Yuanyuan Chen, Zhejiang University, China
Elizabeth Kendall, Griffith University, Australia
This is an open-access article distributed under the terms of the
The power of action research to create change by anchoring research results in practice was challenged in an action research project at a specialized rehabilitation unit for persons with acquired spinal cord injury. Despite the co-researchers' new insights, approaches, and actions supporting patient participation, it was not possible to change the basic conditions for the practicing of nursing. We aimed to raise awareness of the mechanisms that govern barriers by exploring these barriers as experienced by nurses in their effort to change their practice to improve patient participation.
We used Fairclough's critical discourse analysis drawing on Foucault's practical systems; ethics (identity, relation to oneself), power (action, relation to others), and knowledge (representation, aspects of the world), which he combines with discourse-analytical concepts.
Our discourse analysis of the empirical data at micro-level uncovers the nature of barriers to change in practice. In addition, our analysis at macro-level unveils how these practices are embedded in larger historical, societal, and institutional discourses. This identified two current discourses: a biomedical discourse and a biopsychosocial discourse. In the light of these two discourses, the nurses at micro-level saw themselves as strong agents for the best rehabilitation by acting in accordance with the biopsychosocial discourse. But they were unable to find the time and space to do so due to tasks, structures, and practices specified by an organization dominated by the biomedical discourse.
This article explores challenges in changes resulting from an action research (AR) study investigating nurses' possibilities to facilitate patient participation in a Danish rehabilitation unit for patients with spinal cord injury (
The importance of patient participation in rehabilitation is recognized in nursing. The close connection between patient participation and care is centered around the patient's perspective as outlined in several studies (
During the AR study by Steensgaard (
The challenges in changing the nurses’ practice were even more surprising because their professional ambition of caring for the patient's whole existence and meaningful life was similar to the goal of rehabilitation (
The need to engage the patient was highlighted by Kirkevold (
To gain awareness of the mechanisms governing the barriers of change by exploring how these were experienced by nurses in their effort to change their practice to improve patient participation.
This discourse analysis study is a follow-up on a larger AR project investigating how nurses can contribute to patients' participation in rehabilitation.
The project and its processes used various methods, such as observations, meeting minutes, and written logs of nurses' reflections on their work. These reflections were discussed in workshops and consecutive meetings. The data from these sources formed the basis for actions in practice.
The AR study was carried out in line with the dialogue tradition in AR, which has primarily been developed in the Scandinavian countries (
The study took place at a Danish highly specialized rehabilitation center for patients with a spinal cord injury. The center is related to a hospital. Approximately 100 patients are admitted annually and the center has 35 beds. The center employs more than 100 inter-professional staff members, including doctors, secretaries, psychologists, social workers, occupational therapists, physiotherapists, nurses, and nursing assistants.
An advisory board consisting of a representative from the co-researchers, one former patient, the supervisors, and representatives from the nursing and inter-professional managers facilitated the process and anchored the project.
Data for the discourse analysis was selected among the AR data collected in the period between 2016 and 2018. The AR data consisted of the log-book notes of eight nurse co-researchers, four one-day workshops, and nineteen one-hour meetings. All meetings and workshops were audio-recorded and transcribed verbatim.
For the discourse analysis, we selected passages where the nurses were challenged and thus problematized their effort to engage the patient to participate. This data material consisted of 66 transcribed pages for analysis and discussion among the authors. The data material was reviewed, categorized and coded in relation to semantic choices, themes and discourses realized through the nurses' use of language.
In accordance with both Foucault (
The micro-field includes text-oriented approaches to discourse analysis (TODA), which perform close discourse analysis at micro-level such as conversation analysis, multimodal analysis, social semiotics, discourse-oriented ethnography, and narrative analysis. This allows us to closely analyze the specific linguistically construed discourses in our data material at micro-level such as the construction of themes or discourses, positions, power, identities, and relationships between nurses, patients, management, and other professional groups created as a result of observations and nurses' reflections. Analysis of the social practice at macro-level allowed us to analyze the orders of discourse such as the larger institutional, scientific, societal, and historical discourses in which the concrete practices are embedded. The macro-field constitutes social-oriented approaches to discourse analysis, (SODA), which focus on the social and historical aspects of discourse. Fairclough (
Starting with the micro-oriented approach, we chose to search for everything describing barriers to change using critical discourse analysis. We analyzed the empirical data to discover the nature of barriers to change in practice. At the same time, these concrete practices are also embedded in larger historical, societal, and institutional discourses, which can create barriers and be more difficult to change as time and effort are needed to change organizational and cultural barriers. We thus examined the relationship with the specific practice and looked for a deeper understanding of what could be changed within the organizational framework (macro-oriented approach). To illustrate the challenges, we present a case based on observations of a typical real-life scenario.
