The enactment of ‘dialogue’ in person-centred health care: analyzing multiple voices in conversations between nurses and patients with chronic illnesses.

‘Patient- or person-centredness’ has become a central principle of social and health care policy globally. The patient has moved from being a passive target of medical intervention to a partner with a degree of personal responsibility for her health and an active part to play in collaborative decision-making about her treatment. According to the ideals of person-centred care, patients and relatives are ‘empowered’ as dialogue partners, together with health professionals, in co-creating knowledge and collaboratively reaching decisions about their own care.
But how exactly – and to what extent - are patients empowered as agents in their own care through dialogue across multiple voices? And what tensions are in play in dynamics of inclusion and exclusion where some voices, articulating particular forms of knowledge and subjectivities, dominate and others are marginalised? This paper addresses these questions through analysis of telephone conversations between nurses and patients with chronic illnesses in a Danish person-centred health care initiative entitled “Active Patient Support”. The aim of the Active Patient Support initiative is to empower patients through strategies of self-care. The research presented in the paper is part of an action research project in which a group of patients and nurses, together with the researchers, co-create knowledge about coaching conversations in order to develop a communication model for training purposes. Methods of data production are audio recording of the telephone conversations and co-creation workshops with researchers, nurses and patients. The telephone conversations are analysed using the theoretical framework, The Integrated Framework for Analysing Dialogic Knowledge Production and Communication (IFADIA). This framework is based on a combination of Bakhtinian dialogic communication theory and Foucault’s theorization of discourse and power/knowledge. The framework draws on Bakhtin in order to analyse dialogue in terms of the tensional negotiation of meanings across multiple voices, and combines this with Foucault in order to address how tensions arise in the play of power in which certain voices dominate and others are marginalized or excluded. The focus of the analysis is on how “dialogue” is interactionally accomplished as nurses shift between different dialogue positions and patients’ respond in different ways. Three main positions are identified: an inquiry mode in which nurses ask about relevant aspects of the patient’s life; a support mode in which the nurse provides empathy and confirmation; and a solution-oriented, sparring mode in which the nurse invites collaborative decision-making about what path to take in relation to tackling specific problems. The analysis focuses on tensions that arise in the negotiation of meaning across the voices that are articulated in the nurses’ adoption of these positions and patients’ responses. For instance, a key tension identified in the nurse’s inquiry mode is between opening up for patients’ perspectives on their own life, on the one hand, and following a particular line of inquiry based on the nurse’s own professional perspective. A key tension arises in the nurse’s support mode between engaging in warm, interpersonal relations, on the one hand, and performing a role as professional in a position of authority. In relation to the nurse’s sparring mode, a key tension emerges between opening up for patient agency in decision-making on the one hand and offering specific suggestions for how to act based on the nurse’s expert knowledge, on the other. The conclusion explores the implications of the empirical results in relation to dynamics of inclusion and exclusion at work in the negotiation of meaning across multiple voices. It also discusses how the results can be used to develop a communication model (for training purposes) that is sensitive to the dialogic, situated nature of meaning-making.