Discursive construction of the patient in online clinical cancer pathways information

Aim: To explore how the patient is constructed and socially positioned in discourses of web-based pathways information available to cancer patients in Norway.Design: Mixed qualitative and quantitative design, using Corpus-Assisted Critical Discourse Analysis.Methods: The study, conducted in January 2020, examined the language of one general and six specific web-based cancer pathways information brochures. The approach combines analysis of word frequencies and concordance lines using corpus analysis software to identify the ‘linguistic fingerprint’ or ‘aboutness’ of the text prior to further qualitative critical discourse analysis.Results: The analysis identified three core discourses which constructed the patient differently: 1) a participating active person, in a brief, inclusive discourse; 2) a passive person lacking knowledge or perception of their situation within dominant, medical and interprofessional expert discourse; and 3) reduced to a disease and a code in the pathways discourse.Conclusion: This study offers insight into the construction of patients in online clinical pathways information for cancer treatment. The analysis revealed how governance systems such as New Public Management and its demands on efficiency and productivity influence the cancer pathways. The World Health Organization has promoted a person-centered approach, emphasizing the importance of participation and a partnership of equals. A person-centered approach to care was not evident in the discourse of the online documents. The dominant ideology of these pathways was paternalistic with patients constructed as passive persons who get standardized treatment.Impact:This study gives new insight that can be valuable for nurses, other healthcare professionals and the government. The lack of a person-centred focus in the cancer pathway information could have a negative impact on the patient`s health outcomes by promoting a culture of inattention to the patients’ needs and wishes among practitioners. The results may provide a stimulus for discussion about the role of patients in cancer treatment.Keywords

Fra paternalisme til pasientmedvirkning? Eldre pasienter som blir behandlet med hemodialyse, deres nære pårørende og sykepleiere: et diskursivt perspektiv på erfaringer med pasientmedvirkning i dialyseavdelinger

The rights of patients and their families to participate in treatment and health care are guaranteed by international law and by national law in Norway since 1999. The overall aim of this thesis is to explore and analyze the discursive practices of patient participation in the context of hemodialysis. It is not found previous studies that deal with this topic. Research Questions: 1. How do older patients with chronic renal failure undergoing hemodialysis treatment perceive patient participation? 2. How do family members of older patients with chronic renal failure undergoing hemodialysis treatment perceive patient participation? 3. How do nurses perceive the way in which patients over 75 years undergoing hemodialysis and their next of kin participate in treatment and interact with the clinical team? Method and theory: The studies have an explorative, qualitative and critical approach. Data were derived from transcribed interviews with eleven patients, seven family members and ten nurses. Fairclough’s critical discourses analysis was used to analyze the data, and interpretations were undertaken through Fairclough’s discourse theory, theory about patient participation and ethical theory. Results: From the patients perspective two discursive practices are found: 1) the health-care team`s power and dominance 2) the patients struggling for shared decision- making. From the family members perspective three discursive practices were found: (1) to care and take control, (2) to struggle for involvement, and (3) to be forgotten and powerless. From a nurse's perspective, three discursive practices were found: 1) the nurses' power and control, 2) sharing power with the patient, 3) transferring power to the next of kin. Conclusion: The rights of older patients and their next of kin to participate in hemodialysis treatment seemed not to be well integrated as a social practice in dialysis units. The predominant discourse in the dialysis units in connection to older patients undergoing hemodialysis treatment and their next of kin seemed to have an ideology of paternalism. The paternalistic discourse was dominant both in the patients, the next of kin and the nurses’ stories. The nurses generally used a biomedical explanation and passive patients and the ethical principle of beneficence to justify their actions. However, from both the patients and their next of kin and the nurses there was a discourse of patient participation, a discursive practice with focus on dialogue, shared power and shared decision-making, as can be seen as a hegemonic struggle to establish ideological meaning of patient participation. The patients and their next of kin struggle for participation, some of the nurses express an ideology and a social practice of patient participation. These nurses showed support for engaging in dialogue and shared decision-making and for using ethical narratives as a way of allowing older patients undergoing hemodialysis to participate in their treatment. The nurses justified their actions with relational ethics. The difficult decisions in relation to termination of treatment seemed to involve autonomous decision-making and the ethical principle of autonomy as is transferred to the next of kin. Changing the social practices in dialysis units from a paternalistic ideology to an ideology of patient participation will require an assessment of the context, the dialogue and the process of sharing power and decision making with patients and their family

