Setting norms
or negotiating feasibility?
On eating enough in a care home
Name: Yolande Daphne Schöller
Student number: 10003861
Supervisor: Prof. dr. Annemarie Mol
Second reader: Dr. Kristine Krause
Master programme: Research Master Social Sciences, University of Amsterdam
Email address: yolandescholler@gmail.com
Abstract
Too many residents in Dutch care homes are not eating enough. According to nutritional scientists, eating enough is eating recommended specific amounts of nutrients. This norm in the form of quantifiable nutrients needs to be achieved in order to prevent or treat under-nutrition. Because in practice this norm is often not achieved, solutions are sought in educating caregivers and care-receivers on sufficient nutrients. However, in this article I argue that improving the problem of under-nutrition is much more complex. I have done extensive ethnographic research on ‘eating enough’ in a Dutch care home, where I also have been working as a health care assistant for three years, to answer the question: How is eating enough done in daily practice in a care home? By building on Actor-Network Theory and doing analytic auto-ethnography, I opened eating enough up and found that it is not about knowing how many nutrients a resident should eat, but rather about negotiating how much food a resident can and wants to eat. All kinds of human and non-human entities have to be put together, coordinated, in the right way in order to work as a network through which eating enough can be negotiated. This is done differently between settings. One setting eating enough is physically negotiated, the next setting it is about negotiating expectations, and in another setting arguments are negotiated. When the negotiation temporarily ends, the resident has eaten enough for this particular moment. I advocate for a shift from norm setting to improving the feasibility of eating enough.
Key words: Actor-Network Theory, analytic auto-ethnography, care home, eating, elderly,
Eating enough and the setting of norms
My colleague, Jacqueline, and I are sitting at the dining tables together with the residents of the psychogeriatric department. Some are still eating their potatoes with gravy, green beans and steaks, but most are already done. Jacqueline is sitting at the table with Ms De Wit, a skinny looking lady who – in her words – finds it important to stand up for herself. Ms De Wit eats very little, according to all the employees and residents in the care home. Jacqueline nicely asks her if she would have preferred another menu, but Ms De Wit replies that it was just fine. My colleague says: “But you have only eaten the green beans”, on which Ms De Wit reacts: “Yes, I have eaten a lot from the green beans, because I would rather do that than getting sick from something that I do not like. I have always been a small eater”. Jacqueline: “Do you think that is enough for your age?”. Ms De Wit: “Yes, otherwise I would eat more!”.
I have done extensive ethnographic research on ‘eating enough’ in a Dutch care home, where I also have been working as a health care assistant for three years now. It is a part-time, paid job, on the basis of worked hours, for which I do not need any qualifications in health care. Mostly I take care of dinner for the psychogeriatric residents and for the residents who eat in their apartment. In Dutch care homes, too many residents are not eating enough1. According to nutritional scientists, eating enough is eating recommended specific amounts of nutrients2. This norm in the form of quantifiable nutrients needs to be achieved in order to prevent or treat under-nutrition. Because in practice this norm is often not achieved, the ‘Dutch Malnutrition Steering Group’ (a multidisciplinary group of clinical practitioners and nutritional scientists) aims to implement screening techniques and treatment plans throughout Dutch health care (Malnutrition Steering Group, 2011), and create awareness of the problem of under-nutrition by informing health care professionals and care-recipients about how many and which nutrients are needed to be healthy.
Setting the norm of eating recommended specific amounts of nutrients can be seen as goal setting: one should eat so many nutrients each day. In the context of physical !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
1!In 2014, The National Prevalence Survey of Care Problems reported that 17% of the elderly in Dutch care homes are undernourished (Halfens et al., 2014: 66).!
2!I am basing this statement on interviews I have conducted with two project leaders of the ‘Dutch Malnutrition Steering Group’, attending a conference called ‘Nutrition and Elderly’ (hosted by the Dutch Dairy Association on November 27, 2014), investingating the website of the ‘Dutch Malnutrition Steering Group’ (www.stuurgroepondervoeding.nl) and of ‘ESPEN: The European Society for Clinical Nutrition and Metabolism’ (www.espen.org/espenguidelines.html), in addition to reading several articles in nutritional science journals.
rehabilitation, Struhkamp (2004) refers to Barnes and Ward (2000) when she writes the following about goal setting: “some authors address the problem of goal setting by suggesting an improvement of the procedure of goal setting: goals require particular criteria and they should be formalised, monitored, documented, and assessed” (p. 132). Baker, Marshak, Rice and Zimmerman (2001) are cited when she continues: “others argue for better patient and therapist education, which would improve the compliance of goal setting in practice” (ibid.). Here, the problem of goal setting is the fact that the norm – eating recommended specific amounts of nutrients – is not achieved in practice. The Steering Group indeed addresses this problem by suggesting an improvement of the procedure of goal setting, through screening techniques and treatment plans, and by arguing for better patient and therapist education.
