In Nordic societies, the use of mobile phones for record-keeping during homecare visits has become an unquestioned routine. Care practitioners’ agency with these technologies has been explored mainly as a situationally constrained activity, neglecting their long-term orientations. Our empirical contribution is to explore care practitioners’ agentic relations to technology in a more nuanced way by including both dimensions. The theoretical contribution is to show synergy between temporal conceptualizations in theories of human agency and technology-in-practice, which highlight human agency as deliberation between situational and long-term temporal orientations.
Seven Finnish care practitioners were interviewed, and their entire work shifts were observed, consisting altogether 48 video-recorded homecare visits. The analysis of the ethnographic material was focused on situational and long-term temporal orientations of the care practitioners related to technologizing care.
Care practitioners in old age care approached technology use with three different kinds of temporal orientations: adapting – preferring to remain in the present; opposing – longing for the past; and engaging – viewing the technologization of old age care as positive for the future.
The situational usability of technology is not the only problem to be solved when technology is adopted for human-centred care; longer-term visions of how care and care work will change should also be voiced in healthcare organizations.
Temporal orientations may explain how and why care practitioners either just adapt to technology-use in care or act as change agents transforming both technologies and care.
1. Introduction
As the population ages in many Western countries, old age care faces demands and challenges to become more efficient. Remedies for the care crisis are currently sought from different welfare technologies that, for example, optimize care practitioners’ homecare visits, monitor older people in their homes and make some homecare visits video-mediated – all aiming to make care efficient and saving public resources (Frennert and Östlund, 2018; Kovalainen, 2021). Despite the critique of social scientists (Bergschöld, 2018; Ertner, 2019; Tufte, 2013; Hämäläinen, 2020) who argue that the standardized logic of technologies collides with the logic of care, such as sensitively responding to the situationally unique needs of the clients with respect by being attentive and listening in care (Waerness, 1984; Tronto, 1993), mobile technology has become an unquestioned part of care provision particularly in Nordic countries. One of the main technologies to affect the daily organization of homecare work is the enterprise resource planning system (ERP), which can be in the form of either computer software or an application on homecare practitioners' mobile phones. The system allows supervisors to allocate homecare visits among the team and then monitor the daily arrangement of care work in real time. It functions in parallel with electronic health records (EHRs) and service planning systems which also work on mobile phones. In Finland, hopes are high that the use of mobile technologies will increase the time spent at the client’s home as opposed to time spent at the office.
The increasing number of technologies raises concerns about how care practitioners will cope and act with technologization of care. Using mobile phones to update EHRs or care service plans during client visits has become an organizational obligation for care practitioners. Our article examines how care practitioners’ agency is manifested in relation to mobile technology, particularly when the practitioners interact with their clients and strive to provide good care. Based on the sociomaterial approach to care, Mol et al. (2010) have argued that care practitioners and technologies entail each other in practice. Technologies do not work or fail in of themselves, instead they depend on care work and on the practitioners’ willingness to adapt their tools, but also adapt their care to the tools, endlessly tinkering (Mol et al., 2010). We think there is a need to investigate in greater detail, how the human agency in this human-technology relationship has been theoretically defined. Therefore, we examine how temporality aspect and particularly the short- and long-term temporal orientations are conceptualized in theories of human agency (by Emirbayer and Mische, 1998), and practice-based approach, namely “technology-in-practice” (by Orlikowski, 2000). Both theories consider human agency as a relational phenomenon (Emirbayer and Mische, 1998; Orlikowski, 2000), in which agency emerges and is transformed through relations with other people and material entities such as technologies.
Before presenting the theoretical conceptualizations, we introduce related empirical research on how the agency of care practitioners has been represented in them. Our study explores empirically the variety of the human agencies in old age care work with the help of the defined theoretical conceptualizations in three ways: how care practitioners see their relationship with mobile technologies in homecare, how this relation appears in care, in mobile phone use situations and what kind of implications the different temporal orientations may have for the future of care. Seeing both situational and long-term schemas in human agency may explain how care practitioners act with the technologies in care: why they may avoid learning to use technologies or become change agents transforming both technologies and care work. Knowing all these relations provide more opportunities for the healthcare organizations to understand where the motivation or resistance of the care practitioners to use technologies in care derives from.
2. Related research
In the following, we relate our study to the recent ethnographic or qualitative studies, which have analysed care practitioners’ technology use in old age care from the practice-based view. Although mobile technology use has been researched as such among healthcare workers (e.g. Braun et al., 2013) old age care differs significantly as a technology implementation context from health care because of its social demands. Use of mobile technology may be disrupting the empathic and meaningful encounters required of care practitioners in old age care (Saari et al., 2024). Previous studies of the technologization of homecare have provided us with a view that care practitioners relate to technologies from different agentic positions. They may become non-users or critics (Højlund and Villadsen, 2020) of the technologies in care, adjusters between good care and the time-saving logic of mobile technologies (Tufte, 2013; Højlund and Villadsen, 2020; Koskela et al., 2023), time-savers (Bergshöld, 2018) in the standardized logic of homecare, tamers of technological properties (Hämäläinen and Hirvonen, 2020), or implementors and resource persons, whose agency may have been deployed for implementing new technologies and guiding older people in their use (Ertner, 2019).
Based on Niklas Luhmann’s systems theory, Højlund and Villadsen (2020) studied Danish nursery homes and a homecare unit to determine how care workers adapt the technologies to their practical needs and their care ethics. They found that employees’ strategies for technology adoption, by which they assessed how the technology could be applied to care work, varied between intentional disregard, productive adaptation, rule adherence and civil disobedience. Being able to provide care according to its ethical premises was one motive for adapting technology, such as intentionally disregarding technology use or bending the rules embedded in the technologies to focus on human interaction in care situations. More technology-oriented motivation to adopt the systems manifested as rigidly obeying the rules embedded in the technologies, such as in rule adherence (Højlund and Villadsen, 2020).
