Rhythmic rush: everyday outpatient care within microgeographies of home and “service complex systems”

As ageing beings, the home spaces we inhabit in old age become pivotal in engendering a sense of security and emotional and physical well-being. Therefore, long-term outpatient carers work in highly sensitive contexts, wherein the establishment of a trusting atmosphere is of great significance. The introduction of the private sector into the long-term care market in Germany has led to the establishment of standards for each care task. This paper explores the rhythms of the implemented system of the so-called “service complexes” for long-term outpatient care by using a rhythm analysis. In doing this, I reflect on the effects of constructed standards on body(spaces), work processes and home spaces, which are sustained by digital technologies. The research is grounded in qualitative fieldwork conducted in the rural Altenburger Land, a region with one of the oldest populations in Germany. The findings illustrate the impact of the commodification of care on nurses, the corporeality of clients and their spaces of private retreat.

1 Introduction

As populations age, demands for home-based elderly care rise. Today, still more than half of the approximately 5 million people receiving care in Germany are looked after exclusively by relatives (Statistisches Bundesamt – Destatis, 2024). But as the demographic change proceeds, the need for formal care increases continuously. In response to shortages of care professionals, Germany implemented a system of service complexes and time schedules to improve efficiency in outpatient care. So, the question is no longer only one of who provides care but also one of how time is structured within it. Thus, care work becomes extensively regulated, governed by economic logics of acceleration, efficiency and fragmentation, while the ageing body located in domestic spaces is characterized by slowness, requiring attention and continuity. What emerges is a profound incongruity in time structures, resulting in a constant rush by the care workers.

This paper addresses debates on precarious care systems by examining the spatial and temporal organization of home-based outpatient nursing in rural areas of the Altenburger Land (East Thuringia, Germany). It integrates and expands on insights from intersectional studies of care, critical geographies of ageing and the lesser-explored system-related rhythm analysis of elderly home care. Care work is physically demanding, and, by acknowledging this, the study's methodology utilizes auditory, tactile and visual sensory impressions to make the time spaces of care perceptible and analyzable. The perpetual processes of professional caring, which are subject to temporal instructions by the service providers, on the one hand, and the domestic, recreational daily processes, on the other, are viewed in their antagonistic unity through interference with each other. With reference to Lefebvre (2004), I analyse rhythms in elderly people's home spaces and identify discrepancies in their logic. This provides insights into the time geographies of paths and trajectories that outpatient nurses¹ take through the homes of those being cared for. At the same time, the analysis generates new knowledge about care-system-related breaks and overloads, as well as the implications of power, which, in turn, highlights the current precariousness of care and nursing skill shortages in Germany.

Despite the extensive work from various disciplines and inter-disciplinary approaches on commodified care, a micro-scaled geography provides a valuable perspective for examining the effects of commodifying care labour. Caring activities are commodified and integrated into market-based relationships across numerous spaces and locations (Cox, 2013:492).

In this paper, I explore the daily routines of home-care nurses and elderly individuals within their residences based on qualitative fieldwork conducted in the rural Altenburger Land region of East Thuringia in the year 2023. To illustrate the application of rhythm analysis in understanding elderly care within the home environment, I begin with a brief overview of existing theories on the experiential aspects of the relationship between ageing, care, home spaces and rhythms. Thereinafter, I present the methods before delving into the analysis of rhythms in body spaces, work processes, home spaces and digital technologies. The conclusion summarizes the findings of the rhythm analysis and points out final prospects.

2 Framing the analysis: home and care in (geographical) gerontology and the Lefebvrian conception of rhythm

Ageing in place has become a prominent topic among social geographers, who aim to demonstrate the relational nature of ageing and space (Hobbs and Pasch, 2024; Schwanen et al., 2012) and who insert a differentiated understanding of space and geography into debates regarding critical gerontology (Skinner et al., 2018). Feminist perspectives on ageing, care and home spaces have been the subject of early work by Young (2004) and Mowl et al. (2005). Bringing together perspectives on ageing, home (spaces) and rhythm, Riley (2020) provided insights into the use and experiences of places by ageing men. Lager et al. (2016) used rhythm analysis to show how a sense of otherness developed between older and younger neighbourhood residents. Other research highlighted temporal dimensions and the relationship between ageing and place, such as a sense of time (Bildtgård and Öberg, 2015; Hall, 2011; Lee, 2013; Stjernborg et al., 2014). Taking a broader view of everyday rhythms and home, Carr et al. (2017) examine the role of material engagements in mediating rhythms. The following section takes a closer look at home (spaces) when investigating rhythm and ageing.

