Caring as Competence Caring as Competence in Organizational Lifein Organizational Life

Amy Wrzesniewski and Jane Amy Wrzesniewski and Jane DuttonDutton

The May Meaning MeetingThe May Meaning Meeting

Ann Arbor, 2004Ann Arbor, 2004

Goals of our paperGoals of our paper

• To reveal the competence in the caring To reveal the competence in the caring that composes service work (by that composes service work (by employees who do critical, invisible work)employees who do critical, invisible work)

• To unpack competence as forms of caring, To unpack competence as forms of caring, knowing what not to do (as rules of thumb) knowing what not to do (as rules of thumb) and cultivating different knowledge and cultivating different knowledge sources and different kinds of knowledge sources and different kinds of knowledge to deliver and adjust careto deliver and adjust care

Starting assumptions and Starting assumptions and definitionsdefinitions

• Define Define competencecompetence as “situational, context as “situational, context dependent responses that flow from the way dependent responses that flow from the way individuals experience their work” (Sandberg, individuals experience their work” (Sandberg, 2000)2000)

• Define Define caringcaring as “any thoughtful human as “any thoughtful human response (or non-response) that enables others to response (or non-response) that enables others to thrive” (Noddings, 1984)thrive” (Noddings, 1984)

• Assume caring competence is foundation for Assume caring competence is foundation for high high quality servicequality service especially in settings like health especially in settings like health care i.e., hospitals. care i.e., hospitals.

• Assume caring competence of individual hospital Assume caring competence of individual hospital employees increases the employees increases the caring capacity of the caring capacity of the wholewhole hospital system. hospital system.

Key findings and Key findings and theoretical positioningtheoretical positioning

• How people see what they are doing in How people see what they are doing in their work is best captured by caringtheir work is best captured by caring

• Caring rests on knowingCaring rests on knowing• Caring competence is knowledgeable Caring competence is knowledgeable

relational action, where “knowing how relational action, where “knowing how is not in the head, but in the practice, is not in the head, but in the practice, and understanding is implicitly in the and understanding is implicitly in the activity” (Tsoukas, 1996)activity” (Tsoukas, 1996)

MethodMethod

• In depth interviews with random sample of In depth interviews with random sample of 29 cleaners in Hi Tech hospital29 cleaners in Hi Tech hospital

• Analyses based on data generated by 2 Analyses based on data generated by 2 questions:questions:– During the course of your job, what kinds of During the course of your job, what kinds of

things do you do for and/or with nurses, things do you do for and/or with nurses, patients, patients visitors and doctors?patients, patients visitors and doctors?

– Where do you draw the line for what you will Where do you draw the line for what you will do or not do for and or with nurses, patients, do or not do for and or with nurses, patients, patients visitors, and doctors? patients visitors, and doctors?

• Standard theme analysisStandard theme analysis

The findings in one slideThe findings in one slide

Core FindingsCore Findings1.1. What care?What care?

2.2. Whether care?Whether care?

3.3. How to care?How to care?

PunchlinesPunchlines1. Direct and indirect 1. Direct and indirect

caring compose the caring compose the caring systemcaring system

2. Rules of thumb provide 2. Rules of thumb provide guidelines for whether guidelines for whether to care and timing of to care and timing of carecare

3. Knowledge sources and 3. Knowledge sources and knowledge typesknowledge types

Cluster 1 findings: What Cluster 1 findings: What kinds of care?kinds of care?

Figure 1: Cleaners’ Care as Part of a CaringSystem

Cleaners’ Care

Patients’Visitors

Patients

NursesDoctors

142 3

5

6 7 8

Cluster 1 findings: Cluster 1 findings: Different forms of careDifferent forms of care

Respond toRequests

Conversation-making

Entertaining Empathetic Concern

Working Around

Patients X X X X

Patients’Visitors

X X X

Nurses X

Doctors X X

Caring form: Responding Caring form: Responding to requeststo requests

• DefinitionDefinition: Caring by providing assistance in : Caring by providing assistance in reaction to a request for helpreaction to a request for help

• Example (for patient, pv, nurses and Example (for patient, pv, nurses and doc)doc)– ““Whatever they ask me, whether it be helping Whatever they ask me, whether it be helping

them find a certain place, getting them things they them find a certain place, getting them things they need such as towels, toilet paper, or sometimes need such as towels, toilet paper, or sometimes they’ll ask well, could I go and get the person they they’ll ask well, could I go and get the person they came in with like their visitor, or ‘Could you go get came in with like their visitor, or ‘Could you go get them something to drink for me?’ Because they them something to drink for me?’ Because they don’t know how to get there and they’re scared of don’t know how to get there and they’re scared of getting lost. I’ll do that, like I said, basically getting lost. I’ll do that, like I said, basically whatever they ask me to do. I have no problem whatever they ask me to do. I have no problem with that.” (25: 337)with that.” (25: 337)

Caring form: Conversation-Caring form: Conversation-makingmaking• DefinitionDefinition: Initiation of /or response to : Initiation of /or response to

conversations of another. Used to comfort and to conversations of another. Used to comfort and to get informationget information

• Example: (for patient and pv)Example: (for patient and pv)– ““A lot of times they want to hold a conversation with you. A lot of times they want to hold a conversation with you.

