towards animated patient communication · 7/6/2012 · multimodal, social semiotic discourse and...
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Towards Animated Patient Communication Reducing patient anxiety across several genres and media
Mia Voldum Aarhus University, Business and Social Sciences
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www.mitforløb.dk
Towards Animated Patient Communication Reducing patient anxiety across several genres and media
A Master Thesis By
Mia Voldum Master of Arts in Corporate Communication
Aarhus University, Business and Social Sciences
Supervisor: Carmen Daniela Maier
Submission: 3rd of December 2012
Total number of characters: 171.367
The thesis has been conducted by Mia Voldum in collaboration with the Regional Hospital of
Silkeborg and Visikon. 2012. In respect of the participating patients and the copyright of the
material that belong to Visikon, this thesis may not be reproduced, stored or transmitted in any
form, or by any means, only with the prior permission in writing of the author., all images and
audio recordings may not be used without permission in any other connection than the evaluation
of the thesis.
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ABSTRACT
Purpose
Motivated by the new preoperative patient communication strategies adopted by the hip
department of the Regional Hospital of Silkeborg (RHS), Denmark, in collaboration with Visikon,
the thesis raises two fundamental questions: Which are the communicative purposes and strategies
of the hip department at the Regional Hospital of Silkeborg when preparing patients for surgery
through face-to-face interactions with healthcare providers, brochures, Visikon’s patient platform
‘www.mitforløb.dk’, and the animation films placed on it and the postcard linking to it? How can
Visikon’s patient platform ‘www.mitforløb.dk’ reduce patient anxiety?
Methodology
To answer the questions, an interdisciplinary methodological framework has been assembled,
which includes the theoretical lenses of corporate communication, healthcare communication,
multimodality, social semiotics, discourse, and genre. More specifically, the analysis sets out in a
multimodal, social semiotic discourse and genre analysis of RHS’ various preoperative
communication genres. Though, acknowledging that these genres are a means of healthcare
communication strategy and a larger corporate communication strategy, the identified purposes
are related first to healthcare communication and later again to corporate communication.
Findings
Through the multimodal, social semiotic discourse and genre analysis it becomes clear that RHS
employs a patient-centered approach when preparing patients for surgery. In corporate
communication, this relates to the socio-economic theory, which shows that RHS focuses on other
stakeholders than just shareholders. More specifically, this involves providing clear and
memorable information to delimit knowledge asymmetries and make the patient adhere to the
treatment, promote optimism, engender trust in the patient and, thus, empower the patient to take
action for his or her own treatment, seeing that this will reduce anxiety.
Specifically for the face-to-face interactions, these aim at providing personal information to
delimit knowledge asymmetries to make the patient adhere to the treatment by facilitating two-way
symmetrical communication. Through the informal dialogue created, a more personal and relaxed
relationship is established, which engender mutual understanding and trust, which encourages a
disclosure of worries, as the patients can fulfill their individual needs for information and thereby
reduce anxiety.
The purpose of the preoperative patient brochure genre is to provide clear and memorable
information to create a mutual understanding and make the patient actively adhere to the
treatment. However, seeing that the brochure is one-way communication, it does not provide the
patients with the possibility to ask questions that are not covered by the informative brochure.
Consequently, it does not encourage a disclosure of worries, as trust has not been engendered,
which might make anxiety escalate.
The information meeting, on the other hand, contributes to engendering trust and encouraging a
disclosure of worries by the healthcare providers’ physical representation offering the patients the
opportunity to ask the questions that might have appeared and share thoughts and experiences
with other patients. Nevertheless, the length and amount of information provided during the
meeting might instead cause more anxiety as a result of the patients becoming frustrated with all
the information they have to remember. This is unfortunate as the illustrations and exercises
initiated by the various healthcare providers seem to be an effective tool for activating the patients
and thereby empower them to bring it home. Nevertheless, it does not enable the patients to
refresh the information at home.
This leads to the final genre, being the new patient platform ‘www.mitforløb.dk’. Compared to the
existing genres, the platform provides new, clear, memorable, and recurrent information by
immersing the patient into the virtual medical world, in which they can move around through their
individually constructed reading paths. Seeing that the animated traits enable details, such as the
surgery, to the exposed, the platform offers information that neither of the other genres does and
in a way that promotes optimism and empowers the patient and, thus, reduces anxiety as they
become more educated. Though, in order for it to be a good corporate communication strategy to
create and maintain beneficial and harmonious relationships with stakeholders/patients, it should
facilitate two-way symmetrical communication by adopting more interactive elements on the
platform. Doing so, the platform, including the animation films, would make up an ideal
communication tool not only to reduce anxiety and other healthcare related purposes but also
more corporate purposes.
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TABLE OF CONTENTS
1! INTRODUCTION*................................................................................................................................*4!1.1! Motivation*.................................................................................................................................................*4!1.2! Thesis*Statement*.....................................................................................................................................*5!1.3! Theory*of*Science*....................................................................................................................................*6!1.4! Data*Selection*and*..................................................................................................................................*8!1.5! Structure*..................................................................................................................................................*11!1.6! Background*Information*....................................................................................................................*12!1.6.1! RHS!..........................................................................................................................................................................!12!1.6.2! Visikon!...................................................................................................................................................................!13!
2! THEORETICAL*FRAMEWORK*.....................................................................................................*14!2.1! Corporate*Communication*................................................................................................................*15!2.1.1! Stakeholders!.......................................................................................................................................................!15!2.1.2! Identity!and!Reputation!.................................................................................................................................!16!
2.2! Healthcare*Communication*...............................................................................................................*16!2.2.1! Aspects!of!Healthcare!Communication!...................................................................................................!18!2.2.2! Implementing!a!ClientCCentered!Approach!...........................................................................................!20!
2.3! Social*Semiotics*and*Multimodality*................................................................................................*22!2.3.1! Interplay!of!Semiotic!Modes!........................................................................................................................!24!2.3.2! Aspects!of!Genre!Theory!................................................................................................................................!26!2.3.3! Discourse!and!Discursive!Practices!..........................................................................................................!29!
3! METHODOLOGY*..............................................................................................................................*31!3.1! Interdisciplinary*Methodological*Approaches*...........................................................................*31!3.1.1! Methodological!Framework!of!Multimodal!Social!Semiotics!........................................................!31!3.1.2! Methodological!Framework!of!Healthcare!Communication!..........................................................!34!3.1.3! Methodological!Framework!of!Corporate!Communication!............................................................!36!
3.2! Limitations*of*the*Interdisciplinary*Methodological*Framework*........................................*37!
4! ANALYSIS*..........................................................................................................................................*39!4.1! Analysis*of*RHS’*Existing*Preoperative*Communication*Genres*..........................................*39!4.1.1! Analysis!of!Interactions!Between!Patients!and!Various!Healthcare!Providers!.....................!39!4.1.2! Analysis!of!Patient!and!Doctor!Interaction!............................................................................................!40!4.1.3! Analysis!of!Patient!and!Nurse!Interactions!...........................................................................................!47!4.1.4! Analysis!of!the!Brochure!................................................................................................................................!53!4.1.5! Analysis!of!the!Information!Meeting!........................................................................................................!58!
4.2! Analysis*of*RHS’*New*Preoperative*Communication*Genres*.................................................*60!4.2.1! Analysis!of!the!Postcard!.................................................................................................................................!61!4.2.2! Analysis!of!the!Platform!.................................................................................................................................!63!4.2.3! Analysis!of!the!Animation!Films!Placed!on!the!Platform!................................................................!69!
4.3! Comparative*analysis*of*RHS’*Communicative*purposes*and*strategies*...........................*76!
5! DISCUSSION*......................................................................................................................................*83!
6! CONCLUSION*....................................................................................................................................*85!
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7! BIBLIOGRAPHY*...............................................................................................................................*89!
8! LIST*OF*APPENDICES*....................................................................................................................*94!
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LIST OF FIGURES
Figure 1 – Data overview
Figure 2 – Overview of Theoretical Framework
LIST OF TABLES
Table 1 – RHS’ communicative purpose and strategies used for attaining these
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1 INTRODUCTION
1.1 Motivation At the Regional Hospital of Silkeborg (RHS), Denmark, accelerated patient treatment programs
for hip-, knee-, and back surgery have reduced the length of hospitalization from ten to one day
(appendix (A) 1). However, acknowledging, in line with several studies (Brull et al., 2002,
Rolfson et al., 2009, and Ip et al., 2009) that preoperative patient anxiety affects recovery and
pain negatively, RHS was concerned with how patients, appointed relatives participating in the
treatment program, and a team of interdisciplinary healthcare providers participate in and
experience ‘døgnhofteforløbet’ (24h program) (Aarhus, 2011: English Summary (A2)), seeing
that an increased experience of pain leads to an increased need for painkillers, which has a
number of side effect that often result in an extended hospitalization. Therefore, to gain an
understanding of the patients and in an attempt to preempt anxiety to escalate, an ethnographer
was hired to make observations of the daily clinical work at the hospital’s hip department; and
from the report that followed, a list of factors influencing the 24h program was identified.
Among these was that many of the patients did not understand the medical language used by the
healthcare providers during face-to-face interactions and they had difficulty remembering and
recalling the information when needed. Consequently, the ethnographer emphasized the need for
proper information and education of the patients prior to surgery. However, given from the
report, the ethnographer also emphasized that the animation films, in opposition to the
interactions, support the accelerated hip program, as the patients generally expressed that the
animation films helped them to recall information, as the films provided the possibility to be
watched several times and whenever the need for information occurred. (A2)
Acknowledging that: low health literacy – (…) the ability to read, understand, and act on
healthcare information – is associated with poorer health outcomes and poorer use of health care
services (Berkman et al., 2011: 97 and Scudder, 2006: 29) and recognizing that: proper
preoperative education makes patients more optimistic (...), limits the use of parenteral narcotics
and avoids the side effects of nausea and vomiting, which is the most important factor
for…satisfaction (Dorr et al., 2007: 7), the hip department at RHS is now in the process of
implementing and testing a new communication strategy that sets out in animation films, seeing
that these, based on the report, seem to constitute an effective genre for improving health literacy
and, thereby, reduce anxiety. More specifically, these films are integrated on a digital patient
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platform called www.mitforløb.dk, on which they make up the primary genre. With its largely
visual approach to communication, the overall purpose of the digital platform, including the
animation films, which is designed and powered by Visikon, is, if not, to ideally replace some of
the existing communication genres, namely face-to-face interactions, brochures, and the
information meeting, then to complement them, in order to fulfill the identified need for proper
preoperative education that reduces patient anxiety and lead to faster recovery and improved
satisfaction among the patients.
1.2 Thesis Statement Following Berkman et al. (2011: 97): Approximately 80 million U.S. adults are thought to have
limited health literacy, which puts them at risk for poorer health outcomes. Recognizing that the
problem of low health literacy is a recognized problem not only at RHS but possibly also for
hospitals across the world, more research on how to minimize the recognized knowledge gap that
exist between professionals and patients and, thereby, reduce anxiety is needed. Based on the
report, animation films might show the way for a new means to communicate with patients, RHS’
communication strategy, including new and old communication genres, makes up an interesting
out set for this exploration. Given that the communication genres respectively being face-to-face
interactions with healthcare providers, brochures, a digital platform, including animation films,
and a postcard linking to the platform, embrace images, text, sound, and speech, it is relevant for
the exploration to consider these semiotic modes and their purposes through the lenses of a
multimodal, social semiotic discourse and genre analysis. Therefore, following two research
questions have been set up:
Which are the communicative purposes and strategies of the hip department at the Regional
Hospital of Silkeborg (RHS) when preparing patients for surgery through face-to-face
interactions with healthcare providers, brochures, Visikon’s patient platform
‘www.mitforløb.dk’, and the animation films placed on it and the postcard linking to it?
How can Visikon’s patient platform ‘www.mitforløb.dk’ reduce patient anxiety?
In the pursuit to answer the two research questions put forward, an interdisciplinary
methodological framework has been comprised by the theoretical fields of corporate
communication, healthcare communication, social semiotics, multimodality, discourse, and
genre, where corporate communication makes up the larger theoretical context, in which the
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other theoretical fields are important parts. Through the different theoretical lenses a comparative
multimodal, social semiotic, discourse and genre analysis of RHS’s existing and new
communication strategies will be conducted in order to answer the two research questions. More
specifically, this involves an analysis of the face-to-face interactions the patients have with the
healthcare providers prior to their operation, the brochure(s) provided by the healthcare providers
at their first meeting, the information meeting offered to the patients before the operation, and
the patient platform www.mitforløb.dk, including the text, images, and animation films placed
on it and the postcard linking to the site and which, in the future, will be provided by the
healthcare providers at their first point of contact. A more detailed description of the data will be
presented in chapter 1.4 and in chapter 4 a detailed presentation of the conceptual tools to
analyze the data by will be presented.
Acknowledging the complexity of many of the concepts introduced and used throughout this
thesis, a glossary is provided in appendix 3 to make it easier for the reader, who may not be
familiar with these concepts, to comprehend the analysis. These are marked by italics throughout
the thesis, to give the reader an indication of the concepts that are elaborated on in the glossary.
However, to preempt any confusion, the quotes used throughout the thesis are also marked by
italics, as can also be seen from this introduction. Speaking of more practical details, it should
also be mentioned here that the appendices are to find in a file on its own, the main reason being
that one of the appendices is a large brochure that could not have been integrated in this book
form. With these more practical details being clear, focus now turns towards a discussion of the
which scientific approach this thesis follows, seeing that this will improve the reader’s
understanding of the choices made throughout this thesis.
1.3 Theory of Science Social interaction, and particularly language, is of great interest to social constructionists (Burr,
2003: 4). Therefore, considering the research questions’ concern with understanding the social
interactions that take place between healthcare providers and their patients through different
genres to, thus, identify the purposes these are serving, social constructionism makes up the
scientific tradition upon which this thesis is based. In the following, focus is to paint a picture of
social constructionism and the implications this has on the research, to immerse the reader into
the author’s world of understanding.
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Following Burr’s (2003) there is no single definition or framework for describing social
constructionism. However, it originates from a number of disciplines, namely that of philosophy,
sociology, and linguistics; and using the metaphor of a family, Burr explains that there is no
characteristic shared by all members of the family, but there are enough to identify the people as
belonging to the same family, being the family of social constructionism.
A predominant characteristic to social constructionism is that it insists that we are critical
towards our, otherwise, taken-for-granted ways of understanding the worlds and ourselves.
Thereby, social constructionism challenges the conventional positivistic understanding
characterizing traditional science as it is based upon mere objective, unprejudiced observations
of the world. Contrary to entering the world as a blank sheet, Burr (2003) argues that all
knowledge of the world and common ways of understanding the world are based upon the
history and culture in which they are created, seeing that understanding is socially constructed
between people. Based on this notion, there is no one ultimate truth in interpretation.
Consequently, we should not assume that our ways of understanding are necessarily any better
than other ways (Burr, 2003: 3). Therefore, in theory, the individual may interpret a text or an
object in many different ways, and all are they, by the social constructionist view, considered as
being equally valid. So for that reason, Candlin et al. (2006: 24) argues that: Any scientific
understanding of human action…must begin with and be built upon an understanding of the
everyday life of the members performing those actions. Accordingly, Fairclough (1989: 20)
argues that the members’ resources—the cognitive resources, including peoples’ knowledge of
language, representations of the natural and societal worlds they inhabit, values, beliefs,
assumptions, and so on, that people draw upon when producing, distributing, and consuming
text—should be taken into account when analyzing discourse from a critical perspective, which
is the intent when analyzing the communicative acts that take place between RHS and their
patients, seeing that the act of doing so complies with social constructionism.
In extension to Fairclough’s notions on members’ resources, Malinowski (1935: 320 in: Sarangi,
2005: 377) argues in his work on applied linguistics research in professional discourse studies
that: one cannot understand the rules of the game without a knowledge of the game itself.
Therefore, for a ‘professional’ applied linguist to operate in another professional context, the
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knowledge of the discipline needs to be supplemented by the knowledge/experience of a given
profession in its organizational environment vis-à-vis their clients. As a condition for
involvement and understanding of the game, Sarangi (2005) presents thick participation, which
involves spending time and space to socialize into the professional ways of seeing and doing
things.
However, having spent time at RHS when gathering the data for the analysis, which will be
elaborated on in the following, the thesis also complies with Sarangi’s (2005) notion of thick
participation; and given that the following theoretical framework chapter introduces the reader of
this thesis to the corporate and medical contexts in which this thesis operate, to thus immerse the
reader into the author’s world of understanding, the thesis complies once again with the social
constructionist view. In the following section, the author’s data selection will be elaborated in
detail.
1.4 Data Selection and Acknowledging that the context plays an important role in social constructionism, time has been
spent at the hip department of RHS in order to achieve a larger understanding of the patient’s
communication experiences with RHS prior to the operation. As implied by the genres
introduced in the first research question, this involves first of all taking part of the examination
of the patients, where a diagnosis to the patient’s problem is approached, and subsequently to
take part of the face-to-face interactions the patients have with different healthcare providers,
namely a nurse, a secretary, an anesthesia nurse, and a blood sample nurse. Here, audio-
recordings (A4a in A4) and images (A4b in A4) were gathered for later to be analyzed with the
lenses of corporate communication, healthcare communication, multimodality, social semiotics,
discourse, and genre, acknowledging that these theoretical fields help the author act in
accordance with the social constructionist approach by developing a critical understanding of the
discourse and genres. As mentioned in part 1.2, this methodological framework will be described
in detail in chapter 3. Prior to the interactions, the author personally explained the patients about
the study and asked for their approval to participate by signing a document on which the usage of
the recordings was clarified. The approvals of the ten participating patients are placed in
appendix 5. Seeing that the research questions is concerned with identifying the communicative
purposes and strategies of RHS, represented by the various healthcare providers, only one
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interaction is analyzed; and although acknowledging that having followed other healthcare
providers might had brought about some slightly different strategies and purposes, one extensive
analysis is considered proficient. During the interaction with the ward nurse, the patient was
provided with a file containing different brochures gathered by different healthcare providers
based on their experience with previous patients of what is relevant for the patients to know
before the operation. Seeing that particularly one brochure was emphasized during the
interaction with the nurse, namely ‘hip prosthesis’, a choice was made to focus on this in the
thesis. Hence, the ‘hip prosthesis’ brochure makes up the second choice of data (A5). The next
meeting the patient has with the hospital is the information meeting and therefore this was
selected as the third research data. Like the interactions, audio-recordings (A4c in A4) were
gathered and brought home for exploration together with the interactions and the brochure.
Recognizing that this is the last communication the patient has with RHS before the operation,
the interactions, the brochure, and the information-meeting make up RHS’ existing
communication genres. See figure 1.
However, taking in mind the motivation for this study regards the new communication genres,
respectively being a patient platform ‘www.mitforløb.dk’, including animation films, and a
postcard that provides a password to the platform, these were also found particularly relevant for
exploration. Seeing that the postcard, which, like the existing brochure, is to be provided to the
patients at their first meeting with RHS, provides the link to the platform and the password for
entering mitforløb (in English my program), this was selected as the fourth choice of data to be
analyzed by the interdisciplinary framework described in chapter 3, while the platform
‘www.mitforløb.dk’ itself became the fifth and the films placed on it the sixth and final choice of
data to be included in the analysis. The postcard can be found in appendix 7 and the platform,
including the films, in appendix 8. If the password for some unexpected reason should not work
when the reader of this thesis wants to enter the platform, the two films analyzed, respectively
being the ‘introduction’ film and the ‘operation’ film, from the platform can also be found in
appendix 4, more specifically the ‘introduction’ film can be found in appendix 4d and the
‘operation’ film in appendix 4e. However, if the password presented on the postcard in appendix
7 works, the reader of this thesis is recommended to use this, as it will enable the reader to get
the same communicative experience as the author and more importantly the patients for whom
the postcard is intended. The introduction film has been selected based on the extensive use of
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storytelling and the operation film based because it shows details from the operation, which
either of the other genres do. However, this will be elaborated on in the analysis chapter.
Recognizing that the research questions demand a detailed multimodal, social semiotic analysis
to be conducted only these two films have been selected as representatives of the film genre. To
see a complete overview of the data to be analyzed, see figure 1 below. From that, focus turns
towards a presentation of how the thesis has been structured form here and onwards to further
give the reader an overview of how the thesis develops and what each chapter contributes with.
Figure 1 – Data overview
Multimodal,!Social!Semiotic!Discourse!and!Genre!Analysis!
RHS'!Existing!Communication!
Genres!
AudioCrecording!!and!Images!from!FaceCtoCFace!Interactions!
Hip!Prosthesis!Brochure,!
Including!Tex!and!Images!
AudioCrecordings!from!Information!Meeting!
RHS'!New!Communication!
genres!
