Practice Qualitative Research

Discourse analysis

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a879 (Published 07 August 2008) Cite this as: BMJ 2008;337:a879
  1. Brian David Hodges, associate professor, vice chair (education), and director1,
  2. Ayelet Kuper, assistant professor2,
  3. Scott Reeves, associate professor3
  1. 1Department of Psychiatry, Wilson Centre for Research in Education, University of Toronto, 200 Elizabeth Street, Eaton South 1-565, Toronto, ON, Canada M5G 2C4
  2. 2Department of Medicine, Sunnybrook Health Sciences Centre, and Wilson Centre for Research in Education, University of Toronto, 2075 Bayview Avenue, Room HG 08, Toronto, ON, Canada M4N 3M5
  3. 3Department of Psychiatry, Li Ka Shing Knowledge Institute, Centre for Faculty Development, and Wilson Centre for Research in Education, University of Toronto, 200 Elizabeth Street, Eaton South 1-565, Toronto, ON, Canada M5G 2C4
  1. Correspondence to: B D Hodges brian.hodges{at}utoronto.ca

    This articles explores how discourse analysis is useful for a wide range of research questions in health care and the health professions

    Previous articles in this series discussed several methodological approaches used by qualitative researchers in the health professions. This article focuses on discourse analysis. It provides background information for those who will encounter this approach in their reading, rather than instructions for conducting such research.

    What is discourse analysis?

    Discourse analysis is about studying and analysing the uses of language. Because the term is used in many different ways, we have simplified approaches to discourse analysis into three clusters (table 1) and illustrated how each of these approaches might be used to study a single domain: doctor-patient communication about diabetes management (table 2). Regardless of approach, a vast array of data sources is available to the discourse analyst, including transcripts from interviews, focus groups, samples of conversations, published literature, media, and web based materials.

    Table 1

     Three approaches to discourse analysis

    View this table:
    Table 2

     Three approaches to a specific research question: example of doctor-patient communications about diabetes management

    View this table:

    What is formal linguistic discourse analysis?

    The first approach, formal linguistic discourse analysis, involves a structured analysis of text in order to find general underlying rules of linguistic or communicative function behind the text.4 For example, Lacson and colleagues compared human-human and machine-human dialogues in order to study the possibility of using computers to compress human conversations about patients in a dialysis unit into a form that physicians could use to make clinical decisions.5 They transcribed phone conversations between nurses and 25 adult dialysis patients over a three month period and coded all 17 385 words by semantic type (categories of meaning) and structure (for example, sentence length, word position). They presented their work as a “first step towards an automatic analysis of spoken medical dialogue” that would allow physicians to “answer questions related to patient care by looking at [computer generated] summaries alone.”5

    What is empirical discourse analysis?

    Researchers using empirical discourse analysis4 do not use highly structured methods to code individual words and utterances in detail. Rather, they look for broad themes and functions of language in action using approaches called conversation analysis (the study of “talk-in-interaction”)6 and genre analysis (the study of recurrent patterns, or genres of language that share similar structure and context—such as the case report, the scientific article).7

    Conversation analysis and genre analysis give more prominence to sociological uses of language than to grammatical or linguistic structures of words and sentences and are used to study human conversations or other forms of communication in order to elucidate the ways in which meaning and action are created by individuals producing the language.4 Lingard and colleagues, for example, studied communication between nurses and surgeons during 128 hours of observing 35 different procedures in the operating room and categorised recurrent patterns of communication. They then used their findings to draw links between interpersonal tensions, the use of language, and the occurrence of errors in the operating room.8 Genre analysis is presented in detail in box 1.

    Box 1 An empirical discourse analysis (genre analysis) of case presentations by medical students*

    This study took place at a tertiary care teaching hospital in Canada. It was conducted in the context of a medical student rotation in paediatrics. The aim of the study was to gain understanding of how the formal linguistic structure of the case presentation is used in academic medical settings.

    The researchers conducted 21 in-depth interviews with medical students and faculty members. Pairs of researchers also observed 16 oral case presentations as well as the teaching exchanges that surrounded them. All of these encounters were tape recorded and transcribed (for a total of 555 pages of text); the transcriptions were iteratively analysed. The analysis was structured to allow themes to emerge from the data (that is, as indicated by multiple examples of such themes throughout the data). However, it particularly focused on themes that helped to illuminate the rules around certain modes of case presentation and on the role of these rules in teaching and learning.

    The study showed a pronounced tension between the educational (“schooling”) uses and clinical (“workplace”) functions of case presentations. For example, students saw the case presentation as a school mode and emphasised that they wanted to get through their presentations without being asked any questions. Faculty, on the other hand, understood the case presentation as a way for professionals to jointly create shared knowledge. Their cross-purposes affected the effectiveness of faculty feedback to the students about their case presentations.

    • *Description based on study by Lingard et al 9

    What is critical discourse analysis?

    Researchers in cultural studies, sociology, and philosophy use the term critical discourse analysis to encompass an even wider sphere that includes all of the social practices, individuals, and institutions that make it possible or legitimate to understand phenomena in a particular way, and to make certain statements about what is “true.” Critical discourse analysis is particularly concerned with power and is rooted in “constructivism.” Thus the discourse analyses of Michel Foucault, for example, illustrated how particular discourses “systematically construct versions of the social world.”4 Discourse analysis at this level involves not only the examination of text and the social uses of language but also the study of the ways in which the very existence of specific institutions and of roles for individuals to play are made possible by ways of thinking and speaking.

