その他

Discourse Analysis of Encouragement in Japanese Healthcare Comic Books
Rieko Matsuoka1

Ian Smith2

Mari Uchimura3

1 National College of Nursing, Japan；1-2-1 Umezono, Kiyose-shi, Tokyo, 〒 204-8575, Japan
2 University of East Anglia
3 Tokyo Medical and Dental University
matsuokar@adm.ncn.ac.jp【Abstract】In this paper, the ways in which healthcare professionals, nurses in particular, use encouragement are examined, in order to explore how
encouragement should be communicated effectively toward patients. Focusing on GAMBARU [ʻto try hardʼ] as the typical expression of
encouragement in Japanese, forty-one scenes have been collected from comic books that use healthcare as their subject, though not comic books that
focus on doctors. Firstly, each scene of encouragement is analysed and discussed as a discourse from three perspectives;（a）the contextual
background of the communication,（b）the relationship with the patients and（c）the patientsʼ response to the encouragement. The patientsʼ responseis evaluated by the imposition of face-threatening acts, social distance, and relative power according to Politeness Theory（Brown & Levinson,
1987）, and by the degree of ʻpoliteness effectʼ according to Discourse Politeness Theory（Usami, 2006）. Secondly, the elicited encouragementutterances from discourse analysis are categorised into ten types based on their functions, such as ʻcheering upʼ and ʻrelieving from anxietyʼ, and thefunctions that succeeded in having politeness effects on the patients are examined. Thirdly, GAMBARU and its inﬂected forms, and other verbal
encouragements, are compared in terms of the relationship between their functions and their politeness effects. Lastly, based on the results, some
implications to enhance the quality of healthcare communication are suggested.

【Keywords】 encouragement 励まし，healthcare communication 医療コミュニケーション，politeness theory ポライトネス理論，
discourse politeness theory ディスコース・ポライトネス理論，face-threatening act フェイスを脅かす行為

Introduction

communication, though vigorous encouragement is not always
recommended in nursing communication, healthcare

In healthcare communication, showing empathy and listening

professionals such as nurses often need to encourage theircarefully to patients are regarded as important（Riley, 2000）.

patients. In such situations, the Japanese often say Gambatte, as

However, the behaviour of showing empathy or listening

Gambatte functions in a versatile way（Miura, 2006）. At thecarefully is not explicitly projected in verbal communication.

same time, however, Gambatte sometimes fails to generateWith regard to nursing communication, Henderson（1960,

politeness effects. For instance, when we are already making1997）points out that the patientsʼ needs for communication are

efforts and someone says Gambatte, we may feel forced to makesatisﬁed if they can communicate their feelings, desires, fears oreven more efforts, as is indicated in Okamoto, Sugimura, andwhatever exists in their minds. Following this principle, she

Kamakura（2001）, one of the few previous studies on Gambaru.

states that nurses should adequately facilitate their patientsʼ

Consequently, such communication cannot provide patients withexpression of their feelings, desires and so on. Therefore, fromappropriate quality care and comfort.

the first stage of interaction with their patients, nurses are

Although apparently sensitive encouragement such as

required to attempt bilateral communication. They need toGambaru seems worthy of careful examination in healthcareacquire communication skills that should lead to mutual trust

settings, the research on communication of encouragement isand a therapeutic and supportive relationship between them.

limited for the present. Therefore, in this study, the authors haveGambatte, the request form of Gambaru, is frequently usedexamined how verbal encouragement such as Gambatte wasamong Japanese speakers. The focus of this study is anused and discussed whether or not Gambaru and its inflected

examination of its effects in healthcare communication, whichforms like Gambatte are adequate encouragement speech acts.

would help to clarify the in-depth interaction between

In addition, the authors have investigated what kinds ofhealthcare professionals and patients. In the actual healthcare

encouragement speech acts are available that might enhance− 31 −J Nurs Studies N C N J Vol. 8 No. 1 2009

patientsʼ comfort and confidence, in order for the quality ofgenerally low. On such occasions, politeness should be carefully

healthcare communication to be improved.

provided.

