, and others not, in unexpected and unpredictable ways.

Wordcount: 234

21
This paper is published in Journal of Service Management. 2009, Vol 20/1, pp 98 – 121.

106
Introduction
Knowledge about the service innovation process is important for our under-
standing of the transformation of offerings, organizations and sectors over
time. However, it is still an underexposed area in the literature (e.g. de Jong
and Vermeulen, 2003; Syson and Perks, 2004), in particular the process of
innovating technology-based service systems (Menor et al., 2002; Van Riel,
2005). Scholars have recently pointed at the complexity related to this kind
of service innovation, arguing that it involves not only technological but also
organizational development (e.g. Magli et al., 2006; Piccoli et al., 2004). It
has further been suggested that the technology-based service innovation
process encompasses many informal and iterative elements, and that it is
influenced by extra-organizational factors, such as the prevailing policies
and cultural values (e.g. Barlow et al., 2006). These insights indicate that
students of technology-based service innovation should take on a broad per-
spective. Alas, the nascent technology-based service innovation literature
does not quite respond to this call. Existing studies largely approach this area
from a technology-oriented perspective, either attempting to 1) model the
systematic sides of technology-based service innovation or 2) investigate to
what extent certain technology-based services respond to certain consumers’
needs (Chircu et al., 2001; Dabholkar et al., 2003; Lanseng and Andreassen,
2007; Massey et al., 2007; Mørch et al., 2004; Slater and Mohr, 2006; Sung-
Eui, 2005; Walker et al., 2002). This tends to produce studies incapable of
capturing the complexity of technology-based service innovation. Indeed,
the prevailing practice-oriented approach tends to generate studies that ne-
glect the informal and unpredictable dimensions of the technology-based
service innovation process and it’s sensitivity to the influence of extra-
organizational factors. This weakness applies to the New Service Develop-
ment literature in general. It is dominated by studies depicting service inno-
vation as a well-planned, formal process, starting with a managerial vision
and ending with full-scale launch (Cooper et al., 1994; Johne and Storey,
1998; Menor et al., 2002). While scholars have criticized these models for
obscuring the iterative and bottom-up sides of service innovation (Ed-
vardsson et al., 1995, Dolfsma, 2004; Steven and Dimitriadis, 2004) alterna-
tive models are hard to find.
In summary, the new service development literature (including studies fo-
cusing on technology-based service innovation) mainly theorizes about the
formal, linear and predictable facets of the innovation process. This in spite
of observations suggesting that many innovation processes are cyclical and
that they involve unexpected, informal interactions between factors at indi-
vidual-, organizational-and societal level. The lack of theoretical understand-
ing of the latter aspects has implications in practice. Such aspects are not
considered in cost analyses or supported with tools or technologies (Maglio
et al., 2006). As a result, informal mechanisms and ideas are not caught up,

107
potential innovations go unnoticed, and many extra-organizational forces
that exert positive or negative influence on the innovation process are not
dealt with, leading ultimately to a reduced financial performance.
The present paper seeks to address the imbalance in the extant literature
by proposing a framework for studying the process of technology-based
service system innovation from a broad perspective, using an approach that
elucidates the non-linear facets of this process. The paper draws on Lévy-
Strauss’s (1966) concept of bricolage, which implies that individuals’ ‘mak-
ing do with resources at hand’, as opposed to managerial visions, can trigger
innovation. To flesh out this concept, illustrating how it is influenced by
certain institutions, resources and events, the present paper integrates it with
the notion of technological drift (Ciborra et al., 2000) and with a model of
emergentism (Chiles et al., 2004; Prigogine and Stengers, 1984).
The paper illustrates the proposed framework using empirical data about
the first phase of developing technology-based elderly care services. Hence,
the paper responds to calls for innovation research in settings other than the
financial sector, which has received a disproportional amount of attention in
the development literature to date (Smith and Fischbacher, 2005; Stevens
and Dimitriadis, 2004). The care setting is relevant as increased healthcare
spending and possibly unsustainable healthcare funding models motivate
many care providers to develop existing care services by using information
technology (IT) or ”telehealth ” applications (Koch, 2006; Lanseng and
Andreassen 2007; OECD, 2004). Service development in this area is how-
ever immature. Indeed, there are internationally few examples of tele-
health services offered in routine care service delivery (Barlow et al.,
2006). This situation and the public healthcare sector in general, have re-
ceived surprisingly little attention in the service innovation literature (Smith
and Fischbacher, 2005).
Drawing on the proposed emergentism framework the paper describes the
beginning of an innovation process, which is triggered by a new technologi-
cal resource being made available in a care organization and proceeding as a
continuous interaction between repurposing mechanisms, feedback mecha-
nisms, institutional regulations and stabilization mechanisms. This way of
understanding the service development process extends the concepts of bri-
colage and drift, by revealing the enabling and constraining dynamics that
reinforce the emergence of certain services and prevent others from realiz-
ing. The applicability of these insights go well beyond the care setting. They
are relevant to students of innovation processes in general. Overall, the paper
opens up avenues for research studying how new services can arise, actual-
ize, materialize in a non-linear and rather unpredictable way, and it thereby
complements the new service development and service innovation literature,
which to date has been dominated by studies outlining “success factors” and
emphasizing the importance of systematic innovation processes (Åstebro and

108
Michela, 2005; Atuahene-Gima, 1996; Avlonitis et al., 2001; de Brentani,
2001).
The paper begins with a selective literature review and a presentation of
the proposed theoretical framework, integrating insights from bricolage
(Lévi-Strauss, 1966), technological drift (Ciborra et al., 2000) and emergen-
tism (e.g. Chiles et al., 2004; Prigogine and Stengers, 1984). Case study
findings from a telehealth project conducted by a public elderly care pro-
vider in Sweden follow. The paper proceeds with conclusions, implications
and suggestions for further research.

The innovation of technology-based services

The concern of this paper is the process of innovating new technology-based
service systems.22 The “new service development” literature has paid little
attention to such innovation processes (e.g. Menor et al., 2002). A review of
the nascent technology-based service innovation literature reveals that it
largely attempts to shed light on the systematic, ordered facets of the devel-
opment process (cf. Chircu et al., 2001; Palmer and Griffith 1998; Passerini
et al., 2007; Sung-Eui, 2005; van Riel et al., 2004). For example, Piccoli et
al. (2004) conceptualize the development of technology-based services as a
migration from one discrete phase to the next, which follows a predictable
pattern determined by the firm’s overarching goal of maximizing its return
on its technology investment. Many service development studies further
focus on consumers’ adoption of technological innovations (e.g. Dabholkar
et al., 2003; Lanseng and Andreassen, 2007; Massey et al., 2007; Slater and
Mohr, 2006; Walker et al., 2002; Vrechopoulos et al., 2001). This research
produces important insights, but tends to produce an understanding of the
innovation process as predictable and possible to control.
Now, a few recent studies have suggested that the process of innovating
technology-based services is more complex than this. Barlow et al (2006)
highlight that this process involves integration between the technological
innovation and the service provision system (including authority structures).
They also argue that the policy context, contemporary values and cultural
norms can influence the innovation process.23 In general, they point at a
mishmash of factors, at various levels, that can play important roles in the
process of innovating technology-based services. Maglio et al., (2006)
similarly suggest that technology-based service innovation involves not only

22
Innovation can broadly be described as an idea, artifact, or behavior that is new to or per-
ceived as new by the organization adopting it (Daft, 1978; Zaltman et al., 1973). This paper
deals with the process that generates such ‘outcomes’.
23
Barlow et al (2006) write about “implementing” a technological innovation, but I be-
lieve that it is more appropriate to talk about service innovation. The overall discourse
needs to shift focus from technology implementation to service innovation.

109
technological, but also organizational and individual relationships, i.e. that it
should be understood as a matter of developing new service systems. Their
examination of IT- service delivery systems suggests that such systems
comprise a large share of non-planned tasks and negotiations performed by
individuals and that other ‘fuzzy’ factors, which are beyond the manager’s
direct control, influence the development of such systems.
These latter study examples indicate that the technology-based service in-
novation process 1) involves more than the ordered implementation of a new
technology; is 2) cyclical rather than linear and that it is 3) influenced by
informal and unpredictable factors, among which many are beyond the orga-
nization’s control. As noted above, such aspects have however not seen
much light in the new service development literature. It is however impor-
tant to note that recent research on innovation systems more generally is
increasingly underlining that innovation can occur through other pathways
than well managed and systematic processes. Indeed, observations suggest
that innovation trajectories are often informal, ad hoc and unpredictable
and that they should be understood as cyclical, including various feedback
loops and evolving through complex – often unexpected and even accidental
– events (Consoli, 2005; Gadrey et al., 1995; Jensen et al., 2007; Metcalfe
et al., 2005; Rothschild and Darr, 2005). However, few models elucidating
how these factors interact have been suggested. Hence, there appears to be a
need for a more comprehensive framework that allow for a multi-level
analysis of the dynamics between micro processes at individual and organi-
zational level on the one hand, and structures at societal level on the other
hand, in the innovation process. In the next section I shall try to present such
a framework. I will start by introducing the notion of bricolage (Lévi-
Strauss, 1966) and technological drift.

Bricolage and technological drift

The concept of “bricolage” often referred to as making do with “whatever is
at hand” (Lévi-Strauss, 1966: 17; Miner et al., 2001; Weick, 1993) helped to
describe and understand the innovation process observed in this study. This
paper draws on Baker and Nelson (2005) who define bricolage as “making
do by applying combinations of the resources at hand to new problems and
opportunities” (pp. 333). Resources at hand refer to a set of pre-existing
‘odds and ends’ (Lévi-Strauss, 1966:18) e.g. available materials (Lanzara,
1999), coping mechanisms (Hatton, 1989) and skills and ideas (Baker and
Nelson, 2005). Bricolage implies that such resources-at-hand are reused for
different applications than those for which they were originally intended or
used (Garud and Karnoe, 2003; Miner et al., 2001). In other words, bricolage
is the repurposing and refashioning of the old in making something new
(Weick, 1993) and it involves recombining existing elements rather than
fabricating them from scratch (Baker and Nelson, 2005).

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 Bricolage contradicts the rational model of innovation as seeking means
to reach a given end. In bricolage, the ends are not clearly known at the out-
set and the “reasoning” process does not use logical deduction but is more of
a spontaneous process (Innes and Booher, 1999). Indeed, bricolage is related
to improvisation. To paraphrase Miner et al. (2001: 314): “…as improvisa-
tion permits no temporal gap between the design and execution of activities,
improvisers have little opportunity to seek resources beyond those already at
hand, and they therefore typically engage in bricolage”.
Hence, in contrast to conventional views on innovation, bricolage sug-
gests that innovation can be understood as actors departing from the means
and gradually learning what aims are possible. It is difficult to foresee the
result of such practices. Bricolage is associated with unexpected outcomes
that are half-realized, hybrid and imperfect, but which do their job and can
be improved (Lanzara, 1999; Miner et al., 2001). As this paper deals with
technology-based services, insights about the unpredictability of outcomes in
the information systems (IS) literature are relevant to consider here. The IS
literature discusses this in terms of technological drift (Ciborra et al. 2000),
i.e. the tendency of technologies to deviate from their planned purpose for a
variety of reasons (pp. 4). Technology often performs in unexpected ways
and it tends to produce unintended side effects when implemented. As a
result, users often have to revise goals and intentions or try to find ways to
alter or work around the technological properties over time (Ciborra et al.,
2000; Pickering, 1995). The affordance (Gibson, 1979) of technology, i.e.,
users’ perception of what action is possible with the technology, is further
highly contextual. This shapes the consequences of IS implementations in
unpredictable ways (Orlikowski, 1992 cf. Feenberg, 1999; Murata, 2003).
Summing up, the concepts of bricolage and technological drift comple-
ment each other, suggesting that the innovation of technology-based services
can be triggered by individuals making do with resources at hand, and that
the outcomes of such practices, i.e. the new technology-based services that
actually emerge, may be different from what was initially envisaged by
technology designers or the user organization. These insights were valuable
when analyzing the innovation process studied here. However, it soon be-
came clear that there was more to the process studied than actors “making do
with resources at hand”. Further, neither bricolage nor technological drift
could sufficiently explain why certain technology-based services came to be
while others were prevented from being realized. Why did outcomes “drift”
in one direction and not another?

111
Proposing a framework for studying the emergence of new
technology-based services
Indeed, while the literature applying bricolage and technological drift do
shed light on the triggering and outcome related elements of the innovation
process, the bricolage process has essentially remained a black box. To open
this black box, i.e. unpack the intermediate dimension of the innovation
process, this paper uses insights from complexity theory (cf. McKelvey,
1999). Complexity theory is suitable for the study of how new services can
come to be as it focuses on emergence, on “becoming rather than being” and
on “process rather than state” (Gleick, 1987: 5). It can be used to explain
how and why a phenomenon evolves from the interaction of myriad events,
small and large, spontaneous and deliberate, and at multiple levels (Chiles et
al., 2004). The idea that emergent properties amount to more than the sums
of the properties of their parts is central in emergentism theory (Gleick,
1987). This paper draws on the dissipative structures model (Prigogine and
Stengers, 1984; cf. Chiles et al., 2004), which posits four interacting mecha-
nisms of emergence24: 1) ‘fluctuation’ refers to injections of energy repre-
sented by new activities, events or resources that interrupt the existing order
and catalyze the emergence of a new order; 2) ‘feedback dynamics’ amplify
the initial fluctuations, helping the new order to take hold and gain momen-
tum; 3) ‘stabilization dynamics’ are deep structures that shape novelties and
guides choices in a way consistent with the systems accumulated history and
learning, preserving the systems identity and core behavioral patterns; and 4)
‘recombination dynamics’ refers to how the system’s existing elements are
reused, rearranged, reconstructed, re-leveraged, and re-created.
Hence, the dissipative structures model overlaps with bricolage but it also
extends this concept by elucidating the forces that enable and constrain what
individuals can make of the technological resources at hand. While organiza-
tional students have used the dissipative structures model to explain how the
evolution of organizational systems proceed from a “punctuated emergency”
to the next, i.e. from one order to another over time (Chiles et al., 2004;
Leifner, 1989), this paper draws on it to explain the first phase in a service
development process, i.e. the emergence of a new service, which can be un-
derstood as the evolution of one new order.

Figure 1. A framework for unpacking the concept of bricolage in the con-

text of the innovation of technology-based services.

Take in figure one about here

24 This version of the dissipative structures model is simplified to suit the purpose of this paper. See
further Prigogine and Stengers (1984).

112
The framework (see fig. 1) suggests that the development of new services
can be triggered by the injection of energy in terms of a new technology
resource being made available in an organization. The organizational mem-
bers will engage in bricolage (Lévi-Strauss, 1966) by making do with the
new resource, i.e. they will repurpose it and recombine it with old resources
and as a result, they will learn what the technology affords in context. The
individual members’ acts of making do should however not be confused with
boundless freedom and endless creativity. Positive and negative feedback
mechanisms shape their acts of making do. That is, the immediate responses
the personnel encounter when using the new resource will amplify certain
uses and prevent others from being repeated. The (unexpected) performance
of the new technology, when implemented, will also actuate responses and
developments in certain directions rather than others. These responses con-
tribute to the definition of the boundaries of the emerging service. The emer-
gence of new ways of using the new resource, i.e. the birth of new technol-
ogy-based services, is further influenced by more permanent institutional
constraints and stabilizing mechanisms such as organizational structure,
regulations and cultural values (Chiles et al. 2004; Prigogine and Stengers,
1984). The innovation process will unfold as a continuous interaction be-
tween these enabling and constraining mechanisms and it will produce re-
sults that may drift from the original intention of technology designers and
the user organization (Ciborra et al., 2000). In general, is difficult for any
single actor to control the outcome of this process as it is shaped by partici-
pants and forces at various levels and at different points of time.
This view of the innovation process has emerged during the process of
writing this paper, see method section, and it has guided the analysis and
presentation of the findings.

