Communicative action for building nursing knowledge

It is a theoretical essay aiming at proposing the usage of the communicative action theory, by philosopher Jürger Habermas, as a mediator of educational technologies in building nursing knowledge. Based on the contributions by the philosopher and authors such as Demo, Morin, Assman, Perrenoud, Waldow, and Ramos, we reflect on technological advances and the necessary innovations in the field of nursing education. We believe that this proposal can contribute to implementing the national curriculum guidelines in undergraduate courses.     

Jürgen Habermas and the dilemmas of experience of disability

The article addresses Jürgen Habermas’ theory of communicative action, which offers very productive tools for analysing disability. The Habermasian division of social reality helps examine positive and negative effects of tensions between the lifeworld of a person with disability and the system. By exploring such an individual's communicative action, one can obtain an insight into his/her validity claims and disruptions in the communication process and self‐understandings inscribed in group narratives. The study reported in the article used in‐depth interviews, which narratively reveal the experiences of a person with disability in family, education, sports and labour. The key findings are, first, that the rationalization of lifeworlds of people with disability increases while processes in which they are colonized by the system intensify; second, that education and family are significant factors in the raising of validity claims; and third, that validity claims as tools of verbal communication should be augmented with arguments from non‐verbal language (e.g. gesture, empathy).     

The process of nursing work in collective health and interdisciplinary studies

This study aims at discussing and stimulating reflections on the need of an interdisciplinary dialogue when the object of work is the health-illness-care process. The authors discuss the definition of Nursing by considering its essence, care, its history and practice. Following, considerations about inter- and trans-disciplinary studies on collective health are presented and the authors conclude with a proposal of basing care on the theory of communicative action developed by Jürgen Habermas.     

The Meninos do Rio Program: lifeworld, adolescence, and health risks

This study focuses on health risks among teenagers from two towns in the Sao Francisco River Valley (Ibiai and Morada Nova) and slums in Morro das Pedras, Belo Horizonte, Minas Gerais State, Brazil. The study discusses teaching and extracurricular activities by the Federal University in Minas Gerais in these localities, aimed at promoting health in adolescence. The authors use the Habermas communicative action theory as the main theoretical and methodological approach. The research adopted a qualitative and quantitative methodology, including dynamic observation, focus groups, interviews, and questionnaires answered by high school students. Sexuality, work, and violence were the main themes and were associated with numerous health risks. Work in the 10-to-14-year-old group was associated with nearly all types of health risks. The authors analyze the relations between context and adolescent behavior using the Habermasian concept of lifeworld colonization.     

Midwifery practice and the crisis of modernity: implications for the role of the midwife

Almost since its inception, the concept of modernity was found to display tensions between its emancipatory potential to liberate the human subject from the manacles of tradition, and the application of reason to co-ordinate and control the natural world through scientific knowledge. This paper presents a qualitative analysis of in-depth interviews with 12 midwives about their role in the Irish maternity services and argues that, in a period of late modernity, these tensions continue to manifest themselves in the context of the midwife's role. Although the contemporary period is marked by a loss of faith in scientific truths, widely contested obstetric knowledge and practices continue to exercise mastery over nature while undermining a central feature of the midwife's role-the liberation of the autonomous subject. Drawing on the theory of communicative action developed by the critical theorist Jürgen Habermas, it is argued that the midwife's role in facilitating the autonomous choices of women through communicative action is impeded by the colonization of the lifeworld of labour and childbirth by the technocratic system of obstetrics. Although participants reported that their role involved empowering women and facilitating choices through dialogue congruent with communicative action, data also suggested that participants used strategic communication with clients aimed at achieving particular ends. The use of strategic communication was linked to the way in which the midwife's role is determined to a large extent by the practices and protocols of obstetrics, and also to the notion of client passivity. The instrumental rationality of obstetrics is linked to an outcome orientation to power and money, and a political economy perspective of medicine. It appears that communicative action between midwives and obstetricians is important in bringing about structural changes to facilitate the conditions for communicative action between midwives and their clients.     

