The production and maintenance of inequalities in health care : A communicative perspective

Abstract: The Swedish health care system does not offer care on equal terms for all its end-users. Discrimination toward patients can take the form substandard communication toward women or foreign born patients. Discrimination is also embedded in the organizational context. Health care is under pressure to increase efficiency and quality of care at the same time. There is a risk that demands for equality will be pushed aside. This thesis aims to contribute to our understanding of how discrimination is expressed in interpersonal- and organizational communication within health care, and highlight educational implications for health care practices. This thesis is comprised of three empirical studies and one conceptual study. In the first study, critical discourse analysis (CDA) is used to categorize gender patterns in communication between health care workers and patients, and finds that both patients and health care workers reproduced the gender order. Open questions created a setting less prone to be limited by gender stereotypes. In the second study, CDA is used and complemented with Linell’s dialogic perspective in order to explore whether patients who were native speakers of Swedish were constructed differently than those who were not, in patient-physician consultations. Findings indicated that the non-native speakers actually were model, participative patients according to patient-centered care. Notwithstanding this they were met by argumentation, whereas the more amenable native patients were met by accommodating responses. In the third study, qualitative content analysis is used to analyze how health care workers talked about patients in their absence. The results revealed that communication about patients who were perceived as not acting according to socially accepted gender norms contained negative and disparaging statements. The final study focused on Clinical Microsystems, a New Public Management-based model for multi-professional collaboration and improvement of health care delivery. Drawing on theories of New Public Management, gender, and organizational control, this study argues that the construction of innovative and flexible health care workers risks reproducing the gender order. The thesis concludes that gender and ethnic stereotypes are reproduced in health care communication, and that an efficiency-inspired organizational and institutional discourse may be an impediment to equal care. This calls for focus on learning about communication for prospective and existing health care workers in a multicultural health care context.