ENTRAR            

THEORETICAL

The institution and the patient. Declaration of principles, reality and paradox

Esperanza Cachón Rodríguez
Enfermera. Docente en ejercicio libre de la profesión, Madrid, España

Manuscript received by 5.05.2006
Manuscript accepted by 6.10.2006

Index de Enfermería [Index Enferm] 2007; 56: 35-39

How to cite this document

Abstract

The Health General Law promulgation in 1986 was the beginning in our country of the concern of the patient rights. Two years before, the Humanization Plan justification in 1984 of the National Institute of Health no longer in force in our country, recognized the necessity of improve the humanization side in our hospitals. However, the principle declarations appeared to be in contrast with the health assistance reality in our public hospitals, they showed lots of paradox. The assistant processes that happen within a hospital, cover two characteristics strokes, one would be the biomedical model and the other would refer to the asymmetrical relationships. In this work I will reflect on the hospital reality and its paradox, on some of the factors having an influence on the professionals work and on the necessity of incorporate an antropological and social gaze in the daily nursing processes to guarantee more humanized, personalized and higher quality cares.

Introduction

     In 1984, when the Spanish National Institute for Public Health Care (INSALUD) elaborated the so-called Plan de Humanización de la Asistencia Hospitalaria (Humanization Plan of Hospital Care) justified it by stating that "disease generates, both in the patient and his family and his social environment, a defenceless situation that makes him feel helpless, that is why he needs the most humanized health system possible (...). Undoubtedly, there are excellent professionals (.) and the welfare quality the Spanish Health centres offer is completely comparable to that in any other European countries; however, it is also true that Spanish hospitals need to foster and improve their humanitarian side".¹ The axis of the abovementioned Plan was the Carta de Derechos y Deberes del Paciente (Charter of Rights and Duties of the Patient), the officialization of which meant a declaration of principles that would be implemented and put into practice through the means anticipated in the Humanization Plan; INSALUD assured in the presentation that the Charter "starts from the need of harmonizing the relationships that are established among the different elements of the health system and its patients in the conditions required by a democratic state based on freedom and the respect for human dignity".¹
     Some time later, in 1986, the Ley General de Sanidad² (General Health Law)  exposed the rights of the National Health System users. Later on, the Spanish Law 41/2002, 14 November³ and other legislation insisted on users' rights. We have gone through the Law 12/2001, 21 December,⁴ of Health Regulation of the Autonomous Region of Madrid.
     More than twenty years have passed by since the first declarations of principles in relation to patients' rights took place, and several conferences^5-9 have been undertaken aiming to put them into practice, but both some research works related to the issue and the simple observation of the reality of medical care in Spanish hospitals show a lack of effective respect for some patients' rights and a dissatisfaction about health care in the hospital.
     The aim of the current article is to reflect about the existing dichotomy between some of the Principles that support the legal regulation of the rights and duties of the patients and the reality of medical care; about the paradox resulting from the lack of coherence between the objectives that were put forward and the actions that are carried out or not in order to render their fulfilment effective. For that reason, it becomes necessary to take into account the institutional setting in which hospitals are framed and also the socio-cultural context with the purpose of understanding some of its cultural features and the factors that influence it, since they can give an explanation of the conditions in which their professionals work, the way in which they set their relationships with each other and the mode in which they render their services.

The institutional frame

     The hospital, as an Institution, is an organized system that implies established rules, norms, customs, habits, etc., and can be objectively studied. From a functionalist point of view of the institution we can reflect on the instituted and the instituting. The instituted has needed of the instituting power of man, although it will often end up having an own life and looking more like an end than a means, being sometimes in clear dissonance with the reasons that justified it in its beginnings. When this circumstance occurs, the instituting capacity of man must be also used to raise questions about the Institution itself.
     But, who make up the Institution of the hospital? Who exert the instituting capacity? To what extent the other members of the Institution can raise questions about it? To what extent the instituted is consistent or can be useful to provide a suitable answer to the necessities of patients of the Institution/hospital?