Accordingly, the research questions for this study are;a. In what way do healthcare professionals use verbal

Politeness effectThis is the effect of politeness, that is, the strategy forencouragement with their patients?
b. What kinds of function and politeness effect does verbal

reducing the impact of fact-threatening acts. In cases where thepoliteness is successful in reducing the impact of face-encouragement have towards patients?
c. How different are Gambaru and its inﬂected forms fromthreatening acts, the effect is positive. In cases where theother verbal encouragement in terms of their functions andpoliteness causes no reduction but also causes no increase inpoliteness effects?

impact, the effect is neutral. In case of failure, where the impactof face-threatening acts is increased, the politeness effect isDeﬁnition of terms

negative.

Communication
MethodThe notion of communication has been discussed since the1940s（Northouse & Northouse, 1998）in a variety of ways. For
this study, communication is defined as the transactional andData collection

affective process of sharing information, feelings and attitude

Comic books in Japanthrough the use of symbolic behaviour such as language

Comic books in Japan should be treated as a different genre（Northouse & Northouse, 1998）. Healthcare communication isfrom the genre of comic books in western countries, in regard to

the communication conducted in healthcare settings such as inboth their forms and functions. They have been labeled as

hospitals.

Manga in order to distinguish them from the general category ofcomic books. Japanese comic books, or Manga, may well be
regarded as ʻgraphic novelsʼ. Natsume（2004）, the grandson of

Encouragement
Based on the belief that both verbal and non-verbal

Soseki Natsume, established Manga-gaku as an academic ﬁeld.

communication for encouragement should be included in themental and physical recovery of patients dealing with ill-health

Healthcare comic books in Japanand misfortune, encouragement behaviour is defined as verbal

Some comic books address healthcare issues and their mainand non-verbal behaviour to facilitate the mental and physicalcharacters are doctors or nurses. Such comics have been popular

recovery of patients（Kurokawa, 2001）. In this study, however,in Japan and the genre of healthcare comic books, or Iryo

mainly verbal encouragement behaviours are examined.

Manga, is well established. Osamu Tezuka, who is regarded as
an important ﬁgure in Manga, was a medical doctor and wrote
ʻBlack Jackʼ, the ﬁrst ofﬁcially recognised medical or healthcare

Face
Face is a self-image that has been established in the personʼscomic story in the 1970s. Some other comic books have been

life history. According to Goffman（1967）, face means social

supervised by healthcare professionals（Yomiuri shimbun,

value, or how importantly an individual is regarded by other2007）, or based on factual accounts of healthcare settings, as has

people and by the outside society.

one of the comic books used for the present study（Sasaki, 2000,
2001, based on the account by Kobayashi）.

Face-threatening act
A face-threatening act is deﬁned as an act negatively affecting

Rationale for using comic books

the individualʼs face. The degree of this act is determined as

Due to the strict code of ethics for protecting the rights ofhigh or low by the imposition given to the hearer, the social

patients, raw data from clinical sites have become difficult to

distance between the interlocutors, and their power relations.

access.
Japanese comic books contain words or lines in speech-

Politenessballoons in each picture, as do comic books in other countries;

In this study, politeness is defined as the strategy forbut they have fewer words or lines, which seems to reﬂect the

mitigating such face-threatening acts. In cases where the face-communication style among Japanese people, who live in whatthreatening degree is high, comfort levels in communication are

has occasionally been referred to as a high-context society（Hall,

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1977）. Because of the abundant graphic images contained in

to 362 pages（Nurse Station 6, 1999）. They are as follows;a）Uehara, K.（1994-2006）. Inochi No Utsuwa [A Vessel ofcomic books, they attract vast amounts of readers. In such

Life] 9 volumes. Tokyo: Akita-shoten

circumstances, the authors of comic books in general attempt tob）Kurita, R.（2003）. Puchi Nurse [Petite Nurse]. Tokyo:

be sensitive towards the needs of their readers and consumers,
and their content, for the most part, is a reasonable reﬂection of

Kodansha.
c）Koshino, R.（2004-2007）. Ns’ Aoi [Nurse Aoi] 13

the real world. Though they are fictional and some parts areoverly exaggerated in order to seize the readersʼ attentions and tovolumes. Tokyo: Kodansha.

create dramatic impact that could generate sales, they would faild）Sasaki, M.（2000-2001）. Otankonaasu [Stupid Nurse],

to get a sympathetic and empathetic reaction from their audiencefrom an original story written and documented by

if they lost the reality of everyday life. Maynard（2004）lists

Kobayshi, M, 19 volumes. Tokyo: Shogakukan.
e）Shimazu, K.（1997-2002）. Nurse Station, 20 volumes.