Method
The present paper explores how the mechanisms depicted in figure 1 operate
in a particular context such as technology-based care service innovation.
That is, the purpose is to develop rather than to test theory. The study is
based on a single case. This case was chosen for theoretical reasons, i.e. as it
could reveal an unusual phenomenon (technology-based care service innova-
tion) and support the elaboration of the emergent theory (theoretical rather
than representational sampling (Yin, 1984)). Studying the single case during
over 3 years (2004-2007)25 allowed the researcher (author) to follow the
informal, gradual processes of service development over time in its real-
world context and to use various information sources (Yin, 1984). In gen-

25
This study is part of an ongoing research program investigating the infusion of information
technology (IT) into elderly care.

113
eral, the case study approach is suitable for longitudinal research seeking to
unravel the underlying dynamics of phenomena that play out over time (Sig-
gelkow, 2007).

Data generation
A telehealth project conducted by the community care organization in Heby
in Sweden constitutes the case studied. Heby is today one of few elderly care
providers engaged in the development of IT-based services in Sweden. The
author has participated in a large number of formal and informal meetings in
Heby during 2004-2007. Field notes have been taken from these observa-
tions. Home-helpers’ service documentation has further been scrutinized and
summarized in field notes. In 2006, 12 un-structured interviews were per-
formed with home-help and managerial personnel within the Heby commu-
nity care organization. The interviews revolved around visions about the
telehealth technology and the actual use and development of services on
basis of this technology (see appendix). The longitudinal study allowed the
researcher to ask follow up questions such as, why did you not exploit that
function, etc. see how one thing led to another (interactions).
Interviews were performed at the nursing home where personnel gather
before they deliver home-help services. The interviews included open-ended
questions in order to allow for unexpected issues to emerge and lasted about
90 minutes each. The interviews were recorded, transcribed and translated
(Swedish to English) by the author.

Data analysis
Following the pattern for inductive research (Denzin and Lincoln, 1998;
Miles and Huberman, 1994), the author worked recursively between the
interview transcripts, field notes and the theory being developed. Field notes
and interview transcripts were analyzed at two levels. The author first fo-
cused on building detailed descriptions of particular acts where the individu-
als involved in the telehealth project created new ways to use the new tech-
nology. These descriptions were then coded tentatively, using key words
emerging from the empirical data (Miles and Huberman, 1994). When
documenting patterns in the data, tentative theoretical explanations were
constructed based on an initial framework. The individual-level, pragmatic,
ad hoc and bottom-up tendencies ran across interview transcripts as well as
observational notes. Similarly, the role of forces at structural level were evi-
dent in several sources. The author discussed uncertainties in the data with
two of the home-helpers at several occasions. Several working papers that
attempted to explain regularities in the data were written. These papers were

114
presented to peer scholars and critical feedback was received. During the
repeated process of interrogating the data, revising the theory, and returning
to the data, Lévi-Strauss’s concept of bricolage was discovered as a good
characterization of the behaviors observed in the case. However, it became
obvious that this concept did not explain the process alone. The dissipative
structures model emerged as relevant after some modification. And after
several rounds of experimental coding, the themes reported in the present
paper eventually emerged (Denzin and Lincoln, 2000). In the presentation of
the results, illustrative examples of the data from which the author drew
inferences are provided (Miles and Huberman, 1994). When quotes are used,
the names of the informants are coded.

The case
The study focused on a sub-unit of the Heby community care organization
(as this unit implemented the new technology). This sub-unit employed 18
home-helpers at the moment. The municipality director of Heby is ultimately
in charge of the care delivered by these home-helpers. There are also re-
gional managers, heading over group leaders, who in turn lead groups of
home-helpers.
In 2003/2004, the Heby municipality director and regional manager de-
cided to invest in an activity monitoring technology. At this time, Heby was
suffering from financial constraints (budget deficit). The managers used
money from a temporary municipal development fund to cover the invest-
ment. The new technology has similarities with “traditional safety alarms”
that are provided to seniors in the community. The monitoring units are
wrist-worn and include a button that seniors can manually press when they
are in an emergency situation. The new monitoring units however also in-
clude functionality that differs radically from the traditional alarms. Embed-
ded sensors continuously monitor seniors’ activity level, transmit this infor-
mation to service providers, and present it in the form of graphical activity
curves displayed on a computer screen. The monitoring system also sends
automatic alarms to personnel if significant changes in activity level are
detected, e.g. if a senior is completely inactive as this can indicate an emer-
gency. Hence, the system provides information about subtle changes in ac-
tivity patterns over time, i.e. non-emergency information, but also about
drastic changes in activity levels via automatic inactivity alarms, i.e. emer-
gency information. The Heby managers bought 23 end-user monitoring
units. The technology was installed in 23 elderly households located in a
sub-region of Heby. They also purchased a PC with a certain application
installed, which was needed in order for personnel to be able to analyze the
patient activity information (graphical activity curves) generated by the sys-
tem.

115
Findings
The development process studied was characterized by a continuous interac-
tion between the mechanisms in the proposed theoretical framework. The
mechanisms are illustrated with examples from situations where they were
salient.

An injection of energy: Introducing a new technological

resource without a clear end in sight
A group of managers in the Heby community care organization initiated the
development process studied. They envisioned that new technology-based
services could contribute to a more cost-effective care service production
and they decided to invest in a telemonitoring system. There were numerous
new care technologies available on the market, but few targeted the elderly
homecare sector. Hence, the managers pragmatically “settled” with a tech-
nology that seemed to hold some promise. An important reason for the man-
agers paying attention to this particular technology was an informal relation-
ship between key actors (as opposed to a systematic scanning of all tech-
nologies available). Serendipitous events such as people being seated next to
each other at a grand dinner played a role here. The vendor marketed the
monitoring system as a tool for ensuring the safety of seniors living in single
households.

“…The message was that the monitoring system would enhance our capacity
to detect emergencies...And the extended information about the senior pa-
tient’s ‘general status’ would enable us to ‘know’ our seniors better...”
(Birgitta, Manager).

While the managers were animated by such claims, they were uncertain
about what benefits the use of the technology could produce at a more con-
crete level.

“We found it difficult to predict…At this stage, our belief was that the advan-
tages of the monitoring technology in practice would emerge along with the
staff members starting to use it” (Anna, Manager).

Indeed, it was difficult for the managers to formulate a new service concept
at this stage as they were unsure of what the new technology, in the hands of
the home-helpers, could do.

116
Making do: “Creating” the resources needed to innovate
services
The managers saw to that the new hardware and software was paid for. Their
engagement was however limited to the purchase of the new technology.
Hence, the front-line employees (home-helpers and their group-leader) faced
the challenge of installing, configuring, and using the new technology with-
out any new resources formally being allocated to this. The empirical mate-
rial revealed that the personnel, “out of nothing”, created resources that,
taken together made it possible for the technology to be used and the innova-
tion of new services to begin. Take for example the issue of finding a place
for the new PC (to which the monitoring information would be sent). The
home-helpers don’t have an “office” as they are always out visiting seniors.
The home-helpers however meet every morning at one of the community
nursing homes for demented patients. The group-leader repurposed a room
that was not occupied by any senior to create space for using the technology.

“This room is rarely used, and it can be locked, which is important as the eld-
erly [nursing home residents suffering from dementia] may otherwise wander
through the door and start playing with the computer” (Liv, group-leader).

There was further a need to “find” time to install the new monitoring devices
in the elderly households. The group-leader managed this by reallocating
time from other tasks that could wait. As this was not always possible, the
installation was sporadic and spanned over a long period of time. Moreover,
the personnel were forced to “create” technical support, as there were no
formal resources allocated to this. The group-leader took advantage of her
good relationship with an employee at the technology vendor in this context.

“There were a lot of unexpected problems in the beginning. I can tell you
that… so I called Fredrik [employed at the technology firm] and told him that
we just had to make the monitoring devices work again...Poor Fredrik I
called him often, but he was always willing to help me. He has a hard time
saying no, he is that type of guy… Fredrik really wants us to like the new
technology…so that we can spread the gospel I guess […] we don’t pay for
this…” (Eva, group-leader).

Finally, there was a need to innovate some rules for how to respond to the
new alarms generated by the new technology. The personnel reused existing
routines in this context. They decided to respond to the new inactivity alarms
in exactly the same way as when they are notified about the traditional man-
ual alarms: two home-helpers working shift at the nursing home take a
community car and drive immediately to the senior in question to check on
him/her.

117
 “…we were not sure of what kind of events would actually trigger inactivity
alarms, I mean, these automatic alarms are totally different from the other
alarms [manually triggered alarms], but it seemed reasonable to use our ex-
isting routines…that we are all familiar with” (Jenny, home-helper).

Hence, by making do with the resources at hand the front-line employees

created a platform that enabled them to start using and innovating services
on the basis of the new technology.

Feedback mechanisms during the use of the new technology

As the personnel started using the new technology, feedback mechanisms
reinforced certain features and affordances and impeded others. An impor-
tant feedback link was that from the monitored senior consumers. Most of
the seniors appreciated being provided with new, “modern” alarms with
monitoring functionality. This encouraged the personnel to keep on using
and learning about the new technology. However, some of the seniors started
to rely too much on the technology.

“…Jim told me he had felt really bad before my visit. But he didn’t call on us
as he thought the technology would notice this anyway. You could see this on
the computer, couldn’t you, he said…but we couldn’t…“(Jessica, home-
helper).

This feedback taught personnel what the monitoring technology was not, i.e.
a general health monitor, as they had initially envisaged. The personnel
rather started to define it as a complementary source of information, which
reflected a single and very specific aspect of seniors’ health.

Redefining the automated alarms triggered by the new

technology
As opposed to what was initially expected by the vendor and the care pro-
viders, none of the automatic inactivity alarms triggered was caused by
emergencies.26 The home-helpers’ alarm documentation revealed that the
automatic alarms were rather caused by various rather subtle changes in
activity. For example, one note said:

The alarm was presumably triggered by Jeff lying still most of the day. He
was tired, recently discharged from hospital. I gave Jeff a sandwich when I
arrived. He appreciated this.

Another example:
26
There were also a large number of “false” alarms that were triggered by seniors sleeping
unusually deep during the study period.

118
 Lillian confirmed she was just tired and a bit sad when I arrived. We talked
for a few minutes. This made her happy. I told her I would call back in half
an hour.

The personnel learned that the monitoring system could detect and notify
them about situations when seniors were “unusually weak”. New services
emerged as the personnel responded to such situations. They paid the sen-
iors, from whom alarms were automatically triggered, extra “support visits”.
The content of these visits was deemed highly contingent on the senior and
necessary to innovate in situ. A home-helper explains:

“you have to feel what is right in these moments. The automatic alarms can
be triggered by various reasons. Perhaps the seniors are weak and just need
you to sit next to them, hold their hand for a minute. In other cases, making
them laugh may be the recipe to make them feel better…” (Joni, home-
helper).

The seniors’ responses suggested that the new customized support visits
could produce feelings of safety and reduce anxiety among the seniors.

“…Essentially, I think these visits make the seniors feel watched over and
cared for…” (Hannah, home-helper).

Interviewees also claim that the new support services have preventive value:

“…Visiting a senior who is merely feeling a bit tired and sad may prevent
him/her from getting really anxious and completely passive…[…] and if sen-
iors feel safe at home, this may prevent them from applying for placement at
a nursing home…” (Gunilla, group-leader).

Redefining the patient data continuously provided by the

technology
The monitoring technology also generates real-time information about the
seniors’ activity level over time, displayed as graphical activity curves on a
computer screen. The personnel realized that this activity information al-
lowed them to see whether or not the seniors wear their alarm. This is im-
portant as many seniors forget to wear their alarms and are hence unable to
call for help in emergencies.

“… I realized that I can see if seniors are wearing their alarm or not on the
screen…if the line is straight this means there is no signal, [that] the senior is
not wearing the alarm…we didn’t think of this in the beginning…”(Ulla,
home-helper).

119
The personnel started to remind the seniors (who according to the activity
data was not wearing their alarm) to wear their alarms. That is, a “making-
sure-that-seniors-wear-their-alarms” service started to take shape. As there
were no pre-existing routines to copy in this context, the personnel impro-
vised when reminding the seniors about the alarms, combining the new pa-
tient data with their “old” consumer knowledge. For example, Jenny says:

“We saw on the screen that Siv never wears her alarm during the night … I
did not really know how to talk to her about this though. I didn’t want to say
that we “can see” if she wears it or not...Siv would find this privacy threaten-
ing, I know her. I ended up not talking about the monitoring system at all.
Instead, I talked about the risk of falling… and I think it worked…” (Jenny,
home-helper).

This way of using the new patient data generated the desired results.

“…We have seen an effect on the curves. When we tell them specifically
about this, more or less directly, they tend to start using their alarm. Hence,
they can call on us when in danger. This provides the seniors and their rela-
tives with a greater sense of safety…they’ve told us this…” (Maria, home-
helper).

Institutional constraints and stabilizing mechanisms

The personnel assert that they could use the monitoring system in a number
of preventive ways beyond what has been mentioned above.

“…We could use it [the new patient data] to identify seniors who appear to
be extremely passive daytime or suffer from insomnia at night and help them
become more active during the day for example… introducing targeted daily
activity services could prevent a lot of sleeping disorders from getting worse.
This could prevent fall accidents, which are more common among tired sen-
iors…” (Maria, home-helper).

However, the home-helpers don’t have the authority to make any major
changes in the services they deliver.

“…The home-helpers have to stick to the service plans, they cannot just add
new services…We would need to create a new role structure, where front-
line employees could adjust the content of the services they deliver on basis
of real-time information generated by technologies like this…” (Anna, man-
ager).

In general, the data revealed that the reimbursement system and organization
of the national care system constrained the care providing organization’s
possibilities to realize service innovations that respond to “new” needs.

120
 “Addressing seniors sleeping disorders or irregular activity patterns in pre-
ventive purpose … is beyond our public commitment…we would have to
bear such production costs without being reimbursed by the government for
this…sure this could generate long-term health improvements and thereby
cost-savings…but there is no evidence of this. And who knows if I will ever
get any return on such investments, political shifts may change my budget to-
tally…” (Karin, manager).

Privacy concerns further hampered more extended customized prevention

services from being realized. The monitoring technology actually provides a
lot of information about the seniors. When they leave the house, when they
sleep, how deep they sleep, and it is possible to infer quite a lot on basis of
their general activity level. The home-helpers could use this information to,
in a preventive purpose, intervene in the seniors’ behavior. However, the
home-helpers did not use the data in this way. Eva explains:

“…I mean sure, we can see if the senior leaves the house and at what time. I
can see that Elov leaves the house every day at about the same time and that
he returns after 15 minutes. I knew this before; he likes to take a morning
walk every day. But if I would see that he didn’t leave the house one day I
wouldn’t call him and tell him to take a walk – even if it is good for his
health. This would invade on his privacy! But if he would stop performing
this daily routine of his completely, I would perhaps tell the girls to check on
him a bit extra, during their regular visits…” (Liv, group-leader).

Similarly, Jessica says:

“If an activity curve indicate that something is not OK, you feel like asking
the senior about this... But we cannot say to a senior that ‘we have seen on
the curves that you are very inactive during the days’. This might make the
seniors feel watched in a negative sense… ” (Jessica, home-helper).

Interestingly, the data also indicated that the value attached to principles
such as autonomy and pluralism impeded certain services to emerge.

“…Unless there is an alarm, we rarely do anything about the changes in ac-

tivity level we see on the screen. .. I mean, how long is it normal to have a
‘low activity’ level? In some cases low activity level can be a sign of depres-
sion or a signal that something is wrong health-wise… something that could
get worse if we do nothing about it…but, seniors may simply need a lot of
rest some days…and who are we to decide what’s ‘normal’ and not?...” (Eva,
group-leader).