Of the few qualitative studies that have been conducted on under-nutrition in institutionalized elderly, many, among which Bonetti, Bagnasco, Aleo and Sasso (2013), come to the conclusion that the problem of under-nutrition in institutionalized elderly is the lack of awareness of caregivers around poor nutritional care. Politicians and civil servants also tend to put much responsibility on caregivers when it comes to solving the problem of under-nutrition in elderly care (Mamhidir, Kihlgren & Soerlie, 2010). However, during work I frequently saw several under-nourished residents not ingesting their daily recommended allowance of nutrients, even in cases where screening techniques and treatment plans were used, and caregivers knew about sufficient nutrients. This observation indicates that turning norms into practice is more complex than studies now suggest. Struhkamp’s (2004) argument supports my observation. She states that assumptions behind goal setting have rarely questioned, thereby hiding the complexities of targeting goals in a medical setting. She subsequently argues that tensions arise when goals are turned into practice.
How is eating enough done?
In this article I will show how setting the norm of eating recommended specific amounts of nutrients is in tension with what happens in practice. Therefore, I will answer the following question: How is eating enough done in daily practice in the care home? Just as Struhkamp (2004) did, although rather implicitly, I am building on Actor-Network Theory (ANT) in this article. Rather than staging ANT as a theory with fixed concepts (which it is not; even its vocabulary shifts all the time) and providing an overview of its history, I want to use its adaptability and sensitivity in studying reality (Mol, 2010a). ANT can be viewed as a method of analysis that treats reality as a continuously generated effect of networks of heterogeneous relations, which are carried by practices. In short: it assumes that reality is enacted (Law,
2009). In practice, multiple networks of relations (also called ‘modes of ordering’) co-exist, which implies that there are relations, frictions and resonances between them that can be unravelled (Mol & Mesman, 1996). I have already referred to Struhkamp (2004), who has unravelled frictions between goal setting and physical rehabilitation practice. Likewise, Pols (2003) has for instance examined the interference between two modes of doing good in mental health care, and Moser (2008) explored the interference and co-existence of the “mattering” of Alzheimer’s disease between a number of locations.
What I intend to do with ANT in this article is not to make great theoretical claims, but rather to show how eating enough works in practice, in order to make it available for improvement. Food work is often overlooked by being conceptualized as common sense and as one of the most mundane and elementary tasks in health care (Heaven, Bamford, May & Moynihan, 2013). However, Mol, Moser and Pols (2010) argue for careful attention to all kinds of care practices, including “food work” (or nutritional care practices), in order to protect them from rules and regulations that are alien to their specificities. Mol, Moser and Pols (2010) received the critique that they did not (re-)define ‘care’ and ‘practice’, but I agree with their response that this is exactly the purpose of their book (Mol et al., 2011). Similarly, since my aim is to open ‘eating enough’ up for study, I will intentionally not re-define it at the end of this article. In order to grasp how eating enough is being done, I need it to remain a fluid concept.
Some words on method
Having this made clear, I will now turn to some methodological aspects. It was, for example, not always possible to separate my double role in the field, nor in this article. According to Law (2000), it is necessary to include “the personal” in ethnographic writing, because it is always part of the reality the researcher is studying. Since I was part of the nutritional care practices in daily practice in the care home, I had to include myself as well in the observations and analyses. To prevent becoming over-invested in my own experiences as a health care assistant, I aimed to do ‘analytic auto-ethnography’. The term analytic auto-ethnography was proposed by Anderson (2006) in reaction to the popular ‘evocative auto-ethnography’, which, according to Anderson, lacks in scientific analysis. Its five key features are: (1) complete member researcher status, (2) analytic reflexivity, (3) narrative visibility of the researcher’s self, (4) dialogue with informants beyond the self, and (5) commitment to theoretical analysis (p. 378).
research methods to enrich my own experiences. I have had informal conversations as well as interviews with residents and caregivers, attended a meeting of the menu committee, and observed nutritional care practices in different sites of the care home and at different times. For this article, however, I use my own work experiences to illustrate how eating enough is done. In this way I use the advantage of being a health care assistant in the field. When working as a health care assistant, I would (re-)act first as a health care assistant and then reflect on it from an anthropological perspective, meaning that I focussed on human and non-human entities, co-constitution and networks of relations in my observations and field notes. The stories in this article are therefore not merely a health care assistant speaking, but also an anthropologist.
Eating enough and the negotiation of feasibility
What I found by opening up eating enough in the care home is that the norm of eating recommended specific amounts of nutrients is not achieved, because it is often not practically achievable. Eating enough in the care home is not as simple as explaining or giving a resident the recommended daily allowance of nutrients, but requires a complex negotiation with the resident about how much and which kind of food (s)he can and wants to eat. Caregivers negotiate eating enough with residents by trying to let them eat (a little bit) more. All kinds of human and non-human entities have to be put together, coordinated, in the right way in order to work as a network through which eating enough can be negotiated. This is done differently between settings. One setting it is physically negotiated, the next setting it is done through negotiating expectations, and in another setting through negotiating arguments. All three repertoires show the tension that arises when the norm of eating recommended specific amounts of nutrients is turned into practice. Eating enough in the care home is about negotiating feasibility, instead of setting norms. The residents have eaten enough when the negotiation temporarily ends.
