Work-related well-being in the transformation of nursing home work

396 Pages·2005·3.24 MB·English

WORK-RELATED WELL-BEING JORMA
MÄKITALO
IN THE TRANSFORMATION OF
NURSING HOME WORK Faculty of Medicine,
Department of Public Health Science and
General Practice,
University of Oulu;
Center for Activity Theory and
Developmental Work Research,
University of Helsinki;
Merikoski Rehabilitation and Research Centre
OULU 2005
JORMA MÄKITALO
WORK-RELATED WELL-BEING IN
THE TRANSFORMATION OF
NURSING HOME WORK
Academic Dissertation to be presented with the assent of
the Faculty of Medicine, University of Oulu, for public
discussion in the Auditorium 10 of Oulu University
Hospital, on June 22nd, 2005, at 12 noon
OULUN YLIOPISTO, OULU 2005
Copyright © 2005
University of Oulu, 2005
Supervised by
Docent Kirsti Launis
Professor Yrjö Engeström
Professor Hannu Virokannas
Reviewed by
Professor Jaakko Virkkunen
Professor Gustav Wickström
ISBN 951-42-7766-X (nid.)
ISBN 951-42-7767-8 (PDF) http://herkules.oulu.fi/isbn9514277678/
ISSN 0355-3221 http://herkules.oulu.fi/issn03553221/
OULU UNIVERSITY PRESS
OULU 2005
Mäkitalo, Jorma, Work-related well-being in the transformation of nursing home
work
Faculty of Medicine, Department of Public Health Science and General Practice, University of
Oulu, P.O.Box 5000, FIN-90014 University of Oulu, Finland; Center for Activity Theory and
Developmental Work Research, University of Helsinki, P.O.Box 26, FIN-00014 University of
Helsinki, Finland; Merikoski Rehabilitation and Research Centre, P.O.Box 404, FIN-90101 Oulu,
Finland
2005
Oulu, Finland
Abstract
The purpose of this study was three-fold: to analyze how the work-relatedness of well-being has been
constructed by the presently prevailing work stress approach, to develop better ways of
conceptualizing the work-relatedness of well-being on the basis of cultural historical activity theory,
and to test these new conceptualizations with empirical data from two nursing homes for the elderly.
An analysis of the development of work stress theory and previous studies of nursing homes
showed that their foundations lie in the paradigmatic person – environment formulation which
inhibits taking into account the activity of the individual, the changing of the work process and the
specific context in which stress is experienced. With respect to work-related well-being two activity-
theoretical hypotheses were developed: the object-dependedness of work-related emotions (object-
dependent well-being) and the increased physical and psychological work load as a result of
disturbances in the flow of work (disturbance load).
An empirical analysis of the historical development of the two nursing homes showed how the
function of the nursing homes had changed several times and continued to do so. The analysis also
suggested that changes in the work-related well-being of the employees followed the developmental
phases of the work activity. The second empirical analysis showed how the employees' explanatory
models of both tiring- and strength- giving events were related to several historical, present and
possible future aspects of the object of their work. Signs of individual motive development could be
detected in the interviews. The third empirical analysis of videorecorded morning routine episodes
showed how the current institutional script carried out by the employees collided with the residents'
own script resulting in resident resistance which increased the physical and psychological workload
of the employees.
Focusing on disturbance load may uncover important sources of emotional distress and physical
tiredness among employees. Understanding work-related well-being also as qualitatively developing
object-dependent well-being points to the need to create a dialogue between the development of the
collective activity and the object and motive development of individual employees.
Keywords: activity theory, developmental work research, elderly care, emotions, nursing
home, physical work load, psychological work load, work stress, work-related well-being
Acknowledgements
This research would not have been possible without the support, guidance, encourage-
ment and understanding of a number of people.
First and foremost I would like to thank my principal supervisor, Docent Kirsti Launis
from the Finnish Institute of Occupational Health, for the generosity, help, advice, forbear-
ance and kindness with which she has led me through the different phases of my work. It
would be difficult to enumerate the hours we have sat together discussing and evaluating
the analyses and texts which, finally, comprise the present book. What amazes me most is
the fact that despite the long gestation of my work, there was no occasion on which Kirsti
ever turned down my requests for help and consultation.
During the time I spent at the doctoral school (and over the years since then), Professor
Yrjö Engeström, Director of the Center for Activity Theory and Developmental Work
Research has been an inexhaustible source of inspiration and ideas as well as an example
to me. It is a pleasure to acknowledge my deepest gratitude for the patience and insight with
which you have guided my academic trajectory. I am also very grateful to Professor Hannu
Virokannas from the Department of Public Health Science and General Practice at the Uni-
versity of Oulu who helped me – during several phases in the development of the thesis –
to clarify my findings, offering valuable suggestions as to how they could best be presented
in the manuscript. Both Yrjö and Hannu have acted as co-supervisors of the present work.
