Attunement as a practice of encountering dementia time in long-term eldercare work

Abstract

Discussing time and temporality in care work is becoming more central as societies with growing proportions of older persons with care needs strive to arrange cost-effective eldercare. As resources become scarcer, the efficiency of care work is emphasised, and care is increasingly sorted into cost-per-minute units. In our paper, we will analyse the different ways care professionals themselves describe their temporal experiences and practices concerning care interactions in long-term dementia care. Our data consists of semi-structured interviews with care professionals (n = 25) working in round-the-clock service housing in Finland. Using thematic content analysis to analyse the data, we show that, along with a holistic understanding of temporality, good dementia care necessitates understanding alterity, which is insufficiently regarded in linear or quantitative understandings of time. By using concepts of temporal duration (Bergson), crip time (Kafer) and dementia time (Yoshizaki-Gibbons), it is possible to understand another person's alter-temporal experience, into which care can aim to enter and towards which it can attune itself. We argue that a concept of attunement is needed to fully make sense of the ideal temporal practices of dementia care. Our analysis presents attunement as understanding dementia time, receptive practices, and expressive practices, and describes limitations of attunement as temporal discordance.

Introduction

Discussing the temporalities of care work is becoming increasingly urgent as societies with growing proportions of older persons with care needs strive to arrange cost-effective eldercare. As resources become scarcer, the time efficiency of care work is emphasised. However, as shown by several studies carried out in areas such as sociology (Adam, 1994; Altomonte, 2016), care work research (Bergschöld, 2018; Davies, 1994; Hirvonen & Husso, 2012; Kamp, 2021), disability studies (Yoshizaki-Gibbons, 2020), care ethics (Tronto, 2013) and nursing research (Dierckx de Casterle et al., 2020; Egede-Nissen et al., 2013), time efficiency and good quality care do not necessarily go hand in hand, in that cost-effectiveness, which compresses care into measurable time units, conflicts with the very idea of the ‘rationality of caring’ (Waerness, 1984): that care should be provided when needed, not when planned.

Expanding the knowledge of existing studies on temporality and care, our attention in this paper is on the temporally idiosyncratic experiences and practices of round-the-clock eldercare work, focusing on care professionals’ encounters with residents with dementia. As Eriksen et al. (2020) claim, little attention has been paid to the experience of time in research on dementia. The past research on the temporalities of dementia (Eriksen et al., 2020) and dementia work (e.g. Yoshizaki-Gibbons, 2020) have revealed the urgent need for more research on what dementia means for and requires from our understanding of temporality. A person with dementia can, under the scope of ‘normal’ understanding of time, causality, memory and futurity, seem like an ‘irrational’ agent; however, the lifeworld of dementia is no less temporally meaningful in its momentary situatedness. In this paper, we will aim for a conceptualisation of what is at stake in terms of temporal practices in a relation between a caregiver and a person with dementia in need of care and attention. With a focus on attunement as a definitive temporal practice in dementia work, we will exemplify how one-to-one care interactions in round-the-clock eldercare practices related to dementia care bring forth temporal meanings, and how this attunement is in conflict with the confinements of neoliberal temporalities (Yoshizaki-Gibbons, 2020: 213).

Analysing Finnish long-term care (LTC) professionals’ semi-structured interviews (n = 25) by means of thematic content analysis (Boyatzis, 1998), in this article, we ask: what kind of temporal practices are at play in LTC professionals’ care interactions with older persons with dementia? We will demonstrate the importance and restrictions of attunement to another person's temporal experience as part of carrying out mundane care tasks and giving good care. Our conceptual take on attunement derives from understanding both caregiving and living with dementia as phenomenological lifeworlds. With a focus on intersubjective relationality, we draw our concept of attunement from Henri Bergson's proto-phenomenological concept of ‘duration’ (durée) (Bergson, 2014), whereby it is possible to focus on time as a qualitative, lived phenomenon. Given that our primary interest lies in the idiosyncratic lifeworlds of caring for persons with dementia, we also utilise sociologically inclined concepts that situate this qualitative perspective explicitly in bodies and alter-temporal embodiedness. Kafer's (2013) ‘crip time’ and Yoshizaki-Gibbons's ‘dementia time’ are concepts formulated in the field of critical disability studies, and with the help of these concepts, we approach duration as co-embodied temporality. These concepts strengthen our aim of presenting attunement as a relational temporal practice requiring a profound understanding of the embodied lifeworld of another being. By focusing on the meanings that surface with attunement, we aim to identify the concrete temporal complexities of LTC of older persons, thereby also contributing to the conceptual and theoretical discussions on time and temporalities in the context of care.

In the article, first, some key theoretical perspectives on temporality in care will be briefly introduced. Second, the empirical context, intensive service housing (ISH) in Finland, will be described in detail. Third, the data and method of the study will be presented. After that will follow a section including an empirical analysis of attunement as a dementia care practice. Lastly, a discussion section will consider the theoretical significance of the empirical findings and will present the broader implications of the article.