Framing eating enough as a negotiation, resonates with the view of care not being a unidirectional activity from the care-giver to the care-receiver, but rather full of interdependency, reciprocity, and multi-directionality – a view popular in health and human geography, and advocated by for instance Hankivsky (2004), Milligan and Wiles (2010), and Herron and Skinner (2013). However, rather than assuming that negotiations are verbal and between humans (i.e. social), this article shows that negotiations are also physical and between all kinds of human and non-human entities (i.e. socio-material). This becomes visible when making practices the focus of study, instead of experiences. Or, as Mol and Mesman
(1996) argue, when doing semiotics (in this case ANT), instead of symbolic interactionism. Including ‘the will’ of the resident in the negotiation fits the popular discourse that “clients” have a choice in the care they buy. This is a reaction to the perceived lack of power of care-receivers, and often celebrated as empowering3 the patient. Mol (2008) calls it the ‘logic of choice’ and opposes it with the co-existing ‘logic of care’. She refers to them as logics, because they carry “a whole world within it: a specific mode of organising action and interaction; of understanding bodies, people and daily lives; of dealing with knowledge and technologies; of distinguishing between good and bad and so on” (p. 8). Mol argues that care entails many complexities that are better captured by a logic of care, than by a logic of choice. By framing complex problems as patient choice, one overlooks all the careful attunements that have to be made in good care practices. In practice, the two logics interfere with one another, which becomes evident in this article as well.
In the remaining part of this article I will show the negotiations by discussing three repertories of eating enough. I have ordered them around three female, under-nourished residents in their nineties: Ms Sanders, Ms Schouten and Ms De Wit, whom I have already introduced at the beginning of this text. Since I work evening shifts, the repertoires discussed in this article only concern eating enough during dinner time.
Helping Ms Sanders eat
Almost all residents in the Blue Home4 eat by themselves, but there are a few who need to be manually helped with eating. One of these is Ms Sanders, who lives in her own apartment. She sits in her special customized wheelchair the whole day, because she cannot walk. She is a frail woman in her nineties who cannot communicate properly anymore due to aphasia. Most of the time when I walk into her room, she is sitting slumped, her head hanging down on her chest. On her dining table, which she does not use since her wheelchair has its own small table, stand old pictures of her husband, sister and herself. Apparently she used to be a well-fed lady, but her slim wrists, arms and chest leave no proof of this. Ms Sanders eats very little.
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3!Using Tengland’s (2008) proposed definition of empowerment, the empowerment meant here is an increase in the person’s control over the determinants of his/her quality of life through an increase in freedom, and not necessarily an increase in health or knowledge (p. 90).
4!The Blue Home (a fictitious name) is a Dutch care home that accommodates about 70 independently living residents. It has a separate psychogeriatric department where 12 residents live who are to some extent demented. In the Netherlands, only elderly who need professional care several times a day can live in a care home.
On my first working day, three years ago, my colleague Anita showed me what I had to do. When we entered Ms Sanders’ room, Anita told me that Ms Sanders likes a special plate, which is brown and soft pink and has two angels on it. From that moment on I always use that plate, although I never actually heard Ms Sanders say she liked it. Ms Sanders eats a cooked meal for lunch and in the evening – that is when
I work – only one slice of brown bread 5. The first time I cut it in pieces that were too
big. Anita told me that Ms Sanders could not eat that, because it would not fit into her mouth. After experimenting with how big the pieces could be, I cut her bread into nine smaller pieces. I noticed that if you cut even smaller pieces, it would take her longer to eat it, since every new bite costs her energy.
When Ms Sanders could still speak a few sentences, I asked her what she liked on her bread. My colleagues would often give her bread with cheese or cold meats, but Ms Sanders actually preferred jam. In this period Ms Sanders could still eat her bread by herself, although she would eat more and faster when you stayed to help her. When I was talking to my colleagues about helping her, I used to say “feeding Ms Sanders”, but Maria, another colleague, corrected me by saying that the residents are not animals and that I should say “helping Ms Sanders eat” instead. Due to the lack of time it was not often possible to help Ms Sanders eat. Putting jam on her bread could therefore lead to a sticky mess, since Ms Sanders would sometimes accidentally drop a piece of bread on herself, the table, or the floor. However, because she liked it so much and would get it so little, I mostly put jam on her bread. She was pleased when I put this in front of her and always complimented me with how neatly I prepared her bread. I tried to stay with her as long as possible so I could help her eat.
In order to negotiate eating enough with Ms Sanders, I try to make eating as attractive as possible for her. All kinds of entities come into play: I am using a special plate, experimenting with how big the pieces of bread should be, asking for her food preferences, putting jam on her bread, and have to tinker with time. If one of these entities fails to work, for example when I cut the bread into pieces that are too big, Ms Sanders is likely to eat less.
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5!Like many Dutch people, the residents eat a cold meal (for example a sandwich, porridge, or rusk) two times a day, and a cooked meal one time a day.
Sometimes there is no jam in her fridge, or the bread is old and hard. Ms Sanders’ relatives have to buy her food products6, so they play a role as well in negotiating eating enough.
