Two Views of Agency in Patient Advocates' Problem-Handling Work: Storytelling and Rule Use.

Abstract

Patient advocates are hospital employees who handle the non-medical problems and complaints that patients and their families experience while receiving care in hospitals. Using qualitative data from interviews and shadowing at teaching and Veterans Health Administration (VA) hospitals, this dissertation develops two accounts of agency in patient advocates' problem-handling work. First, my analyses suggest that patient advocates are organizational storytellers who construct accounts that enlist the participation of others to resolve patient and family members’ problems. I identify several relational practices that patient advocates use to accomplish their problem-handling work. Second, the analyses also suggest that patient advocates draw on organizational rules to construct legitimate paths of action for patients, families and staff in hospitals. Four patterns of rule use emerged, but in different frequencies across teaching and VA hospitals. The different institutional logics in the two hospital types help explain the variation in rule use practices, in that they supply guidelines for the kinds of rule use patient advocates may creatively employ within an organizational setting. This portrait of work is fundamentally relational, in the sense that storytelling and rule use occur primarily through interaction with others. Through these relational practices, patient advocates are able to effect small changes within their respective hospitals. In addressing the work of patient advocates in this way, the dissertation contributes to research on work, problem-handling roles, and agency.