Where Three Roads Meet: Triangulation in the Care Sector, A Psycho-Social View on Caring and Vulnerability SIEBELIEN FELIX Awarded Posthumously February 2017 December 2016 A thesis submitted in partial fulfilment of the requirements of the University of the West of England, Bristol for the degree of Doctor of Philosophy Faculty of Health and Life Sciences University of the West of England, Bristol ABSTRACT Where Three Roads Meet: Triangulation in the Care Sector, A Psycho-Social View on Caring and Vulnerability In this thesis I explore the effect on the lived experience of care workers and their managers in the residential elderly care sector of The Netherlands in relation to changes in and around the sector. Like in most western societies The Netherlands has to deal with ever increasing health costs. In 2006 the Dutch government opted for (semi-) privatizing the sector in the hope that competition would lead to more efficiency and reduction of costs. One of the major changes is the emergence of a powerful third party: the private insurance companies. As of 2006 healthcare and health cure providers have to negotiate with these companies about costs and services. The research perspective is a psycho-social approach, which aims to achieve a beneath the surface understanding of the interaction between macro and micro level phenomena. In doing so I wish to avoid approaching this issue from a single perspective such as organisational studies or social policy, in an attempt to adopt a more holistic understanding, viewing it both psychologically from ‘inside’ this experience and culturally/politically from outside. The data is collected through two case studies - two Dutch care homes for the elderly- where I applied three research methods: organisational observation, facilitated workshops and psycho-social interviews. The data was analysed by using a thematic, theoretical, deductive top down approach and with the help of reflection groups and postgraduate supervision. In this thesis I argue that macro level phenomena indeed are projected into the care sector and influence the running of the organisations and the lived experience of those working in the sector. The macro level phenomena are two feelings of anxiety in wider society: The fear of death and vulnerability and the fear that society can no longer afford the cost needed to care for vulnerable elderly. As such these feelings engender social defence like reactions and leads to ‘as if’ behaviour. It is as if good care is being delivered but in reality abuse is around the corner. I also argue that the sector has to learn to deal with thirdness or a form of triangulation. By given a third stakeholder – the insurance companies – the task to reduce costs etc a form of triangulation is brought into the sector. However this form in practice turns out to create fear. Management constantly focuses on the outside world and tries to comply with rules and regulations and leaves the carers to their own devices. The third party is regarded as a punitive superego, a negative third. I argue for a different form of triangulation in which the -one-in the third is allowed to be so that a true dialogue can emerge between the three partners concerned; the care recipient, the care provider and the financier. Acknowledgements I am extremely grateful to everyone who helped me to set up this research, to develop my thinking and to make it possible for this research project to have taken place My director of studies professor Paul Hoggett and supervisor Matthew Jones, Associate Professor of Public Health, have been vital in this and have guided my through and have stimulated me to develop and use my creative thinking. I foremost am very grateful to the two case studies. Both organisations gave me access to their inner worlds and created time to speak to and follow the management, the key workers, the carers and the facilitating staff. Without their valuable input the data of this study would not have been able to emerge. The existence of the Centre of Psycho-Social studies founded by Paul Hoggett recently relaunched as the Centre for Understanding Social Practices, and finding a home with Lita Crociani-Winland as new psycho-social team leader has been of the utmost importance. May the Centre for a long time continue its creative thinking. All of the academic staff and my fellow researchers at the Centre for Psycho-Social Studies helped me to identify and explore unconscious dynamics that I might otherwise have overlooked. Many among my friends and family supported me and had faith in my efforts. Foremost my husband Leo van de Valk who inspired me, stood by me through out and who supported me through thick and thin. Throughout the course of this research my father died. I would like to dedicate this thesis to him, who was extremely proud of the fact that I undertook this effort and who would hopefully have been proud of the outcome of the thinking. TABLE OF CONTENTS Chapter 1 Where Three Roads Meet: Triangulation in the care sector 1 Introduction ………………………………………………………………………….. 