Several studies of old age care (Tufte, 2013; Bergshöld, 2018; Ertner, 2019; Hämäläinen and Hirvonen, 2020; Koskela et al., 2023) have examined the time-saving logic embedded in work-planning ICT systems or EHRs, both operated by mobile phones. Tufte (2013) showed that care workers in Danish homecare adapted their performance according to the current needs and everyday life situations of the older adults by allocating different times to home visits than those in the optimized work schedule. Furthermore, Bergshöld’s (2018) practice-based study of Norwegian homecare described care practitioners as skilful time-savers, when using an app on their smartphones that scheduled their homecare visits. However, their professional selves were depicted as being shaped by digitized representations, even to the extent that the care workers perceived performing their work in a short amount of time as a sign of professional competence. Although agency was not an explicit theoretical concept of the studies, the care practitioners’ ability to “steal time” from some of the visits for future visits can be interpreted as an indication of time-saving agency.
In the practice-based study of Finnish homecare workers (Koskela et al., 2023), the practices of balancing good care and the time-saving logic of the mobile technology were made even more explicit. The study found five different strategies for combining mobile record-keeping and good care: (1) multitasking, (2) pausing interaction with the client, (3) recording without the client noticing, (4) double recording using a memo or a piece of paper and (5) moving the recording task outside the client visit. These strategies manifest adaptive agency in relation to technology-use, in which the relationship between good care and use of technology was seen as tensional (Koskela et al., 2023), although the concept of agency or its various temporal orientations were not used in the study.
Hämäläinen and Hirvonen (2020) used the concepts of taming and unleashing (Pols and Willems, 2011) in their practice-based study to describe how EHRs are used in the long-term care of older people. The results indicate an active position in relation to technology-use, in how care workers reshape and make the prescription of EHRs by taming it to better suit care work practices. On the other hand, EHRs were described as having the potential to unleash care workers to enable them to provide care in better coordination with their colleagues (Hämäläinen and Hirvonen, 2020). The concept of taming and unleashing concerned the user’s way of acting in a certain care situation without referring explicitly to human agency, while simultaneously referring to the properties of the technology. However, care workers’ agency can be interpreted as being rather adaptive, but sometimes opposing to the organizational obligation to use EHRs during client encounters, manifesting as care workers’ complaints about the logic and functioning of the EHRs.
Ertner’s (2019) ethnographic study of a Danish homecare unit revealed the most positive agencies in relation to technologies among homecare workers: acting as implementation agents and technology resource persons, who are responsible for implementing technologies in older people’s homes and guiding older citizens. Managers cultivated this kind of agency by training, pampering, and rewarding care workers in order to increase their sense of emotional attachment to the technologies (Ertner, 2019). Although it used the concept of agent, the study did not use the theory of human agency as a framework either. However, it implicitly suggested that the dynamics of enhancing and persuading care workers to act as spokespersons for the technologies are needed for a certain human agency to evolve in the organization.
Our study delves into where these agencies of the care practitioners derive from by investigating their temporal orientations with the technologies and the future of care. The temporal orientations are conceptualized through the theory of human agency and technology-in-practice approaches, which we now address as theoretical frameworks.
3. Theoretical approach
3.1 The position of human agency
The practice-based studies of care work previously cited have not emphasized the significance of human agency and its intentionality, nor have they leaned on the theory of human agency when analysing the dynamics of organizational activities and technology-use situations. Practice-based analyses tend to examine actors and objects as sociomaterial assemblages (Orlikowski and Scott, 2008, p. 455), treating human beings and material artefacts as even symmetrically powerful agents in some research streams, such as in actor-network theory (Callon, 1986; Latour, 1993). In information systems (IS) studies prioritizing and analysing the agency of human being in relation to technological agency have been seen relevant for understanding why sometimes the implementation of technologies fails or how technologies change work practices (Chu and Robey, 2008). The theory of human agency and its temporality (Emirbayer and Mische, 1998) has previously been used in IS studies to study for example adoption of online learning system in healthcare work (Chu and Robey, 2008), and patterns of human agency and mobile technology use in nomadic computing environments (Cousins and Robey, 2005). These studies have revealed in a nuanced manner how patterns of technology use derive from conflicting temporal elements of agency, in relation to either personal life environment (Cousins and Robey, 2005) or work practices and context (Chu and Robey, 2008). The temporal nature of human agency; the ability to react to the present situational circumstances but deliberate simultaneously the actions in relation to the past or the future (Emirbayer and Mische, 1998), distinguishes us as human beings from the agency of the material artifacts. Material artefacts do not make plans or take actions to change the activity (Miettinen, 1999), as human beings do, nor do they create routinized practical consciousness to reinforce work practices as they are in the past (see Giddens, 1984). Inspired by the significance of the temporality in human agency as an explanatory dimension, we bring the theory of human agency by Emirbayer and Mische (1998) into discussion with the practice-based approach (Orlikowski, 2000). We investigate how these theories conceptualize temporalities of the human agency, such as situational actions together with the long-term imagining of the future development. Our focus is thus not only in identifying the different temporal orientations and technology use patterns as such and in situ (as Cousins and Robey, 2005; Chu and Robey, 2008), but to understand how they may influence on the development of care in the future. In the next two sections we describe the conceptualizations concerning temporality in human agency more in detail and for the use in empirical analysis.
3.2 Theory of human agency
Emirbayer and Mische (1998, p. 963) have conceptualized human agency as a temporally embedded process of social engagement informed by the past but also oriented towards the present and the future. The temporal-relational contexts are explained as existing simultaneously in human action and these agentic orientations are characterized as iterational, referring to the past; as practical-evaluative, referring to the present; and projective, referring to the future. The structural environment of action is both sustained and altered through the variable, changing orientations of human agency within the flow of time. Human consciousness is seen as being constituted through the capacity to be temporally and relationally in a variety of systems at once (Emirbayer and Mische, 1998.).
