The Dramaturgical Act of Positioning Within Family Meetings: Negotiation of Patients’ Participation in Intermediate Care Services

Theoretical Framework

Drawing on Goffman’s dramaturgical theory, supplemented by positioning theory (Davies & Harré, 1990), we demonstrate the multiple roles and positions the participants play to negotiate their opinions and values. In his dramaturgical theory of human interactions in everyday life, Erving Goffman (1990) argues that we display a series of masks to others in acting roles, controlling and staging how we appear, being concerned with how we come across, constantly trying to set ourselves in the best light. Roles are patterns of behavior that are representative of the person’s social status, for example, the role as patient or nurse, that fit the social norms of society. However, we might wear different personality masks within the same role, for example, we can be deadly serious or likewise laugh with joy. We might be “sincere” or “cynical” in what we say and do, and even switch mask as a tactic. We play a range of different parts, determined by the situations we take ourselves to be in and how we think we present ourselves in the room of negotiation. We adjust our behavior, depending on whom we are interacting with (Goffman, 1990).

According to Goffman (1990), a performance can be defined as a transient activity by a person during an interaction with a particular intent of influencing others. A performance assumes a physical location/stage, props, and costumes. Front-stage is when the performance takes place in front of an audience, while back-stage is when the performer retreats from public gaze and privately receives assistance. Props are objects for performers to use or abuse while enacting their positions, for example, the room’s furniture, while costumes means the way we dress, for example, business suit or the white lab coat. In our case, the family meeting’s location may be considered to be front-stage, where the performers enact different parts. The back-stage might be in the medical room where the staff discuss patients. A team is a group of people who collaborate to define the situation, for example, the IC team or the patient-relative team. However, one person might also function as a team: the patient as a single performer. The team controlling the stage is the performance team, while the audience listens. Different parts are enacted in our interactions, some more influential than others. “Directors” possess great power and can control the positions of the other performers. The nonperson is positioned by the audience and the performers as someone “who isn’t there.” In addition, Goffman argues that secrets might be used to maintain a performance in the team. Inside secrets imply knowledge shared only by team members, whereas strategic secrets mean future intentions of the team kept hidden in the present. In this article, we consider communication as both expressions given and as expressions given off, the latter being nonverbal and unintentional (Goffman, 1990).

As a supplement to Goffman, we add the concepts of “positioning” and “discursive practices” to grasp some of the structures behind the interactive performances in everyday life. Positioning, as introduced by Davies and Harré (1990), is the discursive process whereby people are positioned through conversations in jointly produced story lines. “Positions” are dynamic “roles,” and in line with the use of masks. During a conversation, a person can say something that positions another, called interactive positioning. However, a person can also position oneself, called reflexive positioning, for example, the patient who positions herself/himself as a nonperson or as a director. Each position entails moral rights and duties that determine what can be said and done in the given context. A discourse is to be understood as an expression of social practices including beliefs, knowledge, religion, norms, and values and as an institutionalized use of language and language-like sign systems (Davies & Harré, 1990). Thus, wearing different masks in their interactions, the participants in the family meetings are either positioning themselves or being positioned, which is both a logic strategy to coming across but also an expression of the associated discursive practice.

Context of the Study

To meet demographic changes, the city of Oslo, Norway, has synchronized all municipal short-term and rehabilitation services into four major institutions, organized and managed by The Nursing Home Agency in Oslo. The study was conducted in three of these IC institutions, serving three quarters of the districts in West, East, and North of Oslo, with a total of 350 beds. To meet the complex needs of geriatric patient within IC services, the care is usually organized as an interdisciplinary team approach. The IC institutions aim to deliver geriatric rehabilitation, support timely hospital discharge, and prevent unnecessary hospital admissions to fulfill the policy of “aging in place,” which implies being able to live at home for as long as possible. Patients in IC typically receive rehabilitation after hospitalization to manage activities of daily living (ADL), a home visit with an occupational therapist, and follow-up services from the district after discharge to home.

