Yolŋu  co-researchers from remote Northern Territory , the concept of ganma  was foundational for understanding and applying relationality (gurrutu), deep listening , and the use of metaphors—approaches that strengthen productive dialogue, described by Yolŋu co-researchers as weaving a ‘mat we can all sit on’. The research results are reported in a subsequent article.Research remains a site of struggle for First Nations peoples globally. Biomedical research often reinforces existing power structures, perpetuating ongoing colonisation by dominating research priorities, resource allocation, policies, and services. Addressing systemic health inequities requires decolonising methodologies to facilitate new understandings and approaches. These methodologies promote a creative tension and productive intercultural dialogue between First Nations and Western epistemologies. Concurrently, the potential of critical theory, social science, and community participatory action research approaches to effectively prioritise First Nations peoples’ lived experience within the biomedical worldview is increasingly recognised. This article describes learnings regarding research methods that enable a better understanding of the lived experience of rheumatic heart disease—an intractable, potent marker of health inequity for First Nations Australians, requiring long-term engagement in the troubled intersection between Indigenist and biomedical worldviews. Working with  Research remains a site of struggle over knowledge claims and power for First Nations see  people gBox 1Terminology regarding identity is varied and complex. We use the term ‘First Na-tions’ where we discuss international concepts and reflecting an international readership (except where we retain the terms preferred by cited authors). Aborig-inal and Torres Strait islander peoples are the ‘First Nations’ of Australia. In this paper, we use the term Aboriginal when describing the communities, co-researchers, and participants in this study. No disrespect is intended to Torres Strait Islander peoples or the diverse cultures, histories, and languages of other First Nations Australians. Yolŋu-speaking Aboriginal co-researchers used the term Yolŋu to refer to all Aboriginal people, and, where appropriate, we have retained this. Balanda is the Yolŋu term for non-Aboriginal people. Such traditional positivistic or medicalised approaches reinforce existing dominant structures of power and control, thereby perpetuating the ongoing impacts of colonisation, shaping research priorities, resources allocation, policies, and models of care ,4. CritiConcurrently, despite the depth, longevity , and legAddressing the systemic injustices that underpin inequities in First Nations peoples’ health requires new knowledges and understandings based on decolonising methodologies and a critical understanding of power dynamics. Decolonising methodologies that de-centre Western epistemologies seek to privilege the concerns, practices, and participation of First Nations people as researchers . Rather More than just a ‘middle ground’, the idea of productive dialogue can be traced to ancient Greek, Native American, and other Indigenous cultures, as a unique kind of conversation that features people listening deeply to each other, ‘deepening connectedness, building trust, and a willingness to disclose’ . It alsoIn parallel with developments at the cultural interface, the potential of sociology, medical anthropology, and community participatory action research (CPAR) approaches to effectively mitigate the impacts of colonisation through better integrating patient lived experience into the biomedical worldview is increasingly recognised . Such deRheumatic heart disease (RHD) is a potent marker of health inequity for Aboriginal and Torres Strait Islander Australians . Despite the extensive medical, research, and policy initiatives to address the high rates of RHD experienced by Aboriginal Australians compared with non-Aboriginal Australians, there has been minimal sustained reduction ,29. The Findings from projects interviewing RHD key stakeholders ,31 identThe publications that sought to identify barriers to adherence expressed a commonly reinforced view that noncompliance was a failure of families to provide care, with perceived parental confusion attributed to a direct shortcoming of responsibility . Such reIn this way RHD research provides a powerful example where ‘the language of non-compliance is bound up with medical authority and control’ , p. 16),6,1,36], The research described here took place with the Yolŋu people in the north-eastern tip of Arnhem Land, Northern Territory. Settled in 1972, Yilpara is the largest homeland community in the region, but still a very small community of approximately 100 people see . As partYilpara was featured as a case study of self-determination by anthropologists Frances Morphy and Howard Morphy . Francesganma was shared by Yolngu leaders in the early 1990s to provide a place-based model of productive dialogue [Ganma describes the mixing of salt water from the sea and fresh creek waters; it not only refers to brackish water but also to where two or more ideas, stories, or peoples are intermingled in an unconditional way. Developing and implementing ganma as a research process was described early on as an act of self-determination, just as the Balanda research has always taken a side but never revealed this, always claiming to be neutral and objective. My aim in ganma is to help, to change, to shift the balance of power . For the purposes of this article, productive dialogue, ganma and both-way learning are considered synonymous.). As a productive dialogue metaphor gether’ rocesses ,51. YolŋWe report here on experiential learnings from developing and implementing research approaches and tools (methodologies and methods) in a project that sought to better understand the lived experience of RHD. The research was undertaken in collaboration with Yolŋu co-researchers from remote Northern Territory. Through a commitment to both-way learning, we created a space of productive dialogue together, described by Yolŋu co-researcher Makungun Marika as weaving a ‘mat we can all sit on’. A companion article published in this edition of the journal provides the research findings that resulted from applying these learnings . While attempting to address the limitations of traditional positivistic and medical approaches non-Indigenous qualitative researchers are equally at risk of being constrained by disciplinary knowledges and shaped by ‘imperial legacies; ongoing settler colonial relationships; unequal class, race, and gender divisions; and an increasingly corporatised university culture’ Acknowledging these critiques, the intention to work in the intercultural space on the topic of RHD was combined with a desire to extend standardised Western qualitative research methods to reflect a decolonising stance and privilege Aboriginal ways of knowing being and doing within the research activities. Adopting a decolonising stance, we deliberately employed two strategies to widen the space of both-way learning—reflexivity  and building relationships and trust with Yolŋu co-researchers.Reflexivity requires researchers to reflect critically on how their worldview  influences the broad range of perspectives, activities, and outcomes that make up research processes. This is critical in establishing the rigor and trustworthiness of qualitative research . ThroughPrior to commencing the project described here, building on existing relationships initially formed by co-author AM, the first author (EH) was invited to live in Yilpara for 12 months to co-ordinate a CPAR project . ConcurrEthics approval was obtained from the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research. Approval number HREC 2016-2678. Reciprocal approval by UWA Human Research Ethics Office, Ref: ROAP 2020/ET000283. The following approvals were obtained prior to commencing the research: Ochre card (NT Working with Children); Northern Land Council (permit to reside in a homeland); and written approval from the Aboriginal elders of the community and the local Health Ser-vice.nhina, nhäma ga ŋäma ; and metaphors as basis for critical and conceptual thinking. As with ganma, these concepts were widely used and accepted traditional Yolŋu ways of knowing, being, and doing, existing prior to any discussion of research. Through critical reflection and immersive, experiential learning, we identified how Western research methods could be aligned to Yolŋu concepts and applied in a research context. That is, as Marriot et al. [We report here on three Yolŋu concepts that can be applied as research approaches (both methodologies and methods): Relationality; t et al.  recomment et al. , p. 2). t et al. , p. 5).Aileen Moreton-Robinson, in her review of the First Nations social research methods of Canada, the United States, Hawaii, Australia, and New Zealand, concluded that in different but similar ways Aboriginal ‘knowledge systems are grounded in relations to land, place, entities, ancestors, creators and people’. From this foundation she identifies the concept of ‘relationality’ as the ‘interpretive and epistemic scaffolding shaping and supporting Aboriginal social research’ .Morton-Robinson identifies a variety of relationships to be considered, such as those between the Aboriginal researcher and the Aboriginal community; the Aboriginal community and the researcher; the Aboriginal researcher and the Aboriginal academic community; non-Aboriginal researchers and the Aboriginal community; and between the academic community and Aboriginal methodologies .gurrutu. Through their gurrutu connections and their local residence, Yolŋu people ‘know the country and are known by it, they speak the language and their sweat is familiar’ ‘understood not