Postcard.!Including!Image!
and!Text!
Patient!Platform,!Including!Text,!Images,!and!
Animation!Films!
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1.5 Structure In order to state the context in which the communication genres are a part, the introduction
chapter rounds off by introducing RHS and Visikon and their respective focus areas. From here,
the thesis moves on, in chapter 2, to present the theoretical framework that describes the
fundamental theories used to conduct the multimodal, social semiotic, discourse and genre
analysis. More specifically, the chapter presents theories from the fields of corporate
communication, healthcare communication, social semiotics, discourse, and genre. In the
subsequent methodology chapter (chapter 3), the specific interdisciplinary methodological
framework utilized for answering the two research questions will be demonstrated and used in
the analysis chapter that follows. The analysis chapter (chapter 4) starts out by analyzing RHS’
existing and new communication genres, namely face-to-face interactions the patient has with
the healthcare providers at their first meeting, the brochure provided at that meeting, the
information meeting offered to the patient two weeks before the operation date, and finally the
new patient platform ‘www.mitforløb.dk’, including the text, images, and films placed on it and
the postcard linking to the platform, to identify the communicative purposes and strategies of
each of the respective genres. To place the purposes and strategies in the context to which they
belong, the strategies and purposes will, throughout the analysis, be related to healthcare
communication theory. Subsequently, the key purposes and strategies for attaining these will be
elaborated on through a comparative analysis of the genres, to further clarify the findings.
Simultaneously, the comparative analysis will be a means to further emphasize how Visikon’s
animated platform can reduce patient anxiety, seeing that this is relevant for adequately
answering the second research question. Having answered the research questions, from a
healthcare communication perspective, the following discussion in chapter 5 will relate the
findings to corporate communication, seeing that corporate communication is the larger context
to which the strategies and purposes belong. With the discussion being the last means of
exploration, the following conclusion (chapter 6) will summarize the sub-conclusions made
throughout the analysis and put the analytical findings into perspective by outlining some further
areas of investigation the thesis has opened up for.
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1.6 Background Information In the following, the contextual background that this thesis sets out in is introduced, seeing that
understanding how RHS and Visikon works and cooperate is important.
1.6.1 RHS RHS, which is placed in Silkeborg, a Danish town in the middle of Jutland, has since April 1.
2011 been merged with three other hospitals also placed in the middle of Jutland (A9). These are
the Regional Hospitals of Viborg, Skive, and Hammel. Together the four hospitals make up
Hospital Unity Central (Hospitalsenhed Midt), which, with its 4,400 employees who by its
annual treatment of more than 400,000 outpatients and sign out of more than 50,000 patients
after hospitalization is the second largest hospital unity in the center region of Jutland, Denmark.
(A9). Placed at RHS is the Center for Planned Surgery, here among hip surgery, which is the
focus of this thesis (A1). For several years, RHS has been a leading hospital within the
development of accelerated patient courses, which has reduced the length of hospitalization from
ten days to just a single day in the last decade (A1). Seeing from the ethnographic report
mentioned in the introduction, which is one of the initiatives taken by RHS to further the
development of accelerated patient courses, there is still space for improvement as a
communication gap has been identified, of which patient anxiety is a result (A2). Therefore, the
hip department has, as the first in Denmark, gone into a partnership with Visikon to develop a
new way to communicate with patients, being through the animated, digital patient platform
Mitforløb.dk; an initiative that is intended to empower the patients through effective multimodal
communication and, thereby, reduce patient anxiety. Having spent time at RHS to gather
information for this thesis, it has been become clear, that RHS is determined on continuously
improving the patient courses. (A1, A2, and A9)
1.6.1.1 RHS’ hip program Having been referred by the family doctor, the patient meets at RHS for a pre-examination at the
hospitals’ hip department, where one of the hospital’s surgeons will perform the examination. In
collaboration with the doctor, they here find out whether a new hip is the solution to the problem
or not. If it turns out that a new hip is the solution, then the patient enters the hospital’s
predetermined hip program. The first step in this program is a meeting with the nurse who was
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also participating in the pre-examination. This starts immediately after the pre-examination. At
the meeting, the patient is provided with a brochure and a contact card to bring home.
Subsequently, the nurse takes the patient to see a secretary, an anesthesia nurse, and a blood
pressure nurse, in that specific order. Then, about one or two weeks before the operation date,
the patient is invited to a pre-scheduled information meeting about the hip program. The next
meeting the patient has with the hospital is the day of the operation, unless questions have
occurred before.
1.6.2 Visikon Visikon is a sub-unit to the visual communication consultancy company Mark Film
(www.markfilm.dk), which, at this early developmental stage of its existence, is the producer of
mitforløb. Visikon is a partnership between Mark Film’s founder and CEO, Anders Nejsum, and
a doctor at RHS and founder of the company MedData, Martin Vesterby. The partnership
emanates from collaboration between Mark Film and RHS, about the animated hip film that was
mentioned in the introduction part, which Mark Film is the producer of. As the titles of the two
partners are a witness of, Anders Nejsum and Martin Vesterby enters the partnership with
completely different backgrounds. Anders Nejsum being the founder of Mark Film, which is
consulting in and producing dynamic visual communication to public and private companies,
museums, and healthcare institutions, while Martin Vesterby, on the other hand, is a doctor and
PhD. at RHS. However, with Martin Vesterby’s interest in tele-medical solutions, which he is
working on and offers lectures in through his company Meddata.dk, their shared passion for
patient communication have created an overlapping niche within which the respective
professional backgrounds complement each other perfectly. Therefore, the hip film produced by
Mark Film for RHS became the first out of what is now a series of animation films, which, today
is a part of the larger patient platform Mitforløb.dk, on which they are placed.
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2 THEORETICAL FRAMEWORK
In this chapter, the theoretical foundation considered relevant for carrying out and understanding
the subsequent analysis and discussion will be accounted for and discussed. Due to the
complexity of some of the theoretical concepts introduced in the following, these will, as
mentioned in the introduction, be marked by italics, which will not only emphasize their
relevance, but will also indicate that an elaboration of its meaning is offered in the glossary
placed in the appendices (A3). Seeing that corporate communication is the theoretical
background from which I arrive as well as it is the context in which the more specialized field of
healthcare communication is a part, this is a natural place to start, before moving into subsequent
fields of healthcare communication, social semiotics and multimodality, discourse, and genre.
See figure 2 below.
Figure 2 – Overview of Theoretical Framework
Corporate!Communication!
Healthcare!Communication!
Social!Semiotics!and!Multimodality!
Discoure!and!Genre!
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2.1 Corporate Communication According to the corporate communication theoretician Cornelissen (2008: 5): Corporate
communication is a management function that offers a framework for the effective coordination
of all internal and external communication with the overall purpose of establishing and
maintaining favorable reputations with stakeholder groups upon which the organization is
dependent. Seeing from this quote that the practice of corporate communication transcends the
specialties of individual communication practices such as internal communication, public affairs,
branding, investor relations, etc., managing the communication is a comprehensive discipline
that requires an integrated strategic approach. However, it also means that in reality, developing
effective corporate communication strategies that serve the interest of the organization at large is
a complicated and challenging task that is greatly influenced by social and contextual parameters
in which it is used. For that reason, Cornelissen has denominated three conceptual tools that are
fundamental to the understanding and practicing of the concept of corporate communication,
namely: stakeholders, identity and reputation.
2.1.1 Stakeholders Starting with the concept of stakeholders, Cornelissen (2008) emphasizes that there has been a
shift in stakeholder management from a neo-classical economic theory, which considers making
a profit for themselves and their shareholders to be the only purpose of organizations, to a socio-
economic theory, which also considers other groups outside shareholders to be important for the
continuity of the organization and the welfare of society. In sum, this distinction means that
contemporary organizations have come to understand the importance of communicating with
stakeholders is not only for profit (instrumental) reasons but also for moral (legitimate) reasons.
Accordingly, when Cornelissen (2008: 414) states that: (…)the future of a company depends
critically on how it is viewed by key publics(…)of the community in which the company resides.,
the relationship of the organization with these various stakeholder groups is no longer linear but
one of interdependence. Grunig (1984) refers to this interdependence as the two-way symmetrical
model. More specifically, Grunig expresses that the key to creating and maintaining beneficial
and harmonious relationships with stakeholders, is through high-quality communication
processes, which he argues to be more symmetrical than asymmetrical. Hence, only by
constantly adapting itself to the values and demands of its publics, an organization can achieve
harmony. The opposite model, in which organizations persuade publics to behave in ways that
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fulfill the organization’s needs and demands, is referred to as the two-way asymmetrical model.
Contrary to the symmetrical model, this, however, does not take into consideration the ideas,
attitudes, and behaviors of its publics, which is important according to contemporary theoretical
approaches within the field of corporate communications and public relations, from which
Grunig (1984) arrives, because researchers and practitioners are realizing that the organization
depends on the satisfaction of these stakeholders.
2.1.2 Identity and Reputation With the previous in mind, this takes the discussion to Cornelissen’s (2008) second and third
concepts of ‘reputation’ and ‘identity’ seeing that one way, in which organizations often address
the challenge of dealing with different demands and expectations of stakeholders, is to build
strong reputations with their stakeholders through strategically embedding a particular positive
image of the organization with the stakeholders, often referred to as a corporate identity or
corporate brand. Following Cornelissen (2008: 64): Such strong reputations in turn lead to
acceptance of the organization by different stakeholders and to the organization being found
legitimate. Moreover, a good corporate reputation has a strategic value for the organization as it
forms a skill that is difficult for competing organizations to imitate. Having introduced the
fundamental corporate communication aspects, focus now turn to the more specific healthcare
communication.
2.2 Healthcare Communication Having created an overview of the general theoretical concepts within corporate communication
and the development within the field, focus will now turn towards the theoretical field of
healthcare communication, seeing that the social interactions take place within this field.
Following Harvey and Adolphs (2011: 470): Healthcare communication, by definition, refers to
all aspects and modes of communication that take place within medical contexts or broadly
relate to the subject of health and illness. This definition stresses that healthcare communication
is an all-embracing concept that is comprised of communicative practices including modes of
both spoken and written languages as well as various more emerging forms of communication,
such as digital communication in the form of e-mails, online forums, etc. However, it does not
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tell what the purpose of healthcare communication is, nor does it introduce the participants
involved. For this, we will have to dig deeper into the field of healthcare communication.
Doing so, Young’s (2006) perspective on the medical examination will be looked into firstly,
seeing that this theory offers a thought provoking aspect to the topic, which contributes to fill out
the missing details. According to Young (2006), medical examinations threaten the person’s
embodiment, or self, with unpleasant intimacy. This happens because, in the realm of medicine,
the person is turned into a patient. (…)Medicine constitutes a separate realm in which the body
as lodgement of the self is transformed into the body as object of scrutiny(…) (Young, 2006:
407). Naturally, as a consequence to this altering of the person into a patient, medical
examinations make the person feel that he is loosing control, not only of his body but also of his
person as a whole. Consequently, to protect the self, patients tend to reconstitute the self during
medical examinations in an attempt to sustain reality. In this reconstitution the patient can either
choose to break the agenda of the medical realm by distending, misinterpreting, or violating its
conventions or support the framework, but insert into the realm of medicine a narrative part of
another being. What exactly happens, is that an enclosure for stories is created by the patient
within the narrative frames of the medical practices’ prefaces, openings, beginnings, endings,
closings, and codes; and it is here the patient’s self is being disembodied. Within these frames,
storytelling becomes a tool for the social construction of an alternate reality, a tale world, which
is different from the reality surrounding the frames, being the medical reality, in the sense that
the person presented in these stories, typically (…)is not himself but a story containing a
protagonist who may happen also to be himself. (Goffman, 1974: 541 in: Young: 408).
Nevertheless, in this alternate reality, the patient reappears as a person; and for the benefit of the
medical examination, this person respects, although with help from narrative tools from a
different ontology, the conventions of the realm of medicine. Nevertheless, seeing that patients
constitute an alternate self out of fear of loosing the self, this could imply that there is a need for
better communication within healthcare. (Young). Therefore, the following will look into some
further aspects of healthcare communication.
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2.2.1 Aspects of Healthcare Communication Borrowing from the realm of law, Candlin et al.’s (1995) work “Orientations in lawyer-client
interviews” focus, like Young (2006), on the communication between professional and lay
people, the strategies that both parties bring to the professional context, and the challenges
connected to that. Therefore, despite of its original focus on relationships between lawyers and
clients, it contributes to the discussion of healthcare communication with some valuable
theoretical points. Candlin et al. (1995) stress that both lawyer and client understand that they
come together in order to focus their joint attention on a personal issue, which the client believes
to be important in his or her everyday or professional life. Nevertheless, within this professional
realm, in which the communication takes place, natural knowledge asymmetries are prevalent.
On the one hand, the professional brings to the interaction complex rules, upon which the
lawyer’s actions and recommendations on behalf of the client are based, while the client, on the
other hand, brings to the conversation a personal story presented in lay language based on lay
knowledge and lay sensibility. This means that: When lawyer and client interact, each confronts,
in the world the other inhabits, something new and opaque, yet something of indisputable
relevance to their relationship. (Felstiner and Sarat, 1992: 1454 in: Candlin et al., 1995: 43).
Following Candlin et al. (1995) these knowledge asymmetries causes the creation of two
different views or expectations of what this professional relationship is or should be: the rule-
oriented and the relational-oriented. As the designation implies, the rule-oriented account
strictly follows the rules of law, without taking into consideration the client’s prior knowledge,
personality, or social relationships. Accordingly, the communication becomes highly factual and
impersonal. Relational accounts on the other hand, sets out in the client’s social relations; and
based on these terms, the legal problems are analyzed and described. In agreement with social
constructionism, Candlin et al (1994: 12) stresses that: (…)the purposes of the law and social
justice would be better served by a more participatory model of lawyer-client relationships, in
which clients are encouraged to ask questions and to make decisions on matters relevant to their
problem or case. Yet, the rule-oriented account represents the predominant image of the lawyer-
client relationship in legal discourse. Given that the professional-lay interaction brings together
two diverse views, communication within the professional discourse of law (or medicine)
becomes a challenge, as the parties frequently switch from one discourse to another in the
pursuit to fulfill their (personal) communicative and institutional purposes (Discourse will be
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elaborated on later in the theory chapter). For that reason, the communication aspect in the realm
of the medical discourse should not be neglected.
Harvey and Adolph (2011: 471) agrees in that point, which shows in the following quote:
Communication is a central aspect of healthcare and healthcare provision, especially…in terms
of how discourses produce a cause and effect, given that the professional causes the patient to
adopt or modify certain behaviors. Nevertheless, they also argue that within healthcare, there has
been a shift from a medico-technical focus, referring to the rule-oriented account if relating it to
Candlin et al.’s (1995) work, towards a more client-focused practice, if referring to Candlin et
al.’s relational-oriented account, which places emphasis on the independence of the patient and
on shared decision-making. This communicative turn is, according to Harvey and Adolphs,
clearly demonstrated in the way some domains of healthcare have replaced the term ‘patient’
with the appellation ‘client’. However, given that the appellation ‘patient’ seems to be the
common appellation at RHS, I have decided to remain with the appellation ‘patient’ from here
and onwards.
Web (2011) contributes to this matter and stresses that the shift away from the medico-technical
model, which he refers to as the medical model, towards the client-focused model, which he
refers to as the bio-psychosocial model, is a result of the fact that there has been a shift in
healthcare, like in corporate communication towards a more customer/public-focused approach,
which Web (2011) refers to as the age of consumerism. What has pushed healthcare into an age
of consumerism is the fact that people today are …living longer with chronic conditions such as
cancer, bi-polar disorder and severe physical or learning disability. (2011: 6) and therefore
quality in healthcare has become almost as important as survival. Consequently, the clients
demand from the practitioners a much more client-centered approach to healthcare, including
more and better communication, which is why the choice of treatment in the bio-psychological
model has come to depend much more on the preferences of the individual client and his or her
values and expectations. Health professionals who can communicate at an emotional level are
seen as warm, caring, and empathetic and engender trust in their patients, and this encourages
disclosure of worries and concerns that patients might otherwise not reveal(…) (Letvak, 1995;
Bensing, 1991 in: Web, 2011: 5). Additionally, informative and useful communication between
the practitioner and the patient is shown to encourage patients to take more interest in their
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condition, ask questions, and develop greater understanding and self-care. This is particularly
so when the patient is given time and encouragement to ask questions and be involved in
treatment decisions. (Crow et al., 1999 in: Web, 2011: 5).
Seeing that the designation ‘bio-psychosocial’ derives from the biological, psychological, and
social aspects of the client’s well-being that are taken into account when addressing the concern
of the client in the new model, Scheeres et al. (2008) contribution to the topic is also relevant. In
line with Web, Scheeres et al. (2008: 20) express that healthcare providers should gain: an
integrated understanding of the world from the patient perspective, their whole person, their
emotional needs and life issues, because (…)patients want patient-centered care that explores
the main reason for their visits, their concerns and their need for information. This is naturally a
challenge to hospitals when time and money is short. However, if failing to gain this integrated
insight into the patient, the healthcare provider will not be able to recognize and respond to the
individual needs of each patient and therefore not be able to deliver patient-centered care.
Consequently, the patients’ are left with a feeling of having lost control of their independence,
which, as mentioned in the previous, causes increased anxiety, which again may leads to
violation of conventions (Scheers et al., 2008 and Young, 2006).
2.2.2 Implementing a Client-Centered Approach In line with the client-centered approach described in the previous, Garcia-Miguel et al. (2003)
emphasize the importance of preoperative assessment and consultations as tools to reduce
anxiety. They argue that through these, insights into the patient’s internal reference and present
concerns can be gained, meanwhile the patients’ trust and confidence is enhanced; and according
to Garcia-Miguel et al. this is a means to prevent anxiety to escalate.
Acknowledging that, Rollnick et al. (2008) present a gentle form of counseling known as
motivational interviewing (MI), which has been found effective for fostering change across a
wide range of health behaviors. (2008: 4). In line with social constructionism, MI works by
activating patients’ own motivation for change and adherence to treatment. (2008: 5) following
four guiding principles: Resist the righting reflex, understand your patient’s motivations, listen to
your patient, and empower your patient. Resisting the righting reflex is important because this
often automatic reflex of correcting another’s course can have the opposite effect than the one
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intended, the reason being that human beings have a natural tendency to resist persuasion.
Understanding your patient’s motivations is important because it is the patient’s own reasons for
change, and not yours, that are most likely to trigger behavior change. (2008: 9). Likewise it is
with the third principle, being that of listening to your patient, which is important because the
answers to behavior change most likely lie within the patient itself. Finally, Rollnick et al.
theorize the task of patient empowerment, seeing, like Web (2011), that a patient who is active in
the consultation, thinking aloud about the why and how of change, is more likely to do something
about this afterwards (Rollnick et al, 2008: 10). In this thesis, the main change of concern is that
of reducing the patient’s anxiety, which, according to Sheers et al. (2008) will change the
patient’s behavior postoperatively and lead to better results and patient satisfaction.
Nevertheless, concerned with examining the practitioner’s attitude and approach to helping
patients, Rollnick et al (2008) offer two additional concepts: style and skills that determine the
practitioner’s consistent habits in healthcare consultations. Using these tools well increases the
practitioner’s freedom to conduct the consultation in a time-efficient and productive manner
(2008: 19). Considering the concepts’ original concern is to make meaning of the practitioner’s
communication with the patient in consultations, the concepts are highly relevant tools for
studying the preoperative face-to-face interactions that take place preoperatively at RHS.
In extension to Rollnick’s concepts, Tannen’s and Wallat’s (1993), who are also concerned with
interactions in healthcare, contribute with yet two concepts: interactive frames and knowledge
schemas, as a means to reflect the notion of structures of expectations in interactions e.g. in
medical settings. Important to the examination of interactive frames, is the use of identifiable
linguistic registers. Here, it is important to notice that different registers are appropriate for
different settings and audiences, and a mismatch of schemas triggers the frame switches (1993:
66), which is why register shifting should be considered alongside the examination of frame
shifting when comprehending meaning of the interactions at RHS.
Continuing the discussion, Martin and White (2003) contribute to the discussion by emphasizing
the importance that patient’s understand the meaning of the surgery. They argue that, by using
proper preoperative education, the patient will develop a more optimistic mindset and have
greater expectations of succeeding. More specifically, the patients will have improved function
and better psychological health, which has shown to be vital to patient satisfaction.
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Nevertheless, following Jlala et al. (2010: 369): the ideal way of delivering this information is
still unknown. Written information has been used as an effective way of delivering information to
patients, but not all patients are literate enough to read and understand an information sheet; in
addition, patients will retain information to a variable extent.