“…It is a scary thought, that we would use this to control that everyone has a
perfectly regular pattern, sleeping during the night and being active during
the day. We know that sleeping patterns change when one ages. It is impor-
tant to allow variation here. Some elderly may enjoy staying up until 3 am,

121
 sleeping until 6 am and sleeping in the afternoon instead…” (Birgitta, Man-
ager).

Scepticism toward “high-tech business” further discouraged the personnel to

exploit the functionality of the new technology. The monitoring system can
be set to trigger various alarms, e.g. if the senior leaves the apartment etc.
The home-helpers however decided to keep such alarm functions latent.

“We decided to only activate the inactivity emergency alarms, in this first
stage of use…using all the new functions seemed too demanding and compli-
cated…We are not in a high-tech business. We are not high-tech people…”
(Jenny, home-helper).

Finally, the data indicated that the deeply rooted view of elderly care as a
matter of human (read: face-to-face) contact contributed to personnel using
the new information as a complement rather than as a replacement to face-
to-face visits.

“…We would never collect information about our elderly merely via com-
puters instead of visiting them. This would be out of the question, care is
about human contact…” (Ulla, home-helper).

Interactions
There were numerous interactions between the mechanisms. For example,
stabilization mechanisms influenced the “energy-injection mechanism” as
financial constraints encouraged the managers to choose a relatively low-
cost technology and the prevailing healthcare culture made them inclined to
not choose a too radical technology (e.g. robotics). Stabilization mechanisms
in terms of prevailing values further influenced the “feedback mechanism”
in terms of the positive reaction among seniors (via their high belief in the
reliability of modern technology). Prevailing values also influenced how the
workers interpreted the feedback signals from the seniors and how the work-
ers, as a result, redefined the purpose of the technology. There were also
interactions between the stabilization mechanisms and “making-do mecha-
nisms” (operational employees’ acts of bricolage). Workers were forced to
make do with available resources due to institutional constraints such as a
limited budget and the rigid financial structure. Cultural values further con-
strained their use of the technology. Hence, stabilization mechanisms influ-
enced how workers made do with the technology, and this of course influ-
enced how seniors reacted to the new technology, which in turn also influ-
enced how workers continued to make do with the technology. These exam-
ples illustrate the cyclical nature of the emergence of new technology-based
services in the case studied.

122
Drift: redefining the new technological resource – unexpected
services emerging
In summary, as a result of the implementation of the monitoring technology,
new technology-generated patient data entered the work-life of personnel.
The new data unexpectedly brought to the fore the fact that seniors often
forget to wear their alarms and it occurred to the personnel that they could
use the technology to detect and respond to this problem. The personnel also
understood that the technology could notify them when seniors were “weak”
and thereby provided them with an opportunity to address such more subtle
health changes. Overall, the personnel gradually learned that the new tech-
nology primarily enabled various preventive services. This view differed
from the technology vendor’s claims and the managers’ initial expectations
of the new technology, which revolved more around its role as an emer-
gency-detector. The personnel redefined the new technological resource,
increasingly referring to it as a complementary decision support and an
“early warning” tool. On the basis of this contextualized understanding of
the technological resource, the personnel started to provide seniors with new
“extra support visits” and “alarm-usage control services”, carefully adjusted
to the senior and the situation. Neither the vendor nor the managers had an-
ticipated the emergence of these new services. The services are still in a nas-
cent stage. The personnel and managers however assert that they will con-
tinue to use the technology to further learn what it enables them to do for
their senior consumers.

Conclusion, implications and further research

This paper proposes a theoretical framework for studying technology-based
service system innovation as a non-linear and emergent process. The frame-
work extends the notion of bricolage by drawing on ideas from emergentism
(the dissipative structures model, which originates in complexity theory
(Prigogine and Stengers, 1984)) and technological drift (Ciborra et al.,
2000). The paper has shown the relevance of the enabling and constraining
dynamics incorporated in this framework in the study of service innovation.
More specifically, the paper has described the emergence of new technol-
ogy-based services as a continuous interaction between the injection of en-
ergy in terms of a new technological resource, personnel making do with
resources at hand, feedback dynamics, and stabilizing mechanisms. These
dynamics helped to explain how and why certain new services emerged, and
others not, in the case studied. For example, the personnel started to tinker
with the new technological resource in the actual context, combining it with
existing resources, and various unexpected actions made possible by the
technology, i.e. new “service affordances” emerged. The personnel’s realiza-

123
tion of these possibilities were influenced by feedback mechanisms that at-
tenuated certain acts and others not. There were also more permanent stabi-
lizing forces that prevented the personnel from even starting to carry out
certain ideas that emerged.
The applicability of these insights go well beyond the care setting. The
framework suggested can be used by students of technology-based/service
system innovation more generally. In particularly by researchers seeking
models allowing a broad analysis of the innovation process, including its
non-linear, informal and unpredictable facets. The framework can also in-
spire researchers seeking models encouraging an exploration of the influence
of individual factors and of extra-organizational dimensions at societal level.
In general, this paper suggests an approach that complements established
thinking on service innovation. Much of the service innovation literature to
date appears primarily interested in identifying success factors in innovation
projects, underlining the importance of allocating resources to multi-
functional, autonomous development teams, engaging external parties such
as consumers, suppliers, competitors and other stakeholders in all stages of
the process, creating an innovation-friendly climate, etc (Alam and Perry,
2002; Åstebro and Michela, 2005; de Brentani, 2001; de Jong and Ver-
meulen, 2003; Johne and Storey, 1998; Kelley and Storey, 1999; Matear et
al., 2004; Ottenbacher et al., 2006). In contrast, the present paper reports
about “trivial” acts and events, which taken together led to the emergence of
new service ideas and to the provision of a few new services. There is reason
to believe that “mundane” development processes and results such as those
reported in this paper are no less common than innovation processes that are
aligned with the recommendations in the new service development literature.
As noted by Sundbo (1997), service industries seldom have R & D depart-
ments. Hence, to understand how new services emerge, we need to acknowl-
edge that services may sometimes emerge as a result of fluctuations, i.e.
injections of energy, spontaneous or deliberate, that trigger more or less un-
expected responses and in an ad-hoc manner lead to incremental changes.
This too is innovation in services.

Managerial implications
This paper does not set out to provide managerial recipes for how to conduct
optimal innovation processes. It is descriptive rather than prescriptive. How-
ever, the findings do provide insights about issues that managers should
recognize in their decisions about how to plan for and how to support the
innovation process. To start with, this paper reports about how a service
innovation process can unfold in the absence of a clear strategy, that is,
without much managerial planning. In the case studied, the managers simply
made a new technological resource available to front-line personnel and their
idea was to see what new care services could emerge as a result. This is in

124
contrast to innovation processes beginning with the managerial definition of
a “service objective” and proceeding with the formal allocation of the re-
sources necessary to achieve this objective, as has been proposed (Alam and
Perry, 2002; Cooper et al., 1994; Edgett, 1994). In the case studied, the new
technology was the only resource formally allocated to the service develop-
ment project. There was no “development team” or “development budget”
devoted to the service innovation as is often recommended in service innova-
tion literature (de Jong and Vermeulen, 2003; Edvardsson and Olsson, 1996;
Johne and Storey, 1998; Kelley and Storey, 1999; Stevens and Dimitriadis,
2004; Syson and Perks, 2004). The present study however shows that this
did not prevent innovation from happening. It rather forced front-line per-
sonnel to make do with the resources at hand, i.e., to engage in bricolage
(Lévi-Strauss, 1966). In creating the prerequisites for employing the new
technology, i.e. creating space for service innovation, they reallocated time
from activities that could wait and repurposed resources at hand, such as
abandoned facilities, social relationships and private experiences. Indeed, the
absence of any formal allocation of resources to the innovation process stud-
ied may have had positive implications. For example, hidden and seemingly
unrelated resources had perhaps not been put to any productive application if
a development budget had been available. As it were, bricolage sometime
created value without withdrawing resources from any current use. Further,
as the operational personnel could not delegate tasks to some “development
team”, they were forced to infuse the new technology into their work life
without disrupting their day-to-day work. As a result, the technology was
fairly integrated in the organization.
However, most likely, lack of “new” resources and the reliance on re-
sources at hand made the personnel strive for a workable rather than a break-
through solution. The absence of an innovation strategy further led to ad hoc
choices that tended toward the option requiring the least cognitive effort and
time (Douglas, 1987). As a result, the personnel were inclined to choose
paths that avoided dramatic changes. These factors contribute to the fact that
incremental rather than radical or disruptive (Christensen, 1997) innovations
were produced. In general, the creative use of bits and pieces has produced a
“bits and pieces” innovation, a half-realized innovation. Elements that are
vital to the development of a sustainable service are still lacking. As noted
by Baker and Nelson (2005), “coaxing”, a large degree of ad hoc responses
and improvisation can be anathema to the establishment of reliable imper-
sonal routines. The provision of the new service is dependent on the employ-
ees’ capability to create space to use the new technology as no formal roles
or responsibilities have been created. Further, the vendor will not provide
“free” support forever. It needs to be noted though that the process is far
from finished. More formalized processes and roles will most likely emerge
over time.

125
 In general, the findings presented here are relevant to managers not only
in the care setting but in service settings in general. Indeed, this study high-
lights the complexity related to the innovation of technology-based service
systems, and the many forces that managers need to take into account before
and during such innovation processes. Although it is difficult for managers
to control the mechanisms involved, such as individual workers improvisa-
tions, pragmatic acts of ‘making do’, institutional constraints and reactions
among consumers, managers need to be aware of the significance of such
forces. They should establish support systems for, in terms of e.g. rewards or
other incentives to support and encourage workers tinkering with the re-
sources at hand. They should also engage in continuous follow up meetings
to catch up emergent, incremental ideas. And they should try to reflect on
how institutional regulations and cultural values may influence the innova-
tion process.
In summary, the present study suggest that while innovation processes
may be difficult to predict and control, it is possible to distinguish patterns
and to in advance ‘prepare for’ certain interactions. The findings elucidate
how individuals’ engagement in bricolage is not merely a matter of arbitrar-
ily departing from the means available; it is also shaped by attenuating and
reducing feedback mechanisms. Outcomes do not drift randomly, but as a
result of structural and cultural factors. Institutional constraints had particu-
lar significance in the context studied. The personnel could not innovate new
services merely on basis of what was technically afforded and what could
produce values to their senior caretakers. They rather had to keep their pub-
lic commitment in mind, i.e. what needs they are and are not reimbursed for
responding to. Deeply rooted values such as maintaining privacy, autonomy
and the prevailing healthcare culture with the view of care as a matter of
human (face-to-face) contact also influenced the emergence of new services
by disallowing more radical uses of the new technology.

Theoretical implications, limitations and future research

directions
The present exploratory study is based on a single case. And the public
home-help setting studied is idiosyncratic in many ways. However, the pur-
pose was to develop rather than to test theory (Eisenhardt and Graebner,
2007). As noted by Siggelkow (2007), single cases can serve as counterex-
amples, thereby enabling the development of existing theory by pointing
to gaps and beginning to fill them. The present study can be viewed as an
attempt to, if not ’falsify’ then at least challenge the prevailing tendency to
speak of technology-based service innovation as a predictable, systematic
process that is contingent on managerial decisions. The present study has
hopefully illustrated that as an alternative, the concepts of bricolage, techno-

126
logical drift and complexity theory can sensitize researchers to important
cyclical dynamics inherent in the emergence of new technology-based serv-
ice systems. Of course, further research needs to validate and refine the pro-
posed framework (figure 1) in other settings. Explorations of how organiza-
tions can make use of new technologies (e.g. digital and nanotechnologies)
to provide new services in complex settings such as health care are particu-
larly warranted. Such innovations indeed occur in interfirm modularity set-
tings (Staudenmeyer et al., 2005) where it is difficult for a single actor to
develop all parts of the final offering as this requires deep insight in 1) what
is technologically feasible as well as insight in 2) the specific service deliv-
ery processes in question. Longitudinal studies, using multiple cases, cover-
ing various actors (not only the service provider but also technology vendors
etc) and combining qualitative and quantitative data generation methods
would benefit the further development of the framework suggested here.
Also, this paper studied the early stage of a single service innovation proc-
ess. Research focusing on later phases in such emergent processes would
further our understanding of how new services are legitimized and actually
become available to consumers. Paying attention to the differences between
private and public actors in this context is relevant. In general, the purpose of
this explorative study was to begin to outline a new direction in new service
development research, one that goes beyond the interest of providing man-
agers with unrealistic recipes for how to create optimal innovation processes,
but instead takes on a multilevel analysis and considers the influence of
forces at individual as well as societal level to describe how new services
actually come to be. Complexity theory (cf. McKelvey, 1999) provides op-
portunities for learning more about how new services can emerge in this
context. The service innovation literature would benefit from this theory
being applied to elucidate how single events at micro level can trigger
changes at macro levels, leading to the emergence of new orders and para-
digm shifts in the services industry, i.e. multilevel analysis (Chiles et al.,
2004).

127
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132
4. The Two Facets of Electronic Care
Surveillance: Exploring the Elderly
Caretaker’s View 27

Abstract:
Scholars are increasingly questioning the notion that electronic surveillance
merely constrains individuals’ liberty and privacy. However, illustrations of
alternative perspectives are few and there is a need for empirical research
exploring the actual experience of surveilled subjects. This study, carried out
in Sweden, seeks to offer a nuanced account of how elderly caretakers expe-
rience electronic care surveillance in relation to their privacy. It is based on
in-depth interviews with 17 seniors who have participated in a telemonitor-
ing project and who have experience of being continuously activity moni-
tored in their own homes. The findings suggest that elderly caretakers can
perceive electronic care surveillance as freeing and as protecting their pri-
vacy, as it enables them to continue living in their own home rather than
moving to a nursing home. One individual however experienced a privacy
violation and the surveillance service was interrupted at her request. This
illustrates the importance of built-in possibilities for subjects to exit such
services. In general, the study highlights that e-surveillance can be not only
constraining but also enabling. Hence, it supports the view of the dual nature
of surveillance. The study also illustrates the agency of the surveilled sub-
ject, extending the argument that various agents actually participate in the
construction of surveillance practices. It analyzes the indirect role and re-
sponsibility of the surveilled subject, and thereby questions the traditional
roles ascribed to the agents and targets of surveillance.

Introduction
Academics have worried about the threats to privacy associated with elec-
tronic surveillance (e-surveillance) for decades (e.g. Davies, 1992; Flaherty,
1989; Floridi, 2006; Garson, 1988; Goodwin, 1991; Lyon, 2001; 2002; Lyon
27
This paper is published in Social Science & Medicine. 2008. Vol 67/1 pp 128-136.

