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Participation and power in care: Exploring the clientin client engagement Andrea Petriwskyj a, , Alexandra Gibson a , Glenys Webby b a The University of Queensland, UQ/ Blue Care Research and Practice Development Centre, 56 Sylvan Rd, Toowong, Qld 4066, Australia b Blue Care, 56 Sylvan Rd, Toowong, Qld 4066, Australia article info abstract Article history: Received 2 July 2014 Received in revised form 15 September 2014 Accepted 15 September 2014 Available online xxxx Despite growing recognition in health and care services of the necessity for client engagement, it is still not easily put into practice. This is owing to a range of factors relating to participating staff and clients, as well as the broader institutional context. One of the central factors affecting client engagement is the challenge it poses to traditional power relations inherent in care relationships and contexts. This is particularly the case in aged care services, which have traditionally positioned older adults in passive roles as recipientsof care, or as lacking capacity to participate in care decision making. This paper presents an exploration of client engagement practices within a large aged care service provider in Australia. Interviews and focus group discussions with clients and staff were analysed for the ways in which clients were positioned by both themselves and by staff in terms of the roles that they hold within engagement practices. Four positions were identified: Passivity, disempowerment and bestowal of power, Role of expert/consumer, Resistance, compliance and manageability, and Complexity, diversity and uniqueness. While clients were positioned at times in empowering roles, they were simultaneously limited by personal, relational, or organisational constraints, making opportunities for client engagement provisional. This reflects a tension between passive and empowered client roles in the context of aged care provision. © 2014 Elsevier Inc. All rights reserved. Keywords: Client Engagement Older adults Care services Power Participation Background Expectations around engaging clients or service users at different levels of planning and decision making have increased over the past decades. This has been driven by underpinning values such as democratisation, service user empowerment, and the redistribution of unequal power relations (Beresford & Branfield, 2006; Cornwall & Shankland, 2008), as well as a greater focus on the rights and abilities of service users, rather than on their functional limitations (Gilliard, Means, Beattie, & Daker-White, 2005). This has highlighted clients' or service users' potential to participate actively in, rather than passively receive, care services. Patient rights' movements, citizenship and social rights' movements, scrutiny of professional power and ethics, and international reform agendas have additionally contributed to the momentum behind this shift (Sarami Foroushani, Travaglia, Eikli, & Braithwaite, 2012). In Australia, where this research took place, recent reforms to the care system such as the mandatory offering of consumer-directed (CDC) models of community aged care have placed a strong spotlight on the client's role. This shift has occurred at different times, and to differing degrees, within both disability and aged care systems, as well as more broadly in health care. While adoption of this shift in the aged care system has been arguably slower, the client increasingly is central to the system and the models of care that are provided. This paper adopts a critical qualitative approach to interrogate client engagement practice in this changing Australian aged care context. Client engagement that is, interacting and communicating with clients effectively and ensuring opportunities for them to have input into planning and decision making is a vital part of care services. It is also, increasingly, an expectation within the care system; for example, in Australia it is a criterion under Journal of Aging Studies 31 (2014) 119131 Corresponding author. Tel.: +61 7 3377 3305. E-mail addresses: [email protected] (A. Petriwskyj), [email protected] (A. Gibson), [email protected] (G. Webby). http://dx.doi.org/10.1016/j.jaging.2014.09.007 0890-4065/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Aging Studies journal homepage: www.elsevier.com/locate/jaging

Participation and power in care: Exploring the “client” in client engagement

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Journal of Aging Studies 31 (2014) 119–131

Contents lists available at ScienceDirect

Journal of Aging Studies

j ourna l homepage: www.e lsev ie r .com/ locate / jag ing

Participation and power in care: Exploring the “client” inclient engagement

Andrea Petriwskyj a,⁎, Alexandra Gibson a, Glenys Webby b

a The University of Queensland, UQ/ Blue Care Research and Practice Development Centre, 56 Sylvan Rd, Toowong, Qld 4066, Australiab Blue Care, 56 Sylvan Rd, Toowong, Qld 4066, Australia

a r t i c l e i n f o

⁎ Corresponding author. Tel.: +61 7 3377 3305.E-mail addresses: [email protected] (A. Petriw

[email protected] (A. Gibson), g.web(G. Webby).

http://dx.doi.org/10.1016/j.jaging.2014.09.0070890-4065/© 2014 Elsevier Inc. All rights reserved.

a b s t r a c t

Article history:Received 2 July 2014Received in revised form 15 September 2014Accepted 15 September 2014Available online xxxx

Despite growing recognition in health and care services of the necessity for client engagement, it isstill not easily put into practice. This is owing to a range of factors relating to participating staff andclients, as well as the broader institutional context. One of the central factors affecting clientengagement is the challenge it poses to traditional power relations inherent in care relationshipsand contexts. This is particularly the case in aged care services, which have traditionally positionedolder adults in passive roles as “recipients” of care, or as lacking capacity to participate in caredecision making. This paper presents an exploration of client engagement practices within a largeaged care service provider in Australia. Interviews and focus group discussions with clients andstaffwere analysed for theways inwhich clientswere positioned –byboth themselves and by staff– in terms of the roles that they holdwithin engagement practices. Four positionswere identified:“Passivity, disempowerment and bestowal of power”, “Role of expert/consumer”, “Resistance,compliance and manageability”, and “Complexity, diversity and uniqueness”. While clients werepositioned at times in empowering roles, theywere simultaneously limited by personal, relational,or organisational constraints,making opportunities for client engagementprovisional. This reflectsa tension between passive and empowered client roles in the context of aged care provision.

© 2014 Elsevier Inc. All rights reserved.

Keywords:ClientEngagementOlder adultsCare servicesPowerParticipation

Background

Expectations around engaging clients or service users atdifferent levels of planning and decisionmaking have increasedover the past decades. This has been driven by underpinningvalues such as democratisation, service user empowerment,and the redistribution of unequal power relations (Beresford &Branfield, 2006; Cornwall & Shankland, 2008), as well as agreater focus on the rights and abilities of service users, ratherthan on their functional limitations (Gilliard, Means, Beattie, &Daker-White, 2005). This has highlighted clients' or serviceusers' potential to participate actively in, rather than passivelyreceive, care services. Patient rights' movements, citizenshipand social rights' movements, scrutiny of professional power

skyj),[email protected]

and ethics, and international reform agendas have additionallycontributed to the momentum behind this shift (SaramiForoushani, Travaglia, Eikli, & Braithwaite, 2012). In Australia,where this research took place, recent reforms to the caresystem such as the mandatory offering of consumer-directed(CDC) models of community aged care have placed a strongspotlight on the client's role. This shift has occurred at differenttimes, and to differing degrees, within both disability and agedcare systems, as well as more broadly in health care. Whileadoption of this shift in the aged care system has been arguablyslower, the client increasingly is central to the system and themodels of care that are provided. This paper adopts a criticalqualitative approach to interrogate client engagement practicein this changing Australian aged care context.

