In line with PAR methodology, the process is a part of the result and is therefore described in this section, addressing (in chronological order) the three PAR sub-cycles that together made up one over-arching PAR cycle (see Figure 3), and lastly describing the created work model. All of the enablement foundations and facilitators of enablement described by Rensburg (40) were utilized in the overarching par-cycle, but they varied in pertinence over the course of the PAR process.
At the beginning of each sub-cycle, all participants were provided a folder with information and writing material, to use as they liked. All workshops were structured to include a warm-up phase, a working phase, and an ending phase, and ongoing engagement was expected between workshops. Participants were encouraged to reflect on a specific part of the design process in light of their daily work, and researchers reviewed the previous workshop(s) and prepared material for the next. In the first round, researchers provided more structured tasks, and in the second round, the participants were encouraged to take on a more active role.
First round: two sequential sub-cycles of questioning, reflecting, and prototype development
This round consisted of two sequential sub-cycles with similar layouts. The structure of both sub-cycles was inspired by Futures methodology (33), beginning with reflecting upon loneliness among care recipients, envisioning a “social future” for older care recipients and modeling a concrete plan for change. The creative assignments used to explore topics and questions were inspired by creative group work and process mapping (41), used to stimulate reflection and operationalization.
Since researchers and participants were new to each other and the project was in its initial stages, two of the “enablement foundations”(40) were of particular relevance: creating a ‘shared vision of possibilities’ and exploring how ‘change, transformation, liberation, and actualization’ could come about. In addition, two “facilitators of enablement”(40) were highly relevant in the first round: using intentional ‘communication’ and ‘fostering relationships’. In the interdependent relationship between researchers and participants, researchers took on a relatively active role in introducing objectives and activities.
Sub-cycle 1 with group A
This sub-cycle corresponded to the first phase of the overarching PAR cycle: reflecting upon loneliness among care recipients and investigating how social participation could be supported within the existing organization of home care services. The sub-cycle also included the initial steps of development of an action plan and the “implementation” of this plan into a first model draft.
Objectives and activities
The objective of group A’s four workshops was to generate a work model draft. The very first warm-up assignment invited participants to reflect on their own social lives through a mind-mapping exercise discussing the activities and relationships they valued. After a miniature lecture about research on loneliness among older adults, participants explored their perceptions of older care recipients’ loneliness and social needs. To spark creative and visionary thinking, the group drew an “avatar”: a fictive care recipient for whom they formulated a vision of a rich social life. Thereafter, the participants examined how they work today and how they could, within the boundaries of their role, enhance their work to identify, address, and evaluate social needs. They noted specific work-tasks and ranked them from easy to difficult to accomplish. Participants discussed different structures that could visualize their described work-tasks in a process, and chose a pie-chart design, into which they fitted their work tasks. The researchers prepared a clean copy of this draft, which the participants used as a base for discussion and changes. They also wrote a short description and a fictive case example for each step in the model prototype. Finally, the participants made a video presenting their prototype and wrote down questions for the next group about aspects they thought needed further development in their prototype.
Facilitators of enablement and group climate
The assignments for group A were intentionally partitioned and concrete, intending to break down the investigative process into manageable pieces. The researchers were deliberate in using constructive and encouraging communication, aiming to foster positive relationships within the group and to generate an open-minded and creative atmosphere. The participants seemed comfortable with each other, showed enthusiasm toward the matters at hand, and were able to work independently during the workshops’ work-phases. Although discussions sometimes became tangential, they also managed to pull themselves back on topic and appeared engaged and goal-oriented. The researchers’ impression was that their suggested questions and assignments fitted the participants’ competencies well and successfully contributed to the positive and creative climate.
Beginning by reflecting upon one’s own social preferences seemed to accentuate the idea of social needs as being universal in essence but also highlighted individual differences, which produced subsequent discussions on care recipients’ variations in social needs. Creating an ‘avatar’ seemed to spark imagination and concretize the visionary discussion, which has been previously described as a fruitful method in participatory processes (42). Participants were both confident and competent in discussing the concrete details of social support for care recipients, whereas mapping and abstracting these competences proved more challenging, which was reflected when discussions drifted away and their progress slowed down. However, the group did reach a model prototype that delineated their work process from identification to alleviation of loneliness.
Sub-cycle 2 with group B
This round corresponded with the middle phases of the overarching PAR cycle: continuing with developing the plan and initializing implementation and refinement.
