Rick Iedema

Multimodality, resemiotization: extending the analysis of discourse as multi-semiotic practice

This article has the following two overarching aims. First, it traces the development of multimodal discourse analysis and sets out its main descriptive and analytical parameters; in doing so, the article highlights the specific advantages which the multimodal approach has to offer and exemplifies its application. The article also argues that the hierarchical arrangement of different semiotics (in the way common sense construes this) should not be lost from sight. Second, and related to this last point, the article will advance a complementary perspective to that of multimodality: resemiotization. Resemiotization is meant to provide the analytical means for (1) tracing how semiotics are translated from one into the other as social processes unfold, as well as for (2) asking why these semiotics (rather than others) are mobilized to do certain things at certain times. The article draws on a variety of empirical data to exemplify these two perspectives on visual communication and analysis.

Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study

Objectives To investigate patients’ and family members’ perceptions and experiences of disclosure of healthcare incidents and to derive principles of effective disclosure. Design Retrospective qualitative study based on 100 semi-structured, in depth interviews with patients and family members. Setting Nationwide multisite survey across Australia. Participants 39 patients and 80 family members who were involved in high severity healthcare incidents (leading to death, permanent disability, or long term harm) and incident disclosure. Recruitment was via national newspapers (43%), health services where the incidents occurred (28%), two internet marketing companies (27%), and consumer organisations (2%). Main outcome measures Participants’ recurrent experiences and concerns expressed in interviews. Results Most patients and family members felt that the health service incident disclosure rarely met their needs and expectations. They expected better preparation for incident disclosure, more shared dialogue about what went wrong, more follow-up support, input into when the time was ripe for closure, and more information about subsequent improvement in process. This analysis provided the basis for the formulation of a set of principles of effective incident disclosure. Conclusions Despite growing prominence of open disclosure, discussion about healthcare incidents still falls short of patient and family member expectations. Healthcare organisations and providers should strengthen their efforts to meet patients’ (and family members’) needs and expectations.

'It's an Interesting Conversation I'm Hearing': The Doctor as Manager

The aim of this article is to outline in discursive-linguistic terms how doctor-managers (or ‘physician-executives’ as they are termed in the USA) manage the incommensurate dimensions of their boundary position between profession and organization. In order to achieve this we undertook a discourse analytical study of both recorded, situated talk and open interview data focusing on one doctor-manager navigating between profession and organization. The doctor-manager at the centre of this study locates himself on the boundary of at least three discourses which, in many respects, are incommensurate. These are the profession-specific discourse of clinical medicine, the resource-efficiency and systematization discourse of management, and an interpersonalizing discourse devoted to hedging and mitigating contradictions. While this multi-vocality in itself is not surprising, data show that the doctor-manager positions himself across these discourses and manages their inherent incommensurabilities before a heterogeneous audience and on occasions even within the one utterance. In this particular case, boundary management is achieved by weaving incommensurable positions together into the social and linguistic dynamics of a single, heteroglossic stream of talk. This highly complex and dialogic strategy enables the doctor-manager to dissimulate the disjunction between his reluctance to impose organizational rules on his medical colleagues and his perception that such rules, in the future (to some extent at least), will be the appropriate means for managing the clinical work, and through that the organization.

Making clinical governance work

The current focus on quality and safety means most doctors have negative views about clinical governance. But done properly, clinical governance has the power to improve NHS performance

A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation [LP0560737]

BackgroundAccreditation has become ubiquitous across the international health care landscape. Award of full accreditation status in health care is viewed, as it is in other sectors, as a valid indicator of high quality organisational performance. However, few studies have empirically demonstrated this assertion. The value of accreditation, therefore, remains uncertain, and this persists as a central legitimacy problem for accreditation providers, policymakers and researchers. The question arises as to how best to research the validity, impact and value of accreditation processes in health care. Most health care organisations participate in some sort of accreditation process and thus it is not possible to study its merits using a randomised controlled strategy. Further, tools and processes for accreditation and organisational performance are multifaceted.Methods/designTo understand the relationship between them a multi-method research approach is required which incorporates both quantitative and qualitative data. The generic nature of accreditation standard development and inspection within different sectors enhances the extent to which the findings of in-depth study of accreditation process in one industry can be generalised to other industries. This paper presents a research design which comprises a prospective, multi-method, multi-level, multi-disciplinary approach to assess the validity, impact and value of accreditation.DiscussionThe accreditation program which assesses over 1,000 health services in Australia is used as an exemplar for testing this design. The paper proposes this design as a framework suitable for application to future international research into accreditation. Our aim is to stimulate debate on the role of accreditation and how to research it.

