In the following, we present the results of our qualitative analysis in three sections, each of which focuses on one specific topic in our participants’ talk about client involvement, which arose inductively from our analysis of the empirical data. First, we examine how the members of our workshops discussed the ideal of promoting client involvement, demonstrating the high level of consensus that existed among our participants with regard to the topic. Second, we consider an issue that the participants oriented to as more conflicting: is it enough that clients are heard or should they also have actual power to influence the decisions made regarding their services? Finally, we examine the differences in how clients and professionals oriented to the complex interwovenness of cooperation, authority, and responsibility.
3.1. Client Involvement Should be Promoted
In our workshop data, both the clients and the professionals agreed that, on a general level, client involvement should be promoted by giving the clients more opportunities to influence the development of their services. This topic was often discussed as a future ideal, the main obstacle for its current realization being the health care system. The “system” was seen as a common enemy that neither the clients nor the professionals had power to influence. This will be demonstrated in Extract 1, in which one of the professionals (P1) suggests that client involvement necessitates trust between clients and professionals, but that the professionals have not been given time to build trusting relations with clients, as their employer demands them to have a high number of appointments per day. The excerpt is taken from a small group discussion during the first workshop, in which the participants—consisting of both professionals and clients—are given the task to discuss how they understand the concept of client involvement.
- 01 P1:
mikä tohon asiakkaan osallistamiseen
what is needed to make the client involved
tarvitaan niin tota jos on ikääntyneist kyse ni se
I mean erm if they are elderly people then
et saa sen semmosen luottamuksen siihen ni se vaatii
gaining that trust requires sufficient
sen ajan et jos se niinku työnantaja sit taas sanoo
time but if the employer then says that
et pitää olla käyntejä niin ja niin paljo ni sit
you should have so and so many appointments
toisaalta et se et saa sen luottamuksen asiakkaaseen
and on the other hand that trust is needed to
ja saa hänet osallistuu ni tota se tarvitsee kyl sen
get her involved then it really requires a
certain amount of time.=
- 09 P2:
- 10 C1:
ja tähän liittyy myös se et tuota sitte tää
and this is also connected to the point that the
palveluntuottaja tai kotipalvelussa henkilö ei vaihdu
service provider or homecare personnel doesn’t change
tai että lääkäri ei vaihdu tai et (.) sais niinku
or that a doctor doesn’t change or that (.) so that
tniitten määrättyjen tuttujen [ihmisten kanssa asioida.
you could deal with the [same familiar people.
- 14 P2:
[the same employees.
In the first lines (1–7), a professional (P1) elaborates on her view on client involvement. She suggests that, in order to get the client involved, a certain amount of trust between the client and the professional is needed. P1 also states that building a trusting relationship necessitates time, which she does not necessarily have. Immediately after her turn, another professional (P2) shows agreement with her view (line 9). Then, a client (C1) takes a turn, which she constructs as a straight continuation of P1′s turn (note the turn-initial connector ja
“and” in line 10). In C1′s view, the question of trust is further associated with the issue of constantly changing service providers. P2 responds in overlap, suggesting candidate words for her co-participant’s turn completion (line 14). This type of anticipatory co-completion has shown to demonstrate understanding [53
] and strong agreement between participants [54
In sum, both the professionals and clients agreed on the line of action that described obstacles and concerns about the realization of client involvement. They perceived these obstacles as being related to organizational factors that they had no power to influence, such as excessive workload (lines 4–8) and the permanency of the staff (lines 10–14). Thus, when considering client involvement as a future ideal whose realization was out of their hands, the views of the professional and client members of the workshop were mutually congruent.
3.2. Being Heard or Exerting Influence?
Listening to the client is commonly considered a critical component of all aspects of social and health care services, e.g., [55
]. Understanding the client’s situation and lifeworld relies on the professional’s capacity to listen to the client’s experiences and to respond to what they hear [56
]. Being heard during consultations is also something clients seem to desire more than anything else [57
]. In our workshop discussions, both the clients and the professionals considered the professional listening to the client’s questions and concerns a prerequisite of client involvement. This topic was associated with a relatively high level of apparent consensus. Yet, content-wise, the professionals and clients emphasized slightly different ideas, which points to a subtle discrepancy between the views of these two participant groups. Below, we first show an example how this topic was discussed among the professionals only and then an example of the discussion among both professionals and clients.
