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Rinnakkaistallenteet Yhteiskuntatieteiden ja kauppatieteiden tiedekunta

2021

Ambiguous discursive practices in healthcare project plans - A

keyword-assisted critical discourse analysis of the term

Lunkka, Nina

Emerald Publishing Limited

Tieteelliset aikakauslehtiartikkelit

© 2020, Emerald Publishing Limited

CC BY-NC http://creativecommons.org/licenses/by-nc/4.0/

http://dx.doi.org/10.1108/QROM-09-2019-1827

https://erepo.uef.fi/handle/123456789/24460

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Qualitative Research in Organizations and Management

Ambiguous discursive practices in healthcare project plans

A keyword-assisted critical discourse analysis of the term

“patient”

Journal: Qualitative Research in Organizations and Management Manuscript ID QROM-09-2019-1827.R3

Manuscript Type: Original Article

Keywords: document analysis, project management, project communication, healthcare, critical discourse analysis

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Ambiguous discursive practices in healthcare project plans:

A keyword-assisted critical discourse analysis of the term “patient”

Abstract

Purpose: The purpose of the paper is to investigate project management’s ambiguous language use in healthcare project plans in a manner that accounts for the wider, institutional, public healthcare context.

Approach: The article deploys a case study approach and draws from Faircloughian critical discourse analysis (CDA) as well as keyword analysis to investigate two time-sequenced versions of the same project planning document for a healthcare project in Finland.

Findings: In the project plans investigated, the study identified patient as a keyword possessing various meanings within the public healthcare context. By examining the discursive practices around the keyword patient, the study demonstrates their role in constituting the institutional context as well as the function of this context in constraining these practices.

Originality: By looking at the potential of CDA to investigate discursive practices of the keyword in two sequential versions of a project plan within the broader context of public healthcare, the study adds to the scant existing literature on critically-oriented healthcare project communication studies.

Keywords: document analysis, healthcare, institutional context, project communication, project management

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Introduction

Communication for project purposes is typically described as the transfer of clear and correct information to or among project stakeholders (Söderlund, 2011; Ziek and Anderson, 2015). Clarity, or a lack of ambiguity, of language is a main standard for effective project communication (Ziek and Anderson, 2015). Recent studies of healthcare projects present language as a process that establishes project reality (e.g. Lunkka and Suhonen, 2015). Ambiguous language in project planning documents may not pose problems involving the development of misunderstandings between stakeholders (Leitch and Davenport, 2007; Abdallah and Langley, 2014). Instead, project plans may offer project managers a tactful mechanism for conveying different meanings to various stakeholders with varying interests relevant to the project (Jarzabkowski et al., 2010). Hence, use of ambiguous language by project managers’ in project plans is considered strategic (Jarzabkowski et al., 2010; Abdallah and Langley, 2014). However, neglecting the wider healthcare context in which healthcare project plans

are drafted and implemented omits the influences of this context on project managers’ use of ambiguous language in project plans and the resulting social consequences of the use of ambiguous language (Fairclough, 1992, 2003).

The purpose of the paper is to investigate project management’s ambiguous language use in healthcare project plans in a manner that accounts for the wider institutional context in which the plans are created and received. Drawing from Faircloughian (1992, 2003) critical discourse analysis (CDA), the paper views language use as a social practice and thus provides a means of studying project planning documents as social events occurring within a broader institutional context. Institutional context – defined as the historical, sociocultural, economic and political context that shapes norms, values and expectations (Buchanan et al., 2013) – is considered an interactive element of healthcare project management. The institutional context is not simply a container in which healthcare project management occurs, but a dynamic and fluid environment that shapes, and is shaped by, project events (see Buchanan et al., 2013). People participating in projects are often unaware of these environmental influences, yet CDA facilitates revelation of the role of discursive practices – through which project plans are produced and received – in maintaining or changing the broader institutional context (Fairclough, 1992). The motive of this paper is to help healthcare project managers and participants become conscious of both the consequences and the opaque causes of their language use in projects, particularly in project plans (see Fairclough, 2001).

This investigation occurred in the institutional context of the public healthcare system in Finland which, in recent decades, has been influenced by the market and management discourse often called New Public Management (NPM). NPM is a hybrid of neoliberal views held by the state and by managerialism (Sześciło, 2016), an alternative mindset regarding the supervision of public

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operations that emphasizes management and enterprising over public administration and professionalism (Nordgren, 2008). The empirical setting for this study was a project intended to install a new children’s and women’s hospital (NCWH) at a university hospital in Finland and one of the project goals was to enhance patient orientation in the new hospital. The study gave primary attention to two time-sequenced versions of the same project planning document (i.e. the preliminary plan and the actual plan). Using a keyword-supported CDA, the study investigates discursive practices around ambiguous use of the keyword patient, which was identified as a pivotal word possessing many meanings in the investigated project plans within the public healthcare context.