2.1 Framing the analysis I: home (space)

Home, as Wiles and Coleman (2024:184–185) state, is “a place, layered with social, material, and symbolic meaning”, enhancing “a person's confidence in their self-identity and connection to local places and people”. According to Blumen et al. (2013) and Blunt and Dowling (2022), the concept of home is characterized by sentiments of familiarity, continuity, security and safety. Home may also be considered on a larger scale, analysing it from a feminist perspective on infrastructures of energy systems with concepts of care (Aue, 2024). Then again, it is described as a “pocket of local order” (Ellegård and Vilhelmson, 2004) on a smaller scale. However, living in a place does not self-evidently come along with a feeling of “being at home”; on the contrary, it may entail feelings of fear and threat as a result of being at someone's mercy or potentially being exposed to violent assaults (Blunt and Varley, 2004:3): “These feelings, ideas, and imaginaries are intrinsically spatial” (Blunt and Dowling, 2022:9). This is what makes me use the term home space. Empirical studies have focused on the home space in particular, including its imaginaries and ideas, which geographers have described as central to the creation of identity, meaning and attachment (Blunt, 2003; Duncan and Lambert, 2004) and which Mallett (2004:68) conceptualizes as a socio-spatial system encompassing both the physical and the social unit. Research indicates that, as people age, the emotional significance of one's own home space grows, deeply intertwining with personal biographies (Oswald and Wahl, 2005:13) and also varying by gender (Mallett, 2004). All of these studies implicitly or explicitly imply the influence of time in the production of private home spaces and the historicity of body spaces within private spaces. The entanglement of domestic space and corporeality is highlighted in Imrie's (2004) analysis, making it a crucial reference for examining how bodily conditions shape everyday spatial practices. In particular, home care at an older age can pose challenges (Angus et al., 2005; Martin-Matthews and Torrejón, 2022; McDonald et al., 2019; Milligan, 2009; Tamm, 1999; Taylor et al., 2024). Further, elderly people's subjective perception of care in their own home may result in difficulties, which Jarling et al. (2018) reflect upon, while Dyck et al. (2005) consider the management of bodies and spaces in the homesite of long-term care. The latter is highly relevant to the present analysis.

2.2 Framing the analysis II: care, caring, care work

In the absence of a common definition of caregiving, Hermanns and Mastel-Smith (2012) point to the need for skills, knowledge, time and a relationship with the care recipient. Dobrusskin and Helbrecht (2021) highlight visibility and belonging as key spatial dimensions for developing a sense of well-being among care workers. Then again, the conceptualization of care and time aims to understand the nature of care and home space on a structural level. With a critique on structural circumstances, Gröning (2017) examines the precarious circumstances of elderly care work in Germany today, which often lead to moments of shame and desecration. The challenge arises from the application of industrial notions of productivity to care services, which devalues both societal recognition of care and progress towards gender equality (Fisher and Tronto, 1990; Meier-Gräwe, 2018). Bock and Duden (1977) analysed this issue in one of the earliest works, examining how capitalist principles intertwine economic logics with familial and affective needs. Folbre (1995) extended this analysis by highlighting the economic undervaluation and the paradox this poses for feminist economic theory and policy. Madörin (2006) then argued for an autonomous theory of the care economy, emphasizing its gendered nature and calling for a dedicated analytical framework that integrates unpaid and paid care activities into the core of economic analysis.

To enter the interlinkages of economic logics in German outpatient care and to ultimately conceptualize temporality in elderly home care, this research study incorporates insights from Lefebvre's rhythm analysis. Lefebvre's rhythm analysis demonstrates his interest in the contrast between the capitalist system on the one hand and the daily lives of individuals on the other hand. By interlinking the findings of the rhythm analysis and the experience of austerity in everyday life (Hall, 2018; Hitchen, 2019; Wilkinson and Ortega-Alcazar, 2018) with narratives of gender, we can understand the psychic, emotional and social effects of austerity (Hitchen and Shaw, 2019; Shaw, 2019; Wilkinson and Ortega-Alcazar, 2018).

2.3 Framing the analysis III: rhythm analysis

Lefebvre separates rhythms between the cyclical and the linear, tracing the cyclical back to the cosmic nature: “days, nights, seasons, the waves and tides of the sea, monthly cycles, etc.”, while the linear “would come rather from social practice, therefore from human activity: the monotony of actions and movements, imposed structures” (Lefebvre, 2004:8). Simonsen (2005:8) interprets it as being mechanical, “constrained and colonized by the space of the commodity and the territory of the state; it is the dominant temporality of modernity”. Lefebvre famously states that “Everywhere where there is interaction between a place, a time and an expenditure of energy, there is rhythm” (Lefebvre, 2004:15), which results in the interference between cyclical and linear processes (Lefebvre, 2004:15). The rhythm analysis aims to show the complex tensions which arise from interferences between cyclical and linear rhythms in everyday life (Rau, 2019:13). Lefebvre formulates complementary considerations to do so. He introduces polyrhythmia as the overlap of the multiplicity of rhythms by describing the example of animals and nature, which form a “simultaneity of the present (therefore of presence)” (Lefebvre, 2004:17). In this context, places are seen as “polyrhythmic ensembles” (Crang, 2001:190). Eurhythmia is depicted as the unity or accordance of rhythms “in the state of health, in normal (which is to say normed!) everydayness”, while a discordance or conflict of rhythms is depicted as a pathological state of arrhythmia (Lefebvre, 2004:16). In Lefebvre's understanding, only a few isorhythmias – that is to say rhythmic equalities or equivalences – exist (Lefebvre, 2004:67).

As these provide a valuable concept for understanding the intersection of social and biological rhythms, with the body serving as the point of contact (Elden, 2004:6), researchers must use appropriate methods to explore one's own perceptions of and relationship to the environment, for example, via internal and external perception (Kessler-Kakoulidis, 2019:217). Based on Lefebvre's analysis, Davies (2001) engages with the time space structures of everyday life from an embodied and feminist perspective, thereby providing an important reference point for my analytical approach.