The hospital within the socio-cultural system

     According to Menéndez, "every medical system, whether traditional or cosmopolitan, implies certain knowledge, as well as an ideological shaping that is conditioned by social, political and economical orientations of the society where it develops".¹⁰ The processes of medical care that take place in hospitals are highly influenced by health policies that determine the distribution and management of resources, regulate supply and demand and affect transversally on the whole institutional system. It is from this political and economical power that health policies are defined, so that the analysis of economical and political structures becomes essential in order to understand the development of medical care processes in hospitals.
     Vázquez Montalbán, in dealing with the topic of cultural mundialization, stated that "nowadays the idea has been adopted that there is a globalized system that rests upon an economic unity and there is, for the first time, a worldwide economical system that is solid and not controversial.".¹¹ The prevailing philosophy is economicism and everything else is pervaded by it; and what it seems most important, it is the economic achievement that is above every other one. It seems that if economy goes all right, everything else goes all right. This philosophy has its reflection on the medical policy and goes down to all levels of the structure of the Spanish Health National System. Within the hospital setting, it dominates the decision making in managerial levels, so distribution and the management of resources is fundamentally performed according to criteria of economic profitability in absolute terms. If economy goes all right, everything else goes all right. Although this aspect does not represent the central object of these reflections, it turns up to be significant, since it is a cause and a consequence of a determined management style, that is predominant and growing up, a style that does not exactly promotes the values of the Organization. And no doubt the hospital management style, like in any other firm, influences directly the motivations and attitudes of the staff towards customs (patients).

Some features of the culture of hospital

     A feature of the culture of hospital is the biomedical model, predominant in medical care processes, wherein health care focuses on the biological dimensions of disease (biologicist reductionism), does not consider what the disease means for the person who suffers it and how he lives through it nor the incidence on his environment. The explanation of the disease for the person who suffers it and its meaning are built starting from his ideas, values, knowledge, beliefs, traditions and customs; in short, from his culture, being factors that are not taken into account in the bio-medical model, so neither is recognized the value of other therapeutic practices as possible alternatives.
     A second feature is the asymmetry in relationships. There is a power relationship of professionals that searches for the patient's adaptation. It is a relationship of dominance-submissive adaptation or dominance-rebellious adaptation. In any case, the patient must adapt himself to what has been instituted. Otherwise, he takes the risk of being excluded. A hierarchic therapeutic relationship is established: distress person (patient) / solution person (professional).
     Although the relationship of asymmetry is more evident in the case of the doctor, it also affects other professionals. It is the result of processes of empowerment where the groups of power (professionals) dominate the adequate. There is a whole production of hegemonic ideology focussed for example on the technological or pharmacological effectiveness, on certain medical attention, etc.
     If the patient belongs to a cultural field that is different from the professional's, where the explanation of the disease or the therapeutic practice are radically different to those of the bio-medical model, the asymmetry in the relationship is enormous. The patient rarely has other choice but to submit to the hegemonic model -the biomedical one- or to reject the help offered by the System. Anyway, as far as it concerns to other cultures, we are faced with a biomedical hegemony that is reluctant to find generic medical care factors within such cultures.
     This hegemonic model has persisted along time in the western world, has perpetuated in the system and has influenced the formation of doctors and nurses in Spain. With regard to nurses, this influence was especially notable between 1952 and 1977. From 1977 on, their incorporation to Universities has caused significant changes in the formation of nurses that coincide with relevant political and social changes in Spain and with a new approach to health at a global level, what contributes to create a new conscience of nurses about their mission: "to help individuals, families and groups to determine and achieve their physical, mental and social potential, and to do it within the defiant context of the environment in which they live and work.".¹²
     Although this new awareness is regarded as evident in the levels of Primary Care, it has barely filtered into the hospital setting. Hospitals, as institutions, are ""cultural subgroups with economic relationships of power and prestige that generate a social system of interactions with behaviour patterns and limits of performance of both professionals and patients".¹⁰ Economic and socio-structural factors have an influence on hospital organization and condition the kinds of relationship between different professional groups and between these groups and patients. These are factors that go beyond individuality, causing professionals to have no other option but to do what they actually do; there are norms and established processes in which there is no place for an effective participation of the professional.

