Den ældre medicinske patient: En udfordring for sundhedsvæsnet

Abstract

In this master thesis I investigate the creation of the new concept; “preventive admissions”, and the existence of this concept effect on the treatment of the elderly patients in the Emergency Department. The term “preventive admissions” concerns elderly patients and the basic idea is that these patients can be diagnosed and treated at home by municipal Acute teams with skilled nurses. This is a political idea grown from the fact that the elderly population will enhance substantially over the next 20 years. Before the concept of “preventive admissions” developed, was another more passive concept of “inappropriate admissions”, meaning elderly patients that should have been treated at home. The thesis consists of two parts. First part is a document examination of public health care documents from 2010 and forward concerning elderly patients and “preventive admissions”. The second part consists of three interviews with doctors and nurses from a Danish Emergency Department. The main research question is: How does a political concept such as “preventive admissions” affect staff's performative norms around the elderly medical patient in the Emergency Department? To the analysis of the documents, I used Koselleck's theories about the formation of concepts and how these are filled in content over time in a political game about power. In addition, I have looked at the Emergency Department with Luhman and Åkerstrøms organizational theories. According to Luhman a system is autopoetic and consists only of communication. Furthermore the system is socially closed but functionally open, these matters became clearly evident in the analysis of the interviews. Finally, I made an analysis of the interviews with Rennisons theory of the polyphone organizations and the leadership of such organizations. This revealed paradoxical strategies and opened ways of dealing with these. One of the main findings in the political documents where, that the concept of the elderly patient developed slowly to a concept about the elderly citizen. The citizen is not as sick as the patient, the citizen is more empowered and the citizen would rather stay at home than visit the Emergency Department. This development came simultaneously to the development of the concept of “preventable admissions”. In this way politicians hope the concept of “preventable admissions” will be accepted in hospitals and society. The problem of this development could be that the citizen is really sick and need the hospital. The other problem is that the concept of “preventable admissions” is not yet a concept among the staff in the Emergency Department. The interviews revealed that they have no idea of what a “preventable admission” means, but they were familiar with the concept “inappropriate admission”. This shows, a timely delay from a political concept to a term known by the staff in the organizations. Furthermore, it was obvious from the interviews that the Emergency Department is a socially closed system, which only communicates about other systems, if they are considered of importance to the Emergency Department. Finally, the Emergency Department is a polyphonic organization with a primary code of health, but other codes are emerging, examples are care, flow and law, none of these codes have a natural hierarchy and therefore the clashing of codes is evident. The clashing codes had the staff develop a distance to the patients and the care they are entitled to. The staff in the Emergency Department uses the codes of flow as a mental shield between them and the elderly patient. The increasing number of elderly patients is a challenge for several organizations. Therefore, in these years many solutions are discussed, the political solution is prevention of admissions, and this is attempted to be implemented in health care. In this thesis it is clear that the concept does not make sense to the staff in the Emergency Department, probably due to a delay, as the concept is relatively new. On the other hand, the concept of “inappropriate admissions” make perfect sense, and there is a strong tendency for the staff to objectify the elderly patient, and excuse their failing to live up to our own standards for patient treatment, with the importance of maintaining patient flow. On the other hand, there is a political current to neglect the diseases of the elderly patients and change diseases into conditions, at the same time as elderly patients are turned into citizens. In this way, there will be fewer elderly patients and several tasks that can be solved in the municipality or by relatives. In the Emergency Department, the powerlessness and frustrations are growing around this patient group. The elderly patient is neither sick nor healthy, and above all complicated and requires time and peace. We are in a system that must take care of the acutely ill patients and at the same time maintain a high patient flow. Here, the elderly patient and “inappropriate admissions” become a disruption of the system and the staff blames the outside world. It is the municipality, the nursing education, 1813, the policies, in short, everyone else's fault. The result is that employees and management end up in an incompatible cross-pressure between several codes, which leads to the development of de-paradoxical strategies, dominated by decoupling. This means, that the organization does not up fill ts own standards for treatment of elderly patients, neither concerning medical professional level, care nor humanity.