Attunement as a crip time practice within care interactions

In round-the-clock residential eldercare work, understanding time shifts from dealing with daily, scheduled care tasks, to dealing with unexpected events caused by physical impairments, to dealing with temporal unclarity and complex existential, ethical and epistemological dilemmas brought about by dementia. This article will broaden the scope from time-use in dementia care work in the general sense, such as scarcity or allocation of time resources, to a focus on temporality, as in the perceived experience of time (e.g. Adam, 1994). Also, following Changfoot et al. (2022), Kafer (2021), and Ward et al. (2022), we do not primarily understand dementia care as a narrative or biographical practice, in that they carry with them implications of linear timescales whereas the lived temporality of dementia and therefore dementia care is often chaotic, visceral and contingent (Ward et al., 2022). Rather, our focus is on the immediate experiences, meanings and practices found in one-to-one dementia care interactions.

Elaborating on the content of such intricate interactions requires a qualitative understanding not only in the methodological sense but also in terms of how time is theoretically understood. Influential accounts of the non-linear, qualitative character of time have been given in philosophy and sociology (e.g. Adam, 1994; Baraitser, 2017; Bergson, 2014; Giddens, 1991; Harvey 1989; Heidegger, 2010). Such accounts are already well covered in the history of time research carried out in philosophy and social sciences, and in this article, we will not engage in a phenomenological or sociological discussion on time or temporality as such. However, our aim of elaborating on the impact of and responses to the temporal alterity of dementia requires some kind of base assumption of temporality understood as a qualitative phenomenon.

Therefore, we engage in a brief reading of Henri Bergson, who wrote of temporality as duration (durée) (Bergson, 2014: 100–106), whereby time is essentially understood as qualitative experience, the occurrence that occurs within and as its own duration, rather than quantitative, instrumental change as we have become accustomed to understanding time since the invention of clocks (Guerlac, 2017: 1). In this qualitative shift, the inner, immeasurable temporal experience takes analytical precedence over objectively acclaimed knowledge of time where the world is mediated symbolically. The problem with symbolical temporal mediation is that it suspends and limits what we experience as an immediate occurrence in our temporal flow. (Guerlac, 2017: 19.) For Bergson, any such objectifying attempt is an attempt to reduce time as space (as is the purpose of a clock), which, by its very nature, steers focus away from the event itself. This tension is also evident in the conflicts between instrumental time pressures and ethical ideals of care.

Qualitative temporality can be further demonstrated with Alfred Schütz's (1996: 246) famous, phenomenological example of experiencing a music piece, which applies well also to the immediate event of a caring action (or any event of interpersonal interaction for that matter). To experience a piece of music it must be lived through as the whole piece in the inner temporal experience of the listener, in that such experience cannot be instrumentally dissected into temporal units in outside (or spatialised) time without losing the content of the duration itself (Goettlich, 2014; Schütz, 1996). In other words, unlike a physical object that can be put aside for a while or assessed from different spatial perspectives, a song happens from the beginning till the end; there is no other way to experience it but by synchronisation of temporal experience with the flow of the piece.

To have explanatory power with regard to care relations, duration as a temporally idiosyncratic phenomenon needs to make sense also in terms of the radical alterity that is found in encountering the other person. Notions of the gendered (Davies, 1994, 2001) and the embodied (Twigg et al., 2011) aspects of temporality have been developed, usually denoting clock-time as a by-product of (patriarchal) economic power structures, in that the temporalities in care relations arise from the (often conflicting) demands of bodies, workplaces, social norms, technology and social situations (Twigg, 2010). A body is guided by its organic and individual processes such as sleeping, eating and toileting, which can be in conflict with institutional schedules. However, such alter-temporalities found in the heart of care are not merely instrumental processes – A taking longer than B to accomplish X – but alterity on the level of temporal experience (i.e. ‘duration’). In terms of temporality and alterity, this has been elaborated well in critical disability studies with a concept of ‘crip time’:

Crip time is flex time not just expanded but exploded: it requires reimagining our notions of what can and should happen in time, or recognising how expectations of ‘how long things take’ are based on very particular minds and bodies. […]Rather than bend disabled bodies and minds to meet the clock, crip time bends the clock to meet disabled bodies and minds. (Kafer, 2013: 27)

Samuels and Freeman (2021: 246) show an example of crip time by noting that in the COVID-19 pandemic, we live(d) in universal crip time. As the collective nature of our embodied vulnerability was suddenly exposed, the world had to comply with the temporality of our bodies: there was no rushing recovery. However, they continue, this is nothing new to sick and disabled people: ‘crip time isn’t easy, it isn’t fair, it cannot be reasoned with’ (Samuels and Freeman 2021: 247). The temporal practices in any care encounter relate to what is meant by crip time: understanding that another person's particular and situational embodied possibilities also mean a temporal alterity that requires serious attention.

