During the last fifteen years, the behavior of "user-patient" – described as the recipients of health care services – within French hospitals has changed : they are better informed, express their expectations more freely and they are represented in the hospital governance. Indeed, the French regulation allowed the user-patient to have access to their medical file (due to the implementation of the patient Charter and the law of 4th March 2002). Further, access to information has been facilitated by a widespread distribution of information via the use of technologies. User-patient groups have been formed since the 1970's to collectively defend user-patient rights. Moreover French hospitals have established since 2002 the institutionalization of user-patient representatives within hospital governance resulting in participation on the board.
These evolutions are manifestations of the actions of the new social movements (Giddens 1991, Melucci 1980, Touraine 1991) which have put in question the frontier between expert and non-expert knowledge and have ask to participate in the definition of their life choices. In the health care sector, women’s movements contest the male medical power on women’s body and mind, like on the question of maternity, abortion and some have created women’s popular medical clinics. On an individual basis, user-patients mode informations on their symptoms, disease and the cure that the medical institutions offer and will argue with the medical personnel on this. Later, there will be users patients movements to protest and ask for action in the case of the infected blood scandal or in the case of the rare diseases.
These changes resulted in modifying the relations of user-patients and hospital staff at three different levels. First, at the work-site level, the better informed and more demanding user-patients the working practices of the medical staff, particularly nursing staff how are the most exposed to direct contact with user-patient. Second, at the organizational level, the user-patient board representation may influence the decision-making process, especially decisions concerning human resource management and social bargaining. These two dimensions concern the industrial relations issues. Third, at the state level, user-patients have gathered in order to put pressure on the state to obtain legislative innovations that would give them some say at the hospital level.
The aim of this paper is to explore to what extent the user-patient can be considered as a "new actor" of industrial relations in hospitals (Legault & Bellemare 2008).
To answer this research question, we use literature which explains the way the end-user can be a new actor in industrial relations (Bellemare 2000, Legault and Bellemare 2006) at different levels (public policy, organizational and workplace – Hickey 2012). The way the end-users influence the industrial relations vary according to the type of end-users, the organizational context and the role played by the end-users (Kessler & Bach 2011). The research shows at different degrees how the end-user impacts some dimensions of work organization or the overall organization (Korczinski 2013).
To complete this research stream, we use the concepts of "region" and "regionalization" (Bellemare & Briand 2015) which helps to understand how the end-user is an element of the context and contributes to build this context. A work relations region (WRR) is regarded as a set of relations which ‘“governs” the actions of agents (“rules”) and a distribution of capabilities that enable some and constrain others (“resources”)’ (Arts 2000 p.527). This WRR is both the medium and the outcome of action. Regionalization is the term used to describe and explain practices that contribute to a fairly significant transformation of sets of work relations.
These concepts are used to analyse the way the user-patient can influence the work relations at the hospital. To illustrate this theoretical framework, we use an explorative case study.
We use an in-depth study carried out in a French university hospital. Thirteen structured interviews were conducted individually and collectively amongst a sample of people representing the hospital management, user-patients and hospital staff. We then met with two representatives from human resources management, a director of regulations and of user-patients, a director and head of nursing staff, two nursing professionals (a nurse and nursing auxiliary), three user-patient representatives and four employee union representatives. These interviews questioned participants on their views of the changes carried out in the hospital, especially on the awareness of the user-patient and on the development of patient behaviour, on the changes of organisational structure, on working conditions and methods of social bargaining. All the interviews were recorded and were the subject of a content analysis. The study is also based on an analysis of internal documents provided by the hospital.
Our results show that user-patients can be considered as an actor at the work-site level; due to their behaviors they changed the working conditions of nursing staff. But at the organizational level, the user-patients are not really an actor because their legitimacy is acquired for the executive management but not for the employee representatives. User-patients representatives and employee representatives don't succeed to agree on a common interest, that could be the improving of the health care service and the working conditions. A new work relation region has been built at the work-site level but not (yet) at the organizational level. This research contributes to show to what extent the actors, through their behaviors, can play a role in the work relation region. Then we describe a process of regionalization on the work-site level.
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