The importance of tacit knowledge in practices of care

Authors


  • Conflicts of interest: to be confirmed.

Prof. Dr. Hans Reinders, Faculty of Theology, VU University Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands (e-mail: js.reinders@th.vu.nl).

Abstract

Background  The paper argues that a high quality personal relationship between professionals and clients is a necessary condition of professional knowledge. This epistemological claim is developed against the background of current methods of quality assessment that rely on objectively measurable ‘indicators’.

Method  A philosophical analysis regarding the nature of professional knowledge in the care sector. The analysis proceeds from Michael Polanyi's concept of tacit knowledge to account for the personal dimension of professional expertise in the care sector.

Results  Quantitative methods of quality assessment understand ‘quality of care’ as being independent from the professional who generates it. Consequently, quality assessment as currently practiced necessarily renders the personal dimension of professional knowledge invisible, thereby excluding it from managerial attention and support. To indicate the relevance of Polanyi's concept of tacit knowledge, the paper offers some observations from the practice of care in a group home for people with intellectual disabilities.

Conclusion  The paper concludes that a high quality relationship between professionals and their clients is crucial for quality of care. This relationship generates the positive interaction that enables professionals to gain adequate insight in the needs of their clients.

Introduction

In this essay I want to draw attention to a dimension of professional expertise in practices of care and support that in my view is mistakenly neglected in current methods of quality assessment. This is the dimension of personal knowledge. Part of what distinguishes the good practitioner lays in the implicitness of her expertise. Professional expertise involves a ‘tacit’ dimension of practical knowledge in Michael Polanyi's sense (Polanyi 1958). Quality assessment, as we currently know it in the care sector, focuses exclusively on objective measurement of quality. In doing so it ignores an important aspect of professional expertise, or so I shall argue.

Although what I have to say is based on observations regarding practices of caring for people with IDs in the Netherlands, I don't think its validity and relevance are limited in either way. The current methods of assessing quality of care as measured outcome have been introduced in the last decade in at least a number of countries in north-western Europe, and they have been introduced in a variety of social practices, among which education, health care and social work. In other words, I expect that what I have to say will be recognised by professionals and analysts in a wider range of social practices, in a number of European countries.

The central claim of the present essay with regard to these practices is an epistemological one. It regards the nature of professional knowledge. It states that in the care sector, a high-quality personal relationship between professionals and clients is a necessary condition of professional knowledge. This is because only it generates the positive interaction that enables professionals to gain adequate insight in the needs of their clients. If this claim can be sustained, it follows that acquiring adequate insight in a client's needs has inevitably a personal dimension that cannot be ignored without jeopardising the quality of the services provided.

In contrast, current methods of assessing quality rely on ‘indicators’ of quality that can be measured objectively, which means that quality of care is understood as being independent from the agent who generates it. Consequently, these methods necessarily render the personal dimension of professional knowledge invisible, thereby excluding it from managerial attention and support. The burden of this essay is to develop the argument that lends plausibility to this claim.

Quality of care as measured outcome

The introduction of methods of quality assessment that rely on measurability of results has been guided by various political and economic concerns. One is the need for cost control in health care, which has led public authorities to push the goal of cost-efficiency (‘value for money’). Another is the introduction of competition between service providers in order to enable consumer choice. To be able to choose between service providers, consumers have to be able to compare what these providers have to offer. Therefore, they are required to present their ‘products’ in ways that make them comparable in terms of the interventions they offer, their price and their expected benefits. Also in this connection it is numbers that count as ‘proof’. For example, if you provide services for people with behavioural problems, we want to know what your treatment entails, how many clients have been treated by you and for how long, what the result of their treatment has been in terms of frequency and intensity of their problem, how many of them have relapsed, what the average cost of your treatment has been and so on.

The predictable impact of assessing quality as measured outcome has been standardisation. Because product information must enable consumer choice, it is imperative to get rid of all sorts of idiosyncrasies in the way professionals assess what they do. In other words, inherent to assessing qualify as measured outcome is the tendency of eliminating interpersonal variation. Quality must be accounted for in terms that are independent from the one who is providing the service. It should not make a difference for me as a consumer of a particular service whether it is provided by you or by your colleague, or whether I receive it in this part of the country or in another part. The key to that goal has been standardisation.

