Encircling discourses-A guide to critical discourse analysis in caring science.

AIM: The aim of this article was to introduce Fairclough's critical discourse analysis (CDA) in caring and nursing science, to provide a guide on how to perform such an analysis, and to describe the wider context of discourse epistemology. DESIGN: The article is designed as a methodological paper, including (a) epistemological roots of discourse analysis, (b) an overview of discourse analytical research within caring and nursing science which points out an increased trend, and (c) a guide to conducting a CDA. ANALYSIS: It is important that discourse analysis is available and accessible to nursing and caring researchers. Through the process of encircling discourses, valuable insight is given into fields that otherwise would be lost or would not be available. CONCLUSION: Our summary stance is that discourse analysis as it is presented in this article is strongly advisable for use in nursing and caring sciences.

Scandinavian Online Cancer Information as Expressions of Governmentality: A Comparative Qualitative Study.

We compared online distributed information provided to patients with cancer in Scandinavian countries through the lens of governmentality. A secondary comparative qualitative analysis was conducted. Discourses in online patient information showed differences in governmentality techniques across the countries: Norway used a paternalist approach, Denmark an educative approach, and Sweden an individualistic approach and expected the patients to make the "right" decisions. Online information for patients with cancer in Denmark and Norway showed high professional and health care system involvement, whereas in Sweden, there was high patient involvement. There was almost no use of the person-centered approach among the online discourses.

Manoeuvring between interplay and context- an ethnographic study of social interaction in encounters between registered nurses, older patients and their relatives.

BACKGROUND: Social interactions between registered nurses, older patients and their relatives are essential and play a central role in developing a successful care relationship in healthcare encounters. How nurses interact with patients affects the patient's well-being. Limited time and demands for efficiency influence the encounter and complaints from patients and relatives often concern social interactions. Therefore, the aim of this study was to explore the social interaction in encounters between registered nurses, older patients and their relatives at a department of medicine for older people. METHODS: The study has an ethnographic approach including participatory observations (n = 21) and informal field conversations (n = 63), followed by a thematic analysis with an abductive approach reflecting Goffman's interactional perspective. RESULT: The result revealed a pattern where the participants manoeuvred between interplay and context. By manoeuvring, they defined roles but also created a common social situation. Nurses led the conversation; patients followed and described their health problems, while relatives captured the moment to receive and provide information. Finally, nurses summarised the encounter using ritual language, patients expressed gratitude through verbal and non-verbal expressions, while relatives verbally confirmed the agreements. CONCLUSION: The social interaction between registered nurses, older patients and relatives was shaped by a pattern where the participants manoeuvred between interplay and context. When all participants assume responsibility for the social interaction, they become active and listen to each other. The approach adopted by nurses is crucial, thus training in communication and social interaction skills are important. When the asymmetry due to imbalance, is reduced, less misunderstanding and a satisfactory care relationship can be achieved.

The reasonable patient - A Swedish discursive construction.

The aim of this study was to analyse how the patient is constructed and socially positioned in Swedish patient information. Corpus-assisted critical discourse analysis methodology was utilised on a sample of 56 online patient information texts about cancer containing a total of 126,711 words. The findings show an overarching discourse of informed consent guided by specific features to produce a patient norm that we name "the reasonable patient", who is receptive to arguments, emotionally restrained and makes decisions based on information. Through the discourse of informed consent, the norm of the reasonable patient emerges, apparently to even out the imbalance of power between patient and professional, but in reality, more likely to construct a patient who is easily controlled and managed. When the self-responsibility towards health is incorporated into the everyday domestic spaces via digital health technologies, the ideas and concepts of the patient role need to be reconsidered based on these new conditions. We conclude that it is important for nursing researchers to broaden the research on patients to include the relationship of power created through language. This study demonstrates both methodological and empirical possibilities to do so.

Striving to establish a care relationship-Mission possible or impossible?-Triad encounters between patients, relatives and nurses.