Orientation of time has for a long time served as an indicator of the severity of cognitive impairment (O’Keeffe et al., 2011). The aforementioned connection of qualitative temporality and radical alterity brings us to temporal meanings and practices taking place in care encounters with persons with dementia. Studies on temporality and dementia have shown that dementia as a lived experience is not simply ‘living in the past’, but rather an experience of being engaged with all the dimensions of time – the past, the present and the future, requiring ‘time work’ (Flaherty, 2011) of persons with dementia themselves (Eriksen et al., 2021). Although few, some recent studies have connected good dementia care with temporal flexibility and an ability to accept the care receiver's time experience. For example, Lillekroken's (2020) study showed that ‘slow nursing’ in dementia care ward encounters sustains both the personhood and sensory experiences of care receivers. The results of Egede-Nissen et al. (2013) show that good dementia care requires a flexible time culture, emphasis on rhythms and the discarding of clock time in the process, leading to a requirement of ‘time ethics’ by the writers. Rushton et al. (2016) argued for the importance of past research on temporality, especially plurotemporality, person-centred time and process time for ideal, person-centred dementia care. Important as these outputs are, they do not result in a coherent conceptual outcome concerning the immediate experience in relating and responding to the care receiver's temporality.

However, akin to our argument on attunement in this article is Yoshizaki-Gibbons’s (2020: 13) notion of ‘dementia time’:

Dementia time, as an extension of crip time and queer time, is a temporal dis/orientation that challenges and disrupts normative and dominant forms of time. Dementia time involves focusing on a particular moment in time and space and embracing that individual moments may be self-contained, nonlinear, intermittent, irrational, and idiosyncratic, yet are no less meaningful or valuable.

As tenets of dementia time, Yoshizaki-Gibbons asserts focusing on the moment, maintaining rhetoricity to practice inclusion and affirm personhood, acknowledging and respecting situated realities, and emphasising a politics of collectivity and care (Yoshizaki-Gibbons, 2020: 191). Her analysis lays out a novel and essential view on the yield of cognitive impairments for crip time theories. On the other hand, it also shows how notions of crip temporality may reveal the lifeworld of dementia. While her work provides us with a productive concept to work with, the content of Yoshizaki-Gibbons's analysis functions mostly on the level of affirming the care receiver's personhood in the dementia ward encounters. Such affirmation of course aligns with our arguments in this paper. However, as Yoshizaki-Gibbons also writes, dementia time is a ‘coalitional concept’ – it refers to the radical temporal alterity between able body-minds and body-minds with dementia, therefore primarily emphasising the political significance such a gap brings forth.

We take Yoshizaki-Gibbons's idea as part of our analysis, but we argue that a more practical and reflexive concept is needed in order to figure out the full scope of the temporal idiosyncrasy of dementia care work practices. The importance of dementia time is clear in moments of affirming personhood, for example, when older persons with dementia momentarily long for their parents or other emotional contents in their personal histories, but the impacts of dementia time are also present in all other LTC practices and encounters. Therefore, we are interested in what ways care professionals engage, or ‘step into’, dementia time as part of practical and mundane LTC tasks. With our following analysis, we argue that such reflexive-practical engagement is best understood by a concept of attunement. With attunement we refer to an idiosyncratic practice where the care professional's active engagement in the temporal, momentary lifeworld of the resident is presented as a reflexive movement between receptive and expressive practices, typified as ‘listening’ and ‘speaking’. Attunement will be elaborated in the analysis of care professionals’ descriptions of care events and further in the concluding section; however, first, we will briefly present the context of the study in the following section.

Finnish round-the-clock residential eldercare as the context

Round-the-clock intensive service housing (ISH) of older persons provides a valuable context for analysing the temporal dimensions of caring. In Finland, as in many other European countries, ISH has replaced nursing homes and hospital wards, becoming the most common form of LTC for older people. However, ISH facilities greatly resemble nursing homes, in that care staff are present at all times and provide care around the clock. While ISH is often officially described as a homelike living arrangement, they vary from small homelike units to former nursing homes and other settings that are in fact rather institutional in character. The facilities have care staff working around the clock, usually assigned to morning, evening or night shifts. The personnel are relatively highly educated and include nurses, physiotherapists and occupational therapists who have a tertiary degree in health and social work, practical nurses with a secondary degree, and activity instructors, kitchen staff and cleaning staff with a secondary degree or none at all. The facilities are usually separated into group homes of 10 to 20 residents. Services (including care, meals, and cleaning) are paid for by the residents (a maximum of 85% of the resident's total income). Room rent and medication are paid for separately.