Client engagement – that is, interacting and communicatingwith clients effectively and ensuring opportunities for them tohave input into planning and decisionmaking – is a vital part ofcare services. It is also, increasingly, an expectation within thecare system; for example, in Australia it is a criterion under

120 A. Petriwskyj et al. / Journal of Aging Studies 31 (2014) 119–131

the aged care accreditation scheme (Aged Care Standards &Accreditation Agency, n.d.) as well as being fundamental tomandatory changes to caremodels such as CDC-based packages.There is some evidence, however, that opportunities for fullparticipation by older people in health and care services arelimited (Abbott, Fisk, & Forward, 2000; Brannelly, 2011; Gilliardet al., 2005). Traditionally, frail older people have been involvedin planning initiatives less than those in older people's forums orgroups (Barnes & Bennett, 1998). Opportunities for participa-tion tend to be formal consultative or consumerist approachesthat operate within existing processes and agendas (Baur,Abma, Boelsma, & Woelders, 2013), leaving power relationsrelatively unchallenged. In addition, a wide range of factors caninfluence the effectiveness of engagement initiatives, makingthis a complex and challenging part of practice. Closer attentionto engagement practice and thepower relations inherent in it isneeded to inform practice development. This paper thereforeaims to explore the power relations, both implicit and explicit,in engagement practice in the contemporary aged care context.

Particularly highlighted in the aged care context are issues ofrespect, autonomy, and capacity. These are central issues in acontext in which service users are at risk of being deemed toofrail, lacking capacity, or assumed to be lacking interest inparticipation (Cook&Klein, 2005; Fenge, 2001; Gilleard&Higgs,1998; Scourfield, 2007). Tensions can arise around “expert”knowledge and power imbalances (Gregory, 2007; Penney &Wellard, 2007), and clients can be marginalised through afailure to embed human rights and citizenship principles inpractice (Kelly & Innes, 2012), failure to communicate effec-tively or to engage directly with the client themselves (Penney& Wellard, 2007), or through stereotyping. This is exemplifiedby staff attitudes that appear to be paternalistic (Gagliardi,Lemieux-Charles, Brown, Sullivan, & Goel, 2008) and positionclients as having unrealistic expectations owing to disabilities,such as those related to dementia (Anthony & Crawford, 2000).

Importantly, attitudes play a key role within the engage-ment process. For example, exercisingmutual respect, ensuringdignity of all involved (Beresford, 2000; Chadwick, 2012;Woolhead et al., 2006), and respecting the diversity of clientsand their experiences (Tritter & McCallum, 2006) are funda-mental principles of engagement. Attitudes characterised by alack of respect or lack of trust undermine the relationshipsnecessary for engagement, and a lack of trust can mean thatclients may be unwilling to convey their opinions honestly(Beresford&Branfield, 2006; Social Care Institute for Excellence,2008). Further, tokenism can occur when organisations are notgenuinely interested in clients' opinions (Beresford & Branfield,2006; Social Care Institute for Excellence, 2004, 2008).

Ageist constructions present this as a timeof dependency andloss (Fenge, 2001). A sense of powerlessness can result fromdenying opportunities for participation, limiting choices anddeveloping unequal relationships (Kam, 2002). Autonomy andagency can be constrained within a framework of expertknowledge, designated and limited options, and discoursesaround “realistic” treatment expectations and “risk” (Hicks,Sims-Gould, Byrne, Khan, & Stolee, 2012). Professional dutyof care and other aspects of care related tomanagement of risk,such as constraints of compliance and regulation, risk-averseorganisational culture or clarity of organisational policies, mayall contribute to an environment in which clients' participationand autonomy are bounded, particularly with particular

health challenges of disabilities (e.g. DeForge, vanWyk, Hall,& Salmoni, 2011; Huby, Stewart, Tierney, & Rogers, 2004;Mitchell & Glendinning, 2007) Taken together, this signals theimportance of fosteringpositive attitudes and an organisationalenvironment that supports the engagement of clients whohave various health needs.

Fundamental to these challenges are issues of control andpower sharing, which have long been the basis for critique ofservice user participation initiatives. Power relationships can beimplicit or explicit in engagement processes and in approachesto inclusion and representation. Attention to power relation-ships, and in particular power imbalances, is key to thedevelopment of partnerships between clients and staff (Bauret al., 2013).

These power relationships both shape and are shaped by thediscourses about clients and their roles in care services. Serviceusers are referred variously in both policy and publishedliterature as clients, patients, consumers and citizens — eachwith underlying assumptions about the purpose of engagement,the roles of the actors involved, and the power relations withinservice provision (Rowe & Shepherd, 2002; Scourfield, 2007;Tritter &McCallum, 2006). Theways inwhich clients are framedand discussed, and their roles described, are therefore signifi-cant in understanding how these roles are operationalised.Indeed, older care consumers have been described as “thesubject of others' language, their desires submerged beneaththeir accumulated disabilities while their needs are constructedby others” (Gilleard & Higgs, 1998, p. 242). Calls have beenmade for an understanding of older care service users as fullcitizens, placing a critical spotlight on ideas of what frailty andrequiring care services – including residential care services –

mean for citizenship and decision making (Scourfield, 2007).How clients are positioned by both themselves and others, andthe power relationships these positions reflect are thereforefundamental to understanding engagement processes. Thispaper uses focus groups and interviews exploring the livedexperience of client engagement from the perspective of bothclients and staff of a large care service provider to explore thispositioning of clients.

Research approach

The research was conducted within the services of BlueCare, one of Australia's largest providers of aged careservices, which operates across the state of Queensland. Atthe time of conducting this study, Blue Care was on the pointof implementing a new person-centred, flexible, integratedservice model, called Blue Care Tailor Made, designed to allowclients to choose services tomeet their needs. The engagementprocesses across the organisation were fundamental to thisnew model of care, and this study was undertaken as part of aprocess of interrogation of practice and implementation of thisnew model of care within the organisation.

The research was conducted in 2012 in 17 localities,reflecting the Blue Care service clusters, and incorporatingmetropolitan, coastal, and rural/regional services. These local-ities also included residential and community care services, aswell as retirement living services. The study was approved bythe Human Research Ethics Committee governing research inthe organisation. Staff and clients were then invited through a

Table 1

121A. Petriwskyj et al. / Journal of Aging Studies 31 (2014) 119–131

letter distributed by the service manager at each service ordirectly by the researchers.

The staff perspectives on engagement were exploredthrough 13 focus groups and nine semi-structured interviewswith paid staff members at both operational and strategiclevels within the organisation. Service users' perspectives wereexplored through 12 focus groups and two interviews. Allinterviews and focus groups were conducted and analysed inraw form by researchers from The University of Queensland(Authors 1 and 2), who were not employed by the serviceprovider. Focus groups and interviews were held on locationat each service. As part of the larger study, this data wastriangulated with an analysis of 44 key Blue Care documentsregarding organisational engagement policies and practices;however, this paper reports a subset of the data: the interviewsand focus group discussions. These discussions around clientengagementwere used to examine how clients were positionedby both themselves and by staff, and the power relations thatoccurred within engagement practices in aged care services.

Interviews and focus group discussions were recordedand transcribed verbatim. The transcripts were analysedusing QSR International's (2012) NVivo 10 qualitative datamanagement software. The data presented in this paperwere analysed through exploring themes relating to the staffand client experiences of engagement practice, and the factorsthat facilitate or impede it. Multiple stages of coding, includinga combination of open and axial coding, were used to identifyconcepts, which were distilled and organised within themesthrough an iterative process of merging and refining codeddata (Strauss & Corbin, 1998). Drawing on positioning theory(Davies & Harré, 1990), the data were then further analysed forthe ways in which clients and staff positioned clients in theirdiscussion of client engagement. According to this approach,different positions are offered to speakers in a conversation bythe available discourses or ways of speaking about a subject(Davies & Harré, 1990). This analysis therefore examined whatpositions or vantage points staff or clients took up in relationto the subject of client engagement. The consideration ofclients' positioning highlighted the different ways in which theparticipants understood and negotiated the processes of clientengagement, and what power relations were inherent in thepositions made available to them.