Keyword analysis with CDA facilitates integration of the textual-level analysis of project plans with the analysis of societal debates within the broader institutional context (Fairclough, 1992; Leitch and Davenport, 2007). The paper illuminates the potential role of project managers’ use of ambiguous language, particularly the keyword patient, in both constituting and being constrained by the wider societal debates on patient-centred healthcare in Finland.

The paper contributes to healthcare project communication literature as follows. First, it presents CDA as an approach to studying language in healthcare project plans as a social practice within the broader public healthcare context (Fairclough, 1992, 2003). The study examines the discursive practices around the ambiguous keyword patient and thus demonstrates the potential role of these practices in constructing the institutional context as well as the function of the institutional context in constraining the discursive practices (Fairclough, 1992; Leitch and Davenport, 2007).

Second, by investigating the discursive practices in project planning documents, the paper introduces seldom used empirical data as a valuable starting point for observing healthcare project management practices. Finally, the paper illuminates how a critical perspective of healthcare project communication research reveals fragmented representations of reality and, in this way, enhances emancipatory knowledge that encourages project practitioners to reflect on the taken- for-granted assumptions of healthcare project reality (see Geraldi and Söderlund, 2018).

The following sections discuss previous literature on the role of communication in project management and demonstrate the value of a critical perspective for studying the use of ambiguous language by project managers in project plans in the public healthcare context. Then, for the case in question, the empirical data and the keyword-assisted CDA are presented, followed by examination of the findings and deliberation on the implications of the study.

Ambiguous discursive practices in Finnish public healthcare project plans

In project management literature, communication is typically regarded as crucial for achieving intended project goals (Slevin and Pinto, 1987; Ziek and Anderson, 2015). Communication is seen

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4 as a fundamental skill for project managers (Ziek and Anderson, 2015) through which they can lead people effectively during projects (Sotiriou and Wittmer, 2001) and enhance project performance and productivity (Henderson, 2004). Communication is also regarded as a factor in the success or failure of projects or project management (Söderlund, 2011; Ziek and Anderson, 2015). For example, poor communication was identified as a negative influence on team performance (Katz, 1982) while informal communication was shown to positively affect team performance (Hoegl and Gemuenden, 2001). Nonetheless, both perspectives – communication as a skill and as a factor – highlight that communication is a process of transferring correct information to or among project stakeholders (Ziek and Anderson, 2015). This view of project communication as an instrument emphasizes clarity as a factor of successful communication and considers project plans ‘guides’ to further action (see Abdallah and Langley, 2014; Ziek and Anderson, 2015). From this perspective, project managers are considered rational controllers, and projects are often presented as unambiguous means or tools for accomplishing pre-determined goals (Cicmil and Hodgson, 2006; Thomas et al., 2012; Thomas, 2012).

Some recent project studies in the healthcare context presented communication as a social process rather than as a process of information delivery (Kitzmiller and McDaniel, 2010; Lunkka and Suhonen, 2015). In these studies, language constitutes the world as we understand it (see Ziek and Anderson, 2015). From this perspective, ambiguous language in project planning documents need not be considered a problem involving promotion of misunderstandings between stakeholders (Leitch and Davenport, 2007; Abdallah and Langley, 2014). Instead, ambiguity may offer healthcare project managers a discursive strategy for conveying different meanings, of project goals, for example, according to the interests of the audience (Jarzabkowski et al., 2010). Contrary to regarding project plans as ‘guides’ to further action, healthcare project managers may acknowledge that project plans

“offer inspiring statements of values, goals, and purposes that can mobilize a diversity of stakeholders” (Abdallah and Langley, 2014, p. 237).

Although these interpretive project studies have moved beyond the technical orientation of projects, they typically aim to understand how project management might be improved (Green, 2006).

Moreover, they ignore the wider institutional context within which project management is enacted and tend to overlook how the wider context constrains and shapes project management practices like project planning (Cicmil and Hodgson, 2006). The emphasis on the broader context in project management provides a means for critically investigating how the relationships between project managers and the surrounding environment are (re)produced in the context of project management (Cicmil and Hodgson, 2006). This study investigates the use of ambiguous language by healthcare project management professionals in project plans within a broader institutional context. Hence, this

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study finds fault with conventional knowledge about project communication and suggests that research introducing critical perspectives on healthcare project communication could provide emancipatory knowledge about healthcare project communication practices (see Lunkka et al., 2019). Such emancipatory knowledge invites healthcare project practitioners to engage in

“reflection and transformation of the taken-for-granted assumptions of the status quo” (Geraldi and Söderlund, 2018, p.61).