Effecting change through dialogue: Habermas’ theory of communicative action as a tool in medical lifestyle interventions

Adjustments of everyday life in order to prevent disease or treat illness afflict partly unconscious preferences and cultural expectations that are often difficult to change. How should one, in medical contexts, talk with patients about everyday life in ways that might penetrate this blurred complexity, and help people find goals and make decisions that are both compatible with a good life and possible to accomplish? In this article we pursue the question by discussing how Habermas’ theory of communicative action can be implemented in decision-making processes in general practice. The theory of deliberative decision-making offers practical guidelines for what to talk about and how to do it. For a decision to be rooted in patients’ everyday life it has to take into consideration the patient’s practical circumstances, emotions and preferences, and what he or she perceives as ethically right behaviour towards other people. The aim is a balanced conversation, demonstrating respect, consistency and sincerity, as well as offering information and clarifying reasons. Verbalising reasons for one’s preferences may increase awareness of values and norms, which can then be reflected upon, producing decisions rooted in what the patient perceives as good and right behaviour. The asymmetry of medical encounters is both a resource and a challenge, demanding patient-centred medical leadership, characterised by empathy and ability to take the patient’s perspective. The implementation and adjustments of Habermas’ theory in general practice is illustrated by a case story. Finally, applications of the theory are discussed.     

Cancer surviving patients' rehabilitation – understanding failure through application of theoretical perspectives from Habermas

This study aims to analyze whether the rehabilitation of cancer surviving patients (CSPs) can be better organized. The data for this paper consists of focus group interviews (FGIs) with CSPs, general practitioners (GPs) and hospital physicians. The analysis draws on the theoretical framework of Jürgen Habermas, utilizing his notions of 'the system and the life world' and 'communicative and strategic action'. In Habermas' terminology, the social security system and the healthcare system are subsystems that belong to what he calls the 'system', where actions are based on strategic actions activated by the means of media such as money and power which provide the basis for other actors' actions. The social life, on the other hand, in Habermas' terminology, belongs to what he calls the 'life world', where communicative action is based on consensual coordination among individuals. Our material suggests that, within the hospital world, the strategic actions related to diagnosis, treatment and cure in the biomedical discourse dominate. They function as inclusion/exclusion criteria for further treatment. However, the GPs appear to accept the CSPs' previous cancer diagnosis as a precondition sufficient for providing assistance. Although the GPs use the biomedical discourse and often give biomedical examples to exemplify rehabilitation needs, they find psychosocial aspects, so-called lifeworld aspects, to be an important component of their job when helping CSPs. In this way, they appear more open to communicative action in relation to the CSPs' lifeworld than do the hospital physicians.     

The silencing of Kierkegaard in Habermas’ critique of genetic enhancement

The main purpose of this paper is to draw attention to an important part of Habermas’ critique of genetic enhancement, which has been largely ignored in the discussion; namely his use of Kierkegaard’s reflections on the existential conditions for becoming one-self from Either/or and the Sickness unto Death. It will be argued that, although Habermas presents some valuable and highly significant perspectives on the effect of genetic enhancement on the individual’s self-understanding and ability to experience him- or herself as a free and equal individual, he does not succeed in working out a consistent argument. The claim is that he fails to explain how the existential analysis is related to his reflections on the sociological and psychological impacts of genetic enhancement in the realm of communicative action. It is this lack of theoretical clarity, which seems to render Habermas vulnerable to some of the critique which has been raised against his theory from a number of different scientific disciplines and areas of research. Hence, the first part of the paper provides some examples of the nature and variety of this critique, the second part presents Habermas’ own critique of genetic enhancement in the context of a dispute between so-called ‘liberal’ and ‘conservative’ arguments, and finally, the third part discusses the limits and possibilities of his position in a future debate about genetic enhancement.     

The Role of “Evidence” in Recovery from Mental Illness

Evidence-based practice (EBP), a derivative of evidence-based medicine (EBM), is ascendant in the United States’ mental health system; the findings of randomized controlled trials and other experimental research are widely considered authoritative in mental health practice and policy. The concept of recovery from mental illness is similarly pervasive in mental health programming and advocacy, and it emphasizes consumer expertise and self-determination. What is the relationship between these two powerful and potentially incompatible forces for mental health reform? This paper identifies four attempts, in the mental health literature, to delineate the role of “evidence” in recovery. One is the strong version of evidence-based practice—an applied science model—and three others address weaknesses in the first by limiting the authority of probabilistic findings. The paper also offers a fifth version, based on the concept of communicative accountability, which is derived from Habermas’ work on communicative action. The fifth version responds to the other four and emphasizes learning, disclosure and respect in clinical and other helping relationships.     