Attentionwas paid to the rigour of the research in a numberof ways. Firstly, a two person team of researchers who wereindependent of the organisation under study conducted allfocus groups and analysis. Secondly, reflexive attention waspaid to the researchers' positions as young Caucasian womeninterviewing older people about issues relating to age and agedcare, as well as Indigenous people and people from culturallyand linguistically diverse (CaLD) backgrounds1. Thirdly, a semi-structured interview schedule was used to allow for flexibilitybut consistency in participants' responses. Lastly, guidelines for

1 We have found this difference in characteristics to be an advantagesometimes, causing participants to explain their thoughts and experiences inmore detail. However, the importance of the demographic characteristics ofthe moderator has been emphasised in much of the literature on focus groups(e.g. Krueger & Casey, 2000; Stewart, Shamdasani, & Rook, 2007) and weremained aware of our impact on the dynamics of the groups and on the datathroughout the study, and followed the guidance of a range of referencematerials(Côté-Arsenault & Morrison-Beedy, 2005; Krueger & Casey, 2000; Stewart et al.,2007).

ensuring rigour within qualitative research were followedthroughout the research process (Braun & Clarke, 2006); forexample, data were coded comprehensively, ensuring thatthemes did not simply consist of a few anecdotal quotations,and quotations were reported verbatim in the analysis, toretain participants' voices.

Participants

A total of 94 staff participated, including assistants innursing (AINs), personal carers (PCs), administrative staff,service managers, activities, hospitality, clinical nursing andallied health staff, chaplains, seniormanagement andmanagersof special programmes and initiatives. Of these, 89 werewomen and five men, ranging in age from 22 to 67 years, andhaving worked for Blue Care for between one month and over30 years. One identified as Aboriginal or Torres Strait Islander,and 16 identified as born outside of Australia.

A total of 85 clients participated, including 61 women and24 men aged between 28 and 101, who had been receivingBlue Care services for between two months and 20 years. Fiveidentified as Aboriginal or Torres Strait Islander, and threeidentified as born outside Australia. A breakdown of theparticipants is provided in Table 1.

Results and discussion

As a mechanism for exploring client positions and roles,focus group and interview discussions explored the experienceof client engagement and the issues and factors that influenceits effectiveness. A number of factors which were reported asinfluencing engagement related to client characteristics, be-haviour, or beliefs that impact on their willingness or seemingability to engage. Awareness of opportunities, confidence andcomfort expressing views or discussing issues, willingness toco-operate with solutions, management of expectations, asense of ownership and a desire to contributewere each factorsrelated to clients that participants identified as impacting onengagement. Similarly, a range of factors related to the staff,and their attitudes, beliefs, and knowledge. Positive, responsiveand caring attitude, respect, including respect for autonomy,characteristics such as flexibility, persistence, and responsive-ness, and level of experience, knowledge and skills were keystaff-related factors identified in the discussions. Finally, adiverse range of practical, process, or structural factors werehighlighted. These related to: both verbal and nonverbalcommunication; building rapport, trust and relationships; thebenefits and challenges of family involvement; issues aroundrepresentation; connectedness and networks within the organi-sation and broader community; limitations imposed by funding,

Study participants in each setting.

Participant type Residential Community Retirementliving

Cross-setting

ClientsInterview 1 0 2 –

Focus group 31 43 8 –

StaffInterview 1 1 0 7Focus group 33 45 0 7

122 A. Petriwskyj et al. / Journal of Aging Studies 31 (2014) 119–131

regulations and system constraints; clarity of expectations andguidelines for engagement; human and practical resources; theappropriateness of forums; and a range of particular issues forengagement in rural/regional and remote communities. Theseissues largely reflected those identified in broader literaturerelating to service user engagement in health and social care.

In exploring these identified barriers and facilitators toengagement, certain ways of positioning clients, their families,the organisation and its staff were evident. Different, andsometimes contrasting, implicit discourses about the positionsand relationships between players in engagement and aboutpower in those relationships emerged. This paper addresses theways in which clients were positioned in these discussions,how their roles were defined, and how their relationships tostaff and the organisation were understood. Analysis identifiedfour main ways in which clients were positioned. Thesereflected positions of passivity and disempowerment, expertiseand consumer power, compliance and resistance, and com-plexity, diversity and individuality. Each of these positions wasreflected in the factors influencing engagement identified indiscussionswith both staff and clients, andmore particularly inthe ways these were framed and discussed.

Passivity, disempowerment and the bestowal of power

Often in the discussions with clients and staff, participantsdescribed or understood clients as disempowered to participateor to exert their voice, and power was seen as something thatcould be given through engagement. Clients were framed aseither passive, or more actively constrained or disempoweredthrough factors thatwere bothwithin and outside the control ofstaff.

Clients, for example, were described as limited in engage-ment through factors that were not attributed to the organi-sation or the staff. Some clients were described – by both staffand other clients – as having varying awareness of opportuni-ties to participate, or as unwilling or not sufficiently confidentto put their views forward in a particular forum. This wasattributed to a range of factors including deference to authority,previous experiences with services, with the organisationor with consultation exercises, consultation fatigue, and lifeexperiences which encouraged or discouraged active involve-ment, as well as comfort with the specific forum itself. Forinstance, staff members in one group reflected on residents'unwillingness to engage in group meetings, but their willing-ness to engage one-on-one:

… The residents might have a meeting and any compli-ments and complaints, which is part of meeting, just getsquiet for a minute and everyone looks at each other andthen oh well … They tell us afterwards.

[Residential staff]

Some clients reported that they were not comfortablediscussing problems, whereas others were reluctant to expresstheir concerns or needs as they did not want to be “pushy”, orto feel they were placing their own needs above those of otherclients:

… (Staff) do all these other things … so that's why I don'tcomplain or ask them to do it because there are other

people in worse circumstances than me. But it would benice.

[Community client]

For these clients, an unwillingness to assert themselvesresulted in less effective engagement processes.

However, clients sometimes positioned themselves asmoreactively disempowered by the actions of staff. One client, forexample, shared the experience of staff going “over her head”to her child, who held power of attorney, although she haddecision-making capacity. The client expressed her frustrationand anger towards the staff responsible, emphasising hercapacity to manage her own affairs and the importance ofcontrol and privacy. Another client described her frustration atthe futility of responding to menu surveys, on which theoptions offered rarely reflected her preferences and often didnot result in the meal she requested:

There's this menu that you're supposed to fill in and eventhough you fill it in … at least half the time you don't getwhat you put on that thing … They give you a choice whatyouwant, and you tick what youwant, and half the time it'snot what you want at all … What's the use of filling in thething?

[Residential client]

Thus, for some clients, staff behaviour had a direct impacton their autonomy and control.

Staff positioned clients or the community as needing tohave a sense of ownership of the engagement process and ofthe outcomes. In addition, they highlighted the importance ofclients' desire to contribute to the process, to ensuring theyremain engaged, and that a mutually satisfactory solution wasreached.

The survey goes out, the chef asks them to list the thingsthey want on their winter menu and then we go toresidents' meetings they'll talk… they're getting what theywant and they're happy with it. And they give you thatfeedback and they've been part and parcel of that decisionmaking to get to there so it's given them some ownership ofit.