This study acknowledges that healthcare project plans are not drafted or interpreted in a vacuum and, hence, that healthcare project managers are not to be treated as autonomous actors that use ambiguity strategically when producing project plans to engage different stakeholders for project goals. Drawing from Fairclough’s CDA (1992, 2003), this study considers project planning a social event. Discursive project management practices are enabled and constrained by a relatively fixed broader institutional context while simultaneously contributing to the nature of this broader context (Fairclough, 1992). Project plans are treated as ‘samples’ that facilitate investigation of how the wider institutional context influences and is influenced by the discursive practices manifested in project plans.

Engagement in such an investigation requires comprehension of the context in which the project plans are produced and received. This investigation occurred within the institutional context of public healthcare in Finland. Professional hierarchy, professional norms and asymmetrical professional knowledge are known to be distinctive features of the healthcare setting (Currie et al., 2012; Nilsen and Riiskjær, 2013; Reay et al., 2016). The most salient professional groups in healthcare organizations are physicians, nurses and managers (Currie et al., 2012; Nilsen and Riiskjær, 2013). Physicians possess expert knowledge about medical cases, while nurses provide less technical, more holistic patient-focused care and are subordinate to physicians (Currie et al., 2012).

Healthcare managers ensure smooth operation of the organization and facilitate physicians’ work (Currie et al., 2012).

In addition, public healthcare is a politically- and administratively-regulated context (White and Griffith, 2010). As a Nordic welfare state and by international comparison, Finland is a social (not a liberal) democracy (Hartmann et al., 2016), and Finnish healthcare services are provided and organized widely by the public sector (Hakulinen et al., 2011; Hartmann et al., 2016). However, the public healthcare sector has changed, as Finnish healthcare has been adapting to the ideas of New Public Management (NPM) since the 1990s (Hakulinen et al., 2011). NPM ideas are expected to increase efficiency in the healthcare sector by introducing criteria from private sector management into traditional methods of public administration and professionalism (Nordgren, 2008; Alonso, 2015) and by “emulating not only the practices but also the value of business” (Denhardt and

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Denhardt, 2000, p. 549). In healthcare settings, NPM is a response to concerns about rising healthcare expenditures fuelled by technological and medical advances in treatment and an aging population (Acerete et al., 2011; Simonet, 2013; Alonso, 2015). Although medical professionalism in the healthcare context is threatened by changes in healthcare management, physicians retain positions of power in healthcare organizations (Battilana, 2011).

One assertion argues that NPM ideas over-emphasize performance measurements and outcomes and, as a result, public organizations tend to focus too much on intra-organizational performance and control instead of inter-organizational processes (Osborne et al., 2013). This tendency poses the risk that public organizations, like hospitals, will become more interested in productivity than provision of service to the citizen (Denhard and Denhard, 2000; Sześciło, 2016).

Another concern is that application of management theories from the manufacturing sector may lead to public organizations forgetting the reality that public services are acts of assistance and not products (e.g. Osborne et al., 2013).

When public organizations started adopting NPM ideas, different economical terms, such as customer or consumer (understood here as referring to the patient) started pervading the public healthcare discourse (Nordgren, 2008). Legitimization of market and management terminology by the healthcare sector has transformed the care-seeking, waiting patient into a consumer and a value- creating customer “who, according to service management, chooses care and creates value in his/her own process” (Nordgren, 2008, p. 511). This investigation abstained from the debate regarding acceptable use of the term customer, consumer, client or patient, but acknowledged that varying stakeholders in the healthcare setting may have different interpretations of the term patient. For example, healthcare administrators typically apply management theories from the manufacturing sector or from service research that prefer the term customer (see e.g. Nordgren, 2008; Osborne et al., 2013), while healthcare researchers and literature authors often prefer the term patient, particularly in the hospital context (Torpie, 2013; see also McColl-Kennedy et al., 2017).

The attempt to redefine the role of the patient from passive to active, so that the patient has more responsibility for managing his/her own health, has resulted in several practice approaches amongst healthcare researchers, such as patient-centeredness, patient participation or patient empowerment (McColl-Kennedy et al., 2017). Also, patients in healthcare settings are unlike other kinds of customers because their status is affected by illness or injury which makes them vulnerable as they are typically in pain, frightened, medicated and/or exhausted (Torpie, 2013).