Now lets turn to the ‘helping her eat’ part7:
Ms Sanders was the first person I ever helped eating. With the fork I put a piece of bread in front of her mouth, after which she opened it. That was the easy part. Then I had to put the piece into her mouth; far enough so that it would not fall out, but not too far because then she might choke on it. Ms Sanders had to do her part of the job as well, since she had to get the piece of bread of the fork. Her tongue needed to move to her palate and her jaws needed to close a bit, but not too much as the fork would get stuck between her teeth. Then I had to gently remove the fork and Ms Sanders would close her lips so that the piece of bread stayed in her mouth. It required a lot of coordination for the both of us, but after a while it became an embodied routine.
This is where Ms Sanders and I physically have to work together in order to achieve eating enough. The negotiation is mediated by a fork, the openness and depth of her mouth, and the movement of her tongue, jaws, and lips. As the description shows, they all have to function as one system in order to work. After a while it stopped working. Ms Sanders was temporarily replaced to another care home for six months, and when she came back her condition had gotten worse. She was often confused about where she was and could not communicate short sentences such as “I would like to have jam on my bread” anymore. All there was left was to guess what she wanted. Ms Sanders could not eat by herself. Helping her eat became more difficult, and I had to get used to this new situation:
The first time I helped her eat again, I did what I always did but it did not work. Ms Sanders was not really responding when I held a piece of bread with jam in front of her mouth, and when she finally opened it, she would not open her mouth wide enough to get a piece of bread in it or she would close it too soon. I made a mess out of it; pieces of bread were falling out of her mouth. The fork was not very useful so I tried to
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6!Cold meals are prepared with food products belonging to the resident, often purchased by their relatives, whereas cooked meals are arranged by the care home.
7!About feeding assistance Pierson (1999) argues: “feeding [assistance] ... is a complex and embodied activity, which appears so mundane that it is taken-for-granted. And because of its apparent simplicity and mundaneness, feeding [assistance] is considered a social fact, well-ordered, and unworthy of examination” (p. 130). She conducted an ethnomethodologic analysis to open up the black box of feeding assistance.
gently put the rest of the piece of bread in her mouth with my fingers when her mouth was still open. It took a very long time for her to eat one piece of bread. She used to eat very fast because she did not want to waist our time – so she told me once. I did not like to ask her many times if she would like another bite. She seemed so absent and
not into eating8. After a while I gave up. I was happy that she at least ate a few pieces
of bread. When I told my colleagues, Susan and Eva, about this they said that it was okay. The next time I came to help Ms Sanders, she was asleep and I could not wake her up. I tried to speak loudly and to softly shake her shoulder, but it did not help. I felt uncomfortable trying even harder, since I did not want to shout nor touch her in a rude way. This time other colleagues, Laura and Annie, told me it was fine to let her sleep.
Instead of using a fork, I tried to use my fingers to help her eat enough, but it did not help much. Ms Sanders tool to negotiate with me is her mouth; when she closes it, no food gets in. Time was becoming an issue for me, as well as Ms Sanders’ will to cooperate. By informing my colleagues about the situation, they also became part of the negotiation. After a while I accidently discovered a new way to negotiate eating enough:
Unexpectedly, the next time I saw Ms Sanders she was sitting awake and more alert in her wheelchair. After I helped her eat, I waved her goodbye because I did not know if she would understand it if I would just say “Bye!”. She smiled. This inspired me the following time I helped Ms Sanders. She did not open her mouth wide enough again, so I widely opened mine and she did so as well. I felt a bit silly for some reason, maybe a bit uncomfortable because I was showing an adult how to eat, but it worked and that was great. I put the piece of bread in her mouth, only she kept it just as open. I laughed internally because I realized that I had to close mine as well. I exaggeratedly closed my mouth and Ms Sanders imitated me.
After a few bites, I found a new way of using the fork. The fork was more an obstacle than a tool ever since Ms Sanders’ condition worsened, since I could not get it properly in her mouth most of the time. By experimenting I found out that if I would softly move the fork to her lower jaw and then slowly out of her mouth, the piece of
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8!Perhaps Ms Sanders was enacting her appreciations? “The act of appreciation takes place in a specific situation in which a person, however quietly, enacts an appreciation vis-à-vis certain constraints and possibilities” (Pols, 2005: 215).
bread would come off in her mouth because it gets stuck behind her teeth. I finally knew how to properly use the fork again.
Unfortunately, Ms Sanders still has evenings on which she does not open her mouth. When I saw a dessert standing on her dining table (left over from her lunch when she eats a cooked meal) I suddenly remembered how she liked desserts when she could still talk. A few times Ms Sanders did not open her mouth for bread, but when I put a spoon with dessert in front of her, she did open it. Desserts are easier to eat because she does not have to chew on them. Using the spoon is different from using a fork, since now I had to get the spoon out of her mouth by moving it upwards instead of downwards, so that her upper lip would keep the dessert in her mouth.