[Residential staff]

and

Going into those smaller towns to deliver those servicesso, you know that's important to them and that's theircommunity and they want to have a say about how theyorganise what happens in their community. And that's fine;and that's the only way that gives them that control over,you know the direction of their, what happens to them. Soyou know, that's really important.

[Community staff]

Interestingly ownership was referred to here as being“given” to clients or community stakeholders through theengagement process.

Significant discussion focused on autonomy and respectfor autonomy in working with clients. Both clients and staffdiscussed autonomy in relation to health and care decisions aswell as the everyday. They saw autonomy as clients having

123A. Petriwskyj et al. / Journal of Aging Studies 31 (2014) 119–131

decision making authority, being able to act independently,and behave or arrange their space the way they wish. Itwas notable, however, that in these discussions, the implicitassumption was that staff retained power in the decisionmaking process.

And the staff are very helpful, they don't say you must puton this frock or that … they leave you to choose, theyrespect your privacy, that if you want to wear this frock orwhatever, they give you the dignity of still making yourown decisions which means a lot at our ages and beingincapacitated, that's how I feel, you're not treated like achild, you're still treated with dignity which means a lot.

[Residential client]

In the phrasing: “they give you the dignity of still makingyour own decisions” is revealed the implicit assumption thatstaff hold the power to bestow or withhold decision makingauthority, even in “everyday” decisions, and with it, dignity.This finding is noteworthy in light of previous researchaddressing staff members' justification of restrictions to clientautonomy, which highlighted the use of the power conferredby the institutional context (Persson & Wästerfors, 2009).

Some clients were positioned as disadvantaged, oftenthrough references to limited capacity, with participationfacilitated by staff. For example, both staff and clients identifiedclient capacity as a barrier; however, engagingwith clientswhohave challenges to their physiological or cognitive functioning,or who have difficulty communicating, was seen as beingfacilitated by adaptive strategies by staff. This consisted offinding ways to work around the client's limitations to ensurethey could participate, or alternatively working with existingcapacities and finding alternative communication tools thatdrew on the client's strengths. Staff highlighted the importanceof confirming assessments of capacity, assuming capacity foreach individual in the first instance, and listening to the client,regardless of their assumed capacity or previous history. Staffnoted that it was essential to be flexible in responding to theseclients and to be willing to accommodate individual prefer-ences, as well as to be patient and persistent in engaging withthe client over time. Staff also emphasised observation skillsand responsiveness to observed signals, both verbal andnonverbal, as a way of communicating.

Sometimes if you ask them… there is one lady in particular,she can't talk, and I've said to her are you comfortable, youblink your eyes twice if you can't talk, and once if you're not.And she has blinked once and I fixed her up, just trieddifferent things, and I said are you comfortable now, and sheblinked twice, so — you know, there are ways of gettingaround it. And just by sight, if you've got them in a positionwhere they don't look comfortable to you, well then they'renot going to be comfortable, you know.

[Residential staff]

These discussions reflected a general positioning of clients asable to participate and contribute, regardless of their perceivedchallenges, but requiring the assistance of staff. Thus staff werefacilitating agents in engagement who had the ability, and theresponsibility, to reflect, identify issues, and alter their practiceto enable participation. This retained a passive rather than

proactive role for clients; however, at the same time it contrastswith traditional care positions, in which limitations to clients'ability to participate have often been assumed (Abbott et al.,2000; Barnes & Bennett, 1998; Brannelly, 2011; Gilmour &Brannelly, 2010).

As one staff member explained, however, their ability tofacilitate engagement could be constrained by the system itself.

I mean people talk about empowerment — how are peopleallowed to make decisions for themselves? That's terrific.But you knowwhat, they all can't. The idea that somehoworother you have to make a decision because you have thecapacity. … And sometimes they can't and they need extrahelp. But there's no extra help there because the mentalityof squeezing the dollars and all that sort of thingmeans thatthere's only a certain amount of helpwe can give you, yeah?… In other words we are saying, well we expect you toaspire to that and if you can't too bad.

[Community staff]

Similarly, both staff and clients highlighted the issue of time,or lack of time, for staff to spendwith clients. In particular, staffhighlighted a feeling of being constrained by their schedulesand tasks; clients were portrayed by both themselves and bystaff as passive in this circumstance. As one staff memberdescribed:

Being able to interact with them, and even just sometimesyou might have done your time, your hour's nearly up andthey'll saywould you like a cup of tea? And you've got to sayno, I've got to go. But then other times you say, well alrightthen, you know you shouldn't but you do.…

[Community staff]

These extracts illustrate a positioning of clients asdisempowered, passive, or having limited opportunities orcapacity for engagement. Notably, this was sometimes referredto in relation to clients' characteristics, placing the responsibil-ity on clients, whereas in other cases, responsibility was placedon staff to facilitate engagement in site of these characteristics.Power was described as something that was transferred or“given” to clients through engagement, reflecting traditionalpower relations within care services; however, at the sametime, the importance of facilitating participation, positioningclients as desirable and even required actors in decisionmaking reflects contemporary and emergent perspectiveson the client's role.

Role of expert or consumer

In contrast to disempowered or passive positions, clientswere also positioned by both themselves and staff as “experts”or less explicitly as critical evaluators of practice or of processes(regardless of actual opportunities to utilise their expertise), oralternatively as “consumers”with an implicit authority tomakerequests and expect these to be met.

A key issue raised by both clients and staff, for example, wasaround demonstrating respect — for the person, their values,beliefs and preferences, their contribution, their knowledge,and their role as experts in their own care, and treating themwith dignity.

124 A. Petriwskyj et al. / Journal of Aging Studies 31 (2014) 119–131

And it's about respect. Respect, respect, respect. And toestablish that relationship I find that that's the big thing thatgets your foot in the door. And if you want to have a decentinteraction with them, it starts out that you're equal. It's notthat you are professional more than them. They're theexpert in themselves. Even when they have diminishedcapacity, there's a respect for the fact that they have lived alife and that they're valuable human beings and that theystill have something to offer. Even if it's slightly muddledand confused.

[Community staff]

In this quote, the staff member emphasises the importance ofrecognising the expertise of the client in their own life history,needs and preferences. Interestingly, with her final comment,the notion of “still having something to offer” even if “slightlymuddled and confused” contrasts with the stronger positionpreviously expressed of “expert”who is on “equal” terms withthe staff; however, the comment simultaneously highlights theimportance of their contribution. Similar ideas were expressedby this staff member:

Well I think respect for the client. I think it's a necessity toengage with clients and get their views. Respect and don'ttreat them like they're children just because they can'tthink for themselves all the time, you still need to asktheir opinion and give them a lot of say about the waythey want things done and even if you think it might notbe appropriate, you've still got to respect their wishesand as much as possible, as long as you use the policies asa guideline, then listen to them and yeah, try to helpthem.

[Community staff]

An important juxtaposition of ideas is evident here. Theoverall message of the conversation that is reflected above isthe importance of respecting the client's wishes, whether ornot the staff member agrees or thinks it is “appropriate”. Thisreflects a belief in the importance of autonomy, which was animportant theme throughout the discussions. At the same time,the staff member speaking here sets implicit parameters on theextent of the client's control. By using qualifiers like “give thema lot of say” and “as long as you use the policies as a guideline”,the speaker positions staff as arbiters of decision making,although they self-regulate this power (this is to complex to dojustice to here andwill be discussed inmore detail in a separatepaper). In this discussion, the client's autonomy and right tomake choices are highlighted; however, the staffmember holdsthe power to provide or not provide choice, in this case guidedby organisational policies. By the same token, the client ispositioned as a decision-maker with capacity that may need tobe facilitated — “try to help them”. Therefore while the staffmember may be the arbiter of decision making they may alsobe – and indeed often are – in the role of facilitator. The client istherefore ‘expert’, but the use of their expertise occurs withincertain parameters in the care context and, at times, subject tofacilitation by the staff.