133
& Zureik, 1996; Mason, 1986; Ogura, 2006; Parenti, 2001; Solove, 2006;
Weckert, 2001). However, as noted by a large number of scholars (e.g.
Wood, 2003; Lyon, 2006; 2007; Haggerty, 2006; Haggerty and Ericson,
2000; Hier, 2003; Rössler, 2005; Solove, 2001; Vaz & Bruno, 2003), the
extant surveillance literature is overly dominated by the Big Brother (Orwell,
1949) and Panopticon metaphors (Bentham, 1969; Foucault, 1977), which
inspire one-sided and dystopic views on surveillance. To paraphrase Lianos
(2003), contemporary e-surveillance studies routinely refer to the erosion of
privacy and liberties by sinister and totalitarian forces, which “is damaging
as it is superficial and analytically unfounded, and it pre-empts the feelings
and opinions of the public, usually with great inaccuracy” (Lianos, 2003:
414). Similarly, Haggerty and Ericson (2000) argue that “far from the nega-
tive connotations that tend to be attached to surveillance, many surveillance
practices today are not only supported but encouraged by those who serve as
the primary targets of data gathering systems” (pp. 401). Indeed, the wide-
spread assumption in the surveillance literature that subjects are surveilled
against their will is now being questioned (Lyon, 2007; Pecora, 2002). Few
studies have actually explored the experience of surveilled subjects (Hag-
gerty, 2006; Lyon, 2006). In general, the contemporary surveillance litera-
ture tends to analyze surveillance technology in isolation, as given and as
inevitably producing certain effects in a predictable fashion (Ball, 2002;
Haggerty and Ericson 2000; Hier, 2003; Haggerty, 2006). It therefore fails to
give balanced accounts of how users interact with surveillance technologies
in practice.
Recently, studies taking the locality and particularity of e-surveillance ap-
plications and the agency of surveilled subjects into account have however
emerged (Dubbeld, 2006; Koskela, 2006; Fotel & Thomsen, 2004). Drawing
on insights from the field of science and technology (e.g. Latour, 1987; Bi-
jker, Hughes & Pinch, 1989), these studies highlight that the operation of
surveillance technology is by no means given, but rather contingent on the
user-context. It is also argued that e-surveillance should not only be under-
stood as constraining but also as enabling (Bogard, 2006; Lyon, 2007).
These insights have however not been used to explore the relation between
e-surveillance and privacy. In general, this perspective is underdeveloped
and more research is asked for, in particular as regards the view of the sur-
veilled subject (e.g. Lyon, 2006; 2007).
Given these weaknesses in the surveillance literature, the present paper at-
tempts to provide a nuanced account of individual subjects’ experience of
electronic care surveillance in relation to their privacy. Care surveillance has
received little attention in the surveillance literature (Lyon, 2001; 2006;
2007; Vaz & Bruno, 2003; Dubbeld, 2006; Wood, 2003). As noted by Vaz &
Bruno (2003), this neglect may partly be due to the challenge related to
studying e-care surveillance in a critical fashion. Surveillance and control are
integral parts of care and it is difficult to separate these elements. Neverthe-

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less, electronic care surveillance technologies such as in-home telemonitor-
ing are emerging and authors have underlined the pertinence of taking the
issue of privacy into account when evaluating such technologies (Bauer,
2002; Hensel, Demiris & Courtney, 2006; Von Tigerstrom, 2000). Respond-
ing to these calls, the paper uses empirical data from the Swedish elderly
care setting, exploring how care takers perceive that being continuously ac-
tivity monitored in their own home affects their privacy. As this is a fairly
unexplored area, the paper also asks more broadly how we can understand e-
surveillance and privacy in this context.
The findings highlight that electronic care surveillance can be perceived
as enabling by surveilled subjects. The majority of the seniors in this study
feel that electronic care surveillance can indirectly protect their privacy by
enabling them to continue living in their own homes rather than moving to a
nursing home. In general, care surveillance makes the majority of the seniors
interviewed feel cared for and safe rather than constrained. What makes
them feel safe is however the fact that certain familiar care workers watch
over them. The technology merely becomes a link between themselves and
the care workers. The study also highlights the importance of built-in possi-
bilities for subjects to exit from the service. One individual experienced a
privacy violation and felt constrained when monitored. The surveillance
service was interrupted at her request.
The article begins with a definition of privacy. Next, widespread assump-
tions in the surveillance literature are problematized in relation to care sur-
veillance and privacy. Alternative perspectives are outlined. Findings from
the in-depth interviews with 17 seniors follow. The article ends with discus-
sion, conclusions, implications and limitations, which suggest further re-
search avenues.

Defining privacy28
Warren & Brandeis (1890) defined privacy as the right to be let alone. This
definition has since been extended and includes various multi-dimensional
conceptualizations (cf. e.g. Altman, 1976; DeCew, 1997; Gavison, 1995;
Inness, 1992; Westin, 1967). Rössler (2005) recently provided a comprehen-
sive definition, outlining three interrelated aspects of “the private sphere”: 1)
Informational privacy (protection against unwanted access to personal in-
formation about us); 2) Decisional privacy (protection against unwanted
interference in our decisions); and 3) Local (physical) privacy (protection
against the unwanted admission of other people to personal spaces or areas).

28
There has been a debate regarding whether or not a “right to privacy” exists and even if
there is a unified concept of privacy (cf. Friedlander, 1982; Schoeman, 1984).

135
 Empirical studies of patients’ perception of privacy focus on hospital or
nursing home settings (e.g. Damschroder, Pritts, Neblo, Kalarickal, Creswell
& Hayward, 2007; Parrott, Burgoon, Burgoon & LePoire, 1989). This litera-
ture suggests that hospital patients experience a loss of privacy when they
cannot withdraw or find a personal, private space, e.g. when they have to
share room with other patients (Barron, 1990; Marini, 1999; Mattiasson &
Hemberg, 1998; Woogara, 2005). What also emerges from this literature is
that patients experience privacy violations if they have to witness other pa-
tients’ problems (Sidenvall, Fjellstrom & Ek, 1994). This aspect of privacy,
which has been neglected in the surveillance literature, is in this paper re-
ferred to as freedom from observing and reacting to others.
What emerges from the privacy and care literature is that patients primar-
ily desire privacy in relation to other patients rather than in relation to care
professionals. It seems reasonable to assume that patients are relatively in-
clined to willingly disclose personal, health-related information to care per-
sonnel if they believe that this is relevant for the care services to be pro-
vided. I will return to this point below.

Care surveillance as a potential privacy harm

As noted above, much of the surveillance literature builds on the concept of
the panopticon society (Bentham 1969; Foucault, 1977; Boyne 2000), sug-
gesting that e- surveillance can violate individuals’ privacy by intruding on
their informational and decisional privacy (e.g. Gandy, 1993; Lyon &
Zureik, 1996; Floridi, 2006; Michelfelder, 2001; Nagel, 1998; Rössler, 2005;
Solove, 2006; Udo, 2001). It is argued that the harm of surveillance is that, if
unsure about whether one is watched or not, one must constantly present
oneself as though one were being observed. The result is inhibition and self-
censorship, i.e. a loss of autonomy in terms of the authenticity of one’s be-
havior, which is turned into behavior “as if”.
This view provides significant insights. However, it highlights certain as-
pects of surveillance while ignoring others. Importantly, studies bringing this
view of surveillance to the fore build on certain presumptions. For one, elites
with malign intentions to discipline and exert social control are the assumed
agents of surveillance. Second, the intention to control is understood as an
ambition to constrain the behavior of the targets of surveillance. Third, the
targets of surveillance are depicted as passive victims. And fourth, the sur-
veillance technology itself is viewed as the source of negative effects (cf
Bogard, 2006; Dubbeld, 2006; Haggerty, 2006; Lyon, 2007). I will argue
below that these four assumptions are not easily generalized to the care sur-
veillance setting.
What makes care surveillance a complex subject of study is the inter-
twined relation between control and care (Dubbeld, 2006; Lyon, 2006; Vaz

136
& Bruno, 2003). The work of Lianos (2003) can provide some clarification
here. Lianos (2003) highlights that institutional control is integral to specific
surveillance activities, but that “It would be reductive and unjustified to see
such activities as relating exclusively or principally to control”. He gives an
example: “One could look at a CCTV system which monitors the traffic on a
road network; is this dispositif about repressive surveillance (traffic of-
fences), detective surveillance (stolen vehicles)…accident prevention or the
improvement of access times for emergency services…?” (pp. 415). He an-
swers that the system is about everything at once. This is indeed applicable
to the care surveillance setting. The intention behind care surveillance in-
cludes but cannot be reduced to a malign ambition to control (cf Lyon,
2007). In this respect, the general definitions of e-surveillance do not quite
capture the meaning of care surveillance. E-surveillance is often referred to
as the systematic observation and recording of acts of compliance and devi-
ance in order to manage or influence behaviors by means of information
technology (Clarke, 1988; Lyon, 2001). Dictionaries further define surveil-
lance as: “to watch over; supervision or superintendence; close observation
of a person or group… especially one under suspicion e.g. a prisoner, or the
like (usually by the police)” (dictionary.com 2007). While the first definition
says little about the intention behind surveillance, the latter highlights that
surveillance is associated with observation of “suspected” individuals and is
understood as something that is done for the sake of others rather than the
surveilled.
Can we not watch over others because we care about them, then? Of
course, we can suggest this is so (cf. Lyon, 2007). Consider the meaning of
care: dictionary definitions of care include: “Watchful oversight; charge or
supervision; to be concerned; have thought or regard; to make provision or
look out for someone in need…providing treatment for or attending to; have
a special preference for; to have inclination, liking, fondness or affection
for…” (dictionary.com, 2007). Major caring constructs in the nursing litera-
ture are compassion, empathy, nurturance, succorance, comfort and support
(Cloyes, 2002; Jecker & Self, 1991; Kreuter, 1957; Lavoie, De Koninck, &
Blondeau, 2006; Leininger, 1977). Hence, care is, just like any type of sur-
veillance, associated with supervision and “watching over”. However, care
also refers to the concern about and feelings directed to a person - a person
in need. An act of care is generally thought of as performed “for one’s own
sake”, i.e. to maintain or improve the surveilled subjects’ health or safety.
Hence, in studies of care surveillance it is important to consider that care
surveillance includes but cannot be reduced to an ambition to control. It can
also incorporate an intention to maintain or improve the patients’ health.
Let us return to Lianos (2003): he also maintains that institutional control
is often perceived as beneficial “and sometimes even liberating as much as
constraining” (pp. 415). Others have recognized the dual function of surveil-
lance (Lyon 1994, 2001, cf. Giddens, 1984). For example, Bogard (2006)

137
refers to surveillance both as capture (fixing a flow, surveillance as determi-
nation) and as flight (releasing a flow, surveillance as resistance). Bogard
(2006) argues that to surveil means to guard and he writes: “guardianship is
not a simple constraint, but an art of control that makes it safe for something
to move freely…” (Bogard, 2006: 98). From this view, surveillance practices
can in a sense be viewed as freeing. Drawing on these arguments, this paper
assumes that care surveillance can be perceived as both enabling and con-
straining from the viewpoint of individuals.
Finally, the surveillance literature tends to discuss the effects of surveil-
lance technologies without considering that the consequences of a certain
technology are by no means given (Ball, 2002; Dubbeld, 2006). The present
paper assumes that while a certain technology facilitates certain behaviours
and impedes others, there are also opportunities for people to choose how to
use and not use the technology (Berg, 1997; Bijker et al. 1989; Latour, 1987;
Oudshoorn & Pinch, 2003). This perspective makes clear that users are not
necessarily victims passively subjugated to technological domination or dis-
ciplinary surveillance. It allows for a consideration of the potential resistance
from users (Ball, 2002; 2006; Dubbeld, 2006; Wood, 2003).
In summary, scholars have begun to suggest alternatives to the dystopic
and deterministic principles traditionally applied in the surveillance litera-
ture. There are however no empirical studies illustrating how these principles
work in relation to privacy, in actual empirical settings and from the perspec-
tive of the surveilled subject.
This paper seeks to address this gap in the literature by exploring indi-
viduals’ experience of being surveilled in relation to their sense of privacy.
Privacy is here defined as 1) the freedom to escape being observed or ac-
cessed when desired. This implies protection from unwanted access to per-
sonal information about us, i.e. informational privacy; unwanted interference
in our decisions, i.e. decisional privacy; and unwanted admission of others to
personal spaces or areas, i.e. local/physical privacy (Rössler, 2005). Privacy
also refers to 2) the freedom to escape observing and reacting to others (Si-
denvall, Fjellstrom & Ek, 1994). The question of concern is: how do indi-
viduals experience care surveillance as enabling and/or constraining in rela-
tion to their privacy? The premise is that a surveillance technology needs to
be understood in relation to how it is used and not used in the actual context,
i.e. how the care surveillance practice is constructed. The surveilled subjects
are viewed as participating in this construction.

Method
The purpose of this paper is to understand not only if, but also why seniors
feel that electronic care surveillance (telemonitoring) does or does not vio-
late their privacy. The paper further attempts to illicit not only expected, but

138
also unexpected, privacy issues arising from the viewpoint of elderly indi-
viduals. Hence, an open-ended, in-depth interview approach was deemed
appropriate. As noted by McRobb & Rogerson (2004), quantitative instru-
ments may be too blunt and may obscure more than they reveal, as our un-
derstanding of consumers’ privacy conceptions is as yet limited.
Research setting. In 2006, a public long-term care provider in the munici-
pality of Heby, Sweden, decided to introduce a new telemonitoring service
in their community. The new e-service was seen as a potential replacement
to traditional manual alarms that were currently in use. The monitoring serv-
ice requires that the user wear a monitoring device on the wrist. Sensors
embedded in the monitoring device continuously collect “activity data”
about the user. This data is transmitted to the care center. Care personnel can
access the data, which is presented in graphical format as activity curves on
a computer screen. The activity curves provide information about the user’s
sleeping patterns (e.g. how many sleeping interruptions and sleeping periods
per day and night, how many times the user gets out of bed during the night),
when the user leaves the house and takes off the wrist worn unit, among
other things. The activity curves can be analyzed over time in order to detect
changing activity patterns, which can indicate emerging health problems.
During the first two days of use, the monitoring system registers each user’s
“normal” activity pattern. Thereafter, automatic alarms are generated when
the sensors detect that the user’s activity diverges from her/his normal pat-
tern, e.g. in cases where the activity level is unusually low due to the senior
having fallen and turned unconscious. Users can also activate alarms manu-
ally by pushing a button on the device, just like with “traditional” pendant
safety alarms. The alarms are also transmitted to the care center. The Heby
managers decided to provide the new service to 20 seniors, as a first step,
before expanding the use of the new monitoring technology. Two social
workers recruited 20 seniors that were: 1) living alone in their own home; 2)
vulnerable and exposed to health risks in their home and therefore provided
with manual safety alarms; 3) capable of being interviewed. 3 of the seniors
could not use the devices due to allergies etc. The seniors were informed
about the monitoring service via letters and were given the opportunity to
ask further questions in follow up telephone calls. They were told that that
their activity level would be monitored, that automatic alarms could be trig-
gered if there would be a radical change in activity level and that this was
performed to ensure their safety.
It’s worth noting that the personnel did not see any radical health-
problems on basis of the surveillance data during the study period, but rather
that the seniors were sometimes not wearing their alarms and that they were
not sleeping well. The personnel were “discrete” when acting on this kind of
information. They did not say “we have seen on the data that you did not
sleep well” for example. They tried to embed questions and reminders, e.g.
about to wear alarms in their regular conversations with the seniors.