In the Netherlands, the most conspicuous example has been the introduction of the Diagnose-Treatment-Combination in medical practice. Linking a particular diagnosis to a particular therapy with a prescribed time frame and against a prescribed price, the introduction of the Diagnose-Treatment-Combination assures me as a client that everywhere in the country I will receive the same treatment for the same ailment for the same price. Needless to say that health insurance companies have pushed the introduction of this instrument to weed out what they regard as professional ‘inefficiency’.

Closely related to this instrument is the introduction of so-called ‘evidence-based care’. Quality must be proven and the only proof that counts as such is objectified scientific evidence. Again the outcome is predictable. When a particular treatment or therapy has been proven to be effective, it is likely to be prescribed as ‘state of the art’ for all practices in the entire country. What scientific evidence confirms is ‘best practice’, and ‘best practice’ is where health care authorities and health insurers put their money. While there is much to be said for scientifically supported best practices, it is the standardisation of their results that creates standardised patients. In this respect, the laws of supply and demand do for the care industry what they do elsewhere, namely increase the price for specific needs and preferences.

The popularity of standardisation among policy makers, insurers, inspectors and other supervisors does not eliminate the – in my view quite urgent – task to criticise it from a scientific point of view. It has brought about a transformation of professional practices that now even public authorities begin to be worried about (Reinders 2008a). In the Netherlands this is shown in the declared policy of the current government to aim at deregulation of professional practices. But there is more at stake than the levels of bureaucracy induced by instruments of standardisation. The current methods of assessing quality are changing the nature of professional activity in ways that do not so much enhance quality as destroy it. This claim regards explicitly the personal dimension of professional expertise.

Specifying difference

Before I develop the argument regarding the epistemology of professional expertise, however, I want to draw the reader's attention to a philosophical point. It regards the question of how assessing quality as measured outcome affects our ways of thinking about the nature of professional practices in the care sector. My point here is that these methods disregard the particularities and differences of these practices.

Let me illustrate what I have in mind with an example. It is arguably a good thing to allow eye laser operations to be offered by private health care. It is a kind of medical intervention that is highly standardised and routinely performed successfully without many complications – an organisation called LaserTravel based in Turkey advertises on the web with a track record of 70 000 operations in 15 years (See http://www.lasertravel.de). Apparently, eye vision corrections performed by surgeons working for this organisation do not require a qualitative professional–client relationship to be successful. In fact you can book a trip to a LaserTravel clinic in Istanbul from any European country based on the diagnosis of your own physician who shares his data with the surgeon; such that the latter already knows everything he needs to know about you before he has laid his eyes upon you.

The problem with current policies of quality assessment is in the assumption that the logic of standardisation underlying the organisation of eye laser operations is applicable to all kinds of professional interventions in the care sector, regardless of their particularities. Obviously, all professional interventions in this sector require some mixture of expert knowledge, technical skills and moral attitudes that make for a good professional. But it is highly implausible to assume that the same mixture applies to health care practices regardless of their difference. A nurse working in a LaserTravel clinic must be quite different from another one working in an intensive care unit of an academic hospital, and again from a third one working in a mental hospital. As soon as we introduce practices of care and support for people with learning disabilities, or patients with dementia, the differences multiply.

The point of my objection to current methods of assessing quality as measured outcome is therefore that it eradicates the importance of taking into account the particularity of specific practices. While the parameters of these methods adequately fit the services provided by a clinic of LaserTravel, it is highly unlikely that the same is true for services in which the mixture of expert knowledge, technical skills and moral attitude is different. As I said in the introduction, the analysis presented here is largely driven by the practices of care and support for people with learning disabilities. I trust, however, that it will also hold for the practices of caring for the elderly, for patients with chronic mental illness, for drug addicts, as well as for the practices of care and support for homeless people, just to name a few. The list is not intended to be exhaustive but to indicate a common denominator. The common denominator is that in each of these practices – unlike the eye laser operation type of practice – professionals are engaged in their clients' lives over a longer period of time. Their job is to work various aspects of physical, mental and social well-being that usually cannot be dealt with in isolation because they are interacting and often are mutually reinforcing one another. For such practices, the argument in the following sections is meant to be both relevant and valid.