comic books as a legitimate genre for data in discourse analysis.
In prior studies of discourse analysis in Japanese, in fact, comic

Tokyo: Shueisha.

books have been used as effective source material for analyzingf） Yoshizaki, S.（2004）. Open Mind 1. Kodansha: Tokyo.

feelings and emotivity to use Maynardʼs term or emotionalityg）Aimoto,M.（1993, 1994）. Hanagoyomi byouinn no（Maynard, 2005）. In the healthcare studies, attitudes towards

hitobito [People in Hanagoyomi Hospital] 2 volumes.

smoking in the healthcare comic books have been analysed andTokyo: Kodansha.

discussed（Kawane, Watanabe, & Takeshita, 2007）.
Procedure
Data for this study

Discourse analysis

Fifty-six titles of comic book series addressing healthcare-

Based on the belief that all utterances can be face-threatening

related subjects were listed（see the Appendix）as appropriate

acts depending on their contexts, as Usami（2006）posits, verbal

data via internet search engines, and these books were checked

encouragement should be analysed in context instead of beingat the Japanʼs National Diet Library, in March, 2007. Among

removed and treated as a decontextualised utterance. Usamithem, five titles were not found, even though the Japanʼs（2006）gives as an example the utterance ʻToday is Saturdayʼ,

National Diet Library should store all the writings, includingwhich seems not to be a face-threatening act. However, if this iscomic books, published in this country. The publishers of thesaid to a person whose deadline for a submission was Friday, it

missing five titles（7, 52, 53, 55, & 56 in the list）may havewill be a face-threatening act. In another interpretation, based

failed to give a copy to the Japanʼs National Diet Library.

on the assumption that people are off work during the weekend,

The Japanʼs National Diet Library has 35,933 comic books

the same utterance could also be face-threatening because it

published from 1993 to March 2007, and approximately one

could function as a refusal in a context where someone has

percent of these books are recognised as so-called healthcare

asked the interlocutor to do something.

comic books, though the Japan National Diet Library has not

Accordingly, in order to answer the first research question

established the genre of ʻhealthcare comic booksʼ yet（the Japan

concerning the ways in which healthcare professionals use

National Diet Library, personal commucation, December 6,

verbal encouragement towards their patients, the forty-one

2008）. As some comic series have numerous volumes, there arechosen scenes were subjected to discourse analysis using threeroughly one hundred titles of comic book series involving theperspectives.

healthcare related matters.

The ﬁrst perspective was the context of communication, or theAfter examining the fifty-five series of books stored at thesituation where the given communication took place. The

Japanʼs National Diet Library, six comic series, a）to f）listed

second perspective was the relationship or mutual trust between

below, were chosen for this study, based on the criterion of

the healthcare professionals, mainly nurses, and their patients.

whether or not they included verbal encouragement fromThe last perspective was based on the Politeness Theory ofhealthcare professionals.

Brown and Levinson（1987）and the Discourse PolitenessAn additional series, g）Hanagoyomi-byoin no hitobito （56thin the list）, was included because the last author owns copies,

Theory of Usami（2006）who modiﬁed Brown and Levinsonʼs
Politeness Theory according to the Japanese context.

although the Japan National Diet Library does not have it.

Specifically, taking the first and second perspectives into

The seven series used for the present study amount to sixty-

account, the patientsʼ responses were analysed with regard to theﬁve volumes, which range from 132 pages（Nsʼ Aoi 11, 2006）

degree of the face-threatening acts involved and the politeness− 33 −J Nurs Studies N C N J Vol. 8 No. 1 2009

effects. The degree of the face-threatening acts was evaluated asutterance of encouragement seems illegitimate. Accordingly, thehigh or low by three factors: the imposition of the given act; thelabeled functions need to be considered not as absolute but associal distance between the healthcare professionals, such as

relatively appropriate.

nurses and their patients; and the power or power relations
Taxonomy

between them in the given context, on the basis of the Politeness
Theory. The politeness effect was evaluated using the