3 Methodical approach

In 2023, I conducted a study with the ethnographic method of shadowing in the rural Altenburger Land, focusing on elderly home carers. Three major home care services enabled the observation of seven different female caregivers during their morning shift, starting at approximately 06:30 LT, and twice during their midday shift, which involved bringing lunch to clients, over a period of 3 weeks. Finally, I accompanied the caregivers to over 50 home visits as each shift covered between 8 and 10 clients. After each day, a daily verbatim record of memories was compiled to ensure the data privacy of individual clients, with a particular focus on the work processes of the outpatient nurses. The mobile method of shadowing allowed me to attend the tight routines of the nurses and to talk with the persons involved wherever possible since shadowing allows one to study the “work and life of people who move often and quickly from place to place” (Czarniawska, 2007:17). Extensive conversations with the nurses were viable during ride-alongs (Kusenbach, 2008) in the nurses' cars between the homes of the clients. Participation in (smoke) breaks and discussions with care managers provided structural insights. The companionship of the nurses through their everyday workday made the paces of the nurses on the one hand and of the clients within the home on the other palpable through the bodily experience of shadowing. The strength of the process lies in the reflexive unveiling of the other body, which bears the ageing person. As Czarniawska (2007:21) points out, an observer may not know better or cannot say more about an actor, but “observers and strangers can see different things”. Beyond seeing things differently, the method made me feel different things. Unlike an interview situation, the temporal aspects of elderly care imposed themselves on me through the very bodily elements of this mode of ethnographic method, enabling a rhythm analysis of care routines. I found myself listening to the physical aspects of my body while shadowing the nurses in their everyday routines, collecting various rhythms besides my own and perceiving and recording in-depth elements of home care. Lefebvre outlines the basic methodological procedures of rhythm analysis “to make one's body into a metronome, hence a special kind of parameter for `listening' to the bodies of others in search of the mutual integration of the outside and the inside of these same bodies” (Frehse, 2019:100). Although each home space, caregiver and client in the data collection had its unique characteristics, I observed similar rhythmic processes. While shadowing is heretofore commonly used in organization studies, it proved to be exceedingly suitable for studying care work in all its dimensions and scales. The aim of this paper is not to conduct a thematic analysis of the qualitative data but rather to leverage key situational data to illustrate how a rhythm-focused approach can reveal critical intersections of temporality, gender and care, ultimately exposing forms of institutional power.

4 Service complexes and its scope

In the following analysis I delve into the rhythms of home care by examining standardized service complexes and their interplay with the temporal and spatial dynamics of caregiving, as well as the embodied experiences of both caregivers and care recipients. Drawing on rhythm analysis, the chapter explores how cyclical and linear rhythms intersect and clash within body (spaces), work processes and home spaces. The chapter ends with the account of digital monitoring and its interconnectedness to the three analysed aspects.

4.1 Assigning the social with standards

This chapter analyses the parameters under which the System of Service Complexes was established. In 1995, the German government introduced the system of service complexes (Leistungskomplexe), which combines nursing and domestic tasks into service packages. Each service complex is valued with points. In the German state of Thuringia, one point is worth EUR 0.0529. The nursing care insurance fund negotiates individually with each care service provider how much time is allocated to execute a service complex. This means that the service complexes ultimately determine how much time is envisaged to spend on each task. Nursing staff therefore find themselves in a tightly knit, highly standardized field of work. The standardization of home care targets three key aspects of care work, facilitating the quantification of routines, processes and outcomes.

Firstly, the service complexes are based on the idea of standardized bodies. Within the German care sector, a system of categorizing the abilities of individuals into five degrees of care needs (Pflegegrad) has been established, which influences the billing of a care service complex. In Thuringia, for example, a small morning or evening toilet for someone with care degree 1 is worth 185 points, which equates to EUR 9.79 and equals around 10 min of work. This indicates that elderly bodies which got allocated to the same care level are constructed as identical in their care needs.

Secondly, highly standardized work cycles are constructed in which time becomes a commodity. While, in nature, according to Lefebvre, time is always perceived in space, it has been replaced by the artificial time of clocks and measuring devices in the social space of modernity that emerged with industrialization, market orientation and the necessary economic calculation (Rau, 2019:11). The care work cycles get constructed and therefore become rationalized around this time measure.

Thirdly, the system of service complexes assumes that elderly people dwell in the same kinds of built environment since similar care practices should be applied in precisely the same time frame. Implicitly, this time frame, which is inherent in the system, draws home as a template which is subject to standardization. Home spaces become homogenized spaces. However, if increased productivity depends on and seemingly enforces strict time discipline, the worker's use of time can only be effective through the proper utilization of space within the workplace (May and Thrift, 2001:4). Contradictorily, while the proposed use of space cannot be guaranteed, the time spent is monitored by technology.

In March 2024, the Act to Accelerate the Digitalisation of the Healthcare System (Digital Act, DigiG) came into force (Section 360 (8) SGB V) in Germany. During the data collection, most of the home care services were already using tablets to record the working time. The German care system thus reveals a Taylorisation of care (Aulenbacher and Dammayr, 2014; Voß and Pongratz, 1998). With the help of technology, the production of care is of course not spatialized in the factory but in the home, whereby it is constructed as repetitive and “optimally” sequenced in a metronome-like manner.

