Caring as Competence in Organizational Life

1. Caring as Competence in Organizational Life Amy Wrzesniewski and Jane Dutton The May Meaning Meeting Ann Arbor, 2004

2. Goals of our paper • To reveal the competence in the caring that composes service work (by employees who do critical, invisible work) • To unpack competence as forms of caring, knowing what not to do (as rules of thumb) and cultivating different knowledge sources and different kinds of knowledge to deliver and adjust care

3. Starting assumptions and definitions • Define competence as “situational, context dependent responses that flow from the way individuals experience their work” (Sandberg, 2000) • Define caring as “any thoughtful human response (or non-response) that enables others to thrive” (Noddings, 1984) • Assume caring competence is foundation for high quality service especially in settings like health care i.e., hospitals. • Assume caring competence of individual hospital employees increases the caring capacity of the whole hospital system.

4. Key findings and theoretical positioning • How people see what they are doing in their work is best captured by caring • Caring rests on knowing • Caring competence is knowledgeable relational action, where “knowing how is not in the head, but in the practice, and understanding is implicitly in the activity” (Tsoukas, 1996)

5. Method • In depth interviews with random sample of 29 cleaners in Hi Tech hospital • Analyses based on data generated by 2 questions: • During the course of your job, what kinds of things do you do for and/or with nurses, patients, patients visitors and doctors? • Where do you draw the line for what you will do or not do for and or with nurses, patients, patients visitors, and doctors? • Standard theme analysis

6. Core Findings What care? Whether care? How to care? Punchlines 1. Direct and indirect caring compose the caring system 2. Rules of thumb provide guidelines for whether to care and timing of care 3. Knowledge sources and knowledge types The findings in one slide

7. Cluster 1 findings: What kinds of care?

8. Cluster 1 findings: Different forms of care

9. Caring form: Responding to requests • Definition: Caring by providing assistance in reaction to a request for help • Example (for patient, pv, nurses and doc) • “Whatever they ask me, whether it be helping them find a certain place, getting them things they need such as towels, toilet paper, or sometimes they’ll ask well, could I go and get the person they came in with like their visitor, or ‘Could you go get them something to drink for me?’ Because they don’t know how to get there and they’re scared of getting lost. I’ll do that, like I said, basically whatever they ask me to do. I have no problem with that.” (25: 337)

10. Caring form: Conversation-making • Definition: Initiation of /or response to conversations of another. Used to comfort and to get information • Example: (for patient and pv) • “A lot of times they want to hold a conversation with you. You know, they’re lonely or sick already. I try to hold a conversation. There’s a lot, all kinds of people come in here, you know, different backgrounds. Some people are interesting, they tell you about their life, their occupation, sometimes they catch your attention and you know, you listen and talk to them, you know. You may learn something. They like that. They say, ‘Hope to see you again tomorrow’ or ‘Come back and see me’ or whatever. “ (12: 195)

11. Caring form: Entertaining • Definition: Taking actions intended to make another laugh or be amused in some way • Example (only for patient) • “The patients, when I go into a room I tell them, ‘What are you doing here?’ I mean I, you know, ‘It’s time for you to get out of here, you’re wasting my time or you’re in my way.’ I try to cheer them up, you know. So I know how patients are. I’m a very healthful person, and I don’t like to be pampered when I’m sick, but I like to be cheered up too, because I’m bored. I think of people in the hospital being bored, got nothing to do, and then here comes an insane guy pulling his garbage, and tell them, ‘What the hell are you doing in that bed? It’s time for you to get out of here!’ But that’s the way, I mean with the patients I get along, you know, excellent with them, you know.” (20: 278)

12. Caring form: Empathetic concern • Definition: Displaying general regard or concern for the other, involving expression of affective arousal prompted by the situation of the other • Example (for patient and pv) • “I got to experience and feel some of the pain they have been dealing with their loved ones that are sick. Letting them, telling them how I went through a similar (thing) with my sister, letting them know that they’re not the only ones who have gone through this, and it does get better. And I like giving people that encouragement that it does get better, you know. And it kind of makes them feel better, because they cry a lot, and I let them know also it’s all right to cry; it sometimes helps. So, I like to give that encouragement, and I think they like to know when they talk about things that somebody is actually listening, you know?” (25: 310)

13. Caring form: Working around • Definition: Adjusting the timing and content of one’s work to accommodate the work of another • Example: (for docs) • “One thing you do for them is if you’re cleaning a room and you see them coming in there, most of the time you leave the room so they can examine a patient or talk to a patient. You know, you make it convenient for them, most of the time you stop what you’re doing and then you’ll come back after they leave and do the room.” (12: 215)

14. Cluster 1 conclusions • Mindfulness about how they cared and the difference it made • All caring forms embody flexible responsiveness: • Behaviors that convey monitoring the state of the other responding in ways intended to improve the condition of the other • Willingness of cleaners to be used as a type of flexible instrument

15. Cluster 2 findings: Knowing whether to actPrimary goals and Rules of thumb Primary Goal: Promote the health of the patient Example: “A lot of times I’ll talk to the patients because there are times when there are things that bother them they don’t want to tell the nurse or the doctor, and they’ll tell me. And if I think it’s pertinent enough, then I’ll let the nurse or the doctor know that this patient says such and such but don’t let them know I told you that. But I think it’s…pertinent for their case.” (4: 229)

16. 1. Knowing when not to act Rule of thumb: Do not put the patient in direct or indirect harms way • Direct :“They (patients) might ask me to come and move their bed or something like, I tell them to call a nurse because you know, I don’t want to mess with that, if I put them in the wrong position.” (15: 128) • Indirect: “I don’t talk about the stress of the hospital because they are already stressed that their family member is here… try not to say anything negative around visitors or patients.” (4: 314)