I used my own body in the negotiation by demonstrating the physical movements Ms Sanders has to make in order to eat. I also experimented with the use of the fork, and adjusted it to Ms Sanders new condition. She is not able to work with me anymore, so I had to do the work for her by moving the fork in such a way that the piece of bread gets stuck in her mouth. When this also failed (because of Ms Sanders’ closed mouth) I tried to negotiate with her over another food product: dessert. The texture of this food product allows for less work on Ms Sanders’ part, since she does not have to chew before swallowing it. However, it took me some learning to use a new tool: the spoon. I had to make new movements in order to make it work.
What this, rather extensive, repertoire of eating enough shows is that the practice of eating enough can be very physical in nature and quite complex to coordinate. Eating enough is not just giving Ms Sanders a slice of brown bread with jam, but letting several coordinated entities do a lot of work to let Ms Sanders actually ingest (a part of) her meal. The normative enough – eating specific amounts of nutrients – is obviously not met in this repertoire, but in daily practice eating enough is about something else. My colleagues and I were well aware that Ms Sanders was not ingesting her recommended daily allowance of nutrients, but we were more concerned with how we can help her eat as much food9 as she can and wants to. Through different sets of actions I negotiated eating enough with Ms Sanders, but when the negotiation temporarily ended, she had eaten enough for this particular moment.
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9!Nutritional value is just one of the ‘goods’ relevant to food. For an account on the tensions between, and tinkering with, different goods relevant to food in the nursing home, see Mol (2010b).
Serving Ms Schouten dinner
Every day in the Blue Home the residents can compose their cooked meal by choosing between two different menus10. Residents who eat dinner in the restaurant choose their menu at their dining table, whereas residents who eat in their apartment11 have to choose it a week beforehand. These choices are stated on a menu list, on which residents can also mention specific requests, such as apple sauce, stewed pears, mashed food, no fish, a half portion, or an extra portion. This menu list is brought to the reception desk and then passed down to the kitchen. Someone of the kitchen staff transforms the menu lists into individual cards that state the name, room number, week number, specific requests, and a chart displaying the days on which a cooked meal is excepted and specifying the choice of menu (A or B) for each meal component. The cook heats up the foods that he received from the food distribution centre in his kitchen. The meals and corresponding individual cards are placed on serving trays and then put in a food trolley. Subsequently, a health care assistant takes the food trolley to the apartments of the residents, and serves them their meal.
This is one of my main responsibilities. There is one resident, Ms Schouten, a short, assertive woman in her nineties, with whom I have a lot of interaction during this event. Ms Schouten is one of the residents who has quite specific food preferences. She does not like all kinds of fish and meat, dislikes certain vegetables, requests extra applesauce and wants to vary between mashed and cooked potatoes.
On an evening shift I arrived with the food trolley at her apartment to serve her meal. I performed the same actions as always: first I rang the doorbell, then I entered her apartment with my keys and said hello to Ms Schouten. I carried the serving tray into her apartment and put it on her dining table. Next to a white tablecloth, a glass of water, her medicine and cutlery, was her menu list. Since Ms Schouten has bad eyesight, I checked the meal with her menu list. While I took the iron lid off the plate and looked at the menu list, Ms Schouten finally arrived at her dining table as well (she used a walker) and looked at her plate. Although she has bad eyesight, she immediately saw something wrong with her meal.
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10!Struhkamp (2005) argues that one way in which health care professionals seek to respect patient autonomy is by giving patients a choice in their dinner. She additionally argues that food choices are dependent on care activities and their material conditions, and shaped by the organisational setting of the health care institution. This repertoire of eating enough supports her argument.
11!The non-psychogeriatric residents can choose between eating dinner in the Blue Home’s restaurant or in their own apartment. Because of safety reasons, the kitchens in the residents’ apartments are not equipped with a stove. This makes it necessary for residents to request a cooked meal from the Blue Home’s kitchen.
Alongside some vegetables and a few potatoes with gravy, was a piece of dark brown meat on her plate. To be honest, I did not know what kind of meat it was. Except for the straightforward looking potatoes, I often struggle with guessing at the inside of a piece of meat or the content of a sauce with vegetables (where are the vegetables anyway?). To Ms Schouten it did not matter either what kind of meat it was. All she cared about was that it should not be on her plate. She was so angry about it – to be fair, Ms Schouten’s meals are often not exactly what she asked for – that she refused the meal entirely. At that moment it seemed silly to me: everything was correct except for the meat, why refuse to eat at all? I tried to convince her by saying that she could eat the potatoes and vegetables, but I did not succeed. On the contrary: she explicitly demanded me to take back the meal. Her anger directed at me and my lack of understanding of her irritation, resulted in a blunt reaction on my part. I said: “Fine, don’t eat it” and left the room.
Eating enough in this repertoire is not very physical, but rather a negotiation about expectations. The cook is seen by Ms Schouten as responsible for her cooked meal, which makes him part of the negotiation. Menu lists that state food preferences, individual cards that state menu choices, and I, are supposed to mediate this negotiation between the resident and the cook. If the menu list or individual card fails to work, it becomes harder for me to tinker with my time and harder for Ms Schouten to eat enough. What is negotiated is not a piece of bread with jam that is easy to eat, but a cooked meal that has to meet the food preferences of the resident. It has to be “lekker” 12 and comply with what is requested, in order to work.