In 2019 in Finland, 7.3% of persons aged over 75 and 15.8% of persons over 85 were ISH residents. It has been estimated that over half of the ISH residents have been diagnosed with Alzheimer's or another form of dementia (Finnish Institute of Health and Welfare, 2021a, 2021b). The residents of ISH have, as the name suggests, the most intensive care needs, ranging from a constant need for help with hourly bodily functions such as eating and drinking, toileting, and transitions from bed to the toilet, from apartments to general areas and from there to outside. Furthermore, the personnel of ISH are required to address residents’ social needs, understand their psychological conditions, and overall give them round-the-clock caring attention. As being often the last place of living, ISH is a site of care where, ideally, everything about the person is potentially a matter of care.

The demands concerning cost-effectiveness have led to scarcer resources in LTC for older people in Finland (Van Aerschot et al., 2021). Lack of staff and lack of time for care have been prominent issues in Finnish eldercare for years, and at the beginning of 2019, the revelations of poor-quality service levels in private ISH facilities caused a stir in the Finnish media (Jolanki, 2019). Previous studies have shown that feelings of hurriedness in care work have increased and represent one of the main stressors/reasons for care workers’ turnover (Kröger et al., 2018; Van Aerschot et al., 2021). Compared with workers in other sites of health and social care work and the workforce in general, significant levels of mental and physical strain, such as work-related poor health, stress, and burnout (Olakivi et al., 2021), have recently been reported by care professionals working in Finnish LTC of older people. As reasons for this, they reported insufficient support from managers, few opportunities to influence their own work, feelings of inadequacy, feelings of time pressure and a poor worker–client ratio (Kröger et al., 2018; Van Aerschot et al., 2021). Along with relatively low wages and a high proportion of temporary work contracts, these factors partly explain the high turnover rate and high intentions to quit one's job among care workers in LTC (Kröger et al., 2018; Van Aerschot et al., 2021), especially among younger care workers (Olakivi et al., 2021). In this article, we use the terms ‘informant’, ‘care worker’ and ‘care professional’ interchangeably, thereby highlighting that working in ISH is hard work but also requires highly professionalised skills.

Data and method

Our analysis is based on semi-structured interview data (n = 25), which was collected in 2018 by the first author and his colleague from two Finnish cities. The informants were care professionals working in ISH, representing the typical ISH workforce: practical nurses (n = 14), registered nurses (n = 8) – some of whom had a managerial role in their unit, activity instructors (n = 2) and an occupational therapist (n = 1). Of these informants, 23 were women and two were men, reflecting the situation in health and social care in Finland. The informants’ ages varied between 24 and 57 years.

We acquired approval from the Ethical Committee of the University of Jyväskylä before the data collection. Research permits from the two cities’ housing services departments were also acquired. We recruited the informants either directly through care unit managers or by distributing an invitation to an interview on the units’ email lists. Especially in the former case, we are aware that this sampling method may have provided us with informants whose participation was not necessarily fully voluntary and may also have left out some who might have wanted to participate. Some informants were familiar to the other interviewer due to his work experience in one of the research sites. Twenty-three interviews were carried out at the informants’ workplaces, one on the premises of the University of Jyväskylä and one in the interviewer's home. Afterwards, the interviews were recorded and manually transcribed. Their durations varied from 50 min to one-and-a-half hour. Semi-structured interview themes included daily work practices and habits, emotions, technologies used, responsibilities, etc. and were further addressed using key questions and prompts when necessary.

Analysis of the data was carried out using thematic content analysis (Boyatzis, 1998) including both data-driven and theory-driven approaches. First, the first author read all the data through and copy-pasted all words, sentences and parts dealing with temporality (excluding reports on work careers, temporalities outside work, and interviews with service managers whose work content did not include hands-on care work) into another file, resulting in 52 pages (font: Cambria, size 11) of data. After this, another round of analysis was carried out by the third author, who excluded parts that did not concern temporalities related to LTC workers’ immediate care relations with residents (for instance, speech about work schedules), resulting in a data corpus of 28 pages. Next, all three authors read the data corpus separately and carried out their own analyses, concentrating on the manifestations of attunement in the data regarding the informants’ first-hand experiences of care of older persons. The resulting analyses were then compared and combined into a structure that is presented in the following section concerning the findings of the study.

Findings

The analysis presents, first, how the informants speak about the importance of understanding the alter-temporalities of dementia and the disposition that is connected to this understanding, akin to what Yoshizaki-Gibbons conceptualised as ‘dementia time’. Second, attunement is described as receptive practices, meaning that stepping into dementia time requires listening and breaking from care home time and also from one's own temporal experience. Third, attunement is shown to function also as expressive practises, that is, as speaking, for example, commenting on the upcoming or ongoing care tasks the care professionals address the alter-temporality of dementia and become attuned to the care receiver's lived experience of the event at hand. Finally, we discuss temporal discordance, as in what limits the possibilities of temporal attunement in the current ISH settings.