The complexity of the care role is also highlighted here,particularly in the tension apparent between the responsibil-ities and regulations of care, such as “the policies” whichnecessitate a degree of judgment and boundary-setting, and

the need for autonomy. A key question is highlighted thereforeregarding the extent to which staff do and should set theirown boundaries in relation to autonomy and decision making,and, importantly for organisations, the guidance and policiesprovided to the staff in this regard.

In a different perspective on the ‘expert’ role, both clientsand staff described clients as empowered to choose whetheror not they engage with the organisation, its staff, or withactivities that are offered

Some people don't go. That's their choice. We've been herefour years, and not sixty metres from this house, lives aperson who I've seen twice since I've been here. You don'teven see them at the rubbish bins. It's crazy isn't it? Butthat's that person's choice.

[Retirement living client]

This client autonomy was also constructed as manifestedthrough particular clients' characteristics:

You give everybody options and it's their choice. But you getsome residents who are unsociable, they probably wereunsociable all their lives and you have to respect that… youwon't ever change them and you have to respect who theyare.

[Residential staff]

Clients here are positioned as knowing their own needsand wishes – that is, as “expert” in their own perspective andwishes, which must be respected. Clients are also seen ashaving both power to (not) engage, and the responsibility tomake the choice. This creates an interesting contrast to theimplication of bounded choice discussed earlier and againhighlights the complexity of the care relationship. Thatclients may be constrained not necessarily by the staff or theorganisation, but by their own preferences and perspective,was identified by both staff and clients. This is a view whichpositions clients as judges of engagement opportunities andchoosers of opportunities that will suit them. Thus they arepositioned as expert in their own preference for engagement,not only in their preferences for care. This highlights thecomplexity of both staff members' and clients' roles withinengagement practice.

Clients also positioned themselves as expert, and eventeacher and advisor. For example, one client described herrelationship with her cleaning service staff:

… she gets abused because they can't understand hersometimes because she still can't get her tongue aroundEnglish words. So she says she knows to come to me now,and she says she can't say what client, I said it's not crient,it's client. I said you've got to put your tongue around yourteeth. And she sits there saying client, client, client. And Isaid you're getting it. And she gets it.

[Community client]

This client takes on the role of helper and advisor to the staffmember, who seeks her expertise. This is a role that holds adegree of power, which is used benevolently by the client. It isnoteworthy that this reversal of traditional power dynamicsexemplified a reciprocal relationship of care, rather than one-

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way relationship of service provision. Another client describedtaking the initiative to create change in one area of everyday lifein a residential facility:

… we were doing the one thing, playing bingo and just thesame music and that, and I felt we needed a change, therewas nothing to stimulate the people. … And I said to [staffmember], in the office, what about we try artwork, not thatI've ever done art. … and they were quite willing to try itand it has worked successfully, hasn't it [fellow client]? Sowe get very good response to that.

[Residential client]

This client, seeing an opportunity to make a change in herservice, actively took on the role of advisor to the staff on anactivity that may be of interest.

Clients were not always empowered to act, however,despite being capable, knowledgeable and willing. Someclients, for example, described situations in which the rulesof the organisation – sometimes determined by funding orregulations – placed limitations on them despite their capacityand desire to act. For some this was reflected in limitations onthe flexibility of their care; for one group of clients, thisconstrained their ability to engage in activities such as certaintypes of fundraising. Similarly, one client described beingprevented from assisting other clients because she had notundertaken training:

… there were all these old people you know, feeding, thenurse had … a spoonful in that mouth, and a spoonful inthat mouth, you know? … and I said to her well surely Icould feed one or two of those for you because I'm justsitting here with nothing — oh no you can't do that either,despite all those years of nursing experience, because Ididn't have that little bit of paper…

[Residential client]

Others saw themselves as less explicitly or overtlyconstrained, although no less knowledgeable. One clientrecounted her experience as a retired nurse identifying somestaff behaviour that she saw as a health hazard. Despite havingthe expertise to judge the situation and make professionalcomment, she chose to remain silent on the issue as a previousattempt to address a professional issue with the staff hadresulted in “…a hell of a fuss”. In each of these instances,the clients positioned themselves as expert and identified apotential contribution they could make; however, they feltconstrained, either by organisational policy or more directly bythe actions of staff.

It is interesting to note thatwhile in other contexts – such asaddressing agitated behaviour in people with dementia –

meaningful activities and valued roles were identified by staffas important for clients, in the examples presented aboveattempts by clients to adopt valued roles for themselves aredescribed as being restricted. Such roles for clients weretherefore seen as desirable within organisational parameters,or, while permitted,were not necessarilywelcomed by the staffconcerned. This contrasts with previous examples in whichclients took up active roles outside of that of care service user(e.g. language advisor or generator of ideas), which both theyand the staff valued.

Clients were also positioned as consumers to be satisfied,with staff acting as the facilitators to solutions. Often, this took acustomer service focus. For example, flexibility, persistence,and dedication, willingness to think outside the box, to identifydifferent ways to meet a client's needs and find ways to satisfythem were seen as important by both clients and staff.

(Staff member) is very proactive. Now at our meeting theother week, I thinkwe had five or six items that cropped upat the meeting…well as fast as we asked the question, shehad the answer. ‘That's already been taken care of, I'mgetting quotes for that,’ or ‘… we've already engaged it.’She's ahead of the game. And that's terrific. That is terrific.

[Retirement living client]

Such discussions also reflected expectations around re-sponsiveness: in cases recounted by clients where staff wereunable to achieve the desired result, the client still felt heard ifthe staff member took the issue seriously and worked hard toresolve it. Openness to what clients had to say, and willingnessto hear feedback was important, while openness to negativefeedback was also highlighted. One client described thewillingness of staff to respond, and to escalate issues on herbehalf when required:

I think if we did have a grievance and we took it to the girlshere they would take it higher up for us. They would nothesitate. And that's a good feeling to have. You have thatfeeling that if you've got a grievance you can go to them, andyou know then that something can be done about it.

[Community client]

Implicit in this client's understanding of the client ascustomer, however, is the framing of the complaints systemas reliant on the responsiveness and good will of the staff.Contrasted with the previous quote, in which the clientreflected on and appraised the staff member's behaviour inresponding to issues, this client took a more passive role.

In these discussions, staff roles centred around respondingto requests and complaints, finding solutions, and providingcustomer service. Some staff saw clients as empowered agentswithin the system:

Speaker A: They don't seem to have any problem in ringingus up and telling us if they don't like something.Speaker B: That says to me that they feel empowered todo so.Speaker A: Well they are empowered.

[Community staff]

In contrast to the discourse of passivity and disempower-ment previously identified, this perspective positioned clientsas service users, with particular expectations — a position thatinherently holds a degree of power. This empowered role wasalso reflected in the position of customer:

So it's a bit of trying to work around different options —

show them the different beds… Andwe try to give them asmany options as we can. At the end of the day it comesdown to a choice and the only person that can make thatchoice is the client or the client's representative, we give

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them the option of this choice, this choice or this, andwe tryto give them as many facets as possible, as well as anotherservice, service provider if needed, if we can't meet — ifthey're not happy with any of those choices.