4.2 Observing the outpatient care complex

As described, the establishment of the system of service complexes led me to identify three key issues concerning the spaces and temporalities of everyday home care work. Accordingly, I provide insights into the rhythmic dimensions of affected “body (spaces)” as the temporal disregard of the individuality of bodies and their spatial needs weighs on the performance of care work. Afterwards, I unveil the temporally and spatially challenged organization of “work processes” as care workers strive to synchronize the manifold rhythms they are confronted with. Finally, I illustrate how temporally inscribed “home spaces” transform as care needs of clients increase, becoming sites of rhythmic adaptations and negotiations, where boundaries of privacy are increasingly redefined. The chapter reveals how outpatient care unfolds through complex spatial and temporal entanglements, in which the interplay of bodily, organizational and domestic rhythms becomes a core challenge and the very texture of everyday care work.

4.2.1 Body (spaces)

The rhythm of the body is conditioned by environmental surroundings, such as light, season and weather, as well as bodily needs of sleeping, intimate care and eating (Hägerstrand, 1970). Over time, these cyclical rhythms tailor the living space, enabling each home to create individual biographies of dwelling since “the spatial body's material character derives from space, from the energy that is deployed and put to use there” (Lefebvre, 1991:195). With decreasing mobility and health, as well as decreasing (physiological) energy levels, experiences of place can change drastically, narrowing the range of movement and lowering the tempo of everyday life (Schwanen and Kwan, 2012:2044; Stjernborg et al., 2014). The decisions over one's own pace in old age and bodily routines within everyday life spaces create a harmony, an isorhythm. In contrast, the nurses' shifts start very early in the morning due to the mere number of clients, failing to adapt to the self-chosen routines of the clients. For example, medicine is to be taken at certain times and periodic intervals. As Lager et al. (2016:1572) described, such medication routines can confine individuals to their homes, reducing the chances of coordinating time spent outdoors, especially when given by external caregivers. The daily cyclical rhythms are connected with environmental change that can reduce the sphere of movement and change daily plans.

Starting with the morning toilet and ending with the evening toilet (Leistungskomplexe 1–7) outpatient care builds itself around the everyday life of work life, resulting in nursing shift beginnings of around 06.30 LT, rather than orientating itself based on the routines of the care receivers. It, therefore, often fails to adapt to the individuals receiving care. Almost all of the clients complained about the early hour at which the nurses tend to arrive:

The woman sits on the edge of the bed and mutters that it is too early for her. Her husband is already in the kitchen when we arrive, with his head stuck in his singlet. [The nurse] laughs and helps him get into his singlet. (230320_ABG)

The clients' vulnerability is exposed through their bodies, which are likely to be visible to a different nurse every day. Clients were seldom notified beforehand about which nurse would visit or about the timing of the visit; instead, they had been given an approximate time window. This corresponds with the findings of Jarling et al. (2018:5), who point out that the high staff turnover rate disrupts the continuity of caregiver relationships. Further, their handling of unclothed bodies increases the client's stress levels, which may engender feelings of shame. Policy and institutional practices treat bodies as manageable entities through the implementation of state-disciplined practices. This institutional inscription neutralizes and objectifies bodies, particularly within the context of home care, which is traditionally considered to be a private and feminine sphere and is often deprioritized in political concerns (Dyck et al., 2005:176). Such neutralization becomes problematic when it intersects with the inflexible routines and recruitment challenges of the care system. This presents itself when, for example, older women express their preferences for female caregivers (230418_SLN) and have to deal with the care services' inability to accommodate their desire. The impossibility of predicting not only the time of the nurse's arrival but also the gender of the nurse emphasizes the care systems' objective of a mere maintenance of featureless bodies over the adaptation and reintegration of care into natural, cyclical rhythms as institutional practices. Recognizing individuality would demand a more nuanced approach, acknowledging that individual bodies have unique bodily, as well as temporal, needs. Lefebvre's rhythmic analysis highlights that, while linear rhythms dominate, cyclical rhythms of mental and social functions persist, influencing each other and sometimes causing arrhythmia (Edensor, 2010:14). Since the service complexes exclude characteristics like gender, religion or skin colour, the nurses are not adequately trained to address these aspects. This leads to an overburdening and individualization of struggle for the nurse and a sense of abject misery for the client. In addition to the client's body, the nursing body is not considered by the operating sequences of outpatient care since these are exclusively comprised of care activities and do not allow for the consideration of other factors. The inability of service complexes to adapt to the individual rhythms of the elderly body and its needs results in its perception as solely a sanitary issue, following a depersonalization and objectification of individuals (Gröning, 2017:42). Above all, the tight time frame troubles not only the clients but also the nurses:

[The nurse] says that eating is difficult – she can't get anything down that early [before 6:00] and she often forgets to drink. In winter it's usually too cold, and in summer, when it's over 30 degrees outside, the apple juice provided by the employer starts to boil. On top of that, each drop of water she drinks has `to go somewhere' afterwards, and she doesn't want to go to the toilet at the client's place if she can avoid it. (230320_ABG)

The body's natural rhythms, such as heartbeat and breath, ultimately resist complete subjugation to linear repetition (Potts, 2010:38). Caregivers and care recipients are put into a shared marginalized social status, blaming labour disputes on an individual level, exacerbated by low income and ageism (Timonen and Lolich, 2019:14), reinforced by the dirty work which links the care work with a perception of lack of skill (Toynbee, 2007). The additional devaluation of care work is a critical social function since questioning the low status of caregiving could challenge the gendered power structures.