Understanding: Recognising dementia time as an alter-temporal disposition

First of all, when asked about ideal care and practices for meeting the needs of persons with dementia, the informants talked frequently about the general need to understand the alter-temporalities of dementia in order to provide good care. While not yet explicitly referring to practices of attunement as part of carrying out care tasks, these general descriptions are viewed here as dispositions related to dementia time: for example, the informants talk about approaching the care receiver with ‘sensitive antennas’ and ‘recognising their moods’, in other words understanding the need to attune to their lived, temporal experience. This dispositional understanding is akin to Yoshizaki-Gibbons’s (2020) ‘dementia time’ – the care professionals feel that they have to make a temporal step into the lifeworld of dementia in order to be good caregivers. This is viewed as an occupational practice and a skill that also develops over time:

INF17: Having worked here for eight years, I have learned to slow down my pace, since I was sort of a firecracker before. So, I’ve understood that they really need the time; if I hurry, the restlessness will only grow and so might the aggression too. So, I think that if I now allow the time and get this thing done, then that will be it. But if I don’t, I might have to do it all over again later.

The informant above speaks about slowing down as a way of doing things properly, making sure that the residents will be taken care of in a holistic way. However, such a dispositional understanding of temporality is not a given approach in ISH settings. Care professionals do not necessarily learn how to consider dementia time in nursing schools, but do so rather by becoming slowly immersed into the lifeworld of ISH settings. As the informant above describes, as part of these tasks it is important to make temporal adaptations by ‘slowing down the pace’. As another informant put it, ‘the residents don’t have to hurry anywhere and can’t perhaps do things quickly, so why require quickness from them?’ In addition to this, an aspect of linear time is also evident in the quote: apart from being insufficient care in the lived sense, an insufficient understanding of alter-temporality may lead to having to repeat the same task in the near future.

Listening: Attunement as receptive temporal practices within care encounters

The first practices of attunement regarding dementia care we themed as listening. By listening, we do not refer only to listening to what the care receivers have to say, but to having a holistic, nuanced and receptive awareness of the other's alter-temporality manifested as speech and other embodied expressions. The informants described the importance of being able to halt the actions, and how ‘just being there’ is, or ought to be, a crucial part of LTC work. Far from passivity, this is a practice of temporal attunement that takes the alter-temporality seriously and prompts an active gesture of listening. Simply focusing on listening to the person with dementia at the moment is a crucial act of attunement. Many informants spoke about how ‘just sitting there for a while’ can have a great effect on the resident's, as well as the care professional's, well-being.

Q: What kind of things enable that kind of a good interaction with the resident?

INF14: Well, presence and listening, absolutely. And that there is time for that. If there are lots of people who are sick or if the list, like now [during] the Christmas [the workshift] list is planned so that there are only two [nurses] in the morning [shift], then of course those nurses are in such a hurry and you can yourself be in such a hurry when you’re helping that it jeopardises the ability to listen and be present.

Q: So, it's like a basic thing that you sit down [with the residents] if you have time?

INF14: Yes, it is. It's perhaps not that valued, sitting down with the residents.

The informants talk a lot about the importance of complete breaks from care home time as part of good care in the LTC of older persons. A break from pre-determined care tasks allows attunement as active listening to the other's lived temporality. The informants often contrast ‘sitting down with’ or ‘simply listening to’ the resident to ‘conveyor belt’ or ‘machine-like’ ways of carrying out care tasks. These examples show the broad meanings that are related to listening: it is not only about listening to the speech of another person but presence as such. Good care of older persons who live in round-the-clock residential care settings is not only about concrete, established manifestations of attending to embodied needs, but also simply about being present for the residents in their everyday lifeworlds, temporal states and rhythms. Therefore, listening becomes a holistic practice of attuning to the lived time of a person with dementia.

Q: If we think about a person with a moderate to severe memory disorder, how does it impact the interaction?

INF8: Well usually there's not that much speech anymore, so then you have to interpret gestures and facial expressions, and be even more concretely present. If they aren’t able to concretely talk about their situation, then you have to know how to interpret body language.

Apart from contesting care home time, listening can also be understood more broadly as the ability to understand the other person's lived temporality and vulnerability as embodied expressions, as is shown in the quote above. This reveals the idiosyncratic temporality of dementia care as an inevitably embodied practice. In this sense, attunement is not simply about affirming personhood by colloquial listening and conversation, but also involves listening as a radical, embodied ability (to attempt) to step into the lived time of a person with dementia. This embodied character of attunement is also evident in the next theme of ‘attunement as expressive temporal practices’, where attunement emphasises the meanings connected to the other end of the embodied dyad in the dementia care dialogue.