[Cross-setting staff]

The client (or their representative) is positioned here as acustomer who has options and who can choose to remaina customer of that service provider or take their businesselsewhere. The onus is on the service provider to find a solutionthat the client is “happy with” and to ensure their experienceis positive to build “customer loyalty”. Implicit here is theassumption that the client has the power of a consumer in avaried market. For one staff member, this went further, withthe client – community care clients in particular – seen as an“employer”:

… everybody has to live and breathewhat they're doing andrespect the resident in that bed as an indirect employer anda home owner that we've been invited into to work for.

[Community staff]

Similarly, the role of the client as a partner of theorganisation was explicitly identified. This partnership in-volvedworking to identify, negotiate and implement solutions.

I always think about the levels of it first, from the partneringwith the client at the service delivery level to ensure they,the family, the friends, whoever they want to involve, havea real opportunity to be a partner and engage in decisionsabout the services…

[Cross-setting staff]

This notion of equal partnership and negotiation wasfurther reflected in discussion about being able to say no toclients:

… that's where the whole issue of engagement is about,from the client perspective, and the staff perspective, notexpecting that Blue Care is going to do everything for them.So it actually is about being able to say no sometimes, andfor that being ok as well. So we need to respect clients'decisions to decide what's right for themselves, and clientsneed to respect Blue Care's decision to say no we can't dothat, orwewon't do that… It's a twoway conversationwithrespect of positions of both parties …

[Cross-setting staff]

It was also reflected in the significant amount of discussionthat centred on the importance of respect as a central principleof engagement. For example, staff described everyday interac-tions in which respect could, and should, be shown:

Speaker A: Knocking on the door before entering, wait untilthey answer.Speaker B: Introduce yourself every time you go in.

[Residential staff]

In this discussion and others, clients were positioned asdeserving of respect and courtesy but also, implicit in this, thedeference due to the client as customer.

Notably, while clients were positioned as consumers, theywere not referred to in any of the discussions as empowered tobe proactive in the organisation or within their service. Clientswere described as organised to different degrees — retirementliving clients in particular described organised and largelyclient-managed processes such as meetings. However, anyproactive engagement – such as asking for things to be doneor making suggestions to the staff or management – wasdiscussed as occurring within established organisational pro-cesses, whether formal or informal. The “activist” client wasmissing from these discussions.

Both staff and clients described engagement practice inwhich clients were positioned as “experts” or “consumers”.When positioned in this way, clients appear to hold a degree ofpower in relation to their wishes, opinions, and expectations,which staff will attempt to respect or accommodate. Never-theless, these positions, as described in the discussions, wereoffered and taken up within the constraints of organisationalpolicies and processes, with limitations on clients' level ofempowerment. Theywere also restricted in their scope, mainlyfocused around the individual, and to some extent the service,rather than the broader organisation.

Resistance, compliance and negotiation

A key theme that emerged from the discussions concernednegotiation and resistance in response to a mismatch betweenstaff and client expectations. In someof these discussions, someclients were positioned as difficult, uncooperative or non-compliant. There was a sense among some staff, for example,that there are those clients who are not willing to co-operatewith solutions:

I suppose the only negative situation that we had was aresident that came in and that was never really happy fromwhen she first came here and nothing you could do wouldappease her for anything thatwas a concern or a problem…

that became a real situation to get her to cope the best shecould, every single day …

[Residential staff]

In some instances, client mental health was seen bystaff as a hindrance to co-operation. Client groups alsodiscussed these issues and emphasised the importance ofclients being patient and willing to work with existingorganisational processes — something which did not alwaysoccur.

I know one that the Queen's service wouldn't be goodenough for her, she'd want the whole 24 hours, 7 days aweek every day of the year.

[Community client]

Implicit – and at times explicit – in these discussions wasthe notion of individual responsibility of clients to be willingto work, at least to some extent, within the processes of theorganisation, or to work with the staff to find solutions. Thisreflected the concept that clients and staff needed to work inpartnership and to negotiate. Implicit in this is a more equalrelationship of co-operation.

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Staff described “difficult” or “non-compliant” clients asrequiring a different approach, and resulting in a differentrelationship. As one staff member described:

In saying that, if we have a difficult client, we don't treatthem any differently to the waywewould treat a client thatwas adorable, you still give them the respect, you have to…

you don't have that verbal bonding, there are very limitedverbal comments made by the carer usually, but you stillare speaking to them with respect … you're still having adiscussion, how was your day, how was your weekend,whatever. You've just got to watch how you word things Iguess and how you respond to things, so you're on edge.

[Community staff]

For this staff member, the “difficult” client was placed at agreater emotional distance than the “adorable” client and wasengaged at a more superficial interpersonal level. Staff also,however, discussed ways that developing an understanding ofeach client's circumstances and personality could help staff toengage effectively and find ways to meet clients' needs; in thisway, a client who was difficult to engage, or who appearedunwilling to co-operate, could be engaged effectively with theright kind of approach or with a better understanding of thereasons for their responses. Staff talked about persisting andtrying to build a relationship over time.

Speaker A: … I know very well at the beginning he didn'tlike me at all, but I just persisted, because I said, I'm theclinical nurse, I've got to do this. And he's quite a sweetmanunderneath all that. … And he's got a lot on his plate, so…Speaker B: There's a journey in front of him that's the end…and the clinical staff are involved in this journey with him,because it is a journey and we're privileged to be walkingwith them. But some days it's very hard.

[Residential staff]

In this case, the client is positioned as challenging, but hisbehaviour is seen as a response to his circumstances. Discussionaround his situation reflected contrasting perceptions of hislevel of responsibility for his behaviour towards the staff. Staffwent on to discuss the ways in which they managed thisclient's behaviour, for example:

I just tried nicely to manipulate it by saying some of thenurses here are students and they are very young… andwehave to be a bit careful sometimes about how we speak tothem. And that's kind of getting through to him.

[Residential staff]

This discussion positions the client as needing a sensitiveapproach, with the onus on staff to meet him half way. Implicitin many of these discussions was a sense of empathy forthe client, positioning them as understandably difficult and inneed of support. Engagement in this sense was a way to showempathy and to provide support rather than a mechanism fordecision making alone. The clients in the above quotes weretherefore positioned as the subject of empathy, understandingand compassion, not simply as resistant or “difficult”.

As discussed earlier, there was an interesting juxtaposi-tion between the attitudes of the staff. On the one hand, they

professed the belief that the clientwas the final decisionmakerwhose autonomy was vital, while on the other, discussed theconcept of managing risk to the clients and steering themtoward outcomes seen as being in their interests. This balanceof advising, making suggestions, and relinquishing control ofdecision making was an important example of power relation-ships in practice:

Well the client ultimately makes the last decision, so if thatperson doesn't want to do it, then you cannot force them.They do have the right to refuse, even going to hospital …Same with getting into the shower, but you can talk themaround and quite often if you do it the rightway, and you doit gently and you talk themaround to it, you can talk…‘lookI really think this would be a good idea’, and then they'll say‘oh alright then, okay. I'll trust you, alright, I'll do it’, or ‘I'llget in the shower’, whatever.