Reflections on the reality and paradoxes of the hospital

a) Diversity vs. uniqueness. Facing the necessary diversity of the medical care processes reality shows us a persistent uniqueness. There are a lot of norms that in the practice involve a unique treatment towards all the patients, regardless of the group they belong to, their values, expressions, beliefs and actions based on their lifestyle and culture, their habits and customs, their opinions and feelings, needs, desires and expectations. There are a lot of examples of uniqueness in hospital care. We will explain below some of them as a sample.
     - General Information on admission. The Guía de Acogida (Guide of Acceptance) of the Health Institute of Madrid¹³ that is delivered to patients on being admitted in hospital and it contains information and norms on the documentation to be submitted, stay, visits meals, discharge, etc. at the end of this Guide the charter of the patient's rights and duties is included. We have confirmed through some hospitals that this Guide is only edited in Spanish language, and they also recognize that patients who do not speak or understand Spanish are increasingly being admitted; in such cases, if a member of the hospital staff happens to speak the patient's language, he plays the interpret or they turn to the corresponding Embassy or Consulate or to some Association; they recognize that in many cases, the response of the institutions is a positive one, but in some cases nobody comes to the hospital or they take some days in doing so. How much would it cost to edit the guide in other languages and so make it easier at least the understanding of general information on admission?
     Without going into further analysis wit a quantity and diversity of variables that would be more complex than the pretensions of the current article, how can be put into practice the right that is recognized to the patient in point 5, article 10 of the General Law of Public Health: "to be granted in comprehensible terms (.) complete and continual information, both spoken and written, on his process, including a diagnostic, prognosis, and alternatives of treatment?"² This right is related with other ones and the possibility of taking them into practice depends on the former one; the most significant of them are those that recognize the patient the capacity of choosing freely among the different treatment alternatives and refusing to the treatment.
     - Visits. It is significantly emphasized that "as a general disposition, no visits of children under 12 are allowed. It is assumed that a hospital is not a suitable place for a child and it can be harmful for his health";¹³ this rule corresponds to the one established in 1984 by the INSALUD and states that "the management does not allow entry to children under 12, as far as their presence in a hospital can be risky for them":¹ Why a hospital is not a suitable place for a child? Which scientific base supports that it can be harmful for his health? Does such a risk exist for them also in children hospitals? When establishing this regulation, is it taken into account the significance that for patient can be receiving a visit of an under-12 son or daughter? And for the son or daughter the significance of having the possibility to visit his/her father or mother? Has the patient being asked about this?
     - Meal Hours. "You will be informed in your Unit on meal hours". There is a timetable of regular meals that is established according to organizational requirements of the Units more than according to the patients' needs and/or habits. Whatever they might be, breakfast is served between 8 and 9, lunch between 12,30 and 13,30, afternoon snack at 17,00 and dinner between 19,30 and 20,30.
     There are many other examples of uniqueness upon which we could reflect:
     - health care timetables,
     - rules on hygiene, rest, room environment, etc.,
     - attitudes and rituals towards death, a subject of especial significance both for the patient, his family and social group.
     Uniqueness of criteria turns out to be paradoxical, since it is contradictory with the declarations of principles and the philosophy of quality, and being put into effect would imply to personalize patient's attention, setting him as a central referent for decision- making in all the levels of the Organization.

b) Satisfaction of patient vs. ignorance of the patient by professionals. A lot of emphasis is being set on achieving and measuring satisfaction in patients as an indicator of quality, not as much for its meaning and intrinsic value (the content of the aspects that are measured and the way in which it is done support such an assertion) as for being a factor with a lot of weight in the assessment of quality in hospitals and because the necessary and growing competitiveness within the system demands the achievement and maintenance of certain results in such assessment.
     However, there is a great paradox: the quality perceived by the patient, which determines his degree of satisfaction or dissatisfaction, is basically related to his needs and prospects that shape the service expected by the patient. A question could be posed: how many professionals would be able to give an answer to the question: what the patients do really expect from them? Do they really know patients? Do they listen to them? Or rather know the disease or the reason why the patient is in hospital, his diagnostic and prognosis and starting from there, and from an external view (etic approach) they built -through their professional criteria and generally good will- what the patient needs, but they do not know how the patient perceives himself, what meanings his disease situation has for himself (emic approach); they fail to recognize -perhaps because they do not know and neither they are unaware of its importance- the cultural aspects of human needs, so they carry less beneficial or effective health care practices, even to the evidence of dissatisfaction of the patient with the service received, what means a limit for his recovery and welfare.

