Sairaanhoitajaksi kasvattaminen : Sairaanhoitajakoulutus ja siinä käytetyt oppikirjat Suomessa vuoteen 1967 asti

The historical development of Finnish nursing textbooks from the late 1880s to 1967: the training of nurses in the Foucauldian perspective. This study aims, first, to analyse the historical development of Finnish nursing textbooks in the training of nurses and in nursing education: what Foucauldian power processes operate in the writing and publishing processes? What picture of nursing did early nursing books portray and who were the decision makers? Second, this study also aims to analyse the processes of power in nurse training processes. The time frame extends from the early stages of nurse training in the late 1880s to 1967. This present study is a part of textbook research and of the history of professional education in Finland. This study seeks to explain how, who or what contributed the power processes involved in the writing of nursing textbooks and through textbooks. Did someone use these books as a tool to influence nursing education? The third aim of this study is to define and analyse the purpose of nurse training. Michel Foucault´s concept of power served as an explanatory framework for this study. A very central part of power is the assembling of data, the supplying of information and messages, and the creation of discourses. When applied to the training of nurses, power dictates what information is taught in the training and contained in the books. Thus, the textbook holds an influential position as a power user in these processes. Other processes in which such power is exercised include school discipline and all other normalizing processes. One of most powerful ways of adapting is the hall of residence, where nursing pupils were required to live. Trained nurses desired to separate themselves from their untrained predecessors and from those with less training by wearing different uniforms and living in separate housing units. The state supported the registration of trained nurses by legislation. With this decision the state made it illegal to work as a nurse without an authorised education, and use these regulations to limit and confirm the professional knowledge and power of nurses. Nurses, physicians and government authorities used textbooks in nursing education as tools to achieve their own purposes and principles. With these books all three groups attempted to confirm their own professional power and knowledge while at the same time limit the power and expertise of others. Public authorities sought to unify the training of nurses and the basis of knowledge in all nursing schools in Finland with similar and obligatory textbooks. This standardisation started 20 years before the government unified nursing training in 1930. The textbooks also served as data assemblers in unifying nursing practices in Finnish hospitals, because the Medical Board required all training hospitals to attach the textbooks to units with nursing pupils. For the nurses, and especially for the associations of Finnish nurses, making and publishing their own textbooks for the training of nurses was a part of their professional projects. With these textbooks, the nursing elite and the teachers tended to prepare nursing pupils’ identities for nursing’s very special mission. From the 1960s, nursing was no longer understood as a mission, but as a normal vocation. Nurses and doctors disputed this view throughout the period studied, which was the optimal relationship between theory and practice in nursing textbooks and in nurse education. The discussion of medical knowledge in nursing textbooks took place in the 1930s and 1940s. Nurses were very confused about their own professional knowledge and expertise, which explains why they could not create a new nursing textbook despite the urgency. A brand new nursing textbook was published in 1967, about 30 years after the predecessor. Keyword: nurse, nurse training, nursing education, power, textbook, Michel Foucault

Scheffleriläinen rationaalisuus ja kasvatustodellisuuden monikerroksisuus : Jännitteitä ja ratkaisuja Israel Schefflerin kasvatusfilosofiassa