A nurse enters a patient's room at 7.30 am. The patient has been awake for a while because he used to get up at 6 to be ready for work—before the injury. Now his body is stiff and hurts, and he cannot wait to get out of bed.
The nurse enters the room with energy and tries to spread a good and cozy atmosphere by small talking, smiling, and joking. A plan for the morning is presented to the patient; “besides you, I also have another patient and I have to prepare for rounds”.
The patient says that he must be ready for training at 9.30 and that he has been late several times this week.
The nurse avoids commenting and immediately starts preparing for emptying the bladder with a catheter, preparing a commode, and finding towels, and clothes. While she is lifting the patient, her phone rings. The nurse stops the procedure to pick up the phone with the patient sitting naked on the commode with a small towel to cover his private parts.
The patient asks to take a shower while emptying the bowel to save time. The nurse stays in the bathroom because she needs to assist the patient with bathing. At this point, neither the nurse nor the patient can leave the room, and the nurse takes the opportunity to ask the patient about his life situation; how everything works at home, and how the plan for selling the house is progressing (a necessity because the patient is too disabled to get back to his former house) and how the patient feels about going home for the weekend.
When the patient is back in bed ready to get help with the clothes, the nurse's phone rings again. The nurse leaves the room after a short conversation over the phone telling the patient that she will return as soon as possible.
The patient asks her not to take too long because time is running, and he will almost certainly be late. The tone is appealing and on the edge of demanding.
After 20 min the nurse returns. The atmosphere is tense now and the patient comments on her late return. The patient is rushed into his clothes, a quick comb through the hair, tooth brushing—shaving must wait until later or another day. It is 9.25 am. The patient leaves the room in a hurry. Breakfast will have to wait or just be skipped for the day. The nurse rushes to finish off helping her other patient get ready for his training, before doing rounds, attending meetings, and documenting her nursing. The nurse attends to the patient one more time that day to empty the patient's bladder.
We used critical discourse analysis (
A:
Example 1 (Workshop 1):
CR: (…)
Example 2 (Co-researcher meeting 7)
CR: (…)
Example 3 (co-researcher meeting 10)
A: (…)
In these examples, nurses are in the process of reflecting on a new understanding of their professional role and identity. This includes showing care by being a good dialogue partner, who has time to listen to the patient's feelings and experiences without making suggestions, solutions, or helping to solve the patient's problems. As the new understanding of the professional role is evolving, the co-researchers mark their statements with a lower degree of certainty and thereby an openness to interpersonally negotiate their new identity and role in the dialogues:
Example 4 (Co-researcher meeting 16)
A:
Example 5 (co-researcher meeting 7)
These examples construe the relation and collaboration between the nurse and the patient and the other professions in the unit. Nurses find it difficult to find space and room for dialogue with the patient among other tasks. The extracts consist of speech acts e.g.,
Example 6 (workshop 1)
CR:
CR:
Example 7 (evaluation of experimenting action 2)
CR 1: (…)
CR 2: (..)
CR 3:
In these examples, experimenting actions represent a biopsychosocial discourse in rehabilitation. It is referred to by the word “
From the specific linguistically construed discourses in our data material at micro-level, we found that in the concrete practices, the larger historical, societal, and institutional discourses of rehabilitation were embedded at macro-level. This left us with two simultaneous and competing discourses: a biomedical discourse and a biopsychosocial discourse. In the light of these two discourses, the nurses at micro-level saw themselves as strong agents in providing the best rehabilitation by acting on the biopsychosocial discourse but being unable to find the time and space to do so due to an organization based on the biomedical discourse. This demands a new organizational focus to allocate time, which will involve a change in other professionals' workflow and use of resources.
The AR study explored how nurses could promote patient participation and showed that it was possible to work with a biopsychosocial understanding to rehabilitation. This also entailed a renewed and enhanced professional identity and role for the nurses in their relational work with the patients.
The patient-nurse dialogue proved to be central for the co-researchers to obtain an in-depth understanding of the patient as an individual as well as to build a trusting and cooperative relationship. Furthermore, the patients recognized their situation through dialogue, which led to motivation and actions in the rehabilitation process. The dialogic space thus led to? understanding, learning, and cognition. The joint dialogue between the nurse and the patient also led to a mutual reconciliation of expectations and adjustment of services, resulting in progress, motivation, and thus a more individualized rehabilitation. Involving the patient's special circumstances proved to be a stronger approach to rehabilitation than the dominant one-size-fits-all biomedical approach.