I learned from my unpleasant experience with Ms Schouten and adjusted my behaviour the next time her meal was not right:
I calmly sat down next to her and asked if I should go back to the kitchen to get another meal. This however would be quite a hassle for both the cook and me, given the lack of time to do all the tasks. Ms Schouten changed her behaviour as well. She did not get upset and responded that she would eat as much as she could from this meal. However, after a few weeks Ms Schouten had a hard time accepting this recurrent problem again. She had a sore mouth for a while, which made eating very painful and difficult for her. She ate soft foods, such as applesauce, mashed potatoes
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12!Dutch word for tasty. See Mol (2013) for an empirical account of the Dutch word “lekker” in several care home practices.
and desserts. When I brought her solid foods from the kitchen, she said that she could not eat that. She got upset and rightly asked: “How am I supposed to get my strength back if I cannot eat the food?”. Instead of eating the meal, she drank a breakfast drink, which she had stored in her kitchen.
I became more willing to tinker with my time and Ms Schouten more willing to tinker with her food preferences in order to negotiate eating enough. However, after a while a sore mouth became an important entity in the negotiation; Ms Schouten needed soft foods instead of solid ones. When the menu list or individual card failed to work again, a breakfast drink in Ms Schouten’s kitchen played a key role in eating enough.
What this repertoire illustrates is that eating enough is not always about the actual practice of eating. It is also about making menu lists and individual cards work, and the will to tinker with time and food preferences. In contrast with Ms Sanders, Ms Schouten was physically able to eat recommended specific amounts of nutrients, but she would not do it if she does not like what she has to eat. A sour mouth, however, made eating enough about the practice of eating soft foods. When the negotiation was coming to a temporal end, a new entity, that was brought in by Ms Schouten, allowed eating enough to be negotiated a bit longer. This again shows that in daily practice eating enough is not a matter of knowing how many nutrients a resident needs, but of negotiating how much food a resident is willing to ingest in certain material circumstances.
Observing Ms De Wit’s eating behaviour
At the psychogeriatric department eating enough is done differently yet again13:
The caregiver fills out the menu list for the residents. All psychogeriatric residents get the same menu to prevent jealousy; they might forget what they have ordered and become upset that the others have something else to eat. The caregiver, who has known the residents for a long time, takes their food preferences into account, but also looks at the time. Chicken carbonnade for instance, is not often ordered, because of the time-consuming task for caregivers to remove the bones for the residents. The cook, who orders the food from the food distribution centre, brings the requested food
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13!See Hung and Chaudhury (2011) for an ethnographic account on personhood in dining experiences of residents with dementia in long-term care facilities.
to the psychogeriatric department’s kitchen, where the caregiver heats it up in an oven. This causes a certain smell to form in the corridors.
The psychogeriatric residents can sit together in a living room that also functions as a dining room. When it is almost dinner time, the caregiver and I set the tables with colourful placemats, paper napkins, plates, cutlery, and glasses with water. We turn the music off and bring all residents to the living room. The residents have a permanent place at one of the tables. Their places are determined by the caregivers, who try to prevent quarrels between residents. So, residents who do not like each other are placed in such a way that they cannot see each other during dinner. Then we go the psychogeriatric department’s kitchen, put the heated food on a food trolley and take it to the living room. Here we serve it to the residents. Most of the time we dish the food directly up on the residents’ plates, instead of using serving dishes. This saves some time. When dishing up, we so by inquiring how much the residents would like to eat. However, we already know their preferences, because we have done this many times before. When we put the plates with food front of the residents, they give a reaction about the amount or about how tasty it looks. The frail residents often indicate that it is too much, even when we have given them little, on which we always respond that they do not have to finish the meal, but at least try to eat as much as they can.
What stands out from these descriptions is that eating enough at the psychogeriatric department includes more than just one resident. Residents have to be “coordinated” by seats at a table, and by being served only one menu, so that the atmosphere stays nice and residents are not distracted from eating their meal. Turning off the music is thought to prevent distraction as well, whereas colourful placemats and napkins are used to make eating a nice experience. In contrast with Ms Sanders and Ms Schouten, the psychogeriatric residents are able to anticipate the cooked meal by the smell of the food in the corridors. Another difference is that the meals are dished up in presence of the residents, allowing for a more direct negotiation of eating enough.
Ms De Wit is one of the frail psychogeriatric residents. As was already described in the introduction of this article, Ms De Wit had hardly eaten from her potatoes with gravy, green beans and steak. My colleague, Jacqueline, suggested a different meal, but Ms De Wit argued that she has always been a small eater. The conversation continued:
Ms De Wit became angry and said: “Everyone is keeping an eye on my eating behaviour, but I decide what I eat!”. Now another resident, who was sitting at the same table, got involved as well: “But we are worried about you!”, on which Ms De Wit responded: “That is not necessary. You should keep out of it, it’s my decision!”. Ms Smit, a resident who was sitting at my table, quietly said to me: “We don’t decide everything for ourselves here (referring to the psychogeriatric department), some people have an influence on it”. Later I heard from another colleague, Annette, that Ms De Wit was seen throwing away her Nutridrinks in the bushes outside of the Blue Home. When she was asked why she had done this, Ms De Wit explained that she could not throw it into her trashcan, because then the caregivers would find it and know that she had not drunk it. She said she does not like the taste of the Nutridrinks.