In extension to that, Bondy et al (1999) argue that multiple material formats should be offered
preoperatively to ensure that all patients, including those with hearing and vision disabilities, are
approached, while Jlala et al. (2010: 373) claim that: Audio-visual information reduces pre- and
postoperative anxiety and can be particularly useful to those with reading, comprehension
difficulties, or both.
In agreement with the latter, Li et al. (2009: 380) argue that: (…)in teaching contexts, if the same
information is provided in two different formats, text and pictures rather than text alone, it will
be processed in two different cognitive subsystems, leading to two different representations that
will be integrated in the learners’ mind, resulting in better memory and recall of information.
Nevertheless, in order to understand the strengths and weaknesses of these, a thorough
understanding of the various modes and their qualities is necessary. Therefore, social semiotics
and multimodality is the focus of following theoretical discussion.
2.3 Social Semiotics and Multimodality Complying with social constructionism, Halliday (1996) argues that language, as well as
meaning, is a product of social processes. Accordingly, it is a social semiotic resource that arises
in the life of the individual through an ongoing exchange of meanings with significant others
(Halliday, 1996: 89) and thus constitutes a culture. Recognizing it’s shared meaning potential
Halliday uses language to construct meaning of social structure and social systems. This involves
the difficult task of focusing attention simultaneously on the actual and the potential, by
interpreting both discourse and the linguistic system that lies behind it in terms of the infinitely
complex network of meaning potential that is what we call the culture. (1996: 92-93). To
accomplish this difficult task, Stillar (1998) has, in line with Halliday’s understanding of
language as a semiotic resource, developed a hybrid model that investigates how real text
constructs social activities and relations. By bringing together concepts from Halliday’s
systemic-functional linguistics (SFL), communication linguistics, and social semiotics, the
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model supports rhetorical and social analysis with discourse analysis (will be elaborated on in
subsequent parts), which makes it an adequate tool for interpreting the language used in RHS
communicative genres to identify the communicative purposes of these. This investigation is
structured along three interdependent functions: the ideational, interpersonal, and textual
metafunction. The ideational function examines the language’s resources for constructing
content through: process types and participant roles, circumstantial roles, time and perspective,
and concept taxonomies. The interpersonal function regards language’s resources for shaping
interaction and relationship through speech function, modality, attitudinal lexis, and sentence
adjuncts. The textual function examines the structure- and coherence-building parts of a text by
examining the thematic structure and cohesive devices. If considering these metafunctions,
particularly the interpersonal, in light of the previous healthcare communication discussion, these
can be used in combination with Rollnick et al.’s (2008) style and attitude, Tannen and Wallat’s
(1993) interactive frames and knowledge schemas, among others, to analyze the relationships
between RHS and their clients.
However, given that Stillar’s (Halliday) framework considers language only, it is restricted to
analyze semiotic resources in language. Notwithstanding, its meaning-making potential, has
inspired a line of other researchers to broaden the approach to also include other modes. Among
these are Kress and van Leeuwen (2004) who explain how the visual mode, like language, is also
a semiotic resource that can produce meaning respectively at the representational (ideational),
interactive (interpersonal), and compositional (textual) level. This is relevant for this study to
access the full meanings of the old and new communication packages, which also contain
images. At the representational metafunctional level, the visual mode is seen as a semiotic
resource that, according to Kress and van Leeuwen (2004: 45): not simply reproduce the
structures of reality. On the contrary, they produce images of reality, which are bound up with
the interest of the social institutions within which the pictures are produced, circulated and read
(Ibid). Hence, the narrative and conceptual processes are means to construct meaning by
representing people, places, or things and their relations. At the interactive level, the visual
processes of (eye) contact, social distance, and attitude comprise the resources to understand the
relations between the text’s represented participants (human or not) and the viewer. Finally, the
compositional level considers how the representational and interactive elements are arranged in
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terms of information value, salience, and framing to relate to each other and, thus, fit into a
meaningful whole. (Ibid).
2.3.1 Interplay of Semiotic Modes Later, Kress and van Leeuwen (2001), however, realized that their work on visual design was yet
another monomodal framework, which did not fit into the twentieth-century’s desire for a
framework that was applicable to all semiotic modes. Consequently, the move towards a
contemporary and multimodal semiotic approach to communication was made, which, in
contrast to the traditional linguistic version, but in line with social constructionism,
acknowledges that multimodal resources make meaning in any and every sign, at every level,
and at any mode (Kress and van Leeuwen: 2001: 4). However, in order for the examination to be
multimodal, which is the intention of this study, other semiotic resources should also be
examined.
Therefore, Stöckl (2004: 26) made a contribution with a study examining music as a semiotic
resource. Within this, he argues that while language and sound are usually geared towards the
denotative meaning, as it can refer to concepts, music clearly provides associative meaning, like
the visual mode, as it can tap into individually valid facets of meaning. Later, van Leeuwen
(2006) examined the semiotic resource of sound, including music, which’ meaning-potential is
realized through perspective, which considers the sound in layers, and social distance, which is
determined by volume. As more modes came about, the new social practice of multimodality
became a reality; a contemporary social practice that considers the individual modes and
acknowledges that they reinforce each other, fulfill complementary roles, or be hierarchically
ordered (Kress and van Leeuwen, 2001: 20). More specifically, what happens is: When several
modes are involved in a communicative event (e.g. a text, a platform, a spoken interchange) all
of the modes combine to represent a message’s meaning. (Jewitt, 2009: 24-25). Yet, following
Jewitt (Ibid): Not every mode is equally ‘usable’ for a particular task... In fact, he argues that:
Each mode (as it is realized in a specific social context) possesses a specific social logic and
provides different communicational and representational potentials, referred to as modal logic.
Given that RHS’ preoperative communication kit constitutes a combination of these modes, the
question of concern in this study is what meaning each mode represents and what discourses are
embodied?
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One theorist who acknowledges this new social practice of multimodality is Iedema (2001), who
has developed yet a social semiotic approach that applies the tripartite, metafunctional approach
to that of filmic texts. It sets out to explore: how I, the viewer, am positioned by the tele-film in
question, and how I see certain social allegiances and values being promoted over others
(Iedema: 2001: 187). Therefore, it makes up an adequate tool for questioning how social reality
is (re)presented by the different modes on Mitforløb.dk. At the representational (ideational)
level, Iedema’s framework is concerned with how meanings are represented visually, verbally,
musically, and sound-wise. At the orientation (interpersonal) level, the analysis is concerned
with how the visual and aural mode arranges characters and the readers-viewers. Finally, at the
organizational (textual) level, the focal point is on how the meaning-making modes are linked
together in terms of rhythmic units and integrated into dynamic text. (Iedema: 2001). However,
relevant to the this is also van Leeuwen’s (2005) thoughts on information linking, in which he
considers how items of information are meaningfully linked to other items of information by
means of elaboration and extension.
Given that this thesis is concerned with understanding the purposes of RHS’ communicative
acts, the following approach of Martinec (2001) is also considered relevant. Martinec (2001:
117) is concerned with …the means of construction and expression of interpersonal relations
through action, for which he maps out the resources of actions (or movements). In particular he
distinguishes between three types of action: presenting, representing, and indexical. The
interpersonal resources of presenting action are (presenting) engagement, modality, and affect.
And as the appellation implies, the meanings communicated by presenting action regard the
immediate context only; and mostly, it consists of whole bodies and of facial muscles. The main
interpersonal resource(s) of representation is sign function, which consists of following
categories: statement, question, command, and offer, which are usually realized by hand and arm
movements. Different from presenting action, representing action functions as a means of
representation of the immediate context. Finally, the interpersonal resource of indexical action
prevails, being that of (indexical) engagement. Indexical engagement is different from presenting
engagement in that it is the interactants’ hand and arm movements, or the combined distance and
angle of these movements, which are used for identifying the meaning of actions between
interactants. The rule here is, that the more the angle is toward another interactant, the greater the
effort the gesturer makes to engage the other in his/her expressions. Accordingly, the more
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oblique the angle is towards other interactants, the lesser effort the gesturer is making to engage
others. Nevertheless, yet a distinction should be made to that of presenting engagement, being
that indexical action can only be understood if the meaning of the simultaneously occurring
speech is understood. (Martinec, 2001)
In line with multimodality, Lemke (2002) argues that no text and no image have the exact same
set of meaning-affordances; and: it is this essential incommensurability that enables genuine new
meaning to be made from the combinations of modalities (Ibid: 303). Nevertheless, Lemke
(2002: 300) argues that: Hypermodality is more than multimodality in just the way that hypertext
is more than just plain text. It is a web of ‘pages’ that is combined through links, the so-called
trajectories, which combine the whole or some parts of it to the whole or to some parts of
another page ...(or even another part of the same page) in some way other than by the default
sequential convention of ordinary reading. (Ibid). These trajectories or reading paths are
constituted by sequences of signifiers in different modes to produce more specific or new kinds
of meaning not otherwise available. Concerned with understanding these design resources,
Lemke takes Stillar’s (1998) tripartite approach yet a step further and applies it to hypertexts.
Seeing that Mitforløb.dk is a web of ‘pages’, Lemke’s (2002) approach constitutes a relevant
means for understanding the communicative purposes positioned within this web. Nevertheless,
when analyzing this platform, it is important to keep in mind that our eyes and interests wander
due to the many sources of visual salience (trajectories), which means that the reading paths and
thereby the meaning, to a larger extent than in print text, is a creation of the individual
user/reader. (Lemke, 2002)
2.3.2 Aspects of Genre Theory So far, the various social semiotic resources of multimodality have been described through
various theoretical approaches within the field of social semiotics and multimodality. Though, in
the following, different aspects of genre theory will be discussed seeing that the definition of
genre is as follows: Genres are how things get done, when language is used to accomplish them.
(Eggins, 1994: 26). Many different genres exist. To mention the genres interesting to this thesis,
these are: face-to-face interactions, brochures, information meetings, postcards, platforms, and
animation films. Each of these genres has different social characteristics. In the following parts
characteristics of hypertext and animation genres will be exploited and discussed, seeing that
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these two genres plays a predominant role in RHS’s new communication genres. The reason for
not exploiting the genres of RHS’ other genres is because these are covered by previously
described theory.
2.3.2.1 Hypertext Given from the previous section ‘Interplay between Semiotic Modes’, the Internet as a medium
has a number of characteristics which significantly influence and contribute to the way the web-
mediated genres look and are used. (Askehave and Ellerup, 2005: 121). Consequently,
hypertexts cannot simply be treated as static products. Askehave and Ellerup account for specific
genre characteristics of non-linear, multimodal, web-mediated documents. The first
characteristic being links, which provide access to the various levels of a hypertext and, thus,
contribute to the way the text is used. A variation of generic links and specific links should be
present on a platform to ensure that the communicative purposes of the site are accomplished.
The second characteristic regards the modal shifts between reading mode and navigating mode,
which, according to Askehave and Ellerup, are activated in the reading process. In continuation
to these characteristics, Stigel (2001), however, also addresses the problem of how to involve the
absent party in media-borne communication and, thus, make him a participant, seeing that
reciprocity and interaction in media-borne communication is vital to create communication that
is interpersonal. More specifically, he (ibid: 323) argues that: The recipient…must…be ‘let into’
or at least relate to – a virtual world which to some extent he accepts, takes over, identifies and
sympathises with, and perhaps is surprised by, as this actualizes a space for communication that
creates tensions and mobility in the viewer’s notions, which main purpose is to seduce and
persuade the viewer to engage. Hence, the diegetic or non-diegetic narrator acts as a connecting
link between the screen event and the screen viewer, which enables the movement of the viewer
“into” the screen event and offers the viewer with a presumed involvement and “gradual
consent”.
2.3.2.2 Animation There is much disagreement to whether animation is a genre, a medium, a code, or a text
Following Greenberg (2011), the reason for this confusion, as he calls it, is namely that the term
’animation’ is often associated with the term ’cartoon’, which is defined a comic genre by
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Lindval and Melton (1994). This will be elaborated on later. However, according to Greenberg’s
(2011: 5) definition: (…)animation is a text – aimed at producing meaning, shared by both the
producer and the reader. His argument is that animation has no unifying traits in terms of
content (genre), style (code), or delivery (medium). Nevertheless, he does recognize that certain
traits distinguish animation from other texts. One of these traits is its ability to convey concepts
over objects. However, other interesting traits are its ability go beyond the familiar, physical,
and its ability to bring life to things that are not defined as ‘alive’ such as a lamp or a car.
Greenberg (2011: 5) states that: real possibilities available to the animator are to subvert our
accepted notions of ‘reality’, and challenge the orthodox understanding and acceptance of our
existence…to go beyond the familiar, physical reality. Hence, this emphasizes yet a trait, being
the one of absence or deletion of elements, seeing that animation according to the latter quote is
concerned with the creation of reality rather than the attempts to reflect it. Nevertheless, in
realistic drawing, understanding the principles of the physical world that it wishes to move
beyond, is vital. Therefore, as a means to remain realistic, animation has the possibility of
blurring reality and representation so that parts, such as either the ‘setting’ or the ‘person’,
remain realistic. Though, it is its strength in blurring reality and representation, often through its
blending into other forms of media, that, together with the often comic element that it is
associated with, makes it difficult to distinguish animation from other forms of media. Therefore,
for readers of the twenty first century, an important ability is that of being able to distinguish
animation from other media.
This takes us back to the discussion of what animation is. As promised in the beginning of this
section, the perspective of Lindval and Melton (1994) will now be presented and discussed,
seeing that they make an important point. Despite of their placement of animation among comic
genres, they (Ibid: 63) also stress that: …“animation” as a form extends beyond the realm of the
“cartoon”… Hence, it challenges the dominant classical style of narrating by providing a
distance to the workings of a text. Moreover, animation, namely animated films, demonstrates
self-reflexivity in three overlapping ways. First, they are transparent in the way they reveal the
methods of their working process. Second, they have the ability of working as a discourse that
speaks directly to their audiences through communicating subjects. And third, they reflect the
relationship to their creators, as the animators become part of their own films directly or
indirectly, where their role is to explore and reflect upon their own work. Nevertheless, this does
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not make the reader’s role irrelevant. In fact, Lindval and Melton (68) argues that: The reader is
neither a passive consumer of unyielding ideologies nor an independent constructor of brave
new worlds, but one who seeks a meeting of minds in text. If relating this back to the topic of
healthcare communication, particularly to Candlin’s (1995) perspectives on the relationship
between professionals and lay people, the role of the reader becomes important because these
readers seek professional expertise to help them solve their personal issues; and seeing from the
previous ‘healthcare communication’ section that client’s understanding of the practitioner’s
mind or intensions is crucial for the final surgery outcome, as research shows that understanding
of the surgery reduces anxiety, this latter quote of Lindval and Melton is important to remember
when analyzing the animated platform and the films placed on it.
2.3.3 Discourse and Discursive Practices In agreement with Halliday, Stillar, Kress and van Leeuwen, etc. and the social constructionist
view, Fairclough (1989:21) argues that language is a social practice that: …varies according to
the social identities of people in interactions, their socially defined purposes, social setting, and
so on. Or said in another way: it is …the product of social conditions specific to a particular
historical epoch (Ibid). However, different from language, discourse refers to the process of
social interaction as a whole, the whole referring to the society, of which text, in the sense of
language, image, action, sound, etc., are just a part. In the work of Michael Foucault (1977 in:
van Leeuwen, 2009: 144), discourses are defined as: socially constructed ways of knowing some
aspects of reality… or put in a different way: …context-specific frameworks for making sense of
things. Accordingly, Fairclough (1992: 269) theorizes that: the purpose of discourse analysis is
to reach explanatory understanding of how particular sorts of text are connected with particular
forms of social practice, and how the connections are mediated by the nature of the discourse
practice. Seeing from this, that discourse analysis constitutes a means for paying detailed
attention to participants’ use of language in a given context, it complies with the social
constructionist view and, therefore, it becomes particular relevant for this thesis when the
purpose is to make meaning of RHS’ different communication genres. Though, it means also that
discourse, in this thesis, constitutes both the object of study and the process through which I
examine the professional practice of healthcare at RHS.
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However, in search for meaning, van Leeuwen (2009) sees that discourses are not only modeled
on social practices, they also recontextualize the social practices, like animation, by leaving parts
out (deletion/exclusion), adding things (addition/inclusion), or replacing things (substitution) in
the service of the communicator. In detail, recontextualization refers to the discursive practice of
removing elements (text, signs, or meaning) from its original context (genres, discourses) to
build new ones, to meet the requirements of a new social and institutional practice. Given that
new orders of discourse emerge through this process, Fairclough (1992) terms this form of
intertextual incorporation and transformation of elements interdiscursivity. In view of the latter
definitions, the focal point of the processes of both recontextualization, intertextuality, and
interdiscursivity is, therefore, not only that of identifying the degree of heterogeneity of texts
when dealing with discourse analysis for the sake of doing it, paying attention to these discourse
structures can be a means to expose power and dominance in social practices, which is relevant
for this thesis, seeing that it revolves around healthcare communication.
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3 METHODOLOGY
Having presented the theoretical fields that this thesis revolves around, this chapter will present
the methodological framework used for answering the two research questions set up for this
thesis.
3.1 Interdisciplinary Methodological Approaches To explore and understand the meanings of RHS’ communication genres, which were introduced
in chapter 1.4, the thesis adopts a multimodal, social semiotic approach, through which the
various genres and discourses are accounted for. However, recognizing that RHS is an
organization and the patient (healthcare) communication genres are corporate strategies, the
multimodal discourse and genre analysis is related to a selection of relevant approaches from
healthcare communication and corporate communication theory, seeing that this, in agreement
with social constructionism, offers the possibility to make an exhaustive social semiotic
discourse and genre analysis that is useful for healthcare and corporate communication
practitioners. In the subsequent parts, a conceptual breakdown of the interdisciplinary
methodological fields is provided with the purpose of establishing mutual knowledge and
understanding of how the selected theoretical concepts are applied to answer the research
questions in a sufficient way. Despite that corporate communication makes up the overall
context in which this thesis takes place, and healthcare communication the more specific context,
the initial framework is that of multimodal social semiotics, seeing that the multimodal, social
semiotic concepts are essential for understanding RHS’ various communication genres.
Therefore, this will be described firstly.
3.1.1 Methodological Framework of Multimodal Social Semiotics Considering that RHS’ patient communication strategy is comprised of various genres and
modes, different theoretical concepts will be presented in this section to comprise a
methodological framework that can be used to adequately answering the research questions of
this thesis.
Recognizing the strengths of Stillar’s (1998), Kress and van Leeuwen’s (2004), and Iedema’s
(2001) metafunctional approaches to analysis lie in the structural possibilities that ensure that the
meaning-making elements – text, image, and film – of various forms of texts are analyzed
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alongside three (metafunctional) levels, namely: representation, orientation, and organization,
makes them an insightful and logical structure for conducting a detailed analysis of the various
communication genres. However, seeing that using one structure will ease the analysis, it will,
more specifically, be structured across Iedema’s metafunctions: representation, orientation, and
organization, given that this also take into account the dynamic aspects. However, to enable yet a
deeper level of analysis and to be able to understand the characteristics of animation (the
animation films) and hypertexts (the platform), additional theories are applied to each
metafunctional level to analyze, in detail, the communicative means behind each semiotic mode
and multimodal choice. These specific concepts will be introduced and accounted for in the
following under the structural headlines: representation, orientation, and organization.
3.1.1.1 Representational Metafunctional Level At the representational level, the focus is on the functional means of each mode – visual,
textual/verbal, and/or aural – used in the respective genre and their ability to provide information
that is relevant to reduce the patient’s anxiety preoperatively. Hence, the visual analysis includes
Kress’ and van Leeuwen’s (2004) approach, which, at this level is used as a means to identify
how the narrative and conceptual processes of images represent or symbolize meanings and
thereby determine the communicative purposes and strategies of the respective genres. Based on
Halliday’s thoughts, Stilla’s (1998) thoughts are used to examine the symbolic meaning-making
elements of the verbal and textual mode, which, at this particular level, is concerned with
process types and participant roles, circumstantial roles, time and perspective, and concept
taxonomy. To analyze the animated genre, represented (primarily) on mitforløb.dk, Greenberg’s
(1994) animation traits are used. And finally, to ensure that the meaning-making modes in the
films placed on mitforløb are accounted for, the aural mode, which provides meaning through
sound and music, will be analyzed using Stöckl’s (2004) thoughts on music.