[Community staff]

Reflected in some of these discussions was the use ofresistance as a means of retaining power. Once client describedthis use of resistance by other clients:

… you've got to sort of treat the older ones in awaywithoutordering them what to do, just talk to them and give a littlebit of advice and so forth, nicely though, and they'll answeryou back. If you start ordering them they won't talk to you.

[Residential client]

In this client's description, passive resistance to staff controlis taken by clients who choose not to respond or interact. Thisresistance is also reflected in earlier extracts; for example, thenon-compliant client described earlier whowas on a “journey”to the end of life was positioned by the staff as behaving in achallengingway in response tohis circumstances. His “difficult”behaviour, therefore, was seen as a form of resistance to thecircumstances of his sudden diagnosis and reluctant admit-tance to the care facility.

At times, clients were positioned as acting in “difficult”or resistant ways. Staff were simultaneously responsible forameliorating the situation, by communicating with clients orby encouraging them to act as partners. When clients werepositioned as being uncooperative, staff described themselvesas needing to “manage” or work around clients, again takingon responsibility for effective engagement. While clients werepositioned as holding the power of resistance, an unequalpower relationship between clients and staff was highlighted.These findings are interesting in light of previous research inthe aged care setting which has highlighted client attempts tochange or circumvent institutional order, and staff strategiesfor managing these attempts, highlighting the challenging andreproduction of existing power relations (Harnett, 2010). In thepresent study, a sense of negotiation, allowance-making andadjustment contrastedwith depictions of resistant or “difficult”behaviour.

Complexity, diversity and uniqueness

Clients were framed as complex individuals with diverseperspectives and needs, with the onus on staff to recognise andrespond to these in order to facilitate engagement.

128 A. Petriwskyj et al. / Journal of Aging Studies 31 (2014) 119–131

I think you have to treat everyone differently – as anindividual – and you knowwhat is going to suit one personis not going to suit another, so we really do have to be opento listen to them and hear what they're saying to us about,well, I don't want you to domymedication, I want that and Iwant to do it myself. Sowe have to be open and take that onboard and say how can we make this happen.

[Residential staff]

This was reflected in discussion such as that of addressingissues of capacity, and the need to be flexible, patient, andemploy alternative strategies to facilitate participation whenengaging in a particular way (including through verbal commu-nication) was challenging for the client. These alternativestrategies were also seen as being facilitated by buildingrapport and relationships, and getting to know the individualand understanding the life history and life experiences ofindividuals in order to engage them appropriately.

And youdo develop a relationship, a rapportwith them, youdo get to understand how they're reacting and whetherthat's appropriate to their needs or not.

[Residential staff]

These relationships were a key theme in the discussions,and were seen as important in building an understanding ofthe individual client and their perspectives and needs. Theseoccurred with varying levels of intensity or closeness, some-times reflecting a compassionate, caring relationship, some amore equal, reciprocal one:

… they know all about us and we know all about them, howmany grandchildren they've got and where their son's livingin America and all that kind of thing, and it goes bothways, sowework as a big family. And I think that's important that wehave that relationship, it's a very comfortable relationship.

[Residential staff]

Some relationships were less equal and more superficial,although they reflected similar behaviours:

Or sometimes, it's even how's the dog, or your kids? Evenwe feed them little bits … and don't want them knowingtoo much about us, or our phone number or anything.

[Residential staff]

Some clients described unequal – or unresponsive –

relationships as being inadequate:

There are some staff that come on during theweek that youlove to have around you. … They're very special about you,they know all about you, and they knowyourwants and notwants, you know? And you don't have to worry. But whenother staff come on, they just do as little as they can for you.Which is not good enough.

[Residential client]

Different power dynamics were reflected in these relation-ships. In the first extract, for example, equality and reciprocitywere highlighted, with the individual experience of bothstaff and clients acknowledged. In the second, staff retained

the position of power-holder and clients were positioned asrecipients of their relationship-building efforts, andwithin theirparameters. In the third, the client positioned themselves as thejudge of, or “expert” in, what is an appropriate relationship andwhile effectively disempowered by what was seen as limitedresponsiveness to her individuality, reclaimed a degree ofpower in the position of ‘evaluator’. The extent to which theserelationships respond to the individuality of the client and theirneeds and wishes similarly differed, with closer, reciprocalrelationships demonstrating a more personalised approachthat reflected greater recognition and valuing of the individualperson.

Cultural competence was also seen as important, and wasreferred to in a number of ways, including: knowledge aboutand being willing to accommodate traditions and preferences,aswell as having an understanding of historical issues thatmayimpact on behaviour, an understanding of individual differenceand diversity among individuals, not just groups, and havingrespect for difference. One staff member, for example, sug-gested that it is important to be aware that not all issues arerelated to cultural difference or cultural norms.

… remove that … judgmental attitude and look at them,focus and see the human being in there rather than theVietnamese, or the Sudanese; remove that, and work withthe human being. That is…what I call cultural competence.

[Community staff]

The importance of understanding the client's life history wasonce again identified, particularly for clients from differentcultures but also for Australian-born clients who may haveexperiences relating to people from other cultures (e.g.prisoners of war). These discussions reflect the importance ofthe individual in staff understandings of clients.

As discussed earlier, staff discussed the importance ofworking around clients' different communication needs, whichwas facilitated by the building of relationships.

And for those people who don't speak English or haveimpaired capacity to vocalise, it's knowing that person, andtrying to make sure that the staff know them, so encouragecontinuity of staff, have the same staff, so they get torecognise … the resident gets to know those people, okaytoday it's himor her, and you can see their facial expressionsabout that.

[Residential staff]

Therefore in addition to effective communication, build-ing relationships and trust with clients and connecting withthem on an interpersonal level has important implications forstaff–client interactions, with relationships seen as a tool forfacilitating engagement. This reflects a person-centred approachto care. Although there were power differences inherent inthese contrasting relationships, staff were largely positioned asactive and responsible and while the client holds power similarto that of the “customer” – that is, the onus is on staff to findways towork that suit the client –ultimately the client is passivein this relationship.

Diversity among clients was described as challenging forother forms of engagement as well. Staff saw strategies suchas consumer representatives on advisory groups, for example,

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as having mixed success. In particular, upper and middlemanagement staff raised concerns about tokenism and issuesof internal dynamics within these groups.

I don't thinkwe have anything formal in the sense of… likein some sectors like the disability sector, they will actuallyhave a committee of residents or clients that have directinput into decisions about service delivery, we don'tactually have that and there has been numerous attemptsto try and look at that as an issue, how do we go about it?But it's quite difficult to have that in place, sometimes it justtends to become a token thing because how can one or twoor three or four individuals truly represent the whole suiteof our clients, so I think that's a massive challenge …

[Community staff]

This highlights concerns relating to the diversity amongclients, as a group that cannot be “represented” easily indecision making. It was notable that although this strugglewith the concept of representation was present, a deeperdebate about inclusion in engagement was absent from thediscussions. Notably, the passive position of being invited intothe decision making space at an organisational level, or ofbeing represented by others, reflects more implicit limitationsin the roles of clients, as well as the explicit lack of formalmechanisms for input.

Staff at various levels of the organisation thereforereflected on the diversity and complexity of clients' needs,wishes, and personal backgrounds. This was most oftendiscussed in reference to clients born outside of Australia, orclients with limited communicative or cognitive capacity. Inresponse to this, staff described themselves as working toaccommodate clients' diversity, in order to improve engage-ment. Clients were simultaneously placed in relatively passiveroles — as once again being recipients, rather than activepartners, in person-centred care, and in the relatively powerfulposition of an individual whose needs andwishes needed to beaddressed and accommodated. The importance of relationshipsalso highlighted the potential for more equal roles, centredon the meaningful recognition of individuality, as well asdisempowered ones.