You know, they’re lonely or sick already. I try to hold a You know, they’re lonely or sick already. I try to hold a conversation. There’s a lot, all kinds of people come in conversation. There’s a lot, all kinds of people come in here, you know, different backgrounds. Some people are here, you know, different backgrounds. Some people are interesting, they tell you about their life, their occupation, interesting, they tell you about their life, their occupation, sometimes they catch your attention and you know, you sometimes they catch your attention and you know, you listen and talk to them, you know. You may learn listen and talk to them, you know. You may learn something. They like that. They say, ‘Hope to see you something. They like that. They say, ‘Hope to see you again tomorrow’ or ‘Come back and see me’ or whatever. again tomorrow’ or ‘Come back and see me’ or whatever. “ (12: 195)“ (12: 195)

Caring form: Caring form: EntertainingEntertaining• DefinitionDefinition: Taking actions intended to make : Taking actions intended to make

another laugh or be amused in some wayanother laugh or be amused in some way• Example (only for patient)Example (only for patient)

– ““The patients, when I go into a room I tell them, ‘What The patients, when I go into a room I tell them, ‘What are you doing here?’ I mean I, you know, ‘It’s time for you are you doing here?’ I mean I, you know, ‘It’s time for you to get out of here, you’re wasting my time or you’re in to get out of here, you’re wasting my time or you’re in my way.’ I try to cheer them up, you know. So I know my way.’ I try to cheer them up, you know. So I know how patients are. I’m a very healthful person, and I don’t how patients are. I’m a very healthful person, and I don’t like to be pampered when I’m sick, but I like to be like to be pampered when I’m sick, but I like to be cheered up too, because I’m bored. I think of people in cheered up too, because I’m bored. I think of people in the hospital being bored, got nothing to do, and then the hospital being bored, got nothing to do, and then here comes an insane guy pulling his garbage, and tell here comes an insane guy pulling his garbage, and tell them, ‘What the hell are you doing in that bed? It’s time them, ‘What the hell are you doing in that bed? It’s time for you to get out of here!’ But that’s the way, I mean for you to get out of here!’ But that’s the way, I mean with the patients I get along, you know, excellent with with the patients I get along, you know, excellent with them, you know.” (20: 278)them, you know.” (20: 278)

Caring form: Empathetic Caring form: Empathetic concernconcern• DefinitionDefinition: Displaying general regard or concern : Displaying general regard or concern

for the other, involving expression of affective for the other, involving expression of affective arousal prompted by the situation of the otherarousal prompted by the situation of the other

• Example Example (for patient and pv)(for patient and pv)– ““I got to experience and feel some of the pain they have I got to experience and feel some of the pain they have

been dealing with their loved ones that are sick. Letting been dealing with their loved ones that are sick. Letting them, telling them how I went through a similar (thing) them, telling them how I went through a similar (thing) with my sister, letting them know that they’re not the only with my sister, letting them know that they’re not the only ones who have gone through this, and it does get better. ones who have gone through this, and it does get better. And I like giving people that encouragement that it does And I like giving people that encouragement that it does get better, you know. And it kind of makes them feel get better, you know. And it kind of makes them feel better, because they cry a lot, and I let them know also better, because they cry a lot, and I let them know also it’s all right to cry; it sometimes helps. So, I like to give it’s all right to cry; it sometimes helps. So, I like to give that encouragement, and I think they like to know when that encouragement, and I think they like to know when they talk about things that somebody is actually listening, they talk about things that somebody is actually listening, you know?” (25: 310)you know?” (25: 310)

Caring form: Working Caring form: Working aroundaround

• Definition:Definition: Adjusting the timing and content Adjusting the timing and content of one’s work to accommodate the work of of one’s work to accommodate the work of anotheranother

