The logic of ‘home care time’

Abstract

The study investigates temporal aspects of home care in Sweden, as experienced and interpreted by older care users. Data consists of 34 interviews with 36 care users and 15 participant observations during home visits by care staff. By focusing on care users’ recalibration of time and events, the analysis identifies a form of interpreted experience – here termed ‘home care time’ – that comprises two governing sublogics – care users’ understanding of themselves as part of the home care organisation, and care users’ empathetic understanding for care staff – where each sublogic evolved from several approaches where care users expressed time empathy, tried to increase time efficiency, or adapted to other care users. Some care users described attempts to take control and influence temporal aspects. Such attempts resulted in adjustments to services at the individual care user's request, but they were also associated with the risk of conflict between care users and care workers. The study addresses the gap in the literature, which mostly studies and theorises care from a care provider perspective. The logic of home care time identified in the study can explain why older people may say they are satisfied with services though poorly performed due to time shortages. This explanation is a corrective to stereotypes that portray older care users as docile and grateful.

Introduction

The literature on home care for older people often debates the question of time. Studies of time usually focus on how care workers experience cutbacks or the introduction of schemes and technologies intended to make care provision more efficient (Bergschöld, 2018; Hirvonen and Husso, 2012; Rubery et al., 2015; Strandell and Stranz, 2021; Tufte, 2013; Tufte and Dahl, 2016). Research shows that care workers are negatively affected by a lack of time, and the problem of providing care that meets the shifting needs of older people is stressful in ways that may result in care workers quitting (Andersson, 2007; Elmersjö et al., 2022; Karlsson and Gunnarsson, 2018; Strandell, 2020, 2022b). Research about time management in home care has shown that care workers use several strategies in relation to time constraints, for example by prioritising between care users – ‘stealing’ time from some care users to spend on others – or by working during breaks and mealtimes and outside normal working hours (Cranford and Miller, 2013; Martin-Matthews, 2007; Strandell, 2022a).

In terms of theory, much of the research on eldercare relies on the approach originally developed by feminist scholars. Gilligan (1993) argues that a ‘feminine morality of care’ is based on relational values such as cooperation, empathy, and compassion, expressed as an ethic of care. Nordic care researchers such as Wærness (1984) and Eliasson-Lappalainen (1995) have developed this approach in analyses of formal eldercare. All care theory shares an emphasis on care as an empathetically grounded activity embedded in social relations. The standardised procedures that characterise industrial work are therefore unsuitable for the development and provision of good care. Using this approach, Davies (1994) distinguishes between clock time and process time, where clock time (also called linear time) is measurable and works well in defined schedules so it is possible to streamline and standardise work tasks, and process time is situation-bound and embedded in social relationships. An act of care is rarely limited to the clock time it takes, since empathy and consideration must be included, as well as the chain of events that the act is linked to. Hirvonen and Husso (2012) described this in terms of ‘overall attention to the other in care relationships’ (p. 354), which cannot be fixed in time. Wikström (2005) exemplifies process time with the act of comforting. It is difficult to measure how long it takes to comfort someone because the act is relational and woven into the situation.

Despite the literature's important insights about care, such theories have not paid adequate attention to older care users, not even as the focus on the empathetic, relational activities of the carer. Some studies about time, however, do concentrate on the home care users’ experiences and perspectives. Looking at home care in Australia, Doyle (2012, 2014) discusses temporal matters in terms of a struggle for control. Losing control has also been a theme in the literature on Swedish home care, with several researchers finding that care users were frustrated by stressed care workers and unpredictable visits, but were reluctant to complain because of their loyalty to staff or the worry of causing a conflict (Andersson, 2007; Dunér et al., 2019a, 2019b; Wikström, 2005). Yet, little research acknowledges that older people are reflecting participants, actively involved in the performance of formal eldercare. Problems of time and timing have rarely been explored using the theoretical approaches and concepts that have been central to studies of the provision of care. The recent study by Palmqvist (2022) is an exception. What Palmqvist (2022: 960) calls ‘care-giver bias’ points to the main focus in eldercare research: care work is framed as a relational practice, but is theorised and investigated from the perspective of those who provide it. This one-sidedness is strikingly different to disability studies, where the service user is acknowledged as both a citizen with rights and an individual with experiences, interpretations, and strategies that demand theorisation and investigation (Erlandsson, 2014). Prominent scholars in the field of disability studies have placed the person living with disability at the centre of their investigations, questioning normative orders as ableist (Morris, 2001; Shakespeare, 2014). Researchers have theorised ‘crip time’ as a lived experience with several meanings (Ljuslinder et al., 2020; Samuels, 2017), even arguing that crip time ‘bends the clock’ to meet disabled bodies and minds (Kafer, 2013; Palmqvist, 2022).