    Foucault’s study of madness, for example, uncovered three distinct discourses that have constructed what madness is in different historical periods and in different places: madness as spiritual possession, madness as social deviancy, and madness as mental illness.10 In a similarly oriented study, Speed showed how different discourses about mental health service in use today construct individuals’ identities as “patients,” “consumers,” or “survivors” and are made possible by specific institutional practices and ways for individuals to “be.”11

    In a different context, Stone contrasted the specific discourses used in the education literature for diabetes patients (“patient self care” and “autonomy”) with the medical literature’s use of doctor centred discourses (“compliance” and “adherence”). Stone related the resulting tension (and the important implications for patients’ behaviours) to the ways in which the roles that physicians and patients play are historically determined by different and conflicting models of what disease and healing are.12

    Finally, Shaw and colleagues used a discourse analysis to illustrate the many ways in which research itself can be defined (for example, by a lay person, a medical editor, the World Medical Association, a hospital, the taxman) and how these various definitions are linked to the power and objectives of particular institutions.13

    In these examples of critical discourse analysis, the language and practices of healthcare professionals and institutions are examined with the aim of understanding how these practices shape and limit the ways that individuals and institutions can think, speak, and conduct themselves. Table 2 illustrates how a critical discourse approach to diabetes education would compare with discourse analyses using other linguistic and empirical approaches to research.

    Although our categorisation (tables 1 and 2) emphasises the distinctions between these approaches to discourse analysis, in practice researchers often use more than one of the approaches together in a study. For example, genre analysts may invoke critical theorists in order to study the origins of the sanctioned methods of communication, asking, for example, “What historical and contextual factors led to the adoption of the scientific journal article as a legitimate form of expression of medical ‘truth’ rather than the adoption of another format?”

    What should we be looking for in a discourse analysis?

    Given the wide variety of approaches to discourse analysis, the elements that constitute a high quality study vary. Rogers has argued that some discourse analysis research suffers from scanty explanation of the analytical method used.14 Thus one should expect clear documentation of the sources of information used and delimitation of data sources3 (including a description of decisions made with regard to selection of groups or individuals for interviews, focus groups, or observation) and, importantly, a description of the context of the study. The method of analysis should be clearly explained, including assumptions made and methods used to code and synthesise data. Finally, given that the goal of critical discourse analysis is to illuminate and critique structures of power, it is especially important that researchers describe the ways in which their own individual sociocultural roles may influence their perspectives.

    Conclusion

    Discourse analysis is an effective method to approach a wide range of research questions in health care and the health professions. What underpins all variants of discourse analysis is the idea of examining segments, or frames of communication, and using this to understand meaning at a “meta” level, rather than simply at the level of actual semantic meaning. In this way, all of the various methods of discourse analysis provide rigorous and powerful approaches to understanding complex phenomena, ranging from the nature of on-the-ground human communication to the inner workings of systems of power that construct what is “true” about health and health care. While these methods are gaining popularity, much remains to be done to develop a widespread appreciation for the use, funding, and publication of discourse analyses. As a start, we hope this article will help readers who encounter these approaches to understand the basic premises of discourse analysis. Box 2 offers further reading for those interested in learning more or undertaking discourse analytical research.

    Box 2 Further reading

    Books
    • Fairclough N. Language and power. London: Longman, 1989.

    • Foucault. The archaeology of knowledge and the discourse on language. New York: Random House, 1972.

    • Jaworski A, Coupland N, eds. The discourse reader. London: Routledge, 1999.

    • Kendall G, Wickham G. Using Foucault’s method. London: Sage, 2003.

    • Mills S. Discourse. London: Routledge, 2004.

    Journal articles
    • Barnes R. Conversation analysis: a practical resource in the health care setting. Med Educ 2005;39:113-5.

    • Ford-Sumner S. Genre analysis: a means of learning more about the language of health care. Nurse Researcher 2006;14(1):7-17.

    • Roberts C, Sarangi S. Theme-oriented discourse analysis of medical encounters. Med Educ 2005;39:632-40.

    Summary points

    • Discourse analysis is an effective method for approaching a wide range of research questions in health care and the health professions

    • Discourse analysis is about studying and analysing the uses of language

    • A vast array of data sources is available to the discourse analyst

    • The various methods of discourse analysis provide rigorous and powerful approaches to understanding complex phenomena, ranging from the nature of on-the-ground human communication to the inner workings of systems of power that construct what is “true” about health and health care

    Notes

    Cite this as: BMJ 2008;337:a879

    Footnotes

    • Related to doi: , 10.1136/bmj.a288
    • doi: , 10.1136/bmj.39602.690162.47
    • doi: , 10.1136/bmj.a1020
    • doi: , 10.1136/bmj.a949
    • doi: 10.1136/bmj.a1035
    • This is the fourth in a series of six articles that aim to help readers to critically appraise the increasing number of qualitative research articles in clinical journals. The series editors are Ayelet Kuper and Scott Reeves.

    • For a definition of general terms relating to qualitative research, see the first article in this series.

    • Contributors: All authors contributed to the conception and drafting of the article and its revisions, and all approved the final version.

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; externally peer reviewed.

    References