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Keywords:

  • discourse analysis;
  • health services research;
  • hospital patients;
  • older people;
  • patient participation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References

Aim and objective.  This study focuses on how older persons’ accounts of participation might be framed and constructed based on their social and historical situatedness.

Background.  The picture emerging from contemporary research tends to portray older people as a group who prefer to leave decisions to the professionals during a hospital stay. Through an approach that sought to contextualise the respondents’ accounts of participation, different features of patient participation became visible.

Design.  The study is based on a postmodern framework using a discursive approach, informed by the works of Foucault and on works that have been developed in line with his main ideas.

Method.  Eighteen individual in-depth interviews with older people (age 80+) were conducted between one to two weeks after discharge from hospital.

Results.  Findings indicate that older people actively position themselves in relation to various discourses at play in the hospital, and display a wide variety of strategies aimed at gaining influence. To the older persons in this study, participation was practised in a subtle and discreet way, as a matter of choosing a good strategy to interact with the personnel. Participation was also seen as a matter of balancing their own needs against the needs of others and as a behaviour that required self-confidence.

Conclusion.  The accounts of patient participation given by the older persons differed from the dominant and taken-for-granted discourse of patient participation as a right.

Relevance to clinical practice.  As the older persons’ understanding and practice of patient participation do not ‘fit’ the contemporary idea of participation, it is in danger of being ignored or overlooked by care-givers as well as by researchers. To identify older patients’ wish to participate, one must actively search for it.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References

Patient participation in hospital care has been discussed in the international research literature since the early 1980s (Cahill 1998). One of the topics under debate is whether older patients desire or are capable of participation to a lesser degree than other patients (Bastiaens et al. 2007, Deber et al. 2007, Levinson et al. 2005, Say et al. 2006, Swinkel & Michell 2008, Wetzels et al. 2004).

Studies of older patients’ participation often adapt an individualistic approach, where participation is seen as shaped by qualities within the older persons themselves. These studies tend to depict older people as not able to participate in decision-making processes because ‘growing older inevitably results in reduced capacity for involvement’ (Dewar 2005, p. 48). Examples of reduced capacity are described as hearing difficulties (Penney & Wellard 2007), mental and physical impairments (Kennelly & Bowling 2001) or lack of knowledge (Wetzels et al. 2004, Belcher et al. 2006). Personal traits are also described as an obstacle to participation as older people feel that it is difficult to state their opinion without the risk of being regarded as impolite (Berg et al. 2005) or distrusting (Belcher et al. 2006). Other researchers have adapted a more interactionistic perspective, where participation is seen as a result of the ways older people interface with professionals. Studies within this perspective have shown that health professionals tend to neglect to include older persons in decision-making about their care (Berg et al. 2005, Jacelon 2002). Poor communication between older persons and professionals is described as a key mechanism causing low levels of participation (Huby et al. 2007, Bentley 2003, Doherty & Doherty 2005, Florin et al. 2006, Tjia et al. 2008, LeClerc et al. 2002). Others have focused on prevailing rationalities as an explanation of low levels of participation among old persons (Sinding & Wierrnikowski 2009, Efraimsson et al. 2004). Although the view that older hospital patients prefer to leave decisions to the professionals is not unanimous, the overall impression, as reflected in a recent review, is that ‘older patients are usually less interested in the decision-making process independent of their health status’ (Longtin et al. 2010, p. 55).

Perceptions of the aged and of patient participation

Researchers approach notions of participation from different epistemological orientations. Throughout the relatively short history of gerontology, theories of ageing have been quite contrasting, from activity theory that stresses the importance of keeping active to adjust to a healthy ageing process, to disengagement theory that promotes an understanding of ageing as a process of re-drawing from earlier activities (Katz 1996). Different focuses in research might be understood as reflecting local ‘schools of thought’ situated within more basic dominant discourses in a society and thus generating different perceptions of older persons and of their ability to participate in health care.

New ways of understanding the actors within health care also go hand in hand with new ways of organising, financing and managing health care. Contemporary understanding of patient participation in modern Western societies is not based on the humanistic aspect or religious discourses that carried the traditional ideals of listening to the patient and heeding the patients’ autonomy. Existing ideas of participation are situated within the discursive frame of liberalism, built on discourses where the individuals’ free choice and legal rights as well as their responsibility for their own health are in focus (Nolan et al. 2007, Rose 2007). This frame constructs participation in a particular way where participation in decision-making becomes not only a legal and ideological right but a precondition in health care.