The present study is part of a research project where home care is acknowledged as a relational and context-bound practice, but, inspired by disability studies, eschews the provider perspective to investigate home care users’ experiences, interpretations, and strategies. It may have much to say about older care users as active agents in the context of formal care, but this approach also promises theoretical knowledge about the governing logic of home care that results in particular interpretations and care user behaviour. The present analysis offers an alternative to the stereotypical descriptions of older people as docile and grateful that are used to explain care users’ acceptance of time shortages in eldercare (Damberg, 2010; Jönson and Jönsson, 2015). The aim of this study is thus to investigate the temporalities of home care as interpreted and handled by older home care users.

As Nowotny (1992) notes, because of the obvious link to collective action and the norms and order of social life, time has been extensively theorised in sociology. In this study, we apply the concept of adaptation, what Sharma (2011) terms ‘recalibration’ arguing that although there is no shared experience of time, there are temporal orders and logic that exert power over people's lives. People synchronise their bodies, experiences, and perceptions of time to external relationships. The social control brought into focus by recalibration occurs in relation to other individuals, institutions, and systems embedded in various power structures. Such power relations have been investigated in terms of the ‘time discipline’ primarily associated with clock time (Thompson, 1967), but also with process time. As Foeken (2023) argues, process time may be an alternative to clock time, but research on care has overlooked process time's disciplinary function as moral expectations associated with specific contexts and positions. This disciplinary function is visible whenever eldercare staff compensate for organisational problems by sacrificing their own free time to provide good care (Karlsson and Gunnarsson, 2018; Strandell, 2022a).

Our starting point is the care theories’ central claim that care is a relationally and empathetically grounded activity, but, concentrating on older care users as active agents in what is an organisationally embedded practice, we also discuss clock time and process time as enabling and disciplining aspects of care use. The ‘overall attention to the other in care relationships’ (Hirvonen and Husso, 2012), used to describe process time in studies of care staff, may also be part of the user experience of eldercare.

Swedish home care

Swedish eldercare is characterised by a policy of ‘ageing in place’, whereby older people receive formal care in their own homes rather than in care facilities. About 7% of the population aged 65 and over receive home care, rising to 28% of people over 80. As with all Swedish eldercare, home care is publicly funded and provided according to need. The official decision to grant home care is handled by a local authority needs assessor, while services are provided by the local authority or private care providers according to a purchaser–provider system. Care users pay a fee, but it is capped regardless of how many services they require (SEK 2359 a month in 2023, equivalent to €200) and can include such services as personal hygiene, housekeeping, personal alarm monitoring, and meal deliveries (with an additional cost for the meal). A typical day for an older person with moderate needs might consist of three visits: a morning visit for the care user to get up, have breakfast, and take any medicines, and sometimes to have a shower; a second visit at midday to prepare lunch; and a third in the evening for supper and to get ready for bed. In addition to daily visits, home care staff can help with laundry, cleaning, and shopping, accompany care users for walks, and sometimes pay visits to prevent social isolation.

Care users in Sweden are usually granted services (food preparation, showering, etc.) rather than time measured in minutes and hours. Nevertheless, staff members have schedules based on how many minutes it usually takes to perform each task, and care providers typically allocate time for visits in order to schedule staff activities. When their schedules are tight, staff tend to experience stress (Hirvonen and Husso, 2012; Strandell, 2022a). The time allocated by the care provider or by members of staff is rarely communicated to the users as the organisation's decision, the exceptions being activities such as ‘social time’ and accompanied walks. The lack of information about time puts users at a disadvantage and leaves them wondering whether the services they have been granted have indeed been fulfilled during visits. When staff, trying to fend off demands for services, inform care users about the inadequate amount of time allotted for visits, users may feel obliged to adapt to what is possible in the clock time communicated to them rather than demanding that their actual needs are respected.

Method

The data for this study consists of qualitative interviews with care users and participant observations of the performance of home care services. The qualitative interviews consisted of 34 interviews with 36 home care users in southern Sweden (22 women and 14 men) whose ages ranged from 68 to 96 and about a third were 90 or older. Interviews were carried out between 2021 and 2023 in the study participants’ homes, in a variety of geographical locations ranging from Sweden's third-largest city and its suburbs to small towns and rural areas. Interviews lasted between 30 and 120 min. Among the participants were retired blue-collar workers, farmers, academics, and business owners. Four had been born outside Sweden. A majority of participants lived in single households, but in five instances a cohabiting partner (not counted as a participant of this study) contributed by answering interview questions, either partially or entirely, in collaboration with or in the presence of the care user. Participants had varying care needs, but most had home care several times a day. There was also variation in their length of care experience, ranging from a few months to more than 20 years. Participants were recruited with the help of the home care organisation in three local authorities, one of which had already been in the pilot study that preceded this study. Additional participants were recruited through media coverage and social media, asking individuals who wished to participate to contact the researchers. Individuals living with cognitive impairments or aphasia were only included when a cohabiting partner could be present for the interview.