More dilemmas appeared from the co-researchers' realization that patient participation required time and space for the patient's voice to be heard to adapt nursing interventions and promote the patient's rehabilitation. This was considered of utmost importance in the co-researchers' understanding of rehabilitation to ensure that the patient could obtain a level of physical functioning to live a meaningful life. Unfortunately, this contrasted with existing procedures involving a tight time regime to which both patients and health professionals had to conform. Thus, the focus was on finishing e.g., the morning task-based routines and physical training instead of involving patients in the tasks, which could contribute to mental and physical improvements. Therefore, the need for both time and space for dialogue was particularly important. It should not be “something extra” that nurses had to find time for in addition to their existing tasks, which would lead to increased work pressure. The revealed contrasts between the biomedical and the biopsychosocial discourse led to dilemmas and choices had to be made.
The time pressure to get patients ready for training meant that nurses had developed coping techniques resembling assembly line work to help more patients at the same time. The nurses had to focus on finishing practical tasks, for making it possible for therapists to train with the patients and thus improve their physical condition. This practice is illustrated by the case described above. Nursing aims to improve patients' overall situation, including both biological, psychological, and social well-being, and importantly that patients feel seen and heard and thus acknowledged as valuable human beings.
As illustrated by the case, when the nurse was not in a position where she could meet the patient's psychosocial needs, she was careful not to open a discussion about deeper needs, which could not be managed within the time frame while preparing the patient for physiotherapy. Due to time constraints, the potential of using the morning routine to improve the patient's physical capacity was not exploited. Furthermore, the possibility to expand the interpersonal relations between the nurse and the patient could have positively promoted the patient's experience of being acknowledged as a human being and not just as a part of an assembly line workflow. This interprofessional hierarchy impacted the nurses' understanding of their role and profession, as their efforts were not included as a part of the improvement of the patient's understanding of the situation. The focus was on getting the job done and making the patient ready for the “real” physical rehabilitation aiming at improving functioning in accordance with the biomedical discourse.
The example with the morning routine emphasizes the strong focus and priority on training as the way to ensure rehabilitation progress. This is exemplified by spending the time on ensuring the patient's optimal physical condition for training. This included that the patient was well-rested, pain was managed, food had been consumed, morning routines involving personal hygiene had been completed, and supportive brace devices had been fitted. The mental preparation to make the best of the physical training seemed not to be important or require any specific effort. A change happened when the patient needed help to take a shower and the nurse could not continue her work getting more patients ready at the same time. The nurse then used this short period of time to build a dialogue with the patient, although it was time for emptying bladder and bowels and taking a shower. This showed that the nurse-patient dialogue was central to the nurse—not just to get the task done but to understand the patient and his or her situation. The dialogic space was acknowledged as creating understanding and acknowledgment leading to rehabilitation.
The question is why the opportunity to start a dialogue was seized while solving practical tasks instead of focusing on how the practical tasks could contribute to and promote training? Furthermore, the time-constrained dialogue during practical personal hygiene routines limited the patient's ability to voice his/her perspective and the nurse's ability to adapt her nursing to ensure the best conditions for rehabilitation. The explanation may be that nurses do not have a practice for only entering into a dialogue with the patient. Nursing was focused on practical tasks and the nurses' new recognition of the importance of the space for dialogue required a changed understanding and practice of the profession.
Considering training to improve physical functioning as the most important task revealed a production logic. This biomedical approach may be in line with the value of the professions offering this service. This differed from the nurses' perception as they experienced not getting the space to perform their care. They lacked their preferred biopsychosocial understanding to unfold their nursing care for the patient by focusing on his/her lifeworld. We saw how nurses struggled to legitimize care and conversation by investigating if values such as time for care and time for dialogue could be considered equally important as the production logic by incorporating these elements in nursing to achieve legitimacy in the organization. In the current situation, the biomedical discourse dominated the biopsychosocial approach in the way rehabilitation was prioritized. These elements contrasted with the nurses’ renewed recognition of the importance of listening to the patient's perspective to promote the organization of rehabilitation, increase patient compliance as well as increase meaningfulness of the rehabilitation stays in relation to patients' future life.