c) Quality and effectiveness vs. reductionism and quantitative assessment. Many of the objectives (welfare, quality and effectiveness) are established from an economicist approach, so reducing the measuring of their attainment to an absolute quantitative assessment, something that turns out to be paradoxical, since it does not allow to assess the least tangible costs -quantitative assessment- (unnecessary suffering and stress, dissatisfaction) and its repercussion on economic costs (medicalization, unproductiveness, invalidity, costs of other therapies, etc.).

d) Realistic objectives (feasible) vs. resources and measures for its fulfilment. There is little institutional consistency between quality objectives and the measures and resources that are taken in order to attain them. What is established is frequently an element that makes difficult or limits the achievement of the objectives that are drawn up, reason why they turn up to be unattainable. Reaching a high degree of satisfaction in every single patient means taking into account his individuality and complexity. Knowing the person and his cultural environment involves listening to him carefully, showing consideration for his view and seeing how he disagrees or otherwise is compatible or complementary with the principles or practice of the professional, in order to get his effective consideration in the health care processes. Leininger states that "cultural blindness, shock, imposition and ethnocentrism on the part of nurses reduce considerably the discovery of knowledge and consequently the quality of the attention supplied to the patients. (.) The culturally coherent cares are those that render the patient convinced that he has received good medical attention, and make up a powerful healing force for his health".¹⁴
     From a reductionist approach, we tend to simplify the problems of humanization in hospital to the sensitivity and attitudes of professionals. Although it is true that the attitudes of professionals are a conditioning element of the quality of the services rendered, their capacity and willingness to know, understand and respect effectively the patient -with everything it entails, that is, the personalized attention of each patient, considering his specificity- it does not only depend on the sensitivity, willingness or attitudes of professionals; their work is influenced by multiple factors, the variability of which mostly depend on the Institution, what deletes the possibility of some influence of certain professional groups. Some of these factors stand out:
     - Training. A lot of professionals' training is hardly influenced by the biomedical model, with scientific-technical orientation, with little or no humanistic training, so that the competence they have acquired are basically in the technical field, so existing little relational competence. Although it is true that some of the new professionals (especially women nurses) that join the hospital have received a differently oriented training, they quickly socialize themselves by acquiring the working modes and behaviour of the group they join. The possibility of keeping own criteria in front of the group or introducing essential changes is scarce; it demands huge efforts and risk- taking, since the Organization and groups' influence is a strong one.
     It is within the field of the competence in human relations where the greater training gaps can be found, the consequences of which constitute one of the main causes that generate dissatisfaction in patients because of the cares received and, however, continued training programs given in hospitals are basically oriented to the acquisition, maintenance or improvement of technical competence, giving scarce importance to the acquisition of other kind of competence.
     - Motivation, which influences attitudes. It is a noticeable reality the high degree of dissatisfaction in professionals, the causes of which are complex (perception of their own professional role, the scarce economic and symbolic recognition, the strong pressure of health care, etc.).
     - The instituted: that is, the structure, resources and norms that condition and limit the possibilities of performance of professionals, whose real capacity to modify what has been instituted is rather scarce; instituting power is located in the political levels of health system and in certain managing levels of the hospital.