Defining the Situation

We observed 14 family meetings within IC services. The initial family meeting is supposed to take place within the first 2 to 3 days of the patient’s IC stay. As a standardized routine, the aim is to voice the patient’s needs, make a rehabilitation plan, and discuss follow-up services. Although the meetings are organized in different ways, the patient, relatives, the IC team, and the municipal DC are usually present. The 14 participating patients were of an average age of 87 years (range: 74–97 years), nine women and five men. The most common diagnoses were fractures (hip/femoral/rib/arm), osteoporosis, heart and lung conditions, cancer, neurological conditions, infections, frailty with malfunction, and fall issues. According to medical records, six of the patients showed clinical signs of initial cognitive impairment, that is, memory loss situations and confusion in relation to time/place. Thirteen of the patients needed municipal home care after discharge, and 14 used a zimmer frame. The relatives were present at nine of the family meetings, were aged between 50 and 87, respectively: daughters (7), sister (1), daughter-in-law (1), and sons (4). The IC-team present were most commonly a nurse or a nursing assistant, a physical therapist, and an occupational therapist. The DCs attended 10 of the family meetings. Overall, the meetings lasted between 10 and 56 min, with an average of 32 min, and were held the fifth to sixth day of the patient’s IC stay. Eight of the meetings took place in the patient’s room, whereas the others were held in a conference room. The negotiations conducted in the meetings were mostly about defining the patient’s goals and needs, discussing appropriate interventions within IC and follow-up services after discharge. Another aspect of great relevance was the length of the patient’s IC stay. The patient and relatives frequently tried to convince the staff about the need for an extended stay in IC.

Data Collection

The manuscript is based on observational data consisting of meeting notes and audio recordings. In the first step, we included the patients, a strategic sample to embrace the diversity in IC. Patient inclusion criteria: age > 65 years, admitted to IC from hospital or home due to acute or chronic disease and/or frailty, and dependent in ADL but with an objective of being able to live at home. Participants meeting the inclusion criteria were informed about the project by staff working in the three IC institutions. Patients who agreed to participate were then given additional information and, with their consent, their chosen relative was contacted and asked to participate by Linda Kvæl. Furthermore, the IC team and the municipal DC were informed and asked to participate. Thus, the researcher was introduced to all the participants in advance of the meeting observations. Linda Kvæl then observed all the initial family meetings, nonparticipating, positioned in the background, while taking notes. The meetings were also recorded and transcribed verbatim by the same researcher to process sensitive data. The family meetings took place between April and December, 2017. The researcher present at the meetings has a background as a physical therapist and broad experience within geriatric rehabilitation and IC services.

Ethical Considerations

The Norwegian Center for Research Data (No. 53013) preapproved and registered the study. All participants in the family meetings gave their informed consent after receiving oral and written information, which included the assurance that they could withdraw their consent at any time without consequences. In compliance with Norway’s Privacy and Electronic Communication Directive, the audiotapes were secured in Services for Sensitive Data.

Data Analysis

Data were first analyzed using thematic analysis based on Braun and Clarke (2006). This resulted in three main themes, presented in Table 1, representing all the 14 family meetings. Initially, all the authors read the transcribed data from the meetings in an open way, searching for meaning and patterns. Linda Kvæl then listened to all the audiotaped meetings again and, in combination with the meeting notes, wrote up the essence of what occurred in the meetings. In the following discussions in the author team, it became apparent that patient participation in the meetings often implied negotiation, the use of different strategies or positions to get one’s point across. Accordingly, we realized that Goffman’s dramaturgical theory, supplemented by some of the concepts from the positioning theory, could serve as a suitable framework for the ongoing analysis. Consequently, all the data material was coded by Linda Kvæl, and organized into themes, moving back and forth within the material to ensure that the themes were supported by quotes from the family meetings. The authors’ backgrounds are within physical therapy, nursing and nutrition, including extensive research and/or clinical experience within the field of health care for older people. The process of identifying, collapsing, and reviewing themes led to an extensive discussion among the authors to preserve variability and reflexivity and to establish credibility (Morse, 2015). To enhance validity, Linda Kvæl talked to the patients and relatives about the observations (reported in another article: Kvæl Debesay, Bye, Langaas, & Bergland, 2019) and further discussed the analyzed findings in a stakeholder group in IC. During the analysis, four of the meetings stood out as representative of all the 14 family meetings to convey the complexity of positions found within our data. We have thus chosen, rather than breaking our data into incoherent fragments from the family meetings, to present the four cases in the demonstration of the three main themes (Yin, 2011). We believe that the decision to use subcases as a way to convey more general findings can be helpful to other researchers, as it overcomes some limitations of thematic analysis, particularly the fact that it tends to violate the integrity of the situations that qualitative researchers observe in the field.