The iterational dimension, as a locus of agency, is manifested in how the human actor recalls, selects and applies the tacit or routinized schemas of action that they have developed through past interactions (Emirbayer and Mische, 1998, p. 975). Schemas are described as corporeal, affective and cognitive patterns that consist of mental categories, embodied practices, and social organization (Emirbayer and Mische, 1998). In the empirical analysis of care work, these schemas of action might be connected to historically recognized values and ethics of care which propose that care should be conducted with attentiveness, responsiveness and respect (Noddings, 1984).
The practical-evaluative dimension of agency is manifested when the encountered situation becomes somehow ambiguous, unsettled, or problematic and something must be done to solve it. Human agency comprises deliberation, which involves more than merely adjusting to the concrete demands of the present; it also comprises conscious consideration of how to respond to situational contingencies in the light of broader goals (Emirbayer and Mische, 1998, pp. 998-999). The deliberation over the decision on how to act is followed by its concrete execution, which in turn is influenced by situational and broader contexts. In the context of care work, this means understanding not only to how the care practitioner acts in a care situation, but also understand how they see the future of care and their own actions in that imagined broader context.
The projective dimension of agency refers to how agentic processes give shape and direction to future possibilities by reaching forward to the unknown. The locus of agency is about moving beyond themselves by inventing images of where they think they are going, where they want to go, and how they can get there from where they are at present (Emirbayer and Mische, 1998, pp. 984-987). In the empirical analysis of care, we may evaluate how care practitioners’ ways of using mobile technology may reveal how they value the role of technology in care, both in situ and on a broader scale; in how they see the technologization of care changing the future of care.
The intentionality of human agency can be heard in how Emirbayer and Mische (1998, p. 1003) formulate human agency with these various temporal orientations: “actors alter or shift between their agentic orientations, dialogically reconstructing the internal composition of their chordal triad, they may increase or decrease their capacity for invention, choice, and transformative impact in relation to the situational contexts within which they act.” As the theory of human agency does not specifically describe the structural environment as technological tool use, we next show how the temporalities are conceptualized in the technology-in-practice-theory.
3.3 Technology-in-practice
Technologies-in-practice approach directs attention to how knowledgeable human action is engaged and acts with given technological artefacts and how, by using the technology recurrently, it constitutes and reconstitutes emergent structures (Orlikowski, 2000, p. 421). It acknowledges human agency and its transformational position in relation to technologies and structures. Orlikowski (2000) describes three kinds of consequences as outcomes of users’ participation: processual, technological and structural. Processual consequences refer to changes in the execution and outcome of users’ work practices, whereas technological consequences refer to changes in the technological properties available to the users, and structural consequences refer to changes in the structures that users enact as part of the larger social system (Orlikowski, 2000, p. 421). Then, in terms of how the user integrates the technology into their prevailing way of doing, Orlikowski distinguishes between three types of enactments. In the inertia type of enactment, users show little interest in integrating the technology into their work practices, they choose to use the technology in such a way that they retain their existing way of doing. In the application type of enactment, users choose to use the new technology to augment or refine their existing ways of doing things. The outcome of enactment reinforces the structural status quo but makes changes to the technological artefact and work processes. In the change type of enactment, the users choose to use the technology to alter their existing ways of doing things, which also transforms the structural status quo, and changes the users’ work practices as well as the technological artefact (Orlikowski, 2000.).
3.4 Summary and research questions
To sum up, the practice-based approach proposes that the enactments of inertia, application and change consider the human agent an intentional avoider, integrator or change-maker of the technology between the past, present and future states of the activity in which the technology is supposed to be used. The theory of human agency in turn makes the different temporal orientations explicit: iteration, practical-evaluative and projective, from which the motivation for the agentic moves of the human actor could derive. Table 1 summarizes the conceptualizations of the temporal orientations of the presented theoretical frameworks and how they apply to care work, on the basis of which the research questions were formulated.
Theoretical concepts and their synergy applied to care work
| Temporal orientation in care practitioners’ agency | Past How the past influences on agency of care practitioner? | Present How care practitioner encounters the present situations with the clients and technologies? | Future How care practitioner sees the future of care? |
| Human agency–theory Temporal orientations manifesting in care | Iteration manifesting how tacit or routinized schemas developed through past interactions are applied, such as working according to ethical premises of care | Practical evaluation manifesting how concrete situations are solved deliberating between situational demands and broader view, such as how the future of care is seen | Projective shaping and giving direction to future possibilities, such as what care practitioners think technological development will lead to in care |
| Technology-in-practice Temporalities in technology use in relation to care work | Inertia type of enactment, with little interest to integrate technology in care work, preferring to retain their old way of caring | Application type of enactment to refine their existing ways of caring | Change type of enactment to alter their existing ways of caring and properties of technological artefact into new future way of doing |
Source(s): Authors’ own work
Research questions to be analysed:
What kinds of temporal orientations do care practitioners have towards care work and the mobile technologies used in the context of old age care?
How do care practitioners’ agencies manifest in client interactions when they use mobile phones, and how can their agencies be interpreted from the perspective of the future of care of older people?
With these questions we may delve into phenomenon of agency to find out how intentionality and motivation of the care practitioners may derive from different temporal orientations. Asking these questions from empirical data, provides a possibility to interpret care not only as a situational practice, but being affected by imagined visions about the role of technology in old age care in the future.
4. Data and methods
4.1 Finnish homecare as a research site
In recent years in Finland, social policy has aimed to reduce the proportion of institutionalized care of older people because of its high cost and to increase the proportion of older people’s homecare (Rantala et al., 2022). Public care of older people has been a pioneer in digitalization compared to private and third sector. Digital technology, for example, ERP, electronic service plans and EHRs, are seen as vehicles for improving the efficiency of homecare work and have significantly influenced the organization of working hours, how many clients are cared for during one work shift and the kinds of tasks that are meant to be conducted at home (Rantala et al., 2022). In Finnish old age care in 2020, almost all public sector organizations reported having electronic client record systems, 67% of which were operated by mobile technology (Salovaara et al., 2021). The change from paper and pen to keeping records on a mobile phone has been rapid in old age care work, taking only a few years and affecting professionals.