BACKGROUND: When patients, relatives and nurses meet, they form a triad that can ensure a good care relationship. However, hospital environments are often stressful and limited time can negatively affect the care relationship, thus decreasing patient satisfaction. OBJECTIVE: To explain the care relationship in triad encounters between patients, relatives and nurses at a department of medicine for older people. DESIGN: A qualitative explorative study with an ethnographic approach guided by a sociocultural perspective. METHOD: Participatory observations and informal field conversations with patients, relatives and nurses were carried out from October 2015-September 2016 and analysed together with field notes using ethnographic analysis. RESULT: The result identifies a process where patients, relatives and nurses use different strategies for navigating before, during and after a triad encounter. The process is based on the following categories: orienting in time and space, contributing to a care relationship and forming a new point of view. CONCLUSION: The result indicates that nurses, who are aware of the process and understand how to navigate between the different perspectives in triad encounters, can acknowledge both the patient's and relatives' stories, thus facilitating their ability to understand the information provided, ensure a quality care relationship and strengthen the patient's position in the health-care setting, therefore making the mission to establish a care relationship possible.

Voices used by nurses when communicating with patients and relatives in a department of medicine for older people-An ethnographic study.

AIMS AND OBJECTIVES: To describe how nurses communicate with older patients and their relatives in a department of medicine for older people in western Sweden. BACKGROUND: Communication is an essential tool for nurses when working with older patients and their relatives, but often patients and relatives experience shortcomings in the communication exchanges. They may not receive information or are not treated in a professional way. Good communication can facilitate the development of a positive meeting and improve the patient's health outcome. DESIGN: An ethnographic design informed by the sociocultural perspective was applied. METHODS: Forty participatory observations were conducted and analysed during the period October 2015-September 2016. The observations covered 135 hours of nurse-patient-relative interaction. Field notes were taken, and 40 informal field conversations with nurses and 40 with patients and relatives were carried out. Semistructured follow-up interviews were conducted with five nurses. RESULTS: In the result, it was found that nurses communicate with four different voices: a medical voice described as being incomplete, task-oriented and with a disease perspective; a nursing voice described as being confirmatory, process-oriented and with a holistic perspective; a pedagogical voice described as being contextualised, comprehension-oriented and with a learning perspective; and a power voice described as being distancing and excluding. The voices can be seen as context-dependent communication approaches. When nurses switch between the voices, this indicates a shift in the orientation or situation. CONCLUSION: The results indicate that if nurses successfully combine the voices, while limiting the use of the power voice, the communication exchanges can become a more positive experience for all parties involved and a good nurse-patient-relative communication exchange can be achieved. RELEVANCE TO CLINICAL PRACTICE: Working for improved communication between nurses, patients and relatives is crucial for establishing a positive nurse-patient-relative relationship, which is a basis for improving patient care and healthcare outcomes.

What are they talking about? Content of the communication exchanges between nurses, patients and relatives in a department of medicine for older people-An ethnographic study.

AIMS AND OBJECTIVES: To explore and describe the content of the communication exchanges between nurses, patients and their relatives in a department of medicine for older people in western Sweden. BACKGROUND: Information, messages and knowledge are constantly being communicated between nurses, older patients and relatives in the healthcare sector. The quality of communication between them has a major influence on patient outcomes. A prerequisite for good care to be given and received is that there is mutual understanding between the parties involved. DESIGN: An ethnographic study was informed by a sociocultural perspective. METHOD: Data were collected through 40 participatory observations of meetings between nurses and older patients and/or relatives which covered 135 hr of nurse-patient-relative interaction, field notes, 40 field conversations with 24 nurses and 40 field conversations with patients (n = 40) and relatives (n = 26). Five semi-structured interviews were conducted with nurses. An ethnographic analysis was performed. RESULTS: The analysis identified three categories of content of the communication exchanges: medical content focusing on the patient's medical condition, personal content focusing on the patient's life story and explanatory content focusing on the patient's health and nursing needs. The content is influenced by the situation and context. CONCLUSIONS: Nurses would benefit from more awareness and understanding of the importance of the communication content and of the value of asking the didactic questions (how, when, what and why) to improve the patients' and relatives' understanding of the information exchanges and to increase patient safety. RELEVANCE TO CLINICAL PRACTICE: Nurses can use the communication content to create conditions enabling them to obtain a holistic view of the patient's life history and to develop an appropriate person-centred care plan.

Learning by supporting others-experienced parents' development process when supporting other parents with a child with type 1 diabetes.