The study is a philosophical analysis of Israel Scheffler’s philosophy of education, focusing on three crucial conceptions in his philosophy: the conception of rationality, the conception of human nature, and the conception of reality. The interrelations of these three concepts as well as their relations to educational theorizing are analysed and elaborated. A conceptual problem concerning Scheffler’s ideal of rationality derives from Scheffler’s supposition of the strong analogy between science education and moral education in terms of the ideal of rationality. This analogy is argued to be conceptually problematic, since the interconnections of rationality, objectivity, and truth, appear to differ from each other in the realms of ethics and science, given the presuppositions of ontological realism and ethical naturalism, to which Scheffler explicitly subscribes. This study considers two philosophical alternatives for solving this problem. The first alternative relates the analogy to the normative concept of personhood deriving from the teleological understanding of human nature. Nevertheless, this position turns out to be problematic for Scheffler, since he rejects all teleological thinking in his philosophy. The problem can be solved, as it is argued, by limiting Scheffler’s rejection of teleology – in light of his philosophical outlook on the whole – in a manner that allows a modest version of a teleological conception of human nature. The second alternative, based especially on Scheffler’s later contributions, is to suggest that reality is actually more complex and manifold than it appears to be in light of a contemporary naturalist worldview. This idea of plurealism – Scheffler’s synthesis of pluralism and realism – is represented especially in Scheffler’s contributions related to his debate with Nelson Goodman dealing with both constructivism and realism. The idea of plurealism is not only related to the ethics-science-distinction, but is more widely related to the relationship between ontological realism and the incommensurable systems of description in diverse realms of human understanding. The Scheffler-Goodman debate is also analysed in relation to the contemporary constructivism-realism debate in educational philosophy. In terms of educational questions, Scheffler’s plurealism is argued as offering a fruitful perspective. Scheffler’s philosophy of education can be interpreted as searching for solutions to the problems deriving from the tension between the tradition of analytical philosophy and the complexity and multiplicity of educational reality. The complexity of reality combined with the supposition of the limitedness of human knowledge does not lead Scheffler to relativism or particularism, but, in contrast, Schefflerian formulations of rationality and objectivity preserve the possibility for critical inquiry in all realms of educational reality. In light of this study, Scheffler’s philosophy of education provides an exceptional example of combining ontological realism, epistemological fallibilism, and the defence of the ideal of rationality, combined with a wide-ranging understanding of educational reality.

Kasvatus- ja valmennustyylien yhteys juniorijääkiekkoilijoiden suoriutumisstrategioihin, tyytyväisyyteen ja joukkueen koheesioon

This thesis focused on the roles of parenting styles (including parental norm-breaking attitudes and parents perceptions of players coach-athlete relationship), players achievement strategies, perceptions of coaching behaviours, coaches own perceptions, and perceptions of team leaders, in explaining player satisfaction and team cohesion. Five studies based on the same data provided by the Finnish Ice Hockey Association (FIHA) were carried out. The sample sizes were as follows: players, 1,018; parents, 979; coaches, 35; and team leaders, 57. Questionnaires and self-report questionnaires were used to collect data. The results revealed that: (1) family-parenting styles provided a basis for adolescents achievement strategies and influenced whether the sons played fairly or engaged in rule breaking. Democratic parenting was associated with the adolescents high level of mastery-oriented behaviour, low level of task-irrelevant behaviour, and low level of norm-breaking behaviour. The adaptive achievement strategies enhanced player satisfaction. (2) Democratic parenting styles influenced parents perception of the coach-athlete relationship, which was further associated with a coaching style that also influenced how the child experienced his own cohesion within the team. (3) The adolescents tended to reflect the similarity in leadership behaviours between home and sport from both democratic and autocratic backgrounds. In particular, the compensating combination of non-demanding styles at home and a high level of support by a positive coach was associated with high team cohesion. (4) The stress factor changed the dynamics of the parenting behaviour. (5) Players ratings, coaches ratings, and the ratings of team leaders all differed upon coaching behaviours and team cohesion. Only the players ratings were associated with cohesion high with positive coaching and low with autocratic coaching. The developmental age and the long-lasting membership on an ice hockey team made positive coaching acceptable for all players. Sixteen year-olds from all families rated high team cohesion with positive coaching. Parenting styles were associated with adolescent ice hockey players achievement strategies, norm breaking, and satisfaction. The combination of parenting and coaching was associated with cohesion rated by players. The staff s experiences of coaching and its effects on cohesion differed from the players experiences. These results contribute to understanding links between parenting styles, achievement strategies, norm breaking, and satisfaction, as well as parenting styles, coaching behaviour and cohesion. This work has importance for parents, coaches, sport organizations, and teachers.

Kehittävän kuntoutuksen mahdollisuudet. : Tutkimus Aslak -kuntoutuksen työkytkennän ja asiakkuuden rakentumisesta.