3.1.1.2 Orientational Metafunctional Level The focal point at the orientational level, regards the interpersonal relations between sender and
receiver. Given that this thesis is concerned with identifying the purposes of RHS’
communicative acts and how these are (or not) means of reducing patient anxiety the relations
between RHS and their patients are identified. The more specific means for doing so is
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considering how RHS (and their patients) are using the respective visual, verbal, and aural
modes for different purposes across the different genres. At this level of analysis, the visual
mode is analyzed using Kress and van Leeuwen’s (2004) visual processes of (eye) contact, social
distance, and attitude to identify the relations between the RHS and their patients. Regardless of
the genre analyzed, the visual processes of (eye) contact are analyzed from the patients’ point of
view, which means that whenever e.g. a demand picture is identified, it involves the patient and
not the researcher. To reach a deeper level of understanding of the relationships presented and
represented, Martinec’s (2001) concepts of: presenting engagement, modality, and affect,
statement, question, command, and offer, and indexical engagement are used for analyzing the
respective genres. Textually and verbally, Stillar (1998) is used, who at this level of analysis is
concerned with how speech functions, modality, attitudinal lexis, and sentence adjuncts position
participants. Seeing that Stigel’s (2001) concepts of diegetic and non-diegetic voice (over) are
closely related to this discussion, these are also used to identify the social distance constructed
between RHS and their patients through the means of verbal narration. However, because of his
focus on interaction in media-borne communication, this perspective is utilized only when
analyzing the animation films placed on www.mitforløb.dk. The same is the case with van
Leeuwen’s (2006) perspectives on sound, which are relevant at this level to identify how social
distance between RHS and their clients is constructed through the use of sound in the films.
3.1.1.3 Organizational Metafunctional Level Finally, at the organizational metafunctional level, focus is on how meanings of the respective
modes are structured and/or sequenced into coherent and/or dynamic text (Iedema, 2001).
Acknowledging this, Askehave and Ellerup’s (2005) thoughts on the digital genre and Lemke’s
82002) approach to analyze hypertexts, and the trajectories used in these, are employed at this
structural level. To analyze the animation aspects, namely on mitforløb, Lindval and Melton’s
(1994) thoughts on self-reflexivity are also employed to identify how these are constructed to
promote specific elements and purposes (discourses) over others. For this purpose, van
Leeuwen’s (2009) concept of recontextualization is also particularly relevant, as it provides a
means to identify how social reality, or parts of it, is recontextualized to serve specific discourses
and, thus, fulfill, specific purposes. In support of these thought, van Leeuwen’s (2005) concept
of information linking is used as a means of analyzing how information is linked to other items
of information across the different modes (and genres, if following Lindval and Melton’s
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perspective on animation as a genre). To make meaning of the visual mode specifically, Kress
and van Leeuwen’s (2004) information value, framing, and salience is employed as a means to
analyze how some elements are promoted over others, again, to fulfill specific purposes, seeing
that the research questions are particularly focused on these. However, to also understand how
some textual parts, like images, are promoted over others, Stillar’s (1998) resources of theme and
cohesion are used for the same purposes, as paying attention to these will also help answer the
research questions. Finally, the aural mode is analyzed using van Leeuwen’s (2005) thoughts on
perspective, to further identify what elements are promoted over others.
As mentioned in the previous, structuring the analysis across the three metafunctions, which
were just accounted for, enables the author to carry out a detailed multimodal, social semiotic
analysis of the respective genres and discourses that RHS use when preparing their patients for
surgery. The comprehensive groundwork on which the following analysis is based is placed in
tables in the appendices (A10, A11, A12, A13, and A14). Acknowledging the
comprehensiveness of the multimodal and social semiotic framework, a breakdown of the
framework relevant for the respective genre is provided to make it easer for the reader to
comprehend the tables and thus understand the analysis described in chapter four. Nevertheless,
given that the thesis is concerned with identifying the communicative purposes and strategies of
a hospital, the multimodal and social semiotic analysis discourse and genre analysis is related to
healthcare communication theory, seeing that this makes the thesis more relevant in the medical
context. Hence, the specific methodological framework of healthcare communication is provided
in the following.
3.1.2 Methodological Framework of Healthcare Communication Considering that the thesis is concerned both with analyzing the purposes of RHS’ preoperative
communication genres and how these, particularly the platform, reduce patient anxiety, the
second framework is that of healthcare communication, given that healthcare makes up the
context to which the communication genres belong.
Therefore, Young’s (2006) thoughts on narrative embodiments in the realm of medicine are
particularly relevant for this. More specifically, her concepts are relevant for discussing the
communicative strategies and purposes used throughout the social interactions that take place
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preoperatively between practitioners from RHS and the patient, where the patient’s construction
of an alternate reality, through the means of storytelling, will be an indication that the patient is
anxious. Hence, complying with Fairclough’s (1989) members’ resources and thereby the social
constructionist view, it is a means to determine the patients’ state of mind during the face-to-face
interactions, but also a means to identify the healthcare providers’ focus and purposes.
Therefore, the main question raised when using Young’s understandings is how the respective
healthcare providers, representing RHS, communicate with their patients?
To help answer this question, a framework of other theories has been comprised starting with
Candlin et al. (1995) concepts of rule-oriented relationships and relational-oriented
relationships, seeing that relationships are created when two participants or interactants meet and
interact, in this case the professional and the lay patient. Therefore, despite of the concepts’
original concern with lawyer-client relationships, they become particularly relevant for this
thesis, given that the aspect of asymmetric background knowledge is also the case here. Thereby,
this also becomes a means for taking into account Fairclough’s (1989) members’ resources and
thereby respect the social constructionist view. In particular, the concepts are used for discussing
what type of relationship is being established between the professional and the client by
considering whether the practitioner is strictly following the rules of medicine, without taking
into consideration the patient’s social prior knowledge, personality, or concerns, or whether he is
transcending the rules of medicine by involving the patient in decision-making and by
encouraging them to ask questions. Considering these two concepts in light of Young’s theory
(2006), a rule-oriented approach would naturally result in more fear than the relational-oriented
model, which makes them relevant for the discussion of anxiety.
Recognizing that there has been a shift towards a more client-oriented practice, Harvey and
Adolps’ (2011) concepts of medico-technical practice and client-focused practice are used as a
means to investigate whether this shift has taken place at RHS, which, according to Harvey and
Adolphs, is given from the healthcare providers’, who represent RHS, use of either ‘patient’ or
‘client’ in daily speech, through the face-to-face interactions, brochures, digital text, etc. In
support of these thoughts, Web’s (2011) medical model and bio-psychological model are used as
a tool for further identifying whether RHS is considering their patients as patients, who are only
concerned with survival, or as consumers, who wants patient-centered care.
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However, to reach a deeper level of analysis, Rollnick et al.’s (2008) four guiding principles for
delivering patient-centered care, particularly motivational interviewing, are used to further
investigate whether RHS’ communicative purposes and strategies involve motivating their
patients to change behavior, namely the behaviors that are related to anxiety.
Given that Tannen and Wallat’s (1993) concepts of interactive frames, knowledge schemes,
linguistic registers, and how these are changing are relevant for this analysis, these are used for
the reflection of expectation structures. However, in combination with these more concrete
theoretical concepts, the thoughts of Martin and White (2003), Jlala et al. (2010), Bondy et al.
(1999), and Li et al. (2009) are also considered relevant in providing the adequate understanding
of what it takes for healthcare to be client-centered/focused, which is an important aspect in
identifying the purposes of the respective communicative strategies used by RHS, seeing that
these further help reveal whether the strategies of the various genres serve the purpose of
preparing the patients for surgery. Following these theoretical thoughts, preoperative information
is important. However, the ideal way of delivering preoperative information is still unknown,
which is one of the motivations behind this thesis. Seeing that a hospital, more specifically RHS,
is also an organization, the communicative purposes and strategies identified through the
multimodal, social semiotic analysis and related to a healthcare communication perspective, are
further related to corporate communication theory. Therefore, the methodological framework of
corporate communication is described in the following part.
3.1.3 Methodological Framework of Corporate Communication Seeing that a hospital is an organization, the genres and communicative strategies used in the
respective genre to attain different purposes is not only healthcare communication, but also
corporate communication. Accordingly, the strategies and purposes identified by utilizing the
methodological frameworks presented in the previous should, as already mentioned, be related to
corporate communication theory as this is the overall context to which RHS’ purposes and
strategies for attaining these belong.
However, when reading the methodological framework of corporate communication, it should be
noted that this is restricted to include only the most fundamental theoretical concepts of
stakeholders, reputation, and identity, given that this thesis is concerned with identifying the
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purposes of the more practical communication genres. Nevertheless, acknowledging that RHS is
an organization and the patient communication genres (healthcare communication) are part of a
larger corporate communication strategy, knowledge of corporate communication should not be
neglected if following the social constructionist stance, which emphasizes the importance of
contexts.
Acknowledging that stakeholders (including the patients whom this thesis focuses on), identity,
and reputation are fundamental for practicing good corporate communication, the identified
communicative strategies and purposes will be related to Grunig’s (1984) two-way symmetrical
and two-way asymmetrical models to find out whether RHS, from a corporate communication
perspective, acknowledges their patients and thereby practice good corporate communication.
However, given that the establishment and maintenance of the corporate identity and reputation
also are fundamental to delivering good corporate communication, the purposes will further be
considered in relation to their ability to serve establish and maintain an identity and their
reputation (Cornelissen, 2008).
3.2 Limitations of the Interdisciplinary Methodological Framework Acknowledging, in accordance with the social constructionist stance, that the previous
methodological framework and the following analysis are subjective because they are based on
the author’s realm of understanding, other methods could be appropriate for the exploration of
corporate communication and healthcare communication. Moreover, seeing that the thesis is
concerned with interpreting the communicative strategies and purposes of the professional field
of healthcare, there is a paradox in that the author goes into this field with a background in
corporate communication and not healthcare. Nevertheless, given that the strengths of the
interdisciplinary methodological framework, described in the previous, lies in the way the
different theoretical fields contribute with various relevant approaches to gain the relevant
knowledge specifically for answering the research questions set up for this and giving that the
commerce of (applied) linguistic analysis is not to deal with technical details and their accuracy,
but to examine their discoursal comprehension and practices and …show how these…vary in
accordance with variations in social context. (Sarangi, 2005: 8), the interdisciplinary
methodological framework is considered highly adequate for answering the research questions.
Nevertheless, following the social constructionist stance, the author does acknowledge that if the
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analysis had been carried out by other researchers and if other healthcare providers had been
followed instead of the ones participating in this thesis, the approach as well as the findings
would probably be slightly different. However, considering that the answers are not based on the
author’s subjective meaning alone, but on the understanding of the various theoretical concepts
of which the extensive interdisciplinary methodological framework is comprised, the outcome of
this thesis is both from a social constructionist and academic viewpoint considered vastly
proficient. Notwithstanding, the author acknowledges that the thesis statement opens up for
further areas of investigation. These will, as mentioned in chapter 1.5, be outlined in the
conclusion.
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4 ANALYSIS
As mentioned in chapter 1.4, the following analyses will revolve around the different genres that
make up RHS’ pre-operative communication strategy. More specifically, a detailed multimodal
discourse and genre analysis will be conducted, using the methodological framework presented
in the previous methodology chapter, seeing that this will help answer the two research questions
set up for this thesis, respectively being:
Which are the communicative purposes and strategies of the hip department at the
Regional Hospital of Silkeborg (RHS) when preparing patients for surgery through face-to-
face interactions with healthcare providers, brochures, Visikon’s patient platform
‘www.mitforløb.dk’, and the animation films placed on it and the postcard linking to it?
How can Visikon’s platform ‘www.mitforløb.dk’ reduce patient anxiety?
Given that the research questions are motivated by the new patient platform, which is currently
being tested and implemented at RHS, as a way to reduce anxiety, the analysis is divided into
two parts: an analysis of RHS’ existing pre-operative communication genres and an analysis of
RHS’ new communication genres, to, later, be able to emphasize what the new communication
genres add to the existing in a comparative analysis of the communicative purposes and
strategies for attaining these.
4.1 Analysis of RHS’ Existing Preoperative Communication Genres The following analysis will revolve around RHS’ existing communication genres. Accordingly,
this includes an analysis of face-to-face interactions between the patient and various healthcare
providers (A4a), the brochure (A5), and the information meeting (A4c).
4.1.1 Analysis of Interactions Between Patients and Various Healthcare Providers Given from the order stressed above, the first genre the patient is presented to after he or she has
been referred to RHS is face-to-face interactions with various healthcare providers. More
specifically, this involves the interactions the patient has with the doctor, the ward nurse, the
secretary, the anesthesia nurse, and, finally, with the blood sample nurse. The patient’s
interaction with the doctor, will be analyzed firstly under the headline ‘patient and doctor
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interaction’, as this is a pre-examination, while the interactions with the different nurses will be
analyzed together under the headline ‘patient and nurse interactions’. All references like these
hh:mm:ss, correspond to the specific time (hour; minute; second) dealt with in the interaction. In
the analysis of interactions, all times refer to appendix 10, in which you will find a table that
provides an overview of how the many social semiotics and multimodal concepts have been used
for analyzing, in detail, each specific part of the interaction.
4.1.2 Analysis of Patient and Doctor Interaction Considering the order in which the preoperative information kit unfolds at RHS, the pre-
examination, will be analyzed firstly, using the multimodal social semiotic tools presented in the
methodology chapter. Facilitated by Iedema’s (2001) metafunctional structure, focus will here
and in the following be to identify the communicative purposes of RHS’ communication genres
through the representational, orientational, and organizational level.
4.1.2.1 Representation The first metafunction ‘representation’ deals with what is represented visually, verbally, and
aurally during the meeting.
Verbally
At the very beginning of the conversation, right after the arrival, the doctor uses relational verbs
such as have been and have got as a means to identify and confirm the scope of the patient’s
problem before now and now. Combined with the words: doctor, x-rayed, and cannot walk, a
case of meronomy is created, where the mentioned concepts are parts that attribute to construct
the overall discourse of examination (00:00:41) (Stillar, 1998).
From here and onwards, focus turns from the patient’s past experiences and pain towards
focusing on the present time as in Are you in pain? (00:00:58), Where is your pain? (00:01:06.),
and Is it uncomfortable what I do here? (00:01:55.). In the first example, the doctor relates the
patient you to the pain, while he in the second, and third example relates the pain to a location
(Stillar, 1998). Again this implies an examination discourse, where the purpose is to identify the
location and scope of the problem in order to find a way to treat the problem and, thereby, solve
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it. However, the fact that the doctor sets out in the patient’s social relations, and based on these,
analyzes and discusses the medical problem with the patient shows that he is concerned with
understanding the patient as his approach or style to help the patient is not only to direct, but also
to guide, by asking questions, and to follow, by listening to what the patient has to say (Tannen
and Wallat, 1993). Considering this in terms of social constructionism, the doctor’s style
complies with the social constructionist view as he tries to gain access to the patient’s world of
understanding. According to Garcia-Miguel et al. (2003), this is a means to prevent the patient’s
anxiety to escalate; and according to Rollnick et al.’s (2008: 5) guide for motivational
interviewing, that of understanding the patient and listening to the patient, make up two
principles for activating patients’ own motivation for change and adherence to treatment. Hence,
activating the patient’s motivation to change and adhere to the doctor’s treatment are the overall
communicative purposes of this shot.
After 00:01:57 the words: x-ray, where, and often are repeated. This implies that a conclusion or
a diagnose is coming up, which in this case is that a new hip should be inserted if the problem
should go away (Stillar, 1998). What is interesting is the patient respond to that conclusion,
which consists of two contrasting words: worst and better, which collocate with the
superordinate category of pain (00:02:12) (Stillar, 1996 and Kress and van Leeuwen, 2004).
Given from the prompt ‘yes’ and choice of wording the patient accepts the doctor’s diagnosis
and treatment, which according to Tannen and Wallat (1993) is realized by the fact that the
patient’s linguistic registers match the doctor’s knowledge schema.
In the following, the doctor constructs a new conceptual field, being that of instruction, where he
is the processor who does the instructing and the patient the phenomenon who is being
instructed. (Stillar, 1998). He does so by using the relational verb: have to to link the patient you
to the mental verb know (00:02:38). The relational/linking: verb cannot, which is used in the
following statement: you cannot be a ballet dancer afterwards, further attributes to this
conceptual field; and with its slightly cautionary tone that comes from cannot, it seems that the
doctor is aiming to make the patient realize the seriousness of that of getting a new hip
(00:02:38). This creates a response from the patient, who asks, with a slight worry in her voice,
whether she can look after her garden afterwards. And this becomes the doctor’s opening for
instructing about the movements that she should be avoiding (00:02:51), informing about the
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risks connected with the new hip (00:03:04), as well as demonstrating the prosthesis (00:09:43),
which are all means to provide clear information. Hence, the communicative purpose is to
provide clear information. Though, taking into consideration that there is room for the patient to
ask questions and time for small jokes (00:00:53 and 00:01:31) and laughs (00:00:57 and
00:01:33), reduces the formality of the examination and the patient comes to relax (Stillar, 1998).
Following Web (2011), this happens because more emotional and personal elements make the
doctor look warm, caring, and empathic in the eyes of the patient and, consequently, this
engenders trust in the patient and she becomes more relaxed. Hence, emotional and personal
elements in the form of jokes and questions make up the communicative strategies for attaining
the communicative purposes of engendering trust and making the patient relax.
Visually
Visually the conversation starts with the doctor rolling out his chair so that he is facing the
patient. This act implies that the patient is the phenomenon of the doctor’s attention as an eye-
line vector is created and connects the two participants. (Kress and van Leeuwen, 2004). The
hospital settings implied by the white coats, the bed, the x-ray of a hip depicted on the doctor’s
computer screen, and now the placement of the two interactors in front of each other, make up
(symbolic) attributes that support the doctor’s language by giving associations to an
examination. However, the relaxed and informal posture of the doctor modifies the examination
discourse and connotes a friendly dialogue, which seems to have a relaxing effect on the patient,
who copies his posture. (00:00:41-00:00:57). Following Web (2011), the involvement of the
patient through dialogue, engenders trust, which results in the patient is coming to relax and start
accepting the doctor’s treatment, which is realized by as the patient lies up on the bed when the
doctors asks so that he can examine her properly, which further demands from her that she bends
her knee and later it involves that of watching the doctor elaborate on the x-ray on his screen
(00:01:18-00:01:48 and 00:09:43).
To sum up on the representational analysis, the visual and verbal mode both imply that the
communicative purpose of the patient-doctor interaction is to understand the patient to approach
a diagnosis and, thus, treat the patient. The representational choice/strategy used for attaining
this purpose is entering into a friendly dialogue with the patient, in which the patient comes to
relax and accept the medical agenda. Consequently, by establishing a relationship with the
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patient, trust is engendered and the patient’s motivation for adhering to the treatment is activated.
Moreover, this immediacy encourages a disclosure of worries, which helps the doctor understand
how to empower the patient and reduce her anxiety. In this case, verbal information and visual
illustration and demonstration become means for this. Once again the involvement of the patient
into these communicative acts, shows that yet a purpose is to activate the patient.
4.1.2.2 Orientation The orientational metafunction seeks to explain the relationship established between the doctor
and the patient.
Verbally
As stated in the previous, the doctor starts out by restating the information that has been sent to
him by the patient’s family doctor. His use of relational/linking verbs such as: have been and
have got links the patient to a previous time (past), location (family doctor), and action (x-ray).
(00:00:41) (Stillar, 1998). Considering these, a case of meronomy is created from the time, the
location, and the possession, which add to the conceptual field of an examination and turns the
statements into questions as an attempt to make the patient confirm the statement. Consequently,
by adding a question tag to the statement, what happens is that the doctor becomes the questioner
and the client the responder. (00:58-01:14). Considering that the nature of the following
questions concern the patient’s pain, the location of the pain, and the perspective of the pain, the
main association brought about is examination, given that the doctor’s verbal acts reveals that
his aim is to understand the patient and the scope of her problem to, thus, find a diagnosis
(00:00:41, 00:00:51, and 00:00:58) (Ibid). According to Rollnick et al. (2008), that of aiming to
understand the patient’s motivations and listen to what the patient has to say, these make up two
of the four guiding principles for activating a patient’s motivation for change and adherence to
treatment.
After the diagnosis has been found, questions are replaced by statements, with which the doctor
seeks to emphasize important information about the operation, here among the risks and physical
constraints connected to it (00:02:38, 00:02:51, and 00:03:40) (Stillar, 1998). However, the fact
that there is room for the patient to ask questions implies that the examination is still a dialogue.
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Visually
The nurse shows the client the way from the waiting room to the examination room. As they
enter the room, the doctor stands up and reaches out to greet the client. The relaxed, yet
confident movement towards the patient as she enters the room, realizes an (presenting)
engagement and involving attitude (Martinec, 2001). Afterwards, with a gentle, relaxed smile
and a relaxed arm movement, the nurse ensures that the client (and the support person) is seated
next to the desk, facing the doctor. (Ibid). The nurse places herself in front of a computer screen
on the other side of the doctor, farthest away from the client. Through her focus on the screen,
rather than on the patient, combined with the now longer social distance to the patient, she
signals disengagement, which seems a bit confusing until the doctor initiates the conversation.