Directives to increase patient focus, for example, compete with institutional norms concerning professionalism, accountability and economic incentives (Nielsen and Riisjær, 2013). In the pluralistic public healthcare context, projects that aim to improve patient orientation in

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organizations can be considered terrains where various norms and beliefs exist. Previous studies indicate that a pluralistic public healthcare context requires the development of strategic texts, such as project plans, that consolidate diverse interests and values (Leitch and Davenport, 2007; Abdallah and Langley, 2014). Hence, project planning documents construct meaning and reveal the fragmented representation of reality (Ika and Hodgson, 2014). This study contends that project planning documents provide an interesting avenue for investigating the use of ambiguous language by healthcare project management as a form of social practice within the wider institutional context of public healthcare.

The study Case

This investigation studied the case of a new Children’s and Women’s Hospital (NCWH) project in its planning phase, and permission from the organization under investigation was obtained to conduct the research. The project was selected because it concerned the medical treatment and care of women and children and, therefore, might hold special collective priority and cultural value. In other words, use of ambiguous language in project management documentation for this circumstance would presumably reveal various worldviews.

The initiative for the NCWH came from hospital upper management who set up a project to survey the current state and future needs of children’s and women’s clinics (CWC). The purpose of the NCWH was to unite several small dispersed hospital units. Spatial centralisation and compaction were expected to improve service quality and treatment safety and streamlining of the functions was expected to increase productivity by approximately 10-15%. An investment of approximately 75 million euros was required for the NCWH. Over time, the NCWH became the first phase of a larger program targeting renewal, construction and renovation of the entire university hospital premises to meet modern requirements and to overcome future challenges.

The university hospital is a leading public hospital in its area and, based on the population, represents the average population of the 21 hospital districts in Finland. The various university hospital departments and wards employ a total staff of more than 4500. The university hospital is owned and funded by the Finnish Joint Authority which consists of 29 member municipalities, each with their own decision-making bodies represented in the Council of the Hospital District. Supreme decision-making power in the Joint Authority is exercised by the Council.

Empirical data

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The empirical data for this study comprised two time-sequenced project plan documents from the planning phase of the NCWH. The project plans concerned assessing of the current state and future needs of the CWC and consisted of 168 pages altogether: project plan 1 included 112 pages and project plan 2 included 56 pages. The aim of project plan 1 was to survey the existing situation and future needs of CWCs and to draft a preliminary operational plan for the new hospital addition. Based on project plan 1, the Council of the Hospital District decided to begin actual planning of the operative functions of the NCWH. The aim of project plan 2 was to provide an actual project plan for the operative functions of the NCWH.

Project documents were produced by the project management team authorized to work on the project by hospital top management. The project management team consisted of a project manager (physician), a project coordinator (ward nurse who was officially promoted to project coordinator after completion of project plan 1), a specialist physician, the head nurse of the CWC and the medical superintendent of the CWC. The role of the project coordinator was to support the project manager during the planning process, to act as secretary in the various meetings, and to organize various practical project affairs. Plan formulation was, notably, a developmental process during which various healthcare professionals from the CWC wards provided information from their wards (such as statistics and key ratios) to the project management team. These other healthcare professionals also participated in various work development meetings during which issues concerning the operative functions of the NCWH were collaboratively discussed. All acquired knowledge was used by the project management team to formulate the project plans, yet only the head nurse of the CWC and project manager were responsible for the actual writing of the project plans. The other members of the project management team mainly commented on the various drafts of the plans. The planning documents were written only in Finnish.

In addition, the project plans were supported by 12 interviews of project participants representing various healthcare professions and positions within the CWC. The interviewees included key project members, including project management team members, and key personnel from the wards (typically front-line managers; both nurses and physicians), who were actively involved in the project through different working groups. Participants were asked to describe the project in question and its trajectory, as well as their roles, experiences and thoughts about the project. Five (5) participants agreed to a second interview several months after the first interview, two of whom were from the project management team and three of whom were healthcare practitioners from the wards.

The average interview length was one hour. The participants were selected using a ‘snowball technique’ (Denzin & Lincoln, 2005) in which the first participant was selected on a discretionary

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9 basis and then asked to recommend further participants. Then, the next participants were asked to recommend suitable study participants, and so on.

Note that, for this study, the interviews were not analysed, in the true sense of the word.

However, they helped us understand the circumstances surrounding formulation and implementation of the planning documents. The interviews were analysed in depth and documented in detail in another paper that focused on the project management experiences of healthcare project participants.

The first author of this paper was responsible for the analyses of both papers and, thus, was able to assess the informal language used by project management participants when describing their project work experiences to the formal language used in project plans. This connection helped her understand healthcare project plans as specific type of texts.

