Transcript Slide 1

Meaning-Making in the
Work of Patient Advocates
Emily Heaphy
May Meaning Meeting
March 31, 2007
Overview
Patient Advocates: Who & Why
Research Question
Research Design and Analysis
Meaning-Making Themes
Theoretical Import
Help from you!
Who are Patient Advocates?
Employed by the hospital
Job Title
Ombuds, patient advocate, patient
representative, guest relations, patient
relations
Typical Complaints
Rude staff, coordination, pain medication
Education
High school to masters
Characteristics of the Work
• Negotiation
• Mediation
Relational
Emotional
Ambiguous
• Communication
• Customer Service
SHCA Professional Association
• Angry family members
• Careseekers’ needs
• Sad patients
• Profession
• Defensive hospital staff
• Loyalties
Why patient advocates?
Insights into studying agency in
organizations
Social Skill (Fligstein, 1997)
Basis of social skill is ability to relate to the
situation of the other
– Versus self-interested actors
Definition: Motivate cooperation in others by
finding common meanings and identities
– E.g., framing, agenda setting
Theoretical context: New institutional theory
Research Questions
How do patient advocates’ make
meaning for self and others?
Data
What do these meaning-making
themes reveal about accomplishing
work?
Theoretical play-time
Questions for you
Do categories of meaning-making
make sense to you?
What do these categories unlock in
terms of agency and accomplishing
work?
What additional theories make sense
to understand this data?
Methods
Cultural/Professional/Institutional Context
Conference
ParticipantObservation
Background
Interviews
Veterans Health
Administration
Individual
Interviews
PA
Shadowing
Work Practice
Documents
Teaching Hospitals
Individual
Interviews
PA
Shadowing
Work Practice
Methods
Cultural/Professional/Institutional Context
Veterans Health
Administration
Individual
Interviews
PA
Work Practice
Teaching Hospitals
Individual
Interviews
PA
Work Practice
Interviews
Sample
Goal:
Interview
Description
24 women
7 men
24 White
7 AfricanAmerican
Individual
Interviews
Understand
patient
advocates’
work practice,
including the
body
Setting:
1-on-1
interviews in
offices
(4
via phone)
31 interviews
19
tertiary
hospitals
Length:
• 45 min. - 3 hours
7 VA
12 Teaching
• Additional informal
conversation, meals,
facility tours
Interviews
Interview content
Background: Career path, typical day
Stories about handling cases
Effective, challenged, ambiguous
Examples of role responsibilities
Taped and transcribed
Wrote field notes after interview & visit
Current Analysis
Data management
Unit of analysis:
Stories about handling cases
Reducing stories to 1-page format
Analytic questions
How do patient advocates make meaning for
self and others?
Moving towards theory development via
coding, memoing, discussions
Meaning-Making Themes
Discernment
Perspective-taking
Co-constructing survivors’ grief
narratives
Meaning-making themes
Discernment
Perspective-taking
Co-constructing grief narratives
Theme 1: Discernment
Defined:
Finding core meaning(s) in others’ stories
Often muddled and contradictory
A process of meaning-making over time
Co-constructing meaning
Discernment
Sorting emotional cues
Creating relational moment for
re-narration
Channeling information for
appropriate meaning-making
Sorting emotional cues
Excerpt of Story #52
Yesterday, at 10 after 4, I had a patient that
both [my coworker] and I know call, leave me a
message, an angry message. I tried to call him back,
he...the line was busy…I called him right up until
4:30, and I couldn’t get through. And then, I’m
looking up...because..he was ranting on the phone,
so you’re trying to figure out, “Okay, what did he
say?”
Because you can’t understand him?
Well, I could understand him physically,
but it wasn’t making sense. He was so angry….
Creating relational moment
for re-narration
Excerpt of Story #28
I’ll have a veteran come in sometimes. It’s
amazing…and they might be out of the service 50
years, married 50 years, and they have some
emotional issues that are coming out, and all of a
sudden, I’ll ask the right question, and they’ll
just burst into tears. And the wife will be sitting
there, and they’ve never shared whatever it is. The
wife had no clue...because they did not share that
information with their families. And I hear this a
lot...they have post traumatic stress disorder,
or they have some kind of an issue that is
eating at them, and they’ve never shared it.