What this repertoire illustrates is that when several residents are involved in negotiating eating enough, the nature of this negotiation is not physical, nor about expectations, but rather about formulating arguments and opinions. Stories that are circulated in the care home become part of these opinions. The taste of Nutridrink is another interesting entity in eating enough. Nutridrink is medical nutrition, which is artificially high in proteins. Medical nutrition is often staged as a cost-effective treatment of under-nutrition (Kok, Scholte & Koopmans, 2014)14, and fits the normative view (i.e. eating specific amounts of nutrients) on eating enough. However, as this story demonstrates, it can fail to work in daily practice due to other related entities, such as taste and the will of the resident. Two logics are namely negotiated as well: ‘logic of choice’ and ‘logic of care’ (Mol, 2008)15. In order to feel empowered, Ms De Wit employed the logic of choice, by stating that she decides what she eats, by not eating more, and throwing away her Nutridrink in the bushes instead of her trashcan. The caregivers and the two other residents employed the logic of care, by expressing their concerns and checking her use of Nutridrink.
Conclusion
The three repertoires of eating enough discussed in this article, demonstrate that eating enough is negotiated differently between settings. Eating enough can be very physical in !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
14!Moser (2010) argues against a form of evaluation of the quality in health care “that works by proving and aims to convince outsiders (politicians, health administrators, insurances, publics) that something is efficient and worth paying for” (p. 277). This seems to be exactly the case with how medical nutrition is staged.
15!Henwood, Harris and Spoel (2011) have also studied negotiations between the two logics. This repertoire, however, shows a different kind of negotiation by focusing on practices and not on narrative accounts.
nature and hard to coordinate when helping a resident eat, it can be mainly about food preferences and managing expectations through menu lists when serving a resident a cooked meal from the kitchen, or about formulating opinions and debating logics when dining together with other residents at the psychogeriatric department. In each repertoire different kinds of human and non-human entities had to be put together, coordinated, in the right way in order to work as a network through which eating enough can be negotiated.
Eating enough in daily practice in the care home is not about knowing and giving a resident the recommended daily allowance of nutrients, but about negotiating with the resident how much and which kind of food (s)he can and wants to eat. This article has shown that negotiations in care are not merely verbal and social, but also physical and socio-material. Ingesting food, for example, is a physical act, which allows for a physical negotiation of eating enough by not opening one’s mouth. Furthermore, eating enough is negotiated through all kinds of human and non-human entities that are put together in a specific way that works. The texture of food, menu lists, forks, stories, mouths and Nutridrink are just as well part of the negotiation as the caregiver and the resident are. In other words: negotiations in care are full of enacted relations with (non-human) entities and non-verbal aspects.
This also explains why informing health care professionals and care-recipients about how many and which nutrients are needed to be healthy is not sufficient to improve the problem of under-nutrition in institutionalized elderly. Caregivers should not only be educated in knowledge of quantifiable nutrients, but also trained in how to achieve this norm in practice – not with nutrients, but with food. There might be better techniques out there to negotiate eating enough with residents. However, not all responsibility should lie with caregivers, since the whole network of relations through which eating enough is negotiated in the care home can be improved: the food itself, communication tools, the cook, dining tables, cutlery, and so on. Not achieving the norm of eating recommended specific amounts of nutrients is a relational effect, not simply the “fault” of caregivers.
The problem of norm setting is the lack of recognition for the practical limitations embedded in care. Within each setting there are different practical limitations encountered, and thus different improvements to be made. In this article I have only discussed three settings within one care home, and some of their material conditions have already changed during the writing of this article. This makes it hard to come up with a clear-cut solution for the problem of under-nutrition in institutionalized elderly. However, a step in the right direction would be a shift from norm setting to improving the feasibility of eating enough.
Acknowledgements
I am grateful to all the employees and residents in the care home who have made my fieldwork possible. I want to thank the Dutch Malnutrition Steering Group for being interested in my research and helpful in providing information. I am also very grateful to Annemarie Mol and Kristine Krause, who have given me their intellectual and emotional support throughout the entire research project. Finally, I want to thank Emily Yates-Doerr, Else Vogel and my classmates for reading and discussing earlier versions, and of course my family and friends for all their kind and encouraging words.
References
Anderson, L. (2006). Analytic Autoethnography. Journal of Contemporary Ethnography,
35(4), 373-395.
Baker, S.M., Marshak, H.H., Rice, G.T. & Zimmerman, G.J. (2001). Patient Participation in Physical Therapy Goal Setting. Physical Therapy, 81, 1118–1126.
Barnes, M.P. & Ward, A.B. (2000). Textbook of Rehabilitation Medicine. Oxford: Oxford University Press.