In our study sample, the participants were both practical nurses (having an upper secondary level vocational qualification of 2–3 years) and registered nurses (having a bachelor’s degree of 3.5 years), and majority of them women. Nurses usually only do two to four homecare visits per work shift and their tasks focus on medical care. Practical nurses do 6 to 12 homecare visits, which focus on basic care, such as helping the client with nutrition, hygiene or dressing.
4.2 Data collection and research ethics
The data consist of qualitative interviews of seven care practitioners and observation of their entire work shifts in two Finnish municipalities. The interviews were conducted in the spring and the ethnographic observations in the autumn of 2021. Originally the sample of participants to be observed was chosen from 17 voluntary interviewed care practitioners from two different Finnish public homecare units. In our sample selection for the observations, we aimed to include as much diversity as possible in terms of gender, education, experience, national origin, and specific work roles. The interviews lasted 55–70 min and covered themes such as work history, changes in work and technology-mediated communication, the use of social media, technological knowhow and agency, relationships with clients, understanding empathy and good care, wellbeing at work, and future work prospects.
In the observed work shifts each practical nurse made 5–12 client home visits, the nurse made three client visits, and the practical nurse who worked with remote homecare made 28 video visits. The homecare visits varied from 15 to 70 min, and the video meetings varied from 8 to 18 min. In the ethnographic fieldwork, one researcher observed each homecare visit at a time during one work shift. All authors made observations. We got an access to videorecord 6 remote video visits and 42 physical homecare visits. We videorecorded the entire visit and wrote a field report including descriptions on the care practitioner’s actions and conversations with others. Our ethnographic approach leans in epistemic sense on feministic research tradition in which research participants are not treated only as sources of data, but rather active participators who bring their view and critics to the interpretations (Pollock, 2012; Stacey, 1988). Therefore, we invested a lot of effort in building a trustful and open relationship with the care practitioners and provided a possibility for them to reflect on their own data. A month after the observations, we watched selected videoclips from each client visit with the care practitioner and recorded the reflections as data. The procedure followed the phases of the Empatia-video reflection method (Levonius and Saari, 2023). The interviews and videorecorded data and field reports functioned as primary data, and the video reflection data provided background data to deepen our understanding of the interactions.
Besides seeing research ethics as relational, we followed the conventional research ethics procedures. The research plan and data collection procedures were approved by the Ethics Committee of the Finnish Institute of Occupational Health (9th October, 2020), and all the participating organizations gave permission for the research to be conducted. Each client and care practitioner were informed about the research aims and signed their written consent before the interviews and observations. All names and other details that may enable identification of the participants were removed or altered in the text and the data excerpts.
4.3 Data analysis
The following figure depicts the analysis as a two-directional process and the ways we integrated explicitly expressed temporal orientations of the care practitioners together with how agency was manifested in technology-use situations in client visits (see Figure 1).
The flowchart shows a first text box at the top with the text “48 video recorded homecare visits of 7 care practitioners, right arrow 42 homecare visits with technology-use situations,” leading to a second text box below that reads “37 mobile record-keeping situations, and 20 videoreflections of their client visits.” Three arrows labeled “Situationally manifested” extend from the second text box and point to a third text box below, which reads “2 emotional talk in technology-use episodes,” “33 non-verbalized mobile phone use episodes,” and “2 care practitioner uses clients’ mobile phone episodes.” A fourth text box below reads the texts, “2 orientations to past,” “3 orientations to present,” and “2 orientations to future.” Two arrows extend from the text “2 orientations to past” and point to “2 emotional talk in technology-use episodes” and “33 non-verbalized mobile phone use episodes,” respectively. An arrow extends from “3 orientations to present” and points to “33 non-verbalized mobile phone use episodes.” Two arrows extend from the text “2 orientations to future” and point to “33 non-verbalized mobile phone use episodes” and “2 care practitioner uses clients’ mobile phone episodes,” respectively. Three arrows labeled “Explicitly expressed” extend from a fifth text box at the bottom, which reads “Analysis of 7 care practitioner interviews: long-term temporal orientation to care and technology,” and points to the fourth text.A diagram of the two-directional analysis process
The flowchart shows a first text box at the top with the text “48 video recorded homecare visits of 7 care practitioners, right arrow 42 homecare visits with technology-use situations,” leading to a second text box below that reads “37 mobile record-keeping situations, and 20 videoreflections of their client visits.” Three arrows labeled “Situationally manifested” extend from the second text box and point to a third text box below, which reads “2 emotional talk in technology-use episodes,” “33 non-verbalized mobile phone use episodes,” and “2 care practitioner uses clients’ mobile phone episodes.” A fourth text box below reads the texts, “2 orientations to past,” “3 orientations to present,” and “2 orientations to future.” Two arrows extend from the text “2 orientations to past” and point to “2 emotional talk in technology-use episodes” and “33 non-verbalized mobile phone use episodes,” respectively. An arrow extends from “3 orientations to present” and points to “33 non-verbalized mobile phone use episodes.” Two arrows extend from the text “2 orientations to future” and point to “33 non-verbalized mobile phone use episodes” and “2 care practitioner uses clients’ mobile phone episodes,” respectively. Three arrows labeled “Explicitly expressed” extend from a fifth text box at the bottom, which reads “Analysis of 7 care practitioner interviews: long-term temporal orientation to care and technology,” and points to the fourth text.A diagram of the two-directional analysis process
To start with the analysis of interviews, we read all the seven interviews several times to obtain a sense of the whole narration, and the technology-related contents and future work prospects, in particular. Then the observation data of each interviewee was examined beside the interview transcription to interpret what kinds of temporally oriented agentic acts, the interactions and the interview content represented. In the agentic acts we looked at how the care practitioner operated with or talked about technology in their hands or nearby, and how they presented their technology-use to the clients. This kind of meaning interpretation is not based on categorization only, but on recontextualizing the statements within broader frames of reference (Kvale and Brinkman, 2009, p. 207): in our case, looking at each set of data per care practitioner. In this way, the data sets of the care practitioner were interpreted as representing three different kinds of temporal orientations in human agency, as described in the findings.