• Example: (for docs)Example: (for docs)– ““One thing you do for them is if you’re cleaning a One thing you do for them is if you’re cleaning a

room and you see them coming in there, most of room and you see them coming in there, most of the time you leave the room so they can examine a the time you leave the room so they can examine a patient or talk to a patient. You know, you make it patient or talk to a patient. You know, you make it convenient for them, most of the time you stop convenient for them, most of the time you stop what you’re doing and then you’ll come back after what you’re doing and then you’ll come back after they leave and do the room.” (12: 215)they leave and do the room.” (12: 215)

Cluster 1 conclusionsCluster 1 conclusions

• Mindfulness about how they cared and Mindfulness about how they cared and the difference it madethe difference it made

• All caring forms embody flexible All caring forms embody flexible responsiveness:responsiveness:– Behaviors that convey monitoring the Behaviors that convey monitoring the

state of the other responding in ways state of the other responding in ways intended to improve the condition of the intended to improve the condition of the otherother

– Willingness of cleaners to be used as a Willingness of cleaners to be used as a type of flexible instrumenttype of flexible instrument

Cluster 2 findings: Knowing Cluster 2 findings: Knowing whether to actwhether to act

Primary goals and Rules of Primary goals and Rules of thumbthumb

Primary GoalPrimary Goal: Promote the health of the patient: Promote the health of the patientExampleExample::““A lot of times I’ll talk to the patients because A lot of times I’ll talk to the patients because there are times when there are things that there are times when there are things that bother them they don’t want to tell the nurse or bother them they don’t want to tell the nurse or the doctor, and they’ll tell me. And if I think it’s the doctor, and they’ll tell me. And if I think it’s pertinent enough, then I’ll let the nurse or the pertinent enough, then I’ll let the nurse or the doctor know that this patient says such and such doctor know that this patient says such and such but don’t let them know I told you that. But I but don’t let them know I told you that. But I think it’s…pertinent for their case.” (4: 229)think it’s…pertinent for their case.” (4: 229)

1. Knowing when not to 1. Knowing when not to actact

Rule of thumbRule of thumb: Do not put the patient in : Do not put the patient in direct or indirect harms waydirect or indirect harms way– DirectDirect :“They (patients) might ask me to come and :“They (patients) might ask me to come and

move their bed or something like, I tell them to call a move their bed or something like, I tell them to call a nurse because you know, I don’t want to mess with nurse because you know, I don’t want to mess with that, if I put them in the wrong position.” (15: 128)that, if I put them in the wrong position.” (15: 128)

– Indirect:Indirect: “I don’t talk about the stress of the “I don’t talk about the stress of the hospital because they are already stressed that their hospital because they are already stressed that their family member is here… try not to say anything family member is here… try not to say anything negative around visitors or patients.” (4: 314)negative around visitors or patients.” (4: 314)

2. Knowing when not to 2. Knowing when not to actact Rule of thumb:Rule of thumb: Do not disrupt others who are Do not disrupt others who are

providing careproviding careDirect: (doctors) “Direct: (doctors) “The conference room is basically the doctors’ rooms, you The conference room is basically the doctors’ rooms, you know. The doctors go in there and they hold conferences, quote-unquote, so know. The doctors go in there and they hold conferences, quote-unquote, so when I seem them in there I know not to go in, you know, because if I do I might when I seem them in there I know not to go in, you know, because if I do I might cause a problem, quote-unquote, as far as rocking the boat there. If they’re cause a problem, quote-unquote, as far as rocking the boat there. If they’re having something done, if they’re having a meeting, okay, and I’m not supposed having something done, if they’re having a meeting, okay, and I’m not supposed to go in there and vacuum that floor. Okay. The floor is trashed out, I know it’s to go in there and vacuum that floor. Okay. The floor is trashed out, I know it’s trashed out, and I’m supposed to clean it. I don’t just barge in there and just trashed out, and I’m supposed to clean it. I don’t just barge in there and just start plugging up vacuums, sweepers and start vacuuming. You know what I’m start plugging up vacuums, sweepers and start vacuuming. You know what I’m saying? I, uh, I look, and I know that they’re having some type of meeting or saying? I, uh, I look, and I know that they’re having some type of meeting or conference, so I, you know, so I stay away from that.” (17: 288)conference, so I, you know, so I stay away from that.” (17: 288)