only as an individual personality but also having obligations and rights on a matrix of kinship and clan relations that constantly and concretely signal the connection and locatedness of everyone in the highly differentiated social whole’.mälk (skin group), or place you are from . This is an ahistorical view—ancestors are contemporaneously present, felt, and taken into account. Working out how you fit into this matrix is essential; when it is not clear how someone is related to you, much time is spent figuring it out and a ‘placeholder’ relationship might be assigned based on your totem, Gurrutu dictates that there are both people and places that are right to sit with (on) and those that are not. Gurrutu also determines the dances you can dance and the designs you can paint (what knowledges you are authorised to know) [Gurrutu is foundational to learning, determining what knowledges can be taught, by whom and to whom, and when and in what formats . to know) ,60. Gurrgurrutu allows an ever-increasing circle of connections to be established. That is, connections within a small family group can quickly be extended to others. Relationships with Yolŋu community researchers was the core of the lived experience of RHD research as they guided learning about Yolŋu ways of knowing, being, and doing. A strong foundation in gurrutu enabled the development of relationships with the community members who became thesis co-researchers, and the broader Yilpara community who acted as a de facto reference group for the research. Trusting relationships meant being confident to share significant life world experiences—for example, weeks of bäpurru  and dhapi (initiation) ceremonies and Balanda conferences were equally challenging both-way learning experiences and highly emotional times of bonding and learning. Significantly, in a concurrent project related to developing community research skills, as gurrutu informs correct behaviour it was therefore quickly equated by the Yolŋu with research ethics. For an outsider, the iterative process of learning about The capacity for empathy is often seen as an essential characteristic of a good qualitative researcher, related to both the quality of the research and the motivations for undertaking particular research topics. Thus, relationality is discussed here in terms of alignment with aspects of interviewing (yarning), thematic analysis and CPAR.The concept of ‘yarning’ is a common feature of oral traditions for knowledge sharing, a form of conversation which utilises storying to impart information. Yarning, in this context, does not mean ‘just chatting about nothing of much importance’, as is implied in general Western uses of the term. It is a recognised technique used by Aboriginal Australians to connect, make meaning, and pass on knowledge and history, socially or more formally . Yarningan informal and relaxed discussion through which both the researcher and participant journey together visiting places and topics of interest relevant to the research study. Yarning is a process that requires the researcher to develop and build a relationship that is accountable to Aboriginal people participating in the research … To have a yarn is not a one-way process but a dialogical process that is reciprocal and mutual.The strength of yarning is its capacity for relational meaning-making, thus broadening the space of productive dialogue. The key elements of dialogue, storytelling, and use of metaphor allow the negotiation of identities, roles, and relationships, rather than just conveying information—that is, yarning encourages empathy .gurrutu who passed away from heart failure complications during the research period. It was these relationships, as well as their love for the community more broadly, that were frequently emphasised by the Yolŋu as the reason for working on the project. Alongside participant observation (see next section) the lived experience of RHD research was based on yarns, many that were lengthy, detailed, and from the heart, involving participants who strongly felt they had a story to tell and were appreciative of the opportunity to share their experience to help others. In common with participation in CPAR, where the research process is collaborative and negotiated with participants , relatioLater, as we read through or listened to the yarns (which the co-researchers had sometimes been involved in conducting) and discussed what they thought were the important ideas, the value of their ‘insider’ knowledge quickly became evident. This was not just cultural knowledge but also their own personal or family experiences of RHD. As a consequence of this understanding of, and immersion in, the lived experience of RHD and a world view that prioritises family/community, the Yolŋu were quick to arrive at themes, the connecting narrative, and also identifying conclusions and recommendations. This rapidity can potentially challenge a non-Aboriginal research expectation of ‘rigour’ that has a tendency to a pedantic and positivist scientific mind set about getting every detail and nuance of words coded, rather than accepting the immediate bigger picture thinking of the Yolŋu. nhina, nhäma ga ŋäma’ is literally translated as meaning to sit with, observe and listen  to get a sense of the depth of meaning inherent in this phrase.). The broader concept refers to a way of learning, a way of being, and way of healing. It can be passive or active—a meditation, or a basis for dialogue or relationship. Nhina, nhäma ga ŋäma suggests a full understanding that occurs quietly and respectfully when one is in the right place, watching, and listening. It also implies waiting for a story to come to the hearer—we listen and observe and, if we are lucky, we learn something. For a non-Aboriginal researcher, it provides an essential guide for a way we can come to understand ourselves, others, and our world through feelings. Each component term holds great depth of meaning. Combined, Nhäma and Ŋäma ‘express extraordinary empathy, to the point that one can almost “become” the sufferer and feel what they are feeling “from within”’ ithin”’ Nhina, nhäma ga ŋäma has not been documented as an Aboriginal research method. Building on the concept of dadirri, initially articulated in English by Miriam Rose Ungunmerr-Baumann (2002), a respected elder and artist from the Daly River region of the NT, it is increasingly referenced as a method of deep listening for action [dadirri as a starting point ‘expands the researcher’s worldview and opens our ears to other Aboriginal epistemologies and how we might engage with them in respectful and ethical ways’ , empathy and observation . Until now, -Baumann 002, a rer action ,66. Takinhina, nhäma ga ŋäma is illustrated in the telling of stories to pass on knowledge in a way that allows the hearer to draw their own conclusions. For example, traditional stories, often referred to as dreaming stories are frequently told in different ways and contexts with different parts of the story told relevant to the ‘lesson’. Other than this selective telling, it is up to the hearer to understand the intended learning, encouraging reflection. In this context, the hearer is not expected or encouraged to ask questions, as Tyson Yunkaporta describes: As a form of learning, the concept of In our world the deepest knowledge is not in words. It is in the meaning behind the words, in the spaces between them, in gestures or looks, inmeaningful silences, in the work of hands, in learning from journeys, in quiet reflection, in the Dreaming.Nhina, nhäma ga ŋäma can also be applied as a form of reflexivity, as one reflects on, listens to, and observes the self.Thus, the concept also embodies the sense of critical thinking as a person fosters their observational and analytical skills, without reliance on open questioning , and is a highly valued capacity within the Yolŋu worldview. Nhina, nhäma ga ŋäma can be broadly applied as both methodology and method. It can be understood as closely aligned to the Western academic concept of participant observation, it can be a stance adopted in the yarning process to facilitate empathy and listening, and it can be applied to data analysis as participants’ emotions and meanings are carefully attended to. Combined with yarning it contributes to a rigorous multi-layered ethnographic methodology. Even to learn about nhina, nhäma ga ŋäma requires taking an experiential and reflective approach, described by MM as ‘close your eyes and the answer will come to you’ .nhina, nhäma ga ŋäma as a research method goes beyond listening/understanding the speech of the person with whom you are communicating, to being aware of their true (deep) feelings. ‘Putting interest in other person, do it with respect, you can feel while you listen, you can feel something. The feeling tells you when you listen’ (Yolŋu co-researcher). It also requires the researcher to have self-awareness: ‘If you have no feelings then you can’t tell the feelings of the other person. Or you can’t feel other people when they’re telling stories’ (Yolŋu co-researcher). Self-awareness and reflexivity are also required when listening with an open heart. Thus, researchers operate in a culturally appropriate manner by asking few/no questions, instead observing and reflecting on the possible feelings embodied in the actions and conversations being observed, thus building empathy/rapport. In essence, nhina, nhäma ga ŋäma in terms of understanding feelings. In this way, the Yolŋu identified that research rigour, a sense of having strong generalisable evidence, is based on stories that ‘come out from the heart as well as the mind’ . That is, one will know when one has the ‘true story’ by how it feels, a notion explored with Dr Lawurrpa Maypilyama, a senior Yolŋu woman and experienced researcher from Galiwin’ku. She described it thus: The Yolŋu co-researchers were not familiar with the term empathy, but through the research it became clear this is conceptually closely aligned to the role of ‘People want to share their stories, the deep meaning … a true story has to be strong, the listener can feel when it’s the truth’. ‘Yolŋu tell a story not by head but by heart–if I tell you from the head you won’t feel anything. But if I have excitement, expression, you can tell it is a true story.