In order to find out what kind of function the verbal

framework of the Discourse Politeness Theory and was labeledencouragement had towards the patients, the functions that wereas positive, neutral or negative. The criterion for the politenesselicited by discourse analysis in this study were categorised into

effect was mainly based on the patientʼs response in each scene.

ten types; a）cheering up, b）relieving from anxiety, c）voicing

Where the patient responded to the verbal encouragementoneʼs thoughts, d）formulaic expression of greetings, e）offeringoffered by the healthcare professional in a preferable way, theassistance, f）giving advice, g）praising the patientsʼ goodpoliteness effect was labeled as positive; it was labeled as thepoints, h）relaying the offer of assistance from the patientʼs

neutral when no substantial differences were found before andfamily, i）empathising and j）joking, referring to the prior study

after the verbal encouragement by the healthcare professionals;（Kurokawa, 2001）. Since Kurokawa（2001）deals with thewhere the patient responded negatively or the relationshipdiscourse of daily life discourse instead of one related to thebetween the healthcare professional and the patient seemed tohealthcare related one, there exist some differences. Seven types

become worse, the politeness effect was labeled as negative.

of functions out of ten types of functions that were taken from

By the same token of polysemy（e.g., Tannen, 1986）, ourKurosawaʼs taxonomy（2001）for this study were a）cheering

discourses may carry plural implications and functions and may

up, c）voicing oneʼs thoughts, e）offering assistance, f）giving

sometimes even be deceptive, which means that the audible

advice, g）praising the patientsʼ good points, i）empathising, andverbal utterance cannot be taken at surface value. For instance,j）joking（the letters have been kept the same as above）.

ʻthank youʼ, superﬁcially the speech act of gratitude, could in a

Therefore, three more functions, which are b）relieving fromcertain context mean ʻstop hereʼ, the speech act of request.

anxiety, d）formulaic expression of greetings, and h）relaying

Furthermore, humans are equipped with a tacit knowledge（c.f.,the offer of assistance from the patientʼs family, were madePolanyi, 1958, 1997）, the underlying knowledge in ourespecially for this study after scrutinising the data. Table 1

subconscious level. Therefore, labeling one function for eachindicates the functions with examples of taxonomy in the present

Table 1 Taxonomy of encouragement in the present study
Functions

ExamplesGambaru expressions

Other expressions

Cheering up“If you try your best,
you will be able to take pictures again.”“You will be ﬁne another 10 years.”Relieving from anxiety

None“You will be ﬁne. You wonʼt die.”

Voicing oneʼs thought“I think you need to be patient.
You should try your best.”“Yes, I am sure of it.”

Formulaic expressionof greetings“Please try your best.”

None

Offering assistance“It will be a long hospitalisation,
but let us try our best.”

None

Giving advice

None“Yes, take time and we will try it little bylittle.”Praising patientʼs
good points“You are doing great.
Yes, you have done so well.”

None

Relaying the offer ofassistance frompatientʼs family“Your husband said he will study
about your disease and treatment（andwill try his best helping you）so
he would like you also to try your best.”“He says he will come here to help you,Grandma, even a little.”

EmpathisingNone“Itʼs all right to be afraid of your illness.
You do not have to feel ashamed.”

JokingNone“Sorry, itʼs a joke. I know Ken will pay
any attention to me. Right?”

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study.

professional: The act of forcing the continued rehabilitation may

Each of the forty-one scenes that were analysed contextuallyprovide the patient with some imposition or burden. The social

using discourse analysis covered the given ten categorised types

distance between them is not close, since the nurse uses theof functions. Whether or not positive effects in politeness werepolite form of –masho as explained below. In the power

achieved was also examined, and the relationship between therelationship the patient seems to have a little less power judging

functions and politeness effects was discussed.

from the fact that he became stiff-faced instead of showing

Lastly, in order to find out how different Gambaru and its

direct anger. Taking all these factors into account, the degree of

inflected forms were from other verbal encouragement,

the face-threatening act is considered high. As line 44 shows,Gambaru and its inﬂected forms, and the other forms of verbal

the patient did not answer. From this, the politeness effect may

encouragement, were arranged out separately and werebe interpreted as negative. In addition, the nurse in charge

compared in their functions and effects.

admits her fault, and may think it is important for her patient tocontinue his rehabilitation. She encourages him to do so byFindings and discussion

cheering him up and saying Gambarimasho. Thus, thisencouragement is categorised as a type of ʻcheering upʼ. It needs