Time after time, patient’s wives will come in and, “I
never knew that.” You know, you’ve been married
to someone 50 years…
Channeling information
for appropriate meaning-making
Excerpt of Story #41
I got a letter from a mother, out West, that
has a son here that’s under the
guardianship of a father, and she was
concerned the father wasn’t doing a very
good job, and the other side of the story
is, the mother hasn’t seen her son in
years, and only talks to him once a month.
And she’s getting the side of the son who’s
not really capable of giving her full
information. But I made sure that letter
Appropriate
went to both the psychiatrist and their
mean-makers doctor. So I mean, whether it’s factual
or not, it’s up to the doctor to decide.
Meaning-making themes
Discernment
Sorting
emotional
cues
Creating
relational
moment for
re-narration
Channeling
information
for approp.
M-M
Theme 2: Perspective-taking
Empathy
Holding multiple perspectives on a
case
Creating perspective-taking in others
“Imaginative” perspective-taking
Empathy
Excerpt of Story #14
A social worker and I worked on a murdertorture sort of case. We worked with the
surviving patient who was a young
teenager…
And I just had a lot of others in the
ICU…particularly where we’ve had a family
member come in with a gunshot wound or
been beaten by a bat. And of course you
can imagine yourself, if you had a family
member who these things [happened to]
are just your worst nightmare ever.
Holding multiple perspectives
Excerpt of Story #17
A patient had some money and jewelry in a
safe, and the patient wanted his girlfriend
to pick it up. So she went to Security and
they wouldn’t release it because the form
hadn’t been filled out properly, and she
was really upset, understandably, and
Security was upset because she was
making such a ruckus. It’s a big hospital I would be ticked off too. So I ended up
giving her a gift card for her inconvenience
- lots of gift cards today.
Creating
perspective-taking in Patients
Excerpt from Story #20
A man was upset about a nurse, and I
can explain that if you were feeling
chest pains, would you want the
nurse to stop and get you water?
And then, he’ll say no, I guess I would
want her to help me with my chest
pains.
Creating perspective-taking in Staff
Perspective
of:
Patient
Physician’s
office
Physician
Excerpt from Story #27
An example…is a patient of a mother of disabled
child who has difficulty arriving for appointments on time.
The physician’s office is very angry, very upset. The
staff person I spoke to was very unforgiving. I said,
have you ever tried to dress a child in the morning
let alone a disabled child and be dependent on
public transportation to arrive someplace on time?
Well no I haven’t. Well until you do, perhaps the
best thing to do is to schedule this non- (inaudible)
for an end of the day when if there is a delay she
hasn’t backed up the whole schedule for the whole
office. Secondly if she doesn’t show that time can be
used as administrative time for the doctor.
“Imaginative” perspective-taking
Excerpt of Story #42
We get reports from people sometimes that
say, “I know so and so is selling their drugs on
the street.” I pass that information onto the
doctor, but it has to be up to the doctor to decide,
because it’s not my choice of whether he’s going
to cut that patient off from his narcotics just
because somebody said he’s selling them. It
could be an ex-wife who’s very angry for all I
know. But the idea is just to get it in the right
direction and let the person...those people need
to handle it.
Meaning-making themes
Discernment
Sorting
emotional
cues
Creating
relational
moment for
re-narration
Channeling
information
for approp.
M-M
Perspective-taking
Empathy
Holding
multiple
perspectives
Creating
perspectivetaking in
others
“Imaginative”
perspectivetaking
Theme 3: Co-constructing
survivor’s grief narratives
Re-presenting artifacts
Creating limits
Re-presenting artifacts
Excerpt of Story #60
Have you see a death certificate? Neither
have I. I’m interested to see what it looks
like but [a deceased patient’s daughter]
said that there is a portion that gives you
the option of cause of death and that under
smoking there are 4 options. The doctor
checked “probably” on it [for her father].
She was upset because she said “My
father was an extreme advocate against
smoking so this is not good
representation.”
