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BY 4.0 license Open Access Published by De Gruyter Mouton March 4, 2020

“She didn’t expect to get a slap”: Modeling “proper” conduct among teachers and students in training classes for care workers in Sweden

Gunilla Jansson and Ali Reza Majlesi

Abstract

The current study is carried out in an ethnically diverse three-semester vocational adult education programme in Sweden for those who aspire to register as assistant nurses. The data is based on field notes taken during participant observations and video-recordings of the classroom interaction in a course on dementia care in the autumn of 2014. In Sweden, care work is framed by the goals stated in The Swedish Social Services Act, which is to promote the elderly’s right to self-determination and independence. In the class in which this study was carried out, this policy informed the teaching of “good” communication practices. The aim of this article is to demonstrate how the strategies taught in school that embody this policy come into conflict with the seemingly unavoidable dilemmas experienced by trainee students on the work floor. We analyse two examples of teachers acting out hypothetical scenes for the purpose of modeling proper caregiver conduct in dealing with frail, powerless individuals with dementia. The students’ descriptions of their own conduct in managing challenging resident behaviour are thereby considered as accountable actions. The article brings into focus the complexity of the power relations and institutional asymmetries at play concerning the teaching situation in training classes for care workers.

1 Introduction

The present article focusses on teacher-student interactions in an ethnically diverse adult education nursing course in Sweden. The interactions revolve around the emotionally charged and normative aspects of care work that arise when the students report on challenging dilemmas that they have experienced during their workplace training in dementia care. These dilemmas centre on the agitation and physical violence exhibited by older individuals with dementia, a widespread and difficult problem among residents in the disease’s intermediate and late stages (e. g. Bidewell and Chang 2010). Whereas doctors and nurses have often been the focus in educational research (e. g. Thomassen 2009), the training of care workers, who are at the bottom of the medical professions’ hierarchy, has received far less attention (for work on this topic, see Cuban [2009]). Because care work has traditionally been closely connected to emotional labour and typically female domains, i. e. traits that women come by “naturally”, education was not considered necessary (Cuban 2008; Karlsson and Nikolaidou 2011; Makoni and Grainger 2002). In Sweden, this situation has radically changed during the last decade (Törnquist 2004). Today, care work requires formal training, and care knowledge is being framed by curricula and teaching materials. With increasing numbers of people who are living with dementia, [1] there is a great need for well-trained staff who can cope with the demanding work tasks while at the same time meeting the needs of dementia patients to maintain a sense of agency and personhood (Kitwood 1997).

The care tasks foregrounded by the participants in this article centre on physical care work, such as when residents are assisted with their personal hygiene. Goffman (1959: 124–126) terms this the backstage “technical work” undertaken by low status workers (see also Cuban [2008, 2009]; Lee-Treweek [1994]). Care work in Sweden employs the highest proportion of migrants (around 13% of the entire workforce in Sweden in 2013 before the mass immigration in 2015, see Jönson and Giertz [2013]). These numbers have since risen and by 2017, migrants accounted for 21% of the entire workforce in Sweden. [2] Many of these migrants are women [3] with rudimentary schooling and few opportunities to advance in the marketplace, and many lack formal training in care work. With a burgeoning ageing population in Sweden, the recruitment of low-paid migrants to the care sector has filled a gap in the labour market. As Cuban (2009: 178–179) has argued, care employers seek out workers from overseas who in many cases do not have much of a choice other than to accept poor working conditions. Similar employment strategies can be found in other occupational groups within the domestic service sector (Ladegaard 2013; Lorente 2012). A telling example is provided by Lorente’s (2010, 2012) study of Filipino workers who are exported to industrialised countries, where they are deployed as domestic workers and socialised into subordinate roles to perform the caretaking and household work of class-privileged women. Similar stories can also be read in narratives told by Indonesian and Filipina domestic workers in Hong Kong (Ladegaard 2013).

The physically and mentally difficult nature of care work is particularly true for dementia care (Williams and Herman 2011). Caregivers of people with dementia are faced with ethical dilemmas on a daily basis (Jansson and Plejert 2014). One such dilemma that the participants in this study deal with includes making decisions about ways to handle opposition to tasks of daily living by older individuals with dementia in residential care. Previous research has pointed to the complexity of performing physically intrusive care tasks while at the same time maintaining the client’s dignity and sense of autonomy (Grainger 1993, Grainger 1995; Heinemann 2009; Jansson and Plejert 2014; Plejert et al. 2014; Williams and Herman 2011). In Sweden, care work is guided by the goals stated in The Swedish Social Services Act (Socialtjänstlagen; SFS 2001: 453), which aims to promote the elderly’s right to self-determination and independence. In the class in which this study was carried out, this policy permeated the course material (e. g. Skog 2009) and informed the teaching of “good” communication practices. The purpose of this article is to demonstrate how the strategies taught in school that embody this policy come into conflict with the seemingly unavoidable dilemmas experienced by trainee students while at work. We analyse two examples of teachers acting out hypothetical scenes for the purpose of modeling proper caregiver conduct in dealing with frail, powerless individuals with dementia. The students’ descriptions of their own conduct in managing challenging resident behaviour (henceforth referred to as student management strategies) are thereby considered as accountable actions. The article brings into focus the complexity of the power relations and institutional asymmetries (Heritage 1997) at play concerning the teaching situation in training classes for care workers. This focus involves multiple perspectives: that of the student, the care recipient, the caregiver and the teacher.