Visibilising clinical work: Video ethnography in the contemporary hospital

Abstract This paper discusses the role of video-based research methods in social research. The paper situates these methods in the context of rising levels of visibility of professionals in government-funded organisations. The paper argues that while visual research may appear to play an ambiguous role in these organisations, it can also enable practitioners to confront the encroaching demands of post-bureaucratic work. To ground its argument, the paper presents an account of a video-ethnographic project currently underway in a local metropolitan hospital. This project focuses on negotiating understandings about existing care practices among a team of multi-disciplinary clinicians. Visual data gathered as part of that project are presented to specify issues which have thus far arisen during the project. Against this empirical background, the paper turns to considering the ambiguous potential of video-based research. The argument developed here is that, besides potentially exacerbating the pressure already imposed on clinicians - thanks to audit, surveillance and risk minimisation - video-based research may provide staff with new resources and opportunities for shaping their increasingly public and visible work practices.

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme

Background: Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited. Objective: To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP). Hypothesis: Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety. Design, setting and participants: Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia. Outcome measures: Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired. Results: No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training. Conclusions: RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.

New approaches to researching patient safety

This article presents an overview of contemporary research into patient safety. The article suggests that patient safety research to date has tended to privilege the formal and structural dimensions of safety at the expense of the social and affective dimensions of safety. The article previews the research articles brought together in this special issue of Social Science & Medicine, paying particular attention to the impact of these studies on the field of patient safety research generally. The present article summarises this impact in the form of the following three patient safety research principles. First, to account for whether and how safe and improvement-oriented practice is achieved, research must engage with both the predictability and the complexity of the sites and processes it seeks to describe, explain and/or impact on. Second, engaging with complexity implicates researchers in experiencing it, and this implicates the research process and its methodology in a process of sense-making of the practical and affective consequences for and with practitioners inhabiting and enacting that complexity. Third, besides numerically-based descriptions, abstracted explanations and procedural prescriptions, patient safety research evidence must encompass experiential data, collaboratively-produced accounts and/or experience-based designs.

Formalizing Organizational Meaning

Formality indexes interactional closure: it limits the possibilities for the renegotiation of agreements and decisions. In this article the focus is on how formality is constructed in organizational settings. The article proposes that organizational formalization is achieved on the strength of the recontextualization of meaning from one discourse or practice to another. Importantly, organizational processes of recontextualization tend to increasingly technologize meanings with respect to both what they signify and their materialization. This means that discursive practices will mobilize, aside from human or embodied modes of meaning making, increasingly disembodied or exosomatic modes of meaning making, such as electronic kinds of communication, as well as other kinds of inscription of meaning (infrastructure, architecture, and so on).

Codesigning as a Discursive Practice in Emergency Health Services: The Architecture of Deliberation

This article addresses the issue of how government agencies are increasingly attempting to involve users in the design of public services. The article examines codesign as a method for fostering new and purposeful interaction among service-delivery staff and their customers. Codesign brings together stakeholders who, in the past, have had limited input into the way public services are experienced. By participating in this emerging discourse practice, codesign stakeholders can construct new ways of relating and deliberating. The data presented in this article are drawn from a codesign study initiated by the New South Wales Department of Health in an effort to improve the experience of staff, patients, and caregivers. The article concludes that codesign presents service consumers, professionals, and government officials with new opportunities as well as new challenges. Its opportunities reside in codesign bringing stakeholders together across previously impervious boundaries, producing new understandings, relationships, and engagements. Its challenges reside in these new understandings, relationships, and engagements only becoming possible and only continuing to be relevant if and when stakeholders are prepared to adopt and adapt to the new discourse needed to realize them, implicating them in what has been referred to as the “design competency spiral.”