When conceptualizing client involvement, the professionals stressed the client’s need to be heard and understood. This pattern is exemplified by Extract 2, which starts by one of the professionals (P1) initiating talk about the question “what is client involvement?” asked by the workshop facilitators, and inviting other small-group members to talk about it.
- 01 P1:
mutta se että miten niinku (0.5) sitte se
but then how about like (0.5)
client involvement then,
- 03 P2:
yks on ihan se et miten tulee kuulluks.
one thing is how you are heard.
- 04 P1:
niin ja ymmärretyks sen [tarpeen kanssa,
yes and understood in terms of that [need,
- 05 P3:
- 06 P2:
- 07 P1:
että ku ensin on se tarve.
when first there is that need.
- 08 P2:
- 09 P3:
In lines 1–2, one of the professionals (P1) refers to the assignment (What is client involvement?
) that the small group is supposed to discuss. She leaves the sentence unfinished (note the turn-final particle nii
“then”), thus encouraging the other group members to present their views. As a response, another professional (P2) states that one aspect of client involvement is that the client is heard. P1 immediately responds with the particle nii
“yes,” claiming agreement with the position presented by P2 [59
]. P1 also extends P2′s turn by adding another element, the client’s need to “be understood,” to the basic idea. These types of extensions that grammatically complete the previous sentence have shown to display strong mutual engagement and shared understanding of the matter at hand [60
]. At this point, both P3 (line 5) and P2 (line 6) produce minimal responses, thus demonstrating their agreement with P1′s view. P1 continues by highlighting that it is this client’s need that the professionals should understand (line 7). Again, both P2 and P3 display agreement with the view (lines 8–9). Thus, there seems to be a strong consensus among the professionals that listening to the client and providing them the experience of being heard is what essentially constitutes client involvement.
The clients, however, raised the possibility that being heard is not the same thing as having actual power to influence the decisions about social and health care services. In this way, the clients invoked the question of an equal (or unequal) relationship between the professional and the client. This is what happens in Extract 3, in which the workshop participants are writing their views on post-it notes and choosing pictures that symbolize client involvement.
- 01 P1:
voisko lapset kuvata sitä asiaa
could children illustrate a situation in which
et tulee kuulluks ja nähdyks.
person is heard and seen.
- 03 C1:
onks se nyt jos tulee kuulluks ni onks se
is it then if someone is heard is it then
sama asia ku vaikuttaminen
the same thing as influencing
et saa vaikuttaa jollain tavalla.
that one can influence somehow.
- 06 P2:
joo kyl se niinku joo-o,
yeah I think uh yeah,
- 07 P1:
mun mielest kyllä mut sä voit käyttää myös sitä sanaa.
think yes but you can use that word too.
- 08 C1:
se osallisuus no nii (.) kohdatuksi samanarvoisena.
that involvement yes (.) to be considered equal.
- 09 P1:
kaks viiva kolme kuvakorttii (.) meil on koht
two to three pictures (.) we’ve used
kaikki otettu käyttöön.
almost all of them.
At the beginning of the extract, one of the professionals (P1) proposes a picture with a child on it and suggests that a child could illustrate the experience of being heard (lines 1–2). At that point, a client (C1) takes a turn but, instead of confirming P1′s proposal, he goes back to the professionals’ initial perception that highlighted the importance of being heard and questions if being heard is the same thing as being able to influence things (lines 3–5). The client’s challenge to the professional’s view is implicit in that it is presented in the form of a question, but—importantly—the client still raises the possibility that these two aspects of client participation may not always go hand in hand, which calls into question the emphasis on the professional view. In response to the client’s question, P2 produces a hesitant answer, which action-wise serves as a confirmation that “being heard” and “influencing” could essentially be perceived as the same thing. After this, P1 takes an even stronger position, claiming that, in her view, these two aspects of client participation are the same (line 7). She also concludes by stating that the client can also use the word “influence” (which most likely refers to the participants’ task of writing down their views on a post-it note). By designing her turn as a permission-like “commissive” (see the modal verb voida
“can,” sä voit käyttää
“you can use”; [61
]) P1 positions herself as someone who has the right to direct the client’s actions in a workshop. After P1′s “permission,” the client suggests that involvement could mean that the client is considered equal (line 9). The professionals do not respond to this client’s suggestion but continue with the agenda of the workshop task.