(Kress and van Leeuwen, 2004 and Martinec, 2001). Then it becomes a signal that the doctor is
taking over the conversation with the patient and, thereby, his authority is made clear and a
relationship established.
As the conversation is about to start the doctor moves his chair out so that he is facing the
patient. The “demand shot” created by this act, combined with the movement towards the
patient, shows engagement and assuredness. (Kress and van Leeuwen, 2004 and Martinec,
2001). However, it also implies that he demands the patient to engage in him, which she does by
keeping eye contact with him. (Kress and van Leeuwen, 2004). However, seen from the way the
patient is leaning back in the chair while she rubs her right arm reveals unwillingness and
tentativeness, which implies that she is not completely comfortable with the situation (00:00:41)
(Martinec, 2001). Though, as the doctor copies her body language by slightly leaning back in his
chair and crosses his arms in front of him while he smiles at the patient, a visual modifier
(modality) is created, which seems to reduce the formality of the situation and make the patient
relax (00:00:40-00:00:57) (Ibid). This shows from the patient’s now more relaxed facial muscles,
implying assuredness, and from her movement towards the doctor, implying willingness and
engagement. (00:00:58-00:01:16) (Martinec, 2001). From here and onwards this pattern is
repeated, with the doctor expressing an empathic attitude and the patient responding to it by
adhering to his treatment (00:01:18-00:01:33). Following Web (2011), the doctor’s concern with
making the patient corresponds to the bio-psychosocial model, which considers the patient as a
client or a consumer, who demands quality healthcare. If relating it to Rollnick et al. (2008), this
gentle form of counseling known as motivational interviewing, has been found effective for
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motivating the patient to change and adhere to treatment. Therefore, this is yet a communicative
purpose.
Given from the doctor’s interfering hand gestures when he in shot 00:09:43 creates an offer shot
of the patient’s x-rayed hip, which is depicted on his computer screen, the purpose, after he has
found the patient’s diagnosis, is to provide the patient with information e.g. about the hip; and
the means to do so is illustration. (Kress and van Leeuwen, 2004) The fact that the patient can
only see the head of the x-rayed hip connotes that the doctor has a subjective attitude towards
what is relevant for the patient to see, which in this case is the head of the hip (Kress and van
Leeuwen, 2004).
To sum up, both the verbal speech and the visual body language imply that the event is first and
foremost to examine the patient. However, a means to do so is to understand the patient, which
the doctor approaches by establishing links between the patient and a previous time, location,
and possession and through the means of confirmation seeking, where the doctor asks questions
that the patient answers through statements (Stillar, 1998). This assigns the doctor with the
speech role of a questioner, making the patient a responder, which, however, is reversed later,
where the patient asks questions that he listens to and answers. Of more visual means, the
doctor’s relaxed and friendly attitude and visual illustration and demonstrations of the hip,
respectively on the screen and by showing a hip prosthesis, seem to further facilitate the
establishment of a more personal relationship, in which the patient can relax (Kress and van
leeuwen, 2004 and Martinec, 2001). This gentle form of counseling corresponds to Rollnick et
al.’s (2008) motivational interviewing and Web’s (2011) bio-psychosocial model, which shows
that the doctor acknowledges the patient as a consumer, whom demands quality healthcare.
However, it also shows that it is a means to make the patient adhere to the doctor’s treatment, as
it creates an opening for the doctor to present his mandatory information and, thus, take the
patient through the compulsory parts of an examination in a smooth way that is acceptable to
both participants in the relationship. (Web, 2011 and Rollnick et al, 2008).
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4.1.2.3 Organization The organizational metafunctional level takes the analysis from focusing on the relationship
established between the doctor and the patient to focus on how modal meanings (e.g. image and
text) are structured into coherent text.
The fact that the nurse places herself farthest away from the patient, while the doctor places
himself right in front of the patient, a connection between the doctor and the patient is
established, as they become each other’s most salient (salience) element/participant (00:00:10)
(Kress and van Leeuwen’s, 2004).
However, it also shows that the interaction is structured in terms of van Leeuwen’s (2005)
concept of visual linking, temporal extension, as the rotation becomes a transition from one event
to another (00:00:41). Hence, it is used for procedural purposes, which implies that the
interaction follows a pre-determined structure, in which this stage makes up the first rhythmic
unit (Ibid and Iedema, 2001). Verbally, this pre-determined procedure is secured by the
continuous use of the verbal link ‘then’, which connects one event to another by means of
temporal extensions (van Leeuwen, 2005). For that reason, it also has the purpose of establishing
cohesion (Stillar, 1998). In continuation to this, it is relevant to mention the doctor’s shift
between the interrogative mood and the declarative mood, as this constructs rhythmic units,
which further adds to the text’s cohesion (Ibid and Iedema, 2001). Then, on the other hand, if
considering the interrogative mood in isolation, it is worth noticing that the questioning-
responding pattern continues throughout the conversation, also with the patient in the questioner
role and the doctor in the responder role, as this connotes that the interaction is not completely
controlled by the doctor, as the patient’s interruptions slightly changes this structure (00:01:06-
00:01:56) (Stillar, 1998). From a healthcare perspective, the doctor’s skills, realized by these
shifts and use of visual and verbal linking, shows that the doctor’s style or approach to help the
patient is not only to direct, but also to guide and follow the patient, which according to Rollnick
et al. (2008) motivates the patient to adhere to the doctor’s initiatives.
However, when the doctor uses visual-verbal linking, namely elaboration, for illustration
purposes (00:09:43), it also implies that the doctor is concerned with providing clear and
memorable information, because following Li et al. (2009), providing the same information in
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two different formats (verbal-visual linking) is a tool that in teaching contexts create better
memory and recall of information. Accordingly, that of recontextualizing the medical discourse
with that of teaching shows that the purpose is once again to make information more clear (van
Leeuwen, 2009)
To sum up, the visual mode at this level of analysis reveals that there is a pre-determined order
of unfolding the various parts of the examination. At first, salience is brought to the doctor, to
establish a focus for the examination (van Leeuwen, 2004). Then through the means of rhythmic
units created by visual and verbal linking, a cohesive procedure is implied, ensuring that the
patient is taken through the examination in a time-efficient and productive way. (Iedema, 2001,
van Leeuwen, 2005, and Rollnick et al. 2008). However, the use of illustration through visual-
verbal linking is also a means of recontextualizing the medical discourse with that of teaching
(van leeuwen, 2009).
4.1.3 Analysis of Patient and Nurse Interactions After the pre-examination with the doctor, the patient is taken to see different nurses, these being
a ward nurse, a secretary, an anesthesia nurse, and a blood pressure nurse, before she can go
home. In the following, a multimodal, social semiotic, discourse and genre analysis of these four
interactions will be conducted in the pursuit to answer the thesis statement. As mentioned in the
previous, all times indicated by hh:mm:ss refer to appendix 10.
4.1.3.1 Representation Verbally
The nurse initiates the conversation by introducing herself by name. Then she “calls” the
patient’s name for then to relate it to a time: now and a perspective: finish up, which combined
with the following action verbs: tell and talk, imply that the event is now and after now and it
involves the actions of telling and later attending. (00:13:25-00:13:24 and 00:13:48) (Stillar,
1998). Based on these strategies, the communicative purpose is to provide information. The
latter action verb relates to the event: information meeting, which will take place after now,
because the patient will not remember if the nurse told it now. The quote: Will not remember is
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contrasting the relational verb to will, which, combined with the conjunctions: because and
cause, implies a reason and a temporal frame (00:13:48). (Ibid)
Later again, the action verbs: read (00:14:29) and contact (00:16:56) are introduced. Combined,
these action verbs make up a case of meronomy as they become parts that contribute to the
overall concept or purpose of the interaction, which, implied from these action verbs is that of
providing different information sources, as they extend to brochure and R (Stillar, 1998).
However, seeing that R is linked to the participant roles: responsible for the information meeting
and nurse through the relational verb: is, the communicative purpose is also to build trust, which
shows that the nurse is following the bio-psychosocial model that is concerned with providing
information that is important to the patient (00:16:56) (Web, 2011). This is further implied by the
word: always, which gives the contact card an ongoing perspective that brings along comfort and
a feeling of safety for the patient. (00:16:56) (Ibid).
From here, focus turns towards the operation day, which is implied by the action verb: meet that
extends to the patient: you, the time 7.15 a.m., and the place in the department. Here, the patient
brings about the topic of anesthesia, before the nurse continues with the list of doings, implied by
the action verbs: go and exercise. Combined with the circumstantial role recovery room and
ward, it becomes clear that the nurse is informing about the time after the operation, the after
now. (00:17:33-00:18:54). (Stillar, 1998)
Subsequently, when the patient is taken to another room to see the secretary, the limited talk and
dialogue implies that the secretary’s focus is solely on the act of booking an operation date for
the patient (00:37:08). However, afterwards when the patient is picked up by the previous nurse
to go and see the anesthesia nurse, the action verbs: talk and ask questions imply that that focus
here is to provide clear information (00:42:15) (Stillar, 1998). This brings about associations to
an education and preparation discourse. However, given from the out set in the patient, by asking
questions, the purpose is not only to make the patient understand, but also to gain an understand
of the patient, which connotes that yet a purpose is to deliver patient-centered care (Scheeres et
al, 2008). Finally, the patient is asked to go and see a blood sample nurse. Here, focus is, like
with the secretary, to get things done, which in this room is to have taken a blood sample
(00:50:41). (Stillar, 1998)
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Visually
The patient and her daughter follow the nurse into a room across the hallway. The room is bigger
than before and in the middle of it is a large bed, which gives associations to an operation room.
(Kress and van Leeuwen, 2004). The room looks cold and sterile, and, therefore, slightly
intimidating. Just inside the door, beside the window, is a desk with a computer and some papers
and brochures. The nurse gives signal to sit down in the chairs next to the desk in front of the
nurse, who takes a seat in front of the desk, but then quickly turns her body towards the patient.
The eye-line vector connected between the two participants as the nurse turns her body towards
her implies the patient is the phenomenon, with whom the nurse is concerned/interested in. This
focus on the patient links the patient to the followings parts presented throughout the interaction.
4.1.3.2 Orientation Verbally
Right after the nurse has introduced herself, she opens the sentence with a vocative: P (00:13:24)
(Stillar, 1998). By addressing the patient directly by using her name, the nurse assigns a receiver
for the following information and demands the patient to engage in the following.
Simultaneously, the vocative has the positional function of decreasing the social distance
between the two participants, due to the personal approach. Social distance is further implied by
the attitudinal sentence adjunct: eh, which immediate meaning is hesitation. (00:13:24) (Ibid and
Kress and van Leeuwen, 2004). However, considering the context, its secondary meaning lies in
the way the attitudinal adds immediacy and, thereby, decreases the level of formality (Stillar,
1998). From the patient’s following response: okay, the attitudinal lexis shows acceptance and
acknowledgement (00:13:47); and, thereby, the nurse has successfully created an opening for the
following statements. Hence, the purpose is to reduce the patient’s anxiety; and following Young
(2006) and Web (2011), it becomes a means of making the patient adhere to the treatment, which
shows that that the nurse’s style is patient-oriented.
The question tag in You are fully anesthetized right turns the patient’s statement into a question
and makes the patient the questioner (Stillar, 1998). Considering the content of the question, this
question connotes two things: involvement and concern. For that reason, the nurse’ replies by
saying: No, spinal, so you cannot feel anything from here and downwards, with which she
emphasizes that the patient cannot feel anything (00:18:21). This denotes comfort, security, and
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certainty, given from the modal verb: will. However, the patient’s question also denotes
curiosity, which is why the nurse uses it as an opening to tell about the operation day, making the
nurse the speaker again. Overall, this implies that the primary purpose of this conversation is to
inform about the operation and the treatment program. Nevertheless, considering that the nurse
modifies her commands and statements to make them less forceful and considering that the nurse
takes into account the patient’s concern and adapts her answers to the patient’s state of mind,
show that the secondary purpose is to promote optimism and reduce anxiety. (00:18:21,
00:19:32). Hence, the nurse is following the bio-psychosocial model (Web, 2011). This also
shows when the patient reacts to the fact that she will go home the day after the operation with a
surprising attitude, which is realized by the attitudinal: Ohh in Ohh, that was quickly and by the
degree adverb quickly. Here, the nurse treats the patient’s statement as a question and replies by
telling the patient that they will call her and talk about her feelings if she gets home the day after.
The modal verb will implies certainty and is utilized as a means to further reduce anxiety.
(00:19:32) (Stillar, 1998).
Later, the nurse takes on the role as a questioner, where her focus is on collecting knowledge
about the patient. An example of that is given from the quote: Is there something you cannot
tolerate?. The following question: I thought Herning was a place where people stayed and then
all your children have moved away? shows, on the other hand, that the nurse also uses her role as
questioner to establish a more personal bond with the patient, which becomes a means of
building trust, as the patient starts to relax. (00:31:03, 00:31:06) (Ibid). This seems to have a
positive effect on the patient, who rounds off the conversation by stating that she is definitely not
nervous now. Following Garcia-Miguel et al. (2003), that of gaining insight into the patient’s
internal reference is a means to reduce patient anxiety, meanwhile the patient’s trust and
confidence is enhanced.
Visually
The nurse who participated at the pre-examination takes the patient and her relative into a room
across the hall. As they sit down and the nurse turns towards the patient, a “demand shot” is
created, with which the nurse demands the patient to engage in her and the situation. (Kress and
van Leeuwen, 2004). However, the frontal angle of the nurse’s body further implies the nurse is
involved in the patient. Considering the equal eye level there is no power difference between the
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two participants as the conversation unfolds. (00:13:24) (Ibid and Martinec, 2001). Nevertheless,
the nurse’ hand and arm movement towards the patient, connote that she is the doer and the
patient the phenomenon, which was also stated at the representational level. (Kress and van
Leeuwen, 2004). The relational meaning of this sign language is that she wants to involve the
patient in the information she is providing, that being brochures, and a contact card (00:14:29
and 00:16:56). Whenever the nurse presents a physical document, as opposed to oral
information, the nurse moves focus away from herself and towards the respective document,
which is a means to involve the patient in the document. However, at the same time it shows that
she involves in the documents that she is presenting and, thereby, believes in the information she
provides. Hence, an “offer shot” is created, implying that the purpose is to offer information.
(00:16:56) (Kress and van Leeuwen, 2004). Once again, this shows that a relational-oriented
account is followed (Candlin, 1994).
To offer information is also the purpose when the patient later speaks to the secretary. (Kress and
van Leeuwen, 2004). The secretary looking into the computer screen rather than on the patient
further realizes this. However, when the patient speaks with the anesthesia nurse, “demand
shots” and involving (involvement) body language once again imply that focus is on the more on
establishing a relationship to the patient and, thereby, build trust and comfort. (Web, 2011)
(Ibid). These involving acts release often an affect, which can be seen from the smile that the acts
induce (Martinec, 2001). These are often combined with relaxed muscles, which signify
willingness. Finally, when the patient is having taken blood samples, focus is again more on the
functional aspects of that of getting the blood samples taken. However, the smiles on both the
patient and the nurse’ face, implies happiness, assuredness, and willingness. (Martinec, 2001)
In sum, the verbal and visual modes add to the construction of a relationship, in which the
nurse’s primary role is as the informing, “commanding”, and involved speaker and the patient as
the listener (Kress and van Leeuwen, 2004). However, in between, the patient interrupts and asks
questions, which shows that she is involved in the information provided, but also concerned with
what is going to happen (Stillar, 1998 and Kress and van Leeuwen, 2004). From a healthcare
communication perspective, this shows that the patient accepts the medical agenda (Young,
2006); and according to Web (2011) this acceptance further implies that the patient trusts the
nurse since she is sharing her concerns with her. This concern seems, however, to become
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smaller as the conversation goes by and as she adapts her answers and modality to the concern,
which shows that she is also concerned with making the patient feel comfortable and safe
(Martinec, 2001). Another means to do so is by asking questions about the patient, and not only
the mandatory questions, but also questions relating to the patient as a person with an identity
(Stillar, 1998). Considering the patient’s concern with the patient, the nurse is following the bio-
psychosocial model. (Web, 2011)
4.1.3.3 Organization The interaction is structured in terms of van Leeuwen’s (2005) information linking. Throughout
the interaction (00:13:24 and 00:18:54) the nurse uses verbal linking in the form of ‘then’ to link
to the next events. Due to the temporal extension, the verbal linking serves procedural purposes,
which establishes cohesion that helps the nurse take the patient all the way through the
interaction. In the same way visual linking is realized, as the shift from one healthcare provider
to another becomes a link to a new event (00:37:08, 00:42:15, and 00:50:41). Hence, visual
linking is also used for procedural purposes. Given that the patient is followed around from one
healthcare provider to another, a smooth transition is ensured, which further creates cohesion,
which assumedly is an attempt to make the patient adhere to the treatment (Web, 2011). Finally,
visual verbal linking, elaboration is used for illustration purposes e.g. to make the verbal
information: There is a whole brochure here… clearer (00:14:29). From a healthcare perspective,
information linking is used to provide clear and memorable information, acknowledging that
providing two different modes result in better memory and recall (Li et al, 2009).
In sum, the organizational strategy used by RHS is information linking, in all of its kinds (van
leeuwen, 2005). Throughout the interaction, the nurse is establishing links to the next event in
order to ensure that the patient is taken all the way. Hence, the communicative purpose is to
make the patient adhere to the treatment by establishing a cohesive sequence (Web, 2011).
Additionally, visual-verbal linking is used for illustration purposes to make the verbal speech
clearer by showing images while speaking. Accordingly, this leads to the conclusion that the
communicative purpose is to provide clear and memorable information (Li et al., 2009).
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4.1.4 Analysis of the Brochure In the following, a multimodal, social semiotic, discourse and genre analysis will be conducted
of RHS’ brochure. As opposed to the dynamic interactions, all references in this part refer to
appendix 11, in which you can see a breakdown of the concepts used for analyzing each part of
the brochure in detail. Where the interactions breakdown was referring to time, the brochure
table refers to page numbers of the brochure e.g. (p.1).
4.1.4.1 Representation Textually
Throughout the brochure, you and we are used as in (…)we believe that it is important that you
get as much relevant information that you can participate actively in the hip program (p. 4).
Considering the sender of the brochure is RHS, we refers to RHS and you to the reader, being the
patient. The action verbs get and participate implies that the communicative purpose is to induce
action. However, given that the action of participating depends on the act that RHS provide the
patient the relevant information as in: you get as much relevant information(…), that of inducing
action has a very polite and implicit commanding form. (Stillar, 1998). Considering that the
following action verbs are: read in read brochure and involve in involve a support person, these
actions are what RHS defines as participating actively in the hip program. (p. 4) (Ibid).
Later on page 18, the action verbs: bend, stretch, move, lie imply that that of participating
actively also involves that of doing the exercises illustrated in the brochure; and on page 29, the
action verb: make implies that the patient should also make the recipe on the protein drink RHS
is providing in the brochure (Ibid). Considering the nouns that the action verbs extend to,
respectively being information (p. 4), support person (p. 4), leg (p. 18), and protein drink, these
make up the parts that contribute to the overall context of being participating. Seeing that
exercises and recipes, which were briefly mentioned by the nurse during their interaction that
took place at RHS, the purpose of the brochure is to provide more detailed information. (Stillar,
1998)
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Visually and visual text
The front page of the brochure depicts a green flower which’ symbolic attributes give
associations to nature, hope, and fertility (Kress and van Leeuwen, 2004). Considering the
medical discourse of the brochure, the image does not make much sense, besides from signaling
hope, which shows that the communicative purpose is to promote optimism and reduce anxiety.
When turning up on the first page of the brochure, an overt taxonomy structure is suggested,
which is realized by the superordinate headlines, marked with red and bold black, and the
subordinate headings. Combined with the page numbers, the implied purpose is to provide the
reader with an overview. (p. 2-3). If looking up on page 4, the covert taxonomy structure
continues with the headline: ‘Patient and relative’s role in the hip program’ being the
superordinate headline that implies what to expect in the subordinate text. Besides from that, not
much is happening visually. On every second page, a sketched tree is depicted in vague green
color. Opposed to the green flower on the front page of the brochure, this image gives
associations to fall, sadness, and loneliness. Therefore, the visual associations contrast with the
encouraging language represented by the textual mode. However, later in the brochure, other
images are represented (Ibid). On page 6 two images depicting a signed hip are represented and
on page 18 four images of a man is depicted. The symbolic attributes of the bed, his clothes, his
movements, in the latter, implies that he is doing exercises; and the arrows inserted to on him,
implies that the purpose here is to illustrate (p. 18). Considering the medical context, the images
on page 6 and 8 represent parts of that of getting a hip prosthesis, which is the title of the
brochure (p. 1). (Kress and van Leeuwen, 2004)
In sum, considering the content of the represented text, the visual and verbal modes collaborate
to provide detailed and well-structured information, with the purpose of providing the patient
with clear and memorable information. However, while the textual strategies and part of the
visual strategies serve the communicative purpose of empowering the patient and reducing
anxiety, by promoting optimism and action, the rather depressive connotations brought about by
the tree and its colors used throughout the brochure serve a contradictory purpose, being
increasing anxiety and depression.