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Table 1.

The Results of the Analysis.

Codes	Subthemes	Themes
The expert patient The critical patient The invisible patient The likable patient The dutiful patient The controversial patient	The competent patient being an advocate of care	The patients’ need for masquerade to participate
	The conforming patient that fits into the system
	The unsuitable patient being too healthy or demanding
	The vulnerable patient in the meeting with expert views
The attacking relatives The emotional relatives The rational relatives The positive relatives The educated relatives	The sympathetic relative playing on emotions	The strategies of relatives in coming across
	The strategic relative playing on resources
	The conscious relative playing on feedback
The strict coordinator The facilitator The service minded The system defender The correct chairperson The nonauthorities	The director of the degree of patient participation	The professionals’ parts in defining the situation
	The server of the routine with little emphasis on dialogue
	The provider with limited administrative authority

Case 1—Knowledge Is Power

The first family meeting took place in the patient’s room 1 week after patient admission. The highly educated female patient (90 years) was sitting as a “queen” in the room’s only armchair, functioning as a prop. Her hair was freshly prepared, her clothes clean, and she expressed a sense of control. On the bed, her two daughters were sitting, wearing fashionable costumes as well: One of them lived next door to her mother. The nurse and the municipal DC arrived 5 minutes late, which clearly irritated the patient as she looked at her watch and then at her daughters with a strict facial expression. The patient had previously met the nurse but did not know her function, while the coordinator was new to her. As a relatively healthy woman, the patient had not received home services in the past. The atmosphere in the meeting was initially tense, with the patient starting out by saying “Ok, so who is leading this meeting?” thus actually positioning herself as the “director”:

Talking to the patient back-stage after the meeting, she revealed that there was a lack of information the initial days, that is, she did not know that the nurse in front of her was her responsible nurse. Furthermore, she did not feel confident about the medical follow-up, asking the nurse in a critical tone if she was representing the doctor. Finally, she was dissatisfied with the fact that she had not received any physical training. Overall, the patient and her daughters were angry but had decided to keep this as a strategic secret. As a response to the patient’s critical director position, the nurse seemed to put on the mask as a system defender, having an answer to all the indirect accusations instead of apologizing for the lack of follow-up services. In what followed, the patient and her daughters continued to clearly voice their needs in a systematic and competent way as a team, using medical terms, referring to props like the medical journal and the oxygen machine, the hospital doctor and professionalism. Precisely, with few words, they expressed that they knew the patient’s rights:

The atmosphere of the meeting gradually became more positive as the DC responded to the needs of the patient team at all points, expressed as an overall more relaxed tone. Accordingly, the case illustrates all the three main themes from the thematic analysis. Using his position as gate-keeper, the coordinator promises that they will work better in the unit from now on, reflecting the purchaser and provider positions. Within this meeting the coordinator entered a position as facilitator, apologizing for the initial lack of services:

Thus, having started out as three teams, they end up as one team where the patient has been successful in her wishes, being a competent patient and, with help from her daughter, an advocate of care, demonstrating that knowledge is power and clearly an advantage in the masquerade to participate. Positioning herself as the director of her own care, she can thus be placed within the discursive practice of the upcoming active user with knowledge, challenging the traditional medical model and the passive patient just receiving health care.

