Pårørendes forhandlinger med sundhedsprofessionelle i forbindelse med ældres akutte indlæggelse

Title: Relatives’ negotiations with health care professionals in relation to older peoples’ acute admission. 

Background: The Danish welfare system has changed over the past few decades, with increased expectations on citizens to take active involvement and personal responsibility. Therefore, access to the Danish welfare services requires strong competencies. For example, when older people are acutely hospitalised and potentially vulnerable, they may need relatives to navigate and negotiate with health care professionals on their behalf. Relatives can experience challenges in meeting the health care system and in the relation with healthcare professionals. This can potentially lead to some relatives being more able to negotiate than others which may contribute to inequality in health.

Aim: This dissertation explores relatives’ negotiations with healthcare professionals and older peoples’ acute admission to the hospital. The dissertation includes three sub-studies examining relatives’ negotiations during three periods of an older person’s acute care pathway. Sub-study one aimed to analyse relatives’ experiences of their interactions with health care professionals prior to the acute hospital admission of the older person to identify elements of importance for relatives’ negotiations with health care professionals. Sub-study two aimed to examine relatives' opportunities and strategies for negotiation with health care professionals during an older person’s acute admission in an emergency department. Sub-study three aimed to analyse relatives’ purposes and strategies for negotiating with health care professionals after the older person’s acute hospital admission.

Methodology: The study is qualitative and theoretically placed within the field of philosophical hermeneutics.

Method: In sub-study one, the data was generated through individual, semi-structured interviews with 17 relatives immediately after the older person was acutely admitted to the hospital. In substudy two, focused ethnography was used to observe the contact between older peoples’ relatives and health care professionals during acute hospital admission. Finally, in sub-study three, individual, semi-structured interviews were conducted with 18 relatives, two to four weeks afterdischarge of the older person. Participants in all sub-studies were included based on the following criteria: 1) Relative to a person more than 75 years of age. 2) Older person admitted to one of two acute medical units in Hospital Sønderjylland between September 2018 and April 2019 with somatic symptoms. 3) Older person’s abode was either the municipality of: Sønderborg, Aabenraa, Tønder, or Haderslev. The empirical material from all three sub-studies was analysed using qualitative content analysis as described by Graneheim and Lundman.

Findings: Sub-study 1: the analysis highlighted four themes influencing the power of a relative’s negotiation; Mandate (whether relatives may speak and act on behalf of the older person), Incentives (the motivation for relatives’ negotiating on behalf of the older person), Capability (relatives’ knowledge and personal resources) and Attitude to action (the degree to which relatives navigate and negotiate on behalf of the older person). These four elements are illustrated graphically in the MICA model. Sub-study 2: The analysis resulted in one main theme; a matter of attitude to action (relatives’ activity level is essential in gaining influence), and three subthemes; frustration in obtaining access (relatives have difficulty gaining access to health care professionals), presenting the case (brief and precise communication from relatives to health care professionals is desirable), and a powerful relationship (relatives’ relation to health care professionals affects negotiation opportunities). Sub-study 3: The analysis resulted in three themes; Braiding strings to make a cord (to create or recreate coherence in the older person’s life), struggling for responsibility placement (negotiations about relatives’ and healthcare professionals' responsibilities), and a twofold agenda (the older person’s and the relatives’ own needs). Findings from sub-study two and three qualified the MICA model, and findings across all three sub-studies generated two different, context-dependent typologies of relatives: the negotiation-potent and the less negotiation-potent relatives. 

Conclusion: Relatives of older acutely hospitalised people negotiate in different ways and have different preconditions for negotiating with the health care professionals inside and outside the hospital context. Relatives' different preconditions for negotiating can be illustrated in the MICA model describing four elements (Mandate, Incentive, Capability and Attitude to action). In the light of Bourdieu’s theoretical concepts, MICA can be understood as a type of capital valuable in the health care system and valuable in strengthening a relative’s negotiation power. The combination of findings from the three sub-studies enabled the construction of two relative typologies, “the negotiation-potent relatives” and “the less negotiation-potent relatives”. Whether relatives are more or less negotiation potent is influenced by the individual relatives’ personal history, actual preconditions and the political, organisational, and interpersonal context.