‘and it is about sacrifice ... You have to put yourself aside to really sit quietly and listen, and then knowledge will come to you’ . This suggestion is a potential source of tension between an emphasis in Western qualitative research on interview data that prioritises the authority of words as evidence. Whereas for the Yolŋu true knowledge is about feelings as a result of listening and watching The important place of metaphor in Aboriginal knowledge systems is widely recognised ,68, partConcern that a non-Aboriginal lens might reduce metaphors to figures of speech has led others to suggest using terms such as ‘images’ or ‘symbols’, as these ‘must be experienced in order to be understood, and the experience of its effects is at once its meaning and its power’ . Permission was gained from community elders for the use of the cultural knowledge contained in these. While these examples provide evidence of a process, the content should not be assumed to be transferable to other settings.lipa lipa (canoe) was found to be a good both-way learning bridge to align Yolŋu ways of observing and analysing data (signs) from their environment with Western research terms. In doing so we came to define research conceptually as looking and thinking deeply, as in guiding the direction of the lipa lipa, the leader (researcher) must look at more than just the surface of the water, looking up to consider factors such as wind direction and below the surface to identify currents and hidden dangers. Central to the development of this metaphor were many long conversations about the link between research as critical thinking and asking the right questions, with a definite sense from the Yolŋu that the research question should be practical and change-oriented. Critical thinking and asking the right question about how things might be different is inherently transformative, demonstrating the empowering effects of developing research skills. The first important and ongoing metaphor was developed at the start of a community-based action research project where the skills developed through the project were aligned with a Certificate II in Community Health Research . At the Later a cohort of community members doing the Certificate II developed further research skills through their involvement in the lived experience of RHD PhD research project. In the course of analysing the yarns, a weaving metaphor for research was developed, initially for a both-way understanding of what thematic analysis and coding meant. This important metaphor stood the test of being retold and added to many times, including with other more experienced Yolŋu researchers from Galiwinku. We argue that it is naïve to think that applying First Nations knowledge practices ‘necessarily divorces the researcher from the colonised and hegemonic space of Western research philosophies’ .nhina, nhäma ga ŋäma, and metaphors as basis for critical/conceptual thinking, demonstrate that First Nations and mainstream research methodologies are not mutually exclusive and can be used effectively to complement and support each other. There are, however, challenges and tensions in this.The learnings reported here from the Yolŋu regarding relationality, nhina, nhäma ga ŋäma, enabling dialogue across two very different linguistic and cultural backgrounds and life worlds. Dialogues included an equal valuing of everyone’s contribution, paying attention to relationships, accepting philosophical discomfort, and thinking critically about power dynamics, all contributing to writing with a transformative purpose. Central to dialogue is attention to difference; it is only when the productive potential of difference is emphasised that the actual work of collaboration is achieved. In terms of approaches to research, the Yolŋu have insider knowledge that is personal, familial, and cultural. This goes beyond empathy. It reflects that the cohering idea of an Aboriginal worldview is the interconnection of everything, therefore Aboriginal research is always holistic. Even ideas are taken to be animate [Each researcher in the project described here needed to hold the stance of  animate  and inte animate . As descThere were many other varied differences that prompted reflection and dialogue–language (including speaking many languages), education type, experiences of Australian government policies and colonisation, beliefs regarding health and wellbeing, degree of connection to country and family, exposure to environmental health risks, and capacity to perceive the world holistically. In addition, beyond the differences within the group of Aboriginal and non-Aboriginal social science researchers, we were aware of the need to bridge the divide between the lived experiences of the Yolŋu with RHD and the biomedical worldview. Enabling clinicians to regard Yolŋu ways of knowing being and doing with equal value, despite its unfamiliarity, and to build their confidence in working in a new way was our hope for better provision of healthcare for Aboriginal people. This requires an appreciation of a worldview that prioritises relationships, empathy, critical thinking, and the well-being of others . Not previously heard in the RHD domain, the findings from the research based in the methods described here reveal fundamental differences between Aboriginal and biomedical worldviews contributing to the failure of current approaches to communicating health messages. The themes identified by the Yolŋu co-researchers (for details see ) affirmehttps://www.rhdaustralia.org.au/champions4change, accessed on 8 March 2022) and new projects that provide opportunities for building capacity with First Nations co-researchers.As described in the last stage of the weaving metaphor , the YolThese practical outcomes are encouraging as they reflect that First Nations and Western research methodologies were effectively combined to complement and support each other through a process of respectfully acknowledging and merging different knowledge systems. However, on their own, these are small steps; radical funding and policy shifts are needed to upscale and embed approaches that prioritise place-based First Nations leadership and governance, funding for primordial prevention, community development, and environmental health on a par with biomedical research such as that for vaccine development.First Nations Community Research Capacity Building To allow for future projects we propose a both-way learning model  in orderThrough the research collaborations described above, co-researchers had opportunities to disrupt colonial narratives and create new possibilities to transform, policies, practice, and systems . By broaThis paper has described how a suitable methodology was developed to undertake meaningful research into the lived experience of RHD. Our companion paper  describe


The original article has been corrected.The article: “Implementation of strategies to prevent and treat postoperative delirium in the post-anesthesia caring unit”, written by Thomas Saller, Klaus F. Hofmann-Kiefer, Isabel Saller, Bernhard Zwissler and Vera von Dossow, was originally published electronically on the publisher’s internet portal on 9 May 2020 without open access. With the author(s)’ decision to opt for Open Choice the copyright of the article changed on 19 October 2021 to ©The Author(s) 2021 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit


To investigate women’s experiences of having a birth assisted by the Odon Device  and participation in intrapartum research.Qualitative semistructured interviews and observations undertaken in the context of case study work embedded in the ASSIST feasibility study.A tertiary referral National Health Service (NHS) maternity unit in the Southwest of England, between 8 October 2018 and 26 January 2019.Eight women, four operators and 11 midwives participated with eight observations of the assisted vaginal birth, eight interviews with women in the postnatal period, 39 interviews/reflections with operators and 19 interviews with midwives. Women in the case study research were recruited from participants in the main ASSIST Study.The Odon Device, an innovative device for assisted vaginal birth.Thirty-nine case studies were undertaken. Triangulation of data sources  enabled the exploration of women’s experiences of the Odon Device and recruitment in the intrapartum trial. Experiences were overwhelmingly positive. Women were motivated to take part by a wish for a kinder birth, and because they perceived both the recruitment and research processes (including observation) to be highly acceptable, regardless of whether the Odon-assisted birth was successful or not.Interviews and observations from multiple stakeholders enabled insight into women’s experiences of an innovative device for assisted vaginal birth. Applying these qualitative methods more broadly may illuminate perspectives of key stakeholders in future intrapartum intervention research and beyond.ISRCTN10203171; ASSIST Study registration; https://doi.org/10.1186/ISRCTN10203171. We used qualitative methodology to assess the experiences of women undergoing attempted assisted vaginal birth using the Odon Device as part of a clinical trial.We obtained observation and interview data from women, operators and midwives to capture a broad range of experiences.Our sample sizes were appropriate to provide initial insights; however, they