Exit, voice and loyalty in everyday home care practice for older adults: Using a telephone diary method

Older adults are often portrayed as unwilling or unable to address quality issues in the formal care they receive. This study explores a methodology that captures the everyday reactions of older care users to quality problems, offering a nuanced understanding of their voice and agency when dissatisfied with care services. Using a telephone diary method, eight care users were contacted twice a week over three weeks to discuss the services they had received in recent days. The data, comprising 45 interviews, were analyzed using Hirschman's exit, voice, loyalty framework to identify strategies employed by care users. Four strategies were identified: (1) everyday voice, involving reminders and complaints to staff and managers; (2) temporary exits, where users avoided unpleasant situations, sometimes as a signal to the organization; (3) renegotiation of needs, involving communication with needs assessors to revise service decisions; and (4) silence, motivated by loyalty, resignation, or fear of being labeled a "problematic" care user. The findings highlight that care users employ various strategies to improve service quality, many of which might not surface during single-occasion interviews. Recognizing these strategies, care providers should enhance communication channels to address concerns. Addressing the fear of being labeled as problematic is essential, as it risks silencing crucial feedback. This study advocates for reinterpreting expressions of dissatisfaction as efforts to uphold older adults' human rights as rights-holders, reframing voice activities as a pathway to quality improvements.