2 Data and setting

The current study is carried out in an ethnically diverse three-semester vocational adult education programme for care workers who aspire to register as assistant nurses. This education programme takes place in an urban multilingual area in Sweden. During a course on dementia care in the autumn of 2014, the first author collected field notes and video-recordings of classroom interaction. [4] The fieldwork covers 35 lessons in a class with 25 students and three teachers (T1, T2 and T3). In total, 16 hours of classroom interaction were videotaped, with informed consent from all participants. In our data, there are 22 instances in which the students report on dilemmas that they have experienced during their vocational training in residential homes for the elderly. The dilemmas centre on how to cope with challenges in care encounters with individuals with dementia, ranging from socio-emotional affects, such as negativism and complaining, to resistance to care and even physical aggression. For this article, we have selected two examples from the majority of cases (14 out of 22) in which the trainee student has been directly involved in the care encounter. In the remaining eight cases, the students have witnessed the ways in which someone else has coped with the situation. The examples span approximately five minutes of interaction. These examples have been chosen to highlight two distinct ways in which a reported dilemma is dealt with in classroom interaction, concerning both the teacher’s assessment of the student’s management strategies and the students’ uptake of the teacher’s instructions. The caregiver conduct described by the teacher in the selected examples was recurrently advocated as a solution to future workplace challenges.

The students in the class in focus have diverse ethnic backgrounds. Out of 25 students, 22 have a migrant background, including the students who are featured in the analyses in this article (one coming from Syria and the other from Lebanon). Eighteen students have immigrated to Sweden during adulthood (most of them coming from Africa, Asia and the Middle East) either on refugee or spousal visas. Swedish is their second or third language. Four are second generation migrants who have grown up in Sweden in families with diverse backgrounds; three are indigenous Swedes. The majority of the students are women. Only five are males. According to the teachers, several of the migrant students had recently arrived [5] and lacked competence in Swedish vocabulary. The teachers described their oral and written skills in Swedish as underdeveloped and in need of training. Most of the students have backgrounds in Sweden as unregistered care workers in elderly care. Some of them work evening and night shifts in residential care or in home care outside the classes. Thus, many of the students are already experienced care workers but lack formal training. The teachers, all females, have received formal training at the university level as teachers in nursing. They have previously worked in dementia care and health care.

3 Analysis

In order to account for the manner in which a reported dilemma is dealt with in classroom interaction, we conduct detailed analyses of sequences of talk informed by ethnomethodology (Garfinkel 1967) and conversation analysis (Sacks 1992). Ethnomethodology and conversation analysis seek to investigate how social activities are accomplished by members of society (Francis and Hester 2004). Macbeth (1990: 191) maintains that “classroom order is a local, methodic phenomenon, consisting of the competencies and practical accounts of persons on the scene, and analyzably so”. For our study, an ethnomethodological approach implies that we perform a detailed analysis of sequences of talk on single occasions that display the local classroom order of modeling normative aspects of care work in dealing with dementia patients.

In the following, we present our analysis of two examples divided into eight excerpts (Excerpts 1a, 1b, 1c and Excerpts 2a, 2b, 2c, 2d, 2e). The interaction in these examples develops as responses to students’ sharing their work life experiences within the classroom. In both examples, the teacher’s instructional work centres on how to tone down institutional asymmetries in the care encounter. In the first example this is done through enacting empathy, and in the second example, through non-threatening bodily comportment. Data have been transcribed according to conversation analytic principles (Ochs et al. 1996). Conversation analytic transcription of talk in interaction allows us to attend to the details of turns at talk and the production of linguistic constructs as well as their real-time prosodic features. In the last decade, research has emphasized the importance of multimodality for the organisation of social worlds (e. g. Streeck et al. 2011). Thus, in order to demonstrate the ways in which aspects of care work are portrayed in teacher-student interactions, we closely consider the participants’ embodied conduct, such as gestures, bodily comportment and gaze (see also Mondada 2016).

3.1 Enacting empathy

The student’s experience from his vocational training in the first example (Excerpts 1a, 1b and 1c) foregrounds a dilemma regarding the elderly’s wellbeing from different perspectives: what a caregiver may consider beneficial or what a care-recipient may desire. More specifically, the dilemma concerns the therapeutic benefit of reliving memories, a care approach described in the course literature (Skog 2009: 127). The example is drawn from a feedback discussion following a group presentation in which taking some objects to people with dementia, with the purpose of reliving memories, is described as beneficial. Unlike the group’s presentation in which remembering experiences from the past is assumed to be healthy and helpful for people with dementia, a student in the class (under the pseudonym of Haydar) has first-hand experience that contradicts this assumption. According to Haydar, he triggered a bad memory when he told a resident about his children and showed her a photograph of them. The resident asked him to stop talking, arguing that she wanted to live “here and now”. This made Haydar believe that it is not always good for the elderly to talk about the past. Rather than resolve this issue, the teacher takes this as an opportunity to build on Haydar’s experience for her own upcoming instructional contribution. Instead of distracting the older individual’s bad memories through topic change, which was Haydar’s management strategy, the teacher advocates a technique in which the recognition of the older person’s emotions from an emphatic attitude should take on central importance. We demonstrate how the teacher portrays this method as a proper way of handling a resident’s affective stance.

Excerpt (1a) begins some minutes into the students’ discussion following the group presentation. Prior to this excerpt, Haydar has formulated a question concerning the risk associated with reliving memories for a person with dementia.