1 Research objectives ………………………………………………………….……. 6 Structure of thesis………………………………………………………………. 9 Chapter 2 The Dutch Health Care System …………………………….…….. 13 A brief overview of the situation before 2006 …………………….………….…….… 13 2006 and onwards …………………………………………………….………….….…. 18 The short-term health care market ……………………………………………………. 19 The long-term health care sector ……………………………………………………… 29 Overall trends ……………………………………………………………………………. 35 Chapter 3 A psycho-social perspective on care for the elderly … 36 A Psycho-social perspective…………………………………………………….. 36 Health, morbidity and care for the elderly …………………………………………… 59 Global issues concerning the care for the elderly …………………………………. 75 Economic and institutional forces and care for the elderly ……………………….. 79 Chapter 4 Methodology …………………………………………………… 98 Introduction ……………………………………………………………………………. 98 Psycho-social case studies …………………………………………………………. 100 The psycho-social method of organisational observation ……………………… 107 Facilitated workshops ……………………………………………………………… 112 Psycho-social interviews ……………………………………………………………. 117 Reflexivity - working with the data …………………………………………………. 120 Working reflexively as a researcher ……………………………………………….. 122 Action research as a consultant …………………………………………………… 130 Cross-case analysis ………………………………………………………………… 131 Objectivity and data analysis ………………………………………………………. 132 Chapter 5 Two Care Organisations In The Netherlands ………… 134 Introduction …………………………………………………………………………... 134 Arborvitae: Background and description of the organisation …………………… 135 The Noturos care group: Background and description of the organisation …… 141 Observing the psychogeriatric unit at Arborvitae ………………………………… 146 Observing At Volte–Face 174 Concluding Reflections 178 Chapter 6 Anxiety And Defences Against Anxiety In Care Organisations180 Introduction 180 Sources Of Anxiety 180 The Impacts Of Anxiety 195 Conclusion 237 Chapter 7 Crossroads of two discourses: The acre discourse versus the business discourse 239 The Care Discourse 239 The Business Discourse 255 Care at the Cross Road of Two Discourses: The position of the Key Workers and their Experiences 271 Concluding Reflections 299 Chapter 8 Analysis of Findings 301 Introduction 301 Fear of dependency, vulnerability and dying 303 Anxiety about the collapse of the welfare state 306 Effect of anxieties 309 Reforms and the healthcare sector - the case studies 311 From a dyadic to a triadic form of cooperation: a process of triangulation 312 A closer look at triadic relationships 314 The triangular relationship in the mind 319 Unsuccessful forms of triangulation causes thick skinned behaviour and as-if like reactions 323 The business discourse triumphing over the care discourse 328 The care discourse triumphing over the business discourse 330 Intelligent kindness 332 Chapter 9 Synthesis 339 THE VERY OLD ONE SINGS 348 Bibliography 349 Appendix 1: Overview of Actors in the Dutch Health Care Sector 384 Appendix 2: Timeline and Overview of Research Encounters at Both Case Studies 387 Appendix 3: Informed Consent Forms 390 List of Figures Figure 2.1 The players and markets in the Dutch public health sector 21 Figure 2.2 The financial flows within the cure sector 29 Figure 2.3 Stakeholders In The Long-Term Care Sector 34 Figure 3.1 Three sets core values in public management 88 Figure 4.1 Research systems 121 Figure 5.1 Painting on the lift 138 Figure 5.2 The communal area 138 Figure 5.3 The ground floor 143 Figure 5.4 Grenier in 1957 144 Figure 5.5 Grenier in the present 145 Figure 5.6 The stairs at Arborvitae 149 Figure 5.7 Room name 166 Figure 5.8 Who’s in / out 172 Figure 6.1. Overview of The Collages 222 Figure 6.2 Collage of Acting Managing Director 223 Figure 6.3 Collage Of Care Manager, Psychogeriatric Unit 225 Figure 6.4 Collage Care Manager Hetty 226 Figure 6.5 Collage Pf Facility Manager Jacques 227 Figure 6.6 Collage Of Care Manager Cecilia 228 Figure 6.7 Collage Of HR Manager 229 Figure 6.8 Grenier Performance Measures 236 Figure 7.1 Marketing Pages Of The Website Of The Noturos Care Group 261 Figure 7.3 An Overview Of The Flipcharts 283 Figure 7.4 Picture chosen by key worker BZ 284 Figure 7.5 Picture chosen by key worker F 285 Figure 7.6 Picture chosen by key worker I 286 Figure 7.7 Picture chosen by key worker G 287 Figure 7.8 Picture chosen by key worker E 288 Figure 7.9 Picture chosen by key worker N 289 Figure 8.1 The triangular relationship in the Dutch care sector 313 Figure 8.2 The triangular relationship in the mind 320 Figure 8.3 Intelligent kindness 333 Figure 8.4 The triangular relationship in the mind at Volte-face 336 Figure A.1 Overview of Actors in the Dutch Health Care Sector 384 Figure A.1 List of abbreviations 385 Figure A.1 Consumer groups and branch Organisations 386 Where Three Roads Meet: Triangulation in the Care Sector A Psycho-Social View on Caring and Vulnerability Chapter 1 Where Three Roads Meet: Triangulation in the Care Sector Introduction Every state of affairs at a given moment is in reality merely a phase of a development: no matter how concise or static or how rigidly formed it may appear.