As demonstrated in Extract 3, the clients displayed an orientation to the expectation of what their role should be, not only that they would be heard with respect to their medical conditions and troubles, but that they would be considered equal to the professionals. Indeed, the notion of being heard is inherently asymmetrical in that it applies only to the clients, portraying them in a somewhat passive position in that their involvement is dependent on the professionals’ ability to understand their situation. What was at stake for the clients, then, was the real power to influence decisions about their services.
3.3. Cooperation, Authority, and Responsibility
As pointed out at the beginning of this paper, client involvement is often conceptualized with reference to an equal collaborative partnership between clients and professionals [9
]. By shifting the distribution of power from professionals to clients, the latter are seen to be empowered with greater influence over the decisions that affect them [62
]. The basic assumption is that when participating in making decisions about their own treatment, clients will take more responsibility for their situations and cope better [63
]. The importance of responsibility as a result of empowerment was also acknowledged by the members of our workshops. However, while the professionals emphasized the responsibilities of the clients, they nonetheless defended their own right to decide on the suitable treatment for the client. The clients, on the other hand, resisted not only the professionals’ sole decision-making authority, but also their handing over the responsibilities to them. Again, we first show an example of the discussion among the professionals only and then among the professionals and clients.
The professionals stressed the importance of the clients’ ability to cooperate in matters concerning their own care. The professional view did not really present this cooperative relationship as one between equals. Rather, the professionals expressed their frustration with situations in which clients do not understand what is best for them. According to the professionals, the clients should—paradoxically—accept their inability to understand what is best for them and give the decision-making power to the professionals. This orientation is visible in Extract 4, which starts by one of the professionals (P1) describing the challenges associated with a client refusing to adhere to a treatment recommendation by the professional.
- 01 P1:
on aika haasteellisii tilanteita et kun potilaat ei
it’s quite challenging when the patients refuse
suostu menee tutkimuksiin eikä suostu ottaa lääkkeitä
to go to examinations or won’t take their medication
eikä suostu tekee mitään ku ne ei ymmärrä sitä omaa
or do anything because they don’t understand their own
tilannettaan niin asiathan ei kauheesti etene.
situation so things won’t really progress.
- 05 P2:
- 06 P1:
eikä lääkärikään kauheest siinä voi auttaa jos potilas
and the doctors can’t help much if the patient
ei oo yhteistyökykyinen tai kukaan terveydenhuollon
is incapable of cooperating or no professional
ihminen oikein pysty auttamaan jos ei oo ja se tilanne
can really help if so and that situation
ei parane välttämättä sitte yhtään [myöskään (.)
won’t necessary get any better [either (.)
- 10 P2:
- 11 P1:
pitäiskö nyt laittaa sit lappu,
should we make a note then,
In lines 1–4, P1 produces a three-part list to describe challenging care-work situations. She first mentions clients refusing to go to referred examinations, secondly refusing to take their medication, and thirdly refusing to do anything, this final “extreme case formulation” serving as a way for the professional to legitimize her claim [64
]. She also explains that such problems arise when clients do not understand their own situations (lines 3–4). In this way, the professional implies that the clients actually hinder the progress of their own care (line 4). In line 5, another professional (P2) shows agreement with the view, the particle nii
“yeah” indicating that she is familiar with this type of situation [59
]. P1 continues, stating further that the professional cannot help the client if they are “incapable of cooperating” (lines 6–8). What she seems to be suggesting is that the clients’ cooperation should realize in that they give the professionals the power to decide what is best for them. At this point, P2 minimally agrees, and P1 suggests that they write it down on the post-it note (line 11), thus treating her co-participant’s display of agreement as sufficient [65
Hence, although they emphasized the importance of cooperation, the professionals still portrayed the client’s role as quite passive. In order to receive adequate treatment and for care to progress, the clients were mainly expected to adhere to the professionals’ recommendations. It was thus suggested that the professionals had the ultimate authority to promote what they consider to be the best for the clients.