Excerpt (1a) “What did you do then?” T1=teacher 1; H=Haydar

06T1va gjorde du då’r¿a (0.3)när hon sa stopp ja vill inte
what did you dothen (0.3) when she said stop I don’t want
07tänka jag lever [här å nu
to think I live [here ’n now
08H            [ja började prata om (0.3) andra sak.=
            [I began to talk about (0.3) other thing.=
09T1=ja:.
=yes:.
10.(0.7)
11Hom- om de kaffet e gott (.) eller int[e,
if- if the coffee is good (.) or n[ot
12T1                     [ja.
                     [yes.

The teacher, who until this point has avoided involvement, halts the students’ discussion, thereby managing a topic shift. She asks Haydar to explain his way of handling the reported challenge in the real situation he just shared with the group (lines 06–07). In response, the student recounts how he managed the situation by finding something else to talk about, for example, coffee (lines 08–11).

In Excerpt (1b), a continuation of the interaction in Excerpt (1a), the teacher depicts a hypothetical scenario of an alternative way of handling the situation by means of enacting an empathic caregiver attitude with two other students, Farhad and Mary.

Excerpt (1b) “You may not always need to distract” T1=teacher 1; F=Farhad; M=Mary ((a few lines omitted))

13T1man kan ju också bara,
one can [PART] also just
14(1.5) ((T turns to M, reaches for her left hand))
15T1s- så gå till de här då,(0.3)
s- so go to this then, (0.3)
((T holds both of M’s hands))(Figure 1)

16T1<validation>(0.2) att man bara sitt:er. (.) å ä:r.
<validation>(0.2) that one just sits:.(.) ’n i:s (there).
((T directs her gaze around and back to M))
17(0.7)
18S◦m:◦
19T1man kanske inte allti behöver<avleda>(.) på en gång=
one may not always need<to distract>(.) at once=
((T directs her gaze around and back to M))
20F=precis
precisely
21(0.3)
((T gazes around))
22M◦m:◦
((M nods))

In line 13, the teacher turns to the student sitting next to her (Mary) and grasps her hands. In this fashion she uses the student as a hypothetical care recipient (Figure 1).

Figure 1: T1 holds both M’s hands.

Figure 1:

T1 holds both M’s hands.

While holding Mary’s hands, the teacher begins to elaborate on Haydar’s strategy, suggesting that one can apply the validation method [6] by just sitting and being there instead of always diverting bad feelings (lines 15–19). This can be heard as a contrastive method vis-à-vis the method used by Haydar of distracting bad memories through topic-change (see Excerpt 1a). In line 19, the teacher demonstrably opposes Haydar, although with a non-assertive modal adverb kanske ‘maybe’: man kanske inte alltid behöver<avleda>(.) på en gång ‘one may not always need<to distract>(.) at once’.

Having introduced validation as an alternative method, the teacher initiates an enactment of what might hypothetically be said to the person with dementia. In this demonstration, Laura, Gary, and an additional unknown student take part.

Excerpt (1c) “I see that you are sad” T1=teacher 1; L=Laura; F=Farhad; M=Mary; G=Gary; S=student (unknown or not in the shot)

23T1utan man kan faktiskt bara sitta(.)å säja att,(.)ja:a.
but one can actually just sit (.)’n say that,(.)yes:/okay:.
((T holds M’s hands, T moves them up-down))
((mutual gaze with M; T nods))
24Lja se:[r
I      se[e:
25T1              [ja märk[er (.) att du e lessen=
              [I noti[ce (.) that you’re sad
((T gazes around))
26F                        [ja
                        [yes
27S                        [m:
28F=ja
yes
29(0.5)
((T gazes around and back to M; mutual gaze))
30T1ja [se:r
I [see:
((T nods))
31M[ja ser
I see
((M nods))
32T1(h)a(h)tt du e less¿en
(h)tha(h)t you’re¿sad
((T & M mutual gaze))
33T1(0.2)ja förstå:r (.) att du e less¿en (.)
I understand (.) that you’re¿sad
((T gazes around))
34ja förstår (.) att de väcker upp känslor hos dej
I understand (.) that it arouses emotions in you
((T gazes around; back to M; mutual gaze with M))
35(0.3)å så kan man bara sitta(.)[en stund(0.2) å hålla
(0.3)’n so can one just sit (.) [a while (0.2) ’n hold
((T gazes to the front; back to M; moves M’s hands))
((G nods))
36F                                                [ja=
                                                [yes=
37Mmm
38Gprecis
precisely
39T1å va:ra (.) nä:r¿a (0.4) att inte va så rädd (0.3)
’n be: (there) (.) close (0.4) not to be so afraid (0.3)
((T gazes to the front))

In line 23, the teacher continues to propose an alternative way of acting by her use of the Swedish adversative conjunction utan ‘but’ in her initial proposal: utan man kan faktiskt bara sitt a(.) å säja att,(.)ja:a ‘but one can actually just sit (.) ’n say that, (.) yes:/okay:.’. While articulating this, the teacher holds Mary’s hands and moves them up and down. Worth noting is the teacher’s use of the Swedish impersonal third person pronoun man ‘one’ or generic ‘you’ in lines 13, 16, 19, 23 and 35, which works to incorporate all individuals in a similar situation as potential recipients of the advice. The social problem of telling the student how to act is thus mitigated (cf. Waring 2007).

