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The production and maintenance of inequalities in health care: A communicative perspective
Jönköping University, School of Education and Communication, HLK, Lifelong learning/Encell.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The Swedish health care system does not offer care on equal terms for all its end-users. Discrimination toward patients can take the form substandard communication toward women or foreign born patients. Discrimination is also embedded in the organizational context. Health care is under pressure to increase efficiency and quality of care at the same time. There is a risk that demands for equality will be pushed aside. This thesis aims to contribute to our understanding of how discrimination is expressed in interpersonal- and organizational communication within health care, and highlight educational implications for health care practices. This thesis is comprised of three empirical studies and one conceptual study. In the first study, critical discourse analysis (CDA) is used to categorize gender patterns in communication between health care workers and patients, and finds that both patients and health care workers reproduced the gender order. Open questions created a setting less prone to be limited by gender stereotypes. In the second study, CDA is used and complemented with Linell’s dialogic perspective in order to explore whether patients who were native speakers of Swedish were constructed differently than those who were not, in patient-physician consultations. Findings indicated that the non-native speakers actually were model, participative patients according to patient-centered care. Notwithstanding this they were met by argumentation, whereas the more amenable native patients were met by accommodating responses. In the third study, qualitative content analysis is used to analyze how health care workers talked about patients in their absence. The results revealed that communication about patients who were perceived as not acting according to socially accepted gender norms contained negative and disparaging statements. The final study focused on Clinical Microsystems, a New Public Management-based model for multi-professional collaboration and improvement of health care delivery. Drawing on theories of New Public Management, gender, and organizational control, this study argues that the construction of innovative and flexible health care workers risks reproducing the gender order. The thesis concludes that gender and ethnic stereotypes are reproduced in health care communication, and that an efficiency-inspired organizational and institutional discourse may be an impediment to equal care. This calls for focus on learning about communication for prospective and existing health care workers in a multicultural health care context.

Place, publisher, year, edition, pages
Jönköping: School of Education and Communication, Jönköping University , 2014. , 179 p.
Series
Doktorsavhandlingar från Högskolan för lärande och kommunikation, ISSN 1652-7933 ; 26
Keyword [en]
communication, gender, ethnicity, health care, organization, critical discourse analysis, social constructionism, social positions, qualitative content analysis
National Category
Pedagogy
Identifiers
URN: urn:nbn:se:hj:diva-24380ISBN: 978-91-628-9074-2 (print)ISBN: 978-91-628-9076-6 (digitalt) (print)OAI: oai:DiVA.org:hj-24380DiVA: diva2:739079
Public defence
2014-09-12, Hb116, Högskolan för lärande och kommunikation, Jönköping, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2014-08-20 Created: 2014-08-20 Last updated: 2014-08-21Bibliographically approved
List of papers
1. Gendered communicative construction of patients in consultation settings
Open this publication in new window or tab >>Gendered communicative construction of patients in consultation settings
2014 (English)In: Women & health, ISSN 0363-0242, E-ISSN 1541-0331, Vol. 54, no 6, 513-529 p.Article in journal (Refereed) Published
Abstract [en]

This study aimed to explore the communication in consultations between patients and health care staff from a gender perspective. We used 23 tape-recorded consultations between patients with Atrial Fibrillation and 5 nurses and 5 physicians at cardiac outpatient clinics at 6 different hospitals in southern Sweden during autumn 2009 to explore the verbal gendered constructions of patients. Through critical discourse analysis, we revealed that the male patients tended to describe their ailments with performance-oriented statements, whereas the female patients usually used emotional-oriented statements. The staff downplayed the male patients' questions and statements, while they acknowledged concern toward the female patients. Both the patients and the staff made conclusions according to a mutual construction. Male patients were constructed as competent, and female patients as fragile through gender-stereotypical communication. Open-ended statements and questions enabled consultations to be less limited by gender stereotypes.