Objectives and activities
The objective of group B’s four workshops was to refine the preliminary model draft proposed by group A and testing it (informally) in practice. This group began with examining their perceptions of older care recipients’ social situation and envisioning a positive future through a brainstorming and collaging exercise. Afterwards, they reviewed group A’s problem and vision formulations, model draft and video, and discussed similarities and differences to their own previous discussion. Group B then investigated the model’s phases and reflected on challenging and supportive preconditions around each phase, and the model’s overall feasibility. They also discussed which other professions might be relevant to the work process. They elaborated the graphical elements of group A’s model draft, aiming to add visual appeal and relevant aspects to the process. Changes included incorporating a symbolic color scheme, changing the pie-chart design into a circle of action points, adding a quick-route, and emphasizing person-centeredness. Based on discussions and sketches, the researchers prepared concrete design examples that depicted the suggested design elements in various ways that the participants used as base for further discussion. The participants also attempted to plan informal testing by individually identifying a care recipient and trying to follow some (or all, if possible) model phases between the third and fourth workshop. Last, the group discussed conditions important for testing the model on a larger scale, such as organizational preconditions, language use, and documentation (Table 1), and prepared a video presenting their refined model.
Facilitators of enablement and group climate
It quickly became clear that the sequential setup of this round (i.e. taking over another group’s work) gave group B different preconditions than the first. Simultaneously investigating their own perceptions while also relating the result to another group’s work process was not ideal and gave them a more challenging start. Another hampering aspect was that two out of the five participants did not have the opportunity to attend the first workshop, which prolonged the group’s formation phase. Participants showed engagement and competence, but independent work proved more challenging in this sub-cycle, especially regarding abstraction of their practice-based knowledge. To adapt to this situation, the researchers altered their approach towards more hands-on discussions and collaborative work: interdependence and collaborative planning and doing became the prominent strategies. A successful approach became the preparation of visual concretizations; i.e. making several design examples that captured the participants’ previous discussions. These concrete examples seemed to spark creative thinking and critical reflection upon how they did or did not want the model to be characterized. In practice, this collaborative work often consisted of scribbling together on printed copies of the prepared design examples while discussing possible improvements, and the researchers prepared clean copies with refined examples/questions (based on previous discussions) for the next workshop.
Initially, the researchers had hoped that sub-cycle 2 would encompass informal testing of the model in the participants’ daily work, but the participants needed all four workshops to reach a model they were comfortable with. The researchers’ suggestion to prepare a small individual plan for testing between third and fourth workshop was received with caution. Although participants did not refuse, they expressed hesitance and insecurity as to how to do it, and ultimately, little testing was carried out. Researchers concluded that testing was likely too difficult under present circumstances, and would require more preparation than had been available. Therefore, the researchers decided to invite both groups to another round of workshops, and to make arrangements to avoid the uneven preconditions produced by the sequential setup.
Table 1: Important conditions when testing the model in a larger scale, as identified by participants.
Second round: a sub-cycle of parallel testing and refining the model
In the over-arching PAR cycle, this round corresponded with the last phase: implementing and refining the plan. Although ‘communication’ and ‘fostering relationships’ remained important in this round, the groups stayed fairly intact since the first round and the relationships between researchers and participants felt relatively established. In this round, the researchers increased encouragement for participants to take on a more active role in the interdependent relationship. ‘Collaborative planning’ and ‘monitoring the process’ became more pertinent facilitators of enablement, and towards the end of the round we also developed ‘strategies for sustainability and handover’.
Sub-cycle 3: groups A and B
In this cycle, researchers increased focused on fortifying active participation and participant ownership (29) of the process and work model. The two groups worked simultaneously and transferred suggestions, questions, and changes through the researchers, to align the groups’ preconditions and to enable a sense of community and shared ownership. The work model was tested in everyday homecare work between workshops. During workshops, participants reported their experiences from testing the work model and suggested ways to refine the depiction and description of this process. In attempt to increase participants’ feelings of ownership, researchers suggested that one (voluntary) participant would moderate the report phase in each workshop. Thus, a typical round 2 workshop began (after recap and small talk) with a test reporting with a participant as chair, and then continued with refining details in the work model according to needs discovered during testing.