An interview guide was developed for the pilot study of 11 participants (who were later included in the 36 home care users in the main study). Interviews were characterised as conversations with broad and open questions. Among the themes identified in the pilot study responses were time pressure, strictly controlled schedules, and cancelled or reduced services when staff were stressed. In view of this, the interview guide was then revised for the main study to elicit home care users’ experiences regarding time:

Thinking about how you live today, have you adapted your life and habits to your home care and any other help?

How do you think the help you receive fits into your life otherwise (routines, relationships, and lifestyle)?

Do you prepare or arrange anything before the home carer arrives?

Have you changed the time you go to bed or wake up or made any other adjustments (mealtimes and bathroom visits)?

For a more nuanced understanding of home care provision, participant observations were conducted on 15 occasions in the homes of six of the care users in the study. On each occasion, the researcher arrived in advance and was present before, during, and after the home carer's visit. Care users were asked about their expectations before the visit and about the outcome after staff had left. Among the care situations observed were getting out of bed, having breakfast, preparing lunch, and showering (in the one case where the care user had requested it).

The study was approved by the Swedish Ethical Review Authority (Dnr 2022-00829-02). All participants were informed of the study's purpose that they were free to cancel their participation at any stage, and how data would be handled and anonymised. Participant observations were subject to special consideration: during visits, there was continuous communication with participants about what they were prepared to allow the researchers to observe. All the care users’ names in this article are pseudonyms.

Coding and analysis

All interviews were recorded and transcribed verbatim. Field notes from the participant observations were rewritten as cohesive texts. The three researchers in the team read all the transcripts to develop a coding scheme. Data was coded using NVivo software and codes were arranged by theme to represent the home care user's approaches to time. Four themes were identified as capturing the key aspects of older people's temporal approaches: (i) expressing time empathy; (ii) increasing time efficiency; (iii) adapting to other care users; and (iv) trying to control time. Further analysis of these themes resulted in the identification of two overarching themes that together formed the governing logic of an interpreted experience we term ‘home care time’. The dictionary definition of logic is ‘a particular mode of reasoning viewed as valid or faulty’. As a concept, logic has been theorised in several research traditions, focusing on cultural constructs and decision-making by individuals and organisations (Valentino, 2021). In relation to time, logic has the type of ‘explanatory power’ that Sharma (2022: 45) associates with temporal orders. Home care time is based on the two sublogics of (a) seeing oneself as sequentially included in the temporal organisation of home care and (b) an empathetic understanding of care staff's working conditions. Attempts to negotiate and control time were both part of the two sublogics and a way to resist the existing temporal order of home care time.

Results

The temporal approaches we identified are related to the governing logic of home care time in both senses. In this section, we highlight recalibration situations where care users adapted to what they understood as possible in terms of life quality, and their attempts to take control of time or demand services that challenged the logic of home care time.

Expressing time empathy

Many participants expressed the kind of empathy for others and their needs that is central to theories of care provision (Wærness, 1984; Eliasson-Lappalainen, 1995). Their understanding of the home carers’ working conditions, other care users’ needs, and time constraints prompted care users to adapt according to the sublogic of seeing oneself as part of the organisation. This recalibration comprised measures to facilitate or compensate for staff members’ work.

Time empathy was evident as care users’ pity or sympathy for staff, reasoning that staff were the victims of a precarious work situation. Ebba, an 87-year-old woman, commented several times on the staff's working conditions, saying ‘It's a pity for them because they actually have a stressful work situation’ and ‘They should have a little more time, they are human beings … they are not machines’. Ebba explained that other care users would ring staff's mobile phones while they were at her home, which she found stressful. In the morning, staff were scheduled just 10 min to help Ebba. Fortunately, her daughter prepared food which the staff could heat in the microwave during their brief visit. Ebba concluded that the help received was ‘fantastic’ and the staff were excellent, but they should be more appreciated. Her evaluation that the service provided was fantastic stemmed from her admiration for the way staff struggled to help her despite not having sufficient time to do so.

The short timeframes and sense of urgency were described as worrying and burdensome by many care users, but they were also said to be a fact of life. For example, Beatrice, an 84-year-old woman explained her home carers’ inability to perform all their tasks:

Well, they are bound by time, I understand that. They can’t stay here because they often get calls … they have a phone, and often someone calls from another place asking ‘When are you coming?’ and ‘Yes, I’m here now but I’ll be along later’ and ‘I’ll just be a minute’, so they are very scheduled.

