Discourse analysis: Negotiating the ‘contested terrain’

Previous chapters have shown the significance of the encounter between the prescriber and patient in enabling the patient’s use of medicines. Issues of power have been shown to be important factors and there are several ways in which patients’ use of medicines are constructed. There has however been minimal empirical exploration of such issues within the non-medical prescribing encounter and the current study is therefore focused on how patients and nurse/pharmacist

prescribers manage the encounter in relation to the patient’s use of medicines. As there is a relatively limited literature in this area the study is exploratory and seeks to examine the patient–prescriber encounter in relation to the ways in which medicines’ use is managed and the views of both prescribers and patients living with a long-term condition. The complexity of issues involved in patients’ use of medicines and the narrow focus on patient behaviour found within the positivist research in this area, outlined in chapter 3, emphasised, at an early stage, the importance of a qualitative research strategy. Qualitative, interpretive approaches enable the collection of rich data and an in-depth analysis (Malson 2010) and involve a number of ‘practices that make the world visible’ (Denzin & Lincoln 2011: 3). The current study is also focused on aspects of the patients’ illness experience and the practices of health professionals which Morse (2011) has identified as two of the key areas in which qualitative health research is undertaken.

Chapter 3 has outlined the many different ways in which patients’ use of medicines is constructed and a qualitative research approach sensitive to patient and prescriber constructions of this issue was sought. Discourse analysis (DA) became the preferred methodological approach since it is concerned with language and the ways in which personal, social and political goals are achieved through language (Cutcliffe & Harder 2012, Gee 2005). It enables examination of the discourse positions adopted by patients and prescribers in relation to medicines’ use and how these positions are constituted. Discourse analysis is usually classed as qualitative research since it has a shared concern in the meaningfulness of social life although it is concerned with how ideas, objects and the social world in general are ‘created and maintained through the relationships among discourse, text, and action’ rather than understanding and interpretation (Phillips et al 2004: 637). It encompasses a number of methodological approaches derived from a variety of theoretical and epistemological traditions including, amongst others, linguistics, sociology, psychology and anthropology (Antaki 2008, Hammersley 2002, Potter 2004, te Molder 2009, Wiggins 2009). The range of approaches within DA means that it can be described as a ‘contested terrain’ (te Molder 2009:312) and should be more properly viewed as a research field (Taylor 2001). The term discourse can also be described as a ‘congested concept’ with numerous definitions of the term arising from its different theoretical legacies (Buus 2005:27).

Key DA approaches used in social sciences research include conversation analysis, discursive psychology, Foucauldian research and critical discourse analysis (Wiggins 2009, te Molder 2009, Hammersley 2002) although other authors classify

several additional approaches as DA, including interactional sociolinguistics and interpretative phenomenological analysis (e.g. Antaki 2008, Wetherell 2001). There are however a number of underlying assumptions common to all of the approaches including the view that discourse, whether written or spoken, is central to everyday life and human relationships and that it has a focus on social action i.e. how social practices are achieved in and through discourse (Wiggins 2009, Antaki 2008, Potter 2004). In addition, most forms of DA adopt a social constructionist approach in that language does not have universal meaning but is an active and constructed tool that co-constitutes the world around us (e.g. Wiggins 2009, te Molder 2009, Antaki 2008, Potter 2004, Cheek 2004, Hammersley 2002).Texts, whether written or spoken, therefore not only reflect a certain view of reality but are active in the construction and maintenance of that view of reality itself (Cheek 2004). Each approach however also involves specific philosophical and theoretical assumptions about, for example, the nature of reality and the importance of context together with a distinctive understanding of the term discourse (Wetherell 2001), depending on the origins of the approach, the subject area and the theoretical orientation of the researcher (Sawyer 2002).

Key differences in some of the common DA approaches, selected for their perceived relevance to the study, are summarised in Table 4.1 overleaf. The table highlights the positions taken by each approach on a number of philosophical and methodological issues. It should be emphasised however that the table presents a relatively simplistic overview of DA approaches as there are a number of variants within each approach, meaning that neither the columns nor rows should be viewed as discrete (Antaki 2008). On a personal level, it proved helpful however in clarifying the relevance of each approach in the context of the study. The rationale for the eventual use of ‘generic’ DA is presented below in section 4.2.

Table 4.1 Selected characteristics of different approaches within discourse analysis Ap p ro ac h to disc o u rs e analys is Paradigm & assumptions re nature of reality

Focus of analysis Political engagement Importance of

context

Nature of actions to be revealed (from Antaki 2008:432)

Conversation analysis

Interpretevist, realist Social action as achieved through sequential analysis of talk, mostly in naturally- occurring but also ‘institutional’ interaction

Generally value-neutral, power may be manifest in talk

Only that which is evident within interaction - context is constituted within talk itself

Accomplishing

interactional life in real time Discursive psychology Constructivist Anti-realist Anti-cognitivist – emotions, cognitions and attitudes exist in interaction, not as inner states

Interpretative

repertoires that explain how psychological concepts such as attitudes are constructed & understood in social interactions

General view that only that which is manifest in talk is important, although this is a source of dispute Generally avoids ‘trading on ethnographic particulars’ (Potter 2004:16)

Displaying and deploying psychological states; describing the world and promoting interests Critical discourse analysis (CDA or FDA) Realist, particularly in linguistic approaches Can be post- structuralist particularly in Foucauldian approach Role of discourse in construction and maintenance of power. Can have a linguistic orientation, although this is less marked in post-structuralist approaches

Overtly political and seeks to expose & challenge ideologies and hegemonic discourses. Generally Marxist conception of power except in Foucauldian approach Essential in understanding the macro-societal context Constituting and

regulating the social and political world: the operation of power