may be limited in capturing the full nuance of opinions and attitudes.Globally, 140 million babies are born each year, with an estimated 2.6 million stillbirths (50% related to intrapartum complications),7AVB is associated with better maternal and neonatal outcomes than Caesarean section at full dilatation, when performed by a skilled operator in an appropriate setting.8AVB is almost always performed in an emergency setting, limiting time for information provision.The consequences of a poorly performed AVB can be devastating and long lasting for mother, baby and operator. Comprehensive training, appropriate supervision and support can drastically improve outcomes and patient and operator experience.13–16Despite recognition of AVB as a life-saving intervention, there have been no significant developments in AVB devices since the 1950s when the ventouse/suction cup was introduced.22A core component in any evaluation of a novel device for AVB is the investigation of women’s experiences. Qualitative case study methodology has previously been employed in maternity settings,27This study investigated women’s experiences of the Odon Device and participation in intrapartum research through exploring women’s and health professional views and combining them with observations collected as part of a broader case study investigation embedded within a single arm feasibility study of the Odon Device for clinically indicated AVB—the ASSIST Study.22 28Qualitative case study methodology enables systematic study of phenomena across cases, enabling identification of similarities and differences and resulting in detailed, contextualised insights. The case does not have to be a person but could be an event, decision, action or object.The study was undertaken in a large tertiary referral National Health Service (NHS) hospital in the Southwest of England with approximately 6000 births per year. It has an alongside NICU that accepts babies from across the region. The Maternity Department supports women, with extensive options for birthplace including: homebirth, midwife-led independent birth unit, alongside midwifery unit and an obstetric-led birth unit for high-risk cases. Approximately, 11% of all births in the maternity unit were AVBs. These were all conducted on the obstetric-led birth unit by an obstetrician with the support of a midwife.Women were eligible to take part in ASSIST if they were: aged 18 years or older, may require an AVB with a live, singleton pregnancy with negative antenatal screening to blood-bourne viruses.28Typical sampling, a form of purposive sampling appropriate for case study methodology, was used to include a range of indications for AVB and a range of operators allowing for the understanding of multiple perspectives across a range of variables and for results to be more transferable.30 31Patient and public involvement (PPI) was undertaken for all aspects of the ASSIST Study.The case study investigation included data from one or more of the following sources for each case: participant observation of the attempted Odon-assisted delivery and interviews with women, operators and midwives. Conducting case studies in the clinical context of device use, with triangulation of data from different sources, generates greater depth of insight through the process of data triangulation, than would be available using other approaches such as serial interviews with women and operators.32Participant observations commenced when the obstetrician entered the woman’s room to conduct the AVB and ended when the obstetrician left the room following the birth of the baby. The researcher was a clinical obstetrician and part of the ASSIST Study Team (EJH). Contextual factors, verbal and non-verbal communication were documented on an observation schedule. The observation schedule was developed during preparatory work, prior to the commencement of the ASSIST Study . Observa10.1136/bmjopen-2021-057023.supp1Supplementary data10.1136/bmjopen-2021-057023.supp2Supplementary dataTranscripts were created from the participant observations made during the birth. All thoughts and interpretations of the researcher were noted, often aiding the creation of specific interview questions. Any issues that required clarification from participants were highlighted during the transcription process for further discussion in subsequent interviews. Findings were successively tested and refined by the researcher as additional transcripts were analysed and explored in the interviews with participants.Data collection and analysis ran iteratively and in parallel.All case study research, PPI, piloting, data collection and analysis were undertaken by a medically qualified obstetrics and gynaecology trainee, Odon Device trainer and Odon Device operator for the ASSIST Study (EJH). The use of the Odon Device to assist birth is highly complex and often takes only minutes to perform; without an in-depth knowledge of the device, its instructions for use and AVB, subtle differences or anomalies in its use may have overlooked during data collection by a non-clinical professional. It is possible that preconceived ideas and suppositions were brought to the study given the researcher’s specialist clinical background. To maintain rigour, reflexive comments were made after each data collection event (observation or interview) and during data analysis. These were discussed with an experienced independent non-clinical qualitative researcher (JW).Presented here is the combination of observational and interview data relevant to women’s experiences of the attempted Odon-assisted delivery and participation in the intrapartum study. Other data relating to optimising use of the device by operators have been analysed separately and will be published separately.The 39 case studies conducted of attempted Odon-assisted births, included eight observations, eight interviews with women observed, 19 midwife interviews, 37 operator interviews and two operator reflections. Demographics and characteristics of the women included are presented in Observations varied in length from 33 min to 68 min. Interviews with women lasted between 7 and 10 min, interviews with midwives lasted between 3 and 13 min and interviews with operators lasted between 5 min and 26 min.A summary of the themes relating to the women’s experiences is presented in All eight women interviewed gave very similar reasons for agreeing to participate in the ASSIST Study and have the Odon Device used to assist the birth of their baby. Women’s experiences were predominantly positive even where Odon use had not succeeded.Half the women interviewed (n=4) stated a specific aversion towards forceps-assisted birth as an important factor in their decision-making. Midwives shared the antipathy for forceps and the wish for an alternative device and an AVB that women would welcome. Aversion towards forceps was linked to previous negative experiences of friends or family:W04: And also the forceps, to me, looked like a torture weapon, so I was keen to give something else a go.W01: I don’t have a lot of experience of it, but I know my nephew had forceps and was very bruised and marked.Women and midwives articulated similar views, the lay belief that forceps are more ‘traumatic’ either physically or emotionally:M14: …but it definitely didn't look quite as traumatic as a forceps delivery… But I do feel like, for her, it was a nicer experience than it might have been for a forceps. I don't know if it’s the word 'forceps' that traumatises ladies, but everyone seems to be terrified of them.Midwives perceived that the Odon Device was kinder than other devices and described the births as ‘softer’, ‘nicer’, ‘beautiful’, ‘easy’, ‘smooth’ and ‘gentle’:M18: The device use and the delivery was actually kind of one of the most beautiful deliveries of an assisted device used that I’ve seen.This belief was also reinforced by observations from women, midwives and operators, which babies successfully delivered with the Odon Device had minimal scalp or face injury following birth. The reduction in visual marks on the baby seemed to have a big impact on the overall perception of the birth:M20: These babies are coming out with no marks on them, it’s fab. I think it’s stunning. It’s absolutely really good.W07: Over the moon. The fact that it has helped with his delivery, the fact that he’s safe, there’s no marks on him whatsoever, he’s completely fine, and he’s just a happy baby. So, that’s all I could ever ask for really.Observations highlighted that all staff members present at time of birth, both clinical and research, strove to ensure that the birth experience was positive for women, perhaps more so than in usual clinical practice. Environmental factors seemed to stand out as creating a calm birthing experience:O01: Low lighting in the room, not main lights but two spotlights providing the light to the operator only. Music on in the background was on already prior to entering the room. It was a very calm and quiet environment.Team members perceived that birth experience was more positive for women who were felt to have really wanted a birth assisted by the Odon Device:M11: And then at that point she said, “Oh, come on doctor,” she said something like, “I’ve got faith in you, you can do it.” So, she [the patient] really, really wanted him [the operator] to do it. And then she [the patient] said, “But if this doesn’t work, I don’t want forceps because of the baby’s face; I’d rather have a section.”The level of engagement of women and their birth partners with the Odon Device surprised the operators:D02: … the husband was leaning over her leg and watching exactly what I was doing and was commentating as I was applying the device… So, when I got to four, he was like, “It’s on four, it’s on four, it’s nearly there, nearly there.” I wasn’t quite sure whether he was