Interestingly, however, the professionals also highlighted the need for the clients to take responsibility for their own care. This perspective to the issue is demonstrated in Extract 5, in which the participants discuss and write down their conceptualizations of client involvement. At the beginning of the extract, one of the client members of the workshop highlights the need to make a person become involved (line 1). This is, however, met with a lack of substantial agreement. Instead, the professional participants of the group turn the discussion toward the topic of “responsibility” as one aspect of client involvement (line 4).
- 01 C1:
onks se myös et osallistetaan,
is it also that a person is made to get involved,
- 02 P1:
kyllä sitäki paljon käytetään mut ei se,
that’s also used a lot but it isn’t,
- 04 P2:
tavallaan kuitenki myös vastuu,
kind of a responsibility, too
- 05 P1:
nii joo totta.
yeah that’s right.
- 06 P2:
riippuu mit- (0.2) oma vastuu omast itestäki.
it depends wha- (0.2) responsibility for oneself.
- 07 P1:
- 08 P2:
mä nyt laitan sen tähän mukaan.
I’ll put it on here now.
- 09 C1:
After the somewhat ambivalent reaction to the client’s proposal (line 2), P2 suggests the idea that client involvement also involves responsibility. This idea is immediately supported by P1 (yeah that’s right, line 5). At this point it is not yet entirely clear what the term “responsibility” entails, but in line 6, P2 makes it clear that she is talking about one’s responsibility for oneself. In this case, the implication is that the client takes responsibility for their own situation and care. Compared to the viewpoint of the same professionals expressed in Extract 4, this idea is radically different. Now the clients are seen in the active role of empowered actors, who have control over their lives. After P1′s agreement (line 7), P2 displays an orientation to a sufficient level of consensus among the participants by announcing that she will write it down on the note (line 8), see [65
]. At this point, however, one of the clients (C1) takes a turn and expresses a different viewpoint: the client suggests the phrase “being understood” as an alternative conceptualization for client involvement. Thus, quite interestingly, when the professionals’ “unspoken” alternative was to consider clients as influential decision-makers and the professionals handing responsibility over to them, the clients agreed less and suggested something very different from “taking responsibility.”
As shown above (see Extract 4), the professionals referred to their own responsibility and superior authority when deciding on a suitable treatment for their clients, and the clients abiding by this norm was seen as “collaboration.” Extract 6 below demonstrates that clients also orient towards compliance with professionals’ decisions as the one and only option for them to demonstrate their willingness and ability to cooperate. At the beginning of the extract, one of the professionals (P1) states that in health care it is the doctor who makes the decisions.
- 01 P1:
kyllähän mun mielest on ihan selvä etteihän ihminen
I think it’s completely clear that a person can’t
määrittele siis terveydenhoidossa (.) ihminen ei
determine things I mean in health care (.) people can’t
sinänsä voi määritellä miten häntä hoidetaan (.)
in general determine how they’re treated (.)
lääkärihän sen päättää lääkäri vastaa siitä
It’s a doctor who decides a doctor is responsible
mitä voi mut potilas voi hyväksyä sen tai ei tai
but a patient can accept it or not or
ylipäänsä sitä neuvotellen kannattaa tehä,
or in general it’s advisable to negotiate,
- 07 C1:
sit taas jos sä et hyväksy ni sit sä et oo
then again if you don’t accept it then you’re not
hoitomyönteinen (.) tätä oon kuullu tosi paljon kans.
a compliant patient (.) this is something I’ve heard a lot too.
- 09 P1:
joo se varmaan on mut tietyllä tavallahan
yeah it probably is but somehow
se sit vaan on niin että tietyi asioita on sitten
it just is so that some things just are like that
sellasii (.) et ihminen ei voi tilata hoitoa ku pizzaa.