Participants frequently commented on how home carers’ work was governed by phones that kept track of their time.

A recurrent theme in the descriptions was a form of empathy, where notions of the care worker's working conditions and experiences were the starting point for the care user's own recalibration, indicated by expressions such as ‘I understand that…’ For both Ebba and Beatrice, other care users’ alarms and phone calls during visits were manifestations of a work situation that impacted on them but that could not be questioned. By concluding ‘They can’t stay here’, Beatrice oriented herself to express her understanding that the limits and constraints on services were absolute.

As an alternative to the argument that acceptance of insufficient care is the result of older people being docile and grateful, we find the time empathy approach was the result of care users’ adaptations to facilitate care out of sympathy. Empathising with staff, some care users accepted that services were performed in a stressful way. Alexander, a 70-year-old man, commented that the staff were often stressed when chatting with him during the ‘social time’ he had been granted, but he framed this as understandable:

Alexander says he appreciates the 30 minutes of social contact, but that the staff are sometimes stressed. He says it's the last shift on their schedule and he knows they want to go home afterwards. Alexander also comments that he wouldn’t want to work overtime either. (Field Notes 220907)

Understanding of the staff's working conditions was based on experiences of rushed visits and comments from staff about time constraints. Some home care users explicitly said their loyalty was to the staff and they would never turn to the care provider's representatives to complain. In several cases, care users referred to their own working lives as the reason for their sympathy. Hulda, a 79-year-old woman, speculated that some staff may not have chosen to work in eldercare and related her understanding attitude to her own professional background: ‘Since I have been in the care field myself… you’re a little more understanding perhaps towards … others’. The staff were in a difficult situation and Hulda was aware of that when evaluating the quality of services.

Increasing time efficiency

Recalibration could also be seen in care users’ efforts to be time efficient and help staff do their job, based on their understanding that time was limited. They helped do tasks and facilitated care provision, adopting the role of co-workers in a joint project. One way to do this was to adapt their established rhythms of hunger, sleep, and toilet visits to their home care schedule. Gunnel, an 82-year-old woman, was a typical example. She described how she had changed her timings and sequence for eating and going to bed to suit the care provider. Gunnel set her alarm to get out of bed and prepare herself for the morning team:

Gunnel: They come, so I sit there in the chair and wait. [–]

Interviewer: Because otherwise you might have still been in bed?

Gunnel: Yes, no, no, I feel like I want to fit into their pattern, because I now belong to them.

Gunnel controlled her actions to streamline the staff's work, but also changed her thinking, feeling she wanted to fit into their schedule. Her words ‘I now belong to them’ reinforced her sense of placement in the organisation, backing her decision to adapt.

Davies (1994) describes process time as a relational, empathetic activity that includes thoughts, concerns, and preparations for those who care for others. Our study shows that such concerns and preparations should not only be theorised from the perspective of care providers: for users, home care is in many instances a sequential activity that starts before staff arrive, as shown in the following observation.

Care user Lars is sitting in a bathrobe on a chair in his living room outside the bathroom. He has a roll of black plastic bags in his hand, the type used for household rubbish. He tries to tear off a bag from the roll but fails. I offer to help and Lars hands me the roll. I tear off a bag and give it to Lars without understanding what he needs it for. Lars explains that it's almost impossible to put on his support stockings when his legs are damp. Therefore, he puts rubbish bags on his legs when the home care service is going to shower him. ‘When we were in the hospital, they used one of those disposable aprons and wrapped it around his legs’, explains Care user Elisabeth, who has returned from the kitchen. Lars has turned his chair a quarter turn, so he is facing the room, with his feet in the black bags. His walking frame is beside him. I interpret this as him getting ready for the home care service to come and shower him. When the home care worker eventually arrives, she seems to know exactly where Lars is in the work sequence. She kneels and tapes the rubbish bags around his legs, then leads him into the shower. By preparing, Lars made the service more efficient for the staff and compressed the process time of the shower. (Field Notes 2022-11-16)

This was one example of a procedure where care users got ready for the part of care that involved staff by doing something usually included as part of the service – here having a shower. Several similar preparations were present in our data.

Efforts to increase time efficiency involved making the help less ‘concentrated’, meaning that care workers did not have to undertake too many time-consuming tasks during each visit. In an interview, Gunnel was asked if she had ever asked for help with something, but the staff said they could not do it.