Notions of patient participation are influenced by our basic notion of power. Thompson (2007, pp. 1308–1309) describes patient participation as ‘a degree of transfer of power from the professional to the patient’. Within a comprehension of power as ‘possessed’, patient participation becomes a matter of ‘giving’ power from professionals to patients. Consequently, researchers focus on how much power patients have been assigned and/or are willing to accept. An alternative understanding of patient participation is adapted in this study. Leaning on Foucault, exercise of power is not ‘a transfer of rights, or power’ (Foucault & Rabinow 1984, p. 540) and thus participation is a question of how power, in a subtle but continuously ongoing way, is shaped and re-shaped in the interaction between the older patient and the professionals. Recognising power as ‘exercised’ rather than ‘possessed’ (Manias & Street 2000, p. 54) implies that power is embedded within discourses of patient participation, constantly not only created by – but also creating – the actors. The older respondents in this study are thus not only understood as passively defined and constructed by health professionals’ practices or by their own features but also as agents actively constituting themselves by both adapting to – and resisting the existing discourses at play.

Aim

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References

The aim of the study was thus to seek insight into how older persons position themselves as participating patients and how ‘the participating self’ of the older persons are constructed within their social, cultural and historical contexts.

Methodology

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References

According to Foucault and Rabinow (1984), contemporary ways of thinking and speaking about aspects of reality within a given field are interconnected and form discourses. Discursive frameworks are created as some understandings are given authority over others that are marginalised. In this way, discourses constitute the existing understandings and practices, in this case of patient participation. Consequently, discursive frameworks both constrain and enable individuals to think and behave in a particular manner. The way older persons constitute themselves as participating patients is thus seen as both a result of the individuals’ life stories as well as of different cultural, social and historical discourses at play continuously shaping ‘the participating self’. Foucault’s notion of the construction of the subject indicates the value of studying the interviews from the point of view of how these texts reflect the participants’ sense of self and statements made by the respondents were seen as mirroring the older respondents’ active constructions of themselves and of the social realities.

Data collection

Data for this study were collected through in-depth interviewing. Older persons, 10 men and eight women, were recruited by nurses at a Norwegian university hospital. The recruitments took part on several surgical and medical wards to promote diversity in experiences. The criteria for inclusion in the study were that the patient was (aged) 80 years or older and was considered by the recruiting nurse to be able to give a conscious informed consent to participate in the study and to take part in an in-depth interview. Patients who were considered by the recruiting nurses to be too physically, mentally and/or cognitively impaired were excluded.

As the time of discharge approached, patients who met the inclusion criteria were given written information about the aim and method of the project and asked to give their permission to be contacted by the researcher one to two weeks after discharge. The project followed the guidelines for research ethics of the Declaration of Helsinki and was approved by the Regional Ethics Committee and the hospital board. Written consent was obtained from the respondents after they had been given written and oral information about the purpose of the study and how data would be used.

The respondents’ ages varied from 80–92 years and their background varied from a housewife to a former director of a large company. The respondents’ levels of education tended to be above average for the age group, for instance only two of the women were former full-time housewives and only four of the men were unskilled workers. The respondents all lived in their homes with spouses or alone and received different degrees of home care. Recruiting patients proved to be difficult. The nurses estimated the refusal rate to be approximately one-third of the patients invited to participate. Patients said that they were too tired and sick at the time of recruitment (one day prior to or on the day of discharge) to consider participation in research. Recruitments were brought to an end when 18 respondents were recruited as this was considered a sample size large enough and the backgrounds of the participants wide enough to provide relevant material for the aims of the research (Nordgren & Fridlund 2001). The fact that a limited number of respondents agreed to be interviewed might imply a selection bias, both in aspects related to health status and sociodemographic factors in the participating respondents. Although different ‘levels’ of education were present in the selection, other combinations of respondents might have given other accounts and thus another main impression.