Indirect (Patents’ visitorsIndirect (Patents’ visitors) “I treat them with respect. I know that, you know, ) “I treat them with respect. I know that, you know, why they’re here and you know, like a lot of times when I go into the visitors why they’re here and you know, like a lot of times when I go into the visitors lounge, you know, to clean, uh, I have to ask them, too. Sometimes I don’t lounge, you know, to clean, uh, I have to ask them, too. Sometimes I don’t bother because a lot of times when I go in to clean, they’d be asleep. So, uh, bother because a lot of times when I go in to clean, they’d be asleep. So, uh, but, you know, supervisors, my supervisor has told me that I’m supposed to do but, you know, supervisors, my supervisor has told me that I’m supposed to do this and I’m supposed to do that, but I, I prefer not to, so sometimes I have to this and I’m supposed to do that, but I, I prefer not to, so sometimes I have to bite the bullet for that. But, uh, I try to work with them because I know, you bite the bullet for that. But, uh, I try to work with them because I know, you know, some of the things that they’re going through with their relative wherever know, some of the things that they’re going through with their relative wherever they’re at. So, but all in all, I really don’t have a problem with any of these.” they’re at. So, but all in all, I really don’t have a problem with any of these.” (17: 346)(17: 346)

3. Knowing when not to 3. Knowing when not to actactRule of thumb: Rule of thumb: Do not act in ways that cause Do not act in ways that cause

complaints or hurt the reputation of the hospitalcomplaints or hurt the reputation of the hospital

– ““I won’t get obnoxious with the visitor. I mean I’ll bite my tongue I won’t get obnoxious with the visitor. I mean I’ll bite my tongue before I say anything, because it will jeopardize my job. I mean you’ve before I say anything, because it will jeopardize my job. I mean you’ve got to use common sense. If the person is beyond reasoning, say, “I’m got to use common sense. If the person is beyond reasoning, say, “I’m awfully sorry” and walk away. It’s the best way, you know, kill them awfully sorry” and walk away. It’s the best way, you know, kill them with kindness. And if that doesn’t work, get the hell out of there fast.” with kindness. And if that doesn’t work, get the hell out of there fast.” (20: 716)(20: 716)

– ““When you got these visitors coming here, you know, you’ve got to When you got these visitors coming here, you know, you’ve got to figure hey, they’re visitors today, they might be patients tomorrow. So figure hey, they’re visitors today, they might be patients tomorrow. So if they say hey I went to (Tech Hospital) and a guy came in to clean my if they say hey I went to (Tech Hospital) and a guy came in to clean my room, and he made me get up so he can move my chair, when I had room, and he made me get up so he can move my chair, when I had been sitting in it for six hours, the hell I’m going back to (Tech been sitting in it for six hours, the hell I’m going back to (Tech Hospital), I’ll go over to (another hospital).” (20: 329)Hospital), I’ll go over to (another hospital).” (20: 329)

Cluster 2 conclusionsCluster 2 conclusions

• Rules of thumb reflect knowledge of Rules of thumb reflect knowledge of boundaries or limits to action. boundaries or limits to action.

• Caring competence is based on knowing Caring competence is based on knowing what not to do that crosses lines (in what not to do that crosses lines (in terms of harming patients or disrupting terms of harming patients or disrupting those who are helping patients) or those who are helping patients) or activates negative feedback (complaints activates negative feedback (complaints or reputation damage to the hospital )or reputation damage to the hospital )

Cluster 3: Cluster 3: Knowledge Resources:Knowledge Resources:Different knowledge Different knowledge

sources and knowledge sources and knowledge typestypes

##1 Knowledge from 1 Knowledge from relationships with othersrelationships with others

Role in care deliveryRole in care delivery: Allows tailoring of : Allows tailoring of response and planning of work flowresponse and planning of work flow

Example:Example:

“ “Knowing illnesses of patients, that comes Knowing illnesses of patients, that comes with knowing your area. But, it also comes with knowing your area. But, it also comes with knowing your nurses, too. For with knowing your nurses, too. For instance, if there’s a patient that may have instance, if there’s a patient that may have AIDS, okay? If you are a nurse and we’re AIDS, okay? If you are a nurse and we’re good friends, I ask you and you tell me. “good friends, I ask you and you tell me. “

#2 Knowledge from #2 Knowledge from perspective -takingperspective -taking

Role in care deliveryRole in care delivery: Allows one to understand : Allows one to understand what other is thinking/feelingwhat other is thinking/feeling

Example:Example: “ “Patients’ visitors are kind of tough, you know. Patients’ visitors are kind of tough, you know.

They’re, you know, the majority are in the They’re, you know, the majority are in the corridors or waiting rooms. And when you’re corridors or waiting rooms. And when you’re doing trash or you’re cleaning carpeting in there, doing trash or you’re cleaning carpeting in there, or getting the chairs organized…you’ve got to be or getting the chairs organized…you’ve got to be very cordial with them, because they feel they’re very cordial with them, because they feel they’re paying the bill. They’ve got somebody in there paying the bill. They’ve got somebody in there that’s close to death. So you’ve really got to that’s close to death. So you’ve really got to watch your mannerism”.watch your mannerism”.