The ethnographic approach followed a new reflexive way of writing (Denzin, 1997, p. 266), which included interpretations of the observed situation from both outside and inside care activities. This means that all the client visits chosen for the detailed analysis and deductive reasoning were the ones reflected with the care practitioner, thus their own sensemaking of the situation was acknowledged. To find the situations in which technology was used during the work shifts, the first author read all the field reports and watched all 48 videos of the homecare visits (42 videos) and remote homecare meetings (6 videos) and made a table with a condensed description of each technology-use situation. Altogether 42 homecare visits (from a total of 48) involved care practitioner’s use of technology. In 37 cases, the technology-use situations concerned mobile record-keeping or the care practitioner’s use of a mobile phone. The videoclips were discussed in the author team and mobile record-keeping episodes were chosen for a more detailed analysis. We use the notion of episode (van Dijk, 1981) to refer to a semantic unit of discourse in the flow of activity, which includes several speech turns on the same thematic unity or sequence of actions with the objects, in this case with the mobile phones. From the perspective of the practice-based approach, we identified that the application type of enactment in which the care practitioner used her mobile phone as part of the homecare visit, without the client or the worker mentioning it, was represented in 33 videorecorded episodes. Four deviations to this trend were identified: emotional talk about the technology at the presence of the client (N = 2) and care practitioner using client’s mobile phone (N = 2). All these deviations and one of the most typical mobile-recording episodes were chosen as samples for detailed deductive analysis. Their interaction episodes were transcribed and then examined and interpreted from the perspectives of human agency together with the technology-in-practice framework.
5. Findings: homecare practitioners’ temporal orientations
5.1 Orienting towards the future – taking care of the client’s technology
In this type of engaged agency related to technology, the care practitioners’ talk shows that technology can improve older people’s lives and offer new opportunity to connect–if not yet, it will do so in the future. As one excerpt one interviewee reflected: “I think all this kind of new technology, whatever you can get is all good. Yes, as the years go by, clients will start to have a bit more digital skills.” (H10)
It is noteworthy that he refers to future as he imagines that clients will have more digital skills than nowadays, therefore he should help them to reach these skills. The positive view of technology resulted from the practitioner having been involved in either developing, implementing or using the technology in the organization. This type of agency includes the capacity to guide and help other professionals and to take on more special tasks devoted to technology use only, such as planning work shifts for others with ERP. However, engaged agency to technology does not seem to override the idea of good care or being present with the client. The organizational obligation for mobile record-keeping is conducted in a discrete way, so that it does not disturb interaction with the client:
If I have time, I'll stay and do them [mobile record-keeping]. If I have the feeling that, well, if it's something short and to the point, I'll do it there [during the client visit]. Then if it’s a longer story, then I don’t stay for it, because many of them are a bit surprised by you sitting there and writing for a longer time, so some ask what you are writing now. (H10)
The care practitioner states that if the client does not understand the purpose of the mobile record-keeping, and it takes too much attention, it may be experienced as rude, and thus part of the care practitioner’s duty is shifted outside of the visit.
The following excerpt (see Table 2) is from a homecare visit with an older female client in her nineties. The purpose of the visit was to take care of the client’s nutrition and medicine. The episode halfway through the visit manifests the how fluently and flexibly the care practitioner uses his own mobile phone to contact the client’s relative, and then helping the client use her own mobile phone.
Engaged relationship with mobile phone in interaction between care professional and client
| Client visit of H10 | Actions |
|---|---|
| (9:57- 17.23- episode 1) E: My fingers won't obey that machine. C: They won't obey that machine. I can show you in a minute. R: They're made that way for young people. .. C: I'll continue writing that message in a minute, since it's going to be such a long message, but I’ll make you your meal first. | E sits at the kitchen table, C sits across the same table and taps at his mobile phone, C glances at the client's mobile phone on the table. C continues typing an answer on his mobile phone. C taps at his phone in silence (50 seconds) E moves the fork and cup on the table to make a sound C gets up from the chair, puts the mobile phone into his pocket and opens the fridge door. C heats up a dish of food and does some prep work for the meal, E takes her medicine, C taps at his mobile phone and tells E that he replied to her daughter, C takes the dish from the microwave and hands it to E (altogether 6 minutes) |
| (17.23 -19.30 – episode 2) C: There are no new photos... There's the video you were talking about. He's screaming down there in the well. E: He’s watching it, when the water goes down the drain. (Sound of splashing water) C: It's good to have a rig like that so you can go swimming in it. E: Good boy. C: It was the ice cream truck, we watched it yesterday. C: You've really taken a selfie like this. E: Yeah. (Smiling) C: That's the last picture where he's at the airport. E: I don’t know if it was when he was about to go or when he was returning. He visited Rovaniemi. He's a kind of cuckoo head. | C sits down at the kitchen table, takes the client's smart phone from the kitchen table. E scrapes a jar of margarine. C shows E the screen of the mobile phone, where E's grandson is playing with water. C and E watch the video together C turns the mobile phone towards himself and flicks the video off. C looks for a new video on the mobile phone. E starts to eat C turns the mobile phone horizontal and shows it to E, E looks at the photo on the mobile phone. C shows the photo to E. E looks at the mobile phone. C puts the mobile phone back on the table. |
Source(s): Authors’ own work
In episode 1, the care practitioner uses his mobile phone to communicate with the client’s daughter. As this takes some time, the client comments to the care practitioner on her own inability to use such a device, as well as to the researcher who is observing the situation. The care practitioner replies that he can help with that in a moment. The researcher tries to be empathetic by commenting that mobile phones are designed for younger people. As the care practitioner taps at his phone for almost a minute, the client starts to move her fork and cup on the table, probably to draw the care practitioner’s attention to her presence. This makes him stop writing the message and turn his focus to the hungry client. He prepares lunch for the client, and then continues with the message. In the episode 2 the care practitioner then takes the client’s mobile phone and searches for videos and photos from the client’s daughter, to show them to the client.