Following the teacher’s introductory framing (Couper-Kuhlen 2007) in line 23, å säja att,(.)ja:a. ‘n say that, (.) yes:/okay:.’, a student (Laura) who is sitting in the row right in front of Mary observing the teacher (see Figure 1), aligns with the teacher’s embodied demonstration by making the first contribution to the hypothetical dialogue (line 24), ja se:r ‘I see’. Adding to Laura’s turn, the teacher extends the dialogue by producing another enactment of what might be said to the person with dementia (line 25), ja märker (.) att du e lessen ‘I notice (.) that you’re sad’’. From line 25 through 35, the teacher extends the enactment sequence by adding more contributions to the hypothetical speech. The enactment consists of potential turns in an authentic interaction. Throughout the sequence, the students align with the teacher’s instructional work. This is manifested by claims of understanding through receipt tokens, and displays of agreement both verbally and with bodily practices (lines 26–28, 31, 35–38).

In this example (Excerpts 1a, 1b and 1c), the gist of an emphatic caregiver attitude is highlighted through embodied practices. Worth noting in this example is not only the teacher’s bodily conduct (holding the student’s hands, moving them up and down) but also her way of articulating hypothetical and explanatory talk through prosody. In the case of using disciplinary-specific vocabulary, the teacher slows down her speech rate. For instance, the term “validation” (line 16) and the action verb for distracting bad feelings (line 19), avleda (‘divert/distract’), are pronounced with a markedly slow speech delivery. Further, verb phrases that foreground particular actions indexing an emphatic caregiver stance (‘see’, ‘notice’, ‘understand’, ‘sit and hold’, ‘be close’) are emphasised through stressed vowels and an extension of the production of the verb phrases as a whole. Note for example the extended production of the phrase in line 39, å va:ra (.) nä:r¿a (‘n be: (there) (.) close’), through the vowel lengthening and a micropause preceding the complement. Modeling a caregiver attitude through prosodically highlighted verbal production with special vocabulary is a typical teacher-talk register (Cazden 1986: 443), which, together with bodily conduct, provides a practical set of features for showing empathy. Also worth noting is the teacher’s use of gaze direction. While performing instructional work, the teacher changes gaze direction from a mutual gaze with the hypothetical care recipient (Mary) to a gaze directed at the students in front and around the class. As Goodwin (1979; see also Rossano 2013) has shown, a speaker’s gaze may not just signal the recipient/s but also their status of knowledge. That is, the gaze is directed to unknowing recipients or those selected to be informed. In the analysed interaction, gaze similarly serves the function of securing all students’ attention as an audience for what is being said, while at the same time functioning as an integral part of the enactment scene.

Haydar never receives an answer to his question concerning whether it is always good for the elderly’s wellbeing to recall memories. Instead of addressing this question, the teacher interrupts the students’ discussion and redirects the focus of attention to Haydar’s management strategies, which she uses as a springboard for teaching. This pedagogical practice reflects a top-down approach to teaching in which students’ lived experiences are not taken into account. Further, the teacher-talk register enforces the asymmetrical role relationships at play in the pedagogical setting.

3.2 Enacting non-threatening bodily comportment

The dilemma in the second example (Excerpts 2a, 2b, 2c, 2d, 2e) centres on the handling of physically aggressive resident behaviour. The excerpts follow immediately upon each other. In this example, a student (under the pseudonym Amanda) describes her strategy for coping with a resident with advanced dementia who would hit her if she did not hold her firmly enough when getting her dressed. In this example, the teacher acts out a scene, using herself as a hypothetical care recipient to pinpoint a contrast between proper and improper caregiver conduct. We demonstrate the way in which the teacher’s enactment of non-threatening bodily comportment is challenged by the students’ counter arguments.

The example is drawn from a teacher-fronted discussion about the students’ learning experiences during their vocational training. The students are in the midst of their training period and are currently gathered at school to discuss what they have learnt up to this point. Three teachers are involved in this lesson, but only one of them (T2) participates with the student, Amanda, in the analysed example below. Excerpts (2a) and (2b) focus on the student’s report of problematic resident behaviour.

Excerpt (2a) “She didn’t expect to get a slap” A=Amanda; T2=teacher 2; T3=teacher 3

01Avi har ju en som e aggressiv. (.) å hon e gjorde
we have [PART] one who’s aggressive. (.)’n she e
02illa en. (0.6) hon har bandage asså hon,(0.8)
hurt someone. (0.6) she (the carer) has a bandage
[ADV] (well) she (the carer), (0.8)
03A[för att hon brukar komma framifrån henne så:.=
[since she usually comes to her (the resident) from
the front like:.=
((A stretches her hands forward))(Figure 2)
04T3[°åkej°
[°okay°
05T2=ja:,
=yes:,
06Ahon var inte beredd på att,
she didn’t expect to,
(1.4) ((A moves right hand to show hitting))
07få en smäll.
get a slap.
08T2då har ni de här med arbetsmiljö
then you (pl.) have this with workenvironment
09Am:
10T2å arbetsmiljölagen å arbetsskadeanmälan å såna saker
’n the work environment act ’n the report for occupational
injuries ’n the like
((A nods))
11T2för får vi en skada så då har ni ju de
’cause if we get injured then you’ve got [PART] it on
12praktikuppgiften att (.) fundera kring (.) hur,
the jobassignment to (.) think about (.) how,
13hur e’re man beter sej då. (0.6)
how is it that one should behave then. (0.6)

