General Practice and Primary Care - Theses
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ItemExploring social constructions of, and the use of power to deal with, patient aggression in general practice( 2015)This thesis investigates the meaning of patient aggression in general practice and the use of power to deal with it, through a multi-case comparison of four general practices sampled on the basis of different business models. Much debate on the topic has focused on encapsulating the concept so that prevalence and associated factors could be determined. Current accounts highlight aggression directed towards general practitioners, but pay less attention to the experiences of other workers. Previous research has overlooked the contested nature of the concept along with contextual and interactional circumstances surrounding patient aggression. This thesis addresses these gaps by exploring how general practice workers from different occupational backgrounds understand patient aggression and how various types of general practice organisations use power to deal with the phenomenon. I adopt a social constructionist approach to argue that the meaning of patient aggression arises from the type of interaction. Qualitative methodologies underpin this multiple case study, which involved semi-structured interviews, observation, and document analysis. To explore the use of power, I draw on an analytical framework based on Steven Lukes’ (2005) critical conceptualisation of power. I discovered two interactional prototypes in general practice: front-line interactions between practice gatekeepers and patients, and rapport-building interactions between health professionals and patients. Gatekeepers tend to normalise patient aggression, whilst health professionals lean towards trivialisation. Normalisation renders the frequent exposure to aggression at the front line an acceptable and normal ‘part of the job’. In contrast, trivialisation enables health professionals to suppress perceptions of heightened vulnerability and avoid victimisation. Both interactional prototypes employ medicalisation and stigmatisation. To understand the use of power to deal with patient aggression, I compare a small partnership practice, a community health service, a large group practice, and a corporate-owned practice. I discuss how these practices manage the meaning of their interactions with patients differently. I interpret this management of meaning as an exercise of power in the third dimension, which is the most sophisticated way to deal with patient aggression. The current understanding of how to deal with patient aggression aligns with the use of power in the first dimension and, therefore, overlooks less manifest types of power. This thesis makes three contributions to the literature on patient aggression. First, it offers insights into different constructions of meaning based on the nature of the interaction. Second, it clarifies how business models shape ways general practices interact with their patients. In departing from a mere behavioural focus, data analysis focuses on processes behind the social construction of ‘patient aggression’ and examines organisational characteristics that determine the use of power to deal with aggression. Third, this thesis contributes to the literature that applies Lukes’ (2005) framework to the examination of organisational phenomena. The findings help in identifying organisational features that influence interactions with patients. Implications for further research include the application of a similar design to a rural-urban comparison, specialist care settings, and a cross-national study. It is also of interest to further explore the impact of the organisational context on other phenomena.