Creating limits
Excerpt of Story #37
This [mother of a cancer patient] was using me as
her therapist…People call and expect more of me
than I can give them. There comes a time when it
needs to end…She’s really looking . . .for
answers and sometimes answers that we can’t
give. Sometimes the answers doctors can’t give.
They want you to say what really happened and to
be honest, we’re all human, and sometimes I think
doctors should just say I don’t know what
happened. I think they don’t feel comfortable in
saying that but we need to say that to people.
There are things beyond our control and I did
the best I could do with the knowledge that I
have and let it go.
Question 1: How do patient advocates
make meaning for self and others?
Discernment
Sorting
emotional
cues
Creating
relational
moment for
re-narration
Channeling
information
for approp.
M-M
Perspective-taking
Empathy
Holding
multiple
perspectives
Creating
perspectivetaking in
others
“Imaginative”
perspectivetaking
Co-constructing grief narratives
Representing
artifacts
Creating
limits
Question 2
What do these forms of
meaning-making reveal about
accomplishing work?
3 answers
1. Meaning-making
Organizes action in self and others
Discernment
Sorting
emotional
cues
Creating
relational
moment for
re-narration
Channeling
information
for approp.
M-M
Perspective-taking
Empathy
Holding
multiple
perspectives
Creating
perspectivetaking in
others
“Imaginative”
perspectivetaking
Co-constructing grief narratives
Representing
artifacts
Creating
limits
2. Withholding from meaningmaking is a form of work
Discernment
Sorting
emotional
cues
Creating
relational
moment for
re-narration
Channeling
information
for approp.
M-M
Perspective-taking
Empathy
Holding
multiple
perspectives
Creating
perspectivetaking in
others
“Imaginative”
perspectivetaking
Co-constructing grief narratives
Representing
artifacts
Creating
limits
3. The work of re-narrating “biographies”
in bureaucracies (Heimer, 1995)
Discernment
Sorting
emotional
cues
Creating
relational
moment for
re-narration
Channeling
information
for approp.
M-M
Perspective-taking
Empathy
Holding
multiple
perspectives
Creating
perspectivetaking in
others
“Imaginative”
perspectivetaking
Co-constructing grief narratives
Representing
artifacts
Creating
limits
Potential Theoretical Import
Elaborates theory of social skill by
Describing how meaning-making occurs
Links individual actions with making (small)
organizational alterations
Example of meaning construction – and coconstruction – as a core task of work
Other ideas?
Questions for you
Do categories of meaning-making
make sense to you?
What do these categories unlock in
terms of accomplishing work?
What additional theories make sense
to understand this data?
EXTRAS
Meaning-making themes
Discernment
Sorting
emotional
cues
Creating
relational
moment for
re-narration
Channeling
information
for approp.
M-M
Perspective-taking
Empathy
Holding
multiple
perspectives
Creating
perspectivetaking in
others
“Imaginative”
perspectivetaking
Co-constructing grief narratives
Representing
artifacts
Creating
limits
How does meaning-making help
accomplish work?
Discernment helps organizes action
Perspective-taking gives them
cognitive flexibility
Helps enlist others in concerns/issues
Constructively (towards problem
resolution) channel emotions in
organizations
Theoretical import?
Co-construction of meaning to agency
Patient advocates’ meaning–making
as translating between cases and
biographies (Heimer)
Making bureacracies navigable
How does meaning-making help
accomplish work?
Organizes action
Cognitive flexibility
Helps enlist others in concerns/issues
Constructively (towards problem
resolution) channel emotions in
organizations
Why is discernment important?
Organizes their action
Excerpt of Story #2
This case is kind of odd to deal with because the wife just
called about a month ago and the complaint is from 2004
when her husband passed away….I don’t think she feels
that anything went wrong and nothing did but the family,
especially the wife…hasn’t really gotten through the
grief process. A lot of times that’s what we also find
especially with patients who have something like cancer or
something. You would think they would be prepared but
they’re just never prepared
…. I’m going to make sure someone from Spiritual Care is
actually [at the family meeting]…it just sounds to me
that’s just where this family is….