Other supporting data included: the intranet and internet pages of the hospital organization, informal conversations with a program manager (during the conducting of the project plan 2 the renovation started to concern the whole university hospital and the program manager was recruited for this) as well as different project participants and stakeholders, the PowerPoint presentations of two consultants, observations from two informational events, and the proceedings and annual reports of a hospital district council for the years 2010-2015. This secondary data helped us form an overall picture of the project and the case’s organization, and helped us understand the context of the project in question.

Analysis

The analysis of the study focused on the project planning documents. As previously noted in this paper, Fairclough’s (1992, 2003) CDA provides a way of exploring healthcare project plans as part of healthcare project management practices. The aim of CDA is to reveal the role of discursive practices in the maintenance of the social world. Project planning documents are considered a feature of social events, and discursive practices are actions through which these project documents are produced (created) and consumed (received and interpreted) (Fairclough, 2003; Jørgensen and Phillips, 2004). CDA is a means of exploring “the dynamic discursive practices through which language users act as both discursive products and producers in the reproduction and transformation of discourses” (Jørgensen and Phillips, 2004, p. 17). The benefit of using CDA is that it aids the connection of project plans with the broader institutional context while simultaneously maintaining a focus on the local production of discourse (Nicolini, 2012).

Using CDA enables critical reflection on realities constructed through discursive practices that are often taken for granted (see Alvesson and Sköldberg, 2000). Discourse is defined as

“ideological work that shapes social actors’ relationships to the world in ways that are not always

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apparent to the social actors themselves” (Mumby, 2004, p. 238). Ideologies, in turn, are types of internalized social structures (including belief systems, values, worldviews) that both enable and constrain language use in particular social situations (Fairclough, 1992). Ideologies manifest through discursive practices and lead to reproduction of certain values, beliefs, and worldviews (Fairclough, 1992). Within a pluralistic institutional context such as public healthcare, various ideologies shape, and are shaped by, specific instances of language use (Fairclough, 1992). They control the use of various discourses by aggregating the available types as communication resources (Fairclough, 1993; Jørgensen and Phillips, 2004). This leads to emphasizing certain discourses and marginalizing others, resulting in the production of some knowledge and the exclusion of other knowledge (Fairclough, 1993; Jørgensen and Phillips, 2004).

This investigation adopted the idea of using a ‘keyword’ (Williams, 1983) to capture the various worldviews manifested in project plans. A keyword denotes a pivotal concept (or several) within specific texts and discourses and possesses many meanings that can be traced to the various ideological positions and/or sets of interests brought together by discourse participants (Leitch and Davenport, 2007). The keyword describes instances in which “words and meanings are implicated in processes of social and cultural contestation and change” (Fairclough, 1992, p. 186). Therefore, keyword analysis includes the micro-level sub-analysis of individual words alongside the macro-level analysis of institutional conflicts and debates (Leitch and Davenport, 2007). For this investigation, the keyword patient was identified as the most prominent, by far, in the project plans analysed by us as it seemed to include various worldviews, beliefs and values.

Project plan analyses were conducted by the first author. Other authors commented on preliminary findings, approved final findings, and assisted by participating in discussions during the analysis when needed. Analysis began with a careful perusal of each printed project plan. Both the perusals and the analyses were conducted in Finnish. The N-Vivo program was used to identify the keyword and to find frequently-used words in the project plans. All frequently-used conjunctives like and, because, and when, and commonly-used verbs like am, are, is, have, and has were excluded from the analysis. Frequently-used words related to the public healthcare context as well as to the current project and its goals were then identified. Consideration was given to whether an identified word manifested various worldviews encompassing various beliefs and values in the healthcare context.

Surprisingly, explicit use of the term customer was limited while use of the term patient was emphasized; the latter fulfilled the criteria for the keyword over the former, despite occasional use of both words as synonyms. After agreement on the keyword patient, excerpts of the plans containing the term patient were coded. To illustrate the textual-level features of the keyword patient,

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collocations were presented from both project plans. These collocations concerned the identification of words surrounding the keyword, thereby illuminating attitudes based on associations between words’ meanings (Baker, 2006; Aluthman, 2018).

Next, the analysis targeted determination of the means by which discursive practices formed ambiguous use and interpretation of patient in the text and contributed to the establishment of the context in which they occurred (Jørgensen and Phillips, 2004). This analysis phase focused on identifying and analysing the types of discourse associated with use of the keyword and integration of the keyword into language use. Thus, the analysis required sensitivity to the context of text production and interpretation. This phase searched for the impact of social conditions on language use and the subsequent social effects of the language use. More specifically, we sought to understand how the patient in the project plans was portrayed by using our own interpretations of the term as a resource for analysis. Various subject positions regarding keyword use, author placement of the keyword, and the values and beliefs influencing keyword use were all explored to obtain an understanding.