Case 2—The Broken Dialogue

At the second family meeting, also held in the patient’s room, there was no family member nor any DC present, only the patient and the IC team. The IC team faced the patient in line, like a panel. This female patient (94 years) had applied for a stay in nursing home three times as her health declined. However, the care services claimed that she was not sick enough, even though she had been in and out of hospital with subsequent IC three times over the past months. Furthermore, the patient had recently moved from another unit within the same IC institution. Thus, she was a bit disoriented, and due to short notice, her daughter was not able to participate in the family meeting. In addition, the nursing assistant (NA) started out, using a checklist as a prop, with no initial small talk, to establish a frame or purpose of the meeting. There were two performance teams in this meeting, the IC team asking the questions and the patient as a single performer, trying to answer as best she could, initially forced to choose a rather defensive mask within the apparently unfamiliar setting:

Due to observed hesitation and flickering eyes, it seemed that the patient did not understand the initial questions, felt uncomfortable and that she was not adequately informed about the purpose and function of the meeting. There was a lack of dialogue. Thus, the patient was assigned the position as the vulnerable patient, not able to communicate her real issues. This case illustrates the masks of patient and staff, including the lack of a relative position. The patient was concerned about her clothes. However, at the end of the meeting she reveals her secret, that she is sitting next to an elegant woman with expensive clothes and jewelry. Her real concern was not clean clothes, but being good enough. The patient was also expressing concern regarding the lack of physical activity in the ward. As the meeting unfolded, the physical therapist (PT) took over the director position, asking the patient in a slightly hard and annoyed tone about her physical goals, underlining that everything you do is training.

Previously, the patient went to church and to the day center to socialize. When asked about why she had stopped doing this by the occupational therapist (OT), she pointed out that she did not want to be a burden. She stated: “That’s the worst thing about being old, you don’t want to bother other people.” Overall, the meeting was mostly about physical goals. However, the patient revealed at the end of the meeting that she felt lonely, and experienced a lack of social activities as well. She described the IC unit as “quiet as in the grave.” Although in a nice way, the IC team defended their practice, revealing their focus solely on the physical aspects of function:

The patient, raised during the Second World War, had low education, was not sure if she had nice enough clothes, afraid of being a burden. During conversation the patient expressed several times that the staff were the experts regarding her condition. Thus, the patient is not only positioned as the vulnerable patient, but she also positions herself within the discursive practice of the traditional passive patient who adapts and with a strong belief in authorities.

Case 3—Best of Both Worlds

The next family meeting took place in a conference room 1 week after patient admission. The female patient (86 years) brought her daughter and her son to the meeting. The son came a little late: He was tall with fancy clothes, with the appearance of a successful businessman.

The PT started out as the director, highlighting the patient’s motivation and her intention of getting well. The patient was very pleased, stressing that she had nothing to complain about, smiling, with a positive attitude. Thus, the patient took the position as the conforming patient who fits within the system, adapting to routines, following the schemes. Two teams were playing their roles and positioning each other, trying to define the situation: the patient team (patient and relatives) and the IC team. At the same time, there was a good atmosphere throughout the meeting with laughter and an easy tone. As the play unfolded, the son took over the director role, expressing that the family has large financial resources:

In the further negotiation with the DC, the son discussed the services offered by the district, and what to order from private services to get the best of both worlds. While the son was talking, all the others, the audience, were listening with respect. The patient in this meeting was definitely involved, although presented through her son, who did indeed show her great respect and asked her several times about her opinions and wishes. In the further meeting, the DC was very accommodating in every way, entering a role as a salesperson, service minded, celebrating the idea of using private services. In addition, she gave detailed information about follow-up services in the community, pleasing the customer, even though she at times was talking down the district’s services.

Finally, when the son stated that the patient wanted to be discharged to home the coming Friday, the coordinator recommended waiting until the following Tuesday. The community is better staffed Monday to Friday, so to obtain a high-quality transition, this is better done during the middle of the week. To summarize, the two teams ended up as one team, where the conforming patient and her director son have, through a tactical choice of masks, gained the best from both worlds, demonstrating the strategies of relatives in coming across. In addition, all the participants are coming from the same district with a high socioeconomic status, the patient team, as well as the IC team and the coordinator. The conversation is based on what the patient wants, to obtain a meaningful life, with no restrictions in terms of money. They all can be placed within the same socioeconomic discourse, they understand each other.