Yes, no, there was one time, it was one evening, yeah, it was quite a while ago, when I was going to, I thought I would have something, yeah, food then, and then someone said, no, we probably don’t have time for that, we only have seven minutes. Then I found out they have 7 minutes, 7 minutes to take care of me here in the evening, give me food and so on, no, then you must be careful to take those, because it's included in the 7 minutes, what they are supposed to do. But I think it sounded so terrible: ‘No, we only have 7 minutes’. Yes, I mean, how much can you do in 7 minutes? … Yes. Now they don’t have to do so much here so they can probably manage it in 7 minutes, but I was a little, a little surprised when they said that.

Gunnel had been granted help with a meal and other services in the evening, but like others, she discovered that time was too short for the service to be provided in the way that she wanted. Her reaction was not to question whether the allocated time constituted a formal decision by the home care organisation or whether it was something the staff had informally decided themselves in order to manage their work schedule. Adopting the role of sympathiser, Gunnel changed her understanding and request for services, so they fitted into the allocated clock time:

Gunnel: It sounds terrible to have it like that. So, I’m just trying to make it easier for them so they can do it in 7 minutes without having to look at the clock.

Interviewer: What do you do to make it easier, then?

Gunnel: Well, then I just changed the order there, what it was that I was supposed to have, I don’t really know. No, it's easy to take something else, something that only takes a minute. You have to cooperate a bit, I think. Yeah.

Interviewer: So, you mean your evening meal in this case?

Gunnel: Yes, that was it, it was.

Interviewer: So, you changed your menu there, you might say?

Gunnel: Yes, a little bit. It was maybe just from something … boiled egg to fried egg, because fried egg is probably faster…

The mini drama that Gunnel described followed a pattern where the staff's verbal and non-verbal communication of time constraints and time frames resulted in efforts by care users to increase time efficiency. Gunnel presented herself as a responsible partner in the project of making her own care function within the tightly allocated time the staff had at their disposal. Temporal synchrony has been associated with a sense of wellbeing (Kim, 2023) and Gunnel concluded that the staff appreciated her attitude, because it made it possible for them to perform services within the short time frame. Central to the project of facilitating the care work was the care users’ perception of time as something that should be handled within the carer–user dyad. Alexander, whose reasoning about social time was cited above, accepted that the available time was reduced when he was informed there was a lack of staff due to illness, which he expressed as ‘You have to do that in times of crisis, you know’. The organisation had problems staffing, and by referring to it as ‘times of crisis’ the situation became a matter of adjusting expectations during the visit.

The dilution of approved services was visible in various ways. Several care users described how knowing about the staff's workload meant they accepted their care being cancelled. Matilda, a woman in her nineties, said that on paper she had a shower twice a week, but more often than not it was cancelled. The staff had a hard time, said Matilda, and since she thought the situation could not be changed she followed the sublogic of seeing herself as part of the organisation and adapted. Though she was unhappy about it:

I say, ‘Damn it, I needed that’. No, but it can’t be helped. If they can’t do it, they can’t do it. I’m old enough now so I … when you’re younger, you’re more like ‘it has to be done this way and that way’, but I think, ‘I can manage today and tomorrow’. I don’t go out much, and I wash myself a little bit, but it's just the shower … It has happened that it has been cancelled, sometimes twice in a row.

Matilda returned to how rushed the staff were on many occasions during the interview, but, like Gunnel, she viewed time constraints as something that prompted self-management out of consideration for the staff's working conditions: ‘Because I also have to see it from their perspective, I can’t just yell at them or bargain with them, because it's about how much time they have’. Matilda's recalibration was shaped by the sublogic of empathetic understanding for the care staff, her focus being staff stress and the care worker–user dyad.

The erosion of services was also seen in tasks that were done separately when they ideally should be done in sequence, if only to reduce the stress of what has been identified as a main activity, as a home care visit to the couple Lars and Elisabeth illustrated:

Care user Elisabeth comes out of the bathroom wearing a light brown bathrobe and a white turban on her head. She walks with her walking frame to the table where Care user Lars and I are sitting. She turns to Staff Member Janet, who also comes out of the bathroom: ‘We have some rubbish and stuff today too’, says Elisabeth. Jeanette goes into the kitchen. Elisabeth sits down at the table and explains that they usually try to get the rubbish emptied the day before the shower so that it doesn’t ‘mess things up’. Elisabeth explains that recycling takes extra time and today they had a paper bag with plastic, cardboard, and newspaper. It takes time for the staff to sort the rubbish. Elisabeth describes how she tries to have things ‘clean’ on the days they have a shower so that they can focus on the shower. At first, she and Lars thought it would be nice to have the beds made up with clean sheets after their shower, but they were told that it's not possible. (Field Notes 2022-11-16)

Interviewed with Lars on another occasion, Elisabeth described the same setup to give the staff enough time to perform services well, since showering two people and changing the bed sheets would not be possible within the allocated time. When Elisabeth spoke of trying to have things ‘clean’ she meant keeping the staff's schedule free from other tasks and thus streamlining their work. Even though she hoped to have the beds made up with clean sheets after she and Lars had showered, the problem could be dismissed as a minor matter: ‘No, it works well, I think’.