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If relating this to healthcare communication, providing as much relevant information as the
patient need to participate actively shows that RHS recognizes that knowledge asymmetries exist
between them as professionals and the patient as a layperson. Consequently, RHS is following
what Candlin et al. (1995) names the relational-oriented account, which, as mentioned
previously, take into account the patient. Nevertheless, compared to the face-to-face interactions
analyzed in the two previous parts, the information provided is predetermined by the healthcare
providers according to their previous experience with other patients. This means that the
individual patient’s personality and social relations have not been taken into account; and for that
reason, the communicative purpose of the brochure is merely to provide information and not to
enter into dialogue. Consequently, if the brochure is considered in isolation that of inducing
action becomes a challenge because the patient reading this brochure might have expectations
beyond the ones covered in the brochure and, therefore, becomes anxious. Though, considering it
in combination with face-to-face interactions, the relationship established through the more
personal interactions, might prevent anxiety to escalate; especially if the patient takes the contact
card in use whenever the brochure does not fulfill the patient’s individual expectations and
needs. (Candlin et al., 1995)
4.1.4.2 Orientation Textually
Given from the example elaborated at the representational level, RHS’s speech function is not
only to inform the reader by means of statements, but also to engage the reader by means of
commands (Stillar, 1998). Despite of the polite attitude, the modal verb: shall implies once again
that the speech function of RHS is to command, as this assigns obligation and certainty. (p. 4).
Combined with the manner adverb: actively, RHS implies that the reader should engage by
actively read (p. 4), involve (p. 4), exercise (p. 18), and make (p. 29), which emphasize the
importance of the reader’s role in the hip program. (p. 4) (Stillar, 1998). Hence, the purpose is to
empower the patient, as these actions should provide the patient with the knowledge and practice
needed according to RHS. As stressed at the representational level, the fact that the individual
patient’s personality and social relations have not been taken into account could influence this
purpose negatively, as a relationship to RHS has not been established and, thereby, a disclosure
of worries has not been encouraged. Consequently, the patient might never get his or her
concerns out, which could increase anxiety, rather that reducing anxiety, which may eventually
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lead to inactivity and dissatisfaction (Candlin et al. 1995, Web, 2011, and Garcia-Miguel et al,
2003); and as seen in the motivation part of the introduction, this is exactly what RHS seeks to
prevent.
Visually and visual text
The table of content on page 2 and 3 reveals everything there is know by indicating with
numbers and marked headlines how it should be read. (Kress and van Leeuwen, 2004). This
impersonal structure implies that RHS takes the leading role, while the patient becomes inactive
by the already given structure. However, on the other hand, the reader can use the overview
actively, by using the numbers and headlines to read the information that is relevant to them e.g.
‘Patient and relative’s role in the hip program’ if it is the first time it is read. (Kress and van
Leeuwen, 2004)
The offer shots on page 6 and page 18 imply that the purpose is to offer information respectively
about the hip and how to exercise which are represented as objects of the reader’s contemplation
(Ibid). However, due to the missing gaze at the reader on both pages and the oblique angle from
which the male character is depicted, the images are disengaging; and for a woman, the images
of the man doing his exercises, the images might be difficult to identify with, which makes them
impersonal. (Kress and van leeuwen, 2004)
In sum, given from the textual mode, the purpose of the brochure is to provide clear information
that educates and prepares the patient for the surgery and the treatment in general. However,
seeing that the brochure’s approach to healthcare is to state (statement) rather than to enter into
dialogue, it does not take into account the individual patient’s needs and, therefore, it becomes
impersonal compared to the face-to-face interactions. Consequently, if following Web (2011), it
does not engender enough trust in the patient to reveal his or her concerns; and this might
escalate anxiety and lead to dissatisfaction, which contradicts with the stated purposes of
empowering the patient and reducing anxiety (Garcia-Miguel et al, 2003).
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4.1.4.3 Organization On the front page of the brochure, RHS’s logo is placed ideally at the top. The immediate
meaning of that is that RHS has a leading position in the program. However, it also implies that
RHS is responsible for the information provided throughout the brochure. (p. 1) (Kress and van
Leeuwen, 2004). Accordingly, the information presented is structured in a way that fulfills the
purposes identified at the representational and orientational levels.
Overall, the brochure is structured in terms of van Leeuwen’s (2005) information linking. For
example on page 4, the textual words: responsibility, effort, take part, and support are linked to
the conjunction therefore in order to establish an argument for listening and act upon the
commands (Ibid and Kress and van Leeuwen, 2004). Hence, verbal linking is used to activate the
patient, which shows that the purpose is to make the patient adhere to the treatment. On page 6,
visual-verbal linking is used, as the image is used for illustration purposes to make the textual
explanation more specific (van Leeuwen, 2005); and the same is the case on page 18, where a
man is illustrating the exercises to make the textual commands more specific. Hence, the purpose
is to provide clear information that makes the patient understand. The fact that it is the same man
who is used in all the examples creates coherence because he is the visual link between the
exercises. Hence, the organizational choices show that the purpose of the brochure is to
contribute to the purpose of providing clear information to the patient, which was also one of the
purposes of the interactions. (van Leeuwen, 2005). Seeing that the nurse here referred to the
recipes and exercises in the brochure, the purpose of the brochure is to provide more detailed
information, seeing that the recipes and the exercises are clarified in the brochure.
To sum up, the ideal placement of RHS implies that RHS is responsible for the information
presented in the brochure. The way information linking is used for promoting verbal and visual
connections shows that the communicative purpose is to provide clear information that the
patient understands and can remember (van Leeuwen, 2005). Leaving the brochure analysis, the
following analysis focuses the information meeting.
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4.1.5 Analysis of the Information Meeting Right after the introduction, the coordinator states that: The purpose of today is to tell you about
the hip program and (…)the agenda of today is that I will tell you about the hospitalization, and
about what you can expect… and also a bit about what we will expect from you, because you are
also an active part of this hip program. (00:06:40 and 00:07:34). Here, she explains that the
purpose of the information meeting is to tell about the hip program, the hospitalization, what to
expect, and finally what RHS will expect from the patients (Stillar, 1998). Beyond the act of
informing, focus is also to answer questions (00:40:30-42:47), to inform about anesthesia
(00:44:32-00:52:42) and the physiotherapist’s function (01:21:33). Seeing that the identified
purposes respectively of the conversations and brochure, analyzed in the previous section, were
also to inform about the hip program, the hospitalization, what to expect, and what RHS expects,
the analysis of the information meeting will, as stated in the methodology chapter, focus merely
on what this information meeting adds to RHS’ existing communication kit. (Ibid)
Nevertheless, the method to find these contributions will still be through the conduction of a
detailed multimodal discourse analysis, structured across Iedema’s (2001) three metafunctions.
All references in this part refer to appendix 12, in which you can see a detailed breakdown of the
concepts used for analyzing each relevant part of the meeting. Like the interactions, all
references to time are made in hours, minutes, and seconds corresponding to hh:mm:ss.
4.1.5.1 Representation Verbally
The coordinator of the hip program starts out by introducing herself to the attendants, whom
from here and onwards will be named patients to ease the process. The relational verbs: is and
am are tied respectively to the role: nurse and coordinator. (00:05:46) (Stillar, 1998). These roles
increase the coordinator’s legitimacy and authority, which gives her a reason for speaking.
However, given from the action verb: contact in you are welcome to contact me, which extends
to the goal: me, she is provided with yet a role, being that of the patients’ contact person.
(00:05:46) (Ibid). This means that if the patients have paid attention to the contact card they were
provided with during their conversation with the nurse at the pre-examination day, a face has
now been added to that card, making it more personal. However, the meaning of this will be
elaborated on in the orientation part. (00:05:46). Later, the coordinator is replaced by other
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healthcare providers e.g. an anesthesia nurse (00:44:30) and a physiotherapist (01:23:33), who
inform about their respective field. This shows that the purpose is not only to provide
information about the respective areas, but also to give the patient an opportunity of establishing
a relationship to important roles in their treatment and, thus, engender trust in the patient.
Visually
As the patients arrive at the meeting room, the coordinator approaches each of them individually
(00:00:00-00:04:29). Every patient is arriving at the meeting respectively with a family member
or friend. Considering RHS in the brochure recommends that the patients involve a person to
support them throughout the hip program, the symbolic meaning of this person assumedly is the
support person. (Kress and van Leeuwen, 2004) Besides from showing that the patients have
adhered to the treatment recommended by RHS, it shows that the genres complement each other.
As a result of that, the brochure becomes less impersonal when looked at after the information
meeting, as a relation has been established to the various healthcare providers.
In sum, given from the visual and verbal modes the overall purpose of this two and a half hour
long information meeting is to provide clear information to empower the patient to become an
active part in the treatment. However, seeing that the coordinator is replaced by other healthcare
providers e.g. the anesthesia nurse whenever their respective fields are presented e.g. anesthesia,
implies that the purpose is also to establish a relationship to RHS through these and, thus,
engender trust in the patient.
4.1.5.2 Orientation Visually
After the personal welcome, the patients find a seat or a place in the room to sit or stand until the
meeting is waiting. As more patients arrive, some of them find each other and pair up.
(00:00:00). The frontal angle and eye-line vector connect the patient, which connotes that they
engage in dialogue with each other. This opportunity of engaging in dialogue with other patients
shows that a purpose of the information meeting is also to provide sparring, which should
engender trust and consequently encourage a disclosure of worries. (Web, 2011)
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In sum, the orientational metafunctional choices identified in the previous extend to the
communicative purposes of establishing a relationship to RHS and to other patient for sparring
purposes. Consequently, the communicative purpose implied by these relationships and
immediacy is that of engendering trust and encouraging a disclosure of worries, which should
prevent anxiety form escalating. (Web, 2011)
4.1.5.3 Organization The information meeting is divided into rhythmic units, respectively informing about different
aspects of the hip program. (Iedema, 2001) The fact that the each of the separate parts are
initiated by a new person shows that the meeting is also structured in accordance with van
Leeuwen’s (2005) concept of visual linking, which is used as a narrative means through
extension.
With the information meeting being the last of the three existing preoperative communication
genres, focus now turns towards RHS’ new preoperative communication genres, which leads up
to a comparative analysis of the various genres, through which the key purposes and strategies
identified throughout the previous analysis will be revisited and thereby summarized.
4.2 Analysis of RHS’ New Preoperative Communication Genres In the previous, a multimodal discourse and genre analysis have been made of RHS’ existing
pre-operative communication genres. In the following, an analysis of RHS’ new communication
genres will be conducted, which consist of a postcard, a platform, and animated films, which are
placed on the platform ‘www.mitforløb.dk. To follow the same structure as in the previous, the
postcard will be analyzed firstly, given that this is provided to the patient firstly. In fact, it is
handed to the patient together with the brochure analyzed above.
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4.2.1 Analysis of the Postcard When reading the following analysis of the postcard, it is worth knowing that all references in
this analysis refer to appendix 13, in which you can see a detailed breakdown of the concepts
used for analyzing each relevant part of the postcard.
4.2.1.1 Representation Visually and visual text
On the front page of the postcard, seven signed people are portrayed. The symbolic attributes of
the white and blue coats that the three people are wearing depicted on the left hand side of the
image, imply that they represent healthcare providers. (Kress and van Leeuwen, 2004).
Combined with RHS’ logo above, they represent healthcare providers from RHS. Contrary on
the right hand side, a grey-haired woman, a younger man, and two children are depicted. The
symbolic attributes of their everyday clothes demonstrate that they are lay people, while their
different ages imply that they are related and that the woman is the eldest. The eye-line vectors
created by the female surgeon and the black-haired participant, which point directly at the eldest
family member, realize that the grey-haired woman is the phenomenon and, thereby, the patient
to whom the other characters show their concern. (Kress and van Leeuwen, 2004). The fact that
the patient makes up the center of attention shows at this early point that RHS acknowledges that
the patient is the consumer who demands patient-centered care (Scheeres et al., 2008).
In sum, the way in which the figures are portrayed to focus on the patient in the middle is a
means to signal to the receiver of the postcard, who is also a patient that RHS cares about their
patients.
4.2.1.2 Orientation Visually and visual text
Considering that the frame depicts the characters in full figure, the social distance implied is
impersonal. (Kress and van Leeuwen, 2004). However, considering that two of the characters
look directly at the viewer, a visual “you” is established, decreasing the social distance by
moving the viewer into the screen through the visual demand. Hence, the viewer is demanded to
engage in their world by entering the visual text below ‘www.mitforløb.dk’, which in English
means ‘my treatment’. The use of the word ‘my’ constructs a textual “you”, who combined with
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the visual “you” and the participants’ friendly attitude, implied from their smiles, make up a
strong implicit command. From a healthcare perspective the friendly attitude and use of signed
figures implies that RHS is willing and able to communicate at an emotional level. Accordingly,
the purpose of this strategy is to establish a relationship to the patient and vice versa through
which RHS can engender trust in the patient and, thus, empower the patient to take action, which
will reduce anxiety and increase satisfaction (Web, 2011 and Garcia-Miguel, 2003).
When flipping the postcard, the implicit command ‘www.mitforløb.dk’ is repeated. Combined
with the access code and the ‘kind regards’ from RHS, the viewer is brought closer to RHS and
their reality. Hence, the postcard is an invitation to enter the depicted world and, thereby, adhere
to the treatment suggested by RHS. (Kress and van Leeuwen, 2004) (Web, 2011)
In sum, the friendly attitude realized by the characters’ smiles and implicit commands shows
that the purpose is to invite the patient into their world, in which the patient will be the center of
attention (Stillar, 1998, Kress and van Leeuwen, 2004, and Martinec, 2001). Hence, the
communicative purpose is to make the patient adhere to the treatment by actively following the
link provided by RHS (Web, 2011).
4.2.1.3 Organization Ideally placed at the top of the postcard’s front page is RHS’ logo. The fact that the platform
address to ‘mitforløb.dk’ is placed at the bottom of the card implies that this is a link to more
detailed information. The triptych placement of the characters between the ideal logo and real
platform address, implies that the depicted world is the central concept of the platform linked to
and that the patient, who is placed between the given healthcare providers and the new relatives,
is the center of attention in this world (Kress and van Leeuwen, 2004). Furthermore, the fact that
the relatives are placed as the new element implies that the relatives must also be paid attention
to, which was also emphasized by the nurse and later in the brochure. If relating this to the
interaction with the nurse and the brochure, this latter finding shows that the genres are
complementing each other, as the importance of the relatives were also emphasized by these
genres. Accordingly, it becomes yet a signal that the purpose of the platform is to provide clear
information and reduce patient anxiety. However, given that the depicted figures represent a
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virtual world, visual-verbal linking, elaboration is utilized for making the textual link
‘www.mitforløb.dk’ clearer and more memorable.
However, what contradicts with the interactions and the brochure is the signed genre, which I
despite of the fact that the depicted characters are not moving in this image will allow myself to
name the animation genre. While the conversations and the brochure belonged to a traditional
medical discourse, this postcard’s use of sign language as a means to invite the viewers into the
medical world shows that the medical discourse borrows from the entertainment discourse,
which the animation genre is merely associated with. Hence, the medical discourse has been
recontextualized, to establish a more informal invitation that the viewers can understand and
identify with simply by looking at a single image. (van Leeuwen, 2009). Finally, if following Li
et al. (2009), this shows that yet a purpose is to make the patient understand and remember the
postcard.
In sum, the postcard is structured in terms of visual-verbal linking, which implies that the
purpose is to make the patient understand and remember the information provided on the
postcard.
4.2.2 Analysis of the Platform Hopefully, the patient follows the link ‘www.mitforløb.dk’. Assuming that, the patient will be
presented to a platform on which text, images, and animation films are placed. In the following,
a multimodal discourse and genre analysis of this platform will be conducted. All references in
this part refer to appendix 14, which provides a breakdown of how the social semiotics and
multimodal concepts have been used, in detail, to comprehend the meaning-making elements of
the platform as well as the films placed on it. However, seeing that the films represent a different
genre, these will be analyzed separately here, although with links to the platform of which it they
are parts.
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4.2.2.1 Representation!Textually
When entering the platform ‘www.mitforløb.dk’ the relational verb: have in You now have the
opportunity(…) relates the viewer, being the patient, to the actions of watching and/or reading
about the patient’s course of treatment (1) (Stillar, 1998). Given that the patient is given an
opportunity to choose between two ways of gathering information, shows that the platform, at
this early stage, is more interactive than the brochure, where the only option is that of reading.
Accordingly, the platform is more patient-centered than the brochure (Li et al., 2009). Following
the ‘film’ link, the patient is taken to a new page/level where following four headlines
predominate: introduction, before the operation, operation, and after the operation. From the
time realized by the circumstantial roles: before in before the operation and after in after the
operation, it becomes clear that these headlines provide information to the specific parts of the
hip program (Stillar, 1998). Hence, a case if meronomy is created, where the hip program is the
whole in which these are a parts. (2) (Ibid). If following the first link: Introduction two new
headlines appear: Introduction and My program. Given from the part/whole structure provided at
the previous level, these headings naturally fall into the overall concept. (3) (Stillar, 1998)
Moving to another headline: Before the operation, the subheadings: Preparation, Before the
operation, and At the hospital once again attribute to the overall concept, which is here before
the operation. (Stillar, 1998). Hence they provide information that is relevant to this topic. The
third step in the hip program is according to the third headline: The operation. As the
subheadings imply, the need to know in this step is Anesthesia and The operation. Finally, After
the operation, the subheadings: Before you go home, Home again, and what is allowed imply
that you need to know something about these three aspects. (Stillar, 1998).
If considering the text above the headlines that are accompanying the films, the generic: Films
and brochures links from the front page are present. Having gone through the film section
already, the patient now have the opportunity to supplement the knowledge gathered through the
largely visual film section with the more textual brochures section. When entering this section,
the headline: The role of the patient and the support person during the hip program states
directly that the following text regards the patient and the support person’s function in this
program. The continuous use of you as in You have, Your own effort, and you get continuously
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used throughout the text implies that the patient is you, being the viewer. Recognizing that the
following headlines: Why a hip prosthesis?, Before the operation, and Recipe on protein shake
are restating what the film section is showing and what the nurse referred to during their
interaction, which shows that the genres are complementing each other. (Stillar, 1998).
Following Li et al.’s (2009) notion that: …in a teaching context, if the same information is
provided in two different formats, text and pictures rather than text alone, it will be processed in
two different cognitive subsystems…resulting in better memory and recall of information, the
purpose of this platform is to provide clear and memorable information that prepares the patient
for the surgery in the best possible way.
Visually
The first visual impression when entering www.mitforløb.dk is that RHS is the superordinate
doer to the subordinate information presented under the generic links: Film and Brochures.
(Kress and van Leeuwen, 2004). Following the film link, four images appear and a circle with a
play sign. Common for all four images is that they are signed, which means that the represented
participants are not real persons. Image one depicts two types of people: people dressed in
everyday clothes, representing patients, and people dressed in white coats, representing the
doctors. The second image depicts the same woman but n a different setting. The act of holding
her hand on her hip implies that she is in pain, while the act of the younger man depicted in the
same image implies that he is supporting her. The dark hair, as opposed to the woman’s grey
hair, implies that he is her son and the child the granddaughter of the patient. The third image
depicts a man in a green coat. The symbolic attributes of his clothes and the setting, implies that
what is represented is a surgeon doing surgery. Finally, the fourth image depicts the woman from
image one and two climbing a mountain. The symbolic meaning of this act is that the woman, at
this stage of the program, has regained her strength and will to be active. (2) (Kress and van
Leeuwen, 2004)
If pressing on the first image, two new images appear underneath. The first one is depicting a
doctor holding a hip prosthesis in his hand. The association brought about by the symbolic
attributes is that a doctor is demonstrating the hip prosthesis. Given that a hip prosthesis was also
demonstrated under the pre-examination with the doctor, a lexical relation is created by means of
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repetition. The second image depicts the patient in three different settings, providing the viewer
with an overview of the hip program. (Kress and van leeuwen, 2004)
Going to the brochure section, the visual impression changes radically. When you enter the first
page, text takes up the entire screen. At the left, there is a column of small headlines, which
function as a table of content. Accordingly, associations are brought about to RHS’ physical
brochures, where text was also the primary mode. (Kress and van leeuwen, 2004). However,
scrolling down, images do appear. In shot 8, two images depicting a hip are represented.