The possibilities of developmental rehabilitation. A study on the construction of work relatedness and the customer in Aslak rehabilitation The challenge of work-related rehabilitation is to anticipate the factors threatening work ability and to affect them. The purpose of this study was to analyze how work-related rehabilitation is constructed in practice and what are the challenges and, at the same time, the possibilities of an innovative transformation of rehabilitation when trying to achive this goal. The theoretical basis is cultural-historical activity theory and developmental work research. Based on a historical analysis, I studied rehabilitation activity empirically using the data gathered from one Aslak programme (Aslak = occupationally oriented medical rehabilitation) over two years. I described and analysed the construction of Aslak using ethnographic data and interviews. The data includes audio- and video-recordings of the Aslak course, fieldnotes, documents and other materials used in the course. The study aimed to reveal rehabilitation practices from different perspectives carried out by different stakeholders and participants in the Aslak course. It focused on the Aslak trajectory produced by a multiorganizational subject. I analyzed the rehabilitation activity using the method of ethnographic analysis of infrastructure. The method of analyzing the construction of the object of rehabilititation the customer was a membership categorization analysis (MCD) based on the ethnomethodological research tradition. I analyzed the meanings denoting customers given by different parties during one Aslak process and the relations between the meanings. Based on this analysis, I studied the disturbances, ruptures, and innovations in the rehabilitation activity. The results of the study show that the infrastructure of Aslak has different basic ideas. Aslak is constructed most explicitly on the infrastructure of medical rehabilitation. The second layer has been provided with some tools of identifying and preventing well-defined occupation-specific load factors. However, it has failed to perform a new structure, as Aslak has encountered, at the same time, rapid changes in working life. The study identified some promising markers representing new kinds of work-related rehabilitation ideas, but they proved to be incomplete and fragile. As a consequence of the multilayered infrastructure, the contents of the Aslak course were split into fragmented phases and disconnected themes, which were blocked in by the master idea of medical orientation. Its relationship to work remained weak and obscure. The categorizations of customers in Aslak were manifold and contradictory. According to the results, the possibilities for transforming work-related rehabilitation lie both in changing the orientation to the customer to be more relevant to changing working life and forging the infrastructural innovations related to this change. The results showed that a new work-relatedeness would be difficult but possible to construct. What is needed is the construction of an infrastructure that will support a coherent master idea of work-related rehabilitation over the entire trajectory of a process. A shared idea of a rehabilitation object must be constructed in close collaboration between different stakeholders, such as Kela (the Social Insurance Institution of Finland), occupational health services, work organizations, and rehabilitation institutes. Key words: Aslak rehabilitation, work-related rehabilitation, development of rehabilitation, customer of rehabilitation, developmental work research, analysis of infrastructure, membership category analysis

Spinaalistenoosipotilaiden psyykkinen hyvinvointi ennen leikkaushoitoa ja sen jälkeen

Surgical treatment of lumbar spinal stenosis (LSS) is a treatment option for those patients who remain severely symptomatic after a course of conservative treatment. Majority of the patients treated surgically enjoy good-to-excellent outcomes with respect to pain alleviation and functional recovery. However, between 20% and 40% of the patients who have surgery for LSS do not benefit from it. The knowledge of the psychological factors associated with recovery and treatment outcome is still scarce. The aim of this study was to assess LSS patients selected for surgical treatment. Specifically, the study assessed the prevalence of depression (Beck Depression Inventory, BDI) before surgical treatment and three months after the treatment. Also preoperative life satisfaction (four-item Life Satisfaction scale) of the LSS patients was studied. Furthermore, the patients satisfaction with surgery outcome at the three months postoperative stage was studied. One-fifth (20%) of the LSS-patients were found to have depression preoperatively. The patients assessments of the pain intensity or location were not associated with depression. The factors that did associate with depression were subjective disability of everyday living and poor life satisfaction. In addition to this, low sense of coherence and poor life satisfaction were associated with depression in logistic regression models. Significant associations were seen between preoperative depression and postoperative high disability scores, high symptom severity scores and higher pain intensity ratings. The patients with continuous depression (60% of the patients who had preoperative depression) showed less improvement in symptom severity, disability, pain and walking capacity than the patients who did not experience depression at any stage. In those patients who recovered from depression (35% of the patients with preoperative depression), the postoperative improvement was rather similar to the improvement seen in the normal mood group. One-fourth (25%) of the preoperative patients with LSS were found to be dissatisfied with life. The dissatisfied patients were significantly younger and had more self-reported somatic comorbidity. The dissatisfied patients had also elevated subjective disability scores and more extensive pain locations. Also lower coping resources and higher BDI scores were associated with life dissatisfaction. Younger age and somatic comorbidity were associated with life dissatisfaction in regression models. Two-thirds (66%) of the patients were at least clearly satisfied with the surgery outcome at three months postoperative stage. In group comparisons, the lack of physical, functional and emotional well-being was associated with the patients dissatisfaction with the surgery outcome. Younger age, postoperative symptom severity, disability and depression were independently associated with dissatisfaction with the surgery outcome. The results show that depression and psychological well-being are important factors with respect to LSS patients functional ability and recovery both before and three months after surgical treatment. Therefore, the clinical practice recommendations should include an assessment of depression

