By Kristina Grünenberg, Line Hillersdal and Jonas Winther, Department of Anthropology and Center for Healthy Aging, University of Copenhagen.
In this blogpost, we draw from our current fieldwork on the island of Ærø, a place which has branded itself as “the digital island”, to explore how care workers tinker with screens during the COVID-19 pandemic in order to care for the elderly from a distance.
A New Way of Seeing
Marie is a healthcare worker on the island of Ærø, in the South Funen archipelago, Denmark. She is a dietician and part of her job entails visiting elderly citizens in their homes to see how they are eating. She is an experienced health care worker, who has been to many homes throughout her career in the municipal eldercare. She knows that the relationship between what people say, and what they actually do, is not always straightforward, and that attending to eating habits requires much more than assessing their caloric intake. Furthermore, she is aware that eating can be a complex matter – especially for old people living alone.
Because of COVID-19, and to reduce the risk of infection, the municipality has decided to substitute Marie’s routine home visits for video consultations. This means that Marie now has to attend to her group of citizens through a computer screen, which, according to Marie, significantly alters what she sees and how she sees, and as a consequence how she has to go about caring for the elderly. Initially, working from a distance – through the screen – caused her to doubt her ability to make the right assessments.
Recounting a video consultation with Oda, an 82-year-old widow who lives by herself, Marie describes how she was unsure whether Oda was in fact doing fine, even though through the screen Oda herself insisted that she was. Marie, therefore, decided to bend the rules and visit Oda to make sure that everything was okay. As Marie suspected, Oda was indeed in poor shape: “She couldn’t actually find her way around the kitchen and had not cooked! I would, of course, have picked up on this immediately if I had been able to visit her”. Marie explained that she has had to develop a new way of seeing to be able to assess how Oda – and other citizens – are doing through the screen: “I look at the clothes, is she wearing the same clothes? Is she easily distracted or is she focused?” Through the section of the home that the webcam allows her to see, Marie furthermore tries to assess whether people’s homes are ordered and tidy or whether things look somehow ‘out of place’. In short, Marie tries to learn as much as possible through the screen in order to provide good care in changed circumstances.
Oda and Marie from Ærø are both actors in a large-scale socio-technical experiment taking place in Denmark, in which physical encounters have largely been replaced by virtual ones. The ‘corona crisis’ has effectively been used as a window of opportunity and as an occasion to “speed-implement” new digital technologies in eldercare in order to comply with the governmental corona instruction “stick together by staying apart”. Pervasive and all-encompassing, the corona crisis has disrupted the way we interact, work and get through everyday life as well as how welfare services are delivered and care is organised.
For the dietitian Marie, the corona crisis, and the subsequent implementation of screen-based forms of communication, has compelled her to readjust how she looks at and looks after the elderly. In moving to more screen-based solutions, certain everyday practices become harder to capture for health professionals like Marie, who had not noticed that Oda was unable to cook for herself. Under normal circumstances, Marie would have accompanied Oda to her kitchen and been with her while she was preparing her food. Marie’s usual way of caring is inherently tied to a tacit and embodied experience of “being there” – a form of care and sensibility, which is not easily transferred to the screen. Yet, as the story shows, Marie is readily engaged in finding new ways to provide good care for Oda through the screen.
The story about Oda and Marie highlights how it is difficult to assess everyday routines through the screen and the ‘invisible work’ that these practices entail (cf. Pols 2012; Oudshoorn 2008). This means that it is up to the discretion, imagination and tinkering of the care workers to virtually re-imbed the elderly in their socio-material, spatial, and bodily contexts, or run the risk that they assess the elderly as either more independent or more frail than they are.
Screen visits, however, do not only require new ‘ways of seeing,’ but they also require a well-functioning technological set-up, technical and communicative skills, and the forging of a new type of social etiquette in order to ensure that the screen consultations are framed in a clear and meaningful way. The following example with Lars is a case in point.
Lars suffers from a heart condition and must have his medicine checked regularly by a cardiac nurse. Since the corona outbreak, he has had screen consultations every fortnight with the cardiac nurse based on the mainland. Apart from Lars and the cardiac nurse, a home nurse is always in Lars’ home during the meetings. In the course of our fieldwork we observed one of his consultations, an experience, which drew our attention to the lack of what we call screen etiquette. The story furthermore highlights the cumbersome work of establishing connection and staying in touch.
The home nurse, Lone, attends the consultation dressed in a see-through plastic apron, which crackles when she walks, plastic gloves and a surgical mask. 15 minutes have been set aside for Lars and the home nurse to “get into” the web meeting. Initially, there is some confusion, nothing really happens when Lars presses the buttons on the small tablet that Lone has brought with her. “It’s that [lack of] feeling in the fingertips” Lone says, attributing the troubles to Lars’ fingertips.