Comparison of the discursive practices of the two time-sequenced versions of the project plan provided a means of identifying changes in the ambiguous use of the keyword. Changes in discursive practices around the keyword may indicate knowledge accumulation by project planning participants (see Michaud, 2017), while persistent discursive practices signify prevailing discourses occurring in the institutional context. These distinctions allowed us to analyse

“temporal differentiation” (Michaud, 2017) of the project plans and separate situational factors from influences of the institutional context on project plan production and on ambiguous use of the keyword.

Noteworthily, the social context surrounding ambiguous manifestations of the keyword patient was constructed rather than discovered during the analysis process (Alvesson et al., 2008). The background of the first author of this article, who was responsible for the analysis, is pertinent for understanding the preconditions of this construction process. The first author was a healthcare professional at the university hospital being investigated, albeit not at the CWC.

However, while the NCWH was being planned, the first author was conducting her dissertation in health management and performing administrative tasks for part-time work. As such, she viewed the empirical data from the viewpoint of a healthcare professional, a healthcare administrator and a health management student. The viewpoints of the first author may have enhanced sensitivity to the various values and worldviews embodied in the empirical data. At the same time, it must be noted that this background evidently influenced how she interpreted the empirical data.

Findings

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12 In the following, separate findings from both planning documents are presented. Secondary data is used to describe relevant situational factors involving planning document production and purpose.

The typical collocations of the keyword patient are illustrated in Tables 1 and 3. The interpretation of the ambiguous use of the keyword patient within both documents is demonstrated in Tables 2 and 4. In Table 5, the findings of project plan 1 are presented alongside those of project plan 2 for comparison and to show the temporal differentiation between the plans. Finally, the potential role of the ambiguous depictions of the patient in constituting the context of public healthcare and the function of the broader context in constraining these ambiguous depictions are elaborated.

Project plan 1

Project planning document 1 stated that the NCWH project was set by the hospital management to evaluate the existing situation and future needs of CWCs and to draft a preliminary operational plan for the new hospital addition. The plan included: 1) descriptions of processes for operational functions and care in current CWCs, 2) assessing of critical issues and problems in the clinics, and 3) a preliminary vision of future operating models for a new united clinic. However, this document concentrated primarily on the care processes of so-called “hot operations” (kuumat toiminnot in interviews) or of a “hot hospital” (kuuma sairaala in project plan 1), such as labour and infant care, and intensive care and oncology (cancer care), implying that not all processes were relevant for CWCs. In project plan 1, this was exemplified by the general reference to the patient as a “mother- child couple” (äiti-lapsi pari) requiring a “no separation process” (erottamaton prosessi). Typically, the term patient referred either to a child, the whole family, or a labouring or pregnant mother. Thus, use of the word patient was equivocal and ambiguous. This analysis accounted for excerpts of the project plan in which the term patient as well as its references were manifested. The term patient (potilas) was used 491 times in project plan 1 (ratio 2.3 %). Collocations are presented in Table 1.

< Table 1 around here, please. >

Project plan 1 was generated from May 2011 to March 2012 by the project management team which comprised leading administration staff of the existing CWCs who previously or simultaneously worked as healthcare professionals. The project leader was a physician. Hence, this project plan was generated by persons with vested institutional authority and credibility for presenting the evidence provided. Healthcare projects typically include, and are managed by, healthcare professionals because the work requires strong understanding of the content associated with the environment (see Pohjola et al., 2015).

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13 Project plan generation was a developmental and participative process. Under project management, several working committees comprising selected healthcare professionals participated in planning the operative functions of a new hospital addition through various working groups. As such, many competent people from the organization – experts in their field, therefore, possessing the best understanding and greatest knowledge about the care of children and women – committed to working collaboratively to plan for the NCWH.

In project plan 1, the word patient was preferentially used over the term customer. If the latter was used, in many cases, it was soon replaced with the former. For example, if the text mentioned that the new hospital addition would be designed to enhance customer orientation, the subsequent sentence included the word patient in reference to the customer.

As is standard for official documents, the style of the project plan was declarative, factual and informative, and the passive voice was used more frequently than the active voice (Peräkylä and Ruusuvuori, 2011). Diagrams and tables were widely used to illustrate presented facts and descriptions of the wards and their spaces, as well as their care processes, were presented. Evaluation of the strengths and weaknesses of the current state were shown to demonstrate how the new hospital building would enable more effective care processes. Finally, detailed statistics and key ratios from previous years and predictions of future developments were presented, stratified by ward.