encouraging his wife or encouraging me, but it made me smile.Initial generalised altruism regarding research participation was overtaken by genuine engagement and specific interest in the study:W01: I’m quite cynical and I was like, “I’m not going to hear about this again. I just have to say yes to this.” Then I read about it and actually I did find it quite interesting, so I was more than happy to sign up to it.Several women stated their surprise when they needed an AVB having assumed during the consenting process that they would not require an assisted birth.”W06: It’s such a low percentage, isn’t it, probability-wise. So, you just, kind of, almost think, “Well, it probably won’t come to this. So, might as well [consent].Women expected and presumed that there would be observations of device use in the ASSIST Study. They appreciated it was important to observe the device in real-life settings and to learn from its use:W02: You’re not going to know any different. It’s easy saying, “simulations, we’ll do these,” but until it’s gone into practice on a real baby…You need to observe to see how it works…Or how can you, maybe, if something went wrong, fix it. How are you ever going to learn if anything…When asked about the possibility of videoing the AVB instead of having a formal observation by a researcher, views from women were very mixed. For some it was acceptable, providing there was anonymity and that it was used for training, one stated ‘no’.Women valued various aspect of the recruitment process, including provision of information through multimedia format, the manner of the recruiter, timing of when they were approached and treating consent as a process and not a single event, so checking consent multiple times.The provision of the information video allowed women to visualise and understand how the Odon Device works. They already knew what was going to happen at the time of assisted birth:W02: …we watched the video. That’s what, I think, made us say yes, I suppose, the video. Just, it’s quite a good little demo on the video that makes you think…Women preferred this innovative multimedia approach rather than reading the information leaflets:W04: A leaflet you tend not to read it, do you? And a presentation is dull. So yes, I quite liked the video.They appreciated the opportunity to see the team and operators in the participant video.The way recruitment was delivered by the research team was also of the upmost important to women. The women described how the manner of checking consent and regular interactions with the research team increased the trust in them:W06: The woman that came round, she had the right approach. You don’t want to be too pushy or whatever, and you need to, yes, have tact with people, and she was fine. She was good.Research follow-up was experienced as supportive for the women:W07: Even after delivery, just coming in to check and see that everyone’s alright, honestly, I didn’t find any faults.For the women interviewed, birth experiences were not affected by whether the Odon Device was successful or not or the number of healthcare professionals present at the time of birth.W02: I know, obviously, it wasn’t successful, but it’s not going to be successful every single time. Everyone’s situations are different (unsuccessful Odon birth).Interestingly, women focused on outcomes for their baby and their feelings at the time of birth rather than their own pregnancy outcomes or birth complications when discussing their experiences.Women could feel overwhelmed at the time of needing an AVB:O06: At the time of needing an AVB, she was losing the plot and scared, she said “help me” “I cannot do this” (successful Odon birth).Despite this women reported feeling cared for and the situation felt routine. When asked about their birth experience, women reflected on the feeling they had during the birth of their baby:W07: But the device and that, I didn't even make… I know, obviously, it’s a big thing, but I didn't even really pay any attention to it. I just thought it was a normal device, like forceps (successful Odon birth).Some women ascribed an unsuccessful Odon birth to their baby rather than to device failure. Interestingly, they saw an unsuccessful AVB with the Odon Device as providing useful insights for future understanding and births:W02: I know, obviously, it wasn’t successful, but it’s not going to be successful every single time. Everyone’s situations are different. It was just our baby being difficult. It’s different if every single person going didn’t like it. But no, I’d, 100%, consent again (unsuccessful Odon birth).Some women were surprised that there were increased numbers of staff present at the time of birth but did not state that this affected their birth experience:W04: I must say, it was quite overwhelming when everyone came in at the time the help was needed… They explained they were all for different stuff and for different jobs (successful Odon birth).Half of the women stated that having extra staff present at time of birth was fine as they perceived that the more people, the safer the environment:W02: I think the more people there, the less you can worry, because you know you’re in safe hands…Yes, but you’re thinking, “Right, there are 10 people in this room now, so someone’s going to be alright” (unsuccessful Odon birth).Qualitative research in the form of a case study investigation into the feasibility of using an innovative device for AVB was used in this study to investigate women’s experiences of the attempted Odon-assisted birth and of participating in intrapartum research. This study included observations of attempted AVBs, interviews with women involved and interviews with midwives and operators to explore women’s experiences in detail. Women’s experiences were overwhelmingly positive (more so than had been expected by the study team), regardless of the outcome of using the device. Study recruitment and follow-up processes were valued by women, and in-person observation of the birth was acceptable.Women and midwives want an alternative to forceps and ventouse. There are wide inconsistencies in the use of AVB worldwide and these are often multifactorial, relating to concerns regarding complications of AVB and the associated litigation,This is the first study to undertake an in-depth qualitative exploration of the Odon Device for clinically indicated AVBs. Capturing the experiences of women is vital in assessing the device in clinical trials. Conducting case study methodology on the labour ward enabled researchers to gather a ‘genuine’ representation of experience within the environment, in which the device is used that might not have been achieved using alternative approaches.10.1136/bmjopen-2021-057023.supp3Supplementary dataDespite these advantages, there are limitations to this study. Only women accepting participation in ASSIST were observed or interviewed and those declining participation may have different views. There were only eight case studies involving observation and interviews with women, because data saturation was reached from observations. This limitation raises the possibility that findings are less generalisable. Furthermore, the interviews with women were short. There are several reasons as to why this may be the case. First, women were only asked a very small number of questions specifically relating to their birth experiences. Operators and midwives, however, were asked questions not only on experience but also on device use, technique, design and trial methodology. Additionally, women were interviewed at day 1 postnatal, when likely fatigued. This was discussed during the PPI sessions and women agreed that interviewing women in hospital close to the birth was more suitable than later at home, as women were aware that their memory of their birth experience may not be reliable. The case studies were undertaken by a specialist trainee in obstetrics and gynaecology meaning that preconceptions and existing knowledge may have influenced the collection and interpretation of the data. However, at the time of commencing the case studies, the researcher was naïve to the use of the Odon Device in the clinical setting. Finally, operators may have changed their behaviours during observations, perhaps not reflecting their real-life practice. It is possible that there was response bias as women knew that the researcher was a clinician in the trial. However, this was discussed during PPI and valued as an attraction of the study for women. Women and their partners were keen to discuss their birth with a clinician who knew the device, feeling it was an essential aspect of the research process.With novel devices being tested in clinical trials, it is vital that experiences of key stakeholders are explored. Having an innovative device for AVB that has high clinical efficacy is not useful if women find it unacceptable. Our findings suggest that women are willing to accept an alternative device for AVB, especially one that is perceived as kinder to their babies. Women commended the use of video during the recruitment process and expressed support for intrapartum research.This study demonstrates that qualitative case study methodology enables the detailed exploration of experiences and views of women and healthcare professionals in intrapartum research and that the methods  were acceptable and expected by women.When introducing or implementing a novel device into clinical use, it is vital that the experiences and opinions of stakeholders are considered. Case studies provide a way of exploring these views in detail by integrating data from multiple sources, providing a comprehensive and authentic exploration. Case study methodology is used widely in other avenues of research; however, it has not yet been widely adopted in implementation research during device or surgical trials.