Bonetti, L., Bagnasco, A., Aleo, G. & Sasso, L. (2013). ‘The transit of the food trolley’ malnutrition in older people and nurses’ perception of the problem. Scandinavian
Journal of Caring Sciences, 27, 440-448.
Halfens, R.J.G., Meijers, J.M.M., Meesterberends, E., Neyens, J.C.L., Rondas, A.A.L.M., Rijcken, S., Wolters, S. & Schols, J.M.G.A. (2014). Report Results National
Prevalence Survey of Care Problems 2014. Maastricht, The Netherlands: Universiteit
Maastricht, CAPHRI School for Public Health and Primary Care, Department of Health Services Research Focusing on Chronic Care and Ageing.
Hankivsky, O. (2004). Social policy and the ethic of care. Vancouver: UBC Press.
Heaven, B., Bamford, C., May, C. & Moynihan, P. (2013). Food work and feeding assistance on hospital wards. Sociology of Health & Illness, 35(4), 628–642.
Henwood, F., Harris, R. & Spoel, P. (2011). Informing health? Negotiating the logics of choice and care in everyday practices of ‘healthy living’. Social Science & Medicine,
72, 2026-2032.
Herron, R.V. & Skinner, M.W. (2013). The emotional overlay: Older person and carer perspectives on negotiating aging and care in rural Ontario. Social Science &
Hung, L. & Chaudhury, H. (2011). Exploring personhood in dining experiences of residents with dementia in long-term care facilities. Journal of Ageing Studies, 25, 1-12.
Kok, L., Scholte, R. & Koopmans, C. (2014). Under-nutrition underestimated. The costs of
under-nutrition and the efficiency of medical nutrition. Amsterdam, The Netherlands:
SEO Economic Research, SEO-report nr. 2014-11.
Law, J. (2000). On the Subject of the Object: Narrative, Technology, and Interpellation.
Configurations, 8(1), 1-29.
Law, J. (2009). Actor network theory and material semiotics. In Turner, B.S. (ed), The New
Blackwell Companion to Social Theory. Oxford: Wiley-Blackwell.
Malnutrition Steering Group (2011). Guideline Screening and Treatment of Under-nutrition. Amsterdam, The Netherlands.
Mamhidir, A-G., Kihlgren, M. & Soerlie, V. (2010). Malnutrition in elder care: qualitative analysis of ethical perceptions of politicians and civil servants. BMC Medical Ethics,
11, 1-7.
Milligan, C. & Wiles, J. (2010). Landscapes of care. Progress in Human Geography, 34(6), 736-754.
Mol, A. (2008). The Logic of Care: Health and the Problem of Patient Choice. Routledge. Mol, A. (2010a). Actor-Network Theory: sensitive terms and enduring tensions. Kölner
Zeitschrift für Soziologie und Sozialpsychologie, 50(1), 253-269.
Mol, A. (2010b). Care and its values: Good food in the nursing home. In Mol, A., Moser, I. & Pols, J. (Eds.), Care in Practice: On Tinkering in Clinics, Homes and Farms. Transcript Verlag.
Mol. A. (2013). Language Trails: ‘Lekker’ and Its Pleasures. Theory, Culture & Society, 0(0), 1-27.
Mol, A. & Mesman, J. (1996). Neonatal Food and the Politics of Theory: Some Questions of Method. Social Studies of Science, 26(2), 419-444.
Mol, A., Moser, I., Piras, E.M., Turrini, M., Pols, J. & Zanutto, A. (2011). Debate: Care in practice. On normativity, Concepts, and Boundaries. Technoscienza: Italian Journal of
Science & Technology Studies, 2(1), 73-86.
Mol, A., Moser, I. & Pols, J. (Eds.) (2010). Care in Practice: On Tinkering in Clinics, Homes
and Farms. Transcript Verlag.
Moser, I. (2008). Making Alzheimer’s disease matter. Enacting, interfering and doing politics of nature. Geoforum, 39, 98-110.
Moser, I. (2010). Perhaps tears should not be counted but wiped away: On quality and improvement in dementia care. In Mol, A., Moser, I. & Pols, J. (Eds.), Care in
Practice: On Tinkering in Clinics, Homes and Farms. Transcript Verlag.
Pierson, C.A. (1999). Ethnomethodological analysis of account of feeding demented residents in long-term care. Journal of Nursing Scholarship, 31(2), 127–31.
Pols, J. (2003). Enforcing patient rights or improving care? The interference of two modes of doing good in mental health care. Sociology of Health & Illness, 25(4), 320–347. Pols, J. (2005). Enacting Appreciations: Beyond the Patient Perspective. Health Care
Analysis, 13(3), 203-221.
Struhkamp, R.M. (2004). Goals in Their Setting: A Normative Analysis of Goal Setting in Physical Rehabilitation. Health Care Analysis, 12(2), 131-155.
Struhkamp, R.M. (2005). Patient autonomy: A view from the kitchen. Medicine, Health Care
and Philosophy, 8, 105-114.
Tengland, P-A. (2008). Empowerment: A conceptual Discussion. Health Care Analysis, 16, 77-96.
