Several studies identify obstacles to patient-centered care that can be eradicated by bridging the gap between policy goals and practice. In this article, “patient-centeredness” is theorized as an unstable entity riddled with intrinsic, ineradicable tensions. The purpose of the article is to propose a reflexive approach to the tensions as the most appropriate strategy for narrowing the gap between policy and practice. The reflexive approach is illustrated in an account of an action research project on a Danish, patient-centered initiative, “Active Patient Support.” The account focuses on the development of a dialogic communication model through collaborative, reflexive analyses of the tensions in the enactment of “patient-centeredness” in dialogue between health care practitioners and citizens—in particular, the tension between empowerment and self-discipline. Finally, the conceptual expansion of one of the dimensions of patient-centeredness, “health-practitioner-as-person,” is discussed as a platform for reflexivity, and the limitations of reflexivity are addressed.

In the current socio-political conjuncture, collaborative, dialogic forms of knowledge production abound and are idealised as democratic and inclusive. The aim of the article is to contribute to the body of critical, reflexive analyses of collaborative research by analysing how complex dynamics of exclusion as well as inclusion create tensions in researchers’ attempts to establish collaborative relations in the initial phase of an action research project. The analysis applies a framework combining Bakhtinian dialogic communication theory and Foucauldian theory to explore inclusion and exclusion in the tensional interplay of multiple voices whereby certain voices dominate. Finally, the article offers a typology of ideal types of collaborative research relations that can be used in the initial research phase as a platform for reflexive discussion between researchers and potential collaborative partners about their respective understandings of collaboration and dialogue and corresponding expectations about the research process and results.

No abstract

In the literature, difficulties in implementing policy principles of patient-centredness are often understood as obstacles to patient-centred care leading to a gap between the ideals and practice. This article proposes that what are often identified in the literature as obstacles can be usefully construed as intrinsic tensions that cannot be eradicated. It offers a theoretical framework for exploring the tensions that builds on Bakhtin's theory of dialogue and Foucault's theory of power/knowledge. The framework is designed to "unpack" the tensional, context-specific nature of "patient-centredness" through empirical exploration of how particular forms of "patientcentredness" are produced through tensional meaning-making in particular contexts. The use of the framework is illustrated in an analysis of how "patient-centredness" is ascribed specific meanings and enacted in collaborative telephone counselling conversations in a Danish patient-centred programme entitled "Active Patient Support". The analysis shows how the interweaving of genres and voices works to manage the patient's uncertainty in ways that both empower and self-discipline the patient. The discussion explores the implications of the specific form of "patient-centredness" articulated in the conversations with respect to patient empowerment and participation. It also critically reflects on the theoretical framework as a reflexive approach to tackling the tensions in "patient-centredness".