The 18 in-depth interviews were conducted in the respondents’ own homes by their own choice. As the concept of patient participation might be unknown to some of the respondents, the interviewer gave an introduction in which patient participation was introduced by statements like: ‘being heard, being able to have a say, participating in decisions’. A thematic interview guide was used to focus the interviews on: the respondent’s views and associations on participation both during the actual hospital stay and in general; their thoughts regarding the possibilities available for whether or not they had any influence; and finally, what actions did they or did they not take to exert influence. The interviewer aspired to let respondents speak as freely as possible and to articulate their experiences, perceptions and understandings. Still, acknowledging that we think, act and speak through a variety of different discourses (Foucault 2002) also signifies acknowledging that power affects the interview situation. Discourses related to factors such as age, education and gender will affect how both the researcher and the respondents position themselves throughout the interview and thus contribute in shaping the stories told by the respondents in ways that these are impossible to comprehend and describe fully (Aléx & Hammarström 2008). The same interviewer, a middle-aged female researcher, conducted all interviews. Each interview was audiorecorded to enable the interviewer to focus on the conversation.

Analysis

Works by Foucault and the work of others informed by his work (O’Connor & Payne 2006, Manias & Street 2000, Katz 1996) informed the analysis in this project. Discourse analysis is broadly described by citing O’Connor and Payne (2006, p. 830) as ‘to make explicit and reveal how different discourses in everyday experiences operate in particular contexts’. The respondents’ statements were seen as embedded in discursive frameworks that are historically and socially created and situated. Situating the respondents’ statements was achieved by constructing a link between individual accounts of their hospital stay and the cultural, social and historical discourses. This provided an insight into why some statements are made and others not and as a consequence helped identify the underlying assumptions implicit in the older persons’ account of patient participation. Focusing on how older persons’ accounts of participation are produced directed an analytic focus towards how historically as well as contemporarily located processes enabled and constrained the older respondents’ understanding and practices of participation.

Consequently, the emphasis of the first level of the analysis aimed at identifying the ‘surface layers’ (Manias & Street 2000, p. 58) of the data. In this phase, the researcher sought to disrupt any taken-for-granted views on participation. A main ‘tool’ in this phase was always asking why any particular statement was given and not another. The second phase of analysis sought to identify the dominant – and the competing – discourses at play, trying to identify and understand what mattered to the older respondents. Foucault (2002, p. 329) emphasises different forms of resistance, stating that resistance is present everywhere within power. This inspired an awareness of statements indicating resistance as well as acceptance as part of the construction of the respondents’ accounts of participation. In this final step of the analysis, statements were thus conceptualised by relating subject positions and strategies of subjectification to their social, cultural and historical situatedness.

Findings

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References

During the interviews, the respondents spoke about two main themes: the hospital with the care-givers and themselves as patients. Although these themes were not addressed as separate issues, the findings are presented under two headings to reflect the variations. The statements that exemplify the respondents’ construction of the hospital environment and the carers are presented and explored in the first section, followed by statements related to the construction of the ‘participating self’.

The construction of the hospital and carers

Each interview was initiated by inviting the respondents to share their reflections on having ‘a say’ or ‘being listened to’ during their recent hospital stay. This invitation triggered all respondents to relate stories about the hurried pace of the hospital. Statements like:

I’ve never seen such a swarm of people in white rushing back and forth, but they were really polite and nice. When I think back on the hospital stay, the picture that stands out is a lot of people all sweeping past me on their way to something or somebody. There was no time for nonsense I can tell you. But, they were all very nice and friendly, mind you. (housewife, age 88)

and

Oh, it’s a rush, isn’t it – they really have to hurry all the time, you don’t want to disturb them. (retired male administrator, age 82)

or

Everybody is really helpful; they run all the time. Never in my life have I (ever) seen such a swarm of people dressed in white running back and forth. I was hospitalised once in the 50′s. Back then it was easier to have a chat and you kind of got to know them, but not this time. This has totally changed now and you kind of felt outside everything. (former female shop assistant, age 81)

are all examples of statements describing the ‘kind but busy’ hospital environment and professionals. The statements all carried an understated duality where the professionals are described in a positive manner as helpful, polite and nice, but simultaneously with hints of disapproval; it is difficult to ‘disturb’.