In conclusion, the intersection of body and rhythm in home care reveals three challenges through the individualization of structural dynamics. Firstly, the disregard of nurses' and clients' bodily, as well as spatial, characteristics individualizes the potentially conflictual nature of interaction. Secondly, the moral imperative of care alludes to individual responsibilities towards elderly clients, and, by that, it likely prevents unionization, labour disputes and strikes. Thirdly, the individualized dynamics of care, coupled with the clash between natural and imposed rhythms, create an environment where the needs of both caregivers and care recipients are often unmet. The impact of imposed specific work process on the body will be presented in the following section, illustrating how the rigorous work processes penetrate the nursing body through meticulous controls of power.

4.2.2 Work processes

The clients would notice if they showed that they have strict time constraints, she explained to me later. They must hurry between the flats, but in the flats themselves they take time to say hello, take off their jackets (inconspicuously), and hang them up. [The nurse] wouldn't need to take her jacket with her because the distances between the car and the flat are short. I often feel out of place with my jacket on – more of a guest than [the nurse] because I radiate “we/I'll be gone again soon – it won't take long”. [The nurse] doesn't. She seems to take a lot of time for everyone individually. (230320_ABG)

Small actions – such as ringing the doorbell before entering the apartment with the provisioned key, switching on the coffee machine or hanging the jacket on the coat rack – reaffirm the clients' role as hosts in charge of their living spaces. Often, sensing a deep solicitude for the clients, I recognized that the nurses feel caught between the longings and needs of elderly clients and the schedule of the service complexes. With small courtesies like taking out the garbage instead of drinking an offered cup of coffee with the elderly person (230320_ABG), they show personal devotion without spending much time. The small actions depict the endeavour towards a unison of rhythms to achieve a swift interaction since the individual environmental and bodily isorhythms do not match the nurses' work shifts. Following Neis et al. (2018:1183), the environmental and employment-related geographical mobility rhythms of home-care workers are “complex, time-consuming, disruptive and costly”, including journeys to work, as well as journeys within work between several home places. The described small acts demonstrate that the nurses attempt to achieve a synchronization or at least a harmonization of rhythms, although taking more time with the execution meant a higher pace on the way between the clients, a rush climbing the flat stairs to the next client's home. At the same time, these small actions signal a resistance against the predetermined time frame and its integral speed. The effects were made visible in one of the meetings of the staff with the care manager:

I read ... that the nursing service and day care are in the red numbers and that an evaluation is to be carried out to find out why and to educate the carers about what services [Leistungskomplex] entail what kind of execution. (230420_SLN)

My data collection confirmed the observation by McDonald et al. (2019:11) that managers empathize with the constant time pressure yet “appear powerless to do anything about it”. The imperative of clarification indicates that the implementation of stipulated care routines is regarded to be a priority over the establishment of trust and the fulfilment of clients' wishes. The effort to achieve a synchronization of rhythms simply allows a service complex to take a bit longer, making the mostly female caregivers, positioned in a low-paid sector and subject to cost-cutting measures, face a dilemma: either reduce the quality of care or put in extra unpaid hours to meet their clients' needs (Dyck et al., 2005:182). Most of them struggle, knowing that the exclusion of emotions from professional caregiving further leads to the brutalization of the profession, privileging market-centred focus that dominates the discourse on care work (Gröning, 2017:109).

Women's underpaid and undervalued positions in the labour market is driven by a moral imperative to care for those who cannot care for themselves (Davies, 2001:139). Davies (2001:139) posits that this moral imperative and its ideological embeddedness to care often lead women to bypass bureaucratic regulations and routines that are predicated on a linear and commodified conception of time. This commodification of care constructs service complexes around bodily tasks while excluding the emotional and mental aspects of care work. Consequently, the rhythmical dynamics of the service complexes underscore the gendered nature of bodywork, where female nurses feel that their professionalism is threatened if they do not adhere to temporal constraints as the time spent on caring words and activities is often devalued as sentimental and unprofessional (Teresa-Morales et al., 2022; Valizadeh et al., 2018). As a result, the caregivers face struggles in aiming to gain control over their time to meet their needs and those of their clients. The need for flexibility within the home space results in a sacrifice of individual routines and expectations (Jarling et al., 2018:5). By dealing with carers who sometimes visit up to 20 clients in a 6 h shift due to the labour shortage, clients have to learn to cope with poorly focused and correspondingly stressed carers by arranging their home spaces accordingly (230320_ABG).