From the practice-based perspective, the care practitioner’s actions first reflect the application type of enactment, when the use of his mobile phone happens in the middle of preparing lunch. However, the episode suddenly turns to the client’s phone, reflecting the change type of enactment by the care practitioner. This act represents a deviation compared to the other observations, because it was one of the only two episodes in our entire videorecorded data in which the practitioner also used the client’s own phone for the client’s good. This change in the interaction manifests a projective agency of the care practitioner, as a facilitator of technology for a less capable client to check on her behalf if any new messages had arrived for her to read. We consider this act exceptional in old age care work and an act that keeps up the client’s social ties with her relatives. Seeing her grandchild in a video clip while eating her lunch was not the same as seeing them face-to-face, but nonetheless it gave her a moment of joy. It was also an act that could easily have been left undone. It seems that the care practitioner sensitively interpreted the client’s wish from her indirect phrase: “my fingers don’t obey that machine,” and promised to help with it.
The engaged relationship with the technology is shown situationally by smoothly operating with the mobile phone while verbalizing the contents of the display, and as even caring for the client’s technology while responding to and prioritizing the basic and social needs of the client. Compared to previous research, this type of agency resonates with the description care practitioners working as implementation agents and technology resource persons (Ertner, 2019).
5.2 Staying in the present – reconciling the use of a mobile phone into care
In this type of adapted agency related to technology, the care practitioners’ talk manifests how they expect the number of technologies in homecare to increase and how they try to adapt to the change by fitting the use of technologies into care. Mobile record-keeping as an activity is seen as an indispensable necessity, a task that care practitioners try to smoothly integrate into care while interacting with the client before, after or at the same time as their documenting duty, as the following excerpt indicates:
When you can record things a bit faster on your mobile, you have more time to be with your clients. With the other [ICT system] we had to write such a lot and there was a lot of writing, but here, there are more clicks and then I write when necessary, so this has been good for the clients, it allows more time for them, when it seems … At least I always feel that I’m on the phone too much when I’m with the client. If I could choose, I would have no phone, but we’re forced to do mobile record-keeping during the visit, so then there’s no other option. (H44)
This excerpt reflects how adapted the care practitioner is to the mobile record-keeping and to changes in documenting methods, because she thinks she is forced to do so. It indicates that the care practitioner prioritizes being with the client without the phone.
The following excerpt (see Table 3) from a client visit demonstrates a moment during a homecare visit, when a care practitioner does not hide their use of their mobile phone but interrupts her tapping to respond to client’s questions. In this episode, the care practitioner and an older female client in her eighties are sitting opposite each other at the kitchen table.
Adapting relationship with the use of mobile record-keeping
| Client visit of H45 | Actions |
|---|---|
| (2.45 -5.00) C: Sorry to bother you, now you can continue E: Those edges are a bit hard. C: Yeah, cut the edges off with a knife. E: In some places it's hard. C: Yeah. E: Is that the medicine? C: Yeah. I'll give you some water. Just eat in peace. (3.50) E: Hmm. E: How come I've got this strange feeling in my head, I've had it all night. Is it because of the low blood pressure or what? C: You've said before that your head gets weird in the evening. We can measure your blood pressure. E: Somehow if I get out of bed when I'm lying down, it's kind of weird. C: Yeah. | (After C administering eye drops to the client in the middle of client eating) C sits opposite E, eyes on her mobile phone which she taps with her thumbs. C eats half a pizza C looks at E’s eyes over the phone C puts down the mobile phone and takes the medicine from the medicine roll on the table into a dispensing cup and puts it in front of E. C takes the mobile phone from the table C looks at E over the phone. C glances at E over the phone. C turns her head downwards, looks and taps at her mobile phone with her thumbs C looks at her mobile phone, which she is holding with both hands, tapping at the phone in silence (60 seconds) |
Source(s): Authors’ own work
The episode begins after an interruption by the care practitioner, who had administered eye tips to the client and then returned to sit opposite to her. The care practitioner alternates between mobile documenting and listening to the client’s worries. As the care practitioner’s attention is mainly on her phone, the client eats silently at first but then initiates conversation. The care practitioner stops recording her notes and gives the client her medication, and the client responds by asking: is that the medicine? After this the care practitioner continues mobile recording. She does not verbalize the contents of the mobile recording to the client. The client does not comment on the act either, instead she takes initiatives regarding her own state of wellbeing. The care practitioner shows compassion by displaying understanding. This episode illustrates the application type of enactment. It shows how the homecare visit’s interaction has dual aims: being attentive to the client according to the ethics of care but documenting and reading the client’s service plan on the mobile phone, which are then combined in a subtle way. The use of the mobile phone during the interaction between the client and the professional slows down the interaction and creates many pauses. The episode reflects the practical evaluation agency type, which aims to solve the tension by alternately providing good care and performing the professional duty of mobile record-keeping. Care practitioners develop several strategies for reconciling the duty of electronic record-keeping into care, and the episode illustrates the multitasking strategy (see Koskela et al., 2023).
5.3 Longing for the past – sharing frustration against mobile record-keeping
In this type of opposing agency related to technology, care practitioners’ talk openly critiques and expresses frustration with technology in care work, manifesting a longing for the past. The old way of documenting in the EHRs – free writing about the health state of the client – is preferred, because in the new method: “you don’t describe how the client is really doing on the whole” (H49), you just try to find menus to click on the phone. A care practitioner wanted to use her own paper notes during a homecare visit to focus on the client and not on her phone. The temporal orientation of the care practitioner can be described as iterational, connected to the past, in which the old way of working is perceived as better, as this cynical claim of one care practitioner shows: “Many of our older caregivers are saying that we used to care for the clients and now we care for the phone.” (H46)
Part of the critique expressed is towards the new obligation to update the phone as a self-service, which took too much time and aroused anger, as one interviewee described: “It must have taken me a whole day to do it, because I tried again and again.” (H46)
The following excerpt (see Table 4) from a client visit presents an episode during a homecare visit, in which care practitioner’s frustration with mobile record-keeping bursts to the client. The care practitioner is visiting a male client in his seventies. His mobile phone has disappeared and needs to be find. At first, they try to find it, but then the care practitioner begins to use her own mobile phone.
