Les Lliçons sobre la destinació del savi.

The findings from Chapters 5 and 6 indicated how person-centred care was predicated on a process of co-validation which influenced and supported relationship development. This chapter builds on the analysis and explicates the relationship further to generate a substantive theory of person-centred care. The first part of this chapter discusses the analytic process used to explicate the teams’ perceptions of the relationship and the emerging paradox that appeared to challenge the relationship. The second part of the chapter discusses how the dimensions and properties of the paradox were explicated using concepts derived from transactional analysis to enhance sensitivity. The chapter concludes with a discussion of the emerging theory of the conditional partnership that was developed through the analytic process.

7.1. Explicating Co-validation.

The process of co-validation appeared to support a relationship that was built on the philosophical principles of personhood such as trust, respect and autonomy as highlighted in the literature review, (Lauyer et al 2000, Paulen & Rapps 1981, McCormack 2003, Balint 1969). However, whilst this revealed some of the processes associated with person-centred care, there was limited insight into the relationship itself, and in particular, the teams’ experiences of the relationship lacked depth. Although Goffman’s metaphorical account helped identify the social exchanges of the team through eliciting process and structure, Goffman’s ideals were limited in assessing the human element of relationships. As the analysis deepened, Goffman’s conservative subtext added little to explicating an understating the individuals agency and hence their actions within a relationship. Using a constructivist perspective to elicit meaning led to further exploration of the ontological layers that were embedded within the relationship. Developing meaning about the relationship meant thickening the analysis about the team’s perspectives of care.

165 The interviews with the teams were also used to explicate the co-validated relationship and their perceptions of person-centred care. During the interviews, the teams appeared to describe how they controlled care and decision-making. This conflicted with the previous findings in Chapter 5 and revealed how participants may have been ‘guided’ into treatment options. Hence, a line by line analysis of the transcripts later revealed in-vivo concepts, such as ‘been given information’, ‘they agree’, ‘treatment contract’ and ‘a two way thing’ as terms used by the teams to describe the relationship. Listening to the teams and the microanalysis of the in-vivo codes revealed additional conditions in the relationship that appeared to be predicated on the team’s expectations of the participants. The following extract from Dr J at Salisbury was one of the first interviews to reveal the conditions of care expected by teams:

I think they’ve been involved in many aspects of how they get onto the programme. They’ve selected themselves for that sort of treatment. They’ve been given information that they’ve been asked to read, that they’ve been asked to comment on, so presumably they feel empowered and we’ve given them a lot of information, and they sign a consent form to say that they agree to come onto the programme. It’s actually a two-way thing, more of a contract actually I think, it’s a treatment contract that they sign. You know, they agree not to do X, Y, and Z and we agree to have them on the programme. We get them to respect… they have duties on the programme, keeping things tidy, not interrupting, respect for other members of the team, respect for other participants on the programme as well, and we do treat them as adults, and often they haven’t been… hospitals tend to not treat people as adults, generally, less so now than before, but it’s a very adult model of learning that we use.( Dr J Salisbury).

Analysing this response from Dr J highlighted a discrepancy between the participants’ descriptions of care and Dr J’s expectations. The following memo was made during the analysis:

Memo 58: I find it hard to understand how the participants felt empowered and in control of their care, when the teams expectations appear to conflict with any person-centred principles. For example, how is autonomy promoted when the teams seemed to push for compliance? Using terms like, they agree, sounds coercive. Moreover, Dr J appears be saying that they have complete control over who gets on the programme, and if the patients don’t do as they have been asked, then they could be removed. The contract he talks about doesn’t really appear to be ‘a two-way process’, and the descriptions of being empowered through ‘giving lots of information’ is not what I understand empowerment to be about. Was there opportunity to ask questions, seek alternative methods of treatment or were participants allowed to disagree? The comments made by Dr J conflicted with the relationship described by the participants and therefore presented a challenge to the process of co-validation. The in-

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vivo codes initially appeared to suggest that compliance with care was facilitated by the teams, and participants were expected to sign a contract. It was unclear however, how the agreement had been reached or whether the outcomes were what the participants expected and wanted. Equally, it was less clear if participants were allowed to disagree with the expected treatment. Explicating this further with other interviews revealed similar perceptions, and suggested that teams retained some control, which appeared to be influenced by additional conditions. For example, the analysis of the Bracknell team interview revealed how the teams expected participants to comply as part of the conditions within the relationship. Although the team described the relationship as a two way process, the way in which this is subtly directed was also discussed:

Chris; It can’t be unconditional, virtually everything we do is because we are very clear it’s a two-way process

Helen: Yes

Dr G: We’ll do our but, you’ll do your bit

Helen: we are only going to move you forwards… Dr G: If you participate

Helen If you participate, and so really it is conditional because we need you to tone up, we need you to do the homework, we need you to do what we ask, and we know if you don’t do that, then we are not going to be able to move you forwards, so it isn’t unconditional

Memo 61. The comment made by Dr G ‘we’ll do our bit, but you’ll do your bit’ seemed to imply a