139
 Data generation. This study is based on in depth interviews with 17 of the
seniors (68-96 years old, 9 female and 8 male) that accepted the use of the
monitoring service. This purposeful sampling strategy can be called extreme
case sampling, i.e. selecting cases that are information rich because they are
special in some way (Alvesson & Sköldberg, 1994). At the time of the inter-
views (September 2006), the 17 seniors had been monitored for 6-7 months.
The seniors were somewhat familiar with the interviewer (author) who had
visited all the seniors to perform interviews once before, and who had chat-
ted with the seniors at least twice on the phone. The interviews lasted 90-120
minutes, were performed face-to-face and within the homes of the seniors.
Interviews were very informal, unstructured, including open-ended questions
in order to allow for unexpected issues to emerge (Patton 2004). The inter-
viewer (author) began by asking the seniors how they experienced the new
monitoring alarms, discussing this at a general level for a while before bring-
ing the issue of privacy explicitly to the fore. Interviews typically proceeded
with a discussion about privacy and privacy threats. Other topics were also
covered, as this study is part of a larger research program. Interviews were
recorded, transcribed and translated (Swedish to English) by the author.
Notes were taken on nonverbal cues, such as general appearance, anxiety
etc. (Patton, 2004).
Data analysis. The content analysis was performed in several steps. First,
all transcripts and observational notes were read through to obtain a sense of
the whole. Meaning units, a word, a sentence or a whole paragraph that an-
swered questions of why and how the seniors perceived or did not perceive
privacy violations, were marked. As privacy perceptions are often covert and
expressed “between the lines” (Bates, 1964), the author tried to be sensitive
to observational notes on non-verbal cues. The meaning units were con-
densed into a description of their manifest content and an interpretation of
their latent content. Themes, i.e. threads of meaning running through the
descriptions and interpretations (Baxter, 1991) were abstracted. The tran-
scripts were thereafter compared with the aim of detecting patterns across
participants (Moustakas, 1994). Next, the themes were compared and ana-
lyzed based on the assumptions presented in the theoretical framework.
Hence, a combined inductive and deductive approach was used (Alvesson &
Sköldberg, 1994). In order to improve the credibility of the interpretation,
the author presented the themes to peer scholars at research seminars (Lein-
inger, 1994). The thematization as presented in this paper is a result of an
iterative process of culling the empirical data, modifying the sub-themes and
refining the theoretical framework. The themes are presented below, illumi-
nated by extracts and quotations. The names are pseudonyms.
The Stockholm University Ethics committee gave approval to the study.

140
Empirical findings
The interviews suggested that the seniors had divergent experiences of the
new monitoring alarms. Two contrasting perspectives are presented below.

Care surveillance as enabling – feeling cared for

The majority of the seniors (16 out of 17) expressed positive views about
being surveilled. Interviews suggest that these seniors believe that the moni-
toring service serves their own interest to get help in case of accidents. For
example, Kurt says:

I think it’s great that they do this for us…they must be very expensive, these
new alarms…they told me it would be safer than the old one [which does not
include any monitoring functionality]…so I feel safe. It must be safer; it is
newer so it should be better, more reliable. And I mean, in this way they can
keep a track of me even when they are not here, which is good because I’m
alone here in my house…

Further, Sonja maintains that:

It is good that they know, it is good thing to be surveilled! I mean the more
they know, the better they can understand my problems …I really trust them,
the girls. Very reliable girls…You know, they are like my friends…of course
I want them to see if something is wrong, I might not be able to press the but-
ton and if I am lying on the floor dying …

And Ingrid states that

”…It is a safety thing… you never know when you will fall. When you least
expect it…”

When asked what he would say if his GP would want to access the informa-
tion, Bror says:

Of course he could do that!…I only see him when something is VERY

wrong...and that is not very often so he does not keep much track of me…I’m
glad if he takes the time to think about my condition! But I have to confess
that I am also glad if I don’t have to go to the doctor.

These seniors clearly want care personnel to know as much as possible about
them and they appreciate that the care providers are interested in gathering
data about them; they see it as a privilege. The seniors also appreciate it if
the care personnel exert influence on their behaviour or intervene, on basis
of the surveillance data. For example Lilly explains:

141
 they can see if I wear the new alarm, and that’s good, because I tended to
forget to wear the old alarm. They remind me if they see that I’m not wearing
the new alarm. They do it in a nice way of course… Now I always use the
alarm, and that’s good… …And my children think its great…

The seniors also believed that being surveilled contributes (in combination
with other home-help services) to them being able to stay safely in their own
homes instead of moving to nursing homes. Henning maintains that:

Sometimes I can feel a bit lonely here living alone. I think, what if something
would happen to me? I mean, no one knows what’s going on here. I think
they have bought these things [surveillance devices] for this reason, they
cannot call me every minute, but I guess they can get some information
now…and of course that’s important if I am to remain here in my own house
[as opposed to being moved to a nursing home]. I really hope I can live here
until I die…so that’s good because its nice if someone else knows if I’m OK
or not OK. Of course, my kids call me now and then, but they may not be
lucky enough to call at the right time so to speak

Further, Ulf says:

“I think we need more things like this, like this new thing, so that they can
keep an eye on us at home rather than moving us to nursing homes…”.

Privacy concerns make many of the seniors reluctant to move to a nursing

home. They mention two aspects of privacy in this context. First, they ex-
press a desire for freedom to escape being observed and intruded on by oth-
ers:

It is important that you can go home, leave others when you feel tired…and I
like to do just whatever I feel like… without anyone looking at me… here [in
my own home] I can walk around in my two day old socks sometimes, if they
are not dirty…I try to not wash too often… (Elov).
If I would move to a nursing home they would see me walking up during
the night… …I wouldn’t want to meet anyone when I get up during the night
when I cannot sleep. Maybe they would force me to take sleeping pills then!
(Anna).

Second, the seniors underline the importance of privacy in terms of being

able to escape observing and being close to others. In other words, the sen-
iors are not only concerned about others watching them, but also about
themselves being forced to watch others, illustrated by the following quotes:

I don’t want company by those I don’t know…I wouldn’t like to sit with
other oldies when I eat…I don’t want to see them eat with trembling
hands…listen to their memories…it would make me feel older I think (Len-
nart);

142
 Last time I was hospitalized it really struck me that there is nothing worse
than being forced to watch people that cannot manage themselves. And I had
to sit next to some of them who had really bad breaths due to heavy medica-
tion I believe…[…] …and I like the peace and quiet in my own home…being
by myself is not too bad. I like being by myself too, you see…even if it is
lonely” (Bror).
I don’t want to sit and stare at others sitting in their chairs like
me…meeting people in the mornings in the corridor…hearing them speaking
on the phone with their children…seems crowded…It’s easier to spend the
days here, where I know what to do. Thanks to my daily routines the days
pass rather quickly…” (Bo).

The seniors consider surveillance to be a service that can help them avoid
moving to a nursing home and thereby escape such intrusions.
The seniors who viewed surveillance as a positive service did not mention
any feelings of “being watched” or feeling intruded on due to the monitoring
services spontaneously. When asked specifically if they have ever felt un-
comfortable by being monitored they clearly reject this idea. They seem
surprised at this question. For example, Bror says:

“…I never think about it!…I really don’t…I hardly feel it. I never take it
off…”

Other seniors expressed similar views, illustrated by the following quotes:

“… [giggles]… I never think about it!!! …Actually never…”(Jim);

“…No, I haven’t thought about it at all. I don’t go around reflecting on
what the alarm does…it feels very natural for me to wear it…[…] who cares
if they see when I get up in the night and go to the toilet…they’ve seen me
naked…” (Elov).
“…On the contrary, no! I feel safer now…” (Sonja).

These seniors understand that information about them is collected and trans-
ferred to the care providers. They also know that care providers can see if
they are wearing the alarm or not and that automatic alarms can be triggered.
But none of them completely understand what the sensors monitor, or how
the technology analyses this information. They believe they have received
sufficient information however. Consider Lilly for example. She was obvi-
ously not very knowledgeable about the data collected about her. I started
explaining a bit more in detail how the new technology operates to her. She
seemed very uninterested, even uncomfortable, and says:

“That I do not understand…”.

When I ask Lilly if she wishes she had received more information about how
the technology works, she says no.

143
 “Oh I think I’ve been sufficiently informed. I don’t need to know everything
about that apparatus …that’s their job, the girls…and I trust them so…”.

This is typical. Indeed, the seniors trust the care providers and are happy to
delegate the task of understanding the new technology to them. It is however
important to note that while the seniors know little about the workings of the
technology, they do not feel that they have no control over the service. The
seniors do not feel that the alarms are forced upon them, or that they have no
possibility to exit this service. On the contrary, they feel that they can inter-
rupt the monitoring service at any time, as illustrated by the following
quotes:

I believe I can get my old alarm back any time, sure. I’d just tell them if that
was the case. (Bror).
You bet I could let them have this new alarm back…I think it’s much
more expensive than the old alarm. And it’s modern technology. So I
wouldn’t trade it against the old alarm! (Linnea).

Care surveillance as constraining – feeling as if under suspicion

One of the interviewed seniors, Siv, experienced a privacy violation. Siv
claimed her personal space right from the start. She agreed to meet me when
I called her to book an interview, but with a reluctant tone of voice. When I
arrive, she opens the door with her dog Toy in her arms.

“ You better not touch me, Toy might get mad then”,

she says and smiles nervously. Siv is anxious, and suffers from an apparent
lack of self-esteem. She worries about her health a lot. She is frank about
this:

“I am a very anxious person…always have been…I worry about every-

thing…anything…the smallest things…”.

Siv says—before I have asked—that she wishes to get her old alarm back.

“ I don’t like it, the new alarm. I don’t like being surveilled. I want my old
alarm back…[…]…it doesn’t matter who looks at the information. The fact
that someone can look is enough…”.

Siv explains her dislike with feelings of being observed. She thinks that her
sleeping pattern is sensitive information. She says

“I don’t want people to know when I take a nap…when Toy [her dog] and I
are lazy…that’s only between him and I…they know enough about me. I
want to spare them my strange habits…”

144
It is also clear that being monitored influences Siv’s decisions:

“It hits me, when I lay down late in the mornings that this is moni-
tored…also, at times when I can’t sleep and get up in the middle of the night
I sometimes think that this might be seen…which makes me reluctant to do
so!”

Siv cannot see that the monitoring service adds anything beyond the service
she already receives. The community care personnel deliver food to her at
noon, and conduct a check up visit in the evenings. She says.

They check on me twice a day already, I think this is enough…I mean, it is

different at a hospital, but in my own home I don’t want people to watch me
all the time…It feels a bit strange, this idea, to monitor people in their own
homes. Your home is your own place; they can’t start turning it into a techni-
cality. You have to let people alone in their own homes. No, that’s going too
far.

During my visit, a home-helper came by to give Siv her old alarm back,
which made her happy.

Discussion
This study explored senior care-takers’ experience of being e-surveilled in
relation to their privacy. The majority of the seniors in this study (16 out of
17) have a positive experience of being surveilled. This has to do with how
the care surveillance technology was used and not used in the particular set-
ting studied but also with the specificity of care surveillance. This paper
initially argued that care surveillance includes but cannot be reduced to an
ambition to control. It can also be understood as incorporating an intention to
provide for individuals in need. This view of surveillance resonates with the
view of e-surveillance expressed by the positive seniors in this study. These
seniors are aware of their frailty and they feel that they need to be watched
over in one way or another. Hence, these seniors do not experience any vio-
lation of their information privacy (Rössler, 2005) when monitored because
they do not want to hide the information collected from care personnel. The
seniors further appreciate that care personnel can acquire digital information
about and influence their behavior. They view it as a benefit to be reminded
to behave in certain ways as this can enhance their own safety. In other
words, they do not perceive that e-care surveillance intrudes on their deci-
sional privacy (Rössler, 2005). Interviews make clear that the seniors do
desire to physically withdraw from care personnel. They do not however
perceive any local/physical privacy (Rössler, 2005) invasion due to the
monitoring service as they feel that they are “let alone” (Warren & Brandeis,

145
1890), even if they are electronically monitored. Indeed, the monitoring
service can indirectly protect informational, decisional and local privacy
from the viewpoint of these seniors. It strengthens their possibilities to con-
tinue living in their own homes rather than moving to nursing homes, where
they expect significant threats to their privacy, both in terms of a reduction
in the freedom to escape being observed but also in terms of a declined free-
dom to escape being exposed to information about other caretakers. These
latter points highlight that surveillance can be liberating rather than con-
straining.
In general, these seniors’ reported experience of care surveillance in-
volves the thought of “a friendly eye in the sky” (Solove, 2001) rather than
of a “Big Brother” watching (Orwell, 1949). It is however important to note
that the conceived of “friendly eye” is not anonymous. The seniors rather
think of certain care workers, who deliver other services to them, as being
“the watchers on the other side”. Being surveilled by the care personnel who
they trust makes the seniors feel safe. Indeed, it makes them feel more cared
for. The seniors do not reflect much about the surveillance technology itself,
it withdraws and merely becomes a link between themselves and the care
workers. This suggests that the technological artifact is far from central in
surveillance practices. What is important to consider is rather how the sur-
veillance service is introduced to the subjects in the actual setting. An impor-
tant aspect in this context was the opportunity for seniors to exit the surveil-
lance service. As we discussed above, one of the seniors used this possibility
and opted out of the service. This woman was more concerned about her
public appearance than the others and she had a lower threshold regarding
the amount of data she was willing to disclose to the care personnel. The
possibility that someone may look at the data collected about her, and the
possibility that her data may not look “normal” bothered this woman. In-
deed, e-monitoring intrudes on her informational privacy and it threatens her
decisional privacy (Rössler, 2005) as the fact that she is monitored influ-
ences – or at least crosses her mind when making— decisions about how to
behave. E-surveillance further invades on her local/physical privacy as she
perceived the surveillance service as a physical intrusion in her home. This
woman was however not forced to continue and the monitoring was inter-
rupted at her request. This illustrates that surveilled subjects can exert resis-
tance.
Hence, the widespread assumption that malign intentions lie behind sur-
veillance practices is not quite valid in the care surveillance context. The
care surveillance practice studied here involves control but this is not per-
ceived as constraining by the majority of the surveilled seniors. On the con-
trary, the seniors appreciate the fact that the care providers collect informa-
tion about and intervene in their health. They feel that someone else takes
responsibility for their well-being and this makes them feel free rather than
constrained.

146
Conclusion
This study suggests that care surveillance practices can be constructed in
ways that make the surveilled subjects feel cared for and liberated. It thereby
challenges the widespread deterministic view of e-surveillance as involving
the destruction of privacy and liberty by sinister forces (see further e.g. Hag-
gerty, 2006; Hier et al., 2006; Dubbeld, 2006). The majority of the seniors in
this study viewed care-surveillance as a means to protect their privacy in
terms of freedom to escape being observed and observing others face-to-
face, as they compare being e-surveilled to moving to a nursing home. (cf.
Rössler, 2005; Lyon, 2001; 2002). Hence, the study illustrates the dual side
of surveillance in relation to privacy, arguing that surveillance is not neces-
sarily constraining but can also be enabling (Bogard, 2006; Lyon, 2001;
2006; 2007). It is however important to note that one senior in this study
perceived the care surveillance service as constraining. The experience of
being surveilled is subjective and it should be expected to vary across indi-
viduals. Of importance here is a built in possibility for individuals to exert
resistance.
One could argue that the care surveillance practice studied here involves
an element of seduction (see Bauman, 1992; Hier, 2003; Rössler, 2005). The
majority of the seniors studied here are indeed attracted by the rewards they
associate with being surveilled (individualized care) and rather uncritically
accept the surveillance service. However, describing the subjects as victims
seduced and manipulated by the care providers would be to oversimplify the
situation and would merely reproduce the view of the surveilled subject as
passive and subject to totalizing powers. We can learn more by broadening
the perspective and analyze the surveilled’s indirect participation and re-
sponsibility for the development of surveillance practices of the kind studied
here. As noted above, the seniors studied here wish to age in their own
homes, rather than at institutions. This is partly because of their desire for
privacy in terms of freedom to withdraw physically from others. In general,
citizens’ wish to “age in place” due to the independence and freedom this
entails has contributed to the emergence of various in-home care surveil-
lance technologies (e.g. Barlow & Venables, 2004). These technologies also
emerge as a result of the governmental desire to reduce costs of nursing
homes and the technology-providers’ strive to make profit. Against this
background, the care surveillance practice studied here may be considered as
predicated on and in the service of a certain type of liberty, namely the free-
dom to age in one’s own home and manage everyday life without being con-
stantly intruded on. This suggests that surveillance can cultivate and protect
certain types of freedom desired by care consumers in today’s society (Lyon,
2002; Rose, 1999 cf. Nock, 1993).

