During the Past Decade the Hospital Sector Has Been Affected by Numerous Changes Within
International Labour Process Conference
6-8 April, 2009
«Work Matters»
Stream 2: Service Work in Hospitality and Care Industries
Authors:
Christelle Havard, ESC Dijon Bourgogne, CEREN
Email:
Christine Naschberger, AudenciaNantesSchool of Management, Centre for the Development of Competencies
Email:
Title :
“Changes of behaviours and statutes of the user-patient within French hospitals: which effects on work and on social dialogue?”
Key words:
PublicHospital – User-Patient –Nursing Staff –Work – Social Dialogue – Triangulation – Social Regulation
Abstract :
During the last decade, the French hospital sector hasbeen affected by many changes within their organisational configuration, their management system or their mode of governance (for example the institutionalization of the representation of the user-patient). Notably, the place and the role of these user-patients have been significantly redefined and contributed to transform certain methods of the work of hospital staffs. The aim of this paper is firstly to describe the increasing influence of the user-patient and its effects on the nature of work of nurse staffs and the consequences for social dialogue within a hospital and secondly to propose a theoretical framework to analyse these phenomena.
1
Introduction
During the past decade the French hospital sectorhas been affected by numerous changeswithin its organisation (the services are split into different medical units, certain logistic activities are outsourced), within their system of management (quality assurance, certification process, introduction of accountancy review procedures, etc) orwithin their mode of governance (patient representation is institutionalised) (Minvielle, 1999). These changes have been justified by the wish for greater economic efficiency (LloydSeifert, R. 1995) and also by the desire to provide improved medical carefor recipients, or rather‘user-patients’[2], according to the terminology adopted by different hospital parties (see also the case of New Public Sector Management in the UK published by Bolton, 2004). These user-patients are in fact seen as claiming greater recognition provided by the law and regulations (Amar & Minvielle, 2000; Mossé2001; Guillaume-Hofnung, 2003, Lopez & Remy, 2007). The patient’s right was gradually established and became officially recognised mainly by the hospitalised patient Charter (Castel, 2005).
These different changes have been the subject of numerous studies (Claveranne, 2003. Molinié, 2005; Mossé 2001), but rare are those studies which have presented them as changes designed for the attention of user-patients (Gasquet 1999,Sainsaulieu, 2005, Pierron, 2007). Today the user-patient exerts a growing influence in French hospitals boththrough his behaviour concerning hospital staff as well as through his representation within hospital management. This increasing influence is likely to affect the working practices of hospital staff (Acker, 2005), particularly nursing staff who are the most exposed to direct contact with user patients and their entourage. User-patient representation on the hospital board can also modify decision-making in the hospital, especially decisions concerning the rules of human resources management which are negotiated in the framework of bilateral social bargaining.In this paper we wish to examine to what degree this increasing user-patient influence affects the work of hospital staff and social dialogue[3] within the hospital.
Our analysis is based on a literature review and on an in-depth study carried out in a French hospital (Havard, Naschberger, Sobczak, 2006). This investigative survey (see box 1) and the associated literature review concerning hospitals enables us to show in the first part how certain working methods of nursing staff are affected by the changing behaviour and expectations of the user-patients that they are in direct contact with. Secondly we show how bilateral socialdialogue between management and staff representatives has today remained relatively unchanged by the new presence of user-patient representativeswithin hospital management. These first findings lead us to reflect on the ways of analysing these phenomena, which are set out in the third part. We therefore put forward a framework in which we can analyse the way in which the growing presence of the user-patient contributes to a triangulation of working relations within the hospital and how this triangulation can be regulated.
Box 1 : Presentation of the investigative study and methodology
The study was carried out in July 2005 at a French university hospital.
Ten two hour structured interviews were conducted individually and collectively amongst a sample of people representing the hospital management, user-patients and hospital staff. We then met with two representatives from human resources management, a director of regulations and of user-patients, a director and head of nursing staff, two nursing professionals (a nurse and nursing auxilliary), three user-patient representatives and four employee union representatives. As our sample was on a reduced scale, we chose to interview only those people who had regular and close contact with user-patients, those being the nursing staff. Other occupational groups like the medical body has often been the subject of studies (particularly concerning the sociology of professions - see Castel 2005) and is less in direct contact with user-patients and their entourage.