The rounds with many people were also frequently commented on:

When they talk to each other, then I’m completely left out. I can’t hear them either, so you just have to trust them, don’t you. (Retired male factory worker, age 90)

and yet another example:

Oh, the rounds, well … they’ve got all these papers in their hands.... that’s what they look at. I suppose they do their best. I don’t think they actually know what to say until they have looked into the papers. They did ask me something once, but I didn’t get it. I did want to talk, it’s not that I didn’t care, but that morning I didn’t feel well at all so I just said to myself that I had to wait for my daughter and let her talk with them. So I can’t say that it really worried me. No, I can’t complain, that would not be fair. (retired male clerk, age 87)

Trust is vital as a patient. However, the statements were interpreted as showing that the respondents do not see themselves as being in a position where they can choose not to trust the health care system.

The quotations given above are examples of statements that could prompt the conclusion that the hurried pace and the institutionalised structures of a hospital do not leave any room for patient participation and the ‘positive’ comments could be interpreted as examples of how older patients accept the system as it is and just ‘make the best of it’. Therefore, how did the elders portray themselves as participating patients in the hurried pace of a modern, efficient hospital environment?

The construction of the participating self

The respondents all gave statements indicating cautiously prepared strategies aimed at providing an opportunity to be heard. In doing so, they displayed the construction of the participating self through two distinct discourses: the construction of themselves as ‘patients’ and as ‘old’ people. The two are intertwined, as might be illustrated by an older woman who explained that:

The doctor asked me if I had any questions before going home, but before I had the time to reflect on how to phrase my questions so that he would understand me, he was gone. Guess I’m too old and slow? (housewife, age 88)

The statement might imply that the patient constitute herself in this discourse of individual responsibility, taking the ‘blame’ for not getting the information she needed. However, although the respondent portrays herself in this discourse, she also indicates resistance by expressing the last statement as a question to the researcher. The respondent does not assign the responsibility of not getting her questions answered to the hospital professionals, but to her old age. During the interviews, several of the respondents gave statements indicating that their advanced age in itself might be a handicap as a patient:

I believe that it is easier to overlook the opinions of older people, I do not believe they could have said what they did if I had been a younger person. Still, you should be allowed to participate to some extent, because you are the only one who can really know how things are, aren’t you? Furthermore it might also help them sort things out. (retired female dressmaker, age 82)

Both male and female respondents displayed different strategies aimed at gaining influence and some actually described it as a technique:

I’ve learned a technique to negotiate things. You have to find someone who’s at the start of the shift. (retired female librarian, age 92)

or a former managing director who stated that:

I’ve got a pretty good nose. I watch the way they walk and their faces. You have to be on your guard to see when the best time to approach them is, then you might get to talk to them. (retired male administering director, age 82)

One way of understanding these techniques is that they are characterised by not displaying the dominant discourse of seeing participation as a legal right, but rather as an opportunity that depends on how well one ‘plays one’s cards’.

One of the respondents summed up his description of ‘actions to be heard’ during a hospital stay by stating that:

It is my firm belief that when you are dependent on others, you have to know that that’s what you are. (retired male electrician, age 84)

The quotation quite explicitly indicates that some older people subjectify themselves in a discursive frame where being old and dependent is negatively perceived.

Old age is not only a matter of age per se; it is also about belonging to a certain generation. The respondents did not make many comments that directly addressed the idea of participation, but some statements were made about their view on expressing one’s preferences, for example:

Well, you know participation that’s for the younger ones. They are strong and confident; they are able to be heard. My son was hospitalised a while ago and his daughters told me how they had complained to the doctors that they were not satisfied with something. I could never have done that, never. I have always felt it difficult to state my opinion. I believe it has to do with the way you are brought up. One learned to do as one was told. (former housewife, age 85)

One needs confidence to make direct claims and furthermore, confidence is related not only to age but also to a generation. This point is further elaborated through the statement of a male patient:

You see I’m from the time when you carried your hat under your arm [authors note: Norwegian saying symbolising humbleness]. In those days, there was a lot of unemployment and stuff, so you learned to crawl a little and just take it because you had no protection. But I try to appeal to both the doctors and the nurses for help. (retired male factory worker, age 90)

The older generation is socialised into a patient role where participation and co-decision traditionally have been given little attention and where the ‘ideal patient’ was the obedient and passive individual. Additionally, today’s older people were raised during an epoch when the spirit of community was strong. Rebuilding societies after the Second World War built a strong spirit of community. This spirit became visible in statements like:

When I am waiting for the doctor to see me, I’m never impatient, I can wait, you have to appreciate that you’re not the only one, you know. We are all part of a larger community and of course you have to remember that you are not alone at the hospital. (retired male printer, age 87)

Sometimes even the smallest wish was presented as being egocentric:

This time I wanted to be selfish and try to get a bed by the window. Watching the blue sky is so wonderful when you can’t get out. I know, because there have been so many times that I’ve been lying in a bed in the corner and that’s a really depressing place to be. (retired male electrician, age 84)

The quotation indicates that the respondent perceives the notion of participation as stating one’s needs or preferences as being selfish. Furthermore, the discursive frame of participation is identified as based on individualistic/egoistic values that are negatively depicted:

I do the best I can, there are more people than me in need of help. My husband was in a prisoner of war camp for three years during the war [Second World War]. I managed myself and three kids during those three years. We ate a lot of potatoes and mountain cranberries I can tell you. I never asked for anything, but everybody knew and there was a fantastic solidarity... yeah... [pause]. People shared with me whatever they had; we were like members of an invisible union. Today, we probably would have starved to death (laughing). But I never asked for anything and I never complained. (retired female rural postman, age 82)

Despite seeing patient participation as an obvious right, the respondents gave statements indicating that they not only knew the ‘rules of the game’ (the dominant discourses) but also manoeuvred in the discourses with awareness. One older woman stated that:

Of course you would like to participate a bit. However, on the other hand, they are the ones at the hospital who have the rights, aren’t they. (retired female factory worker, age 90)

This statement suggests that the respondent perceives the ‘the rights’ and thus the power to make decisions to be in the institution and position herself accordingly, which leaves her in the traditional patient role as opposed to the role of the user.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References

As illustrated, the immediate responses to the question of participation were statements about the hospital pace. Time is an important condition for (or in this case, against) participation. Time management in hospitals is deeply embedded in the professionals’ discourse (Waterworth 2003) and increasingly so with the escalating emphasis on efficiency embedded in the policy of ‘New Public Management’ (Nolan et al. 2007). Friction arises between the ideal of effectiveness and efficiency and the ideal of holistic care (Hau 2004) and might be one of several reasons why patient participation is described as surrounded by tensions (Nolan et al. 2007), as reflected in the respondents’ statements. However, places are constructed by and construct, specific understandings of the roles of health professionals and older people (Foucault 2003). The understanding of what it means to be a participating patient might be a different one if for instance the respondents were recipients of home care.

The elders’ encounter with the hospital staff might reflect a meeting where the needs of the older people are in conflict with the dominant discourses of hospital efficiency. A central brick in the management-ideology is consumerism. Consumerism, of which the notion of patient participation is part, is not based on trust but rather on distrust, as being a consumer means negotiating a good trade and being able to take your trade elsewhere if you are not satisfied (Nolan et al. 2007). Several of the respondents talked about ‘just having to trust the carers’, statements indicating that the contemporary discourse of consumerism does not seem to be part of the older respondents’ perception – or alternatively an awareness of their dependency and lack of opportunity to ‘take their trade’ elsewhere. This attitude might seem as an uncomplicated ‘trusting behaviour’ and thereby be wrongly interpreted as unwillingness to participate.

Discourses of consumerism emphasise the individuals’ responsibility for their own health and health issues (Hau 2004). The respondents took responsibility and/or ‘blame’ for low levels of participation by relating a passive role with their advanced age. This connection might be interpreted in the light of contemporary understanding of the aged and old age. Katz (1996) describes how the aged individual rather than the social conditions of ageing is problematised and how this has provided the grounds for the label ‘the gerontological web’. Within this discursive frame, older people are not only portrayed as weak and passive, but as a catastrophe. Simultaneously ‘old age’ becomes a factor that divides (Foucault 2002, pp. 26–27) as the aged person is different from ‘the norm’. Discursively constructed norms are not recognised as cultural constructions, but as ‘facts’. Hence, subjects will recognise and construct themselves through the very same discourses and position themselves accordingly. The respondent’s statement of being ‘too old and slow’ is an example of older people constructing themselves as being ‘old and burdensome’ in accordance to contemporary discourses of ageing. Cultural construction of ageing are also examined by Chater (1999). Chater finds that non-compliance (for instance, to participate by referring to being ‘too old and slow’) can be interpreted as a (subtle) way of resisting medical and nursing dominance. Speed (2006) provides a theoretical framework that might shed further light on different available discourses. The patient discourse is indicative of a passive acceptance of being old and dependent and thus having to ‘take whatever you get and be grateful’, whereas the consumer discourse is the negotiated component and allows the person to ‘bend’ the existing understanding of old somewhat, while the survivor discourse arises out of a rejection and challenge of the existing discursive understandings of being old. In this orientation, the person ‘creates a space in which one’s own ‘sense’ of the issue can be made’ (Speed 2006, p. 37). The statements where respondents relate their experiences of not being heard to their age might be understood as positioning oneself in an orientation of both acceptance and resistance. No statements indicated a position as a ‘survivor’, but as the sample was limited, and this does not imply that no such patient exists in the age group.

