Trial lecture title: Challenges and strategies when care philosophy and values conflict with rehabilitation practices.
The trial lecture is presented in Norwegian: "Utfordringer og strategier når omsorgsfilosofi og verdigrunnlag kommer i konflikt med praksis i rehabilitering."
The ordinary opponents are:
- First opponent: Professor Helle Wijk, University of Gothenburg
- Second opponent: Professor Arnstein Finset, University of Oslo
- Leader of the evaluation committee: Associate Professor Helene Lundgaard Søberg, OsloMet
The leader of the public defense is Associate Professor Tone Dahl-Mickelsen, Oslo Metropolitan University.
The Main supervisor is Professor Astrid Bergland, OsloMet. The co-supervisors are Associate Professor Jonas Debesay and Associate Professor Asta Bye, OsloMet.
Abstract
The topic of this PhD thesis is patient participation in intermediate care (IC).
The number of older people with multiple and chronic conditions is expected to double by 2035 because of increased life expectancy. In combination with a markedly reduced length of stay in hospitals in Western countries, geriatric patients are particularly vulnerable to suboptimal quality of care.
IC encompasses all services that facilitate the transitions from the hospital environment to the home environment, and the return to functional independence after medical and social dependence.
Patient participation is the cornerstone of IC and this implies that the patient’s needs, goals and capabilities should guide the provision of services. This involves recognizing the person behind the diagnosis, as well as cultivating good relationships with relatives within inclusive organizational environments and cultures.
Despite decades of advocacy geared toward putting the patient at the centre of healthcare, research shows that patient participation is still not part of mainstream practice.
The research-based literature on patient participation within IC and knowledge of IC-related work performed are limited. Thus, the aim of this PhD project was to explore and increase the understanding of the facilitators and barriers of patient participation within IC services.
Methodology
This thesis is informed by a critical realist perspective and employs several qualitative methods, which are described in four published articles.
As a foundation for the empirical data collection, we conducted a concept analysis based on a systematic literature review of patient participation in IC using a method developed by Walker and Avant (2014).
The empirical data collection was conducted between April 2017 and February 2018 in three IC institutions in Oslo, which served the municipal districts in the east, west and north.
The negotiation of patient participation within face-to-face interactions was explored through observations of family meetings in IC (N = 14).
Furthermore, semi-structured interviews with geriatric patients (N = 15), their relatives (N = 12) and healthcare professionals within the interdisciplinary IC teams (N = 18) were conducted to learn about their experiences and preferences.
To enhance the understanding of patient participation in IC, we have considered how individual perspectives are shaped by structures and mechanisms at the organizational and political levels.
Thematic analysis based on Clarke and Brown (2006) was used to analyse the data. We draw on theoretical perspectives on person-centred care, role theory and professional work to enhance our understanding.
Results
Patient participation in IC (article 1) was identified as a dynamic process emphasizing the person as a whole, focusing on the establishment of multiple alliances that facilitate individualized information and knowledge exchange, and ensuring a reciprocal engagement in activities within flexible and interactive/dynamic organizational structures.
The interviews with patients and relatives (article 2) revealed a lack of patient choice in a standardized pathway with a strong emphasis on physical criteria. To enable co-production, the ICs should be guided by a rehabilitation perspective to facilitate mutual engagement.
Patient preferences for voicing their needs vary substantially. Staff need awareness and knowledge of how to motivate patients in activities and promote a good dialogue, while recognizing the contribution of relatives.
Healthcare professionals (article 3) may experience standardized boundaries that prohibit them from using discretion, perceived as a threat to patient participation. Patient participation in IC is shaped by the collaboration between the ICs and the municipal districts.
There is apparently a lack of housing facilities between the home and the nursing home, expressed in the notion of IC used as a storage facility. The family meetings (article 4) may promote patient participation. How we position ourselves, strategically or unintentionally, will influence the room of negotiation.
Patient participation takes place when the family meetings are based on respect and empathy, when the staff restore and elicit patients’ and relatives’ preferences, and there exist alternative outcomes of the meetings. Additionally, the meeting structure, group composition and preparation of the patient-team is of great relevance.
Conclusions
Patient participation in IC implies an important strategy to achieve person-centred care. Although most of the participants profited from their IC stay, patient participation in this context could be delivered in a more empowering way.
There is need to take healthcare professionals working conditions into account to realize empowering patient participation within IC services.
Our findings call for more emphasis on the individualized rehabilitation process by recognizing the value of holistic person-centred care within supportive organizations and healthful cultures. A professional flexibility which allows healthcare providers to break the predefined rules of conduct may empower patients and relatives to be more active contributors in the person-centred process.
The results of this work may inform staff, policy makers and researchers about the complexity of patient participation and increase the awareness of influencing structures such as markets (budgets), bureaucracy (purchaser-provider model), psychology (patient engagement), professionalism (professional discretion) and the force of discursive practices (the medical perspective).