The systematic and descriptive information on hospital ward operations and processes in project plan 1 positioned its authors as mechanical engineers, i.e. as rational controllers. For example, the text described patient flows (i.e. patient transfer from one ward to another) within care processes aiming to demonstrate process inefficiency. In these parts of the text, the patient was represented as an element of the care processes, a naturally presumed depiction that resonated well with the product- oriented logic of organizations, like public hospitals, that strive for efficiency. Previous studies have identified this rationalization as a legitimization strategy empowered by its utility with institutionalized action and the valid knowledge that society has constructed for itself (van Leeuwen and Wodak, 1999). Another presumed patient representation was as an object of treatment. Authors promoting this depiction positioned themselves as competent healthcare professionals who declaratively stated the patient categories within wards and the procedures or operations that the patients needed. These statements required specific medical knowledge and understanding of the contents of the treatments and care.

< Table 2 around here, please >

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14 On the other hand, project plans strongly emphasized the experience of the child while being hospitalized. The importance of the presence of a parent was often accentuated and the document argued for patient orientation that involved the whole family. Project plans also argued for allotment of space for a bed in child patients’ rooms on the ward for parents with a dying child. These plan excerpts positioned authors as ethical, caring healthcare professionals, and portrayed the patient as a child undergoing an experience who must be treated humanely. In addition, emotionally-loaded adjectives such as “the most fragile patient material” (haurain potilasaines) were used in reference to critically-ill infant or child patients. These parts of the text emphasised the moral and emotional aspects of patient orientation. Previous studies refer to such morally- and emotionally-loaded discursive strategies, that validate specific values, as moralization strategies (e.g. Vuontisjärvi, 2013;

van Leuween and Wodak, 1999).

Notably, when a patient was represented as a child undergoing an experience, particularly pertaining to nursing care, discursive practices other than moralization strategies appeared. For example, scientific references or quantitative data were used to support arguments for humane treatment. Hence, exclusive use of moralization strategies to depict the patient as a child undergoing an experience was apparently insufficient and additional strategies, such as quantitative information and scientific knowledge, were needed to support associated arguments. Project plans also justified family orientation by arguing that all other university hospitals planning new labour room additions were committed to including family orientation. These validation strategies used authority based on tradition, custom, or credibility of persons possessing some level of institutional authority (van Leeuwen and Wodak, 1999). Despite patient representation as a child undergoing an experience and justification for incorporating family orientation by using moral strategies together with validation strategies, the depiction of the patient was ambiguous, allowing divergent meanings to coexist:

In the model of the “Single Family Room” the mother and/or father remains with the new-born together in the same room around the clock taking care of the newborn. This model is utilized in Sweden e.g. in Karolinska Hospital. It has been noted, that the

“Single Family Room” model decreases the morbidity of prematurely-born children and reduces the length of time they need to be hospitalized. The result of a randomised study from Stockholm published in 2010 showed that the “Single Family Room” model reduced prematurely-born children’s (before week 37) hospitalization time by approximately 5.3 days (16%) compared to those who received traditional care (32.8 days vs. 27.4 days, p = 0.05; Örtenstrand et al. 2010).

Project plan 1 also portrayed the patient as an object for mobilization and thus resonates with healthcare literature that endorses a patient-oriented or patient-centred approach to care by

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15 encouraging patients to take more responsibility for their own health. These representations depicted patients as recipients requiring motivation from healthcare professionals to engage more with their care, and the project plan excerpts positioned authors as patient-oriented healthcare professionals.

Nevertheless, as the following excerpts demonstrate, patient mobilization was intended to optimize operations rather than to create value for or to empower the patient.

In the future, by encouraging mothers (families) to take part in the care of their babies more actively during puerperium, the number of personnel can be kept to a minimum.

From the patient’s point of view, the change in practices compared to the present state is the emphasis of family orientation. Patient rooms are single patient rooms where parents (at least one of them) have the opportunity to be besides the child around the clock. Parents are in charge of the basic care of their child: feeding, diaper changes, small baths etc. The staff’s working hours are then able to target the real actions of treatment and care.

The excerpt directly above positions project plan authors as fiscally responsible administrators who understand the need for efficient use of the limited resources available for the demands of a publicly-run hospital. Considering this, the patient representation (with patient here including the family) resonated with theories of product-oriented logic as well as the patient-oriented perspective, thus allowing divergent meanings to co-exist.

Hospital services were acknowledged in the project plan by briefly mentioning the importance of a smoother maternity policlinic service. This plan excerpt described the current circumstances and challenged the resulting, shoddy, clinic admission experience for pregnant women.

The patient (a mother) was portrayed as a hospital service user by explicitly accounting for the user’s perspective. However, information on hospital services was marginal and patient depiction as a service user was largely missing from the remainder of the project plan.