As a final reflection and conclusion

     Each human being is unique, unrepeatable and incomparable, reason why diversity is present in every human group, included a cultural group. Nowadays, cultural diversity is present in hospitals and is experiencing a growing trend.
     In order to reach the levels of quality in health care that derive from the Declarations of Principles mentioned, there is a need of a certain cultural revolution. Achieving it can be a long process wherein cultural resistance and professional forces will have to be defeated, but guaranteeing quality implies the recognition of diversity on the basis of respect, what let the offering of a more fair and human health care.
     For this purpose it is necessary to confer consistency to the Organization -to the hospital as an Institution- on the spirit that supports the rights of patients, whose effective respect would mean a real evolution in the medical system, so it is necessary to give consistency to the decisions and behaviours of professionals at all levels of the Organization, focussing decisions and attention on the patient.
     To sum up, it is essential:
     - To make health structures more flexible, so diversity will be taken into account.
     - To personalize the processes of health care, focussing attention on each patient.
     - To raise in professionals awareness towards the diversity of patients and the individuality of each of them, so it is necessary to promote their training in order to include an anthropological and social view in their daily work.
     - To foster the formation of professionals for a relational competence. The development of attitudes such as empathy and the unconditional acceptance and training in abilities such us active listening, empathic response and assertiveness are essential for the professionals to have available tools to let them know what to do and know how to communicate satisfactorily with each patient.
     All this implies political and institutional responsibilities, but also in each of the professionals: each one to their own extent and what he really can do; nobody can become totally exempted of his responsibility. We all can and must do something to guarantee that hospital care, apart from conveying scientific and technical quality will bring human quality for all and every single one of the patients.
     This can only be attainable starting from the recognition of the diversity of people and from the effective respect for every single one in the processes of health care, what undoubtedly would lead them to more satisfactory results for everyone, both for the patients and for professionals, and to a greater efficiency of the health system.

References

1. INSALUD. Plan de Humanización de la Asistencia Hospitalaria. Madrid, 1984.
2. Ley 14/1986 de 25 de abril, General de Sanidad. BOE núm. 102 de 29 de abril, 1986; pp. 15207-15224.
3. Ley 41/2002, de 14 de noviembre, básica reguladora de la autonomía del paciente y de derechos y obligaciones en materia de información y documentación clínica. BOE núm.274 de 15 de noviembre, 2002; pp. 40126-40132.
4. Ley 12/2001, de 21 de diciembre, de Ordenación Sanitaria de la Comunidad de Madrid. BOE núm.55 de 5 de marzo, 2002; pp. 8846-8881.
5. Caballero Oliver A, Montilla Sanz MA, Fernández de Simón Almela A, Garrido Cruz I, Montero Romero E, Navarro Rodríguez A. Análisis de las reclamaciones presentadas en un servicio de urgencias hospitalario. Rev. Calidad Asistencial 1998; 13: 426-430.
6. Alcalde G, Letona J, Arcelay A, Gutiérrez F, Martínez-Conde ME. Satisfacción del usuario en hospitalización ¿cuáles son los factores importantes? Comunicación presentada en el XVI Congreso Nacional de la SECA. Resumen en Rev. Calidad Asistencial 1998; 13. 278.
7. Gutiérrez Gascón J, Jiménez Díaz MC, Pérez Pérez ML, Gallego Milla M, Linares Abad M. ¿Por qué reclaman los usuarios? Rev. ROL de Enfermería, 1997; 230:12-16.
8. Gutiérrez Reyes S, Mederos Sosa L, Vásquez Ocaña E, Velázquez Aranda M. Derechos del paciente hospitalizado. Responsabilidad en la práctica de enfermería. Rev. Enferm IMSS, 2001; 9(1): 15-18.
9. Fernández Sola C, Granero Molina J. Reclamaciones del usuario. Un instrumento evaluador de los cuidados enfermeros. Index Enferm 2004; 47:21-25.
10. Getino Canseco M y Martínez Hernáez A. Nuevas tendencias en Antropología de la Medicina. Revista Rol de Enfermería, 1993; 172:23.
11. Vázquez Montalbán M. La mundialización cultural en ¿Mundialización o conquista?, Sal Terrae. Santander, 1999, pp.45-46.
12. OMS. Enfermería en acción. Ed. Ministerio de Sanidad y Consumo, Madrid,1993, p.29.
13. Guía de acogida. Información para pacientes hospitalizados y familiares. Instituto Madrileño de la Salud, Madrid, 2003.
14. Leininger M, Teoría de los cuidados culturales, en Marriner-Tomey, Modelos y teorías en enfermería. Madrid: Doyma, 1994, p. 430.

RECURSOS CUIDEN

RECURSOS CIBERINDEX

FUNDACION INDEX

GRUPOS DE INVESTIGACION

¿Quiénes somos?
RICO Red de Centros Colaboradores
Convenios
Casa de Mágina
MINERVA Jóvenes investigadores
Publicaciones
Consultoría