Examples of how older people recognise themselves as subjects of gerontology could be identified in several statements and provided indications of why the older patients do not simply state their needs and preferences in a direct way like younger patients do. Patient participation is stated as a right by law in a lot of today’s Western societies (Allen 2000). Nevertheless, being situated in a discourse where old people is seen as a burden does not make it natural to ‘state your rights’ of participation, but might rather initiate attempts to exert influence in more strategic and subtle ways.

The older respondents’ notion that participation is not a right might also have other connotations. The notion that it is selfish to state one’s needs suggests that old persons find values embedded in today’s’ patient participation as different from the values of communality mentioned earlier and find patient participation as a discourse perceived to conflict with the values old persons have learned to heed. Bauman (2001) addresses how our modern society of producers and consumers inevitably creates a society characterised by new forms of individualisation. Free market economies support individualism by placing individual interests above the social whole (Browne 2001). People who have lived a long time are able to compare different values and norms in society and thus they are able to identify changing and conflicting discourses; in this case, the discourses might be labelled ‘discourse of individualism’ versus ‘discourse of communality’.

The power of discourse is said to lie in its ability to prescribe and effect socially accepted behaviour or what can be said and what can be thought (Foucault 2002). One of Foucault (2002, p. 281) interests was ‘how the human subjects fit into certain games of truth’. Data indicate that participation as practised by older persons seems to differ from the dominant understandings and practices of patient participation, a finding that parallels the conclusions of a recent study describing older patients’ perspectives as fragmented and invisible (Huby et al. 2007, p. 55). The point is that older persons’ ways of participating become subtle or even invisible in the eyes of someone who expects participation to look a specific way.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References

This study came from one particular epistemological position. There are multiple positions from which we can view reality and the question is not whether one perspective represents the ‘truth’ or not, but rather whether it is fruitful in the sense that it unveils aspects that would otherwise be hidden from view. Data generated through the chosen perspective in this study did not give the impression that older persons do not want to participate. On the contrary, older people actively position themselves in relation to various discourses at play in the hospital and displayed a wide variety of strategies aimed at gaining influence. However, to the older persons in this study, participation was not practised in an outspoken and direct manner, but in a subtle way, not as a (consumer’s) right, but as a (n) (patient’s) opportunity and as a matter of choosing a good strategy in the approaches towards the personnel. Being heard was not seen as a question of securing their individual needs, but rather as a question of balancing their needs against the needs of others. Finally, participation was not seen as a natural ‘way of being’, but rather as a behaviour that required self-confidence. The needs of the older people were often in conflict with the contemporary practices of a modern hospital based on the existing efficiency discourses.

Relevance to clinical practice

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References

Although people of all ages are influenced by the managerial discourses, the respondents’ very strong association between haste and participation might be seen as an indication that older people are especially vulnerable to a reform designed to maximise efficiency.

The subject positions offered the older participating patients through their historical and contemporary situatedness created practices of participation that are different from younger persons’ participation. This study emphasises how important it is for health professionals to not ‘close’ their understanding of participation, but keep an open mind to different practices of participation in different groups of patients. When it concerns older people, patient participation is not necessarily exercised in a direct and outspoken manner, consequently professionals have to actively look for it.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methodology
  6. Findings
  7. Discussion
  8. Conclusion
  9. Relevance to clinical practice
  10. Acknowledgement
  11. Contributions
  12. Conflict of interest
  13. References
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The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing.

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