These interviews questioned participants on their views of the changes carried out in the hospital, especially on the awareness of the user-patient and on the development of patient behaviour, on the quality and accreditation process, on the changes of organisational structure, on working conditions and methods of social bargaining. All the interviews were recorded and were the subject of a content analysis. The study is also based on an analysis of internal documents provided by the hospital.
1 – CHANGES IN THE WORKOF NURSING STAFF
During the last ten years the behaviour of user-patients within hospitals has changed (1.1). They are better represented, better informed and they express their expectations more freely concerning hospital services. In coherence with a changing society, the aggressive behaviour of user-patients or their entourage has become more pronounced. These changes in behaviour have led to a significant transformation of the working practices of nursing staff and their work has been put under pressure (1.2).
1.1.The changing behaviour of user-patients
Different opinions collected during this investigation and numerous other studies (Castel, 2005) show how user-patient behaviour has changed. As they are better informed they are more demanding with hospital staff and express their expectations more readily. User-patient behaviour and that of their entourage (e.g. family) has become more violent. This behaviour can be observed at all levels of patient care – such as at accident and emergency, reception etc.
The user-patient is better informed of his rights, as this user-patient representative states : “I think that thepatientnow knows his rights.” This change in user-patient behaviour can be explained by the implementation of the patient Charter[4], especially the law of 4 March 2002 which made the health system become democratic. This law allowed patient's access to his medical record.As this user-patient representative claims : “I don’t think the law has gone unnoticed such aswhen asking for a medical file and things like that. I think that the patient tries to become better informed. There are ways like the Internet etc. People look for information a lot more than before” (user-patients representative).
In fact during the last 10 years access to information has been facilitated by the widespread distribution of information and the use of new technologies(specialist medical reviews, hospital ratings in the press, the Internet,Blogs, Forums, etc) (Ghadi & Naiditch, 2001). But patient associations (see below) equally play a role by inciting user-patients to demand for information. As this user-patient representative explains :
“As a hospital visitor[5] I know that if a patient tells me ‘I didn’t have this, I didn’t have that’, I tell him ‘well listen, just say it! You know you have a health questionnaire. If you don’t understand it, ask again.’ ”
User-patients are better informed and educated and have more demanding expectations for information concerning the state of their health and the treatment given.
“Users now want to be better informed of the diagnosis, treatment and conditions. More and more they want to know the consequences that their pathology will have on their lives. They expect a type of prognosis.” (supervisor) .
This development also reflects new types of behaviour which are evolving outside the hospital environment inthe society itself. The user-patients are more able to understand information provided by hospital staff. They grant themselves the right to contest a medical diagnosis, as well as the way in which they are treated in the hospital process. As they are better informed they are therefore more demanding.
“The users are more aware of their rights, so automatically they are all the more demanding” (user-patient representative).
“They ask for more, they demand more. They perhaps demand more rights which they knowbetter, so I think they express them” (nursing staff).
This conveys a profound change in hospital staff relations. They used to be submissive towards hospital experts and passive. But now the user-patient exercises his rights for quality care and satisfaction of requests. He has become more active in the service relationship with care providers. “The patient, now better informed, no longer receives care passively. He can talk about it and negotiate it, thus making the delivery of this care more difficult for the professionals” (Douguet, Munoz, Leboul, 2005, p.12).
“6 or 7 years ago the patient was submissive, he was there like a vegetable, he didn’t give his opinion, he was afraid, he regarded doctors as irreproachable. Whereas now the patient knows that he is a participant. He has the right to ask. And if he doesn’t agree and doesn’t want a certain medicine, he can refuse. He can even refuse treatment” (user-patients representative).
Hospital staff now have to justify themselves to user-patients. They have to produce results.
As this nursing supervisor explains, the nursing staff “are now used to patients filling in questionnaires. They are used to dealing with letters of complaint. Therefore they sometimes feel that, as soon as a patient writes, they will of course be asked to justify themselves”.
This possibility to complain about performance results is facilitated by the procedures for filing complaints used by the user-patient management of the hospital and by legal proceedings. Since 2002,the law has given new opportunities to user-patients to complain.And the Commitee for user relations and for quality of medical care (CRUQPEC) has the aim of helping, guiding and informing all those who deem themselves to be victims of prejudice within the hospital.
Moreover, the hospital environment, like other public services, is confronted with an increase in aggressive, even violent behaviour among user-patients (Michel & Thirion, 1996; Mauranges, 2001; Loriol, 2003). This aggression has been denounced by several people interviewed during the study (representatives of management and nursing staff).