Nurses’ discursive construction of older adult immigrant patients in hospitals

Abstract Background The immigrant population across Europe is ageing rapidly. Nurses will likely encounter an increasing number of patients who are older adult immigrants. Moreover, access to and equal provision of healthcare is a key issue for several European countries. The relationship between nurses and patients is asymmetrical with unequal power relations; however, the way nurses construct the patient through language and discourse can help maintain or change the balance of power. Unequal power relations can affect access and be a hindrance to equal healthcare delivery. Hence, the aim of this study is to explore how older adult immigrants are discursively constructed as patients by nurses. Methods An exploratory qualitative design was used. Data were collected through in-depth interviews with a purposive sample of eight nurses from two hospitals. The nurses’ narratives were analysed using critical discourse analysis (CDA) as described by Fairclough. Results The analysis identified an overarching, stable, and dominant discursive practice; ‘The discourse of the other’, with three interdiscursive practices: (1) ‘The discourse on the immigrant patient versus an ideal patient’; (2) ‘The expert discourse’; and (3) ‘The discourse of adaption’. Older immigrant adults were constructed as ‘othered’ patients, they were different, alienated, and ‘they’ were not like ‘us’. Conclusion The way nurses construct older adult immigrants as patients can be an obstacle to equitable health care. The discursive practice indicates a social practice in which paternalism overrides the patient’s autonomy and generalization is more prevalent than a person-centred approach. Furthermore, the discursive practice points to a social practice wherein the nurses’ norms form the basis for normal; normality is presumed and desirable. Older adult immigrants do not conform to these norms; hence, they are constructed as ‘othered’, have limited agency, and may be considered rather powerless as patients. However, there are some examples of negotiated power relations where more power is transferred to the patient. The discourse of adaptation refers to a social practice in which nurses challenge their own existing norms to best adapt a caring relationship to the patient’s wishes

Viewing the image? Ultrasound examination during abortion preparations, ethical challenges

During preparation for early abortion in Norway, an ultrasound examination is usually performed to determine gestation and viability. This article aims to provide a deeper understanding of women’s and health care personnel’s (HCP) experiences with ultrasound viewing during abortion preparation in the first trimester. Qualitative in-depth interviews with women who had been prepared for early abortion and focus group interviews with HCP from gynaecological units were carried out. A hermeneutic-phenomenological analysis, inspired by van Manen, was chosen. Thirteen women who were pregnant and considering abortion in their first trimester and 20 HCP, namely, 19 registered nurses and one medical doctor, were recruited from gynaecological units at six hospitals. The study was approved by the ethics committee (2014/1276). The essential meaning structure of ‘autonomy under pressure’ consisted of two themes that expressed the different experiences of both the women and the HCP, namely, expectations versus precautions and choice versus protection. The women and HCP expressed different attitudes before the consultation that affected their experiences of the ultrasound examination. While the women had expectations of a clarification based on their choice to either see or not see the ultrasound image, HCP seemed to be more concerned with predetermined rules that they believed would protect the women. Consequently, the basis for dialogue was not optimal, and women’s autonomy was under pressure. Health care personnel are ethically challenged during preabortion ultrasound examinations. Meeting the individual woman’s needs and respecting her autonomy during preparation for abortion requires sensitivity, involvement, and dialogue skills by health personnel. According to the woman’s desire to be informed about the possibility of viewing the image during the abortion preparations, a dialogue that is focused in this direction should arise before the examination