4.2.3 Home spaces

Elderly people in Germany, particularly elderly women, are disproportionately affected by poverty, which limits the diversity and quality of their living spaces. The district of Altenburger Land has the third lowest average gross income in Germany (Diekmann, 2020) and recorded the second-highest migration losses in Thuringia during 2011–2014 (Thüringer Ministerium für Infrastruktur und Landwirtschaft, 2016). Accordingly, most home spaces in Altenburger Land are shaped by low socio-economic circumstances, for example, narrow, cramped apartments. This impacts the nature of home care and the rhythms within these domestic environments. Continuity of bodily tasks in domestic environments shapes home spaces, and these home spaces, in turn, foster a sense of continuity, thus provoking a cyclical rhythm. As previously outlined, home spaces are inextricably linked with the bodily realm, linking feelings and experiences of home with its corporeality (Imrie, 2004; Milligan, 2009). A strong sense of belonging to these home spaces can enhance feelings of agency, autonomy and resilience (Wiles and Coleman, 2024:183). These affective dimensions facilitate the (re)production of place attachments and a profound sense of belonging. The domestic environment is the primary setting for a range of activities related to personal care, including washing, dressing, grooming and preparing for “the world beyond the door” (Imrie, 2004:748), leading Imrie to describe home spaces as a “body zone”. During its biography of dwelling, the body establishes a polyrhythmia with the surrounding environment, the materialities that constitute the home, creating a “simultaneity of the present” (Lefebvre, 2004:17). For example, setting up the care bed in the living room allows the elderly person to engage with the cyclical rhythms of the everyday lives of their relative(s) which once were their own rhythms. This means that care is provided in a setting like the living room, which is designated for other purposes and is closely associated with ideas of family and privacy (Dyck et al., 2005:174). The transition of the home into a workplace with a work schedule oriented on linear rhythms creates a sense of dissonance in the “struggle with accepting care” (Jarling et al., 2018:3). The result may be a blurring of private spaces like the home and public space (Dyck et al., 2005; Milligan and Wiles, 2010; Tamm, 1999; Williams, 2002). The caregiver's rhythm, dictated by external systemic logics, binds the client's body and home space. In this manipulation, I see a complex interplay of power, where the natural, cyclical rhythms of body and home spaces are subordinated to the linear, commodified rhythms of care provision. The nurse's time frame becomes imprinted upon the home space, reflecting the friction between and collision of multiple temporalities. Moreover, a collision of one's sense of time and space can result in situations of vulnerability, as the following observation shows:

He [a client] washes his face with a cloth and defecates on the toilet seat [beside the care bed, in the living room]. (230320_ABG)

The situational description demonstrates a correlation between home spaces, care and the enormous inflexible temporal pressure, which has the effect of two sensitive bodily needs being met simultaneously. It also highlights four crucial aspects: firstly, rather than using the toilet depending on their own needs, the client is forced to rely on the nurse and can only defecate in the manner he has done throughout his life when the caregiver is present. In the absence of the caregiver, the client would be compelled to defecate in an adult diaper while in bed. Thereby, the client is constrained by the time limitations imposed by the caregiver. He adapts his bodily cyclical rhythms to the appearance of the nurse with their linear rhythms. These adaptations indicate how the nurses' routines and rhythms take precedence over the needs of clients and that that adaptation is non-negotiable (Jarling et al., 2018:6). Secondly, the client is accustomed to the situation and displays no signs of shame or discomfort. He does not question the simultaneous defecation and washing. Thirdly, this behaviour is a consequence of the nurse's performance, humanizing and normalizing the clients' bodily needs by establishing an atmosphere of trust. The transition of domestic spaces into a workplace with the work schedule oriented on linear rhythms may give rise to a sense of dissonance in the “struggle with accepting care” (Jarling et al., 2018:3). The nurses, as well as the elderly clients, consequently need time to get accustomed to each other by establishing such an atmosphere of trust. Jarling et al. (2018:7) highlight the importance of trust as a fundamental aspect of a smooth adaptation process, along with the necessity of structural resources and legislation for the establishment of caring relationships. Finally, the domestic environment undergoes a transformation as a result of its utilization. The rooms that have been allocated for specific activities merge into one entity, while the actual bathroom and bedroom cease to bear their traditional functions, altering the biography and sense of continuity of the home spaces.

In the context of continued care for the same client, the nurse noted a change in the placement of the pharmaceuticals. The pharmaceuticals were relocated from the floor in a bag to a chair by a relative. Gratefully, she commented that she no longer had to adopt a crouched position to reach the medicals (230320_ABG). Being with mostly disabled clients, the carers rely heavily on the support of the relatives, who are aware of the time pressures resulting from shift structures based on time rather than tasks (Sims-Gould and Martin-Matthews, 2010). In small tasks, such as putting out the towels, clothing and washing utensils (typically a washbowl, washcloth and soap) in a specific place, relatives can positively impact the quality of direct care by allowing for additional time for the actual caring task and thereby influence specific care dynamics. The nurses, on their end, are obliged to be adaptive to each individual's body and routines and the spatial layouts of homes in general. The sensitive work environment of the client's home spaces creates a primarily uncertain surrounding, given that the client's role used to be that of a host. The body and the home thereby present a paradoxical space, neither public nor private, neither individual nor social. The nurses, together with the clients and their relatives, seek strategies that are inherently spatial to create acts that preserve a social self while also addressing the “care of the body's `private' material limitations and unruliness” (Dyck et al., 2005:181). The inability to determine the duration of the nurse's presence produces a lived space where disparate temporalities collide and interact.

