Sleep and inequality for older patients going through orthopedic hospitalization and the following rehabilitation at home

Background and purpose: In the Danish welfare system all citizens are ensured free access to public healthcare, and yet inequality in health has been steadily increasing over the past decades. The aim of this paper is to show how an institutional practice of sleep is produced within the orthopedic infrastructure and how this contributes to unequal possibilities for older in rehabilitation. The paper is based on my PhD study on how sleep comes to matter in rehabilitation for older patients. Both institutional rehabilitation practice after orthopedic hospitalization as well as research literature on sleep and rehabilitation addresses sleep as a biological process and resource. From this perspective sleep becomes a matter of concern in relation to the patients’ ability to cope with rehabilitation. The biological factors of bodily pain and distress affect older patients in their rehabilitation process. However, the body is part of a lived life and the local context in which it is formed, which is why I investigate how the becoming of sleep as an institutional as well as an everyday phenomenon intra-acts in the making of bodies to be included in healthcare.

Methodology: I examine sleep as a lived and relational phenomenon, thus as a connection between the body and the social and physical world. I draw on a posthuman theoretical framework primarily with reference to Karen Barad, Donna Haraway, Annemarie Mol, and Gilles Deleuze. I consider the body, sleep, and rehabilitation as becomings, and therefore not as stable and delimited entities that can be addressed from either a biological or a social perspective. I see these becomings as enactments rather than a result of inner translation, which is why I suggest that rehabilitation is not a process of transforming biomedical knowledge into action, but about a body with a long biography enacting a new and changed reality. Based on a diffractive and ethnographic method, I integrate biology, space, time, social factors, psychological factors, institutional practice, and everyday life.

Results: The study shows how sleep becomes a performance within a network of different solutions to mobilize the orthopedic patient pathway. This network builds on an institutionally established concept of the patients’ participation in which sleep, body, and aging is constituted in a biomedical pedagogy based on motivation and moralization during hospitalization. Through this infrastructure sleep becomes a mean for patients to meet the expectations of active participation during hospitalization.
This institutional constitution of sleep diminishes the importance of the living body in clinical practice. However, everyday life is the dimension in which the body, sleep, and rehabilitation comes into being, which is why everyday life cannot be understood as detached from, or as an ‘add-on’ to the biological and medical perspective. On the other hand, everyday life is also shaped through institutional concepts, which creates a certain space-time desire directing bodily practice in rehabilitation. This co-creation between everyday life and institutional constituted approaches to body and time creates potential or non-potential bodies that excludes some older patients from being part of the rehabilitative regime.
The application of a diffractive and ethnographic method enabled me to produce new knowledge about how sleep affects rehabilitation. Knowledge that stresses how present institutional logics of participation, individual responsibility, medical evidence, as well as organizational and financial principles builds on each other and creates time-spatial bodies that matches the activity paradigm of our time and relate to political concepts of good and healthy aging. However, bodies especially those with a long biography, enact reality in unequal ways.