Adapting to other care users

The empathetic position central to the understanding care users showed to care workers was to some extent behind the similar understanding they showed to other care users and their needs. In a study of home care staff managing time shortages, Strandell (2022a) identifies a strategy of ‘reallocating time’ which involves ‘stealing’ time from some care users to complete services for others whose needs cannot be met within the specified time. Other care users and their needs were tangible as late arrivals and constant alarms during care visits. Care users adapted their daily routines out of consideration for other care users that staff needed to prioritise. In line with the sublogic of seeing oneself as part of the organisation, care users took on their care provider's sequential view of their own lives.

Several interviewees said they had changed the time they got up, ate meals, and went to bed, but that they did so out of concern for other more needy care users. Matilda described staff arriving late and being in a hurry, yet she also understood that she had to wait because the care workers were short-handed and had to prioritise those with the greatest needs:

There are many who need help getting up and getting dressed and such things, and one should not wait for that, but if there are many who need help then the others will suffer, so you just have to take it. Because I don’t think I need help at half past seven when there are those who are waiting to get up, you know. Now perhaps I’m too kind, but I think it's so that I can wait a little while longer and read the newspaper for half an hour, so that the one who really needs help, now that's the help that's necessary, I’m thinking about, I’m not thinking about anything else, it's for the one who perhaps can’t get up by themselves.

The same logic shaped Alexander's choice to adapt. He related his own need for assistance to the chain of other care users the home care service had to visit. Unlike Matilda, who adapted to the situation by simply staying in bed with a newspaper, Alexander had acted to place himself in the hierarchy of help:

Interviewer: No. But have you had to change your, like, adapt your life to the home care service's schedule, do you think?

Alexander: Yes, they’ve changed it now for me so they should be here, I’m the second man who should have my medicine here. And then they should be here before eight, because I take twelve pills in the morning. It's a lot of pills I take.

Interviewer: That is a lot.

Alexander: Yes.

Interviewer: But how do you know that you’re the second man?

Alexander: Well, I’ve requested it … that I should be.

Interviewer: But not the first?

Alexander: No, the first, there's a guy, he has problems with balance and stuff, so he has to have it earlier because he has to get out of bed. But it doesn’t bother me, as long as they get here before, yes, if it's a quarter past eight, that doesn’t matter, but they shouldn’t come at half past eight, quarter to nine, nine. That doesn’t work.

Alexander expressed his concern for other care users with greater needs and more difficult situations than his. Although he had been forced to change the time he received his evening medication, he did not see it as a major injustice since he knew that the staff needed the time to help people ‘who have nappies and stuff. It's not so nice to sit in it if you’ve pooped or peed’.

Resistance: Trying to control time

Older people do not always adapt to the prevailing conditions. Cranford and Miller (2013) find that care users communicate their demands and needs, directly or subtly, to steer the way care staff allocate time. Negotiations and attempts to control time constituted a theme in our interviews, which in some cases confirmed organisationally bound temporalities and in other cases challenged the logic of home care time. The example of Alexander managing to become the ‘second man’ highlights both functions. Using phrases such as ‘I’ve requested it’, and ‘they’ve changed it now for me’, Alexander emphasised his ability to influence when he received help, but his agency concerned sequential priorities that were similar to how the organisation would decide a hierarchy of needs.

Some care users gave examples of prolonged conflicts over unpredictability, timings, and services; others detailed successful attempts to extend visits to avoid stress or to change visiting times to suit their preferred habits and routines. Participant observations showed care users trying to prepare for the coming days by obtaining information about changes to staff schedules or informing staff about private arrangements or special requests. Attempts to adjust or change home care visits so they would fit in with the care users’ other arrangements were mentioned in nearly all the interviews. This included assistance leaving and returning to the home when using transport services or participating in social activities, which made changes to scheduled home care visits necessary. Adaptations of home care services to meet such requests were described in terms of well-established routines as well as uncertainty, frustration, and disappointment when care staff arrived too late.

Care users’ attempts to take control of time depended on knowing the timings used to calculate staff schedules. Such knowledge strengthened the care users’ position, enabling them to claim that services were not performed well. Participants spoke of trying to find out the time allocated for different services. They then used that knowledge to enforce their demands for services of a particular quality and to fend off the crisis rhetoric.