Paremmin tietäjän paikka ja toisin tietämisen tila : Opettajuus (ja tutkijuus) pedagogisena suhteena

The position of knowing better and the space for knowing otherwise. Pedagogical mode of address in teaching (and in research) This book is a study of teaching, research, and expertise – the position of “knowing better” – as a pedagogical relationship. The focus of the study is empirical research of the classroom practices of four primary school teachers in a Finnish comprehensive school, and the interpretative discussions on those practices between the researcher and the teachers. To know, or knowing, is considered an interactive action: it is different ways of knowing and encounters between the better and the other knowledge. In these encounters, the different pedagogical modes of address construct space for interaction and relationships between the speakers in the space. In teaching and researching one is involved in practices connected to power/knowledge systems and conceptions of the hierarchies of different knowledges. Teaching is considered as a special interactive relationship interrelating knowledge and power through the discourses of the culturally and historically constructed school institution, discourses which operate in the practices and narratives of the teaching, teacher, and the pedagogical dialogue. This study uses the feminist poststructural perspective in which the discursive construction of the subject position is considered as an ambivalent process of subjectification and in which such concepts as marginality and otherness are salient. The pedagogical dialogue of these discursive practices address the learner and learning, and space is constructed for different positions, and for thinking and knowing otherwise. The ethnographic data on everyday pedagogical practices of teachers in the school institution was constructed jointly by the researchr, teachers and pupils durint the empirical study. The analysis and interpretations concentrate on the pedagogical practices in teaching and how teachers talk about them. In other words, how do the teachers enter the culturally and historically constructed, institutional space of the teacher in the classrooms of the comprehensive school, how do they take the position of the teacher and what kind of pedagogical address do they use? And, by taking those positions and using different modes of address, how do they position their pupils in the pedagogical interaction? These pedagogical practices are considered as surrounded and modified by the discourses that can be found in the cultural images of a school teacher, the historical and theoretical narratives about teaching and teachers of the school institution, and in the educational policy texts. The same discourses are also repeated, transformed and intertwined in the practices and narratives of the academic institution. These are considered in the study through the positionings of the researcher in the process of empirical research. The researcher and research are constructed in terms of the production of the power/knowledge dynamics. These dynamics are examined in the construction of the theoretical perspective and in the considerations of the methodology, epistemology and ethics of the study.

Soveltuvuuskokeella täydennetty opiskelijavalinta : Seurantatutkimus eräiden sosiaali- ja terveysalan teknisluonteisten koulutusohjelmien (apuvälinetekniikka, hammastekniikka ja optometria) opiskelijavalinnan toteuttamisesta