Keyword
communication, consultations, critical discourse analysis, gender equity
National Category
Pedagogy
Identifiers
urn:nbn:se:hj:diva-24334 (URN)10.1080/03630242.2014.903551 (DOI)000340402700003 ()24964371 (PubMedID)
Available from: 2014-08-13 Created: 2014-08-13 Last updated: 2017-12-05Bibliographically approved
2. Communicative construction of native versus non-native Swedish speaking patients in consultation settings
Open this publication in new window or tab >>Communicative construction of native versus non-native Swedish speaking patients in consultation settings
2013 (English)In: Offentlig Förvaltning. Scandinavian Journal of Public Administration, ISSN 2000-8058, E-ISSN 2001-3310, Vol. 17, no 4, 21-49 p.Article in journal (Refereed) Published
Abstract [en]

In this paper, we examine patient-centered care through analyzing communicative constructions of patients, on the basis of their native language, in consultations with physicians. Whereas patient-centered care is of current interest in health care, research has not addressed its implications in this dimension. Previous studies indicate that non-native Swedish speaking patients, experience substandard interpersonal treatment far more than native Swedish speaking patients. Our findings show that the non-native Swedish speaking patients presented themselves as participating, whereas the native Swedish speaking patients presented themselves as amenable. The physicians responded in two different ways, argumentatively towards the non-native Swedish speaking patients and acknowledging vis-à-vis the native Swedish speaking patients. When decisions and conclusions were made by the patients and physicians, this resulted in preservation of the status quo in the consultations with the non-native Swedish speaking patients, while the corresponding result with the native Swedish speaking patients was monitoring of their health status. So, whereas the non-native Swedish speaking patients actually were model patient-centered care patients, physicians were more amenable towards the native Swedish speaking patients. We suggest that patient-centered care is desirable, but its practical application must be more thoroughly scrutinized from both a patient and a health care worker perspective.

Keyword
communication, critical discourse analysis, dialogue, health care, patient-centered care
National Category
Pedagogy
Identifiers
urn:nbn:se:hj:diva-23620 (URN)
Available from: 2014-03-17 Created: 2014-03-17 Last updated: 2017-12-05Bibliographically approved
3. Communication about patients in multi-professional teams: a gender perspective
Open this publication in new window or tab >>Communication about patients in multi-professional teams: a gender perspective
(English)Manuscript (preprint) (Other academic)
National Category
Pedagogy
Identifiers
urn:nbn:se:hj:diva-24381 (URN)
Available from: 2014-08-20 Created: 2014-08-20 Last updated: 2014-08-20
4. The gender subtext of new public management-based work practices in Swedish health care
Open this publication in new window or tab >>The gender subtext of new public management-based work practices in Swedish health care
2013 (English)In: Equality, Diversity and Inclusion: An International Journal, ISSN 2040-7149, Vol. 32, no 2, 144-156 p.Article in journal (Refereed) Published
Abstract [en]

Purpose – The purpose of this paper is to propose a theoretical framework for researching gender equality implications of Clinical Microsystems, a new public management-based model for multi-professional collaboration and improvement of health care delivery.

Design/methodology/approach – The paper draws on literature from gender in organizations, new public management, multi-professional collaboration and organizational control to critically analyze the Clinical Microsystem model.

Findings – While on the surface an egalitarian and consensus-based model, it nevertheless risks reinforcing a gendered hierarchical order. The explicit emphasis on social competencies, on being collaborative and amenable to change risks, paradoxically, disfavoring women. A major reason is that control becomes more opaque, which favors those already in power.

Practical implications – The paper calls for researchers as well as practitioners to incorporate concerns of equality in the work place when introducing new work practices in health care. For research, the authors propose a useful theoretical framework for empirical research. For practice, the paper calls for more transparent conditions for multi-professional collaboration, such as formalized merit and advancement systems, precisely formulated performance expectations and selection of team members based strictly on formal merits.

Originality/value – A gender analysis of a seemingly anti-hierarchical management model is an original contribution, adding to the literature on Clinical Microsystem in particular but also to critical studies on new public management. Moreover, the paper makes a valuable practical contribution in suggesting ways of avoiding the reproduction of gender inequalities otherwise implied in the model.

Keyword
Clinical Microsystem, Equality, Gender, Gender equality, Health care, Multi-professional collaboration, New public management, Sweden
National Category
Pedagogy
Identifiers
urn:nbn:se:hj:diva-21144 (URN)10.1108/02610151311324389 (DOI)
Available from: 2013-05-09 Created: 2013-05-09 Last updated: 2014-08-20Bibliographically approved

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