Speaking: Attunement as expressive temporal practices within care routines

In addition to understanding dementia time, which we determined as dispositionality, and listening as the first practical step into the lived alter-temporality of dementia, we will now present expressive practices as ‘the other side of the coin’ regarding attunement. We found that attunement not only relates to the lived time of the residents by listening and other means of receptiveness, but also practices of bringing the residents into the shared moment by means of expression, for example, explaining the ongoing event to provide good care. As listening was determined in a broad sense to cover the receptiveness to and interpretation of embodied expressions, we regard speaking as an allegory for the ability of embodied expression in general. The next quote shows a very concrete example of such attunement practice: commenting on the lived experience before engaging in pre-determined care routines. The informant explains how they approach the resident in the morning. They recognise the vulnerable situation as the person wakes up and starts to orient themselves to the present. Carefully and gently the care professional leads the resident to the present shared moment as the day begins:

[Talk about importance of talking in good care]

Q: What does the talking involve?

INF2: Well, like, absolutely no awful shouting or anything. So you try to go calmly, even though you don’t know anything and your head is completely all over the place and you just do these things all the time, but you just have to try to keep yourself calm and, chat a little bit and see. Let's open up the window a bit, and see, ‘Oh it seems to be morning’ and then just sort of little by little, approach the bed. But if you go straight there and start the situation [more bluntly], it might scare the person, if you’re a stranger to them and everything. It might be that the game is over immediately when you get there, so you have to have a calm approach.

Along with waking up, the daily ISH care settings are filled with plenty of other vulnerable and delicate situations, which underline the embodiedness of temporal attunement: the right way of speaking, a calm tone of voice and a careful approach seem to be key. The ability to temporally attune to another person's emotional and experiential state is described by the informants in terms of slowing down the temporal pace and toning down one's gestures. This is also the case in the quote below, where the informant also talks about the importance of speaking as part of this toning down.

[Conversation about how bed-lifts can be scary for the residents]

INF14: Some of them can express their fear, and then we reassure them while lifting them from the bed. I have noticed this generally as well, the more a nurse talks to the person about what is going to happen, commenting on the event at hand, the safer the resident will feel. But if the nurse is too busy, the hastiness can seem like automated robotics, just doing this and putting things in their place, so there could basically be a robot in his/her stead; then people will become afraid, even those who usually aren’t.

Here, the informant's explicit description of the importance of temporal attunement, when residents are moved from their beds by electric lifts, contrasts careful, humane actions with a robot-like implementation of pre-determined tasks. By making a temporal connection with the residents by explicitly commenting on ongoing events from the residents’ perspective, care professionals can reassure them in uneasy situations, concerning, for example, where they are at the given moment, what is the shared purpose of their ongoing situation, what is about to happen next and for what reasons, and that they are not and will not be alone during the experience. Other examples in the data where such commentary is seen as an important factor in caring are bathing, toileting and feeding. Care professionals can ease entry into the personal, embodied space of residents by taking an empathetic, embodied stance regarding the situation, and by living through the situations with the residents. These are crip time practices par excellence, in that once a person has trouble with their memory and temporal-spatial orientation, the situations highlighted above become situations requiring the utmost delicacy and care.

Becoming fragmented: Insufficient staffing and ill-fitting technologies producing temporal discordance

Finally, along with the previous examples of the idiosyncratic temporal requirements of dementia care work, our analysis also shows how care professionals’ ability to practice their ideals of temporal attunement becomes challenged. We identify temporal discordance in the informants’ speech concerning the everyday events in ISH to further underscore the character of attunement itself. We borrow the term from Julia Twigg (2010, 229), who has written about discordance in the heart of care as ‘rival temporal orderings of the body, home and service delivery’ in the field of home care of older persons. Of course, discordance is not part of the content of attunement as such, but rather works exactly against its content. By paying attention to discordance we wanted to emphasise the delicate character of attunement. By discordance, we do not refer to just any kind of discordance as part of care but to the temporally experiential discordance that occurs between the care professionals’ delicate, bottom-up attunement to dementia time and the top-down demands that attach to linear temporalities. In moments of discordance, holistic attunement is switched to temporal ambivalence. Therefore, rather than clear-cut, instrumental ‘disruptions’ or ‘hindrances’ regarding attunement as part of care events, temporal discordance emphasises the profoundly experiential character of both attunement and discordance occurring on the level of the care professionals’ experiences at each moment.

As is the case in Twigg's analysis of home care, in our analysis of temporalities in ISH discordance can occur in many ways and due to reasons that may reside on macro and micro levels in care settings. They can be about structural causes or more immediate practicalities, but they always reveal the utmost delicate nature of temporal co-presences that always run the risk of turning into temporal discordance. Attunement as either receptiveness or expression is hard if the sociomaterial settings are set up so that they hinder the ideal aspects of dementia care.

As mentioned previously, insufficient staffing was often noted as the reason for insufficient care practices in terms of temporality:

INF9: If the shift is busy, if there are only two nurses, and the residents are restless, we are so few that we don’t have a chance to figure out who to calm down. There should often be a possibility to give time to them, if I could for example stay with a resident for 15 min and sit down next to her/him, it might help. But if there are many of them, I don’t know who to start with, and then the restlessness causes more restlessness. I must somehow stay calm myself in order to calm down the situation.