Although it is certainly possible to argue against the transformation of the caring professions in terms of specific virtues, such as the virtues of compassion, patience, kindness and trust, in this essay I will develop a different line of argument. Stated in terms of moral theory, the point I am arguing is not about virtue ethics as the moral theory appropriate to professional expertise (see, e.g. Clegg 2000). While I have no doubt that an Aristotelian account of professional expertise as praxis would show that the current methods of quality assessment effectively transform it into a technè, thereby undermining its moral virtues (Reinders 2008b). I am presently not pursuing an ethical analysis. Instead, I am considering the epistemological rather than the ethical significance of the virtues inherent to practices of care and support as identified before. In knowing how to relate to their clients, the good practitioners gain insight in their motives, their moods, their problems, their disappointments, their sorrows, their expectations and their hopes. Without being connected in this way, they will not gain the same level and intensity of insight, which lowers their ability of making the right judgment in quite complex situations in which their clients usually find themselves (Schuengel et al 2009). It is particularly in this capacity of making adequate professional judgments that the importance of the personal dimension of professional knowledge proves itself.

The personal dimension of knowledge

The theoretical model for the description of the personal dimension of knowledge is derived from the work of Michael Polanyi who was a historian and philosopher of science. Polanyi and his heirs speak of ‘tacit knowledge’ in this connection. Polanyi's view was that the critical method of the scientific process – for example in the case of scientific discoveries – was shot through with personal elements such as imagination and attachment (Polanyi 1958). These elements constitute the ‘tacit’ dimension of knowledge. Polanyi's argument was that images and intuitions that govern the process are motivated by passion (Smith 2003). Although they serve the pursuit of knowledge, they differ by nature from the way in which this knowledge is presented and tested, namely in the form of propositions. Propositional knowledge states what is the case. ‘Tacit knowledge’ in Polanyi's conception of it is knowledge that is contained in statements that are personally indexed: ‘I have a feeling that . . .’; ‘I believe that. . . .’; ‘something tells me that. . . .’, characteristic of which is that the speaker cannot explain exactly where this feeling, or this supposition comes from. In The Tacit Dimension, Polanyi coins the felicitous phrase ‘we can know more than we can tell’ in view of this phenomenon (Polanyi 1967, p. 4). That what is known without being accessible for articulation as propositional knowledge is what Polanyi calls ‘tacit’ knowledge. It is implicit knowledge, knowledge that is disclosed in the judgment of the ‘knower’, of which it is true that it cannot be reduced to scientific theories or models (Gelwick 1987; Scott 1995). It is knowledge that is generated in a state of being intentionally directed towards, and attached to something. In that sense, tacit knowledge is always personal, says Polanyi, because it involves the knower as a person.

An important implication of Polanyi's account for our purposes is that because of its personal dimension, tacit knowledge is not readily transferable. It is constituted by the fact of the relationship of the knower to what is known (Polanyi 1969, pp. 24–25). I take it to be quite significant in this connection that some of the literature regarding the usefulness of Polanyi's ideas stems from the science of knowledge management. In this particular field, we find more and more emphasis on the personal dimension of knowledge (Hildreth & Kimble 2002). Until recently, knowledge management was spoken of mainly as if it were concerned primarily with the management of information. Some authors apparently have concluded that knowledge management cannot be limited to issues about managing information carriers. Consequently, they have begun to explore the nature of professional knowledge as it is embedded in a practice from which it cannot be readily extracted (Kimble et al. 2001).

Furthermore, I take it to be significant that also in the field of business administration and organisation, the importance of tacit knowledge is recognised. There one finds the argument that the frequent attempt to ‘rationalise’ implicit knowledge mostly result in the neglect of its personal character (Nonaka 1991). It is a type of knowledge that is

. . . hard to formalize and therefore difficult to communicate to others ( . . .) tacit knowledge is deeply rooted in action and in an individual's commitment to a specific context ( . . .) tacit knowledge consists partly of technical skills [and partly] of mental models, beliefs and perspectives so ingrained that we take them for granted and cannot easily articulate them. (Nonaka 1991, p. 98)

The theory of knowledge emerging from this description is apparently more complex than the empiricist theory of knowledge that is presupposed in the notion of evidence-based care. The difference in complexity lays in the inseparability of knowledge and the process of knowing. The connection between knower and what is known cannot be severed without loss. In contrast, the notion of ‘evidence’ as in evidence-based care regards data that can be presented in isolation from the process that generates them. Empiricism claims that scientific knowledge develops through the formulation of hypotheses and theories that are affirmed or rejected by means of empirical testing that is carried out by means of intervention under controlled circumstances (see for example Aune 2008). The difference with Polanyi's conception of tacit knowledge is the requirement of a narrowly defined set of controllable factors that is necessary to determine the exact effect of the intervention.