Excerpt 2a (lines 01–07) starts with Amanda’s account of a case in which an employee is bandaged after being hit by a resident. The caregiver had approached the resident from the front (line 03, Figure 2), a method that the students have been taught in school to apply in care encounters with persons with dementia. The student’s telling of the story, which describes the event with many pauses and inter-turn gaps, indicates that the topic of discussion is a delicate matter. The description of the resident hitting the employee is delayed and mitigated by understatements. In line 02, Amanda uses the word ‘hurt’ (Sw. gjorde illa) to denote the resident’s hitting. It is not until line 07 that it becomes clear that the employee has been hit by the resident with a ‘slap’ (Sw. smäll). In line 06, the student halts her turn in progress hon var inte beredd ‘she didn’t expect to’, and produces an embodied display of the upcoming verbal description of the care worker getting a slap. To do this, she holds up her arms in front of her and gently sweeps her right hand back and forth over the left arm, thus illustrating the resident’s hitting of the care worker with her hand (Figure 2). Also, it is the care worker’s conduct of approaching the resident from the front that is foregrounded, and the resident’s physical aggression is presented as a consequence of this conduct. The event is thus portrayed in the student’s report as a problematic case, one in which a method taught in school does not seem to work in real life. In response to Amanda’s report, the teacher (T2) refers to the Work Environment Act (see Arbetsmiljöverket [Swedish Work Environment Authority] 2015), which deals with occupational safety, health (line 10) and job assignments (line 11). This prompts the students to reflect on the procedures for preventing and treating injuries (lines 12 and 13).

Figure 2: A stretches her hands forward.

Figure 2:

A stretches her hands forward.

Having described the instance in which an employee at the workplace was hit, Amanda proceeds with her report by describing how such aggressive behaviour forced her to hold the resident firmly (Excerpt 2b).

Excerpt (2b) “I have to hold her firmly” A=Amanda; T2=teacher

14Aför ja (.)asså ja har fått hålla i hennes armar
’cause I (.) [Adv] (well) I have had to grab hold of her arms
((A folds arms across the chest)) (Figure 3)
15T2ja:
yes:
16Aför å få på henne en tröja [å: allt de där ja har
to  put her   sweater on ‘n all I have
((A folds arms across the chest))
17T2                                                              [ja
                                                              [yes
18Afått hålla i henne hårt (0.2)
had to hold her firmly (0.2)
((arms across the chest))
19T2ja (0.5)
yes (0.5)

Amanda describes the situation further (lines 14–18) by demonstrating how she has to hold the resident’s arms firmly in order to put a sweater on her. Throughout this description, she holds her arms crossed over her chest with clenched fists (Figure 3). The clenched fists and the crossed arms serve to recreate her effort to prevent the resident from hitting her. In Excerpt (2c), the teacher portrays this conduct as problematic by using herself as a hypothetical care recipient.

Figure 3: A folds arms across the chest.

Figure 3:

A folds arms across the chest.

Excerpt (2c) “I will spit on you” A=Amanda; T2=teacher 2; S=student

20Aför att [hon vill inte (klä på sej)
’cause [she doesn’t want to (put on clothes)
21T2                 [å då kan ja säja er att (.)kommer ni sen
                 [’n then I can say to you that (.) if you come later
22T2å håller m- i mej hårt         [(xxx) ja kommer spotta på er
’n grab m- hold of me hard[(xxx) I’ll spit on you (pl.)
((T folds arms across the chest))(Figure 4)
23S                                                             [hehehe
24T2som ja brukar [hota er me (0.2) ja kommer bita er
          ja kommer å  [sparka er
as I usually threaten you(pl.) with (0.2) I’ll bite you(pl.)
       I’ll               [kick you(pl.)
25S                                [hahaha
26A                                [hon gjorde så
                                [she did that
27(0.2)
28T2a¿: (0.3) för bli’ru hållen,
yeah¿: (0.3) ’cause if you are heldtight
((T folds arms across the chest again & shakes her hands))
29(1.4) (Figure 5)
Figure 4: T2 folds arms across the chest.

Figure 4:

T2 folds arms across the chest.

Figure 5: T2 folds arms tightly across the chest.

Figure 5:

T2 folds arms tightly across the chest.

30så kan de kännas förbaskat obe[hagligt.
so  it can feel          damn                 [nasty.
31A                                                                       [men om man inte gör så då
                                                                       [but if one doesn’t do so then
32smäller hon till å hon vä- vägrar å klä [på sej
she’ll slap and refuse to put on clothes
33T2                                                                                             [ja, å å (0.8)nu
                                                                                             [yes, ’n ’n (0.8) now
34ska väl inte ja undervisa om
I don’t wanna [Adv] (well) teach about
((T stands up & approaches L))
35T2de men men (.) lite grann de här e:, e’re ju hur
it but but (.) a little bit this e:, it’s how
36bemötandet e(.) för kommer ja så här å ska göra saker
encounter is (.) ’cause if I come like this ’n want to do things
((T stands close to L in a confrontational manner))(Figure 6)
37T2så bli:r ju (.) lisa ganska rädd (.) utan ja måste ju
then lisa becomes [PART](.) quite afraid (.)I must rather [PART]
38på nå sätt,
(find) a way
39(0.5) inte kränka hennes revi:r ja kanske e tvungen å
(0.5) not to violate her personal space I may have to
((T sits on her knees,Figure 7))
40T2gå lite i underläge.(0.2) å å höra me me
go a little down (to an inferior position).(0.2) ’n ’n ask
41lisa (0.3)er’e åk¿ej att ja snörar om dina skor (0.3)
lisa (0.3) is it ok¿ay if I lace up your shoes(0.3)