In the event of non-compliance with these temporal demands, the individual may experience feelings of exclusion from life, a sometimes overwhelming sense of chaos, and a lack of a secure place or “home” to rest and be one's true self in order to regain strength: “in essence [the experience of] being homeless” (Hemberg et al., 2019:450) may emerge. The living spaces, with their unique characteristics and personal significance, are reduced to a standardized site of tasks to be completed by the service complexes, thus objectifying the space and stripping it of its individuality. The home-care system, with its schedule, is enforced by (digital) technology, which will be analysed in the following section.

4.3 Temporal culmination in digital technologies

Under the pressure of global competition and the influence of international organizations, issues relating to the quality of education, the financing and organization of care are no longer treated primarily as a socio-political challenge but, above all, as an economic one (Gottschall, 2008:254). Non-profit facilities, which predominated, were placed on an equal footing with private, profit-orientated service providers in 1995². As a result, public cost control and competition triggered an increased focus on efficiency, leaving only a few differences between commercial and non-profit providers (Theobald et al., 2013:31; Ritter, 2024:43). This German system is characterized by a triangular relationship involving public funding bodies (such as social insurances and regional authorities), care institutions (public, non-profit or private) and care recipients (Dunkel, 2011:192). Consequently, service providers must navigate the individual demands of their clients, as well as the bureaucratic requirements set by funding bodies (Dunkel, 2011:192). The contract between client and care providers records which service complexes are to be executed. The care provider is then renumerated by the nursing care insurance fund, which ties each service complex to a negotiated billing of services since each service complex is financially valued with points (see Sect. 4.1). Clients have to partly contribute financially. As described before, the system of service complexes establishes temporal standards, which are also negotiated between the nursing care insurance fund and the care providers. The temporal limit for each client is indicated by the mobile tablet or phone the nurses carry with them. The technical device predefines the linear rhythm and connects the caregiver to the immediate superior of the care service provider and the nursing care insurance fund. Not only the linear rhythm but also the neutralization and objectification of bodies (see Sect. 4.2.1) become foremostly apparent in the technical device since the device only presents the service complex, its task and the time each client gets allocated. The device is used to monitor the exact time which is contractually guaranteed upon. Therefore, it does not ask whether caregivers responded individually and compassionately to the client's bodily needs or if the elderly client's general condition is worsening as ageing and decline are common processes in elderly care and are part of the cyclical rhythm of life. The system of service complexes actively overlooks the embodied care dimensions of affectivity, which encompasses fear, revulsion, anger and the witnessing of human suffering. These disregards, visible in the digital technology, paint a picture of care being simple, mundane tasks, resulting in the lowest possible financial remuneration being offered while strictly supervising the needed time for each task.

The moral imperative to care that nurses feel leads to the bypassing of bureaucratic regulations within care work processes, as also described in Sect. 4.2.2. This becomes clearly discernible in the falsifying of time entries in the devices to cope with these pressures, illustrating the conflict between human care needs and inherently structural constraints which are exercised through digital technology. Not registering their actual procedures into the technical device leads the nurses to tactics of self-managing their work processes, assigning the responsibility of temporal compliance to the nursing individual, making them their own managers with autonomous decision making, just as with 24/7 home carers (Schwiter et al., 2014). The supervising care manager therefore delegates the task of managing interactions and relationships in care through digital technology, effectively transferring its supervising nature into the caregiving environment. This unyielding nature of technology is exemplified in practical scenarios. For instance, a caregiver may be allocated 30 min for bathing a client, with some flexibility if time has been saved in another client's home (230320_ABG). This tension is compounded by the disciplinary potential of digital technology, which can – through the supervision of the care manager – indirectly punish those who do not conform to the regime of clocking in and out (Timonen and Lolich, 2019:15). The self-managing necessitates distinctive flexibility given that care work is an interplay, contingent upon the client's cooperation. The concept of clients and caregivers as co-producers of care (Gittell, 2016) emphasizes the collaborative nature of caregiving. This collaboration aims to establish routines that assist nurses and optimize the care service received (Martin-Matthews and Torrejón, 2022:486). The integration of digital technology in home care reorders and reinscribes the living spaces as a space of care, underpinned by power relations manifested through health care policies and the intertwining of power and specialist knowledge.

As Edensor (2010:9) posits out, technologies routinize sequences of human actions, transforming the fluid, cyclical rhythms of the body and home spaces into linear, regimented schedules. This also introduces an element of precision into the caregiving process, which can lead to various forms of friction and emotional strain. For example, the tight schedule can become problematic for clients with mobility issues, such as those who require a walker and navigate spatial layouts like narrow corridors:

He can only move slowly with his walker. It's a tight walk; the walker barely fits through the door frames, and the path from the living room, which is also his bedroom, to the bathroom is very narrow. (230319_ABG)

The intrinsically intimate character of care within private home spaces eventually blurs the distinction between work time and end of the shift that the digital technology implies. This is because, in home care, nurses often find themselves at odds with the cyclical rhythms of clients, striving to maintain a natural flow that is disrupted by the strict timely demands (see Sect. 4.2.3) transmitted by the technical device. The commodification of care blurs the boundaries between public and private spaces, revealing their problematic relationship (Cox, 2013:492) and the imposition of public, linear rhythms onto the private, cyclical rhythms of clients and their home spaces. Meyer (2008:151) underscores the broader implications of technology-determined life rhythms, noting that such linear rhythms increasingly erase natural time structures. Lefebvre's critique, as discussed by Meyer (2008:151), highlights how capital's rhythm of production and destruction manipulates time, calendars and daily routines, controlling the potential human development of all who serve it. The technical device, seemingly inconspicuous, ultimately inscribes the structural power onto outpatient care work by de-individualizing bodies, work processes, and home spaces and their rhythms through the subjection of time structures. This subordination of life to the rule of the machine – often referred to as “mobilization” – violently subjects caregivers and clients to the rhythm of technology, often at the expense of their emotional and physical well-being, finally resulting in arrhythmia.