In Polanyi's conception, this requirement cannot be met because it assumes the fiction of the isolated fact. Scientific knowledge in his view is necessarily contextual and embedded in particular practices. In this respect, it has been argued that Polanyi's conception in fact anticipated Thomas Kuhn's theory of the pursuit of scientific knowledge as inevitably intertwined with its cultural and historical context (Smith 2003). One way of characterising the difference between both these epistemologies would be to say that whereas in the empiricist theory, knowledge equals information about a given state of affairs, in Polanyi's thought, it equals insight. The difference lies in the personal dimension that is absent from the notion of information. In Polanyi's account, the knower has something of the connoisseur (Smith 2003). In the empiricist account the opposite is true: the knower must not be a factor in the empirical testing procedure, which explains why any given hypothesis is affirmed if and only if the empirical test that affirms it has been repeated by another scientist. Scientific evidence eliminates the contamination that occurs through interpersonal variation.

Professional expertise in practices of care

Precisely at this point, one can see the relevance of Polanyi's account for understanding the nature of professional knowledge in practices of care and support for dependent people. The professional who wants to gain insight in a client's situation surely needs information in the sense of objectified data, but information is only a necessary and not a sufficient condition for gaining insight. For example, we know from experience in medical practice that self-help groups are sometimes better informed about the latest news regarding their disease than a general practitioner might be, but it does not follow that they have better insight in their condition. Information is not a sufficient condition for professional knowledge.

In this respect, Polanyi's conception of tacit knowledge is especially suited to account for the difference, particularly with regard to the practices of care and support that I am concerned with in this essay. This conception discloses a practical knowledge that is, first, generated in being engaged with clients over a longer period of time and, second, regards interacting aspects of their physical, mental and social well-being and, third, reflects the complexity of the problems these clients are facing. It is a kind of knowledge that is generated by a high-quality professional–client relationship. In the context of that relationship, the quality of professional judgment depends upon, among other things, the intentionality of being attached and attuned to the particularities of the client. Professional expertise is necessarily embodied knowledge therefore in this sense that without cultivating its personal dimension, the professional will be less capable of making adequate judgments.

It should be obvious in this respect that if the foregoing account is true, than it must imply the following theoretical principle: the more crucial the professional–client relationship is for gaining insight in the client's needs, the less the logical space for standardisation must be. This principle does not fit well with the empiricist conception of knowledge underlying the notion of evidence-based care as described before. In that conception, as we have seen, the aim is rather to eliminate interpersonal variation. Following the empiricist conception, professional knowledge equals ‘knowing that’. In practices of care and support for dependent people, the knowledge involved in professional judgment is more adequately characterised in terms of ‘knowing how’.

Again, this is not to say that professionals do not need scientifically warranted instruments and information; but it is to say that their use in no way guarantees adequate professional judgment without guidance from practical knowledge that originates from the intentionality of the professional as a person.

In view of this distinction, how does assessment of quality as measured outcome proceed when its relevance is ignored? Let me answer this question again with a (fictitious) example. A psychologist works with clients whose behavioural problems she treats with attachment-based behavioural therapy. The legally authorised budget for her clinic allows her to offer her clients a standardised treatment consisting in 10 therapeutic sessions of an hour. This is based on evidence about cost-effective treatment with this therapy. In case this psychologist regularly succeeds in her treatment of these clients, she will soon be known as her clinic's expert on attachment-based behavioural therapy. To the extent that she keeps up with this track record, her clinic will be ranked accordingly for this item in the benchmark for mental health clinics.

It is not difficult to predict that assessing the quality of professional practices in this manner will do for mental health services what industrialised production has done for the production of refrigerators, DVD-players and television sets. It will increase standardised mainstream care with the effect that within this system, ‘difficult’ clients will be perceived as ‘expensive’. Whereas traditionally such clients would rather be perceived as particularly challenging to professional expertise they now tend to become a liability for one's professional track record.

Suppose the psychologist faces a few clients whose problems still remain even after 10 sessions of attachment-based behavioural therapy, and wants to continue their treatment. It is quite likely that her manager wants an explanation. At any rate, managers of mental health clinics impressed by the rankings of benchmarks will not be pleased by large numbers of such clients. So the likely effect of quantitative assessment of quality is not only that it eliminates interpersonal variation between professionals, but also that it minimises interpersonal variations between clients. Framing quality in terms of efficiency and cost-effectiveness forces the provision of health care and social services to obey the laws of mass production.