Manifesting opposing relationship to mobile-recording during a homecare visit
| Client visit of H49 | Actions |
|---|---|
| (0.00 – 1.45) (1.45-3.30) C: Look! Someone is writing in your care plan. I can't write it down now. It's such a mess. E: Where the hell is the (my) mobile phone? It's not in there either. C: You can't write here if someone in the office is writing on a computer. (laughing) I can't write. With [name of the ERP] comes all sorts of surprises. Who's doing the care plan now? Sometimes you can see who’s doing it. I think I've got the medicine written down. E: It's not on the radiator, is it? No, it's on the little radiator. C: No, but I'll call you in a minute [on your phone]. I don't know what to write down, otherwise I'll forget. But I can make notes, even if someone is re-making the care plan. (3.30 – 5.00) C: Remember who it was yesterday? Was there a substitute? E: It was someone who had never been here before. I wonder where it (she) has put it. C: Yes, this is the evening pill... | C and E are looking for the client's missing mobile phone in the apartment. C sits down and begins to fill in the records on his own mobile phone E looks under the hat on the top of the cabinet E moves to sit at the table. C shows his mobile phone screen to E. C continues tapping the mobile phone C shows the mobile phone screen to the client. C spreads his hands. E eats his breakfast. C talks to herself, looks at her phone. E points at the radiator. C looks at the radiator. C talks to herself C taps at her mobile phone with her index finger for 60 seconds in silence. C puts the mobile phone aside and starts feeling in her pockets, digs out a piece of paper with notes on the client. C moves to the fridge and starts asking E what he wants for lunch. |
Source(s): Authors’ own work
In the episode the care practitioner voices her frustration of being unable to enter information into the electronic systems with her phone because the file seems to be open by someone in the office. She shares her concern with the client by showing him the screen. However, the client is worried about his missing phone. The care practitioner continues saying aloud that she has been able to save some data, lowering her voice, almost talking to herself. At the end of the episode, the care practitioner is curious about who had visited the client the day before, wondering if they were responsible for misplacing his phone. The episode ends with the care practitioner taking a handwritten piece of paper from her pocket, as if checking the tasks she should do. This episode can be interpreted as the inertia type of enactment, because the care practitioners’ agency manifests by her yearning for the old way of using the EHRs. She explains in the video reflection that she often uses just a paper and pen to avoid looking at the phone during the visits. Although negative in tone, the interaction with the client aims to share the concerns that are encountered in the technology-use situation. The problem of the client’s missing phone is not resolved during the visit. This kind of opposing agency resonates with previous description (see Højlund and Villadsen, 2020) of intentionally disregarding technology use or bending the rules embedded in the technologies but provides a more in depth understanding of care practitioner’s agency as deliberating between past way of acting and present demands of the mobile technology.
6. Discussion and conclusions
6.1 Reflections on findings
Previous studies (Tufte, 2013; Højlund and Villadsen, 2020; Koskela et al., 2023; Bergshöld, 2018; Hämäläinen and Hirvonen, 2020; Ertner, 2019) have described how homecare practitioners act with technologies aiming to optimize homecare visits and save time. Our analysis reveals the heterogeneous agencies behind their actions. We explain in a more fine-tuned manner what kinds of temporal orientations the care practitioners may have: whether they are engaged in the past, present or future way of caring, and how their orientations are manifested in their situational relationship with the technology. Our empirical findings resonate particularly with Højlund and Villadse’s (2020) analysis of the rich variety of agencies or technological adoption strategies that care workers may enact, ranging from intentional disregard to civil disobedience to productive adaptation, with the technologies they use. However, understanding how these different technology orientations are related to temporal orientations of the care practitioners, that is, how they would like to see old age care and technologization in the future, may explain their motivation behind these engaging, adapting or opposing relations with technologies in care work situations.
The empirical findings from the care practitioners’ interviews highlight three different kinds of temporal orientations to care that manifested in their client interactions. Our point is not to argue that these are their only possible agentic relations with mobile technology, but to demonstrate with empirical examples how multi-level the concept of human agency is, and how these agentic types may support technological development in care. Table 5 summarizes the three temporal orientations of the care practitioners and points out possible consequences the different temporal orientations and enactments may have on the future of care, in terms of human beings transforming work, technology use and the structural environment.
Temporal orientations of the care practitioners
| Temporal orientation in care practitioners’ agency | Past (2 cases) | Present (3 cases) | Future (2 cases) |
|---|---|---|---|
| Long-term orientations manifested in interviews of the care practitioners | Seeing technologies disturbing the interaction with the client and taking too much attention, seeing the old way of caring more valuable | Seeing technologies increasing in care, and being forced to use it, trying to see its pros and cons | Seeing all kinds of technologies good for care and improving older adults lives, thus trying to learn to use it |
| Temporal orientation and relations to mobile record keeping manifested in client visits | Opposing expressing resistance to mobile-record keeping, sometimes using paper and pen as back in the days, sharing frustration against the mobile-recording with the client | Adapting silently adapting to the mobile record-keeping, trying not to disturb the interaction with the client by reconciling it into care | Engaging using mobile phone in an open way, telling aloud what is documented and taking care even the client’s technologies |
| Implications to future of care and its technologization | Open critique of the technologies in use may slow down the implementation of new technologies in care, and may lead into re-evaluating its consequences for care if it is heard in the organization | Implementation of technologies is not received with enthusiasm, and implicit tensions between ethically sustainable care and technology-aided care exists | Technology helps clients to live their autonomous lives and keep them socially connected, care is seen as technology intensive in the future, and the vision accelerates the technologization of care |
Source(s): Authors’ own work
The first type of relation to technology depicted projective temporal orientation, in which the care practitioner was engaged in using the technology. This type of relation manifested the change type of enactment towards a vision that the number of technologies used in care will increase, and that they will help the client live autonomously at home and keep them socially connected. We may expect this kind of positive engagement in technology to construct and smoothen the path to technologization of care. The care practitioner’s actions of fluently using mobile phone and telling aloud what is documented, and even taking care of the client’s technology helped the client firstly, to understand why mobile phone is used in care and secondly, to benefit from their own technology. Our empirical case concerned mobile phone use but this kind of agency could potentially transfer to the use of other kinds of technologies as well.