147
Limitations
The findings reported here concern elderly care, which is a very specific
setting. Elderly care takers are generally frail and aware of their need to be
“checked on” regularly. The rural Swedish community studied is further
characterized by a low turn over of care personnel and satisfied elderly care
takers. Also, the seniors in this study are grateful for being provided with
new, modern and expensive monitoring alarms and participating in a devel-
opment project. This may lead to overly positive attitudes. There is also the
risk of the elderly seeking to please the home-helpers and the interviewer by
expressing positive views. The author tried to reduce this risk by establishing
a relationship with the seniors and by creating an open and informal atmos-
phere during interviews.

Research suggestions
This study challenges the argument that e-surveillance de-humanizes activi-
ties (e.g. Los, 2006; Ogura, 2006) by showing that care surveillance can
make individuals feel cared for rather than “reduced to digital data”. In the
case studied, e-surveillance complemented rather than substituted face-to-
face visits. More research is warranted about how e-surveillance can be inte-
grated with face-to-face services in order to avoid dehumanizing practices.
While the enabling capacity of e-surveillance deserves more attention in
general, so does its constraining potential. We need critical studies of sur-
veillance practices rooted in good intentions – at what point do they develop
into unacceptable forms of control? This issue is relevant considering the
development toward IT-based preventive health assessment in healthcare
systems internationally. Rising wage costs and reducing costs of technology
will create more instances of e-surveillance. Indeed, Armstrong’s (1995)
argument that we are heading toward “surveillance medicine” is highly per-
tinent. Further, this study highlighted the agency of the surveilled individuals
in terms of their possibility to exit surveillance services. The alternatives
provided to such individuals warrant further research. Will their resistance
imply that they are excluded from certain benefits?
This study further opens up avenues for research problematizing the bor-
der between the targets and agents of e-surveillance. As noted by Lyon
(2007), people today increasingly desire public services that require surveil-
lance. We need to study at multiple levels who initiates e-surveillance prac-
tices?
Finally, this paper highlights that privacy does not only refer to the possi-
bility to limit what others know about us. Privacy also refers to the possibil-
ity to limit what information we are exposed to. Further research about how
this privacy aspect, concerning the information flow from the external envi-

148
ronment to us, operates is relevant considering the vast amount of health
information and advice that is transferred to consumers in today’s society.

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153
5. The corporeality of learning in everyday
practice 29

Authors: Essén, Anna & Yakhlef, Ali.

Abstract
Although it recognizes the practical, spontaneous nature of learning
and knowing the practice-based learning theory remains silent on the
role of the body, overlooking the point that it is the locus of ‘meaning-
ful’ action and ‘knowing’. The present paper seeks to address this
deficiency by suggesting a corporeal approach to learning, drawing on
Merleau-Ponty’s (1962) work. Drawing on interview material elicited
from a group of home care givers, as well as observation notes, we
show the centrality of the workers’ body in understanding and carry-
ing out the practices of providing seniors with care and help. While
the practice-based learning theory still considers reflection as a re-
quirement for learning, our material suggests that reflection can upset
the workers’ skilful action and ‘smooth operation’. The spontaneous
and open nature of their practices does not admit of explicit thinking
and cogitating. Implications of the suggested view for the theory and
practice of learning are drawn.
Keywords
Practices; Learning; Reflection; Body; Non-reflective; Perception; Bodily
skills.

29
This paper has been submitted to the Academy of Management Meeting in Las Vegas,
2008.

154
Introduction
It is increasingly argued that knowledge and learning are the outcome of
social structures and interests (Brown & Duguid, 1991; Gherardi, 1999;
Longino, 2002). The significance of the physical environment, objects and
artifacts in the acquisition of knowledge, dissemination and the codification
of knowledge has also been recognized. Material agency and the role of
‘non-humans’ as sources of knowledge have become common foci in con-
temporary studies (Latour & Woolgar, 1996; Pickering, 1995; Tsoukas,
1996; Hutchins 1996). This emphasis on the role of artifacts represents an
important complement to the view of knowledge and learning as merely
social phenomena. Nevertheless, the focus on “post-human” (e.g. Hayles,
1999) and “distributed” cognitive environments (e.g. Hutchins & Klaussen,
1996; Normann, 1993) in the organization and management literatures has
obscured other ‘human’ aspects of learning such as the role of the body in
the process of learning and acquisition of knowledge.
Although there has recently been, within the area of social sciences, an in-
terest in the role of the body in general (e.g. Howson, 2004; Wolkowitz,
2002; Morgan et al., 2005), in most such studies the body tends to be either
reified as a thing-in-itself or treated as an infinitely malleable phenomenon
which simply reflects social and cultural forces (Shilling, 2005). The recent
‘embodied’ turn in social sciences has tended to produce sociologies about
the body, being mainly concerned with questions of how the body is disci-
plined, dieted, gendered , and abjected (Cregan, 2006; Trethewey, 1999;
Balsamo, 1996; Bordo, 1989; Young, 1990) through different discourses and
forms of institutionalization. This view of the body as an object overlooks
the body’s potential to ‘know’ and ‘act’ in ways that go beyond social rules,
norms and discourses (Bourdieu, 1977; Dreyfus, 1996; Merleay-Ponty,
1962; 1965; 1968; Wacquant, 2005). The body is regarded as the object of
representation, control and knowledge, rather than the source of knowledge
(Bourdieu, 1977) and meaningful ‘action’.
Taking a phenomenological approach, the present study seeks to redress
this imbalance by suggesting a bodily practice-based learning theory in
which the body is treated as a subject (‘body-subject’, as Merleau-Ponty
(1962) calls it). Rather than an object, it is argued that the body (including
the mind) is the locus of all meaningful action and learning and that it is
through our bodily senses that we gain access to the world (Merleau-Ponty,
1962). Learning requires bodily efforts and movement in space – or forms of
embodiment – which also include cognitive efforts. On this count, body and
mind form a body-mind complex whereby the mind is given a body and the
body is given a mind. The link between this body-mind complex and the
practical world is not dis-attached reflection, but spontaneous engagement
with the world, through ‘doing’ things, ‘acting’ and direct experience. Such
doing is only possible through bodily efforts and movements in a specific

155
space and an environment. As an illustration of this approach, we focus on
the elderly care services context to show how care givers acquire knowledge
about, and respond to, the needs of the elderly seniors. We believe that in
this context learning (understood as the acquisition of knowledge) through
the human body is fundamental for accomplishing various care-giving tasks.
Although workers are supplied with instructions as to how to behave with
regard to the seniors, workers are often challenged to spontaneously respond
to emerging situations and to act in a pre-reflexive way, relying more on
their perceptual, bodily skills than on written instructions.
We begin with a discussion of the practice-based learning theory with a
view to showing some weaknesses which are due to its negligence of the
human body. Next we present a phenomenological approach that recognizes
the centrality of the body in learning and knowing. Subsequently, we present
the method, drawing on field work (observations and interviews) to illustrate
some of the proposed ideas. Finally, discussions of the empirical material
and theoretical implications for further studies are drawn.

Practice-Based Learning Theory: A Critique

The recent practice turn in social sciences has captured the interest and
the imagination of organization theorists (Brown and Duguid 1991; Lave
and Wenger 1991; Blackler, 1993; Wenger, 1998; Fox, 2000; Contu and
Willmott, 2003; Roberts, 2006; Handley et al , 2006; Whittington, 2006,
etc). Within this approach, it is increasingly argued that knowledge and
learning are the outcome of social structures and interests, rather than that of
cognitive thinking of individuals (Brown & Duguid, 1991; Gherardi, 1999;
Longino, 2002). However, what the practice-based learning theory (PBLT)
actually does is displace learning from the individual’s mind to what it calls
‘shared social practices’ (Tsoukas, 1996; Ghirardi, 2000), a kind of public,
super-individual, relational, interactional level (Fox, 2000), rather than over-
coming the mind-body dualism to which it initially rightly objects. The bed-
rock assumption of the PBLT is that learning is situated or localized, not in
the mind of the individual, but in the community of practitioners as they
work and innovate (Becker 1953; Brown and Duguid 1991; Lave 1988; Lave
and Wenger 1991; Harding, 1986; Haraway, 1991; Mol 1999; Latour 1987;
Knorr-Cetina, 1981). As an illustration, it is regarded that “the human
agent’s understanding resides, first and foremost, in the practice in which he
[sic] participates. It is shared in rules in such a way as the locus of the
agent’s knowing how to follow a rule is not in his head but in the practice”
(Tsoukas, 1996: 16). Learning is not something that people passively un-
dergo, or have but rather it is “something they do” (Blackler, 1995: 1023)
and can be acquired only through participation in their everyday practices
and activities (Brown and Duguid, 1991; Lave and Wenger, 1991; Nicolini

156
and Meznar, 1995; Elkjaer, 2003; Contu and Willmott, 2003; Roberts, 2006;
Handley et al., 2006). In other words, being in the world is not enough, we
need to do something in the world – rightly or wrongly – in order for us to
learn. As Winograd & Flores (1986: 78) insist, “knowledge and understand-
ing (in both the cognitive and linguistic senses) do not result from formal
operations on mental representations of an objectively existing
worlds…[but] from the individual’s committed participation in …[collective
action that is] embedded in a socially shared background of concerns, action,
and beliefs’”. However, despite this emphasis on participation, reflection
still pervades most theorizing. This reflection, or ‘turning back on ourselves’
(Maturana & Varela, 1998: 24) is assumed to offer a chance to learn how we
learn, to know how we know, and ‘to discover our blindness (pp. 24). It is
further assumed that this reflective learning does not represent any final
stage or end state (Thelen & Smith, 1994), but it offers the capacity of a
continuing refined modesty, perhaps, that may keep us sufficiently aware of
our blind spots. Most often, the reflective mode is articulated in language:
“language is the constitutive and antipoetic social medium through which we
become aware of others and ourselves” (Winograd & Flores 1986 page
number). In a similar fashion, Gherardi and Nicolini (2001: 51) claim that
reflection is necessary for learning because, they assume, it provides ways to
“move learning outcome into the verbal and conscious area, which make[s]
it possible to share with others”. Elkjaer (2003: 48) concurs: “If people want
to learn from their experience, however, they must get them out of the physi-
cal and non-discursive field and turn them into acknowledged and conscious
experience”. By reducing learning to a matter of conscious thinking, it fails
to do justice to the body’s potential to learning.
As a consequence, the practice-based learning is still beholden to the re-
flective mode of being. Reflection militates against our spontaneous bodily
participation in everyday practices. Practices involve the pre-conscious,
automatic mode of operation underlying a community (Bourdieu 1977; Lash
2002). They are related to non-acting and non-thinking entities. Practices are
supra-individual; foregrounding the pre/unconscious (Lash 2002), ruled
more by the habitus, rather than the by intellectus (Bourdieu, 1977). Prac-
tices are the outcome of learning processes through which players know
without knowing the practical sense of doing things—of how things are done
or happen (Bourdieu, 1977). Practices are open-ended, intention-free and
pre-cognitive processes.
The practice-based learning theory is unable to bridge the gap between
‘unthinking’ individuals and their spontaneous practices, or their practical
engagement with the world. Although the body is the medium of practices, it
has been deferred from discussion. Bracketing out the body rests on a mis-
taken assumption that the body is an object of, if not the obstacle to, knowl-
edge and representation, rather that the source of knowledge (Bourdieu,
1977). Merleau-Ponty’s works provide a new connection between body and

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action without falling prey to the mind-body dualism. Merleau-Ponty (1962)
regards the body, including the mind, (through various forms of embodi-
ment) as our access to the world, insisting that ‘consciousness’ is not located
in the mind but in the body. For him, embodiments are a sine qua non for
learning and knowing, and the process of learning is not necessarily a con-
scious one.

The primacy of the perceptual

By making no distinction between the bodily and the perceptual, cogni-
tive, Merleau-Ponty (1962) transcends the Cartesian mind-body dualism:
“It is through the body that we have access to the world. Perception hence
involves the perceiving subject in a situation rather than positioning them as
a spectacular who has somehow abstracted themselves from the situation.
There is an inter-connection of action and perception: “every perceptually
habituality is still a motor habit” (Merleau-Ponty 1962: 53).
To the extent that being-in-the-world involves a lived body engaged in
situated everyday practices, humans are defined in terms of the things they
do in their life-world. However, what they do does not involve unmediated,
bodily activities; rather these activities are mediated through perception,
where perception is not viewed as passive receptivity, but rather as a creative
and skilful capacity that shapes the activities and practices that it accompa-
nies. Such perceptual, bodily activities are referred to by Merleau-Pony
(1962) as embodiments. Embodiment involves bodily efforts (including cog-
nitive ones) exerted with respect to the world. Implied in the notion of em-
bodiment is the idea that cognition necessarily occurs through and within our
bodily structures which are themselves coupled to biological and social con-
texts (Varela, 1991). For instance, “knowledge in the hands is forthcoming
only when bodily effort is made, and cannot be formulated in detachment
from that effort” (Merleau-Ponty 1962: 144). Knowledge is produced when
physical efforts are made by our bodily faculties, such as seeing, hearing,
touching, feeling, smelling, etc. It is only through such embodiments that
individuals come to know their reality (Küpers, 1998: 339).
Embodiment is thus two-fold: it involves physical, perceptual (cognitive)
efforts and a world (consisting of humans and artifacts) that is perceived and
acted upon. However, this world is neither (empirically) given, existing ob-
jectively, nor subjectively constructed by the perceiving subject. For Mer-
leau-Ponty perception is construed to encompass practical action, therefore,
when he talks about the primacy of perception he is also arguing for the pri-
macy of spontaneous, practical action. Perception is responsive accommoda-
tion to circumstances beyond our control (Rouse, 2005: 43). To the extent
that what the body perceives and receives (perceptual receptivity) is only
possible thanks to its accumulated preceding movements and embodiments

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Merleau-Ponty maintains that: “One could also say that the behavior is the
first cause of all stimulations…[and that] it is the organism itself …which
chooses the stimuli in the physical world to which it is sensitive” (1962:
441). What we see and perceive is thus reflected in the shape of the physical
capacities of our body, in the sense that our body conditions what it per-
ceives and does, but it is also conditioned by what is seen and done, for see-
ing presupposes being seen” (Merleau-Ponty, 1962).
The body is the locus of this interactive dialogue between the ‘internal’
and ‘external’. Our consciousness is neither the outcome of private, cogni-
tive processes, nor of objective stimuli imposed on us through sense data
from an external environment. Rather, it is experienced in and through our
body. Things exist for themselves (in a transcendental fashion) because they
resist our knowing them with total certainty; but they exist for us (imman-
ently) because we always experience them in relation to our own body and
the forms of embodiment we have learned. For example, we attend to a chair
in certain ways rather than others, because it allows for certain embodiments
(such as sitting) while disallowing others (such as sleeping comfortably). In
this sense, the chair is both transcendental and immanent and as given to
experience it is an “in-itself-for-me”. It is in this way that Merleau-Ponty
argues that our experiences are inter-connected with the world and the arti-
facts we use. Perceptual experience involves an openness to the world which
is neither given, nor purely spontaneous (Rouse 2005: 44). The stress on the
perceptual is meant to ground practical action in its situation, and to rein-
force the point that “reflection should not feign ignorance of its origin in
perceptual experience”, the point being that the “I can” precedes and condi-
tions the possibility of the “I know” (Merleau-Ponty, 1962: 137). Hence
learning is corporeal in the sense that “A movement is learned when the
body has understood it, that is, when it has incorporated it into its ‘world’,
and to move one’s body is to aim at things through it; it is to allow oneself to
respond to their call, which is made upon it independently of any representa-
tion. Motility, then, is not, as it were, a handmaid of consciousness, trans-
porting the body to that point in space of which we have formed a represen-
tation before-hand” (Merleau-Ponty, 1962: 139).