Tilly: I get the feeling that they say ‘There are so few of us, there are so few of us’ when they are late, for example, and it is usually on Saturdays and Sundays because they have fewer staff: ‘There are, there are so few staff, that's why we’re late’. But then I say if you have a time with me, then you should also be here at that time with me, because they are so stressed and then I become stressed too. And then I can’t manage anything myself.

Interviewer: But this time thing, do you know how long they should be here?

Tilly: Well, roughly, because I have asked several times; they say ‘We have 45 minutes’, or ‘We have an hour’. And then I think they should be here for an hour. And not say ‘We’re in such a hurry we can’t make it’, because then…

Tilly, an 80-year-old woman, had to battle to make the staff stay for a certain duration of time. She hoped to slow the pace and avoid personal stress, but she also wanted to ensure tasks were not left unperformed:

For example, they would say, ‘We don’t have time for that, we’ll do it at lunchtime’, when it came to things like taking out the rubbish, and then they wouldn’t have time for it at lunchtime either. So there's too much of that ‘We don’t have time’. And as I usually tell them; you always have time, take two minutes for those kinds of things.

The conflict that Tilly described was about the staff's attempts to skip tasks to save time – what some users described as staff trying to ‘slink away’. Several participants said they had complained to care coordinators or planners or raised their complaints directly with the staff when neither the time nor the tasks matched what they had been granted. Sometimes, this disagreement had led to open confrontations with staff. For Lena, an 89-year-old woman, knowledge of the designated times was clearly a tool she could use when care workers referred to time constraints. Like several other care users, Lena backed her claim by noting she was a paying customer entitled to the quantity of care she had been granted: ‘It's the time I’m paying for. I must check. If they’re here the whole time, then they have time to do everything they need to do’.

Care users also typically attempted to control the timing of services. In several cases, they requested or demanded that the home care service notify them of delays, and they expressed their dissatisfaction at the failure to do so. Similar to the care users in Doyle's study (2012), the couple Ellen and Jan were frustrated with the unpredictability of the home care service because it stopped them from planning their daily lives. They were annoyed by the lack of information about changes to the schedule that could easily be communicated to them:

No, no, but I mean, in other professions, I mean, you just don’t fail to show up or fail to leave a message and so on, and in this digital world, how hard is it to send the next day's schedule every afternoon?

In their attempt to gain control over time, Ellen and Jan still operated within the framework of home care time. Their complaint was about being informed about changes, and not about staff being on time or the actual changes to the schedule.

Information from staff about tight time frames prompted adaptations from participants such as Gunnel and Ebba, whereas Tilly and Lena used their knowledge about the allocated time for longer visits as a resource to claim their rights to services they had been granted. A strategy among some care users was to argue that minutes-equals-service, but this met with resistance when communicated to care provider representatives. Jessica, a 65-year-old woman, had managed to influence the arrangement of her services, so staff visited in the evening to prepare breakfast and lunch for the next day. This freed Jessica from a series of daytime visits, which she was otherwise offered. She had been informed by staff that the time allowance for evening visits was set at 40 min, with the tasks to be carried out in that time: ‘And then I felt calm and safe to say, “Yes, sure, can you do that too,” because I thought OK, I have 40 minutes, as I have been promised and for which I pay too’. This was a situation where clock time allowed for the care that Davies (1994) assigns to process time; however, after a while, Jessica noticed that the staff left far earlier than agreed. Some care workers told her that the time for the visit had been reduced to 20 min, sometimes only 15 min, and that the reason given was to save money. Like Lena, Jessica referred to the fact that she paid for services, thus invoking a market logic. When Jessica questioned the reduction in time, her concerns were dismissed:

So I have pointed it out, and then unit managers and others working in home care say, ‘We are not allowed to talk about times. We don’t have times here; we only talk about the services. It's the services that should be performed … dishwashing, rubbish, and so on. So we don’t talk about time here’.

The manager argued that staff should not have informed Jessica about the clock times, and even tried to discover who had given her the specific information. Jessica refused to name names and questioned the thinking behind the changes, but as that had had no effect she was now considering changing care provider. The episode illustrated an attempt to challenges organisational temporalities, by placing the conflict about time allocation outside the care worker–user dyad. Here Jessica displayed a well-known dynamic among home care users (Dunér et al., 2019a, 2019b) of refusing the exit option since change would mean no longer receiving help from people she knew and liked. In this sense, the relational character of the care made her more likely to accept the reduction of time she perceived as stressful.

Discussion

Home care enables older people to age in place while being less dependent on care provided by family members, relatives, and friends. The Swedish government's aims for home care are ambitious. The Social Services Act states that care for older individuals should focus on ‘enabling them to live a dignified life and experience well-being’. Most care users we interviewed said they were satisfied with the service they received, and many praised staff efforts. Still, temporal problems were much commented on – staff were stressed, visits were cancelled, unpredictable, or difficult to fit in with the care user's other activities.