The second type of relation to technology manifested care practitioners’ preference to stay in the present, and to adapt to the use of technology. However, this application type of enactment appeared as situationally adapting care to suit technological frames and being simultaneously aware that encountering the client with respect and attentiveness should be prioritized in care. The study of Koskela et al. (2023) revealed how this kind of reconciliation appears in practice. This type of relation may be connected to a vision of accepting the increasing technologization of care if human-centredness could be guaranteed and clients’ interdependency could be seen as a source of their wellbeing. In this vision it is the care practitioner who, by silently fitting the use of technology into everyday care, adapts to the technology, not vice versa. The clients must accept the care practitioners who are not always being focused on care, but on technology. This kind of relation to technology may not accelerate the implementation of technology in care but create implicit tensions between ethically sustainable care and technology-aided care, to retain them as they are and keep them as separated parts of care.
The third type of relation to technology manifested the iterational agency of care practitioners’ longing for the past, in which resistance to the use of technology was voiced, even to the client. In this inertia type of enactment, the care practitioner shows little interest to integrating mobile record-keeping into prevailing work processes, sometimes they even resort to their old methods. This type of non-use or resistance to constantly changing technological functionalities may embed a vision of returning to the old way of providing care, meaning technological devices disturbing sensitive moments with the clients less often, less surveillance and more autonomy for the care practitioner to provide care. Open critique of the technologies in use may slow down the implementation of new technologies and lead to re-evaluating its consequences for care if it is heard in the organization. However, this kind of resistance might not be able to trigger a constructive and collaborative echo if the feedback is seen just as a typical resistance against technological change or if the feedback is just used to make technological properties more user-friendly.
The theoretical contribution of our article was to re-visit the theories of human agency (Emirbayer and Mische, 1998) and the technology-in-practice view (Orlikowski, 2000) and understand how their conceptualizations on temporalities complement each other. Both theories refer to different temporal positions by distinguishing between three types of enactments (inertia, application, change) or agency types (iteration, practical evaluation, projectivity). They provide an avenue to understand that care practitioners’ actions are not only reactions to situational stimulus but also depend on how they see the development and relationship between care and technologies. Both theories consider human being not only adjusting to circumstances and situations, but being an agent, capable of foreseeing how technology may transform work situationally but also in wider context. However, human agency covering both perspectives has been a dismissed theme in many previous practice-based analyses on technology use in care work. This insight is in line with the study of Chu and Robey (2008) who argue that without the contribution of the temporal orientations conceptualized in human agency theory (Emirbayer and Mische, 1998) we do not capture in practice-based studies how and why actors use, or prefer not to use, technology applications. We argue that practice-based analyses on how technologies are used at work, could benefit from more explicit identification of human deliberation defined by Emirbayer and Mische (1998, pp. 998–999) with how employees orient themselves with past, present and future of their work. Human agency comprises deliberation with two horizons; in adjusting to the concrete demands of the present moment and the consideration of how to act in the light of broader longer-term goals (Emirbayer and Mische, 1998, pp. 998–999).
By identifying how the temporal orientations of the care practitioner’s agency varied, we gained an in-depth understanding why they appeared as opposing, adapting, or engaging agents in technology use situations. The collision between standardized logic of mobile record-keeping with premises of good care (Noddings, 1984) are variously resolved in care interactions in all the agentic relations; in engaged relation by helping the client to be autonomous with the technologies; in adapted relationship by balancing between the logics, and in opposed relationship by trying to return to the old way of caring and resisting the use of mobile technology. We do not judge any of the temporal orientations as better than any other; instead, we think that the organization should recognize them all. Revealing both the care practitioners’ temporal orientations to care and how they manifest in situations could open avenues for both better care and meaningful work.
As regards the limitations of the study, the interviewee and observation sample of seven care practitioners’ single work shifts was rather small in terms of generalizability. However, ethnographic study does not aim at statistical evidence, but rather it aims to thick descriptions and identifying deviations from routine ways of acting (Denzin, 1997). A rich a variety of temporal orientations to technology and care was achieved in even this small sample. Being able to interview employees, observe them at work and reflect with the careers on the client visits provided us a double temporal horizon to understand both sense-making of the care practitioner and how their actions varied in different situations and with different clients. It provided enough ethnographic evidence for a solid analysis to show the various agencies and temporal orientations of the care practitioners for demonstrating the theoretical implication.
6.2 Practical implications
Managers and care practitioners hardly discuss how technology changes care in the longer term. Therefore, we think our analysis could work as a point of departure for ethical discussion and for pondering what kind of care and technology-use the employees would like to promote and be involved with. When technology is introduced in care or other people-to-people service work, the operational change it aims to bring about in the longer term should be discussed, and sometimes even questioned, rather than smoothing over situational usage problems. Workers’ resistance may be driven by fundamental differences in values related to the future of care, which cannot be resolved by making technology easy to use. It is also important to discuss what is human agency about in the era of emerging artificial intelligence technologies that promise to automate parts of care work and even replace actions and agency of care practitioners. Analysing temporal orientations in care practitioner’s agency might be a fruitful point of departure to continue with.
The data of this study has been collected in the project of More time for empathy? Technology-mediated communication and work-related wellbeing in care work (2020–2022), funded by the Finnish Work Environment Fund (project number 200101), Finnish Institute of Occupational Health and partner organizations. The writing of the article was funded by the first author’s personal grant of Kone Foundation in 2023 (Empathy in technologizing elder care). We would like to express our gratitude to all the funders for their support.