Warm thanks are due to Matti Anttonen, Director of the Merikoski Rehabilitation and
Research Centre, for his generous support and confidence in me through the years. As a
consequence of my research I haven’t been able to contribute to the everyday life of the
Merikoski center as fully as I would have liked. But without his unquestioning support I
would not have been able to start or finish my book. I am also indebted to Juhani Palonen,
former Director of research at Merikoski, who first introduced me to developmental work
research in 1989. Juhani Palonen led the developmental project (for which this research
forms a part) in the City of Raahe, and I was fortunate to be able to start my field work under
his auspices. Across the millennia, Juhani’s fatherly support has remained a great help and
inspiration to me.
I want to thank the Department of Public Health Science and General Practice at the Uni-
versity of Oulu, directed by Professor Sirkka Keinänen-Kiukaanniemi, for all the help and
support for this work.
I am very grateful to the official referees, Professor Jaakko Virkkunen and Professor
Gustav Wickström, for their many constructive comments and suggestions concerning the
final manuscript of the thesis.
When I started in the doctoral school of developmental work research and adult educa-
tion at the University of Helsinki in 1995, everything was new to me. A crucial element in
my learning process was the doctoral class of 1995 – Vaula Haavisto, Mervi Hasu, Merja
Helle, Kirsi Koistinen, Pirjo Korvela, Merja Kärkkäinen, Juha Pihlaja, Eveliina Saari and
Hanna Toiviainen – to whom I am eternally grateful. The positive spirit we created there,
allied with all of the practical support that you have provided, has been very important to
me. Another group of colleagues that has been appreciated immensely is my team at Meri-
koski. Leena Keränen, Kimmo Keskitalo, Airi Tolonen, Anu Peltola and Hilkka Ylisassi
have supported my work with numerous comments, suggestions and ideas throughout the
years. I am also obliged to Marita Korhonen for her companionship during the fieldwork
period and her continuing support while I have been writing my thesis.
I am very grateful to the residents and personnel of the two nursing homes in the City of
Raahe for giving me the opportunity to enter into their daily life and communities. The trust
and support of Director Viljo Lehmusketo and Director Eeva Tokola from the City of Raahe
was also essential during the fieldwork and the project.
Over the course of my research I have been a member of two communities whose per-
sonnel has helped me in numerous ways. Four senior researchers, Reijo Miettinen, Kari
Toikka, Ritva Engeström and Terttu Tuomi-Gröhn, deserve special thanks for their patience
and insightful comments during my doctoral studies at the Center for Activity Theory and
Developmental Research. The whole staff of the center, and especially Päivi
Karimäki-Suvanto, Leena Harjula-Jalonen and Heli Kaatrakoski, helped me with many
practical matters during these years, while a number of research assistants at the center did
a paramount job in the transcription of the data that is used in this study. Another commu-
nity upon whose help and understanding I have learned to rely is the Merikoski Rehabili-
tation and Research Center. I wish to express my gratitude to all of its personnel. I would
also like to thank my friends Brent Cassidy and Anthony Johnson who helped me to finish
off the manuscript of this thesis.
I am very grateful to the Finnish Work Environment Fund (grant 101026), and the Asso-
ciation for Promotion of Occupational Health, who have supported this research finan-
cially.
Much gratitude goes to my father Reino Mäkitalo and my sister Riitta Veijola for setting
an example to me of the patience and persistence that is required by scientific work. It
breaks my heart that my dear mother Pirkko Mäkitalo did not have the opportunity to see
my thesis finished. It is her I would have liked to thank for the love and encouragement that
she brought to my life. I am also greatly indebted to my mother-in-law Kaisa Krause and
to my father-in-law Ulf Krause for all the help they have generously offered to myself and
my family while I have been busy doing research.
This work has demanded efforts that have spilled over into family life. My dear wife Bir-
gitta has tolerated more than a wife should, and my book would have been impossible with-
out her significant contribution, love and encouragement. Along with our children Vilina,
Siiri, Iris and Ville, she has given me the best that I have in life.