Considering the films elaborated on in the previous, associations to these films are brought about
by these images. Hence, this is a sign that the brochures (physical and digital) and the film
genres are complementing each other. This also shows from image 10 and 12, where the visual
texts Recipe on protein shake and Contact are represented. However, it should be noted that the
digital genre is using animated characters as opposed to real human beings. (Kress and van
leeuwen, 2004)
In sum, the first thing noticed when entering the platform is the film and brochures links, which
implies that the patient can choose between two ways of gathering information about the hip
program. Consequently, the purpose is to empower the patient to become more active and less
anxious. Under the film link, the limited text in form of headlines implies that to learn about the
different parts, the films should be watched. On the contrary, under the brochures link, text, like
in the brochures predominates the screen, although there are more images than in the physical
brochure analyzed previously. Considering that the two options in relation to Li et al (2009), the
purpose is to educate the patient; and the way to do so is to provide both text and images (films),
which emphasize RHS’ concern with providing patient-centered care. Accordingly, the purpose
is to provide clear information that the patient will remember in order to reduce anxiety and
increase satisfaction.
4.2.2.2 Orientation Textually
At the front page, the textual mode combines relational verbs with action verbs to relate the You
to the event watch and read about the program by the means of have (1) (Stillar, 1998).
Combined also with the now, the statement is transformed into an implicit command, which is
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further supported by the two buttons below the text piece. Pressing the film button, the site takes
us to a direct command saying Play all the videos. However, given that the viewer’s name
presented just beyond the four headlines Introduction, Before the operation, The operation, and
After the operation, the direct command is challenged by the more detailed headlines, given that
these provide in formation about what will actually happen in these videos. (1). (Ibid).
Visually
The low angle from which RHS is depicted on the front page of mitforløb.dk puts RHS in a
powerful position, as the low angle makes the hospital look imposing and awesome. (1) (van
Leeuwen, 2004) Following the film button to the second level of the platform, four different
images appear (2). The first image forms a demand shot, as the woman, whom we at this level
know as the represented patient, looks directly at the patient. Thereby, a visual “you” is
established, from whom the depicted patient demands engagement by watching the films.
However, given from the long social distance depicting the characters in full figure, suggests
that the purpose of the image is to provide an overview of the relations of the different
characters, which was elaborated on in the analysis of the postcard. This use of the same image,
and even as the first among four, shows that the two genres complement each other. The happy
and welcoming connotations brought about by the participants’ smiles signals to the viewer that
the hip program would also make him or her happy. (2). While the first image is a demand shot
the three next images are offer shots, which implies that they will offer information to the
viewer. (van Leeuwen, 2004)
In sum, by relating the patient to the two options, through a visual demands and textual
commands, the patient is asked to engage in the platform by following one of the two options
provided. This pattern is repeated in the films section, where demand shots ensure the patient is
engaging in what is represented, and in the brochures section, where textual commands are
continued. Accordingly, the purpose is to motivate the patient to adhere to the treatment (Web,
2011). Once again, that of providing the patient with more than one option to attain knowledge
about the hip program shows that RHS is interested in providing the proper pre-operative
information to educate the patient and, thereby, reduce anxiety. (Web, 2011 and Li et al., 2008)
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4.2.2.3 Organization When entering mitforløb.dk, a drawn version of RHS is represented ideally at the top of the page
together with their logo implying that RHS takes the leading role. (1). Placed at the (real) bottom
of the page are two links, through which the ideal RHS is providing more detailed information.
(van Leeuwen, 2004). At this stage the links are specific links. However, as the next levels will
show, the links are present at all levels of the platform, which makes them generic links. (2).
(Askehave and Ellerup, 2005). The fact that they are generic gives the viewer the ability to
change from one version to the other at all times, making the site easier to navigate. (Ibid).
When following the ‘film’ link, the most salient element is the play sign, which is realized by the
white space around the play icon that is framing the element. (2). (van Leeuwen, 2004). Usually,
the most salient element would make up the first step in the reading path (Lemke, 2002).
However, as the four images provide a more detailed overview of situations relating to the
program and the viewer’s real life, the images make up a trajectory that suggests another reading
path starting with the ‘Introduction’ film at the left hand side and move towards the right hand
side. (Ibid). Though, if for instance the patient has already passed the operation stage, the ‘After
the operation’ option might be more appealing to that patient. The fact that the patient has the
opportunity to choose the most relevant reading path for himself makes the platform more
personal. However, given the name of the platform is www.mitforløb.dk, which in English
means my program, this is also expected. (2). (Lemke, 2005)
In sum, as a means to shows that RHS takes responsibility for the content presented on the
platform and throughout the patient’s treatment program, the hospital and its logo is placed
ideally at the top. To help the viewer navigate the site, two generic links respectively taking the
patient to the film section and/or the brochures section prevails on all levels of the platform
(Askehave and Ellerup, 2005). However, to suggest the viewer specific reading paths, framing is
used to give salience to specific elements and, thereby, create trajectories. When selecting a
film, the lack of trajectories becomes a signal to the patient that the navigating mode is replaced
by reading mode, which is a trajectory in itself that asks the viewer to engage in the film. The
fact that the patient is offered two different ways, watching films or reading, of gathering
information about their course of treatment, implies RHS is concerned with providing clear and
memorable patient information in order to prepare the patient for the surgery (Li et al., 2009).
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Acknowledging that this in healthcare communication is a strategy for empowering the patient
and, thereby, reduce anxiety, these are the purposes of the platform together with the ideal goal
of creating satisfied patients (Martin and White, 2003).
4.2.3 Analysis of the Animation Films Placed on the Platform In the following, a social semiotic and multimodal discourse and genre analysis of a selection of
films placed on www.mitforløb.dk is analyzed. As mentioned in the previous, all references in
this part refer also to appendix 14, seeing that the films are placed on the platform.
4.2.3.1 Representation Textually and Verbally
Selecting the first film link, being the introduction, a window opens in which the word
Introduction appears again to imply that what is about to be represented is an introduction to the
program. In the larger context the film is, therefore, a part or subordinate to the superordinate
whole, being the platform (Stillar, 1998).
The past tense of the first verbal narration: Your body has been exposed to many different
pressures through life relates the verbally created “you”, being the patient, to the past (3.2).
Seeing that the doctor at the beginning of the interaction with the patient also used this strategy,
an implicit verbal link is drawn between the two genres, showing that they complement each
other. The circumstantial roles of prepositions In and there in the following narration,
respectively locate the patient to the place hip, which, realized by the relational verb is is related
to yet a place (Stillar, 1998). Combined, it becomes clear that the represented information deals
with what is inside a hip. Considering the concept is to watch videos about the hip program’, that
of understanding what is inside a hip is emphasized as an important part of the hip program (3.3).
Moreover, this implies that the purpose is to provide clear information about the various parts of
the course of treatment in order to make the patient understand. Following Martin and White
(2003), that of using proper preoperative education is important for the patient to develop a more
optimistic mindset and have a greater expectation of succeeding. Seeing that this relates to
Rollnick et al.’s (2008) guidelines for engendering trust in the patient and encouraging a
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disclosure of worries, this and that of motivating the patient to adhere to the treatment are also
purposes of the film.
From here, the narration moves on to talk about the contingency ruin the hip, which is realized
by the word: becomes (Stillar, 1998). The word and, links this contingency to the reason being,
that By time, the cartilage becomes less flexible. (3.4) (Ibid). However, realized by the following
action verbs: can be removed, return, and replacing, a solution is implied, which induces hope,
as these extend to the subjects: Your and new hip joint. This is further induced in the following,
where the new hip joint is related, by means of the relational verb will be enabling you to resume
everyday chores. And the circumstantial role of soon implies that the time is near future. (3.7).
Nevertheless, this solution demands that you are active, which is realized by the if (Stillar, 1998).
Hence, this is the immediate purpose of this strategy. Nevertheless, if relating it to Martin and
White (2003) an additional purpose or chain of purposes of the film are to promote optimism,
and, thereby, empower the patient to actively take part in the course of treatment, as this will
reduce anxiety and lead to more satisfied patients (Ibid) (Rollnick et al., 2008)
Aurally
The aural mode is only present in the films. Throughout these, calm piano play is bringing about
positive associations, implying that the purpose is to promote optimism in order to empower the
patient, reduce anxiety, and create more satisfaction (3.1, 3.3, 3.5, 3.7) (Stöckl, 2004, Rollnick et
al, 2008, and Martin and White, 2003). However, the music comes and goes. As can be seen
from the appendix, it is present in every second image, why it comes to symbolize transition. In
image 3.5 the music intensifies, which implies that something is about to happen; and in image
3.7 a more cheerful tone is played, symbolizing happiness. Therefore, it functions as a support to
the verbal narration. (Stöckl, 2004)
Visually
At the very beginning of the film a dark-haired woman is “introduced”, standing in front of a
board, which she points at with a stick (3.1). The associations brought about by the (symbolic)
attributes of her clothes, the board, and the stick, she is a young version of the woman depicted
in the images on the platform; and her job is as a teacher. In the next shot, the woman is depicted
doing her laundry. (Kress and van Leeuwen, 2004). Combined with the previous shot, these give
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associations to life’s everyday duties (3.2). From here, there is a transition to an image of a hip
joint (3.3) (Ibid). Given that the woman’s clothes is the same as in the previous image, the
patient knows that the hip belongs to the same woman depicted before. The strategy of going
beyond the familiar physical reality by combining storytelling and functionality is a typical
animation trait, which is used for making the information more clear and interesting (Greenberg,
2011)
In image 3.4 we see an old version of the same woman doing her laundry again. The posture
implies that she, opposed to the previous shot, is in pain here. (Kress and van Leeuwen, 2004).
The explanation for her pain is depicted in image 3.5, where a damaged version of the same hip
is depicted. In image 3.6 the woman is depicted on a bed with a doctor standing over her with a
hip prosthesis in his hand. Given the overall context on mitforløb.dk concerns the hip program,
the depicted doctor is an expected part of the viewer’s hip course. From here, the woman is
depicted doing her everyday duties again. The old hair, the posture, and the smile on her face
symbolizes that this is after the operation as she can do everyday things without pain (3.7 and
3.8). In image 3.8 the woman is even climbing a mountain. Seeing that this scene is new, it
connotes that the patient is stronger than ever, which induces hope and builds trust in the viewing
patient. (Kress and van Leeuwen, 2004). Following Martin and White (2003), this shows that
RHS wants to promote optimism and, thereby, reduce anxiety.
Other films similar to this are found, showing different parts of the hip program (4 and 5). If
selecting the ‘Operation’ film, the operation is depicted step by step. Given that this is the first
genre that shows the action operation, as opposed to solely talk about what happens before and
after the operation, the purpose of the films and, thereby, the platform is to provide detailed
information. And seeing that all the blood and drilling, which a hip operation is usually
associated with, has been left out using animation, shows that the purpose, more specifically, is
to provide clear information that delimits knowledge asymmetries and, thereby, delimit the
intimidating images and expectations that the patient might have (5.2) (Greenberg, 2011 and
Candlin et al, 1995 and 1994). Hence, the purpose emphasized is that of reducing anxiety, which
shows that RHS wants to provide patient-centered care (Web, 2011 and Rollnick et al., 2008).
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In sum, using storytelling and animation, the patient is taken back in time and to different
locations, which imply that the purpose of the film is to make the patient understand where the
problem comes from, for, at the end of the film be able to tell her where she is going. From a
healthcare perspective, the purpose of this strategy is to promote optimism and engender trust,
which according to Martin and White (2003) leads to better function and better psychological
health, which has shown to be vital to patient satisfaction, which become the purposes of the
film(s). This is also given from the use of animation to remove anxiety-provoking elements such
as blood and noises from the drilling, which a hip operation is often associated with, the purpose
of reducing anxiety is also emphasized; and seeing that the patient is provided with an
opportunity to watch an operation, the final purposes are to provide clear information that
empowers the patient and, thus, reduces anxiety. (Greenberg, 2011, Web, 2011, and Rollnick et
al, 2008)
4.2.3.2 Orientation Verbally and aurally
In the Introduction film, the textual You is replaced by a verbal You in Your body has been
exposed to many different pressured through life. (3.2). This non-diegetic male voice-over
narrator brings the viewer closer to the story and, thereby, decreases the social distance between
the screen event and the viewer, as he or she is approached directly by the non-diegetic narrator.
(3.2) (Stigel, 2001 and van Leeuwen, 2006). The addition of the aural mode further decrease the
social distance to the viewer, as it signals when something new is about to happen by coming
and going. And when the speak stops, the music takes over, ensuring that the viewer’s attention
is retained and, thereby, brought through the entire story. (3.3). The use of statements throughout
the film implies that purpose is to inform the patient about what ‘has been’ (3.2), what is (3.3),
what becomes (3.4, 3.5), and what will (3.7) expressing certainty and what can be (3.6)
expressing possibility (Stillar, 1998). Consequently, the purpose emphasized is to prepare the
patient and, thereby, reduce anxiety, which witness that RHS is taking a patient-centered
approach to healthcare. (Web, 2011)
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Visually
Throughout the film different offer shots are represented, implying that the purpose of RHS is to
offer information while the role of the patient is to watch and learn (Kress and van Leeuwen,
2004). However, the frontal angle of the woman depicted in shot 3.1 and 3.2 ensures that the
viewer, being the patient, involves (involvement) in what is represented, which, because of the
frontal angel and the connotations of the actions to everyday tasks, is part of the viewer/patient’s
life (Ibid and Martinec, 2001) Accordingly, when the woman smiles the patient’s thoughts are
brought back to a time when that of doing everyday tasks was not a problem. So, when the
depicted woman, in image 3.4, is no longer happy the patient understands, because of his or her
own situation, that the reason for this change is that the hip joint in shot 3.5 is damaged
compared to image 3.3 where the hip joint looks healthy. When the two contrasting hips are
depicted, the viewer is moved closer to the screen to emphasize this contrast. From here, is
zoomed out to a medium social distance (3.6), before we again is seeing the woman in full
figure, implying an impersonal social distance (3.7 and 3.8). The smile on her face in the last
three shots implies that she is happy with the new hip (3.6, 3.7, and 3.8) (Ibid). Moving to ‘The
operation’ film, the intimate social distance is used again to move the viewer into the screen to
see what is happening under the operation. (5.2). The medium offer shot in image 5.1 implies
that focus here is on the relation between the nurse and the patient, which because of the smile
on the patient’s face is close and comforting, offering faith to the viewer (van Leeuwen, 2004).
Hence, the means of storytelling and animation, the patient is brought into a virtual world
through which RHS can communicate with the patient. The fact that animated figures have been
used as opposed to real persons, makes the film less personal if comparing it to the face-to-face
interactions. However, this also makes the figures easier to identify with for more patients, as
they do not have a name and an identity. It only has the history that the sender wants it to have.
For that reason, it is used as a tool for promoting optimism and for engendering trust in the
patient by letting the patient re-experience his or her life through the visual ‘you’ created by the
animated figure. Accordingly, it is a tool for empowering the patient to adhere to the treatment.
(Web, 2011 and Martin and White, 2003)
In sum, through a variety of long and close shots of the same figure, the patient is brought into a
virtual world with animated figures through which RHS can communicate with the patient. The
use of animated figures makes the film more impersonal than face-to-face interactions. However,
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because a signed figure does not have an identity, it becomes more personal than the brochure,
seeing that it is easier to identify with for more patients. Accordingly, the purpose of providing
patient-centered care is emphasized, which sets out in the patient’s wants and needs and seeks to
fulfill these e.g. by providing proper pre-operative information to prepare the patient for the
surgery, reduce his or her anxiety, empower the patient, which eventually leads to more satisfied
patients. (Web, 2011, Martin and White, 2003, and Rollnick et al., 2008)
4.2.3.3 Organization The addition of the aural mode in the films combined with the replacement of the textual mode
with the verbal mode contributes to the construction of a virtual world, as the story (telling)
becomes more cohesive and dynamic (Stigel, 2001). Through most of the film, the non-diegetic
voice-over makes up the figure, while the calming, instrumental piano play makes up the
supporting ground (Ibid and van Leeuwen, 2005). However, when there is no speak, the music
becomes figure, that ensures the cohesion. Accordingly, when the music stops, for instance when
the non-diegetic narrator tells that: Your pain can be removed(…) in shot 3.6, it becomes a signal
to the patient that attention should be paid to what is being told (3.6); and opposite, when the
music intensifies, for instance when the damaged hip is depicted, it signals to the patient that
something is about to happen (3.5) (Stigel, 2001). For that reason the aural mode constructs
rhythmic units that add to the film’s cohesion and, thereby, supports the verbal and visual mode
in creating a virtual world with a beginning (3.1), a plot, and an end (3.8) (Iedema, 2001) (Stigel,
2001).
However, the visual and verbal modes further contribute to the construction of a virtual world by
linking information to each other by means of rhythmic units of visual and visual-verbal linking
(Stigel, 2001, Iedema, 2001, and van Leeuwen, 2005). Looking at shot 3.2 and 3.4, the scene and
the character is similar, which draws attention to what is different in the image, being the
character’s hair and body language. Noticing that her hair has gone from black to grey and her
body posture from strong to painful, imply that the time has gone by and this has caused the
damaged hip. Hence, visual linking, temporal extension is utilized for narration purposes to
clarify the natural procedure of life. In the same way, visual units are linked to verbal units by
means of visual-verbal linking. For example in shot 3.3, the content of the verbal narration,
which is informing about how the capsule of cartilage ensures that there is almost no resistance
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in the hip joint when the leg moves, becomes more specific when combined with the visual
illustration of the capsule, which shows what the capsule is and how it works. Hence, rhythmic
units of visual-verbal linking, and more specifically, elaboration is used for making the verbal
narration more specific. (van Leeuwen, 2005 and Iedema, 2001)
Taking a look at the signed characters’ placement in a signed virtual world, this was at the
orientational level stressed to be a strategic tool used for moving the viewer into the screen.
Moreover, it was noticed that the fact the characters are signed made them both impersonal and
easier to identify with at the same time. However, what is important to notice at this
organizational level is how these characters have been animated in a way so they offer
information about the medical world, more specifically the hip program, in an involving and
easy understandable manner (van Leeuwen, 2004). This demands a closer look at animation,
because, as mentioned at the representational level, the general associations brought about by
animation are cartoons, humor, fiction, and entertainment. So, seeing that the serious, medical
discourse has been used as a tool for constructing an alternate reality through a virtual world for
the viewer to engage in and identify with, this clearly influences the medical discourse (Stigel,
2001). Following van Leeuwen’s (2009) concept of recontextualization, the fact that the formal
and serious medical discourse has been blurred with the more informal, entertainment discourse,
a new discourse is created, which, if considering the previously mentioned qualities or
characteristics of the two discourses becomes that of infotainment. Hence, the communicative
strategy of recontextualization is used as a means to construct a virtual world that can
communicate with the viewer in a way they can understand and relate to and, thereby, get the
communicative purposes identified throughout the analysis across. Following Lindval and
Menton (1994), this shows self-reflexivity, as the communicative strategies e.g.
recontextualization are deliberately made to fulfill RHS’ purposes. From a healthcare
perspective, this recontextualized discourse shows that RHS is concerned with providing patient-
centered care to delimit knowledge asymmetries, reduce patient anxiety, empower the patient to
take action for their own treatment by adhering to the treatment suggested by RHS, seeing that
this will lead to more satisfied patients. (Web, 2011, Rollnick et al, 2008, Martin and White,
2003, and Candlin et al, 1995 and 1994)
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In sum, the strategy of information linking has been used as means for creating a cohesive story
with a beginning, a plot, and an end, in which the patient should engage and learn about the
treatment program before them. Seeing that this virtual world blends the serious medical
discourse with the more informal entertainment discourse, realized by the associations connected
to the animation genre, the discourse of infotainment has been created, with which the patients
can identify and, thereby, learn from. Accordingly, the purpose is to provide clear information to
educate the patient and, thereby, empower him or her to take actions for his or her own course of
treatment, given that this will reduce anxiety and lead to more satisfaction.
4.3 Comparative analysis of RHS’ Communicative purposes and strategies In the previous a multimodal, social semiotic discourse and genre analysis has been conducted to
comprehend RHS’ existing and new communication genres to, thus, identify the communicative
purposes of the various genres and strategies used for attaining these. In the following, a
comparative analysis of the key communicative purposes and strategies of the different genres
will be conducted in order to further clarify these; and in light of this comparison, the second
research question concerning Visikon’s platform ‘www.mitforløb.dk’, as a way to reduce patient
anxiety, will also be clarified further.