This is not the only effect, however, because the logic of quantitative assessment of quality also implies the production of ‘waste’. What happens to clients whose problems are not effectively treated? Several options are available. The psychologists rework their time frame and bill the insurer for 600 min of therapy but offer their client 15 sessions of 40 min (instead of 10 sessions of 60 min). Or they may decide to work the system, and take in the same client under two diagnoses instead of one in order to have the double amount of billable time for their therapy. Or they may refuse to do anything of the sort, and advise their clients to apply for a reassessment because they are diagnosed within the wrong category.

I take it that in actual practice all sorts of alternatives are worked out, with or without approval of managers. Presumably, the option of reassessment is what the system requires. But the result of this policy may not be all that reassuring as people start trafficking the system as ‘difficult’ clients, a journey that frequent results in their dropping out. It is a well-known fact about large numbers of homeless people in our countries that they have dropped out of the mental health system. Standardised care produces not only standardised professionals but also standardised clients.

There is, however, one rebuttal to my argument for the importance of high-quality relationships between professionals and their clients, namely that this importance is recognised by measurement of client satisfaction. Accordingly, in the Netherlands we often find quality assessment aiming at measured output in terms of efficiency and cost-effectiveness aligned with client satisfaction measurement. The reasoning behind this alignment is, presumably, that in order to check financial and organisational pressures on professional–client relationships, we should ask people about their experiences in this regard. If people are sufficiently satisfied with how they are treated – which usually turns out to be the case – what is the problem?

The rejoinder to this rebuttal should be that it misses the point. The level of client satisfaction does nothing to reflect the epistemological relevance of high-quality professional–client relationships, which is the main point for turning to Polanyi's conception of tacit knowledge. The argument is concerned with what these relationships do in terms of enabling professionals to gain insight in complex situations in order to judge what to do and where to go with a particular client. Client satisfaction is no indicator for the quality of the professional–client relationship as an epistemic condition of adequate professional judgment. Professional judgment in this context is inevitably personal. No toolkit of evidence-based treatments will bring you the personal insight that you need for getting it right.

Tacit knowledge in operation

To sustain this claim in a more positive way, I will finish this essay with a few examples of how the personal dimension of professional ‘know-how’ in the care sector actually works. So what follows is intended as illustrating tacit knowledge in operation. My source is a study that was published recently in the Netherlands as The Art of Caring (Wuertz & Reinders 2009). In this study, the anthropological method of participatory observation was used to describe high-quality professional–client relationships in a group home for people with IDs. Its particular aim was the epistemological meaning of ‘connectedness’, a term that I have replaced here by the more formal notion of professional–client relationship. The method of participatory observation was used to describe how professional caregivers are connected with and attached to the residents of this group home and these relationships inform the capacity of professional judgment in their work. The theme of the observations presented here is ‘communication’.

Communication with the residents of The House – as I will call it – operates mainly, and for some residents exclusively, by means of body language. Four of the eleven residents in The House don't articulate any recognisable syllables, but they do produce sounds. In the case of these residents, communication skills are actually very limited. Both caregivers as well as other residents in The House have to guess from the pitch and strength of their voices what they might mean to communicate, if anything.

Of the remaining residents, two use language but only in a very stereotypical way. Both their verbal and body language appear as ritualised behaviours. Then there are three residents whose speech is understandable but they are frequently hindered by emotional barriers to express themselves clearly. Finally, there are two residents who talk well and like to talk a lot. Evidently, under these circumstances, one of the main concerns of the caregivers is to make sure that everyone has a right to be heard, regardless of her means of communication.

Interpreting behaviour

Caregivers face the challenging task of interpreting the residents' behaviours as signs (Schuengel et al. 2009). Throughout their shift, they are exchanging observations with one another to check whether their colleague sees what they themselves think they see. There is a continuing process of verifying interpretations. When asked how they can be sure that Tom who has only marginal communication skills has understood the question she just asked him –‘do you want a cup of tea?’– Louise responds that whether or not communication succeeds depends on how Tom has been earlier in the day. Maybe a few hours or only a few minutes ago someone may have noticed something about his mood. Such impressions are assembled to create an image of how Tom is today.