Tyrnävä, May 2005 Jorma Mäkitalo
List of figures
Fig. 1. Care services for the elderly in the City of Raahe. . . . . . . . . . . . . . . . . . . . . . . 27
Fig. 2. A schematic layout of City Home. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Fig. 3. Layout and furniture of a cell’s lounge at Home Path. . . . . . . . . . . . . . . . . . . . 29
Fig. 4. Layout of a single room with typical furniture.. . . . . . . . . . . . . . . . . . . . . . . . . 29
Fig. 5. The coverage of previous ethnographic and work stress research
in nursing homes.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Fig. 6. Response-based model of stress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Fig. 7. The demand-control model (DC model) of work stress (Karasek 1979). . . . . . 72
Fig. 8. Stimulus-based model of stress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Fig. 9. Interactional model of stress.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Fig. 10. Transactional model of stress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Fig. 11. The object-orientedness of activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Fig. 12. The social mediations of the subject – object relationship.. . . . . . . . . . . . . . . . 97
Fig. 13. Tool-mediation of the subject – object relationship. . . . . . . . . . . . . . . . . . . . . . 98
Fig. 14. A model of activity as an activity system (Engeström 1987).. . . . . . . . . . . . . . 98
Fig. 15. Different ideal types of cycles of change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Fig. 16. A model of developmental phases and contradictions of
an expansive transformation of a collective activity system. . . . . . . . . . . . . . 101
Fig. 17. The alternation of internalization and externalization in an
expansive cycle of change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Fig. 18. Learning actions in an expansive cycle of change. . . . . . . . . . . . . . . . . . . . . . 104
Fig. 19. Transition to an activity-based analysis from a person –
environment-based analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Fig. 20. The theoretical core of the models for reactions and conscious activity. . . . . 106
Fig. 21. A theoretical model of object-dependent well-being. . . . . . . . . . . . . . . . . . . . 108
Fig. 22. A working hypothesis of the changes in object-dependent
well-being in the course of an expansive developmental cycle. . . . . . . . . . . . 109
Fig. 23. A typology of different approaches to emotions. . . . . . . . . . . . . . . . . . . . . . . 121
Fig. 24. Research design in this study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Fig. 25. Timing of the research process and the developmental project. . . . . . . . . . . . 127
Fig. 26. Developmental dimension of the ideology of care in care
services for the elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Fig. 27. Developmental dimension of the service structure in elderly care.. . . . . . . . . 140
Fig. 28. Four ideal types of elderly care services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Fig. 29. Ideal model of rationalized institutional care. . . . . . . . . . . . . . . . . . . . . . . . . . 141
Fig. 30. Ideal model of respite care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Fig. 31. Ideal model of humanized institutional care. . . . . . . . . . . . . . . . . . . . . . . . . . 143
Fig. 32. Ideal model of a regional multisectorial unit. . . . . . . . . . . . . . . . . . . . . . . . . . 144
Fig. 33. Problems of the municipal home in Raahe in the late 1960s and early
1970s interpreted as secondary contradictions of a double-bind
phase in development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Fig. 34. Developing the idea of City Home interpreted as the object / motive
construction phase of development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Fig. 35. City Home at its beginning interpreted as an activity system in the
developmental phase of application; the separation of the care of the
long-term sick interpreted as a dividing developmental cycle. . . . . . . . . . . . . 156
Fig. 36. The developing of cell working at City Home and the rise of
tertiary contradictions between the model of the beginning of
City Home and the cell model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Fig. 37. The tension between the new demands of the member municipalities
and the cell model of City Home interpreted as quartenary contradictions
in the beginning of the consolidation phase in the developmental cycle. . . . . 169
Fig. 38. Deadlock in institutional care at City Home and Country Home between
1988 and 1995. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Fig. 39. A theoretical interpretation of the development of City Home as six
successive phases in a narrowing developmental cycle. . . . . . . . . . . . . . . . . . 179
Fig. 40. The path of City Home within the developmental dimensions of
elderly care and a hypothesis of its future developmental direction. . . . . . . . 181
Fig. 41. Primary contradiction in the object of activity in the municipal home
and in the nursing home for the elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Fig. 42. Four periods of work-related well-being in the development of City Home. . 186
Fig. 43. Phases in the analysis of the interview data concerning negative
and positive emotions at work. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Fig. 44. A model of object-dependent well-being according to the Duties EM. . . . . . 240
Fig. 45. A model of object-dependent well-being according to the explanatory
models related to the residents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Fig. 46. A model of object-dependent well-being according to four explanatory
models of strength, joy and interest at work.. . . . . . . . . . . . . . . . . . . . . . . . . . 242
Fig. 47. The historical layeredness of emotionally significant objects at City
Home and Country Home.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Fig. 48. The developmental mechanism of object and motive construction in
City Home and Country Home.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
Fig. 49. A historical working hypothesis of the developmental contradictions
in the work activity of City Home and Country Home in 1995. . . . . . . . . . . . 251
Fig. 50. Typical phases of the morning routines within the layout of a
resident’s room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259