Although militaristic metaphors have been pervasive during health crisis in political and science communication, few works have examined how these linguistic devices may influence crisis communication. Drawing on critical discourse analysis (CDA) and on crisis communication literature, I show how political representatives have used the war metaphor for very different purposes in terms of crisis communication and management of the current Covid-19 pandemic. I suggest that these findings challenge previous criticisms of the war metaphor as inherently negative and damaging. Finally, I discuss possibilities of using CDA, and specifically, metaphor analysis to inform and expand crisis communication. Militaristic metaphors have long been used in health crisis in political and media communicative practices, namely in relation to former epidemics, like the Severe Acute Respiratory Syndrome—SARS  and specifically, metaphor analysis, to the understanding of crisis situations.It is against this backdrop that I analyze the use of militaristic metaphors by political representatives during the current Covid-19 pandemic. From the beginning of the emergence of the Covid-19 virus in Europe we have seen the proliferation of militaristic metaphors of war and battle, with the current situation being frequently described as a “war,” health professionals being compared to front line soldiers, and the need for making sacrifices in these difficult and exceptional times being emphasized by several spokespersons. These and similar metaphorical use are contributing to “doing” different things, in terms of crisis communication and management, with implications in terms of biosecurity and biopolitics, but also in geopolitics. Indeed, the findings of this study show how, within the context of Covid-19, war metaphors were important in: preparing the population for hard times; showing compassion, concern and empathy; persuading the citizens to change their behavior, ensuring their acceptance of extraordinary rules, sacrifices; boosting national sentiments and resilience, and also in constructing enemies and shifting responsibility. By revealing the different uses of such militaristic metaphors, I also show how the context is itself construed and controlled differently by the political representatives.I start by presenting some introductory reflections on the literature on crisis communication and its limitations to reflect subsequently on the challenges of communication and management of Covid-19 crisis. Next, I outline the methodological approach used in this paper drawing from both CDA and crisis communication studies. Then, I present the findings of the analysis, showing how militaristic metaphors are used by spokespersons for managing this health crisis in very specific and differentiated ways. Finally, I discuss the main findings and the implications of the prevalence of militaristic metaphors in crisis situations, and argue for the development of a line of research linking crisis communication with CDA and metaphor analysis.Much of the literature on crisis communication emphasizes organizations' practices of reputational management for the effectiveness of their response to the crisis Benoit, , p. 58. Taking a different research perspective, some authors  revealing the persistence of sub-war metaphors  and hence, for the acceptance of exceptional measures such as the state of emergency. At the same time, Marcelo Rebelo de Sousa evokes the long history of Portugal to praise the resilience and expected compliance of the Portuguese with these exceptional measures. And finally, the speaker even re-signifies the meaning of the state of emergency in order to delink it from any idea of chaos or totalitarianism and link it with democracy itself. This discourse was praised by the newspaper “Observador” as “the best speech of Marcelo's life” and in general, the Portuguese citizens did show compliance for the state of emergency measures.The French President, Emmanuel Macron, has uttered the word “war” seven times in his televised speech on the 16th of March, 2020. His use of the war metaphor also precedes the announcement of specific measures to fight the pandemic such as: the suspension of all undergoing reforms; “a new bill allowing the government to respond to emergencies and, where necessary, to legislate by ordinance,” and the decision taken to close the border with the EU and the Schengen area.Nous sommes en guerre. Toute l'action du gouvernement et du Parlement doit être désormais tournée vers le combat contre l'épidémie, de jour comme de nuit. Rien ne doit nous en divertir. C'est pourquoi j'ai décidé que toutes les réformes en cours seraient suspendues, à commencer par la réforme des retraites.Dès mercredi, en conseil des ministres, sera présenté un projet de loi permettant au gouvernement de répondre à l'urgence et, lorsque nécessaire, de légiférer par ordonnance dans les domaines relevant strictement de la gestion de crise. Ce projet sera soumis au Parlement dès jeudi. J'ai vu tout à l'heure les présidents de l'Assemblée nationale et du Sénat afin que ces textes soient votés le plus finement possible, afin aussi que la vie démocratique et le contrôle du Parlement continuent dans cette période. Je les en remercie et je remercie tous nos parlementaires en cet instant....Nous sommes en guerre. Aussi, comme je vous l'ai dit jeudi, pour nous protéger et contenir la dissémination du virus, mais aussi préserver nos systèmes de soins, nous avons pris ce matin, entre Européens, une décision commune. Dès demain midi, les frontières à l'entrée de l'Union européenne et de l'espace Schengen seront fermées. Concrètement, tous les voyages entre les pays non européens et l'Union européenne seront suspendus pendant trente jours./We are at war. All the action of the government and of Parliament must now be turned toward the fight against the epidemic, day and night. Nothing can divert us. That is why I decided that all the ongoing reforms would be suspended, starting with the pension reform.On Wednesday, in council of ministers, a bill will be introduced allowing the government to respond to emergencies and, where necessary, to legislate by ordinance in areas strictly related to crisis management. The draft will be submitted to Parliament on Thursday. I saw the Speakers of the National Assembly and the Senate earlier so that these texts could be voted on as finely as possible, so that democratic life and the control of Parliament would continue in this period. I thank them for that, and I thank all our parliamentarians at this time....We are at war. So, as I told you on Thursday, to protect us and to contain the spread of the virus, but also to preserve our health care systems, we made a joint decision this morning among Europeans. From tomorrow noon, the borders at the entrance of the European Union and the Schengen area will be closed. In concrete terms, all travel between non-European countries and the European Union will be suspended for 30 days.The repeated statement “We are at war” frames the announcement of these decisions, contributing to legitimating the exceptional measures taken. Such framing is reinforced in the first paragraph by the statement: “All the action of the government and of Parliament must now be turned toward the fight against the epidemic, day and night. Nothing can divert us.”soft power), and at the same time, declare that there will be legal consequences if citizens fail to comply (hard power).Linked with the previous goal, the use of militaristic metaphors by political representatives not only serves for preparing the public to accept exceptional measures, but it is also very important to persuade citizens to change their behavior in accordance to these measures. Ensuring compliance is promoted discursively through the combine use of what can be characterized as soft and hard power devices, as when spokespersons ask the public to behave in a certain way  assists in defining what is necessary or possible under this fight and to the speaker's goal of persuading citizens to change their behavior.Good Evening,The coronavirus is the biggest threat this country has faced for decades – and this country is not alone.All over the world we are seeing the devastating impact of this invisible killer.And so tonight I want to update you on the latest steps we are taking to fight the disease and what you can do to help....From this evening I must give the British people a very simple instruction - you must stay at home.Because the critical thing we must do is stop the disease spreading between households.That is why people will only be allowed to leave their home for the following very limited purposes.In crisis communication, it is important to insure the unity and resilience of the community in order to maintain morale and mobilize people to assist in the management of the crisis. The metaphor of war also helps promote a “general mobilization” of the citizens in order to fight the progress of this “invisible enemy.” In the Covid-19 pandemic, several political leaders have used this metaphor to appeal to unity and call for a mobilization of the population.Emmanuel Macron has characterized the virus as an invisible and elusive enemy, presenting it in this way as a hefty threat that requires “our general mobilization.” The use of the possessive “Notre/Our,” as well as the repeated use of the pronoun “Nous/We” strengthens this appeal for unity among the French citizens against this common enemy.Nous sommes en guerre, en guerre sanitaire certes. Nous ne luttons ni contre une armée ni contre une autre nation, mais l'ennemi est là, invisible, insaisissable, et qui progresse. Et cela requiert notre mobilization générale.We are at war, certainly in a health war. We are not fighting against one army or another nation, but the enemy is there, invisible, elusive, and