Shifting from preconceptions to pure wonderment

Abstract The author reflects upon her role as a public health nurse striving to attain practice authenticity. Client assessment and nursing interventions were seemingly sufficient until she became curious about ‘Who is this person sitting across from me?’ and ‘What are her experiences in the world as a lone parent living in poverty at the margins of society?’ The author begins to think that she could shift from mere client investigation to pure wonderment about the Other by imagining herself as a researcher, an explorer of another's life world. Ultimately this process enables her to enhance the ‘caring’ in her practice with the knowledge gained of the perceptions and meanings impoverished clients assigned to their everyday lives. Jurgen Habermas’ theory of communicative competence serves as the reference map guiding exploration. The author uses Habermas’ theoretical principles of intersubjective mutuality – the validity claims of comprehensibility, truth, sincerity, and legitimacy. Comprehensibility embodies understanding, an attitude of unconditional acceptance, and care respect of another's individual person and self‐defined reality. Intersubjective mutuality also requires that one dwell in the moment with the Other, satisfied that communication is founded on truth. Sincerity implies fostering the Other's expression of authentic self apart from oppressive distracters. Lastly, legitimacy reconciles the author's altruistic pursuit to know the Other's ontological truth with the reality of the present world.     

Healthcare organizations, linguistic communities, and the emblematic model of palliative care

The linguistic-communicative paradigm offers some interesting perspectives in a context where the perception of patient needs is considered a critical step in high-quality care. This study describes healthcare organizations as linguistic communities based on the conceptual framework of Habermas' communicative action theory. Four communicative models are present in healthcare settings: objectifying-instrumental (hegemonic model), where elements of interaction are objectified for clinical purposes; dialogic model with strategic perspectives, in which conversations are used unilaterally as tools to access subjective states; non-dialogic-transmissional model, in which linguistic exchanges are replaced with artifacts to transmit information; and full communicative model (present in palliative care based in homecare and informal caregivers, emphasizing health team/family interactions). Based on these premises, we considered palliative care an emblematic communicative model based on multidisciplinary teams devoted to transdisciplinary collaboration. In these settings, linguistic interaction with patients and their families could provide a solid basis for organization of healthcare networks.     

Making the Improbable Probable: Communication across Models of Medical Practice

Cooperation and conversation in the public sphere may overcome historical and other barriers to rational argumentation. As an alternative to evidence-based medicine (EBM) and patient-centered care (PCC), the recent development of a modern version of person-centered medicine (PCM) signals an opportunity for a conversational pluralogue to replace parallel monologues between EBM and its critics, and the calls to EBM to debate its critics. This article draws upon elements of Habermas’s theory of communicative action in order to suggest the kind of pluralogue that is required for stakeholders in modern medicine to benefit more from publicly conversing with each other than speaking alone or using debate to argue against each other. This reasoned perspective has lessons for all discourse when deep value-based and epistemological differences cannot be easily adjudicated.     

Managing Ethical Difficulties in Healthcare: Communicating in Inter-professional Clinical Ethics Support Sessions

Several studies show that healthcare professionals need to communicate inter-professionally in order to manage ethical difficulties. A model of clinical ethics support (CES) inspired by Habermas’ theory of discourse ethics has been developed by our research group. In this version of CES sessions healthcare professionals meet inter-professionally to communicate and reflect on ethical difficulties in a cooperative manner with the aim of reaching communicative agreement or reflective consensus. In order to understand the course of action during CES, the aim of this study was to describe the communication of value conflicts during a series of inter-professional CES sessions. Ten audio- and video-recorded CES sessions were conducted over eight months and were analyzed by using the video analysis tool Transana and qualitative content analysis. The results showed that during the CES sessions the professionals as a group moved through the following five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, the revelation of the value conflict, enhancing realistic expectations, seeing opportunities to change the situation instead of obstacles. In the course of CES, the professionals moved from an individual interpretation of the situation to a common, new understanding and then to a change in approach. An open and permissive communication climate meant that the professionals dared to expose themselves, share their feelings, face their own emotions, and eventually arrive at a mutual shared reality. The value conflict was not only revealed but also resolved.     

Communicative actions,women's degree of social connectedness and child mortality in rural Bangladesh

Background Child deaths are decreasing throughout South East Asia, yet the rate remains high and is a cause of considerable anguish. In Bangladesh, there is also a great deal of variation in child mortality between different regions. Method Reported in this paper is the analysis of a survey of 613 Bangladeshi women who live in six rural villages and have reported on their experience of child death. Factors obtained from an interview based questionnaire were investigated to ascertain their association with child death. Multilevel Poison regression models were developed to relate these factors to the number and proportion of child deaths to children ever born while allowing for variation between the villages. Results It was found that communicative action, especially women's power as the degree of social connectedness, is important in reducing child mortality. Also important in reducing child mortality is the level of women's education. No evidence could be found of sex preference when comparing male and female child deaths.     