Purposeful learning but without a conscious purpose

As noted, embodiment presupposes some kind of perception and some
way to act in response to what is presented; in this response we are solicited
or called to transform the presented situation. In this sense, the know-how
acquired is reflected back to us in the solicitations of the situation correlative
with our disposition to respond to them. Merleau-Ponty calls this tendency to
respond to situational solicitations ‘skilful coping’, which he describes as
activities that do not require a mental representation of their goals. This skil-

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ful coping can be purposive without the agent entertaining a purpose. Our
skilful embodiment enables us to respond to circumstances without requiring
an explicitly formulated aim:
“The life of consciousness – cognitive life, the life of desire or perceptual
life – is subtended by an `intentional arc' which projects round about us our
past, our future, our human setting, our physical, ideological and moral situa-
tion, or rather which results in our being situated in all these respects. It is
this intentional arc which brings about the unity of the senses, of intelli-
gence, of sensibility and motility” (Merleau-Ponty, 1962: 136)
As Merleau-Ponty points out, the concept of ‘intentional arc’ implies a
new account of the relation between perception and action. In contrast to
conventional approaches that treat motivation in psychological terms, Mer-
leau-Ponty provides a more primary form of motivation, arguing that once
one has acquired a certain skill one is solicited to act without needing to
have in mind a goal at all. Our everyday skilful coping, our activities are
experienced as a steady flow of skilful activity in response to one’s sense of
the situation. In our skilful coping, when we sense that our situation deviates
from some optimal body-environment relationship, our motion takes us
closer to that optimum and thereby reduces the “tension” resulting from the
deviation. In this context, one's body is simply solicited by the situation to
get into equilibrium with it. The intentional arc throws new light on how the
human agent is led to act, know and learn – merely thanks to the body’s ten-
dency to achieve an equilibrium which is preparatory and temporary, func-
tioning as a springboard for the renewal of neediness, and as a ground for
further exploration (Rouse, 2005: 44).
Dreyfus (1996) says that as our skills are improved and refined to cope
with more and more things and situations, things show up as soliciting our
skilful responses. Hence, as we refine our skills, we encounter more and
more differentiated solicitations to act. Referring to Gibson’s (1979) concept
of ‘affordance’, Dreyfus notes that the “characteristics of the physical (per-
ceptible) world – what affords walking on, squeezing through, reaching, etc
– are correlative with our bodily capacities and acquired skills. Because mail
boxes, for instance, afford mailing letters we do not reflect upon them objec-
tively, but rather we consider them as part of our perceptual and practical
field. In this way, we regularly integrate aspects of the world within our
schema of bodily capacities. It is in this way that the intentional arc is con-
stantly enhanced, without being goal-directed.
For instance, when using equipment, tools typically are assimilated into
our capacities for movement or physical functions. However, as Rouse
(2005: 45) notices, “although tools can be put aside in a way that bodily
members cannot, the bodily skills acquired in using them become a more
permanent part of a bodily and personal repertoire. I set my bicycle aside
when I arrive at a destination, but I do not set aside my ability to ride or the
expanded mobility that it provides”. We do not relate to tools in terms of

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‘subject’/object’, body/mind, or body/world. Rather, in this inter-connective
way, our embodied skills are acquired through engaging with things and
attending to situations. Our skilful embodiments determine how things and
situations show up for us as requiring and soliciting our response. The more
expert one is, the more one becomes solicited by its environment to respond.
Experts can detect more features of the world and thus are more prompted or
solicited to respond accordingly.
Of course, all this does not mean that we cannot be motivated to learn,
say to play tennis, but what is meant is that as we learn tennis we do not try
consciously to discriminate more and more subtle tennis situations and pair
them with more and more subtle responses (Dreyfus, 1996). Once we get
involved in practicing, the body takes over and does the rest and learning
proceeds outside the range of consciousness. Phenomenologists argue that
the idea of purposive actions without purpose is not confined to brute, physi-
cal activities. Wacquant (2005) quotes Eliasoph (2005: 162) saying “boxing
is not very different from other activities: differences in bodily training
seamlessly slide into differences in emotions and cognition”. Wacquant
(2005) insists that both cognition and emotion are incarnate responses that
engage the trained faculties and proclivities of an indivisible “body-mind
complex”. Even the most “mental” of activities, such as philosophy, mathe-
matics, or playing chess are fully embodied, each in its different way. For,
whether these involve the handling of certain objects or “’intellectual’ activi-
ties such as talking, reading or writing...All these bodily activities then in-
clude also routinized mental and emotional activities which are – on a cer-
tain level – bodily, as well” (Reckwitz, 2002: 251). Thinkers, from many
fields – philosophy, cognitive linguistics, neuroscience, etc – have argued
that thinking itself is a deeply corporeal activity (Ryle, 1949; Merleau-Pony,
1962; Damasio, 1999; Lakoff and Johnson, 1999).
The phenomenological approach adopted in this paper provides an alter-
native to the practice-based learning theory. In these terms, learning is to
take place when our behavior becomes spontaneous and a-theoretical, and
when intuitive responses to an emergent situation replaces reasoning and
thinking. The limitation of the practice-based learning theory lies mainly in
its conception of learning as a thought process, being biased towards the
logic of the ‘I think’, rather than that of the ‘I can’. From this phenomenol-
ogical perspective, even the logic of the ‘I think’ is itself embodied and
structured by what our body ‘can’. By dint of exercise, the body comes to
coordinate a large range of muscular activities in an increasingly automatic
way, until awareness retreats and recedes to the background. Similarly, in
the use of equipment, tools typically become part of our integrated capacities
for movement and practical skills. Because our practical, bodily skills are
petrified in bodily habits, they become elusive to intellection and impervious
to conscious transformation. Consequently, they have the power to define
the boundaries within which conscious thought occurs (Hayles, 1999: 205)

161
and the way social rules and norms are conceived and enacted (Wacquant,
2005). Hence, rather than the social shaping our conceptions of what we do
and learn; it is the body that does all these.
In light of this phenomenological approach we want to illustrate that
knowing and learning takes place through the human body in tandem with
the artifacts that extend its corporeal capacities. In their skillful coping with
their daily activities, workers providing health care services to elderly citi-
zens use their bodies to understand and make sense of the situational re-
quirements in routinized, non-reflective ways. In line with Dreyfus (1996),
we will show that although workers are equipped with minute instructions as
to how to go about delivering their services, learning and knowledge their
tasks presuppose that they forget those instructions and instead, behave ac-
cording to the emergent circumstance and situational affordances they are
presented with in a spontaneous way.

Method
This paper is based on a field study of care workers in two Swedish
communities. Data was gathered during 2003-2007. Getting access to care
workers’ behavior, including their pre-reflective bodily activities and gradual
learning is difficult. Observations, in-depth interviews and the study of
documentation (written rules and laws about public care service delivery)
were used in this study. Observations and informal conversations perhaps
gave us the most valuable access to the workers’ perceptions of their prac-
tices, in actual situations (Denzin & Lincoln, 2000). The observational notes
provided particularly an important grasp of our informants’ embodiment and
the use of various senses in exercising their tasks.

Data generation
The first series of interviews took place in 2003, with 20 front-line em-
ployees (home-helpers) in community A. The duration of interviews ranged
from 60 to 90 minutes. The topics of the interviews revolved around every-
day home-help delivery services, focusing on how the home-helpers under-
stand and respond to the seniors’ needs. Although the interviewing research-
ers/authors employed an interview guide, they tried to let the interviewees
determine, to a large extent, the direction and flow of the conversation (Oak-
ley, 1981). The limited coverage of the written instructions soon became
clear. Workers spoke of the need to constantly adjust to the situation in ways
difficult to articulate, when delivering services. To further understand the
workers’ adjustment to each senior requirements and situation, one of the
researchers (the interviewer) accompanied three different home-helpers
when they visited senior households. Observations were performed on 6

162
occasions, lasting 4 hours each. Observation notes were taken immediately
after in-home visits and refined in the evening (Bernard, 1998). Follow-up
conversations conducted between each visit, while walking or driving from
one household to the next. Notes were audio-recorded and later transcribed,
thereby providing a valuable source of information. In particular, it allowed
us to probe into the workers’ practices and behaviors. For instance, the con-
versation showed that the workers were not often aware of many of their
daily activities, since these are carried out in a spontaneous way.
A second series of interviews (10 interviews) with, and observations (8
hours in total) of, front-line workers employed in community B were per-
formed in 2005, using similar approaches as during the first set. These inter-
views were more focused on learning and the mode in which tasks were
executed. Follow-up phone calls (n=5) were conducted to clarify issues that
were not clear enough for us.
The participants were all front-line service employees, aged between 19
and 50 years, with an experience ranging between 5 months to 30 years. The
majority (19 out of 30) of the participants, however, had a long experience
(more than five years). To protect the participants’ anonymity, their names
are not cited.

Mode of analysis
For our present purposes, content analysis was performed in several
stages (Mason, 2002). In stage one, verbatim transcripts from formal inter-
views and notes from observations and informal conversations were read
through to obtain a sense of the whole. Themes, i.e. threads of meaning run-
ning through the descriptions (Mason, 2002) were abstracted. We analyzed
the material for emergent themes that suggested how the workers use their
bodily skills in performing their daily tasks (Creswell, 2003; Denzin & Lin-
coln, 2000). This iterative process was continued until data saturation was
reached and no new themes were identified (Glaser & Strauss, 1967; Morse,
1994). The identified themes included workers’ increasing reliance on their
bodily senses rather than formal instructions as they gained experience, and
their body perceiving opportunities for action (rather than passively receiv-
ing data about the environment). Data analysis subsequently became an it-
erative process. We went back to the literature to help sensitize us to the
potential meanings of the themes our material pointed at. We developed a
preliminary coding framework, which evolved as we continued to discuss
the field notes. In this way, this interpretive process was emergent rather
than prefigured and set up in advance (Creswell, 2003).

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Findings

The centrality of the body in learning how to perform daily tasks

As noted above, a number of themes has emerged from the interview
material and observation notes with regard to how care givers perform
their practices of care giving. Most prominently, these home-helpers
use their perceptual, bodily skills to spontaneously respond to emerg-
ing circumstances, without reflecting about what they do although
they were provided with written and/or verbal instructions to guide
their responses to the needs of the seniors. There are individual service
plans that specify what services workers are to execute and how. One
such service plan document looks like this:

“…Name: Aina […]. Condition/Need: Chronic Obstructive Pulmonary Dis-

ease, is anxious […]. Granted service: Daily: Help with getting up from bed,
getting dressed, hygiene, making the bed, preparing breakfast, at 8.30 a.m. 20
minutes. Food delivery at 12.30. Help with preparing meal, 16.30. 15 min-
utes. Help with getting undressed, hygiene, go to bed. at 22.00. 15 minutes.
Once a week: Help with shower 30 minutes …” (Service plan document).

New care workers further receive verbally advice and tips from more experi-
enced workers as regards how to deliver the specified care services. How-
ever, interviews suggest that much of the knowledge used in care work is
difficult to learn by reading or following formal verbal instructions. New-
comers always walk beside and watch an experienced worker before going
out on their own. However, watching is not enough. Interviewees maintain
that to learn care work, one needs to actually perform the tasks oneself, using
one’s own body. For example, Eva talks about this process:

“… although I had listened to Sanna’s [experienced worker] advice and I had

watched how she showered Edith, I felt far from sure about how to do it.
Sure, I had watched her several times and I mean, I knew that by heart. Still,
it was quite a different thing to do it myself. Now, I’ve had to find my way of
doing it. I do what Sanna does basically, but I’m sure I do it differently than
she does…. […]… Now I do not think of the advice or the service plan, I just
work my way through it …” (Eva).
The interviewed care workers talked about how they, when they
were new and inexperienced, explicitly concentrated on directing their

164
body to responding to seniors’ needs, but gradually and through prac-
tice, that conscious effort has disappeared:

“…Sure, helping seniors shift side in bed or get out of bed requires certain
bodily technique. When two of us [home-helpers] are required, we need to
coordinate our efforts. It is hard to explain how you learn this... Rita taught
me a lot of things about this…in the beginning she used to tell me to use my
left arm to do that and to bend my knees to get more strength…and she used
to keep reminding me not to be to concentrated while doing that...and so
on… I had a hard time being friendly at the same time as concentrating on
getting the moves right… Now I can do that. I don’t need to think about my
moves at all. I just respond to seniors’ moves and adjust accordingly. Indeed,
I usually see immediately if they don’t like what I’m doing. But I can talk to
the seniors while doing this, and I can talk to Rita about other things. I don’t
need to concentrate in the same way as in the beginning…” (Helena).

“…I remember when I was new...I felt so clumsy… every single move was a
major and challenging decision... It was like, Should I pat her hand now? Or
will she find that offensive? Should I ask her how she is? Can I leave her al-
ready? Can I interrupt her now? And I was so self-conscious, thinking about
how I looked or seemed, how my voice sounded weird… and I had sweaty
hands and thought that seniors would notice this…Now, I seldom think about
myself, I think about the senior instead, if she or he has problems or
so…[…]…I guess I trust my intuition, I usually feel how to move around in
the seniors’ houses. Actually, if I start thinking too much about how I behave,
things tend to get difficult…” (Eva).

Hence, the interviewees even suggest that reflective thinking can impede the
workers’ spontaneous responses, as it interferes with their body’s ability to
take care of things ‘itself’, in a pre-reflective manner.
This form of learning is improved as the home-helpers meet and re-
spond (using their body) to more and more nuanced situational re-
quirements. Furthermore, this learning requires increased ability to
perceive, recognize and select more features sophisticated features of
a situation, as they interact with the seniors:

“…Now I kind of know of know how hot the water should be. In the begin-
ning, when she [a senior helped in the shower] said, could you turn the hot
water on? I had NO clue how hot it should be ….So when I did that, she said
aaoch that is too hot!!! Which was embarrassing…now I know her prefer-
ence, and I can feel when the water is warm or cold for her…or at least, I no-
tice when she thinks it is too hot, as I make sense of her facial expressions…
in that way, I avoid her outbursts…which is a relief, it makes it so much eas-
ier…I don’t have to ask her …because you learn to know these things auto-

165
 matically when you get to know the senior and when you’ve done it a few
times…” (Jessica).

It seems that bodily learning in this context occurs without the care workers’
entertaining motivation or conscious intention. The workers cannot account
for any explicit strategy regarding how they try to make their body discrimi-
nate between more subtle events. But as their body accumulates knowledge
about how to interact with the seniors, i.e. incorporates more ‘moves’ into its
body schema, it also seems to perceive more refined ‘calls’ to intervene in a
given situation. Action and perception are closely interlinked. Indeed, the
empirical material suggests that experienced home-helpers do not passively
perceive sensory facts that they interpret and then transform into intentions
about how to intervene or act. They rather selectively perceive problems or
opportunities for action. To know in this context presupposes a bodily ability
to perceive a situational call to interfere and skillfully respond to that call so
as to redress the emerging tension between the body and the situation. For
instance, olfactory, sonorous and tactile elements experienced during previ-
ous visits are stored in the body of the experienced workers without making
conscious efforts to learn them and remember. Observations suggest that
their bodies open up to relevant information without the workers explicitly
instructing their body about what senses to use and what not to sense. For
example, Hannah explains how nowadays (as opposed to when she was
completely new), her bodily senses are activated and drawn to different as-
pects depending on the situation while visiting the seniors:

“…for instance, sometimes I sense an unusual smell when I open the

door…At other times, I may hear from the pitch of the seniors’ voice,
whether they sound unusually weak or start mumbling…Kurt, I usually touch
his hand at one time or another when I visit him, I remember recently, his
hand was colder than usual when I patted him. This was an indicator …”
(Hannah).