progressing. And that requires our general mobilization.It is important, however, to analyze these statements in terms of what is silenced by these (the relation of the text with the context). In this regard, Macron's suggestion of a shared identity with the audience (the French citizens) and of a national sense of unity stands in sharp contrast with the magnitude of the protests of Yellow Vests (Gillets Jaunes) that emerged in 2018, triggered by fuel tax rises, and expanded into a revolt against Macron's government.Marcelo Rebelo de Sousa, the President of Portugal, also mentions an invisible and insidious enemy, but he is not referring to the virus. Instead, he characterizes this enemy as one that is present in every war and that has several names: “discouragement, tiredness and time fatigue that never ends.” This is a call for resilience in times of “war,” a call for “resistance, solidarity and courage” that resembles another speech, the one of Franklin D. Roosevelt, the 32nd President of the U.S. in his first inaugural address, at 4 March, 1933. In this speech, Roosevelt uttered a statement that would become famous: “The only thing we have to fear is fear itself.”Termino com um pedido.Nesta guerra, como em todas as guerras, só há um efectivo inimigo, invisível, insidioso e, por isso, perigoso.Que tem vários nomes.Desânimo. Cansaço. Fadiga do tempo que nunca mais chega ao fim.Temos de lutar, todos os dias, contra ele.Contra o desânimo pelo que corre mal ou menos bem.Contra o cansaço de as batalhas serem ainda muitas e parecerem difíceis de ganhar.Contra a fadiga que tolhe a vontade, aumenta as dúvidas, alimenta indignações e revoltas.Tudo o que nos enfraquecer nesta guerra alongará a luta e torná-la-á mais custosa e dolorosa.Resistência, solidariedade e coragem são as palavras de ordem.I'll end with a request./In this war, as in all wars, there is only one real enemy, invisible, insidious and therefore dangerous.It has many names.Discouragement. Tiredness. Fatigue of time that never comes to an end.We have to fight him every day.Against discouragement for what goes wrong or less well.Against the fatigue of the battles still being many and seem hard to win.Against the fatigue that kills the will, increases doubts, feeds indignations and revolts.Whatever weakens us in this war will lengthen the fight and make it more costly and painful.Resistance, solidarity and courage are the watchwords.Ursula von der Leyen, the president of the European Commission, also uses the war metaphor to send a message of self-efficacy to the EU, by explaining what “every single one of us” can do to fight the virus and call for a general mobilization in this fight. Interesting in this speech is the use of an economic metaphor of “debt” that here is used in moral terms to express the debt of gratitude toward the health professionals.But what is unique about this fight is that every single one of us has a role to play. Every single one of us can help repay that debt. By keeping our distance we can slow down the spread of the virus. The numbers in the last few days have shown that we can bend the trend – but only if we all do our share.In crisis situations, communicating with “appropriate levels” of compassion, concern and empathy is known to increase the credibility of the message and enhancing the perceived legitimacy of the messenger Coombs, , p. 241.Ursula von der Leyen, for example, has expressed compassion for the victims of the pandemic “currently fighting for their lives,” as well as their “loved ones.” In this speech, the metaphor of “fight” is used to express the harshness of a patient's individual struggle with the disease, and directed at the persons infected by the virus.My heart goes out to all of the victims and their loved ones.And all of our thoughts and best wishes are with those currently fighting for their lives or sick at home.Emmanuel Macron has also expressed empathy, but in this case, regarding the impact of the exceptional measures on the lives of the French citizens, and the difficulty of changing one's habits.Mes chers compatriotes, je mesure l'impact de toutes ces décisions sur vos vies. Renoncer à voir ses proches, c'est un déchirement. Stopper ses activités quotidiennes, ses habitudes, c'est très difficile. Cela ne doit pas nous empêcher de garder le lien, d'appeler nos proches, de donner des nouvelles, d'organiser aussi les choses avec nos voisins. D'inventer de nouvelles solidarités entre générations. De rester, comme je vous l'ai dit jeudi dernier, profondément solidaires et d'innover là aussi sur ce point. Je sais que je vous demande de rester chez vous.My fellow countrymen, I see the impact of all these decisions on your lives. Giving up seeing your loved ones is heartbreaking. It's very difficult to stop your daily activities and habits. This should not prevent us from keeping the link, calling our relatives, giving news, also organizing things with our neighbors. From inventing new solidarity between generations. From remaining, as I told you last Thursday, deeply in solidarity and to innovate there too on this point. I know I'm asking you to stay home.By first recognizing the sacrifices requested from the French citizens, and putting himself in this same group—by using the pronoun “nous”/we—the speaker can then present the situation as an opportunity: for “inventing” and “innovating” in issues of solidarity.The idea of exceptional measures and the need to make sacrifices evokes wartime. Although this specific extract does not include any militaristic metaphor, it has to be understood in the context of the entire speech. All Macron's speech is organized around this idea of being in a war, the pandemic being compared to a war situation (see section Preparing the Public for Hard times). And this is foregrounded in the beginning of the speech:Jamais la France n'avait dû prendre de telles décisions, évidemment exceptionnelles, évidemment temporaires en temps de paix./France has never had to make such decisions, obviously exceptional, obviously temporary in peacetime.Thus, the need to make sacrifices, just like in wartime, had already been put forward by Macron earlier in his speech, allowing at this moment for the speaker to show empathy regarding the impact of the exceptional measures on the lives of citizens.In a long speech of 195 min, which was widely criticized by the Spanish media, Pedro Sanchez, the prime-minister of Spain, presents the virus as an unknown enemy, “un enemigo al que aún estamos conociendo”/“an enemy we are still getting acquainted with” . Besides “enemigo” (enemy), Sanchez uses several other words conveying a militaristic metaphor such as: “resistencia” (resistance), “lucha” (fight), and “batalla” (battle).In terms of crisis communication, the goal of such message is clearly that of avoiding responsibility and mitigating blame for the lack of control of the pandemic. While it is true that Covid-19 is in fact a new virus and therefore unknown, the focus on the idea of lack of control masks the failure of the Spanish government to provide a timely and effective response to contain the damage and protect the population. In terms of crisis communication, failure in acknowledging the government's responsibility corresponds to a lack of candor on the part of the speaker, understanding this as “communicating the entire truth as it is known, even when the truth may reflect negatively on the agency or organization” Seeger, , p. 239.Increasingly weakened politically, Pedro Sanchez will later apologize (on 20 May) for his mistakes in managing the pandemic, although he further justifies these by the “urgency of times, scarcity of resources and exceptional nature and absence of precedents.”Following weeks of downplaying the seriousness of the pandemic, and as the virus spread in the country, Donald Trump, the President of the US, also engaged in wartime rhetoric and even called himself “a wartime President:” “I view it as a, in a sense, a wartime President. I mean, that's what we're fighting” (18 March 2020). In this statement, Trump emphasizes the sacrifices necessary in such times, such as the one of closing part of the economy: “One that you have to close it down in order to defeat this enemy. But we are doing it. And we are doing it well.”Such militaristic metaphors were followed on the following day (19 March 2020) by a naming of the Covid-19 as the “Chinese virus” as Trump made his speech in the Virus Task Force Hold Briefing: “We continue our relentless effort to defeat the Chinese virus.” Such an association of diseases with a foreign place and other has a long tradition and “reveals a link between imagining disease and imagining foreignness” .In this speech, Guterres argues that the war has made people, health-systems and countries more vulnerable, and hence more defenseless also to the attack of the virus. Thus, he effectively shifts the attention away from the virus and its victims to the war and its systemic impacts in creating vulnerable groups  that are also the ones at the highest risk of Covid-19. The speaker goes on framing the audience perspective on both war and the virus. This is made by comparing “the fury of the virus” with “the folly of war” and using the metaphor of disease to describe the war “End the sickness of war and fight the disease that is ravaging our world.” Finally, Guterres uses the lock-down as a metaphor for closing down the war.Subsequently, on the 26 March 2020, the Secretary-General of the United Nations warns that we are not winning this war against Covid-19 and presents the numbers to support his argument.We are at war with a virus – and not winning it.It took the world 3 months to reach 100,000 confirmed cases of infection.The next 100,000 happened in just 12 days.The third took 4 days.The fourth, just one and a half.This is exponential growth and only the