Communication and Cybercoping: Coping With Chronic Illness Through Communicative Action in Online Support Networks

Computer-mediated communication, specifically blogs, has expanded the range of the communicative action of patients with chronic disease from information seeking to information forwarding. The authors examine the effects of these 2 types of communicative action on perceived affective and physical coping outcomes. Using a survey dataset of 254 chronic disease patients, the authors tested 2 models using structural equation modeling: first, the effects of communicative action about chronic illness on coping outcomes; and second, the mediating role of emotion-focused and problem-focused coping processes. Findings indicate overall positive effects of communicative action on coping processes and outcomes, yet with different magnitudes of effects depending on the dimensions of communication behavior, the coping process, and outcome. Implications for patients and health care providers are discussed.     

Patients' Satisfaction With Dentists' Communicative Style

In this article, it is argued that a dentist's chairside manner of communicating with patients significantly influences dental care outcomes such as patients' satisfaction, anxiety, and willingness to return for further treatment. Two dimensions of a dentist's communicative style conceivably influence a patient's responses to dental care. Communicative involvement represents the extent to which the dentist appears attentive, perceptive, and responsive to the patient's comments and needs. Communicative dominance refers to the degree to which the dentist controls the nature and topics of the dentist-patient encounter. Immediately after a dental visit, each of 572 patients of 17 dentists in Lubbock, Texas, responded to a questionnaire assessing his or her perceptions of the dentist's communicative style and satisfaction with the dentist. Several findings were noteworthy. First, consistent with comparable research in medical contexts, there was a strong, positive relationship between perceptions of the dentists' communicative involvement and patients' satisfaction. Second, there was a moderate, negative relationship between perceptions of the dentists' communicative dominance and patients' satisfaction. Third, new patients expressed less satisfaction with dentists who are less involved than did repeat patients. Finally, the relationship between patients' satisfaction and perceptions of dentists' communicative involvement was stronger for patients having a high school education or less than for patients having more education. Possible explanations and implications of these findings are discussed.     

Information-giving in medical consultations: the influence of patients' communicative styles and personal characteristics

Informing the patient is arguably the physician's most important communicative responsibility. Recognizing this researchers have long been interested in the question of why some patients receive more information from physicians than do others. In this paper, it is argued that the amount of information physicians provide patients during medical consultations may be influenced by two sets of factors, patients' personal characteristics (age, sex, education, and anxiety) and patients' communicative styles (question-asking, opinion-giving, and expression of concern). The analysis of audiovisual recordings of 41 physician-patient consultations in a family practice clinic revealed several notable findings: (a) information regarding diagnosis and health matters was primarily related to the patient's anxiety, education, and question-asking, (b) information regarding treatment was primarily a function of the patient's question-asking and expression of concerns, and (c) patients' assertiveness and expressiveness were strongly influenced by physicians' use of 'partnership-building' utterances that solicited the patient's questions, concerns, and opinions. The data suggest that, when attempting to explicate factors affecting physicians' informativeness, researchers must take into account features of the patients' communicative styles as well as physicians' perceptions of certain groups of patients.     

“I Stand Alone.” An Ethnodrama About the (dis)Connections Between a Client and Professionals in a Residential Care Home

Client participation in elderly care organizations requires shifting traditional power relations and establishing communicative action that involves the lifeworlds of clients and professionals alike. This article describes a particular form of client participation in which one client was part of a team of professionals in a residential care home. Their joint remit was to plan the implementation of a new personal care file for residents. We describe the interactions within this team through an ethnodrama, based on participant observations and the embodied presence of the researcher (first author). The narratives and voices of all team members are dramatized in this ethnodrama. Throughout the project the team members experienced confusion relating to the confrontation between lifeworld and system, as experienced by the client and professionals in the team. We analyze these tensions by making use of a Habermasian theoretical framework. We conclude that forms for collective client participation in residential care homes should be developed based on communicative action between clients and professionals, with room for emotional engagement.     

Minds on Earth Hour – a theme for sustainability in Swedish early childhood education

This educational science article illustrates education for sustainability in a theme about Earth Hour (energy conservation) in one Swedish preschool. This case study is based on audio recordings of dialogues between children aged five to six years and preschool teachers. It is guided by critical theory, which is also used as a conceptual tool to explore participation, agency and shared meaning-making. The main findings show that children are engaged and active as equal participants in the dialogue, being eager to understand and take part. However, the intended knowledge content fades into the background when other topics are brought up and as educational framing with purposefully framed play imposes regulations on the constructs of the dialogue content. Further consideration needs to be given to how communicative action together with participation and listening, as well as knowledge development and play, can be intertwined.