Viewing the image? Ultrasound examination during abortion preparations, ethical challenges

During preparation for early abortion in Norway, an ultrasound examination is usually performed to determine gestation and viability. This article aims to provide a deeper understanding of women’s and health care personnel’s (HCP) experiences with ultrasound viewing during abortion preparation in the first trimester. Qualitative in-depth interviews with women who had been prepared for early abortion and focus group interviews with HCP from gynaecological units were carried out. A hermeneutic-phenomenological analysis, inspired by van Manen, was chosen. Thirteen women who were pregnant and considering abortion in their first trimester and 20 HCP, namely, 19 registered nurses and one medical doctor, were recruited from gynaecological units at six hospitals. The study was approved by the ethics committee (2014/1276). The essential meaning structure of ‘autonomy under pressure’ consisted of two themes that expressed the different experiences of both the women and the HCP, namely, expectations versus precautions and choice versus protection. The women and HCP expressed different attitudes before the consultation that affected their experiences of the ultrasound examination. While the women had expectations of a clarification based on their choice to either see or not see the ultrasound image, HCP seemed to be more concerned with predetermined rules that they believed would protect the women. Consequently, the basis for dialogue was not optimal, and women’s autonomy was under pressure. Health care personnel are ethically challenged during preabortion ultrasound examinations. Meeting the individual woman’s needs and respecting her autonomy during preparation for abortion requires sensitivity, involvement, and dialogue skills by health personnel. According to the woman’s desire to be informed about the possibility of viewing the image during the abortion preparations, a dialogue that is focused in this direction should arise before the examination

Viewing the image? Ultrasound examination during abortion preparations, ethical challenges

During preparation for early abortion in Norway, an ultrasound examination is usually performed to determine gestation and viability. This article aims to provide a deeper understanding of women’s and health care personnel’s (HCP) experiences with ultrasound viewing during abortion preparation in the first trimester. Qualitative in-depth interviews with women who had been prepared for early abortion and focus group interviews with HCP from gynaecological units were carried out. A hermeneutic-phenomenological analysis, inspired by van Manen, was chosen. Thirteen women who were pregnant and considering abortion in their first trimester and 20 HCP, namely, 19 registered nurses and one medical doctor, were recruited from gynaecological units at six hospitals. The study was approved by the ethics committee (2014/1276). The essential meaning structure of ‘autonomy under pressure’ consisted of two themes that expressed the different experiences of both the women and the HCP, namely, expectations versus precautions and choice versus protection. The women and HCP expressed different attitudes before the consultation that affected their experiences of the ultrasound examination. While the women had expectations of a clarification based on their choice to either see or not see the ultrasound image, HCP seemed to be more concerned with predetermined rules that they believed would protect the women. Consequently, the basis for dialogue was not optimal, and women’s autonomy was under pressure. Health care personnel are ethically challenged during preabortion ultrasound examinations. Meeting the individual woman’s needs and respecting her autonomy during preparation for abortion requires sensitivity, involvement, and dialogue skills by health personnel. According to the woman’s desire to be informed about the possibility of viewing the image during the abortion preparations, a dialogue that is focused in this direction should arise before the examination.publishedVersio

Beyond autonomy and care: Experiences of ambivalent abortion seekers

Background While being prepared for abortions, some women experience decisional ambivalence during their encounters with health personnel at the hospital. Women’s experiences with these encounters have rarely been examined. Objective The objective of this study was to explore ambivalent abortion-seeking women’s experiences of their encounters with health personnel. Research design The data were collected in individual interviews and analysed with dialogical narrative analyses. Participants and research context Thirteen women (aged 18-36 years), who were uncertain of whether to terminate their pregnancies during the first trimester, were interviewed before and after they made their decisions. The participants were recruited at six Norwegian outpatient clinics. Ethical considerations Approval was granted by the Regional Committee for Medical and Health Research Ethics. Findings The ambivalent pregnant women sought to make autonomous decisions while simultaneously involving their closest confidants and health personnel in the process. The following three types of narratives of women’s experiences with encounters with health personnel were identified: the respected women, the identified women and the abandoned women. Discussion The findings are discussed in terms of the ambivalent pregnant woman’s autonomous responsibility in considering an abortion and how her autonomy can be enabled or impaired during encounters with health personnel. Conclusion and implication Although the women considered themselves autonomous and responsible for their final decisions, they wished health personnel were involved in their situations. The health personnel contributed by enabling or disabling the possibility of decision-making in accordance with the women’s values. The findings indicate that health personnel who care for women considering abortions must be trained in dialogical competence