Limitations

Some points must be noted in drawing broader conclusionsfrom these findings. First, the study was conducted in oneservice provider within one state of Australia. While thisprovided the opportunity for in-depth interrogation acrossdifferent facets of a single organisation, it necessarily limits thetransferability of the conclusions. Second, the demographicdiversity of the sample was maximised as much as possibleduring recruitment; however, it should be noted that onlylimited numbers of staff and clients of Aboriginal and TorresStrait Islander descent were able to be recruited for the study.Similarly, both staff and clients were predominantly women.While this is not surprising given the demographic profile ofstaff and clients in aged care generally, it is an important pointto note in regard to the range of informants for the study.Further, the sample was restricted to clients who were able toparticipate in a group discussion and clients with cognitive orcommunicative challenges which restricted their participation

were therefore excluded. Focused research addressing theperspectives of these clients is an important future researchdirection. Third, it was not possible to conduct a detailedanalysis of the differences between residential and communitysettings while still providingmeaningful conclusions regardingthe organisational context generally, and it was also notpossible to explore different types or levels of engagementseparately. Given that the findings highlighted the complexand dynamic nature of engagement, and the importance ofdiversity in understanding engagement, future studies explor-ing these issues in other organisations and across aged caremore generally, as well as studies that include, or perhapstarget, different groups of clients and staff, would be useful.Further, larger and more targeted studies would allow forgreater consideration of potential differences between resi-dential and community settings and different types or levels ofengagement.

Conclusion

The discussions that took place with clients and staffhighlighted the many factors that can facilitate and constrainthe possibilities for client engagement. The perspectives onengagement that emerged from the findings reflected many ofthe principles highlighted in the literature including respect,ensuring dignity and recognition of diversity (Beresford,2000; Chadwick, 2012; Tritter & McCallum, 2006). Tradi-tional perspectives on the client as too frail, disinterested orlacking capacity (Cook & Klein, 2005; Fenge, 2001; Gilleard &Higgs, 1998; Scourfield, 2007) were contrasted in this studywith attitudes about clients as both able to participate despiteany frailty or other challenges, and as having a right to do so.

In discussing these factors, staff and clients placed clients invarying positions of power: as disempowered, or needing to be“given” an opportunity to participate or take ownership; as“experts” either with or without the opportunity to use theirexpertise, as “consumers” or “customers” with expectations,preferences and choices; as (non-)compliant or resistant; or asbeing “diverse” in their needs and wishes, making engagementa complex process and highlighting questions around repre-sentation. This firstly highlights the varied positions that aremade available to clients in the process of engagement andhow engagement is understood by staff and clients. Secondly,focusing on these positions enables greater insight into thedegrees of power that clients have in engagement processes, inrelation to staff and to wider service provision.

Both clients and staff frequently described the role that staffplay in trying to encourage client engagement, and the effortthat staff make in recognising and meeting clients' variedwishes, needs, and capabilities. Client engagement was alsodescribed, especially by staff, as “good practice”. However, forthe most part, clients were positioned in fairly limited ways —notably as the “recipients” of opportunities for engagement.While clients were largely positioned as having the capacity toparticipate, even if this required alternative strategies, and asempowered to do so, tensions around “expert” knowledge,control of the engagement process and its outcomes, and thedelineated roles, both formal and informal, that clients play,were evident. This is juxtaposed with staff responsibility foractively meeting clients' needs, including them in decisionmaking, and so forth. These issues reflect tensions around

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autonomy, control, expertise and power imbalances tradition-ally reported in health and care contexts (e.g. Baur et al., 2013;Gregory, 2007; Hicks et al., 2012; Kelly & Innes, 2012; Penney &Wellard, 2007). Client power, however, was also reflected inthe positioning of clients as needing to be satisfied and theirneeds and preferences met, and the responsibility of staff toadapt. Thus a tension emerged in the data between “traditional”power relations of care and the concept of autonomous,expert client or active consumer evident in contemporarycare philosophies.

It is important, however, that while the “client”, “con-sumer” and to some extent “patient” were all present inthese discussions, the notion of the client as a citizen in thecare context – as opposed to a passive recipient of care, or aconsumer or customer to be understood and responded to –

was rare. A citizenship approach assumes that participationis about more than simply responding to choice, or to self-interest (Baur et al., 2013). Its absence reflects a lack ofpositioning of clients as capable of activism or collective action.Conventional formal service user or consumerist perspectivesdominated among both staff and clients, as tends to be the casein aged care (Baur et al., 2013). Thus, the positions and roles forclients remain delineated and controlled by the aged carecontext.

The findings reflect key issues relating to power rela-tionships often found in different care contexts, but partic-ularly raised in relation to older people. The multiple, butstill delineated, positions for clients in the care space reflectevolving perspectives on client control, autonomy and voicewhile at the same time highlighting the simultaneous positionsof power and powerlessness clients are offered, and that theyadopt. However, this tension between the positions of powerand powerlessness also reflects the complexity of the emergingcare context. The increasing focus on clients as consumers ofservices and customers of service providers, operating withina care market, or as experts in their own experience whocontribute to shared decision making, has placed a changingrange of expectations on both clients and organisations. Thesecontrasting positions hold different implicit power relationswhich need to be scrutinised in order to understand the impactof the changing care environment on engagement.

For care service providers, this highlights some importantissues for the implementation of changing perspectives on theclient's role in care. Emerging models of care such as the BlueCare Tailor Made model that respond to increasing expecta-tions of flexibility, consumer control and person-centrednessalso adopt evolving discourses relating to power. Indeed, thesemodels of care represent a fundamental shift in the traditionalpower relations of the care context; however, they retain to agreat extent specific positions for clients based on ‘service user’and ‘consumer’ roles. In this way a tension is highlightedbetween empowered and passive client roles. In developing,and implementing, new care models that explicitly respond tochanging discourses about client roles, it is thereforeimportant for service providers to interrogate the assumptionsbehind them and the power relations these may perpetuate orchallenge. Reliance on traditional consultative engagementmethods, even coupled with a consumerist, customer-servicephilosophy, does little to challenge the power imbalance thatplaces clients in passive roles. The tension between empoweredand passive roles that was evident in these findings indicates

that there is room to develop and facilitate roles for clients thatbuild on existing strengths while providing additional guidancefor practice. Adoption ofmore active, inclusive and empoweringmethods of engagement at all levels of the organisation canprovide leadership and demonstrate a broader organisationalcommitment to client participation. In particular, resources andtraining for staff that provide knowledge and skills in thesemethods are an important strategy for facilitating the clientcontrol and autonomy that these service models espouse.Further, adopting an organisational discourse about clientsthat does not limit their roles to passive recipient or ‘chooser’ ofservices – that is, as an active, empowered participant withinthe organisation rather than a customer who simply shops forservices – could open up greater opportunities for powersharing.

Acknowledgements

The contributions to this project of the Blue Care staff andclients who participated and assisted with recruitment aregratefully acknowledged. Thanks go to Associate ProfessorDeborah Parker for her practical and methodological adviceand to Robyn Batten for her comments on an earlier version ofthe manuscript. This research was conducted at the Universityof Queensland and was funded by Blue Care.

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