I had already noticed that Tom has been quite agitated today, but no one has as yet been able to discover the cause. But you observe how he sits on his chair, what he does with his hands. In Tom's case the expressions of his face often tell you what he is about, but it takes time to learn how to read him.

Given the changes in staff during the day as well as the transition from The House to the printing shop where Tom Works, the communication between caregivers is crucially important. ‘Without being informed what happened before during the day you must read him without context’, Louise says about Tom, but her statement applies to other residents as well. However, she is clearly aware of the risk of the exchange between caregivers, even though absolutely necessary. ‘When Tom has been angry or upset I need to know this, but I should not let this knowledge shape my attitude towards him and approach him as being angry or upset’. ‘Reading someone's behaviour is a delicate affair’, she continues, ‘mistaken interpretations lead to mistaken responses’, which is a way of acknowledging that the caregivers’ actions are inevitably part of their residents’ behaviours, and cannot be separated from them.

Empathy

Harry lays on the big cushion on the floor in the living room. People are returning from work and walk in and out, which creates the risk that someone will stumble over his long legs. This afternoon Harry was the first to arrive in The House and he was laid on the cushion because he was tired. Ellen is concerned about what she sees, knowing that Harry's epilepsy tends to become manifest at these moments. In passing by, she constantly watches his face to see how he is doing. Is there anything particular she is looking for?

Well, no, actually I am not sure what it is I am looking for. He looks a little pale, and his eyes are staring, which indicates he is tired. I already notice that when I picked him up from the workshop. His eyes look different. I always watch his eyes, maybe because he has this beautiful smile when he is happy. I also feel his hands. Cold hands means his mind is not there. That's when he does not like to have many people around.

Harry turns away. He pushes his large head in the cushion as if to hide himself. He moves his head back and forth slowly. ‘Shall I take you to your room’, Ellen asks him and without waiting for a sign from Harry she begins helping him to sit straight and get up. ‘I see a convulsion coming’, she explains. ‘You already did have one today, didn't you? Has your day been heavy, dear?’ she says to Harry. She speaks very slowly and calmly, so as not to add to his mounting agitation. Other residents turn to the situation and begin to look worried. Ellen notices this and changes her tone into a cheerful ‘Okay everybody, let's sit down and have tea. I will be with you in a minute’. Everyone takes a chair. Harry moves towards the door.

What does this scene show? A caregiver alternates her attention back and forth between details and the overall disposition of her client. She is observing (paleness of his face, temperature of his hands, pattern of his movement), and watching (Is the cushion all right? Is no one tripping over his legs? How are the others responding? And so on), but at the same time she is taking in what she sees as Harry's physical and emotional state. All this happened in a few minutes before she decides to take him to his room. Ellen is absolute certain she has communicated that this is what he wanted. ‘I try to imagine what he feels, where his mind is. Usually I feel when I am connected. When not, I am in trouble because Harry may react with a convulsion’. On another occasion Ellen's colleague explains how this works.

You have to be open to what presents itself and not focus your attention too strongly, you also try to be aware of preconceptions or expectations you may have in order to be receptive to what is actually there. What does this person want to say to me today? That sort of question. Empty yourself so that you are ready to listen.

Awakening speech

As a child, Mary was capable of speaking and she also sang beautifully. She would say grace before dinner, or sing a song. Some of the older residents in The House remember this from her, so do some of her caregivers. But now she rarely uses her voice and spends her days in silence. Before dinner time, Joanne takes a chair beside her and touches her arm to encourage her. ‘Maybe you could say grace today’, she says. Silence. Joanne waits. The silence is not awkward. It is an active silence. Everybody waits. One of her co-residents explains hopefully: ‘Sometimes she speaks. She can, you know’. Joanne tries again. ‘I know you can do it, I read in your map that you did it today in the workshop. Everyone was thrilled by your voice’. Mary sits still, then softly, but very swiftly, she says a short prayer, hardly audible, but still recognisable for all who know it. Someone quietly applauds, there are relieved smiles.