In response to Amanda’s justification of using force to have the resident put on clothes, the teacher describes what she herself might do if taken hold of by a care worker in the way described by Amanda (lines 21, 22, 24). Here, T2 uses herself as a hypothetical care recipient and the students as caregivers in a future, hypothetical care encounter. She explains that she will spit, bite and kick the students if they hold her hard. During the production of this account, she holds her crossed arms tight to her chest (Figure 4), thus invoking Amanda’s bodily behaviour (see Figure 3). Her folding her arms over her own chest is timed with the production of the verb spottaspit’, and she maintains her gesture while emphatically articulating other physical actions, bita ‘bite’ and sparkakick. In an overlap with the teacher’s turn, Amanda now confirms that the resident in her story actually performed the actions described by the teacher (line 26), hon gjorde så ‘she did that’. In response, the teacher offers an unmitigated description of how unpleasant it might feel for a person who is being held tightly (lines 28–30), emphasising the intensity of the feeling with the amplifier förbaskat ‘damn/bloody’. This description is accompanied by a bodily illustration of this feeling (line 28, Figure 5). With the embodied display of discomfort that Amanda’s reported conduct might occasion, the teacher assesses Amanda’s management strategy as highly improper. Amanda now interjects with an overlap (line 31–32), accounting for her action and counter-arguing that the resident would hit her and refuse to comply with the task (getting dressed) if she did not hold her tightly.

Figure 6: T2 stands confrontationally close to L.

Figure 6:

T2 stands confrontationally close to L.

Amanda’s defensive response to the teacher’s negative depiction of her reported conduct elicits additional instructional work by the teacher. From line 33 onward the teacher enacts an embodied illustration of undesired and desired communicative conduct, using the student, Lisa, as a hypothetical care recipient and herself as a caregiver. She steps forward to Lisa (line 36) and places herself in front of her in a confrontational manner, with arms stretched sideways and raised shoulders as if making herself ready to grasp hold of the student (Figure 6). She thus emphasises the negative impact of this comportment of the body on the person. In line 37, the teacher points out the consequence of such an approach, as Lisa (the hypothetical resident) would be afraid under such circumstances. She then suggests that one should perhaps find a way to put oneself in an inferior position in order not to violate the resident’s personal space. While formulating this, the teacher demonstrates how such a stance may be enacted in a care encounter. To do this, she takes a step backwards and goes down on her knees in front of Lisa (line 39; Figure 7). While remaining in this body posture, she proposes what one might say to the person before carrying out the care-giving task at hand (line 41). This hypothetical talk, formatted as direct reported speech, is marked off as an enactment by the introductory framing (Couper-Kuhlen 2007: 87), å å höra me me lisa ‘’n ’n ask lisa’. As will be shown in Excerpt (2d), Amanda and another student (Jamila) once more problematise the uneasiness of the situation and counter argue that the person with dementia would probably not listen:

Excerpt (2d) “You have to be close” J=Jamila; A=Amanda; T2=teacher 2

42Jom [du ska göra så dom ska höra inte dej (.) ((to T))
if you will do that they will hear not [INCORR]you (.)
43A[hon e dement hon stänger av allt ((to T))
she’s demented she closes herself off from everything
44J[du måste [e:: bli nära(h)=(.) heHEHEHehe
you must e:: become close(r)=(.) heHEHEHehe
45Ss[hehehehehih[ih h h h h h h h h h h
46T2                              [=ja men e:(.)hör hon illa så [gör ja ju(.)
                              [yes but e:(.)if she has a hearing problem
                                                                                                     [I’ll do [PART](.)
((T gazes toward L))          (Figure 7)
47A                                                                                                     [hon e ju dement
                                                                                                     [she’s[PART]demented
48T2på ett helt annat sätt (.)
[it] in a totally different way (.)
((T gazes toward A))
((A waves her hands in the air))(Figure 8)
49Astänger av allting=
[she] closes herself off from everything=
((J turns to the student sitting next to her; smiles and points at her ear))

Throughout this excerpt (Excerpt 2d), Amanda and Jamila problematise other issues (conditions associated with dementia and the resident’s possible hearing problems) that undermine the teacher’s proposed management strategy. Jamila remarks that the client will not hear the request (line 42), and that the caregiver has to get closer to the resident (line 44). This is followed by collective laughter in the class. Amanda also repeatedly points to the fact that the resident ‘is demented’ and closes herself off from everything (lines 43, 47, 49). To illustrate the closing off, she makes a waving hand gesture in an overlap with the teacher’s turn (line 48; Figure 8). In response, the teacher claims that she would act in another way if the resident had the problems raised by the students (lines 46, 48). In Excerpt (2e), the teacher delivers an embodied description of this revised strategy.

Figure 7: T2 turns to L.

Figure 7:

T2 turns to L.

Figure 8: A waves her hands in the air.

Figure 8:

A waves her hands in the air.

Excerpt (2e) “Then you should perhaps use the mirroring technique” T2=teacher 2; L=Lisa

50T2=nä å då er’e väl att man kanske får använda
=no ’n then that’s [ADV] (well) that one should perhaps use
51spegling lite (0.7)
mirroring (technique) a little (0.7)
52T2eller närma sej försiktigt å säja,
or approach (the resident) carefully ‘n say,
(1.5)((T approaches L, sits down at L’s knees))(Figure 9)
53T2¿e’re åk¿ej
¿is it o¿kay
54T2så att ja inte får en spark, (0.3) för de beror ganska
so that I do not get a kick, (0.3) ’cause it depends quite
55mycke på mej själv hur ja bemöter för att liksom, (.)
a lot on me myself how I encounter (the resident) like,(.)
56klara den här situationen.(1.2)sen så händer de ändå
to manage this situation. (1.2) then it happens anyway
57att,(.) men skulle ja hålla i henne så här.(1.0)
that,(.) but if I would hold her like this. (1.0)
((T approaches L, embraces L closely; gazes toward L))(Figure 10)
Figure 9: T2 kneels down in front of L.