In sum, this project plan included representations of the patient as: 1) an element of the care processes, 2) an object of treatment, 3) a child undergoing an experience (within the family), 4) an object for mobilization, and 5) a service user. The first 3 representations were the most prevalent, while the last two were scarce.

Project plan 2

Based on project plan 1, the Council of the Hospital District decided to begin actual planning of the operative functions of the NCWH and project plan 2 was the result. However, over time the project evolved and, instead of including only “hot operations” (kuumat toiminnot, in interviews) from the

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16 CWCs, it now included all CWC operations excluding psychiatry, which was located further away.

The objectives of project plan 2 were to plan the operative functions for all clinics in the new hospital addition and, based on this document, the Council of the Hospital District was to decide whether the NCWH was to be built. Thus, this project plan was critical for the Council’s decision-making process.

The project plan was generated primarily for the Council of the Hospital District, a facet representing owners of the hospital.

The visual appearance of this document was more polished than that of project plan 1. The official hospital logo was used in the header and contact information was presented in the footer.

Also, the text was denser as more comprehensive information was presented with smaller space between the lines, and the page count was only half that of project plan 1. Like that of project plan 1, the style of this document was declarative, informative and factual, and the passive voice was generally used instead of the active voice. Tables, figures and diagrams were widely used to illustrate the facts presented. Overall, project plan 2 had a more official tone than project plan 1.

Project plan 2 was generated by the project management team and completed in November 2014. Project plan 2 was generated in a similar developmental and participative manner as project plan 1. The term patient was often, though not completely, replaced with the term child, newborn, baby or mother. For example, while listing patient orientation as one of the main objectives for the project, project plan 2 was divided into two sub-sections entitled “Children’s rights at the hospital and family-oriented care” and “The experience of a child”, and the text within these sections used the words children, child or mother instead of patient. Also, descriptions of the current state of some NCWH wards included the word child or children instead of patient when explaining the care processes. Moreover, while describing new emergency duty for children, the word child or children was used instead of patient. Otherwise, the word patient was used. The term patient was used 395 times in project plan 2 (ratio 2.3 %). Collocations are presented in Table 3.

< Table 3 around here, please. >

As noted earlier, project plan 2 explicitly emphasized family orientation and the experience of the child. Like project plan 1, this planning document portrayed the patient as a child undergoing an experience; however, it also portrayed the patient as a patient undergoing an experience. Project plan 2 generally used morally-loaded arguments for this perspective, yet emotionally-loaded strategies were less frequently used than in project plan 1. Often the importance of considering the needs of the child/patient undergoing an experience was rather neutrally conveyed, and validation strategies were preferentially used to argue for these human aspects. For example, project plan 2

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Qualitative Research in Organizations and Management

17 referenced statements from authoritative bodies, like the United Nations Convention on the Rights of the Child and NOBAB (or Nordisk förening för sjuka barns behov, a Nordic association representing ill children’s issues), and scientific literature when arguing for family orientation.

< Table 4 around here, please >

Like project plan 1, descriptions of the patient categories and of particular medical procedures depicted the patient as an object of treatment. In addition, wards and their care processes were described, but more succinctly and precisely. These latter descriptions depicted the patient as an element of the care processes. Interestingly, in project plan 2, the patient depicted as an element of care processes was tied to a patient-oriented approach to care:

Fast and smooth patient flows enhance the quality of care and support efficiency goals [of an organization]. Through reasonable planning, patients’ transfers can be reduced and unnecessary transfers decreased.

In the excerpt above, patient transfer within the hospital was observed as a measure of efficiency, quality of care, and a patient-oriented approach. Contrary to previous representations, this excerpt portrays the patient as a source of objective measurements, which resonates with product orientation. The text depicts how product orientation was used to enhance the quality of care and planning of a patient-oriented hospital. In addition, stating patients’ transfers can be shortened may be considered an allusion to service orientation, where a view of the patient as a customer in a hospital is presented.

Despite an emphasis on the need for patient orientation at the hospital, the plan did not portray the patient as an object for mobilization aside from the brief mention in its introduction.

However, the need for inter-organizational collaboration – which was not identified in project plan 1 – was recognized in this project plan while describing development of child emergency duty. Within the short excerpt from project plan 2 identifying the need for collaboration, the keyword patient was not explicitly used, but child or children were used in reference to the patient. Here the authors positioned themselves as competent healthcare professionals rather than service providers and the child was represented as an object of treatment:

The new children’s and women’s hospital enables unity of primary care and special care emergency duty. In this way, it is possible to respond to the regulation of urgent care which states that children are to be recognized as a special group within emergency duty and that

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