Even though the project was successful in supporting the biopsychosocial discourse and approach to rehabilitation among nurses, the implementation faced challenges ascribed to the dominating biomedical discourse and approach. This was found to be a dominating discourse in the healthcare system studied. From the perspective of archaeological knowledge (
The co-researchers perceived the other professions such as physiotherapists, occupational therapists, and doctors as opponents. The assumption was that if the other professions acknowledged their legitimacy, things could be changed. However, based on the prominent logic and discourse, it was not within the power of the other professions to provide legitimacy. The original biomedical logic of their professions was the foundation for organizing the highly specialized rehabilitation offers; the organizational system maintained and reproduced its own logic and discourse. It was not in the power of any individual or group to change the intertwined and branched system behind the organization. Metaphorically speaking, even the miller gets milled in the mill as even the professions that installed the biomedical approach are caught within and unable to change it themselves. The system is almost unwavering, which ensures that everybody contributes to the common production with the same unwavering attitude and discourse making the change that nurses find necessary almost impossible. Even though the current study was facilitated by an advisory board and the interdisciplinary management, only a value-based change was seen among the parties involved, i.e., no organized room for dialogue in rehabilitation was created between patients and nurses. The spread of unanimous values in the organization should make it possible for patients to participate and enable them to promote their perspectives and for everybody to adapt their services to optimize the patients' rehabilitation. However, it is reasonable to assume that the organization of the healthcare system must change to enable this local change.
We were surprised that nurses had difficulties in gaining acceptance for taking the time to have dialogues with patients about their situation and in this way legitimize this as a part of their work. In the micro-analysis, prioritizing to
The dilemma was not only that they were not able to reach the goal of the nursing profession. The lack of change to a biopsychosocial approach meant that the rehabilitation unit did not work in line with the values and beliefs of the health professionals. The biopsychosocial approach illustrated by the ICF model is the recommended approach in rehabilitation (
A dominant biomedical discourse was suggested to explain why the nurses were challenged when trying to implement the results of the AR project. The dominant biomedical discourse prescribes (subject positions) that the nurses must perform the work based on a specified number of activities within this discourse—understanding care, treatment, and rehabilitation. At the same time, the result of the project rested on a biopsychosocial understanding, which required new activities in the form of time for dialogue and individual adaptation to the individual patient's wishes, needs, and opportunities. Since the system was task-oriented in accordance with the biomedical discourse, there was no free time for practicing the new understanding and activities. The nurses solved this conflict individually and jointly by doing both at the same time i.e., they ran faster to both honor the biomedical requirements and experiment with the new biopsychosocial understanding.
The predominance of the biomedical discourse to be a barrier to patient participation was also found by Joergensen et al. (
A frequent reason for few or missing changes is the lack of support from management and involvement of all professionals as well as prioritizing integration of the new practice. However, based on our rereading and reinterpretation of data in our AR study, we identified unrecognized discourses and associated values as barriers to change. Thus, it may be necessary to explore more organizational layers, frameworks, basic assumptions, and organizational structures when conducting a project. In our study, everyone thought that WHO (
A change in an organization's discourse requires a joint effort. A collaborative team process is necessary as the organizational biomedical framework would also limit the biopsychosocial approach for all health professionals. So, by revealing that the nurses alone cannot create their own isolated space to work in accordance with the biopsychosocial discourse in rehabilitation: The whole organization must collaborate to achieve the WHO goals for rehabilitation (
Our study and analysis show a gap between a stated organizational goal of working predominantly from the biopsychosocial approach and actions which in practice were organized from the biomedical approach. The biomedical approach with its related discourses and actions are so ingrained and rooted in a long institutional tradition that individuals or groups of professionals cannot change it alone. According to our research and analysis, it requires a common recognition, awareness and effort involving the mutually agreed efforts of an entire department, and sometimes the entire organization. The implication of our follow-up discourse analysis is that the dominating discourse must be uncovered followed by a reorganization of discourses if changes are to be implemented and patient participation can occur. This is a difficult task because dominant discourses such as biomedical-oriented health care calls for a larger organizational change involving leaders and all staff groups. By developing a mutual organizational understanding, it may be possible to implement a new practice. In rehabilitation nursing this means that the biopsychosocial approach is needed to allow the patient's agenda to be in focus. It follows from this that the organization must allocate time and resources for dialogue and patient involvement. Furthermore, the organization must work systematically to incorporate the biopsychosocial approach into practice for all professional groups. Thus, staff could follow their professional beliefs and values. This will lead to a better, more coordinated rehabilitation by foregrounding the biopsychosocial approach, and thereby generating greater value and quality in the patient's rehabilitation.
The paper is theoretical and data are reflections on a larger study and now
Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
SA: Writing – original draft, Writing – review & editing. RS: Data curation, Writing – original draft, Writing – review & editing. RK: Writing – original draft, Writing – review & editing. SF: Writing – original draft, Writing – review & editing.
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Thank you to the co-researcher nursing staff for their contribution and for sharing their experiences. Thank you to the interdisciplinary group of leaders at the Spinal Cord Injury Centre of Western Denmark. Furthermore, we take this opportunity to express our gratitude to Marianne Godt Hansen for the linguistic advice.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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