Figure 9:

T2 kneels down in front of L.

Figure 10: T2 closely embraces L.

Figure 10:

T2 closely embraces L.

58T2då känns de lite otäckt (.)                     [va. ((to L))
then it feels a bit awful (.)                 [doesn’t it.
59L                                                                             [m: fast, (.) ja:a
                                                                             [m: but, (.) yes:
((L nods))
60(0.3)
61T2ja
yes
62Sshahahahaha [hahahahahahaha
63T2så då kan ja ge mej sjutton på att de här benet
so then it is a heck of a job that this leg
64åker upp.
will go up.
((T kicks with her left leg in the air))
((Discussion continues))

From line 50 onward the teacher addresses the students’ challenging counter arguments, proposing that one can adopt mirroring as a management strategy. In line 52, she performs an embodied demonstration of this technique, suggesting that one should approach the resident carefully. She comes close to the student, Lisa, kneels in front of her (Figure 9), and voices hypothetical talk to get permission to approach the resident, ¿e’re åk¿ej ‘¿is it o¿kay?’ (line 53). Emphasising the importance of the care worker’s behaviour in managing the situation, the teacher portrays the conduct thus illustrated as a method to prevent getting kicked (line 54), så att ja inte får en spark ‘so that I do not get a kick’. Even though the teacher points out that it [being hit] can happen anyway (line 56) – sen så händer de ändå ‘then it happens anyway’ – she is quick to provide a contrastive example when physical aggression most probably would occur. Immediately following her comment in line 57, the teacher initiates a turn that leads up to a demonstration of inappropriate behaviour, men skulle ja hålla i henne så här ‘but if I would hold her like this’. During and subsequent to the production of this turn, the teacher again enacts the wrong way of preventing abuse from clients. Invoking Amanda’s reported bodily behaviour (see Figure 3 and the teacher’s recycling of it, Figures 46), she steps forward to Lisa, embraces her tightly (Figure 10), and asks her if it feels unpleasant. The polar question (line 58), då känns de lite otäckt (.) va ‘then it feels a bit awful (.) doesn’t it’, represents a presupposition (Raymond 2003) that her conduct will make Lisa feel uncomfortable. The teacher’s subsequent bodily demonstration of the client’s hypothetical responsive behaviour with physical abuse (kicking with leg, see lines 63 and 64) attracts attention to the contrast between an appropriate and inappropriate management strategy.

The teacher’s request addressed to Lisa concerning permission to tie her shoelaces (see Excerpt 2c) illustrates a caring-like aspect of the policy advocated in the Swedish Social Services Act (SoL), that is, to promote the elderly’s right to self-determination and independence. Likewise, her bodily comportment of kneeling down in front of the resident, and, in this fashion, achieving a physically inferior position visa-à-vis the resident, enacts a non-threatening caregiver conduct. With this management strategy, the teacher illustrates a way to cope with institutional asymmetries in the care encounter (Heritage 1997). This conduct – to approach the resident from the front and kneel down – was recurrently advocated by the teacher as a strategy to avoid physical violence from residents. As the analysis demonstrates, the teacher’s instruction was received with counter arguments from the students, who point to aggravating circumstances related to the dementia context that undermine the teacher’s proposed bodily conduct.

4 Discussion and conclusion

In this article, we have explored the ways in which teachers act out hypothetical scenes for the purpose of modeling proper caregiver conduct in dealing with persons with dementia. Two examples, both of which considered the accountability of a trainee student’s conduct in managing a professional challenge, have been analysed. In order to highlight and depict a certain aspect of a care method emphasised in the curriculum, the teacher enacts hypothetical talk and conduct. In both examples, the teacher’s instructional work centres on how to tone down power asymmetries in the institutional encounter (Heritage 1997). In the first example this is accomplished through the enactment of an understanding caregiver attitude, and in the second example, through enacting a non-threating bodily comportment.

The findings from this study highlight the seemingly unavoidable conflicts and dilemmas experienced by trainee students during their vocational training in dementia care and the ways in which these dilemmas are dealt with in a classroom interactional setting. The students’ reported dilemmas bring into focus the physically and mentally challenging nature of care work. Amanda’s gesture of holding clenched fists and crossed arms clutched to her chest (Figure 3) recreates her effort to prevent a resident with advanced dementia from hitting her. Her waving hand gesture used to illustrate the resident’s closing herself off (Figure 8) foregrounds the communicative challenge that the student was faced with in this specific care encounter. These gestures portray the difficult conditions under which the care task of getting the resident dressed had to be performed. Likewise, Haydar’s experience from his vocational training describes a dilemma regarding the elderly’s wellbeing from different perspectives. Together, these reported dilemmas highlight what has been described in previous research as a conflict between the care recipient’s needs for emotional support and the task-oriented goal of the caregiver (Grainger 1993; Jansson and Plejert 2014).

The teachers’ instructional work brings forth the complexity of performing physically intrusive care tasks while at the same time maintaining the client’s dignity and sense of autonomy (Grainger 1993; Heinemann 2009, Heinemann 2011; Jansson and Plejert 2014; Plejert et al. 2014; Williams and Herman 2011). For instance, by recycling the student, Amanda’s, gesture (holding crossed arms clutched to her chest) and reusing it in a scenario that features herself as a care recipient (see Figures 4 and 5), the teacher portrays the student’s conduct as improper. Bodily conduct, such as proximity, touch and body posture, makes the teacher’s instructional work a forceful illustration of a strategy to communicate with a person with dementia. As such, the teacher’s embodied practices work to illustrate how empathy can be performed professionally in order to handle institutional asymmetry by adopting a subservient position in a care encounter and making clients feel comfortable.