AIMS AND OBJECTIVES: To describe and analyse coach-parents' development process when supporting parents of children recently diagnosed with type 1 diabetes mellitus (T1DM). BACKGROUND: It has been found repeatedly that providing social support for families with a child diagnosed with T1DM promotes health and well-being for both the child and the parents. Less explored are the processes experienced by those who provide this support. However, research has found that acting as a provider of social support promotes personal development, strengthens communication skills and increases self-confidence. METHODS: The study design was based on Constructivist Grounded Theory, and data were collected, through repeated focus-group discussions, from eight coach-parents at a Swedish hospital from 2012-2015. RESULTS: The core category in the data was identified as a learning process where coach-parents emphasised their own learning in the dyad supporter-supported, and in the interaction with other parents in the repeated focus-group discussions. The coach-parents' motivation for participation was a wish to learn more and to help other parents in a life-changing situation. They also pointed out hindrances and their frustration when unable to provide support. CONCLUSIONS: This study leads to the conclusion that people who provide support benefit from doing so. Encountering people with similar experiences in a supportive situation promotes a reciprocal learning process, based on the supporter's wish to help people in a situation they recognise. A further conclusion is that social support is not only essential initially, but is also important over a longer period and that it follows various life stages. RELEVANCE TO CLINICAL PRACTICE: Setting up repeated focus-group discussions might be a relevant and effective tool for paediatric diabetes nurses to use in promoting health and well-being for both families with a newly diagnosed child and experienced families.

Health care to empower self-care in adolescents with type 1 diabetes mellitus and an immigrant minority background.

BACKGROUND: The pediatric diabetes team aims to support health, quality of life, and normal growth and development among adolescents with type 1 diabetes mellitus. Adolescents with an immigrant background have been found less successful in self-care. Previous research indicated that adolescents who had integrated the disease as a part of their self-image reasoned differently about their self-care to those who had not. OBJECTIVE: The aim of this study was to identify elements in the patient-pediatrician consultations that might influence such integration of the disease among adolescents with type 1 diabetes mellitus. METHODS: A total of 12 pediatrician-adolescent consultations were video-recorded and analyzed. The adolescents all had an immigrant background. RESULTS: Integration of the disease appeared enabled when responsibility was shared; when hope, autonomy, and emotions were confirmed; and when the pediatrician asked probing questions. Letting objective data dominate the adolescent's experiences, using risk as a motivator, neutralizing emotions in relation to having diabetes, and confirming forgetfulness, may instead inhibit disease integration. CONCLUSION: An extended person-centered approach with focus on the adolescent's experiences of everyday life with a chronic disease and less attention on physical parameters in the pediatrician-adolescent consultations may increase integration of the disease.

"The Emperor's new clothes": discourse analysis on how the patient is constructed in the new Swedish Patient Act.

The Swedish welfare debate increasingly focuses on market liberal notions and its healthcare perspective aims for more patient-centered care. This article examines the new Swedish Patient Act describing and analyzing how the patient is constructed in government documents. This study takes a Foucauldian discourse analysis approach following Willig's analysis guide. The act contains an entitlement discourse for patients and a requirement discourse for healthcare personnel. These two discourses are governed by a values-based healthcare discourse. Neo-liberal ideology, in the form of New Public Management discourse, focusing on the value of efficiency and competition, is given a hegemonic position as laws and regulations are used to strengthen it. The new Swedish Patient Act seems to further strengthen this development. The Act underlines the increased entitlement for patients, but it is not legally binding as it offers patients only indirect entitlement to influence and control their care. To safeguard the patient's entitlement under the Patient Act, healthcare personnel should be made aware of the contents of the Act, so that they can contribute to the creation of systems and working methods that facilitate respect of the Act's provisions in daily healthcare work.

Conceptions of diabetes and diabetes care in young people with minority backgrounds.

Adolescents with type 1 diabetes (T1DM) need stable self-care routines for good metabolic control to minimize future cardiovascular health complications. These routines are demanding, and might be particularly challenging in underprivileged groups. The aim of this study was to gain in-depth knowledge on the experience of adolescents with T1DM and a non-Swedish background regarding factors that might influence their ability to take care of themselves; in particular, factors that might influence diabetes management routines, their social situation, and the support they receive from caregivers. We interviewed 12 adolescents with T1DM and minority backgrounds. The results indicated resources and constraints in the adolescents' social context and in the health care organization. The adolescents developed conceptions that helped to explain and excuse their self-care failures, and their successes. These findings highlight the importance of integrating T1DM as part of the individual's personal prerequisites. We discuss implications for the organization of diabetes care for adolescents.

Fathers of Children With Type 1 Diabetes: Perceptions of a Father's Involvement From a Health Promotion Perspective.