Reports on the inability to provide care of sufficient quality are extensive and, unsurprisingly, heavily related to not having enough co-workers per shift to help ease the burden. In our data, the picture presented by the informants is somewhat grim. The ethical stress following from having to perform their care tasks as ‘machine-like conveyor belt work’ against their own care ideals is repeatedly connected to understaffing. This was spoken of as being antithetical to the attunement practices we have elaborated. When asked which three things they would like to change in their work, almost all of the 25 informants wanted increases in staffing. These are important examples of how attunement ought not only to be understood as phenomenological, immediate relationality, but rather something that is also prescribed by instrumental causes that stem from cultural, structural and material circumstances. In Finland, cost-effectiveness has dominated the discussions around the impacts of the ageing society, leading to diminishing resources for the LTC of older people (Van Aerschot et al., 2021). Feelings of hurriedness have been among the main reasons for the rapidly increasing turnover rate in care work (Kröger et al., 2018; Van Aerschot et al., 2021). Other reasons include insufficient support from managers, few opportunities to influence one's work, feelings of inadequacy, feelings of time pressure and a poor worker–client ratio (Kröger et al., 2018; Van Aerschot et al., 2021).

In our data, temporal discordance was also related to speech concerning the technologies that are being used in ISH. Various reporting systems, such as electronic health records, have come to be a significant part of daily work in ISH (Hämäläinen and Hirvonen, 2020) with profound consequences for care professionals’ daily time-use and content of care work evidenced in the data as frustration at having to carry out digital reporting tasks instead of the ‘real work’ of being present to the residents. However, in closer reference to discordance within the care routines themselves, the data reveals one major technological factor: safety alarm systems (referring to bracelets or pendants worn by ISH residents that send a signal to care professionals’ smartphones either when residents press a button on the device or the device registers something unusual in the resident's health data) producing discordance is widely discussed:

Q: […] is technology somehow related to the good and the bad experiences in your work?

INF9: In a way technology is related. We get safety alarms on our smart phones, and you’re helping another resident and you can’t check the alarm, so then your phone beeps the whole time. Some residents might ask, ‘Why are you beeping, what is that sound?’, and I might also get a hurried feeling that the next person already needs my help.

Q: If the residents ask about the beeps, will you explain?

INF9: Yes. I just say it's my phone and nothing else. But some of the residents are smart enough to understand that someone is calling, someone needs help. So, some of them have learned that the buzzing in my pocket means that somebody else is also in urgent need of help.

While safety alarm systems are also reported to reassure LTC professionals of the residents’ safety and well-being, they seem to constantly inhibit the possibilities of holistic care. This is showcased in onomatopoetic expressions having negative nuances in the informants’ speech: the alarms ‘beep’, ‘clank’, ‘tinkle’ and ‘buzz’ right in the middle of meaningful, delicate co-presences. The alarm inevitably reveals that the one caring is suddenly supposed to be elsewhere, therefore disrupting the ability to attune to the residents’ ongoing situation and experience. Given how extensively such irritations were reported, the systems seem to be a major source of temporal discordance concerning dementia care in ISH. Along with the structural resource factors presented before, ideal dementia care is also impacted by technological factors that have come to increasingly exist within the care events themselves. A lot of research on technologisation and care has been written that departs from sociomaterial epistemology and ontology, where the material entities are given performative roles alongside humans within an actor-network (see, e.g. Mol, 2008; Mol et al., 2010; Moser, 2011; Pols, 2015; Pols and Willems, 2011). Sociomaterial care literature offers important perspectives that prohibit analysing care technologies as mere tool-like, technical objects that may or may not have beneficial features in terms of caring but rather as something that constantly reconfigures what is understood as (ideal) care. While such a perspective is needed to fully grasp the tensions between technological actors and ideal care, our analysis shows that understanding the ideality that is connected to the concept of care requires a preliminary understanding of attunement which stems from a more profound epistemo-ontological understanding of temporal alterity, on which the delicate everyday events of care are suspended.

Discussion

The lived experience of a person with dementia is often composed of moments in which the sense of instrumental time is lost, which may lead to feelings of uneasiness, anxiety and depression. For instance, using a bed lift can be a scary experience for a person whose sense of time and place is lost if the task is carried out quickly, without explaining what is being done, by whom, in what manner and for what reasons. We borrowed the idea of ‘crip time’ in order to showcase the need for the recognition of temporalities of diverse bodies and minds that cannot be adjusted to normate time: rather, the care home time needs to be adjusted to the time of diverse bodies and minds. We argue that LTC of older persons requires ‘cripping’ care home time.