Seeing that the face-to-face interactions encourage a personal and informal dialogue through
which the participants can learn about each other and, thereby, build trust that encourages a
disclosure of worries, the interactions make up the most personal genre (Web, 2011, Candlin et
al, 1994 and 1995, Scheeres et al., 2008, etc.). Therefore, seeing that neither of the other genres
offer the same degree of immediacy and possibility to learn about the individual patient, which is
vital for delivering good healthcare communication, the interactions are important. However, if
returning to the issue of health illiteracy identified by the ethnographer chapter 1.1, interactions,
in practice, are not always the best means for preparing patients for surgery as the patients, as a
result of knowledge asymmetries, not always are provided with the information needed during
the interactions. Therefore, considering the information meeting’s, the brochure, and the new
platform’s more detailed, well-structured, recurrent (in the sense that it can be revisited) fashion
these genres comply better with the purpose of providing clear and memorable information,
seeing that they provide information that can be used in more personal settings and whenever
needed.
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This leads to a comparison of the brochure, the information meeting, and the platform. Taking in
mind that the information meeting, like the interactions, represents a line of healthcare providers
that comes to play a role in the patient’s treatment program, the information meeting also offers
immediacy. However, seeing that the information is not specific to the individual patient, but of
more general kind, it is less personal than the interactions, where the healthcare provider adjusts
the information to suit the needs and demands of the individual patient. In spite of that, the
patient still has the opportunity to ask questions. Accordingly, it complies with the purpose of
engendering trust in the patient and encouraging a disclosure of worries, which empowers the
patient and helps to reduce anxiety. However, considering the length of the meeting, the amount
of information provided, and the fact that it cannot be revisited whenever needed, the
information meeting may not be the best genre for serving the purpose of providing clear and
memorable information, which is important for preparing the patient for surgery and, thereby,
further contribute to reduce anxiety.
To serve this purpose, the brochure will be considered, seeing that it is detailed, well structured,
and offers the possibility to be revisited. Nevertheless, considering that it is general information
that is represented in a one-way communication fashion, it is the least personal of all the genres.
Consequently, it does not serve the purpose of engendering trust and encouraging a disclosure of
worries, which is also important for reducing anxiety according to the patient-centered school of
thought (Web, 2011, Candlin et al, 1994 and 1995, Scheeres et al., 2008, etc.). Recognizing also
that the static structure and depressive visuals used throughout the brochure contrast with the
purpose of promoting optimism and, thereby, empowering the patient to take responsibility for
his or her own treatment program, the brochure does not completely fulfill the requirements for
reducing anxiety. Though, given that both image and text is used, the brochure does contribute to
the construction of a teaching discourse, which if following Li et al. (2009) contribute to
memory and recall (van Leeuwen, 2009). However, following Jlala et al. (2010), audio-visual
information reduces pre- and postoperative anxiety, which leads to the last genre, being the
platform ‘mitforløb.dk’, given that the animated films placed on it contain audio-visual
information.
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Opposed to the brochure, the platform goes beyond the linear and merely textual format and
invites, as a supplement to the readings, the patient into an animated universe, a so-called virtual
world, through which the patient is represented to the medical context in an informal and
engaging manner (Stigel, 2001). When entering the platform, after having followed the link on
the personal postcard provided during the interactions, the patient is encouraged to create his or
her own reading path to explore the site, which, already, makes it more personal than the
brochures, which offers only one reading path (Lemke, 2002). Seeing that this makes the patient
an active participant in what, due to the inclusion of animation film, is more an experience than
mere information, demonstrates that RHS perceives their patients as consumers/clients with
needs rather than as patients who’s only need is survival, if following the old thought (Harvey
and Adolph, 2011 and Web, 2011). Although face-to-face interactions with real persons still are
more personal than animation films with signed characters, the figures establish immediacy
because they are easy to identify with for the individual patient, given that they have no identity,
and because they are brought to life through the use of animation, which makes them more real.
Consequently, the platform becomes more involving, engaging, and personal, which makes it an
ideal tool for proving clear and memorable information, seeing that it can be understood by
everyone who can see, as opposed to the brochures, which can only be understood by everyone
who can read and understand Danish (Bondy et al., 1999). Moreover, seeing that the animation
films connect the patient to RHS and, thereby, establish a relationship between the patient and
RHS, the platform also makes up an ideal tool for engendering trust, which encourages a
disclosure of worries that eventually reduces anxiety (Web, 2011). However, seeing that the
platform does not enable the patient to ask questions and, thereby, enable the patient to give vent
to his or her worries and frustrations as they appear, the platform, like the brochures, does only
fosters one-way communication, even though the characters are interactive in the sense they
engages the patient in their world and a Q&A and contact information function prevail, which
respectively serve the purpose of pre-empting the patient’s concerns and provide access to
answers. However, in comparison to the interactions, the platform does not directly encourage a
disclosure of worries. Consequently, in order to fully encourage a disclosure of concerns to
prevent anxiety to escalate, more interactive elements should be added (Stigel, 2001). Though,
on the other hand, seeing that the patient does not always understand the information provided
during the interactions with the various healthcare providers and seeing that these interactions do
not offer the possibility to be revisited, the platform might offer a better and more detailed and
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extensive way to reduce anxiety, simply because the patient can take its time to watch, read and,
thus, understand the information and because it can be understood by everyone who can hear or
see.
Acknowledging that the genres, new and old, complement each other, the purposes of RHS’ pre-
operative communication genres when preparing their patients for surgery are very similar (See
table 1). Overall they are concerned with delivering patient-centered care, through which RHS
pursue to provide clear and memorable information to delimit knowledge asymmetries and make
the patient adhere to the treatment. However, the comparison has also emphasized that the
purpose is to build trust in the patient and, thus, empower the patient to take action for his or her
own treatment, seeing that this will reduce anxiety (Web, 2011, Rollnick et al., 2008, Candlin et
al., 1994, etc). If comparing the existing and new communication genres at large, the old genres
revolve largely around establishing immediacy to engender trust and mutual understanding
through the means of physical contact with various healthcare providers, respectively through
personal interactions and a more general information meeting, and through brochures, while the
new genres establish immediacy through more digital and animated means by inviting the patient
into an engaging virtual universe, which is evoked curiosity to through a postcard and which
unfolds through dynamic animation films placed on the interactive platform. Hence, based on the
theoretical and methodological framework upon which the detailed analysis has been conducted,
the platform, including the animation films, fulfills the purposes of providing clear and
memorable information that delimits knowledge asymmetries better than any of the other genres;
and the main strategy for attaining this purpose is the animation films, given that these offers
clear and detailed information that patients can relate to and understand. Therefore, it, as stated
in the previous, makes up an ideal tool for reducing anxiety, considering that proper preoperative
information and education promotes optimism and empowers the patients to take action by
adhering to the treatment provided by RHS. To get an overview of the various genres different
key purposes and strategies, these are summarized in table 1 below. With this being clear, the
following discussion will, as promised in the methodological framework chapter, zoom out and
relate the findings (communicative purposes and strategies) to corporate communication theory,
seeing that this will make the thesis relevant not only for RHS’ hip department, but also for other
departments, hospitals, and organizations; and considering that low literacy is not only a problem
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within healthcare but also within law, the inclusion of fundamental corporate communication
theory is considered highly relevant for this thesis.
Table 1 – RHS’ communicative purpose and strategies used for attaining these
Pre-operative communication genres
Communicative strategies Communicative purposes
Interactions between the patient and various healthcare providers (Including the doctor and various nurses)
C Link patient to time, location, and possession
C Dialogue C Possibility to relate to the
healthcare providers and ask them questions
C Informing C Engaging C Immediacy C Friendly C Empathizing C Serious C Activating C Immediacy C Informality through jokes
and humor C Urgency
C Provide clear information to delimit knowledge asymmetries and make the patient adhere to the treatment
C Educate patient C Promote optimism to empower
patient C Engender trust C Understand patient and her
problem (diagnosis) C Reduce anxiety C Make patient relax C Encourage disclosure of worries
Brochure
C Detailed and well-structured information gathered by healthcare providers according to their experience with other patients
C Presents new information (like recipes)
C Offers the possibility to refresh information
C Activate patient, however, the structure makes the patients more passive and immobile
C Impersonal compared to face-to-face interactions as it is one-way communication with no option to ask questions
C Provide clear and memorable information to delimit knowledge asymmetries and make the patient adhere to the treatment
C Promote optimism to empower patient, however, the rather depressive connotations brought about by the depicted trees and the colors used contradicts the positive feelings and optimism
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C One person presented gives coherence
C Can be difficult to identify with the person depicted
C Lack of immediacy Information meeting
C Detailed and well-structured information gathered by the different speakers/healthcare providers according to their experiences with other patients
C Medium immediacy Information overload
C Engaging through exercises
C Less personal than interactions, but since the healthcare providers are introduces it is more personal than the brochure and the platform
C Possibility to ask questions C Not all information is
relevant for all the patients C Possibility to share
thoughts, knowledge, feelings, and experiences with other patients
C
C Provide clear and memorable information to delimit knowledge asymmetries and make the patient adhere to the treatment. However, due to information overload it becomes impossible to remember.
C Activate patient C Promote optimism to empower
patient C Reduce anxiety, but seeing that
some information is irrelevant for the patient, it might have the opposite effect
C Engender trust C Encourage disclosure of worries
Postcard C Engaging and involving C Medium immediacy
established trough the signed figures
C Impersonal compared to interactions- however, more personal than brochures
C Evoke curiosity C Make patient adhere to
treatment by following the link provided on the card
Platform (including text, images, and films)
C Detailed and well-structured information gathered by the different healthcare providers according to their experiences with other patients
C Medium immediacy C One-way communication C Dynamic
C Provide clear and memorable information to delimit knowledge asymmetries and make the patient adhere to the treatment
C Empower patient to take action for their own treatment
C Reduce anxiety C Educate the patient C Promote optimism
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C Urgency C Interactive C Possibility to refresh
information C Provide new information
such as the operation C Provide more details than
text and still images C Impersonal compared to
interactions, but more personal than brochures as patient can create its own reading path
C Immediacy C Engaging C Promotes optimism
C Engender trust
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5 DISCUSSION
In the previous, RHS’ various preoperative patient (healthcare) communication genres have been
analyzed to identify the communicative purposes of these and thereby answer the research
questions. Acknowledging that healthcare communication is corporate communication, the
following discussion will relate the healthcare communication, namely the communicative
purposes and strategies for attaining these, to fundamental corporate communication theory,
which considers stakeholders, reputation and identity important.
From a corporate communication perspective, the extensive effort made to deliver patient-
centered care that take into consideration the needs, attitudes, and behavior of the patients,
implies that RHS is concerned with their stakeholders and with building a strong reputation.
Nevertheless, following Grunig’s (1984) models of two-way symmetrical and two-way
asymmetrical communication as an evaluation of what makes good corporate communication,
not all the preoperative communication genres contribute equally well to the fulfillment of these
purposes. Based on the previous analysis, the interactions, including the information meeting, as
the only genre acknowledges two-way symmetrical communication, which, according to Grunig,
is key to create and maintain beneficial and harmonious relationships with stakeholders/patients.
Hence, the personal/immediacy aspect is fundamental to good corporate communication if
following Grunig. At the other end of the scale is the brochure, which, due to its one-way
communication fashion falls outside the frame of what makes good stakeholder relations.From
this perspective, the new patient platform is equally impersonal, seeing that it too only facilitates
one-way communication. Nevertheless, this leads to a discussion of the strategies used for
attaining these purposes; and here, the situation changes. Given that interactions do not offer the
possibility to refresh information whenever the patient needs it, might lead to dissatisfied
patients, as their need for information is not fulfilled by the interactions alone. Nevertheless, if
combined with the platform, through which a virtual world unfolds (through the animation
films), the patient can establish a relationship to RHS and refresh the information provided by
the healthcare providers at the same time. Seeing that the patient can watch the films and thereby
refresh the information that is important to them whenever needed, makes the platform more
personal than the brochure, which was also concluded in the analysis. However, what was not
mentioned was that the virtual world also contributes to the establishment of a corporate identity
for RHS, which, because it can be explored in more personal and relaxed setting in the patients’
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own home, is easier for the patients to understand and relate to. Accordingly, the platform
strategically embeds a positive and legitimate image of the organization (RHS) with their
stakeholders, which …lead to acceptance of the organization and to the organization being
found legitimate (Cornelissen, 2008). Hence, the platform also becomes a means to build strong
reputations. Nevertheless, in order for it to be fully accepted by the patients, it should adopt more
interactive elements to facilitate two-way symmetrical communication, which according to
Grunig is key to create and maintain beneficial and harmonious relationships with
stakeholders/patients. (Cornelissen, 2008 and Grunig, 1984)
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6 CONCLUSION
The thesis has addressed two fundamental questions, the first being: Which are the
communicative purposes and strategies of the hip department at the Regional Hospital of
Silkeborg (RHS) when preparing patients for surgery through face-to-face interactions
with healthcare providers, brochures, Visikon’s patient platform ‘www.mitforløb.dk’, and
the animation films placed on it and the postcard linking to it? And the second being: How
can Visikon’s patient platform ‘www.mitforløb.dk’ reduce patient anxiety? To sufficiently
answer the research questions and in a way that complies with the social constructionist stance
that this thesis is taking, an interdisciplinary methodological framework has been comprised,
which includes six theoretical lenses, namely corporate communication, healthcare
communication, multimodality, social semiotics, discourse, and genre. Seeing that RHS is an
organization and their communication genres are strategies, corporate communication makes up
the overall theoretical context under which the more specific healthcare communication,
multimodality, social semiotics, genre, and discourse are parts. However, when pursuing to
answer the research questions, the initial method is a multimodal, social semiotics, genre and
discourse analysis of the various genres that constitute RHS’ preoperative communication
strategy. More specifically, Iedema’s (2001) approach to make meaning of dynamic texts is
used, seeing that this offers a structure that enables meaning to be made of each of the semiotic
modes (image, language, and sound) across three metafunctional levels, respectively being
representation, orientation, and organization. However, acknowledging that the different genres,
e.g. hypertext and animation films, and modes, e.g. image, language, and sound, have different
meaning-making characteristics, the structure is supported by additional theoretical concepts to
answer the research questions adequately. In extension to this, to also take in mind the medical
context to which these semiotic choices belong; the purposes and strategies are, throughout the
analysis, related to healthcare communication theory, seeing that this is important to make it
relevant in the context observed. Subsequently, a comparative analysis of the communicative
purposes and strategies identified throughout the detailed analysis of each genre is conducted and
broken down in a table for clarification purposes to further clarify RHS’ communicative
purposes and strategies and to emphasize how the platform specifically can reduce patient
anxiety. Eventually, this leads up to a discussion in which the key communicative purposes and
strategies are related to corporate communication to also recognize the corporate context, which
healthcare communication is a part of.
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Seeing that the face-to-face interactions facilitate two-way symmetrical communications by
creating a dialogue between the patients and the healthcare providers, through which the
healthcare providers can deliver information relevant to the patient, but also attain information
about the patient relevant for delivering quality care, the communicative purpose is to create
mutual understanding. Accordingly, the interactions make up the most personal genre, which
from a corporate communication perspective is key to create and maintain beneficial and
harmonious relationships with stakeholders/patients (Grunig, 1984)). However, the immediacy
created through the dialogue, which is realized by humor and a warm and empathizing
communication, emphasizes that the purpose is also to make the patient relax, promote
optimism, engender trust and encourage a disclosure of worries to help reduce patient anxiety;
and seeing that the information and attitude is adjusted to the needs and demands of the specific
patient, the interactions seem to fulfill the requirements for providing patient-centered care.
Nevertheless, the interactions do not offer the possibility to be revisited whenever needed; and
consequently knowledge asymmetries might still exist, despite of the warm and caring style of
the doctor observed seeks to delimit these, it cannot reduce patient anxiety by itself, more
recurrent information sources are needed.
In comparison to the interactions, the brochure is more detailed and well-structured as well as it
offers the possibility to be revisited whenever needed, which demonstrates that the purpose is to
provide clear and memorable information to delimit knowledge asymmetries between RHS and
the patient and, thereby, reduce anxiety. However, as a consequence to the (linear) structure that
contributes to make the information clear, the information becomes more impersonal and the
patient becomes an inactive participant in RHS’ medical world, which contradicts with the
textually stated purposes being that of empowering the patients to take responsibility for their
own treatment. A similar contradiction is created by the imagery, which instead of promoting
positivism endorses depression, and instead of engaging the patient disengages the patient.
Consequently, the brochure does not comply with the purposes RHS aims to fulfill; and seeing
that promoting optimism and engaging the patient should contribute to empower the patient and
reduce anxiety these contradictions are problematic.
Different from the brochure, the new communication genres, being a postcard and a platform
with animation films, engage the patient in the information presented. By going beyond the
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linear and largely textual layout, the platform ‘www.mitforløb.dk’, which in English means ‘my
treatment program’, uses audio-visuals and animation to create a virtual world, trough which
RHS can communicate with the patients and make them understand all the relevant parts of the
program and the operation. Through animation, the films placed on the platform go beyond the
familiar physical and shows images from the operation and from inside the hip that would
normally increase anxiety, but because animation enables frightening elements, such as blood, to
be removed, they successfully enable the patient to get the full experience of the program and the
operation and, thereby, become more prepared for the operation. And given that the details are
wrapped into a dynamic, coherent, and optimistic narration, this education of the patients takes
place almost without they know it, as the characters and the storytelling make the learning a fun
experience. Consequently, optimism is promoted, which empowers the patient and reduces
anxiety. And given that text, image, and sound are used, the platform can reach not only
everyone who can read, but everyone who can hear or see, making it more detailed and extensive
than any of the other communication genres.
Nevertheless, following corporate communication, namely Cornelissen (2008) and Grunig
(1984), two-way symmetrical communication is key to create and maintain beneficial and
harmonious relationships with stakeholders/patients. So for that reason, the platform should
adopt more interactive element that enable the patients to communicate directly with the
healthcare providers. Though, if comparing it to the linear and merely textual brochure, the
platform is interactive, given that the platform introduces a corporate identify through a virtual
world with animated characters that the patients can communicate and relate to better than the
professional healthcare providers. Consequently, immediacy is created, although in a different
way than the interactions that include real people, which, because it offers the possibility to be
explored at home in more relaxed and personal setting and whenever information is needed, has
the potential for being a great tool to fulfill healthcare purposes and corporate purposes, as a
clear identity can be established through the animation films.
The interdisciplinary framework has focused on exploring the communication genres used by
RHS in order to identify the communicative purposes when preparing their patients for surgery.
However, considering the complex meaning-making potentials of the framework, the thesis has
opened up for a new interdisciplinary framework that could also be applied by other institutions
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or organizations than hospitals to communicate difficult subjects to their stakeholders or clarify
their identity and thereby improve their communication strategy. However, the companies should
be aware of the importance of two-way symmetrical communication for delivering good
corporate communication, seeing that this is key to creating and maintaining beneficial and
harmonious relationships with stakeholders. Acknowledging that, the interdisciplinary
framework can be extended to consider further other areas of investigation regarding
interactivity, technology, audience, and reception in order to further advance the framework and
its usage.
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Websites
Cited the 28.05.2012 from RHS’ website: http://www.hospitalsenhedmidt.dk/afdelinger/center+for+planlagt+kirurgi
Cited the 28.05.2012 from RHS’ website: http://www.hospitalsenhedmidt.dk/om+os?
Cited the 07.06.2012 from Visikon and RHS’ platform: www.mitforløb.dk
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8 LIST OF APPENDICES
APPENDIX 1 – ABOUT HOSPITAL UNITY CENTRAL
APPENDIX 2 – ENGLISH SUMMARY OF ETHNOGRAPHIC RAPPORT
APPENDIX 3 – GLOSSARY
APPENDIX 4 – CD WITH DIFFERENT APPENDICES
APPENDIX 4a – AUDIO RECORDINGS OF INTERACTIONS
APPENDIX 4b – IMAGES FROM INTERACTIONS
APPENDIX 4c – AUDIO RECORDINGS FROM THE INFORMATION MEETING
APPENDIX 4d – INTRODUCTION FILM
APPENDIX 4e – OPERATION FILM FROM
APPENDIX 5 – THE PATIENTS’ APPROVAL
APPENDIX 6 – BROCHURE
APPENDIX 7 – POSTCARD
APPENDIX 8 – PLATFORM WWW.MITFORLØB.DK
APPENDIX 9 – ABOUT RHS
APPENDIX 10 – INTERACTIONS TABLE
APPENDIX 11 – BROCHURE TABLE
APPENDIX 12 – INFORMATION MEETING TABLE
APPENDIX 13 – POSTCARD TABLE
APPENDIX 14 – WEBSITE TABLE