Aptitude-based student selection: A study concerning the admission processes of some technically oriented healthcare degree programmes in Finland (Orthotics and Prosthetics, Dental Technology and Optometry). The data studied consisted of conveniencesamples of preadmission information and the results of the admission processes of three technically oriented healthcare degree programmes (Orthotics and Prosthetics, Dental Technology and Optometry) in Finland during the years 1977-1986 and 2003. The number of the subjects tested and interviewed in the first samples was 191, 615 and 606, and in the second 67, 64 and 89, respectively. The questions of the six studies were: I. How were different kinds of preadmission data related to each other? II. Which were the major determinants of the admission decisions? III. Did the graduated students and those who dropped out differ from each other? IV. Was it possible to predict how well students would perform in the programmes? V. How was the student selection executed in the year 2003? VI. Should clinical vs. statistical prediction or both be used? (Some remarks are presented on Meehl's argument: "Always, we might as well face it, the shadow of the statistician hovers in the background; always the actuary will have the final word.") The main results of the study were as follows: Ability tests, dexterity tests and judgements of personality traits (communication skills, initiative, stress tolerance and motivation) provided unique, non-redundant information about the applicants. Available demographic variables did not bias the judgements of personality traits. In all three programme settings, four-factor solutions (personality, reasoning, gender-technical and age-vocational with factor scores) could be extracted by the Maximum Likelihood method with graphical Varimax rotation. The personality factor dominated the final aptitude judgements and very strongly affected the selection decisions. There were no clear differences between graduated students and those who had dropped out in regard to the four factors. In addition, the factor scores did not predict how well the students performed in the programmes. Meehl's argument on the uncertainty of clinical prediction was supported by the results, which on the other hand did not provide any relevant data for rules on statistical prediction. No clear arguments for or against the aptitude-based student selection was presented. However, the structure of the aptitude measures and their impact on the admission process are now better known. The concept of "personal aptitude" is not necessarily included in the values and preferences of those in charge of organizing the schooling. Thus, obviously the most well-founded and cost-effective way to execute student selection is to rely on e.g. the grade point averages of the matriculation examination and/or written entrance exams. This procedure, according to the present study, would result in a student group which has a quite different makeup (60%) from the group selected on the basis of aptitude tests. For the recruiting organizations, instead, "personal aptitude" may be a matter of great importance. The employers, of course, decide on personnel selection. The psychologists, if consulted, are responsible for the proper use of psychological measures.

Käsityksistä ajatuksen poluille : Ammattikorkeakoulun tutkimus- ja kehitystoiminnan kehittäminen

This study deals with the formation of the idea of research and development (r&d) activity at one particular university of applied sciences in Finland. In this study I proceed from examining the conceptions of management regarding r&d-activities to exploring the development of the complex concept that guides these r&d-activities. The aim of this study is, first, to describe conceptions of r&d-activities, and then, second, to describe the formation of a new concept for r&d-activities in one field of study at the university of applied sciences. I used phenomenographic analysis to elucidate the conceptions and collected the data in interviews of personnel (22) who belong to the management of the university of applied sciences. The data for analysing the obstacles faced and the ways of overcoming them during the formation process of the new concept consist of the video-recorded material from ten change laboratory sessions held for the specific field of study at the university of applied sciences. In researching the formation of the concept of the activity, such research and analysis methods are used in which the concept is understood as a material construction, and with the help of which one can work out the formation of the concept during the development process. When the systematic development of the r&d-work was underway, the management of the university of applied sciences held differing views regarding the content, target, factors and organisation of the r&d-activities, as well as regarding the position of dissertations as a part of r&d-activity. Obstacles for developing rd concerned the unclear object and outcomes of the new activity, not having the tools (such as adequate know-how) for the new activity and not having found the necessary solutions for the distribution of work. In addition the rules that quide the activities of the university of applied sciences did not support working according to the new way. To improve r&d-activity, the school’s management defined three development strategies to encourage adequate rd-activity to support working life, regional development and learning. The strategies were based on the expansion of existing methods, such as service activities, dissertation work and the research activities of the teachers. Of the three possible routes, the concept of dissertation in this study was expanded to integrate the services of organisation development and the occupational growth of the students. A group of teachers in the field of social and health studies participated in the development work. The change laboratory method was used as a tool for this work. Analysis of the cognitive trails indicated that, in addition to the cycle of expansive learning activities, microcycles with different purposes can exist. According to Cussins (1992), something already in existence in each microcycle is destabilised, and something else is stabilised to replace it. In this study three microcycles were identified, during which the teachers first destabilised the existing concepts of dissertation work that guided their thinking, and then began to use new concepts to structure their thinking. Secondly, they undermined the existing concepts with material structure that defined their practical work, and developed new practical models to replace them. Thirdly, the problems accumulating in researching and testing the new activities caused the developers to destabilise the r&d-strategies of the university of applied sciences and to define a new conceptual model for r&d-work in the field. During this third cycle, the teachers developed a research arena model, which was a significant expansive innovation. In the cognitive trails developing the new concept for the r&d-activity, the teachers indeed faced the obstacles the management had described as their conceptions. These obstacles manifested themselves as contradictions. During the development process, the nature of the obstacles (i.e. contradictions) changed as the development proceeded. Solving the first and second degree contradictions highlighted the third and fourth degree contradictions. To overcome the obstacles, the teachers had to to articulate the value and motive of the development work throughout the development process. Developing the new concept for r&d-activity required many reconfigurations of practical solutions to overcome the obstacles. Developing the new concept for r&d-activity, both at the level of representations and of new practices, requires universities of applied sciences to adopt new methods in which the actors are partake in construction of new concepts of activity through adequate discussion, analysis and debate. R&d -activity can progress, if instead of implementing partial solutions, the totality of the activities (i.e. the group of partial solutions acting together) will be constructed. The development of the activity system requires many simultaneous changes as well as wide-ranging know-how and discussion related to these changes. What is perhaps most important, however, is that the group of developers mature into a determined collective actor which can engage in many agentive actions. The development of the agency is fundamental to progress.