Beyond autonomy and care: Experiences of ambivalent abortion seekers

Background While being prepared for abortions, some women experience decisional ambivalence during their encounters with health personnel at the hospital. Women’s experiences with these encounters have rarely been examined. Objective The objective of this study was to explore ambivalent abortion-seeking women’s experiences of their encounters with health personnel. Research design The data were collected in individual interviews and analysed with dialogical narrative analyses. Participants and research context Thirteen women (aged 18-36 years), who were uncertain of whether to terminate their pregnancies during the first trimester, were interviewed before and after they made their decisions. The participants were recruited at six Norwegian outpatient clinics. Ethical considerations Approval was granted by the Regional Committee for Medical and Health Research Ethics. Findings The ambivalent pregnant women sought to make autonomous decisions while simultaneously involving their closest confidants and health personnel in the process. The following three types of narratives of women’s experiences with encounters with health personnel were identified: the respected women, the identified women and the abandoned women. Discussion The findings are discussed in terms of the ambivalent pregnant woman’s autonomous responsibility in considering an abortion and how her autonomy can be enabled or impaired during encounters with health personnel. Conclusion and implication Although the women considered themselves autonomous and responsible for their final decisions, they wished health personnel were involved in their situations. The health personnel contributed by enabling or disabling the possibility of decision-making in accordance with the women’s values. The findings indicate that health personnel who care for women considering abortions must be trained in dialogical competence

Beyond autonomy and care: Experiences of ambivalent abortion seekers

Background While being prepared for abortions, some women experience decisional ambivalence during their encounters with health personnel at the hospital. Women’s experiences with these encounters have rarely been examined. Objective The objective of this study was to explore ambivalent abortion-seeking women’s experiences of their encounters with health personnel. Research design The data were collected in individual interviews and analysed with dialogical narrative analyses. Participants and research context Thirteen women (aged 18-36 years), who were uncertain of whether to terminate their pregnancies during the first trimester, were interviewed before and after they made their decisions. The participants were recruited at six Norwegian outpatient clinics. Ethical considerations Approval was granted by the Regional Committee for Medical and Health Research Ethics. Findings The ambivalent pregnant women sought to make autonomous decisions while simultaneously involving their closest confidants and health personnel in the process. The following three types of narratives of women’s experiences with encounters with health personnel were identified: the respected women, the identified women and the abandoned women. Discussion The findings are discussed in terms of the ambivalent pregnant woman’s autonomous responsibility in considering an abortion and how her autonomy can be enabled or impaired during encounters with health personnel. Conclusion and implication Although the women considered themselves autonomous and responsible for their final decisions, they wished health personnel were involved in their situations. The health personnel contributed by enabling or disabling the possibility of decision-making in accordance with the women’s values. The findings indicate that health personnel who care for women considering abortions must be trained in dialogical competence

Women's experiences when unsure about whether or not to have an abortion in the first trimester

Abortion during the first trimester is legal in most Western countries. However, deciding to terminate a pregnancy is a challenging process, and some women arrive at the abortion clinic still not absolutely certain. We explored the experiences of 13 pregnant Norwegian women struggling to finalize their decision, interviewing them before and after their decision. Verification of the pregnancy meant a new reality for the women. They started to consider their readiness, describing the experience as a lonely journey during which their values were challenged. A feeling of existential loneliness dominated the decision-making process and the implementation