This study finds that older care users are actively involved in a form of practical, relational, and rhetorical ‘work’, which includes preparations, adjustments, and efforts to adapt services to their needs and commitments. A number of participants in the study described their successful attempts to change arrangements, either by contacting a needs assessor or as part of their ongoing dialogue with staff who in some cases they had known for several years. Nevertheless, the analysis shows that care users’ ideas and activities were strongly governed by the types of power dynamics that Sharma (2022) associates with temporal orders. Using the concept of recalibration (Sharma, 2011, 2022), we identify two interacting sublogics, central to an interpreted experience – integral to the system of formal care – that we term ‘home care time’. Recalibration can be understood as self-regulation, whereby care users adopt the temporal logic of the home care system, seen in their actions and thinking. The first sublogic of home care time is the notion that home care is temporally bound by the conditions of an organisation that has to work with scarce resources to care for many people. Sequential orders are established. In a study of home care, Palmqvist (2022) describes the well-known situation of home care users left waiting when staff were held up with other care users because of unforeseen circumstances. Since the situation is so common, Palmqvist questions whether it is correct to characterise it as unforeseen. Palmqvist's conclusion contrasts with the crisis rhetoric used by our study participant Alexander to express his acceptance at ‘times of crisis’. In our analysis, we have transferred the situation described by Palmqvist to a context where home care users know of the existence of other care users and their needs. Even though it was an ordinary explanation given by staff for their late arrival – and several care users reported that staff had orders not to talk about other care users – it still resulted in what amounted to a hierarchy of care. In addition to references to other care users to excuse late arrival, the experience of using home care included interruptions by alarms from other care users and mobile calls from colleagues and coordinators, making it clear that care provision was part of a sequence of events that included visits to several other people. Home care users were thus encouraged and educated to act in a manner that optimised the staff and organisation's daily schedule. This perception of home care was prompted by the second sublogic, manifest in expressions of understanding, empathy, and loyalty with the care staff. Older care users took on the role of sympathiser, trying to help staff in their struggles. This facilitated the development of a positive care worker–user dyad that is a core feature, according to the relational approach to care, but made it difficult for care users to voice criticism.

A number of researchers show that care workers are governed by temporal orders, while Strandell (2022a) describes three circumstances that result in stress: the compression of time in schedules, the control of time (by ICT/monitoring), and the unpredictability of time. Staff handle these conditions by working unpaid hours, maximising efficiency, and reallocating time. Strandell warns that the staff strategies of working through their breaks and mealtimes out of loyalty to care users may conceal problems in the system of care. The staff assume responsibility for suppressing the fact that too little time is allocated. Our study shows that the logic of home care time prompts care users to further cover up the problems of insufficient time allocation, and that relational aspects are central to this dynamic. In their study of home care, Cranford and Miller (2013: 796) identified ‘social signals of unmet need’ that care users communicated during visits, and which could trigger a moral commitment among staff to provide more care than was granted. A similar dynamic was evident in our study, when staff signalled they were in a hurry or made the unmet needs of other care users present during their visits. As Strandell (2022a) shows, care workers use techniques that remind care users that time is limited – for example, by setting an alarm to ring after ten minutes during a visit – in ways that invite care users to understand the conditions of the care workers’ work. Clocks and the ‘objective’ nature of clock time are used to convey a governing temporal order. The fact that it is often staff who inform the care users about the length of time allocated to them also makes it difficult to protest. Time frames perceived by care users to be too short were occasionally challenged, but the participants in our study were reluctant to protest for fear of conflicts with staff. Late arrivals and the reallocation – ‘stealing’ – of time that Strandell (2022a) describes as a staff strategy are therefore accepted by care users, partly out of sympathy with staff and others who need help. In our interviews, care users’ attempts to demand that staff who tried to leave early stayed for the allocated time were associated with tension and conflict.

The Swedish system of home care is under severe strain because of cuts and attempts to streamline services, which leaves home care less attractive to both providers and users (Strandell and Stranz, 2021). It is also the case that the Swedish system of eldercare for people aged 65 and over provides less personalised – more standardised – support compared to services under the Severe Disabilities Act. Nevertheless, the annual national user survey by the National Board of Health and Welfare repeatedly shows high levels of satisfaction among older care users. This may be because the system of home care, from the perspective of the user, is seen as operating within tight time frames, with staff struggling to provide good care despite having little time to do so. What is made invisible through the experience of home care time is a perspective that enables care users to understand enabling and disabling aspects of the support they receive as a question of social rights, just as support has been framed in disability policies (Priestley, 2001; Shakespeare, 2014).