Patients’ participation in decision-making in the medical field – ‘projectification’ of patients in a neoliberal framed healthcare system

This article focuses on patients’ participation in decision-making in meetings with healthcare professionals in a healthcare system, based on neoliberal regulations and ideas.Drawing on two constructed empirical cases, primarily from the perspective of patients, this article analyses and discusses the clinical practice around decision-making meetings within a Foucauldian perspective. Patients’ participation in decision-making can be seen as an offshoot of respect for patient autonomy. A treatment must be chosen, when patients consult physicians. From the perspective of patients, there is a tendency for healthcare professionals to supply the patients with the information that they think are necessary for them to make their own decision. But patients do not always want to be a ‘customer’ in the healthcare system; they want to be a patient, consulting an expert for help and advice,which creates resistance to some parts of the decision-making process. Both professionals and patients are subject to the structural frame of the medical field, formed of both neoliberal framework and medical logic. The decision-making competence in relation to the choice of treatment is placed away from the professionals and seen as belonging to the patient. A‘projectification’ of the patient occurs, whereby the patient becomes responsible for his/her choices in treatment and care and the professionals support him/her with knowledge, preferences, and alternative views, out of which he/she must make his/her own choices, and the responsibility for those choices now and in the future. At the same time, there is a tendency towards de-professionalization. In that light, participation of patients in decision-making can be regarded as a tacit governmentality strategy that shapes the location of responsibility between individual and society, and independent patients and healthcare professionals, despite the basically desirable, appropriate, and necessary idea of involving patients in their own situations from a humanistic perspective

Raising the question of dignity through knowledge about tacit practices and politics: sharing learning from the Norwegian welfare state

The focus of this special issue is some of the main tacit policies and practices in the Norwegian welfare state. By looking at what is tacit, mute, unarticulated and neglected we will contribute to raising and presenting knowledge about the social and ethical question of dignity in welfare. This introductory article will first give a short overview of the historical background of the Norwegian welfare state and some of its current features. This will be followed by our positioning of the Norwegian welfare state as situated within complex practices, political discourses and dimensions that might be characterised as tacit, implicit or unarticulated. The article aims to discuss the concept of dignity in welfare services, at the individual and structural level, by asking ‘what kind of practices and structural conditions preserve dignity and where might dignity be violated, ignored or left out?’The various articles in this special issue of the International Practice Development Journal illuminate what can be said and what is mute and tacit in different ways, and consider a range of practice-based responses. By revealing tacit dimensions in the Norwegian welfare this issue offers important insight into practices and discourses where dignity is at stake. It is a requirement of us all that we revisit dignity and its location and representation in our health systems to ensure it is not left behind as the state and other systems within it evolve.publishedVersio

Facilitation of a workplace learning intervention in a fluctuating context: An ethnographic, participatory research project in a nursing home in Norway

Background: This single-site nursing home study is part of a larger cluster-randomised controlled trial that aimed to reduce staff use of restraint. The cluster-RCT study involved 24 nursing homes, and investigated the effect of a standardised education intervention to reduce restraint in dementia care with a person-centred care approach. This article draws on empirical data from one of the nursing homes in the control group of the trial, at which the education intervention was tailored to better account for contextual circumstances. Aim: To explore how a tailored education intervention can reduce the use of restraint in a nursing home. The study aims to investigate what local contextual circumstances influenced the process of facilitation of the intervention. Methods: The study was theoretically informed by the Promoting Action Research Implementation in Health Services (PARiHS) framework, with practice development principles to address local learning needs and contextual issues. External facilitators tailored the education intervention in collaboration with the nursing home leader and staff. A participatory design with data collection based on principles of critical ethnography was used to evaluate the intervention. Results: Fluctuation emerged as the core theme from the evaluation: fluctuating enthusiasm among staff, fluctuating nursing home culture and fluctuating responses by care home residents. Conclusion: The study offers insights into the interplay between a tailored facilitation intervention and fluctuating contextual circumstances in a nursing home. Implications for practice: A successful education intervention requires facilitators who can take into consideration and adapt to fluctuations in the context Facilitation skills must include the ability to value team experiences, recognise learning needs, provide feedback and participate in finding solutions in the moment Flexibility is important in terms of how new knowledge can be used in person-centred ways, notably in attempts to reduce the use of restraint in dementia care8pubpub2 [Article: 4

Dagliglivet i en psykiatrisk institusjon: En analyse av miljøterapeutiske praksiser