Vuorovaikutus ääniterapiassa : Keskustelunanalyyttinen tutkimus harjoittelun rakenteesta, terapeutin antamasta palautteesta ja oppimisesta

This conversation analytical study analyses the interactional practices adopted by speech therapists and their clients during their training in voice therapy. This study also describes how learning takes place during the therapy process. In contrast to traditional voice therapy studies, change is examined here by using qualitative research methodology, namely conversation analysis. This study describes the structures of interaction in voice therapy, shows how the shortcomings in the client s performance are evaluated and corrected and finally, how the voice training sequence and the participation changes during therapy. The database consists of 51 videotaped voice therapy sessions from six clients with voice disorders. The analytic focus is on the practices in one voice training exercise of the trilled /r/. All the sequences of this exercise (in total 36) and all adjacency pairs within (N = 627) were transcribed and analysed in detail. This study shows that voice training consists of successive model imitation adjacency pairs. This adjacency pair works as a resource in voice training. Furthermore, the use of this particular adjacency pair is an institutional practice in all therapies in this study. The structure of interaction in voice training sequences resembles the practices found in aphasia therapy and in speech therapy of children, as well as the practices of educational and counselling interaction and physiotherapy. More than half of the adjacency pairs were expanded to three (or more) part structures as client s responses were typically followed by therapist s feedback. With their feedback turns, therapists: 1) maintain training practice, 2) evaluate the problem of client s performance, 3) deliver information, 4) activate the client to observe the performance and 5) assist her in correcting the performance. This study describes the four different ways that therapists help their clients to improve the performance after encountering a problem. The longitudinal data shows that learning in therapy is manifested in the changing participation. As clients learn to identify their voice features, they can participate in evaluating or correcting their performances by themselves. This study describes the recurrent professional practices of voice therapists and shows how the institutional commitments of voice therapy are managed in and through talk and interaction. The study also provides detailed description of the management of help in voice training. By describing the interaction in training sequences, this study expands the conception of voice rehabilitation and how it can be researched. The results demonstrate that the learning process and therapy outcomes can be assessed by analysing interaction in therapy. Moreover, this analysis lays the foundation for a novel understanding of the practices in speech therapy and for the development of speech therapy theory. By revealing the activities of interaction, it also makes it possible to discuss them explicitly with speech therapy students. Key words: voice therapy, conversation analysis, institutional interaction, learning, change in participation, feedback, evaluation, error correction, self-repair

Asiakkaan ja asiantuntijan pedagoginen suhde : Fenomenologinen tutkimus fysioterapiatilanteista asiakkaiden ja fysioterapeuttien kokemana