After dinner Joanne explains. She was not challenging her, or pushing her to make an effort. ‘What I am trying to do is make her remember her voice. Mary's voice is still there, but she cannot find it consciously, as if it is asleep. By inviting her to speak I am awakening her speech. But it is not in my control when it happens’. The same thought comes up in a conversation with the speech therapist. Talking of awakening Mary' speech, she says:

Speech therapy is not about intervention, it is about communicating feeling. You enter the domain of the soul somewhere between the conscious and the unconscious. To enter that domain is not a matter of technique. You need permission from the other, you need to be welcome. Without that, nothing is going to happen. I can only get her permission when I am tuning in on her emotionally. When I succeed she will relax and give in. That's when she trusts me.

How that Works? It begins with listening to the sound of the door. How does she enter the room? How does she look? What are her eyes telling me? The expression of her face, her hand in mine when she greets me. I am trying to find connectedness. That's when her voice may become alive, if at all. I am not trying to control the situation. I let her be. All this happens in a split second, before I have even spoken a word.

Caregivers also take body language as their lead in trying to include residents in conversation. Mary can look mindlessly through the window during teatime, for example, but her body posture might show whether she is actually listening or not. Joanna names this posture ‘inner participation’ and takes it to be crucial for Mary's presence in the Group. Sometimes she will try to elicit a response by addressing Mary explicitly. ‘Well Mary, what do you think? Is it a good idea to go for a swim after tea?’ Now Mary can fully participate in the conversation with only a nod. Eventually she might respond with a smile, or a silent ‘yes’.

This way of using communication to stimulate residents in their actual presence turns out to be an important aspect of what caregivers are trying to achieve. It is important to make explicit that this attempt regards both residents and caregivers themselves, however. Presence of mind is what caregivers seek to practice because they know that the accuracy of residents' communication depends on the accuracy with which caregivers themselves communicate.

Being present is something that the work itself stimulates. Unless I am fully present, residents will not respond to me. In speaking carefully, we communicate on the level of the soul. The impulse of communication comes from inside, only then the body communicates. So when we think that Paula is turned inwardly and does not communicate well I must try to be open to the possibility that I am not truly present in addressing her. Communication is a question of the soul expressing itself through the body. If there is no true presence there is no soul, and hence no communication.

The articulacy of the last statement notwithstanding, caregivers often find it hard to explain exactly the rationality of what they are doing. For example, in raising the question of how ‘presence’– mentioned in the previous section as a condition of successful communication – actually works, caregivers are most likely to respond that they don't know.

The only thing I do know: if you try to force, or reproduce a response you can be quite certain it will not work. You can try to elicit one, but it is not clear at all why what you do sometimes works, and at other times doesn't work. The only thing you can do is carefully observe how your own behaviour influences elicits a response.

In conclusion

In summary of these exemplary observations, I want to suggest that they succeed in gesturing at what Polanyi theorised about as the personal dimension of knowledge. It is because these caregivers are engaged in particularised relationships with their clients that they are able to see and understand the emotions, state of minds, behaviours, body languages of these clients in ways that cannot be separated from these relationships.

Let me finish returning to my earlier philosophical observation. The current methods of quality assessment do not merely evaluate professional practices but they actually change these practices. Among the more deplorable aspects of these methods is the fact that personalised relationships between professionals and their clients are discouraged. They are rejected inasmuch as they suggest that quality is personal. Quality must be measurable in objective terms, because otherwise professionals remain to be in the position to wield power over their clients. Forcing them into an open competition on a consumer market will change this.

This type of analysis underscores current methods of quality assessment, which explains why these methods have been characterised as a form of ‘organised social distrust’ (Freidson 2003; Reinders 2008a). It also explains why the commodification of care and support as ‘products’ is accompanied by the same type of quality standards – ISO norms – that applies to refrigerators, DVD-players and television sets. Consequently, care and support are regarded as transferable goods that are consumed and, by implication, produced to be purchased by consumers in the market of health care services.

Considerations such these indicate why and how current methods of quality may be related to neoliberal thinking. Neoliberalism has no place for dependent people that thrive on the quality of professional–client relationships in shaping their lives over a longer period of time. As a matter of fact, Neoliberalism has no place for people with needs whatsoever because it only recognises ‘choice’. With need comes necessity, and with necessity comes dependency. The importance of my philosophical observation of how current policy changes the nature of thinking about care and support proves itself precisely at this point. Neoliberal policy does not want to consider dependency. Celebrating individual choice as facilitated by market relationships, it exhibits a pertinent ignorance with regard to the human condition. This explains why neoliberal accounts of professional practices have no stake in the question why these practices came into being in the first place. The argument for this claim takes another essay, however.

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