Most importantly, the analysed examples in the present article bring to light how care approaches taught at school are challenged and sometimes defied by students’ real-life experiences. The incident with Amanda’s colleague who was hit during work by a dementia patient (see Excerpt 2a) led the student to apply a method that is contrary to the person-centred care ideology advocated by the Swedish Social Services Act (SoL) and course material (e. g. Skog 2009). The solution that the teacher recommends to the students in order to prevent violence from residents is to put oneself in an inferior position. This depiction of caregiver attitude is further emphasised by the teacher’s bodily behaviour of kneeling down in front of a hypothetical resident (see Figure 9). Likewise, the practice of easing a worried client through body language (see Figure 1) invokes an understanding and warm-hearted persona. Cuban (2009), in her critical study of migrant women and care in England, describes how migrant caregivers are socialised to withstand difficulties and resolve problems alone by showing understanding about their clients. This individualistic expectation, she argues, is upheld in the managers’ discourse of professionalism. A similar phenomenon takes place in the current study, under the veil of therapeutic terminology voiced from the course material. The teacher’s instructional work focuses on the unacceptability of care workers’ abuse of residents and, simultaneously, the moral view that abuse from clients can be managed (cf. Cuban 2008: 91). Through this discourse, the care workers’ socially inferior position is reproduced in the classroom setting. As described by Lorente (2010), discourses of servitude employed by institutions in the labour market style women into submissive and obedient workers, workers who silently do the “dirty work”. The students bring their lived experiences of workplace challenges to the classroom. In many cases, there is no ready-made answer to the issues that arise. There is a tendency then that the teachers, instead of opening up the classroom for analytical discussion, resort to embodied demonstrations of care methods concerning the physical aspects of care work, thereby using the students’ reported dilemmas for their own instructional work. Bodily conduct and scripted talk that the students can easily remember and adopt at work are used as resources for attention-raising pedagogical strategies. These “all-round” solutions are recurrently advocated irrespective of the details of the setting. For example, the teacher’s hypothetical request to the resident about permission to tie her shoelaces is deemed unrealistic by the students, with the argument that the resident closes herself off from everything due to her dementia.

Finally, the findings from this study bring into focus the complexity of the power relations and asymmetries at play in the teaching situation. As Makoni and Grainger (2002: 814) argue, there are hierarchical differences in all institutions. In institutions for the elderly, the care workers (nurse aides and assistant nurses) – those who do the physically hard work and interact with the residents most frequently – are at the bottom of the institutional hierarchy. The teachers in this study intervene in the students’ communication styles by making them accountable for their actions. For instance, abuse from residents in the second example (Excerpts 2c-2e) is portrayed by the teacher as a consequence of the caregiver’s comportment. This runs contrary to the fact that the caregiver in the specific case had behaved in a way that was in accordance with the fundamental rule taught in school of approaching the resident from the front. As Grainger (1995: 433) puts forth, intervention at the level of communication styles is too simplistic if it ignores contextual factors at the institutional level. Thus, an emphasis on individual communication styles runs the risk of placing the onus of responsibility with those who have the least power in the hierarchical system of institutional care. What we need most of all is a well-functioning educational system in which the status of care work is elevated to the level of a valued occupation and skill and in which the expertise and creativity of those who are recruited into the occupation are respected and validated This solution involves inclusion of a bottom-up approach to teaching and learning that allows for the valuing of individuals’ lived experiences rather than just top-down scripts and approaches that do not take these into account.

Acknowledgements

We are grateful to the students and teachers who participated in this study. The current study was supported by the Swedish Research Council (Grant no: 2013-2020).

Appendix A: Transcription conventions

The following conventions have been used in this chapter. They are adapted with some modifications from Ochs et al. (1996).

:::

Indicate the prolongation of the sound just preceding them. The more colons, the greater the elongation.

=

Utterances follow immediately to each other with no discernible silence between them.

[]

Brackets indicate where overlap begins and where it ends.

((nods))

Double parentheses mark the transcriber’s comment on how something is said or what happens in the context.

(1.6)

Numbers in parentheses indicate silence, approximately represented in tenths of a second.

(.)

Indicates micropause.

(xxx)

x in parentheses indicates something being said, but no hearing can be achieved.

°°

Degree signs indicate talk markedly softer or quieter than the adjacent talk.

yes

Underlining is used to indicate some form of stress or emphasis either by increased loudness or higher pitch.

.

The period indicates a falling or final intonation contour.

,

A comma indicates “continuing” intonation, not necessarily a clause boundary.

¿

The inverted question mark indicates a rise, weaker than a question mark.

Indicates marked shift into higher pitch in the utterance-part immediately following the arrow.

< >

Indicate that the talk is markedly slowed or drawn out.

hhh, hehe, haha

Indicate laughter.

ne(h)j

Indicates within-speech laughter

Appendix B: Morphological gloss abbreviations

PART

particle

ADV

adverb

[INCORR]

incorrect grammar or vocabulary in Swedish

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Published Online: 2020-03-04
Published in Print: 2020-03-26

© 2020 Gunilla Jansson and Ali Reza Majlesi, published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.