Väitöskirja on fenomenologinen tutkimus koetusta asiakas-asiantuntijasuhteesta. Tutkimuksen tarkoituksena on selvittää ihmisten välisiä asiakas-asiantuntijatilanteiden suhteita ja siten mahdollistaa asiakkaan hyvinvointia. Tutkimuskohteena on fysioterapiasuhde, jota aiemmin on selvitetty fysioterapeutin parantamisena, asiakkaan terveyden edistämisenä tai vuorovaikutussuhteena. Tässä tutkimuksessa mielenkiinto kohdistuu fysioterapiatilanteissa koettuihin asiakkaiden ja asiantuntijoiden välisiin suhteisiin. Tutkimukseen osallistuivat 16 fysioterapiatilanteen kokenutta asiakasta ja 16 saman tilanteen kokenutta fysioterapeuttia, jotka toimivat tutkimusajankohtana erikoissairaanhoidossa, kunnan terveyskeskuksessa tai yksityisessä fysioterapialaitoksessa. Avoimen yksilöhaastattelun tehtävänä oli kuvata mitä osanottaja koki juuri päättyneessä tilanteessa. Tutkimusaineiston analyysi etenee ensimmäisessä vaiheessa fenomenologisen tutkimuksen mukaan, yksilöllisten ihmisten välisten suhteiden koettujen merkitysten ja merkityskokonaisuuksien analyysiin ja merkitysperspektiivin synteesiin. Tutkimuksen ensimmäisen vaiheen yksilöllisten merkitysperspektiivien perusteella fysioterapiasuhde osoittautui muutossuhteeksi, mikä ei ollut erilainen eri organisaatioissa, vaan siinä ilmeni pedagogisen suhteen oppimisen ja ohjauksen piirteitä. Tutkimuksen toisessa vaiheessa vietiin pedagogisen suhteen mukaisesti yhteen ja vertailtiin yksilöllisten merkitysperspektiivien merkityksiä ja merkityskokonaisuuksia asiakkaiden ja fysioterapian asiantuntijoiden näkökulmina sekä saman tilanteen yhteisenä koettuna näkökulmana. Asiakkaiden näkökulmasta suhteen voimavarana oli hänen kokema kehollinen vieraus, mikä ohjasi asiakas-asiantuntijasuhdetta neljänlaiseen asiakkaan muutossuhteeseen. Fysioterapian asiantuntijoiden näkökulmasta asiaosaamisena oli asiakkaan parantaminen liikkeen tai toiminnan avulla, mikä ohjasi asiakas-asiantuntijasuhdetta asiantuntijan näkökulmasta erilaisiin ohjaussuhteisiin. Samassa tilanteessa asiakkaiden ja asiantuntijan yhteisenä kokemat aukeamat etenivät spontaaneista turvallisuuden ja luottavaisuuden aukeamista aktiivisiin yhteisymmärryksen ja yhteissanoituksen aukeamiin. Pedagoginen suhde avautui merkityskokonaisuuksina joko vain asiakkaalle tai asiantuntijalle tai yhteisenä koettuina pedagogisina aukeamina. Edellä mainituista kolmesta (asiakkaan, asiantuntijan, yhteisenä koettu) näkökulmasta asiakas-asiantuntijasuhde osoittautui tässä tutkimuksessa neljäksi erilaiseksi asiakkaan, asiantuntijan ja yhteytenä koetun näkökulmia yhdistäväksi pedagogiseksi prosessiksi. Tutkimuksen tulosten synteesi osoitti, että pedagogisen prosessin suuntaa muuttavat yhteytenä koettujen aukeamien väliset dialogit, joissa spontaani, yhdessä näkyvä ja yhdessä koettua sanoittava dialogihetket osoittautuivat pedagogista prosessia kääntäviksi mahdollisuuksiksi. Tämän tutkimuksen mukaan vasta aktiivinen yhteistä kieltä tuottava pedagoginen suhde mahdollistaa asiakkaan kokeman kehollisen vierauden ymmärtämisen ja yhteissanoittamisen. Sanoittamalla kokemaansa asiakas voi jakaa kokemaansa toimimattomuutta tutulla kielellä myös muiden kun tilanteessa olleiden kanssa ja siten oppia itsenäisesti ohjaamaan omaa hyvinvointiaan. Tämän tutkimusten tulosten mukaan vain yhdessä (Pentin ja Sarin) tilanteessa pedagoginen prosessi eteni yhteiseksi kieleksi. Tutkimustulokset haastavat kehittämään asiakas-asiantuntijasuhdetta siten, että pedagoginen prosessi voisi toteutua kokonaisuudessaan. Avainsanat: asiakas-asiantuntijasuhde, pedagoginen suhde, fenomenologia, kokemus, merkitysanalyysi, dialogi, fysioterapia