(.) people can’t order a treatment like a pizza.
- 12 P2:
kaikkee ei voi hoitaa kaikel tapaa et jotku asiat pitää
everything can’t be treated in every way there are some things
hoitaa tietyl tapaa et ne tulee hoidetuks.
that have to be treated in a certain way so to that they will be taken care of.
- 14 P1:
nii et semmosia hoitojuttuja mitkä yleisesti tiedetään
so certain treatment things that are generally known to be
toimiviks et kyllä tässä se semmonen rajanveto tai
effective that there is this kind of line to be drawn
käynti että ihminen tulee kuulluks ja saa sanoo oman
that a person is heard and can state their own
sanansa mutta että tulee sit kuitenkin se hoito tietyl
opinion but that the treatment is determined
in a certain way.
- 19 C1:
nii eihän noi yksinkertaisia asioit oo.
yes these are not simple things.
- 20 P1:
ja siitä se kai periaatteessa se puhuminen vast alkaa
and in principle that’s when the talking begins
jos ollaan kauheen eri mieltä et miten se sit hoidetaan.
when we really disagree on how it’s to be handled.
((begins to talk about the organization moving to a new building))
In lines 1–4, P1 makes a strong statement that, in health care, a person cannot determine how they are treated. P1 uses the clitic particle -hän
, line 1), which has been argued to indicate common knowledge [66
] and expresses certainty in talk (ihan selvä
“completely clear”). P1, in other words, presents her view as something that is self-evident. By announcing and reminding others about this state of affairs, P1 also positions herself as more authoritative and knowledgeable than the others. In line 4, P1 further states that it is a doctor who “decides.” However, she immediately corrects her own speech and states that it is a doctor who is “responsible” for the treatment. By this type of self-repair, P1 displays her normative orientation towards what is meant to be talked about in the given context [67
]. It seems that in the contemporary “client involvement discourse,” professionals’ responsibilities may well be normatively easier to topicalize than their decision-making authority over the client. Indeed, in lines 5–6, P1 seems to seek to further mitigate her prior view on decision-making, emphasizing that it is not only the professional alone, but the client and professional together, who negotiate treatment decisions. The client’s role in this negotiation is, however, presented as narrow: the client can either accept or refuse the professionals’ decisions (line 5).
At this point, however, one of the clients (C1) states—possibly sarcastically—that if a client does not accept the professional’s decision, then they are not seen as hoitomyönteinen
“compliant” (lines 7–8). With this statement, the client seems to be referring to the traditional view according to which a “good patient” is passive and compliant, e.g., [68
]. Thus, if a client wants to be a “good patient”—that is, to cooperate and play the game with its long-established rules [50
]—they have no other option but to accept the professional’s decision. In this way, the client expresses doubt about their ability to genuinely have a say in the decisions made in social and health care encounters. The client substantiates his claim by also pointing out that this is something he has heard from others and does not represent (only) his own experience.
In lines 9–11, P1 responds to the client. She reformulates her prior statement by using a figurative expression “people can’t order a treatment like a pizza” (line 11), which, in this context, comes across as highly defensive. These types of expressions have been observed in connection with complaints, for example, to enhance their legitimacy and to bring the complaint sequence to a close in the face of a lack of agreement [70
]. At this point, another professional (P2) joins the conversations, supporting P1′s view (lines 12–13). He emphasizes the need to have hoitojuttuja
“treatment things” managed in a certain way, which means favoring the solutions that have proven to be effective. He also highlights a need to draw the line between a client being heard and stating their opinion, on the one hand, and the professional determining the client’s treatment, on the other (lines 14–18). The client concedes by agreeing that these are not simple things to deal with (line 19), which is followed by P1 pointing out that client disagreements will be dealt with as they occur in the social and health care encounters. With this comment, P1 closes the discussion and moves on to a new topic.
Thus, even if the professional in this situation expressed willingness to attend to clients’ concerns in the future once they become relevant during the consultations, in so doing, she ignored the client’s concern in the here and now of the client involvement workshop encounter. In this case, the client’s concern was on a meta level, being about his theoretical opportunity to have a say in decisions about his own care.