I ask Hannah whether she “plans” in advance what she would do every time
she calls on the seniors and her answer was negative:

“…I just do it. It is not like I first think that I’ve got to smell if something
smells strange…then I have to go and pat her hand and feel if it is unusually
cold…if I smell something strange smell I think my attention is drawn to this
and I continue to smell and try to understand what it is…” (Hannah).
Further, Joni talks about what she actually does when performing
her so called “check up” visits at seniors’ houses:

“…I simply see whether everything is OK…I really can’t say exactly what I
check, it depends! […]…this work is really about knowing the senior. […]…
I mean, I don’t try to figure out whether Kurt is weak; I know he is always

166
 weak. I try to find out if he is unusually weak…you have to know what is
‘normal’ for each senior… It’s very difficult to explain, I usually feel intui-
tively whether something is wrong… For example, Ingrid is extremely tidy,
and I may ask her if everything is OK if I notice that her kitchen is not as tidy
as usual…[…]…you know, there may be signs here and there…indicating
that something is wrong…”(Joni).

In this case, Joni does not consciously direct her vision to focus on the
kitchen she is just led to the kitchen ‘automatically’, relying on pertinent
clues in the home of the senior. There is no in-advance plan to be followed
or an intention behind each move the home-helpers make. For instance, from
our observation notes, it was possible to notice how the workers’ bodies do
not passively receive sensory data from the situations, but rather they selec-
tively and creatively perceive object attributes depending on their bodily
skills. For example, I joined Hanna one day and observed her while working.
I noted that the senior’s garden was in need of tidying and watering, so I
asked Hanna if she noted this.

“Was it? Well, no… of course, I don’t pay attention to everything…I don’t
even see if the senior has a computer break-down, that’s not my responsibil-
ity…I note problems that I can do something about…“ (Hanna).

Again, perception is a matter of creating meaning and a matter of perceiving

opportunities for action that one has the bodily skill to act on. The experi-
enced workers’ perception of situational features is hard to separate from
their ability to respond to them. Indeed, their knowledge is manifested in
their ability to respond to solicitations in a pre-conscious way. For example,
accompanying a home-helper who visited a senior named Ruth, I observed
the home-helper move very close to Ruth when talking to her one day but
not the next. I asked Joni about this after the second visit. Her answer sug-
gests that she performs this adjustment unconsciously:

“I did that?...Well…a lot of things, one just does … I guess, as concerns

Ruth, I’ve learned that some days she doesn’t hear well. Its really a day-to-
day thing. I think this is related to how well she has slept…if she has slept
well, she hears much better… So I guess I automatically move closer to her
when I feel that she doesn’t hear when talking to her…I guess…I learned this
as she rarely heard what I told her in the beginning…”

Technological artifacts as extension of bodily skills

The care workers do not only use the body to perform their daily activities.
Their work also relies on equipment and technological artifacts. Technologi-
cal artifacts are used to extend their bodily capacity to perceive more refined
features of the environment. Hence the introduction of new instruments and

167
equipment means that workers need to learn how to use them in the same
way they learn how to develop bodily skills. And in the same way, learning
to use instruments implies a shift away from the reflective to the non-
reflection mode of interaction. For instance, the community we are studying
opted for a new way of improving its services to the seniors by devising an
in-home monitoring system. These wrist-worn monitoring devices, equipped
with wireless sensors, continuously collect information about the seniors’
activity level. The information is captured into graphical activity curves and
transmitted to the care center where it is displayed on a computer screen. For
the care workers, such devices initially posed a challenge. They had to learn
to absorb them into their own bodily capabilities:

“…In the beginning, I thought much about how to move the mouse with my
hand…[…]… I tried to understand the [software] program and the computer.
How does this work?? I had a hard time opening new windows on the screen.
I tried to remember what the technology provider told us about how to use
it…Now, I care less about how it actually works, I don’t need to know
that…” (home-helper).

Gradually, learning to use the technology implied forgetting the existence of

that technology. Indeed, learning here implies increasingly incorporating the
technical capacity into their own body and amplifying their own area of sen-
sitivity to the seniors’ needs, being less preoccupied with looking at the dots
on the screen.
One of the workers, talked about how she was getting to learn to read the
curves without the great amount of efforts and stress she used to have at the
beginning. She does not look the curves in their details in order to make a
diagnosis of the health of the seniors she is watching over. One of the
authors observed home-helper use the instrument. She double-clicked on a
specific activity curve. When asked why, she said

“It [the activity curve] looked strange….It may be difficult to see for you, but
I know that this senior’s curve should not look like this. It signals something
wrong to me”.

Hence, it is almost as though the workers, equipped with the instrument,

were able to ‘feel’ more about the state of the seniors than prior to learning
the use of the instrument. The workers’ way of learning how to use the new
technology also highlights how this involves the acquisition of a skill to
perceive more subtle affordances. For example, the monitoring system cate-
gorizes seniors’ activity levels as within ‘normal’ range or as ‘deviant’,
marking such levels as blue or red respectively. The workers talk about how
they were merely able to discriminate between these two states (nor-
mal/deviant) when using the instrument in the beginning. Their accounts
further suggest that they initially concentrated on looking at each curve in a

168
rather systematic way, trying to understand the system’s diagnosis of each of
the seniors. With practice, they have learned to perceive/attend to the curves
in a more selective way, becoming more and more able to perceive more and
more nuanced solicitations prompting them to act.

“…in the beginning, I reacted when it was indicated on the screen that the
senior’s activity level was ‘divergent’ [the activity curve turns red if this is
the case]…Now, I can see more things. I mean, that categorization is rather
crude, normal or divergent...Now, I see more nuances…like, if a ‘normal’ ac-
tivity curve is actually not normal for a certain senior…I mean, it may be
‘normal’ for some seniors to have divergent levels in periods during which
they are ill… its like, I see when something unusual appears in the
curves…[…]…like, if the senior’s pattern changes over time. I may notice
that a senior starts becoming active a bit earlier than usual in the morning,
even if this is’ within normal limits’. I may try to ask the senior about this be-
tween the lines when visiting him the next time. This is in a way preventive
work, noticing subtle changes before the system categorizes it as’ divergent’
levels…” (home-helper).

Interviews suggest that learning how to use the instrument not only implies
developing a more sophisticated perceptual ability to select more features of
the situation, by using the instrument, but also a less conscious capacity to
respond to the senior’s needs. For example, the technology gathers informa-
tion about whether a senior is wearing an alarm or not (this generates a
straight yellow line on the curve). A home-helper talks about how she has
gradually learned to pre-reflectively use this information as an extension of
her perceptual skill:

“…The system marks this [a senior not wearing the device] as yellow, i.e.
not normal. But it is not always that simple, or black and white. A senior
may take off the device if he is about to take a bath or go to the store – that is
OK of course. When should one react? Now I find it easier to determine
when a senior has been without the alarm for ‘too long’…[…]… I don’t try
to exactly count how many centimeters the yellow line is…but its like, I see
when the yellow line looks ‘too long’. This depends on the senior. But I have
somehow started to grasp for how long it is ‘normal’ for certain seniors to
take it off…Agda never takes it off. Hence, I would automatically react if
Agda’s line would be yellow for a long time. This would be unusual for her.
This is something you learn with time. After a while you see it more intui-
tively. Which makes it easier, and I can go over the curves rather quickly
now…” (home-helper).

Similarly, other workers find it hard to explain how they know when a senior
does wear their alarm for too long. It appears as if their helpers’ body re-
members the graphical appearance of a seniors curve. They don’t explicitly
compare the curves (e.g. their length of passivity in cm), their body seems to
have remembered the pervious ‘look of’ senior’s curves and hence, it auto-
matically reacts when the patterns of curves change. Whether or not this

169
knowledge or information is ‘stored’ in the vision, brain or whole body is
impossible to tell. But it is clear that it is not abstract reflective knowledge.
Rather it, it is knowledge in the body, forthcoming only through bodily ef-
forts. This bodily knowledge (extended capacity gained through using the
instrument) is handy. Indeed, the workers can quickly scan a large number of
curves as they ‘automatically’ see when something is unusual. They don’t
have to concentrate explicitly on looking for deviant patterns. Their percep-
tion guides them to it. Their vision is drawn to the ‘right’ curve.
What was also salient in the empirical material was that when becoming
proficient in using the technology (incorporating it to their body schema),
the workers combined their technology-enhanced perception with their other
‘naked’ perceptual capability in a pre-reflective manner. For example, one of
the authors observed a home-helper scroll down the computer, over-viewing
various activity curves. She stops at one specific senior’s activity curve,
double clicks and then continues. When asked afterwards if she noted some-
thing unusual when analyzing the curves, she asserts that everything was
OK. The researcher reminded her that she stopped at one curve. When
forced to think about it, she says after a while:

“oh that’s right, that was probably Anton’s curve. I visited him earlier today
and he was not feeling well and he had to rest; I reacted as his curve sug-
gested he was very active now! It did not make sense; it felt a bit odd. But
then I remembered that his daughter was to visit him in the evening. So I
went on to the next curve… You automatically relate what you see on the
screen with what you’ve observed during visits of course...” (home-helper).

When having incorporated the instrument, the workers do not merely see
activity curves, their bodily experience of a senior’s overall state comes with
it. That is, they automatically combine their extended, technology-mediated
perception, with their ‘naked’ perception, and can thereby make a proficient
diagnosis of the senior’s need. Thanks to this intelligent but pre-reflective
integration of perceptual capabilities, the care workers’ body can discrimi-
nate more features of the situation.

“...When I look at the curves at the computer display, my attention is drawn

to the sleeping patterns… I try to see how the seniors sleep [when looking at
the curves]…[…]…I think we are inclined to look for sleeping disorders as
there is a lot of fuzz about this today, a lot of articles in regular news pa-
pers…but also advertising in journals for care professionals… We receive a
lot of information from the pharmaceutical companies about the medicine
available for sleeping disorders and related problems like depression and rest-
less legs…so we talk more about this…[…]...some years ago I would simply
have said that elderly people often sleep badly, that it is a natural part of age-
ing…and I would not be interested in knowing exactly how they sleep. But
now there is a point in noticing it…” .

170
Discussions, concluding remarks and implications
As noted above, care workers/home-helpers use their body in under-
standing and carrying out the practices of providing seniors with care
and help. Our empirical material strongly suggests that as the care
workers become knowledgeable, explicit verbal or written instructions
recede to the background (Dreyfus, 1996). As they become more con-
fident and experienced care workers rely much more on their bodily
perception and pre-reflective adjustment when delivering care services
than on formal instructions. The findings even suggest that reflection
can disturb the workers’ skilful action and ‘smooth operation’. It is as
if thinking about how to behave ‘crowds out’ their bodily attention
away from its openness and spontaneous response to the situation.
The care workers’ practices are not guided by conscious thinking, nor are
they just per chance happening. Because they are not informed by predeter-
mined, in-advance rules or specifications, they can be spontaneously open to
new possibilities. Their spontaneous and open nature does not admit of ex-
plicit thinking and cogitating, as the practice-based learning theory tends to
suggest when it makes reflection as a requirement for learning (Gherardi and
Nicolini; Elkajaer). Workers sometimes find it awkward and counter-
productive to follow the rules set up to them by regulators. Each situation
has its own demands.
Rather than taking place through abstract thinking, learning how to help
the senior means that the workers have to deploy and use their bodies in
different ways. It entails an increased perceptual, bodily ability to discrimi-
nate more and more refined features of the situation. This perceptual, bodily
spontaneity is not a passive receptivity, but also a creative responsiveness.
To the extent that practices imply an open space of indeterminacy, the
body’s creative responsiveness is necessary to cope with indefinitely new
challenges and new situations. This perpetual call to rise to emergent chal-
lenges is referred to by Merleau-Ponty (1962) as ‘coping’. . This everyday
‘coping’ can be understood as care workers’ body acting with an implicit
‘intention’ to orient themselves and strike a balance between their body’s
dispositional skills and whatever challenge they confront. Driven by this
primary ‘motivation’, the care workers’ bodies ‘automatically’ make various
efforts to reduce tensions between themselves and the situations they en-
counter. The more perceptual skills they acquire to respond to situations, the

171
more their body accumulates and becomes habitualized to perceive more
refined structures in the environment. Indeed, perceiving is an activity that is
tightly linked to their responsive capability. Workers’ perceptual receptivity
and responsive ability are constantly being altered (in however small a way),
becoming a "flexible skill, a power of action and reaction" (Crossley, 1994:
12).
In contrast to the PBLT that places learning at an inter-subjective, social
level, it is suggested that the locus of learning lies in the bodily, perceptual
skills. Indeed, the findings reject the idea that individuals learn by first pas-
sively perceiving sensory data, then interpreting and reflecting upon this data
in their mind, and finally transforming this interpretation to instructions to
their body. Rather, we show how learning takes place without the workers’
thinking explicitly about what they learn. In Merleau-Ponty’s (1962) words,
we are dealing with "knowledge [that is] in the hands, which is forthcoming
only when bodily effort is made, and cannot be formulated in detachment
from that effort" (Merleau-Ponty, 1962: 144).
Furthermore, the primacy of the pre-reflective in the learning process,
and the shift away from the reflective to the pre-reflective, is also evident in
leaning new technological artifacts. Care workers initially engage with the
technology as an object but as they engage with it, they gradually incorpo-
rate it into their body schema, making the extended perception ‘their own’.
Even, when they turn the computer off, the skill they have acquired is a more
permanent part of their body. They gradually reach a state where they,
through the instrument, perceive opportunities for action in an increasingly
pre-reflective way. For example, rather than analyzing the technology-
generated patient data in a calculating, reflective, instrumental fashion, they
‘feel’ whether something is wrong or not. .
While invoking reflection as a requirement for learning is redolent with
the Cartesian, subject-object dualism, our approach suggests that our view of
learning goes beyond the distinction between mind and body, as well as be-
tween (a thinking) subject and an object of that reflection.

Theoretical implications and future research suggestions

The present work contributes to the discussion on the practice-based
learning theory, suggesting an alternative view that brings the body to
the center of human learning and knowledge. While the PBLT can be
credited with dethroning the individual mind as the cognizing unit, it
ignores the body’s ability to make meaningful action and knowledge.
This has been the chief aim of the preset paper, namely, to argue for

172
the corporeality of learning. Learning does not reside in the social (be
it rules, norms, or processes), as asserted by a large number of theo-
rists (see e.g. Brown & Duguid, 1991; Lave & Wenger, 1991; Mol,
1999; Tsoukas, 1996). The present paper lends strength to the view
that learning as associated with doing, but it takes full account of the
concrete and physical nature of action and activities (Bourdieau, 1977;
Lash, 2002).
The present paper also casts doubt over the widespread assump-
tion that learning occurs via reflection (e.g. Maturana & Varela, 1998;
Gherardi & Nicolini, 2001; Elkjaer, 2003). Indeed, rather than assum-
ing that to know is to be able to reflect on one’s actions, this paper
suggests that to learn is to suppress thinking and reflecting. It is our
argument that “being-in” and “thinking-about” the world do not make
a person learn. Rather, she needs to use more than her brain, she needs
to use her whole body in actual situations for her to remember and
learn how to act. The PBLT has failed to show how this process oc-
curs. Indeed, while many contemporary scholars allegedly reject the
mind-body dualism, there is little theorizing that actually provides
alternative conceptualizations. . Indeed, the mind-body dualism is still
implicitly pervasive in the literature through its objectification of the
body, its treatment as an auxiliary component.
The view presented here paves the way for new research that chal-
lenges the mind-body dualism. We need to go beyond repeating the
argument that learning is ruled by social structures and is a matter of
embodying social structures. This work begins to outline a path for
students of learning and knowledge, a path assuming and acknowledg-
ing the centrality of the physical capacity of the human body. It will

173
hopefully stimulate a new direction, not only in learning and knowl-
edge research but also in technology, management and organizational
science more generally.
On a more practical level, the view presented here has significant im-
plications. Challenging the view of learning as guided by conscious
reflection, by abstract mental operations, would imply that we need to
focus more on-the-job training and less on formal training relying on
instructions and books.

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