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.
Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist-the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an 'explanatory theoretical model of change' that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities-narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome. Trial registration number The Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results). The new ZeiTgeisT: pArTiCipATionThe current preoccupation with methods for citizen engagement, public participation and involvement of people with lived experience in health system redesign and service improvement might be said to represent the new Zeitgeist-the spirit of our times.
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In this article, we outline a study method with which structural changes to clinical communication were achieved within a local intensive care unit (ICU). The study method involved in-depth, round-the-clock observation, interviewing, and video filming of how intensivists conducted their practices, as well as showing selected footage to the clinicians for feedback. This feedback component iteratively engaged clinicians in problem-solving their own communication difficulties. The article focuses on one such feedback meeting and describes changes to the morning ward round and planning meeting that this feedback process catalyzed: greater time efficiency, a greater presence of intensivists in the ICU, more satisfied nursing staff, and a handover sheet to improve the structure of clinical information exchanges. We argue that in embodying not a descriptive but an interventionist approach to health service provision, this video-ethnographic method has great significance for enhancing clinicians' and researchers' understanding of the rising complexity of in-hospital practices, and for enabling them to intervene in these practices.
Rick Iedema professor (organisational communication) AbstractObjectives 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. IntroductionHealth providers in Western countries are adopting "open disclosure" policies that promote the discussion of healthcare incidents with patients.1-5 Studies using hypothetical designs have suggested that a gap exists between clinicians' and patients' views of what is appropriate incident disclosure. Clinicians tend to consider unexpected clinical outcomes as less serious and therefore less in need of disclosure than do patients. 6 Clinicians also err on the side of caution, whereas patients expect openness and admission of responsibility.7 Such breakdowns in the disclosure process exacerbate the distress patients experience from the event itself. Several studies have highlighted clinicians' concerns about the personal, professional, and legal consequences of disclosure. 10Clinicians are also concerned about the considerable time and effort often required for incident disclosure, 11 including ; and the importance of provider responses that are caring, honest, quick, personal, accessible, and frequent. 15 Some studies suggest that patients may have an interest in extending disclosure discussions to encompass plans for and evidence of practice improvement, with some interviewees indicating interest in contributing to the monitoring of improvement processes over time. 9 14 16 However, few studies have measured the actual experiences of patients and families with the disclosure process. The dearth of i...
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