#3 Knowledge from #3 Knowledge from observing cues in contextobserving cues in context

Role in care deliveryRole in care delivery: Allows one to adjust form : Allows one to adjust form and degree of caringand degree of caring

Example:Example: “ “There was a time in recovery I was watching TV There was a time in recovery I was watching TV

on break and saw that a teenager had been to an on break and saw that a teenager had been to an accident with her brother and uh, realized that accident with her brother and uh, realized that her brother was dead on arrival and the parents her brother was dead on arrival and the parents had to come in I guess, and view the body. And I had to come in I guess, and view the body. And I had to uh, watch out for any other patients or any had to uh, watch out for any other patients or any other visitors coming, you know, to go in this other visitors coming, you know, to go in this area, you know, to view the body or something. I area, you know, to view the body or something. I just got done watching it on TV. “just got done watching it on TV. “

##4 Knowledge from 4 Knowledge from personal experiencepersonal experience

Role in care deliveryRole in care delivery: Creates basis for : Creates basis for caring connection and deepens knowledge caring connection and deepens knowledge of what to do to careof what to do to care

Example:Example: “ “(I was) shaved (for surgery), and I let (I was) shaved (for surgery), and I let

them know I was shaved too and I show them know I was shaved too and I show my scar, and I let them know if you do my scar, and I let them know if you do your therapy and have a positive attitude, your therapy and have a positive attitude, you’ll do just fine like me.”you’ll do just fine like me.”

Knowledge type:Knowledge type: Knowledge about other’s Knowledge about other’s

conditionconditionRole in care deliveryRole in care delivery: Allows one to gauge and : Allows one to gauge and

adjust how to react adjust how to react Example:Example: ““Some of these people will not live long. So, it Some of these people will not live long. So, it

really pushes me to make everything the best of really pushes me to make everything the best of my ability for them when they come in for their my ability for them when they come in for their visit. Like I said, making them comfortable, visit. Like I said, making them comfortable, making sure everything is clean, tidy, magazines making sure everything is clean, tidy, magazines up to date, anything that I can see would maybe up to date, anything that I can see would maybe irritate them, because when you’re taking chemo irritate them, because when you’re taking chemo therapy and radiation you get kind of irritated with therapy and radiation you get kind of irritated with the least little thing. So you know, anything that I the least little thing. So you know, anything that I can think might irritate them I try to take care of can think might irritate them I try to take care of before they see that.” (25: 619)before they see that.” (25: 619)

Knowledge type: Knowledge type: Knowledge about best Knowledge about best approach with othersapproach with others

Role in care deliveryRole in care delivery: Allows one to plan : Allows one to plan interactions and care for spaceinteractions and care for space

Example:Example: “ “I’m usually pretty good at talking, so after I I’m usually pretty good at talking, so after I

talked to them and let them know, ‘Well, I’m talked to them and let them know, ‘Well, I’m going to make it better. I don’t know who was going to make it better. I don’t know who was supposed to clean the room. But, if after I’m supposed to clean the room. But, if after I’m done and you find something that I missed you done and you find something that I missed you can tell me and I can correct it right there,’ and can tell me and I can correct it right there,’ and they actually got nice after that…it’s just very they actually got nice after that…it’s just very uncomfortable to go into a room where there are uncomfortable to go into a room where there are so many tempers and I’ve learned to deal with so many tempers and I’ve learned to deal with that a lot here.” that a lot here.”

Cluster 3 conclusionsCluster 3 conclusions

• Cleaner’s caring competence depends on Cleaner’s caring competence depends on accessing multiple sources of knowledge accessing multiple sources of knowledge that facilitate reading, connecting and that facilitate reading, connecting and adjusting to changing conditions of people adjusting to changing conditions of people and context in the care system (patients, and context in the care system (patients, visitors, doctors and nurses)visitors, doctors and nurses)

• Caring competence composed by accessing Caring competence composed by accessing these sources and generating knowledge these sources and generating knowledge that facilitates flexible adjustment in situthat facilitates flexible adjustment in situ

So What?So What?

• Caring competence as a f (knowing, being Caring competence as a f (knowing, being and doing in context)and doing in context)

• Attentiveness of low status position (Fiske Attentiveness of low status position (Fiske and Depret) is an asset as individuals highly and Depret) is an asset as individuals highly mindful of othersmindful of others

• People use simple rules of thumb, different People use simple rules of thumb, different knowledge bits, and use themselves as knowledge bits, and use themselves as flexible instruments in achieving caring flexible instruments in achieving caring competence. These competent micromoves competence. These competent micromoves create a collective capability of the whole create a collective capability of the whole which is critical to servicewhich is critical to service