This thesis is a cross-disciplinary ethnographic study of milieu therapy and daily life in two closed psychiatric wards in a psychiatric hospital in Norway, where staff and patients were informants. The study is the result of research collaboration between a University College and a psychiatric hospital. We have described two psychiatric wards milieu therapeutic practices by observing interaction, tasks and events. The milieu therapeutic practices and daily life are analyzed in the light of the national policy and milieu therapeutic ideologies. The study is based on an ethnographic qualitative design which includes participant observation, formal and informal interviews and as well as focus group interviews. The thesis is anchored in social constructivism by interaction theories represented by Erving Goffman, and analytical frameworks represented by Michel Foucault and Dorothy E. Smith. We have pointed out that the medical research ethics tradition and its guidelines are based on the notion of the vulnerability of psychiatric patients as a participant group. These guidelines rub uneasily against participant observation and the ethnographic understanding of the research process. The thesis has further illuminated how staff and patients are caught up in paradoxes due to contradictory frames. Firstly, we have reported that there is a tension between efforts of socializing and normalizing patients for daily life inside the hospital and daily life outside the hospital. Daily life living inside the hospital through participation in activities is of another kind than daily life living outside the hospital, and therefore what patients learn inside might not be useful for life outside. Secondly, we have illuminated contradictions between milieu therapy as a democratic tradition and the psychiatric hospital as a medical hierarchical institution. User participation and milieu therapeutic democratic principles played a minor role in daily life organization. Thirdly, we have reported that the wards' milieu therapy was neither institutionalized in a formal way nor systematically consistent in praxis and seemed to play a supporting role to the medical treatment. The thesis concludes that it is necessary to examine further alternative ways to organize institutional life, which is in line with patients' experiences and perspectives as well as in line with the staffs humanistic ideals

Etik i kvalitativ og kolloborativ forskning – fordringer for forskere, medforskere og andre sundhedsprofessionelle

Ethics is always at stake in qualitative health and nursing research. The article examines and discusses research ethical dilemmas in qualitative health research, with a special focus on collaborative research. Firstly, the article discusses challenges with gatekeepers influencing the recruitment of informants when planning and executing interviews and participant observations. Secondly, the article discusses ethical challenges that arise in collaborative research when following research ethical guidelines such as obtaining informed consent, ensuring anonymization and not least complying with integrity in research. In qualitative health research, ethics must be understood as relational, processual, and situational and as such ethical dilemmas must be solved as the research proceeds. Therefore, research ethical issues and dilemmas must be solved ‘on the spot’ and not only at the desktop before the research project begins

The articulation of impressions An interview with Kari Martinsen

About Kari Martinsen Kari Martinsen is a psychiatric nurse and has a masters degree in philosophy and a PhD in history. She is currently Professor Emerita at the University of Tromsø and VID Specialized University, Bergen Campus. Martinsen has worked at the University of Bergen and University of Tromsø in Norway, and Aarhus University in Denmark. At Aarhus, she and fellow colleagues developed and started the masters and PhD programmes in nursing science in the early 1990s. Her academic thinking has been shaped and expressed in the academic settings she has been associated with and collaborated with, such as the Danish theological research group associated with K.E. Løgstrup’s thinking, a Nordic network of research on diaconal history, research on nursing, and not least a group working with M. Foucault’s thinking and texts. Martinsen’s authorship embraces phenomenology, ethics and social history. Currently she is working with architecture, philosophy of sensing and the sacred (Løgstrup) in relation to heterotopic spaces and traditions of asceticism (Foucault). Martinsen’s style of writing is essay-like, explorative, wondering and unhurried. She has written several books and article

'Keeping up appearances' - Negotiating identities of being fit in older age: A multi-site ethnographic study of daily life in contemporary day centres

Abstract As governments adapt to ‘active ageing’ policies, care services are increasingly oriented towards helping older adults to stay active in order to maintain their physiological and cognitive capacity. Day centres for the frail old adults are adding more planned activities to their conventional social programmes. Although evidence indicates that they may benefit from physical fitness sessions and brain training, little is known about the way in which the activation agenda influences social interaction among participants. The article aims to fill this knowledge gap by exploring how staff and participants manoeuvre between the new activation agenda and processes of coming to terms with the functional decline of ageing bodies. We draw on ethnographic data, collected in four day centres in Denmark and Norway, constituting participant observation of 18 days, 19 interviews with older participants and 18 interviews with staff members. With reference to the dramaturgical approach of Erving Goffman, we demonstrate how different fitness identities are negotiated on different social stages. Firstly, we identify a social stage at a crossroad between staff acting as motivators in training sessions and older participants as active contributors. We demonstrate how day-care staff assist participants in keeping up appearances as fit for one’s age by recognising their performance and concealing flawed performances. Secondly, we identify a social stage where participants socialise with co-participants around the lunch table and other social events. Here the act of ‘keeping up appearances’ turns into a complex art whereby people strive to retain their fitness identity by comparing themselves with peers. Finally, based on observation ‘backstage’, we reveal how participants distance themselves from the functional decline of old age by claiming that they are fit enough. We conclude that day centres are contested sites for active-ageing policies