This study describes how fathers of children diagnosed with type 1 diabetes understand their involvement in their child's daily life from a health promotion perspective. Sixteen Swedish fathers of children living with type 1 diabetes were interviewed. Manifest and latent content analysis was used to identify two themes: the inner core of the father's general parental involvement and the additional involvement based on the child's diabetes. The former was underpinned by the fathers' prioritization of family life and the fathers being consciously involved in raising the child, and the latter by the fathers promoting and controlling the child's health and promoting and enabling the child's autonomy. The results highlight that the quality of the fathers' involvement is essential in the management of a child's chronic illness. It is important for pediatric diabetes health care professionals to assess the quality of fathers' involvement to promote the child's health.

Fathers' encounter of support from paediatric diabetes teams; the tension between general recommendations and personal experience.

The purpose of this grounded theory study was to explore and discuss how fathers involved in caring for a child with type 1 diabetes experienced support from Swedish paediatric diabetes teams (PDTs) in everyday life with their child. Eleven fathers of children with type 1 diabetes, living in Sweden and scoring high on involvement on the Parental Responsibility Questionnaire, participated. Data were collected from January 2011 to August 2011, initially through online focus group discussions in which 6 of 19 invited fathers participated. Due to high attrition, the data collection continued in eight individual interviews. A semi-structured interview guide was used, and the fathers were asked to share experiences of their PDT's support in everyday life with their child. A simultaneous and constant comparison approach to data collection and analysis allowed the core category to emerge: the tension between general recommendations and personal experience. This core category illuminates how the fathers experienced tension between managing their unique everyday life with their child and balancing this to meet their PDT's expectations with regard to blood glucose levels. The core category was supported by two categories: the tension between the fathers'and their PDT's knowledge, whereby fathers reported discrepancies between their PDT's medical knowledge and their own unique knowledge of their child; and the tension between the fathers'and their PDT's goals, whereby the fathers identified differences between the family's and their PDT's goals. As a dimension of the core category, fathers felt trust or distrust in their PDT. We conclude that to achieve high-quality support for children with diabetes and to enhance their health and well-being, involved fathers' knowledge of their unique family situation needs to be integrated into the diabetes treatment.

Swedish pediatric diabetes teams' perception of fathers' involvement: A Grounded Theory study.

The purpose of this study was to analyze how Swedish pediatric diabetes teams perceived and discussed fathers' involvement in the care of their child with type 1 diabetes. It also aimed to discuss how the teams' attitudes towards the fathers' involvement developed during the data collection process. The Constructivist Grounded Theory design was used and data were collected during three repeated focus group discussions with three Swedish pediatric diabetes teams. The core category of the teams' perception of fathers' involvement emerged as: If dad attends, we are happy - if mom doesn't, we become concerned. Initially the teams balanced their perception of fathers' involvement on the mother's role as the primary caregiver. In connection with the teams' directed attention on fathers, in the focus group discussions, the teams' awareness of the importance of fathers increased. As a consequence, the team members began to encourage fathers' engagement in their child's care. We conclude that by increasing the teams' awareness of fathers as a health resource, an active health promotion perspective could be implemented in pediatric diabetes care.

Parents' discursive resources: analysis of discourses in Swedish, Danish and Norwegian health care guidelines for children with diabetes type 1.

The incidence of diabetes type 1 in children, the most common metabolic disorder in childhood, increases worldwide, with highest incidence in Scandinavia. Having diabetes means demands in everyday life, and the outcome of the child's treatment highly depends on parents' engagement and involvement. The aim of this study was to explore and describe discourses in health care guidelines for children with diabetes type 1, in Sweden, Norway and Denmark during 2007-2010, with a focus on how parents were positioned. As method a Foucauldian approach to discourse analysis was applied, and a six-stage model was used to perform the analysis. The findings shows a Medical, a Pedagogic and a Public Health discourse embedded in the hegemonic Expert discourse. The Expert discourse positioned parents as dependent on expert knowledge, as recipients of education, as valuable and responsible for their child's health through practicing medical skills. This positioning may place parents on a continuum from being deprived of their own initiatives to being invited to take an active part and could result in feelings of guilt and uncertainty, but also of security and significance. From this study we conclude that guidelines rooted in the Expert discourse may reduce opportunities for parents' voices to be heard and may overlook their knowledge. By broadening the selection of authors of the guidelines to include patients and all professionals in the team, new discourses could emerge and the parents' voice might be more prominent.