5 Conclusion

This article presents an analysis of the rhythms of outpatient elderly care work. In order to achieve this objective, I initially analysed the structure of the service complexes established by the long-term care insurance funds. Subsequently, I examined the impact of these service complexes, which are characterized by a specific rhythm, on the rhythms of the body, work processes and home spaces, as well as their interaction with technology.

The analysis demonstrated that service complexes embody an explicit temporal demand, which exerts power through technology on nursing bodies, impacting work processes in the home spaces of clients. The home space, which traditionally form a polyrhythm with the client's body, is now subject to a duality of functions: it is simultaneously the nurses' workplace and the surface upon which they attempt to achieve the synchronization of rhythms through the implementation of small actions. The explicit temporality dictated by the service complexes is the underlying cause of the inability to achieve a harmonization of rhythms. The nurses' bypassing of regulations is an expression of this failure to gain flexibility. The performance of small actions aimed at fostering trust and a pleasant atmosphere is measured as worthless by policy making.

Conversely, the advent of service complexes has resulted in the objectification and exposure of home spaces and clients' bodies, rendering them vulnerable. All of these factors are shaped by the context of gender. The bodies of the elderly clients and nurses are inscribed with representations of gender, health, ability, race and age. In particular, elderly people and nurses are situated in a similar marginalized position, especially given their status as women in a politically marginalized sphere, namely the home. Specifically, women experience rising feelings of vulnerability and spatial exclusion in the process of ageing (Hille, 1999). Women (nurses) once again perceive a moral imperative to care, which blurs the boundaries between the private and the professional, in contrast to the objectified imperative of the service complexes. The performance of the service complexes is, indeed, ensured by technology, but the work execution within the home is individualized, leaving the emotional and affective aspects of care processes, with their enormous temporal pressure, to the caregivers alone. This illustrates the extent to which care work and elderly people are devalued. In the rhythm analysis, I demonstrate how the absence of rhythmic synchronization results in elderly people feeling like a burden. At present, the cost of home care is considerably less than that of residential care. However, what are the long-term costs associated with an increase in time pressure due to the skills shortage and a profit-driven regime? To what extent are care standards adjustable? By whom? A diffuse form of policy-making power manipulates time and seeks rhythmic compliance, thereby unveiling the limited thinking of the nature of care work and of its financing, definition and remuneration. In conclusion, the work processes in home care reflect broader societal and economic structures that undervalue and marginalize care work. This results in rhythmical dissonances, arrhythmia, “that sooner or later become illness (the pathological state)” (Lefebvre, 2004:20). This illness becomes manifest in a number of ways: firstly, it shows itself within the system in the form of a significant amount of sick leave, part-time work and a rising demand for care workers throughout Germany. Secondly, the lack of time to provide explanations of the specific care work, to foster a sense of trust and to establish clear roles as host or guest can result in feelings of desecration and shame, which can, in turn, lead to forms of violence. Thirdly and most importantly, the time constraints imposed by the service complexes only allow for clients who live nearby as a trip to domiciles that do not align with the scheduled route of other clients is rendered unprofitable. This leaves individuals with care needs in the periphery entirely up to themselves – regional peripheralizations may lead to the marginalization of ageing bodies.

It cannot be emphasized enough that the rhythmic analysis illustrates how neoliberal ideologies and their affective dimension (Anderson, 2015) have diminished the value of care work, thereby endangering the very nature of it. This is achieved through the implementation of a time regime that represents only a partial fragment of the actual care work and through the highly standardized regulation of not only the home spaces but also clients' bodies and nurses' work processes. Austerity politics push the metronome faster and faster into circumstances that may border on physical violence where home care needs are not being met. Given the high emigration rate of the younger population in Altenburger Land, special attention must be paid to the professional home care sector as the baby-boomer generation in Germany reaches an age with an increasing demand for bodily care. As illustrated by Kadowaki et al. (2015), a reduction in home care services has been shown to result in a decline in patients' quality of life. To gain further insight into the gendered power dynamics at play in the invisible temporality and home spaces and to broaden the understanding of violence in home care, it would be beneficial to conduct further research into the imaginative construction of (homogenized) home spaces and time standards in German insurance funds. These insights would shed light on the historical development of service complexes, the reasons for their variability across federal states and their adaptability to changing care needs.

An investigation into these aspects might show how power-laden, gendered processes are embedded within care structures at multiple levels. It would also explore implications for peripheral locations where care-dependent individuals face challenges in accessing home care providers. Such an approach would help uncover systemic inequalities and highlight the implications of spatial and temporal standardization for marginalized groups within the caregiving ecosystem.