Lone guides Lars through the procedures and helps him remember what he has to do next: “Remember that the screen goes black if we don’t place a finger on it”, she reminds Lars. After a few more actions, and a couple of minutes later, Birthe, the cardiac nurse appears on the screen. After a brief “Hello Lars” Birthe goes straight to the point, which is the need to increase a specific type of medication. Lars finds the medication expensive, and it becomes somewhat muddled, whether the meeting is about informing Lars that he has to take more of the expensive pills if he wants to feel better, or whether the cardiac nurse is actually consulting him on the matter. At this point Lars asks the home nurse whether she can turn up the volume; Lone: I am not sure I can.. wait I’ll just try to press this one… I think it’s on full volume. Did it help? Lars: Yes, a little. Lars leans forward holding a hand behind his ear.
At this point Birthe, the cardiac nurse adds: I also just want to know if you can see me properly? Lars: Yes, yes it’s okay.
The screen is small and reflects the light, which makes it difficult to see Birthe clearly, and the sound is poor. Lars does not complain. He is doing what he can to follow and his body language says it all. He squints and stares intently at the screen, leans forward and at times tilts his head to the right, cups his hand discretely and puts it behind his right ear. But it is rather late into the conversation that it becomes clear that Lars has a hard time hearing everything being said. Fortunately, Lone, the home nurse who is sitting on Lars’ sofa behind the screen, takes notes on her phone. Lone goes over the important issues with Lars after the consultation, corrects misunderstandings and translates potential medical jargon.
Without Lone’s presence, the screen visit would not have been possible. However, Lone cannot see what is happening on the screen. She cannot see how Birthe is positioned or what she looks at, nor the way in which the screen reflects the light and in fact makes it slightly difficult to see Birthe. Maybe these are the reasons why, at times, it becomes unclear who Birthe is directing her questions to, and both Lone and Lars answer; or that there are short silences, where they both seem to be waiting for the other to answer.
All in all the screen consultation between Lars, Birthe and Lone makes it evident that it takes a particular form of tinkering, that is, orchestration of participants and a specific ‘rigging’ of the screen, to make this consultation work. In fact, it requires a new set of technical, communicative, and bodily skills and a particular infrastructural set-up to make the interaction between Lars, Lone and Birthe flow and become really meaningful. The absence of screen etiquette may undercut the intimacy and dynamics of the screen meetings, which suggests that new rituals, adapted to the screen encounters are called for in order to make screen consultations work well. This is particularly so, because elements such as body language, facial expression, and the broader material contexts become blurred or remain outside the frame of the screen.
During our fieldwork, we have come to think of screens as devices that frame not only the health encounter, but also the participants in particular ways. In this context, we find Judith Butler’s 2016 concept of framing helpful. Though developed in a very different context, Butler points to the fact that what we see is limited or enabled by different frames, which variously cut out specific ‘segments of reality’ and thus become that through which we see. Consequently, frames shape how we apprehend and engage with what we see. By using Butler’s notion of frames, we wish to point to the screen in health care as “not a neutral technology of communication that simply exhibit reality, but as a framing device that actively participates in a strategy of containment, selectively producing and enforcing what will count as reality” (2016:6)
Understanding that screens act as ‘framing’ devices for particular professional and personal practices and aspirations allows us to analyse how both health professionals and the elderly strategize, plan and navigate in specific ways in relation to the screens. We call these types of practices “window work”, a concept that we use to zoom in on the multiple engagements and procedures involved in enabling and accomplishing care and meaningful health encounters through screens. In a time, where digital technologies and particularly screens are touted as the obvious step towards a proximate health care system, taking note of how screens re-configure the care worker-citizen/patient-doctor relations and the very process of care is of vital importance.
Butler, Judith. Frames of War : When Is Life Grievable?. London: Verso, 2016.
Pols, Jeanette (2012) Care at a Distance; On the Closeness of Technology. Amsterdam University Press, Amsterdam
Oudshoorn, Nelly. 2008. “Diagnosis at a Distance: The Invisible Work of Patients and Healthcare Professionals in Cardiac Telemonitoring Technology.” Sociology of Health & Illness 30 (2): 272–88. https://doi.org/10.1111/j.1467-9566.2007.01032.x.
 Data collection for this project is supported by the Velux Foundation, which chose to support 13 humanities and social sciences covid-19-related data collection projects in June 2020.
Jonas Winther, Line Hillersdal and Kristina Grünenberg are all affiliated to the Department of Anthropology, University of Copenhagen and Center for Healthy Aging where they also form the research collective ‘Sensing Old Age’ (SOA). Departing in ethnographic research, they focus on ‘the aging society’ and examine the embedded assumptions, imagined potentials and concrete practices related to the use of technologies to manage population ageing in Denmark and elsewhere.
This blog post is a prelude to an upcoming article to be published in vol 41, issue 2 of the Journal of Anthropology and Aging in November 2021. It is also the twenty-second post in The Age of COVID-19 series, co-edited by Celeste Pang, Cristina Douglas, Janelle Taylor and Narelle Warren. Please send your contribution to Narelle.Warren@monash.edu
All contributions will also be published on Somatosphere