“There is aggression, particularly in certain services such as emergency” (personnel representative).
“I think that it is becoming more and more violent compared to ten years ago and it’s not getting any better” (management).
Measures have been taken by our surveyed hospital to protect staff (for example emergency technical and human safety devices and training sessions aimed at dealing with violent situations). However hospital parties have in some respects resigned themselves to this increasing violence which affects society as a whole.
“Behaviour found outside is found inside hospitals. Those who are violent outside are not going to calm down in a hospital!” (staff representative).
“In spite of everything that is set up such as security teams, everyone is screened on entry. But in spite of all that there is serious violence ... As violence has entered the school, it has also entered the hospital. It’s a phenomenon of society”(management).
According to remarks made by hospital staff who were interviewed, the new behaviour of user patients who are better informed, more demanding and sometimes more aggressive has an effect on the nature and methods of the work of nursing staff.
1.2The effects on the work of nursing staff
The more demanding (even consumer-like) attitudes of user-patients have significantly changed the nature of the work of nursing staff and calls for new behaviour, as this nursing manager states :
“Patients express their expectations more but of course it obviously isn’t easy to manage” (supervisor).
The work of nursing staff (but also all hospital personnel) is subject to a greater uncertainty due to the more demanding attitude of user-patients (Allen, 2001). As Sainsaulieu states (2006, p.79), “the patient is a source of limitless unpredictability. He changes beds or wards, his state of health changes (ill or not, seriously or not), he changes his mood or attitude from demand to need.” This unpredictable nature of working with the user-patient (Raveyre & Ughetto, 2003) is accentuated by the increasing turnover of user-patients whose length of stay is gradually decreasing (mainly due to cost-cutting) (Acker, 2005)
“We are in a hazardous profession (....). You never know what to expect each day especially in places where there is a very fast patient turnover” (supervisor).
Hospital professions are also marked by a relative uncertainty due to people coming in from externally, i.e. user-patients and their entourage. We can see that a health care establishment is confronted with a multiplicity of heterogeneous parties.The hospital is open to society which makes the running of it fairly uncertain and unpredictable.
“We have many different types of people here to deal with - we have those who work, families, patients – it’s a lot!(...) A lot of things happen and we must be very reactive”(management).
The presence of the user-patient in the hospital has always shown itself in the work of hospital staff by the relations formed between them and the user-patients (Goffman, 1961). But today it is taking on a growing importance in the eyes of the staff due to increasing patient demands, and also in the eyes of the user-patient representatives.
“With my colleagues in psychiatry we spend most of our seven and a half hour a day with patients.They are always present, with demands and the like. But I would say that we spend more than 75% of our time with patients” (nursing staff).
“Since there has been the obligation to inform and all that, there needs to be more listening” (user-patient representative).
This relationship with user-patients ranges from a simple discussion to a very close relationship between the user-patient and the care personnel.
“The staff speak all the time about the psychological support they give to patients, especially the nurses, but it isn’t them who give the most. It is more often the auxiliary nurses who speak with them when they are in their rooms making their beds” (management).
“I would describe it as a very close relationship. When you care for them, you are intimate with them such as when you wash them, do dressings and shave them. I would call it a very personal relationship because we are close physically, we are really close to them” (supervisor).
This close relationship between user-patient and nursingstaff responds to the growing need for explanations expressed by the user-patients. It also responds to their desire for more personalised treatment (in terms of care but also material comfort).
This activity also corresponds to strong expectations from nursing staff (Acker, 2005).
“The nursing staff area link between the doctor and the patient. We explain the pathology, the tests, why he is in pain and we reassure the patient.... This is because doctors and managers speak in a language that patients and families don’t understand. We are in between.” (nursing staff).
This relationship with the user-patient is at the heart of the nursing profession (Raveyre & Ughetto, 2003, Acker, 2005; Douguet, Munoz, Leboul, 2005) and is often considered by the staff as good for their image - as this nurse emphasizes :
“What I like about this job is that along with the care given we are always close to the patient.”
However this relationship aspect regretfully takes second place according to the remarks of the nursing staff and user-patients :
“The nurse goes into the rooms very quickly. She needs to update patient records so she spends less time with them. The psychological support given to the patient is not as good as it used to be. Today the staff are trained in that....They are trained but they don’t have the time” (management).
“Taking overall charge of the patient and being a good listener, that’s what it’s about. But for example in psychiatry we give out medicine to 25 patients in single file” (nursing staff).