Taking crip time into account is particularly important in the LTC of older people where dementia affects the relationalities of care, however, shifting the focus on alter-temporalities is important in any care setting, whether dementia was involved or not. Regarding care and old age, the importance of understanding crip time will only increase as access to LTC is being increasingly granted only to persons with more severe care needs in order to save societal costs. This argument is in line with past research on the temporalities of care of older persons, and especially so with Egede-Nissen et al. (2013), who wrote about ‘time ethics’ in care homes. Attunement as the ability and skill to engage in alter-temporalities reveals the fact that our relational vulnerabilities, which can be met by caring or unmet by negligence, are straightforward ethical practices. Also, we want to emphasise the theoretical yield of understanding dementia as radical alter-temporality for time theories in general. In our view, and considering our results, the different perspectives of crip time can help us understand the plural and social aspects of time and temporality in general, revealing the politics of time in novel areas in the society.

As such revelations of the ethics and politics of care temporalities, our analysis elaborates, first, how care professionals generally emphasise the importance of understanding the alter-temporalities of dementia and the ethical disposition that is connected to this understanding. This perspective is akin to what Yoshizaki-Gibbons conceptualised as ‘dementia time’ – the recognition of the idiosyncratic lifeworlds that concern dementia and the awareness of the ability to shift normate time towards dementia time (Yoshizaki-Gibbons, 2020: 189). Our goal was to use dementia time as a starting point for further conceptualisation of attunement as a practical, alter-temporal engagement in terms of carrying out daily care tasks, routines and events. Therefore, second, attunement was concretely spoken of as receptive practices, meaning that stepping into dementia time requires primarily an active, embodied shift to meet the lived temporality of the person with dementia. This was described as practices of listening, staying, sitting beside the residents and ‘just being there’. We presented listening as an allegory of being able to be fully present to another person on their terms. This also meant breaking from care home time and diminishing the importance of one's own temporal experience. Third, attunement was shown to have a second function as an expressive practice. For example, by commenting on the ongoing or upcoming care tasks, the care professionals address the alter-temporalities of dementia and attune the residents’ lived experience to the event at hand. This practice is a careful movement between understanding the presence from the alter-temporal perspective of the other person and helping this alter-temporal perspective align with for example an intimidating event such as bathing, lifting or another intricate bodily action. Finally, we also elaborated on the causes of temporal discordance by showcasing the experiences of what limits the possibilities of attunement in the current ISH settings. Quite unsurprisingly, the analysis provided two key limitations for attunement as ideal dementia care: staff shortages and disturbances caused by technology in the form of safety alarm calls. In the hope of increasing care work productivity with the help of digitalisation, further research is needed to determine how increasing technologisation impacts not only time use but temporalities of care.

Our findings show that care professionals hold practices of attunement in high regard in terms of ideal dementia care. One may ask, for instance, why so many of the informants wished they had more time for presence and not necessarily for specific care tasks. What does this presence mean and why does it seem to be so important for the care professionals? We argue that longing for this presence is about acknowledging another person's temporal lifeworld: being truly attentive to the care recipient's momentary need is about attuning one's temporality with that of another person. Of course, this is not to argue that a full understanding of another being's experience can be reached, in that being is always to some extent singular and experienced as otherness by others (see, e.g. Lévinas, 1969), but we do argue that the ethical stance of persons who care for other persons includes an attempt to approach otherness and alter-temporality despite the categorical impossibility of a full understanding. Attunement, by definition, is like the attunement between notes in a musical instrument – the fact that perfect harmony does not exist does not mean that we do not recognise and prefer better harmony to an off-pitch one or that harmony should not be pursued. Staying on the level of musical analogies, and revisiting the importance of understanding the similarities between the immediate care relation and Schütz's example of duration as experiencing a music piece in its entirety (Schütz, 1996: 246), the ability to attune to alter-temporality of dementia reveals itself also as a philosophically intricate practice. Our analysis shows how good caring is about both reception and expression, the two sides of attunement, showing the dialogically delicate nature of the immediate, ideal care relation, connecting temporality and otherness in a single, dialogical event. Importantly, our analysis also shows how easily these attempts at mindful co-presence, these dialogues of temporality, are shattered by institutional temporalities.

To us, it seems that the world of care, particularly eldercare, has been losing something of great value that resides at its core. In this article, we have argued that the ‘something’ that is lost might be nothing less than time itself. We do not aim for a future where clocks are got rid of in LTC facilities, or the impacts and meanings of linear time are completely forgotten. Care policies of course become impossible without spatialised temporal units that create some kind of a common ground to analyse and plan courses of action. However, we want to emphasise that there is also a moment in progress where such a stance on temporality starts to work against its initial goals and ideals. In care, these ideals have much to do with having enough time to basically forget the clock. The temporality of the very immediate care relation, emphasising what it really means when the other person's otherness is taken as a starting point of action, goes against too tightly woven and pre-determined regulation – and if this ‘something’ that resides within care itself is disregarded, we will simply end up with misguided and therefore poor expressions of care.