tip of the iceberg.This war needs a war-time plan to fight it.Solidarity is essential. Among the G-20 – and with the developing world, including countries in conflict.That is why I appealed for a global ceasefire..The metaphor of the war against the virus is invoked here to suggest that the solution must also be a solution tailored to the situation, that is, a “war-time plan,” which Guterres sees as founded on solidarity among the most powerful and peace.The use of militaristic metaphors in health crisis is not new and with the emergence of the Covid-19 pandemic we have again witnessed its recurrent use by political representatives and by the media, particularly in television. In this paper I sought to explore the use of the war metaphor by political actors in its intersection with the practices of crisis communication and management. Drawing from the approach of CDA, and particularly the studies on the use of metaphors in political discourse and crisis communication, I suggest that such an approach can serve both to inform crisis communication literature and to develop CDA. This is in line with Chiapello and Fairclough's understanding of a transdisciplinary approach, which asks “how a dialogue between two disciplines or frameworks may lead to a development of both through a process of each internally appropriating the logic of the other as a resource for its own development” (Chiapello and Fairclough, 2002 cited in Fairclough, The findings show that first, the war metaphor was used often in the context of the recent pandemic of Covid-19, but also that it was used in very different ways in terms of crisis communication and management. Some political representatives have at times, used the war metaphor for purposes such as showing compassion, concern and empathy with the public and promoting self-efficacy and resilience in coping with the pandemic, which can be linked with recognized best practices in crisis communication. And the war metaphor is used by the Secretary-General of the United Nations, António Guterres to paradoxically, call for a global ceasefire and highlight the systemic impacts of war. Nonetheless, as my goal was just to explore and show the different uses of the war metaphor, rather than analyzing in detail the political communication and crisis management strategies of these representatives, from these good examples, it is not possible to conclude that these representatives were always ethical and followed best practices in the way they communicated and managed the Covid-19 crisis.Furthermore, the findings of this study also suggest that the war metaphor is often used for the pursuit of specific goals of crisis communication and management such as: preparing the public for hard times, persuading the population to change their behavior and bolstering resilience and self-efficacy. These are messages that, while using the war metaphor, place the emphasis on adaptation to hard times, rather than on fighting an “invisible enemy.” Subsequent studies should try to go deeper in order to enable a comprehensive and critical analysis of the communication and crisis management strategies of each country or organization.In general, these findings seem to caution against previous generalized criticisms of the war metaphor as inherently dangerous and damaging. Instead, they highlight the role played by the dialectics between text and context in discourse. Political discourse, which is the focus of this paper, is targeted to social groups. Hence, political use of the war metaphor raises the questions of what kind of categorizations are used by the spokespersons, who is included in this fight against the virus, and whose voices or alternative narratives are silenced. Constructions of self and other are also linked to differing ideological uses of the DISEASE IS WAR metaphor, as Chiang and Duann , p. 581 Addressing the issue of the strategic use of the war metaphor requires an understanding of the pragmatics of discourse, or, to put it simply, of what that speaker is doing in terms of political and crisis communication, while using the war metaphor. Is he/she, for example, trying to help citizens to cope physically and psychologically with the pandemics or is he/she attempting to engage in reputation management actions like avoiding or shifting responsibility for failures in the crisis management? Are some social groups being systematically neglected in terms of crisis management? These discursive actions only make sense if one understands the historical, social and political context of their occurrence. This means we need to analyze, as Fairclough , p. 8 haIn this case, it means also to situate the discursive act in the context of the global health crisis in order to analyze the way it has impacted and unfolded in that specific social context, nation or organization. In this regard, although Covid-19 was considered a pandemic, there has been a flagrant lack of coordination between nations even within the European Union. Further studies are needed to understand why this happened, why each nation followed its own strategy of crisis management and communication, but many have converged nonetheless on some measures of lock-down, social-distancing and protective use of masks.It is useful here to look at the exceptions, at the cases where different crisis communication and crisis management strategies were used. Regarding the use of militaristic metaphors during the Covid-19 pandemic, it is worth noting Germany's discursive use of negation—denying that the Covid pandemic was a war. Following Macron speech of 16 March and against it, the president of Germany, Frank-Walter Steinmeier, declared: “It is not a war, it's a test to our humanity!” Such resistance in using militaristic metaphors may be linked to Germany's history, its participation in the WWII and responsibility for the inhumanity of holocaust. However, Germany's strategy for crisis management did not differ much from France's, in spite of this difference in framing the crisis. Sweden, on the other hand, in stark contrast with other European nations, has managed the epidemic by appealing to citizens' individual responsibility and accountability and relying on their trust in the state and expertise knowledge (Nygren and Olofsson, Further studies should focus on the reception of these discourses in order to examine the effectiveness of the war metaphor in the various discursive actions associated with crisis management. Although some authors have sought to challenge crisis communication strong sender orientation (Frandsen and Johansen, Finally, although this paper focuses on militaristic metaphors, these are often used by political representatives in conjunction with other discursive and rhetorical devices, inclusive other types of metaphors. Further studies should analyze how, in the context of Covid-19, other metaphors are being used alternatively to or in conjunction to the war metaphor, for example, the virus as a Killer metaphor, economic metaphors, patriarchal or religious metaphors. Such alternative metaphors, like the killer metaphor may be as problematic in their framing of the issue as militaristic ones (Wallis and Nerlich, An interesting case is how Jair Messias Bolsonaro, the president of Brazil, has consistently denied the seriousness of the pandemic and positioned himself against any lock-down, confinement or social distancing measures by using androcentric and religious metaphors. In this regard, Bolsonaro has suggested that one should “face the virus like a man rather than a kid” in order to repudiate lock-down and social distancing measures. By doing so, he was criticizing anyone who attempted to protect themselves against the pandemic, blaming them for lack of courage and for behaving irresponsibly like “kids.” In fact, Bolsonaro's discourse has tended to equate responsibility with going to work as usual and irresponsibility with complying with lock-down, social distancing, and other protecting measures. Furthermore, when confronted by journalists with the rising numbers of the infected and dead in Brazil, he just replied, making a joke about his own name: “I am Messias but I do not perform miracles.” With such discursive act, the speaker was successfully evading the issue and at the same time, trivializing the impact of Covid-19, which is something he has also done in other occasions. The religious aspect is not a joke though as Bolsonaro has publicly appeared supporting the evangelical church in religious celebrations.In this case, the populist facet of Bolsonaro's discourse drew heavily on religious, patriarchal and masculinity discourses. However, Bolsonaro also used the war metaphor in the context of Covid-19, but not for promoting measures of social distancing and protection against the virus. Instead, the war metaphor was used as a justification for the use of hydroxychloroquine and chloroquine, a highly controversial treatment. This discursive combination of militaristic and patriarchal metaphors is not new, but it is one that seems to be particularly invoked by populist leaders (Steinert, The original contributions presented in the study are included in the article/EC, as the sole author, collected and analyzed all the data, and was the sole responsible for the conceptualization and writing-up of this manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Hoeks, Rasha Kaddoura, Mohamed Izham5, Abdulaziz Alkhulaifi, Amr S. Omar, and Kadir Caliskan, was originally published electronically on the publisher’s internet portal on 11 April 2021 without open access. With the author(s)’ decision to opt for Open Choice the copyright of the article changed on 10 June 2021 to © The Author(s) 2021 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in thearticle’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The original article has been corrected.