What contributes to abuse in health care? A grounded theory of female patients’ stories

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Abstract

Background

In Sweden, 20% of female patients have reported lifetime experiences of abuse in any health care setting. Corresponding prevalence among male patients is estimated to be 8%. Many patients report that they currently suffer from these experiences. Few empirical studies have been conducted to understand what contributes to the occurrence of abuse in health care.

Objectives

To understand what factors contribute to female patients’ experiences of abuse in health care.

Design

Constructivist grounded theory approach.

Settings

Women's clinic at a county hospital in the south of Sweden.

Participants

Twelve female patients who all had reported experiences of abuse in health care in an earlier questionnaire study.

Methods

In-depth interviews.

Results

The analysis resulted in the core category, the patient loses power struggles, building on four categories: the patient's vulnerability, the patient's competence, staff's use of domination techniques, and structural limitations. Participants described how their sensitivity and dependency could make them vulnerable to staff's domination techniques. The participants’ claim for power and the protection of their autonomy, through their competence as patients, could catalyze power struggles.

Conclusions

Central to the participants’ stories was that their experiences of abuse in health care were preceded by lost power struggles, mainly through staff's use of domination techniques. For staff it could be important to become aware of the existence and consequences of such domination techniques. The results indicate a need for a clinical climate in which patients are allowed to use their competence.

Introduction

It has been well-documented that female and male patients can experience suffering from encounters in health care, which is not related to their disease and even despite a medically correct treatment (Brüggemann et al., 2012a, Coyle, 1999, Levinson and Shojania, 2011, Swahnberg et al., 2007a, Swahnberg et al., 2009a, Söderberg et al., 2011). These incidents do not only imply immediate and long-term suffering, but they can also affect a patient's confidence in the health care system (Swahnberg et al., 2009b). A study among long-term sick-listed patients showed that health care encounters devoid of respect can impair their ability to return to work (Lynöe et al., 2011), pointing at far reaching consequences of untoward health care encounters. Harmful encounters or those devoid of care, as seen from patients’ perspectives, have been labeled abuse in health care (Brüggemann et al., 2012a).

Female patients have described their experiences of abuse in health care as feelings of ‘being nullified’ in qualitative interviews (Swahnberg et al., 2007b). Being nullified included aspects of feeling powerless and ignored, feelings that male patients also expressed. However, instead of being nullified, male patients felt ‘mentally pinioned’, as they could not act in accordance with their own convictions (Swahnberg et al., 2009b). In quantitative studies, abuse in health care was operationalized by three questions, displayed in Table 1. Using this operationalization, the prevalence of abuse in health care has been extensively studied in the Nordic countries, where between 13 and 28% of gynecology patients (n = 3641) reported some kind of abuse in health care (Swahnberg et al., 2007a). Prevalence in Swedish male patients was about 8% (Swahnberg et al., 2009a).

A theoretical framework has been developed to understand why abuse in health care occurs regardless of staff trying to provide the best care possible. The starting point is Galtung's theory of violence, which distinguishes between direct violence (face-to-face events), structural violence (processes), and cultural violence (invariants embedded in culture; Galtung, 1990). Galtung depicts these three types in a ‘violence triangle’, emphasizing their interrelatedness. Placing cultural violence at the bottom of the triangle invokes an image of cultural violence that legitimizes and feeds both structural and direct violence. For example, in a case study it was hypothesized that staff can structurally disempower patients by the use of their knowledge, status, or a medical language, thereby making it difficult for patients to speak up (Wijma et al., 2007). This was later supported by a quantitative study, which showed that a majority of female patients kept silent to the health care system after experiencing abusive or wrongful transgressions of ethical principles by staff (Brüggemann et al., 2012b). Such silence can confirm, and thereby reproduce, existing structures, legitimizing future direct events of abuse in health care (Giddens, 1984). Glover's theory of moral identity was later used to explain how such violence can develop and exist in a system that is created to help patients (Glover, 2001, Swahnberg et al., 2006). To explain how humans in certain situations can perform inhumane deeds, Glover describes several processes that can contribute to the erosion of a person's moral identity, i.e., the kind of moral human being this person wants to be. Based on this idea, it was hypothesized that staff can move from feeling guilty about abuse in health care to ignorance, legitimized by a general taboo on talking about abuse in health care (Swahnberg et al., 2006, Wijma and Swahnberg, 2009), which was later confirmed in qualitative interviews with health care staff (Swahnberg and Wijma, 2011).

To gain further theoretical insights in the occurrence and prevention of abuse in health care it is of importance to listen to patients’ stories. In the present study we therefore turned to patients and asked them what contributed to their experiences of abuse in health care, in contrast to earlier patient studies that focused on what it meant to experience abuse in health care (Swahnberg et al., 2007b, Swahnberg et al., 2009b).

Section snippets

Design

We applied a qualitative study design following a constructivist grounded theory approach (Charmaz, 2006). This approach has a starting point in grounded theory methodology as developed by Glaser and Strauss (Glaser, 1978, Glaser and Strauss, 1967). The grounded theory methodology was developed in order to offer a rigid and credible qualitative method, as a reaction to a growing dominance of positivistic quantitative research in the mid twentieth century (Charmaz, 2006). But, as Charmaz (2006)

Results

Our study resulted in four categories using constant comparative analysis: the patient's vulnerability, the patient's competence, staff's domination techniques, and structural limitations. A core category captured the relation between the categories: the patient loses power struggles.

Discussion

Our main research aim was to understand what factors contributed to female patients’ experiences of abuse in health care. The variation in our material, based on interviews with twelve female patients, was best captured by the core category the patient loses power struggles. This core category is the result of the interaction and the clash between the four categories: the patient's vulnerability, the patient's competence, structural limitations, and staff's domination techniques. We believe

Conclusion

High prevalence of abuse in health care has been reported but little is known about what contributes to these events. In this qualitative study we turned to female patients and asked them what contributed to their experiences of abuse in health care. The participants’ stories of these experiences were best described by the core category ‘the patient loses power struggles’. These patients’ sensitivity and dependency could make them vulnerable to staff's dominations techniques. Power struggles

Acknowledgements

We thank the twelve women who participated for their invaluable contributions to the study.

Conflict of interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Swedish Research Council (grant number 2009-2380).

Ethical approval

The study was approved

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