Case 4—Play to the Gallery

The last family meeting presented here took place in the patient’s room 6 days after admission to the IC unit. The patient (88 years) was an intense woman, although funny, with a sharp tone, using a lot of words to express herself. Her daughter was also present at the meeting, in addition to the PT, the DC and a nursing assistant. The patient had had an experience of being discharged to home too early 1 year ago, which can be considered as an inside secret of the patient-relative team:

Taking on the role as director, the patient was in a good mood, satisfied with the help she had received in the IC unit so far, both from the nurses, the assistants, and the physical therapist. She felt she had been treated with respect. The IC team asked her initially “what is important to you now?” and in trying to convince the coordinator that she needed more time, she took on a mask as the dutiful patient by explaining in detail how she exercised and utilized the stay as the exemplary patient. However, during her strategy of describing the good effects of IC, she presented a picture of herself as too fit or healthy:

The DC and the IC team had had a meeting in advance, back-stage, before entering the stage, and had already decided that the patient should go home, based on physical criteria. That was their strategic secret. And when they revealed this secret, the patient changed her tactic completely, from being a good or dutiful patient, to being the demanding patient with rather impolite behavior. Despite the switch of mask, the patient still did not come across to change the opinions of the DC and staff.

The daughter eventually accepted the decision, but the patient did not. Thus, when the IC team and the daughter further planned her discharge, the patient faded out, positioned by herself (she lost interest in the conversations) and the other participants (they ignored her) as a nonperson. Here, the coordinator took on the mask as the strict purchaser, and due to everything already decided back-stage, she just provided the information without negotiation. The physical therapist took on the role, seemingly, as the server, asking the patient about her goals. However, due to the predetermined meeting outcome (discharge next day), that was a play to the gallery. The patient started out by positioning herself as the director. However, the coordinator neglects what she says, drawing on the medical discourse with an emphasis mainly on physical function, leaning toward professional expertise, assuming to know what is best for the patient. Thus, the patient is positioned as powerless, which shows the staffs’ enactment in defining the situation. This family meting can be placed within a bureaucratic discourse celebrating efficiency and standardization at the cost of patient participation.

Strengths and Limitations

To capture the negotiation of patient participation within family meetings in IC we used nonparticipant observation, offering a nuanced and dynamic appreciation of the family meetings that cannot be as easily captured through other methods (Liu & Maitlis, 2010). The overt observations took place in three different IC institutions, and all observations were conducted by the same researcher, with broad experience within geriatric rehabilitation and IC. To promote reflexivity, the author responsible for data collection wrote memos throughout the whole period, in addition to taking field notes and audio recordings from all the meetings. All the authors read the transcriptions and the field notes and took active part in all the steps of the analysis. The themes were discussed moving back and forth in the material until agreement was reached and attempted presented with clarity (Morse, 2015).

Although Goffman (1990) provided an interesting lens for understanding the interactions within family meetings in IC, there are aspects of the findings that somehow escape the framework: the premeeting, back-stage decision that one patient should leave (Case 4), and the fact that one family could buy private services on top of the public assistance (Case 3). Both are examples of structural, material conditions that directly shape the content and dynamics of the meetings. Administrative pressure upon care providers limits their ability to give patients a voice. Favorable economic conditions allow a family to obtain the best of both worlds, even beyond the masks they used in the interaction. However, to glimpse behind these structural boundaries to a certain extent, we included concepts such as “positioning” and the force of “discursive practices” (Davies & Harré, 1990). Through discursive practices, people reproduce preexisting social values by positioning themselves, forces that may be supported, resisted, or transformed in the meeting with other individuals.

The researcher’s presence at the meetings may have influenced the participants’ action, for example, the staff may have increased patient participation to provide a good impression of their practice. Linda Kvæl’s background and knowledge within IC services were helpful to access the field in the first place. To obtain trust and a deeper understanding, she spent a certain time in the IC units ahead of the meetings, balancing a close with a distant role to avoid overempathizing with the participants. Each of the 14 family meetings consists of a unique performance and characteristics defining the situations. The low number of observations per IC institution might be a limitation. However, after analyzing all the family meetings, it became clear that the main roles identified within the different institutions were comparable, thus we assume sufficient information power or data saturation (Malterud, Siersma, & Guassors, 2015). Another limitation might be the overrepresentation of the “children’s role” among the relatives. Due to the case study design, the issue of transferability looms larger than with other types of qualitative research. However, much can be learned from a particular case. Erickson argues that since the general lies in the particular, what we learn in a particular case can be transferred to comparable situations (Erickson, 1986). Thus, we believe our findings will have great implications for staff in similar IC units.