17. 2. Knowing when not to act Rule of thumb: Do not disrupt others who are providing care Direct: (doctors) “The conference room is basically the doctors’ rooms, you know. The doctors go in there and they hold conferences, quote-unquote, so when I seem them in there I know not to go in, you know, because if I do I might cause a problem, quote-unquote, as far as rocking the boat there. If they’re having something done, if they’re having a meeting, okay, and I’m not supposed to go in there and vacuum that floor. Okay. The floor is trashed out, I know it’s trashed out, and I’m supposed to clean it. I don’t just barge in there and just start plugging up vacuums, sweepers and start vacuuming. You know what I’m saying? I, uh, I look, and I know that they’re having some type of meeting or conference, so I, you know, so I stay away from that.” (17: 288) Indirect (Patents’ visitors) “I treat them with respect. I know that, you know, why they’re here and you know, like a lot of times when I go into the visitors lounge, you know, to clean, uh, I have to ask them, too. Sometimes I don’t bother because a lot of times when I go in to clean, they’d be asleep. So, uh, but, you know, supervisors, my supervisor has told me that I’m supposed to do this and I’m supposed to do that, but I, I prefer not to, so sometimes I have to bite the bullet for that. But, uh, I try to work with them because I know, you know, some of the things that they’re going through with their relative wherever they’re at. So, but all in all, I really don’t have a problem with any of these.” (17: 346)

18. 3. Knowing when not to act Rule of thumb: Do not act in ways that cause complaints or hurt the reputation of the hospital • “I won’t get obnoxious with the visitor. I mean I’ll bite my tongue before I say anything, because it will jeopardize my job. I mean you’ve got to use common sense. If the person is beyond reasoning, say, “I’m awfully sorry” and walk away. It’s the best way, you know, kill them with kindness. And if that doesn’t work, get the hell out of there fast.” (20: 716) • “When you got these visitors coming here, you know, you’ve got to figure hey, they’re visitors today, they might be patients tomorrow. So if they say hey I went to (Tech Hospital) and a guy came in to clean my room, and he made me get up so he can move my chair, when I had been sitting in it for six hours, the hell I’m going back to (Tech Hospital), I’ll go over to (another hospital).” (20: 329)

19. Cluster 2 conclusions • Rules of thumb reflect knowledge of boundaries or limits to action. • Caring competence is based on knowing what not to do that crosses lines (in terms of harming patients or disrupting those who are helping patients) or activates negative feedback (complaints or reputation damage to the hospital )

20. Cluster 3: Knowledge Resources:Different knowledge sources and knowledge types

21. #1 Knowledge from relationships with others Role in care delivery: Allows tailoring of response and planning of work flow Example: “Knowing illnesses of patients, that comes with knowing your area. But, it also comes with knowing your nurses, too. For instance, if there’s a patient that may have AIDS, okay? If you are a nurse and we’re good friends, I ask you and you tell me. “

22. #2 Knowledge from perspective -taking Role in care delivery: Allows one to understand what other is thinking/feeling Example: “Patients’ visitors are kind of tough, you know. They’re, you know, the majority are in the corridors or waiting rooms. And when you’re doing trash or you’re cleaning carpeting in there, or getting the chairs organized…you’ve got to be very cordial with them, because they feel they’re paying the bill. They’ve got somebody in there that’s close to death. So you’ve really got to watch your mannerism”.

23. #3 Knowledge from observing cues in context Role in care delivery: Allows one to adjust form and degree of caring Example: “There was a time in recovery I was watching TV on break and saw that a teenager had been to an accident with her brother and uh, realized that her brother was dead on arrival and the parents had to come in I guess, and view the body. And I had to uh, watch out for any other patients or any other visitors coming, you know, to go in this area, you know, to view the body or something. I just got done watching it on TV. “

24. #4 Knowledge from personal experience Role in care delivery: Creates basis for caring connection and deepens knowledge of what to do to care Example: “(I was) shaved (for surgery), and I let them know I was shaved too and I show my scar, and I let them know if you do your therapy and have a positive attitude, you’ll do just fine like me.”

25. Knowledge type:Knowledge about other’s condition Role in care delivery: Allows one to gauge and adjust how to react Example: “Some of these people will not live long. So, it really pushes me to make everything the best of my ability for them when they come in for their visit. Like I said, making them comfortable, making sure everything is clean, tidy, magazines up to date, anything that I can see would maybe irritate them, because when you’re taking chemo therapy and radiation you get kind of irritated with the least little thing. So you know, anything that I can think might irritate them I try to take care of before they see that.” (25: 619)

26. Knowledge type: Knowledge about best approach with others Role in care delivery: Allows one to plan interactions and care for space Example: “I’m usually pretty good at talking, so after I talked to them and let them know, ‘Well, I’m going to make it better. I don’t know who was supposed to clean the room. But, if after I’m done and you find something that I missed you can tell me and I can correct it right there,’ and they actually got nice after that…it’s just very uncomfortable to go into a room where there are so many tempers and I’ve learned to deal with that a lot here.”

27. Cluster 3 conclusions • Cleaner’s caring competence depends on accessing multiple sources of knowledge that facilitate reading, connecting and adjusting to changing conditions of people and context in the care system (patients, visitors, doctors and nurses) • Caring competence composed by accessing these sources and generating knowledge that facilitates flexible adjustment in situ

28. So What? • Caring competence as a f (knowing, being and doing in context) • Attentiveness of low status position (Fiske and Depret) is an asset as individuals highly mindful of others • People use simple rules of thumb, different knowledge bits, and use themselves as flexible instruments in achieving caring competence. These competent micromoves create a collective capability of the whole which is critical to service