The hospital staff has done everything they can to care for this
person yet the family really ends up feeling dissatisfied
because of that one piece. Here we are 2 years later trying
to bring closure to that and justifiably the staff thinking they
had closed that….Just because we do those things
doesn’t mean someone is ready to go through the
process. It can be emotionally draining to do this job.
Research Design:
Patient Advocates are like….
Managers
Disturbance handling
(Mintzberg, 1973)
Toxin handlers (Frost, 2003)
Caregiving roles
Social workers (Kahn, 1993;
Meyerson, 1994)
Nurses (Benner, 1984;
Jacques, 1992)
Service work
Customer Service (e.g.,
Grandey, Fisk, Steiner, 2005;
Rafaeli, 1989 )
Salespeople (e.g., Ramsey &
Sohi, 1997)
Neutral parties to conflict
–
–
–
Mediators (e.g., Poitras, 2005)
Ombuds (Silver, 1967; Gadlin, 2000)
Peacekeepers (Off, 2000)
Representatives in a conflict
–
Lawyers (e.g.,
Eylon, Giacalone, Pollard,
“Dealing
with
2000)
–
Negotiators (e.g., Fisher, Ury, & Patton,
involuntary
1991)
situations and
Investigators
–
Detectives
change
that is
–
Inspectors
partially beyond
the managers’
control”
(p. 82)
Why is discernment important?
“Truth” not the goal
Excerpt of Story #19
A girl came in to me today and told
me she thought a nurse was high. I
think it would be good to know the
truth in that situation, but it doesn’t
mean you will.
Putting themselves in others’ shoes
Excerpt of Story #59
For the phone call that I just got off, the patient was discharged from the
hospital and he was a diabetic. The…wife of the patient…had some
concerns about his treatment while he was here…One of them was that he
hadn’t had his insulin and she inquired about it to the nurse and the nurse
looked through his charts and said, “Oh, he is a diabetic.”
…She should not have had to inquire about what types of medications or
what type of shots he has or has not gotten. This is all things that we
should be concerned about on a regular basis. He’s in our care so if God
forbid he didn’t have a family member to come and visit, how would we have
ever known this? There are some things that we need to do to improve as
an institution and that for an example is something where I think to
myself if this were my father who was in the hospital, number one,
family has a very different way of responding to things especially
when you have a loved one that’s in the hospital.
She addressed me in a very respectful fashion so I want to be on top of
things for this . . . I don’t ever want for someone like that to have to call me
and say, “Have you done anything about it?” I want to be able to call her
and say that this is what’s taken place right now or this is who you can
expect a phone call from.
Research Design:
Organizational Variation
VA hospitals
Teaching Hospitals
Employment
Full-time
Position in
Organization
Centralized Office
reporting 1-3 levels from CEO
through Quality or Customer Service
Patient
Advocates’ tie
to organization
Personal
connection to VA
Employee
(no long-time history)
Predictability of
patients and
issues
Distinct cohorts,
mostly men, with
shared history
Specialty cases, not
gender- or agespecific
Treating all concerns as valid
Excerpt of Story #9
Sometimes we’re completely at fault.
Sometimes the patient is way off base
but you still have to respond in a
manner that their concerns are . . . All
concerns are valid and need to be
treated as valid.
Treating all concerns as valid
Excerpt of Story #63
Do you have a sense like what you did that made her feel
heard?
Most of the time when…I get that response is that they tell
me that I listen and that I don’t say “Oh, that never
happened.” I cannot say that. I can never say what
has happened or can happen or didn’t happen if I
wasn’t there. If a person is giving an impression
because you are automatically defending your staff
person or whomever, oh they would never do that, which
I’ve heard myself, oh nobody on my staff would ever do
that, and then you find out later that somebody on your
staff did do that.
When I’m talking to them or listening to them and I
immediately don’t discount what they say or respond
in a manner which makes them think I don’t believe
them, it validates their position.
Themes: Perspective-taking
Forms of perspective-taking
Empathy
Holding multiple perspectives on a case
Part of comfort with ambiguity
Creating perspective-taking in others
a form of action
“Imaginative” perspective-taking
Part of comfort with ambiguity