Eigen regie en waardigheid in de zorg: een kwestie van persoonsgerichte praktijkvoering

Abstract

Eigen regie en waardigheid in de zorg: een kwestie van persoonsgerichte praktijkvoeringDe gezondheidszorg is aan sterke veranderingen onderhevig. Pregnant is de ontwikkeling naar ondersteuning van eigen regievoering van cliënten. In deze bijdrage plaatsen we twee kanttekeningen bij de invulling van dit begrip. Vanuit een neoliberaal marktdenken ligt de focus op de controleerbaarheid van leven en gezondheid. Dit doet echter geen recht aan de kwetsbaarheid die mensen ook ervaren en hun behoefte aan respect, erkenning en als mens geacht te worden. Vanuit een bureaucratisch organisatie denken staat de beheersbaarheid van organisaties in termen van doelen en kosten centraal. Dit leidt tot fragmentatie van zorg en dreigt professionals tot uitvoerders van regels en procedures te maken. Persoonsgerichte praktijkvoering kan deze knelpunten ondervangen. Het is het voortdurend samen vormgeven van relaties en structuren binnen zorg-, leer- en werkomgevingen zodanig dat eigen regie en waardigheid van alle betrokkenen worden gerealiseerd. Eigen regie is dus geen individuele aangelegenheid, maar een kwestie van “grensoverschrijdend samenwerken” en verbinden vanuit verschillen in waarden, kennis en betekenisgeving. Persoonsgerichte praktijkvoering biedt daarbij een alternatief model voor het expertmodel, dat is aangeduid als het samenwerkingsmodel. Autonomy and dignity in healthcare: a matter of person-centred practice Healthcare in the Netherlands is subject to major changes. Due to rising living standards and new technologies in healthcare, people are living longer and this is related to an increase in multimorbidity. The demand for and cost of healthcare are rising as a result. In the process of trying to transform healthcare and reduce costs, the government is trying to increase the amount of self-care and self-sufficiency. Significant herein, is the development towards support for clients' self-management. This is not a new concept: patient empowerment and patient autonomy have been on the agenda since the 1970s. In order to explain the difficulties that healthcare is encountering in supporting patient autonomy, we use the theory of the American sociologist Eliot Freidson (2001), who makes a distinction between the logic of the market (consumerism), the logic of the organization (managerialism) and the logic of the profession (professionalism). Based on his theory, we would expect that although consumers do now have a stronger voice in their own healthcare, neither patients nor professionals experience autonomy in current healthcare practices. First of all, from a neo-liberal market perspective, the focus of self-management is on the controllability of life and health. However, this does not take account of the vulnerability that people experience and their need for respect, recognition and treatment as human beings. Consequently, patients often do not feel they are seen as people in their own right and do not feel supported in dealing with difficult life questions and issues. Secondly, from an organizational and bureaucratic perspective, the controllability of organizations in terms of goals and costs is central. This leads to the fragmentation of care, leaving patients to manage not only themselves but also their care. Organizational bureaucracy also conflicts with professional autonomy, turning professionals into the enforcers of rules and procedures. Person-centred practice can provide a solution to help overcome these issues and is the subject of increasing attention worldwide. It is part of a humanization movement in healthcare which sees the personal and interpersonal dimensions as essential to good care (McCormack & McCance, 2010; Hummelvoll, Karlsson & Borg, 2015; Jacobs, 2015). Our vision of person-centred practice is inspired by the ethics of care, relational psychology and relational constructionism. These currents are critical of individualism and the focus is on control and manageability in contemporary healthcare. Person-centred care is defined as the continuous co-creation of relationships and structures within care, learning and work environments in such a way that the patient’s own direction and dignity are realized. Self-management is therefore not an individual matter, but a question of “working together across the boundaries” of differences in values, knowledge and meanings. Person-centred practice provides an alternative model for the expert model, which is referred to as the cooperation model. In this model, collaboration involves not only professionals from various disciplines and sectors, but also clients and their stakeholders in healthcare. The expertise required for this by participants is known as dialogical or relational expertise. The intention of cross-border cooperation is to contribute to sustainable change by developing relationships and structures that promote autonomy and dignity.The current transformation of healthcare to provide more support for self-management will benefit from a critical reflection on market forces, and in particular its implicit assumptions of the controllability of individual lives and organizations. People are vulnerable and have a deep-seated need for respect and recognition, even if they are no longer able to manage and organize their own lives. Professionals and organizations benefit from working on the basis of core values to support their own self-management. Self-management is therefore not an individual matter, but a matter of “working together across boundaries” and connecting amidst differences in values, knowledge and meanings. Person-centred practice provides important insights in how to approach this.

Keywords

• autonomy, dignity, self-management, person-centred practice, boundary crossing