Objectives and activities
The objective of this round was to test the model and to produce case examples. Both groups’ initial tasks encompassed deciding how to use the coming workshops to test the model and create case examples. Group A decided to focus their testing on the quick-route (‘here and now’), due to their restrained work situation. Group B decided to aim for at least three case examples of the long route and one of the quick-route of the model, and to maintain the structure of group member–moderators while reporting their testing. The participants in both groups also wished to receive text-messages from researchers each week to be reminded to test the model and note reflections. During workshops groups discussed what they felt was important to add or change in the model, and researchers prepared printed clean copies of their suggestions placed next to the previous version for comparison. Additions concerned, for example, person-centeredness, care recipient agency, assigning a staff member to monitor the process, and tying the Stay In Touch process to existing structures in everyday homecare work (such as care meetings and the ‘contact care worker’). They also formulated questions for identifying loneliness and wishes for specific support, need for documentation, and discussed and determined a Swedish name for the work model [“Håll kontakten”]. Transfers between groups concerned problematic areas meriting further discussion and/or suggestions for changes to text and graphics.
Facilitators of enablement and group climate
In this round, one of the groups had a new manager, which seemed to alter the atmosphere in the group: participants appeared down-hearted, but were nonetheless engaged in the project. In both groups, testing still seemed somewhat difficult to grasp. Therefore, researchers prepared note-taking booklets for each participant in order to make the testing more concrete. The booklets contained headlines and spaces for notes, and covered phases of concern, what had been done, and challenges and opportunities experienced during testing. Our attempt to encourage the groups to take a stronger lead in planning and managing the work seemed to sometimes generate insecurities rather than empowerment. The participants’ roles as moderators during reporting worked unevenly: while some participants adopted the task with confidence, others seemed uncomfortable and insecure. To meet these insecurities without decreasing participant influence, researchers strived to convey availability and support without officially taking over. In practice, this could mean sitting next to the participant–moderator, answering their questions about how to moderate, or help by asking follow-up questions to the group. The preparation of concrete summaries and design alternatives continued to be successful strategies for enabling creative and critical thinking. Weekly text messages were described as helpful for following through with testing, as participants found it difficult to remember and prioritize testing among their regular work tasks.
The Stay In Touch work model
The over-arching PAR cycle, consisting of three sub-cycles, resulted in a work model called ‘Stay In Touch’. The model describes how home care workers can, within the boundaries of their role, act as discoverers of unmet social needs, employ intentional communication, and link to other professions in order to facilitate more person-centered support for social participation among older care recipients. The model can, in a way, be seen as a frame of mind, which illuminates loneliness and social support within in the regular organization of home care and provides guidance in day-to-day contact with care recipients.
The Stay In Touch model consists of a process divided into five phases, depicted as a large circle with an additional inner circle (Figure 4) and a chart describing each phase (Figure 5). Symbols were carefully chosen by participants to convey, for example, iteration, early withdrawal and person-centeredness, and the traffic-light color scheme symbolizes the process moving from a bad to a good situation. Being attentive, responsive, encouraging, adaptive, and exercising professional judgement are strategies emphasized in the participants’ description of how to employ the Stay In Touch process. And although the model describes actions from the care worker’s position, participants were adamant about the care recipient´s agency and control in every step.
The model begins with phase Present situation, and conveys importance of being attentive to signs of loneliness and using ordinary small talk to learn if the person experiences problems with loneliness (or referring this task to another care worker). If the person confirms loneliness, phase Analyze follows. The inquiry continues by asking what the care recipient enjoys doing, which relationships they value, and if they think home care could provide support. The care worker can also, with the care recipient’s approval, discuss potential support with colleagues or the person’s next of kin. One care worker will be assigned to monitor the process, preferably the ‘contact staff member’. Phase Plan includes examining potential support to suggest to the care recipient. In this phase, colleagues or other relevant professions can be involved with the care recipient’s approval. The phase might require application for additional service grants, in which case, a social service case manager will perform planning. However, it is also possible that the care recipient’s aspirations fit within existing grants (such as social stimulation, meal company, or walks), and planning can be done informally or via structures for individual care planning. Lack of clear communication between different professions, and between lay-language and formal language were identified as potential barriers, and careful communication was therefore emphasized in the descriptive text. In phase Implement, the care worker’s role depends largely on the result of previous phase, but emphasizes the need to remain attentive to signs that care recipients require additional support and using judgement and showing that the person’s chosen activities are valued and prioritized is highlighted. The last phase, Evaluate, encompasses dialogue with the care recipient and home care colleagues about whether the plan worked well or needs changing, and distinguishes four aspects to determine whether the process has been successful. The process can start over at a suitable phase if it has not been subjectively satisfactory for the care recipient.
The model also contains an inner circle, Here & Now, which represents a shorter series of (informal) actions that reflects a small scale Stay In Touch process that can be done immediately. For example: a person expresses feeling lonely (present situation) and longing for a relative (analyze), the home care worker asks/suggests a telephone call (plan) and help finding and dialing the number (implement) and the person seems satisfied for the moment (evaluate).