G ABRIEL MIRÓ Y LA ESTÉTICA DE LA MIRADA
L A EXACTITUD DE LO INEXACTO
The first condition ‘being believed’ was significant, however, as the relationship was a two-way reciprocated process of trust. The findings also highlighted the need for faith in the team, which was explored using Goffman as a framework to understand the team processes. Sensitivity about the team’s effectiveness and processes used was enhanced
186 through using Bandura’s (1989) concept of collective efficacy to generate meaning about the team and how this had later influenced partnership working. Believing in the team, meant that the participants had confidence in the teams’ ability which helped to restore their faith in health care. Using Goffman to explicate the teams’ processes in the back stage revealed how team maturity and co-location influenced the development of collective efficacy. Hence, being believed and believing in emerged as two conditions of the relationship that influenced co-validation. Figure 16 illustrates the relationship between caring, empowerment and restoring belief in the team through co-validation.
Figure 16: The Process of Co-validation.
Explicating meaning about the co-validated relationship revealed how this had supported partnership working which helped the participants to regain control of their pain. Conditions in partnerships are rarely reported, but it is accepted that partnerships are associated with terms such as co-operation, trust, participation and collaboration; however, the concept of partnerships with participants in particular is immature (Hook 2006). Partnerships are created from many variables and have been defined as being “an abstract that is expressed in some form with a cluster of critical attributes that are both necessary and sufficient to delineate the domain and boundaries of the concept” (Rodgers 2000). Similarly, Gallant et al’s (2002) concept analysis of partnership identified three key attributes of partnerships, which included empowerment, power sharing and negotiation. Interestingly, the main consequence of partnerships was described by Gallant et al (2002) as ‘the improved ability of the client to act on his/her own behalf’ (p.
187 154), which was consistent with the participant’s descriptions of the ‘life changing’ events and the toolbox. The findings from Chapter 5 indicated how the conditional partnership empowered the participants and their descriptions concurred with the key characteristics of partnership working such as shared decision-making, communication and participation (Hook 2006). However, other key principles associated with partnership working such as autonomy and shared power conflicted with later findings, which exposed the control that the teams had within the partnership. The findings suggest that the partnership conditions were predicated on pre-determined risk avoidance parameters set by the teams and led to the third condition of non- maleficence. The key attributes of partnerships are often context bound and therefore unique. Generalisations about partnerships are problematic because of the variable context in which they are formed. Hence, the first two conditions of the partnership are unique within the context of chronic back pain. The third condition, of non-maleficence, may however be commonplace in other healthcare relationships and is explored next.
7.7.3. Condition 3: Non-maleficence.
Elaborating the analysis through developing theoretical sensitivity revealed the paternalistic approaches to care and highlighted the paradox in the conditional partnership. Hence, participants felt empowered and used terms such as ‘involved’,
‘empowered’, ‘feel more equal’ that related to partnership. However, analysis of the team interviews uncovered codes such as ‘conditional’, ‘provided’, ‘given options’, which illustrated the teams expectations and conditions. Table 19 on the next page presents some of the open and in-vivo codes that were indicative of the developing paradox.
188 Table 19: The Partnership Paradox.
It is recognised that partnering with participants is not without its difficulties and it has been questioned as to whether it is possible to participate in healthcare without being in a partnership (Cheek 2003). Crucially, the teams regained faith through diluting the effects of the sceptical professional; ironically, the teams used terms such as our aims,
because they had a clear idea of what they wanted the participants to do. In doing so, the teams referred to the participants as ‘our patients’ because of their positive controlling Parent Ego-state, which, resulted in care being directed by ‘our options’.
From the outset of care, the team guided participants choice based on what they believed was best. Believing that ‘one knows best’ leads to the imposition of individual values on another. Despite being predicated on ethical principles of beneficence, morally, this does not assume optimum care (Edwards, 1996). Figure 17 illustrates the key components of the third condition.
Codes that illustrated ‘partnership’
Micro-analysis of codes (revealed Parent Ego)
Outcome –Team (positive controlling Parent Ego)
Unconditional Conditional Restrictions set
Involved Informed Part of…
Choice/options Provided Work within limits
Treated as adult Asked to do …. Given instructions
Empowered Given options Parameters set
First name terms Name badge applied Disempowered
Feel more equal Doing my job Not made more equal
Help them Taking over Disempower
189 Figure 17: Mind Map: The Properties and Dimensions of the Third Condition.
Being believed, provided participants with an opportunity to participate in care which created a mutual relationship in which participants were empowered without being an equal partner. This philosophy reflects Naidoo & Willis’ earlier work (1994) which argued that partnerships can be varied and have different levels of involvement and empowerment doesn’t always feature (Naidoo & Willis 1994); equally, it is also acknowledged that some don’t want to be full partners (Gallant et al 2002). Paradoxically, the professional is perceived as the one with the power within a relationship because they retain control through the paternalistic approaches engendered to ensure safe and ethical practice. Similarly, the findings from the team interviews were emblematic of how professionals provided choice predicated on an approach that reduced harm but retained control in which participants were seen but not treated as experts. Whilst it is recognised that the professional status was needed to ensure credibility and authenticity, it may also be argued that caring in this way fosters dependency and participants are disempowered through ‘professional distancing’ as previously highlighted by Goffman. Hence, caring for participants seemed to be reliant upon a non-negotiated power base in which the professional was knowledgeable and thus limited the equipoise of the relationship. Despite the third condition, the participants believed that they had been empowered; ultimately, the team helped restore their independence through a co-validated relationship that restored the(ir) person.
190 7.8. Chapter Summary.
The findings suggested that the teams worked towards rehabilitating the participants through restoring their self-esteem and sense of self. These findings therefore have implications for the way in which person-centred care is conceived by teams and experienced by participants. The conditional partnership provided an explanation of the relationship and generated meaning about the experience of person-centred care for people with chronic back pain. The paradox emerged from the third condition predicated on non-maleficence and presented challenges to assumptions about person- centred care. Autonomy is synonymous with both person-centred care and partnership working; yet, participant autonomy appeared to be compromised by the team’s professional obligation to do no harm. From the outset of care, the team were clear about what the participant could expect based on what they believed was best. The analytic process highlighted key categories that were later developed into a core category through literature and sensitivity however; the emerging partnership paradox challenged the concept of person-centred care. The next chapter discusses the conditional partnership as a theory using Michael Bury’s (1982) sociological concept of the disrupted biography to explain the significance of co-validation and the role of the conditions within the partnership.
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