In order to answer the research questions a）and b）, discourse

to be noted that Gambarimasho, used here instead of Gambatte,

analysis was conducted to analyse and discuss the data. The data

can mitigate the degree of the face-threatening act, as thewas collected from seven titles of healthcare comic book series

inﬂection of ʻmashoʼ here functions as both a mitigated request

chosen from among ﬁfty-six series listed in the appendix. The

and an offering（Niwa, 2005）.

seven series consisting of sixty-ﬁve volumes were examined inorder to extract the scenes containing verbal encouragement

Open Mind 1, p. 115

given by healthcare professionals to their patients; as a result,

52 Patient: I am going to die...

forty-one scenes were elicited.

53 Doctor: No, you arenʼt. Daijobuyo [You will be ﬁne.]

The forty-one scenes consisted of thirty-one scenes witha. Situation and context: The patient is a detective and is also

nurses, seven scenes with doctors, two scenes with both doctors

described as a perfectionist. But when he has to make an

and nurses, and one scene with a physiotherapist. The sevenimportant decision, he has a stroke. In this scene, he had justexemplars given below indicate discourse analysis from three

been listening to his boss in connection with his work, and had

perspectives. Their functions are the top seven types among thesuddenly suffered the stroke. The doctor who happened to be

ten categories identiﬁed in the section about taxonomy. Amongnear him came to help him out.

the seven exemplars, five are conducted by nurses, one isb. Relationship between the healthcare professional and his/

conducted by a doctor, and the other one is conducted by aher patients: They do not have any close relationship because

physiotherapist. The scene with a physiotherapist has two forms

they have met for the first time. It is difficult to decide howof verbal encouragement; as a result, there are forty-two cases

much they can trust each other, judging from only the scenefrom forty-one scenes. The numbers at the left of each line

described above.
c. Patientʼs reaction toward the utterance by the healthcare

indicate the sequential numbers of all forty-one scenes.

professional: As there is no specific description of the patient,
Nsʼ Aoi Vol.2, p. 12

the patientʼs reaction is unknown. Therefore, it is difficult to

43 Nurse: Gambarimasho [Try your best] at todayʼs rehabilitation

judge how much of the face-threatening act this communication
has brought about and how much politeness effect thisagain.
44 Patient:（His face becomes stiff.）

communication has generated. However, the doctor, who isa. Situation and context: The patient has stayed in hospital andfemale, tries to calm him down in a professional way; so hehe fell over when his nurse did not pay him sufﬁcient attention.

should receive a certain amount of the politeness effect. Going

In spite of this mishap, the nurse gathered all her courage andby the fact that this doctor said to the patient Daijobuyo [Youwent to see and talk to him.

will be ﬁne], this communication may well be categorised as theb. Relationship between the healthcare professional and his/ʻrelieving from anxietyʼ type.

her patients: Though an accident happened to the patient, his
Otankonaasu Vol. 5, p. 164

relationship with the nurse does not seem bad.
c. Patientʼs reaction toward the utterance by the healthcare− 35 −

78 Patient: ..You still feel I will recover, donʼt you?

J Nurs Studies N C N J Vol. 8 No. 1 2009

79 Nurse; ...Yes, I am sure of it.

social distance between the patient and the nurse remains

80 Patient: ...thank you...

appropriate. Regarding the power relationship, in the same way

a. Situation and context: The nurse in charge of this alcohol-

as the preceding example, the nurse is more knowledgeable

dependent patient has discovered a place where her patient isabout healthcare-related matters such as the length of time forstoring some liquor, and she has rushed to see him

taking the medicine.

b. Relationship between the healthcare professional and his/

Therefore, the nurse may have control over the patient, and it

her patients: A favorable relationship with the patient had not

can be interpreted that the nurse has more power than the

been established for long; however, their relationship seems topatient. Taking these three factors into account, the degree of

improve and deepen after it is decided the patient will move to a

the face-threatening act towards the patient seems high. The

different hospital. This scene of communication is from the day

patient does not say anything（91）in response to her nurseʼswhen the patient is to move; therefore, their relationship isutterance（90）, and she just looks up at the ceiling absent-

regarded as good.

mindedly（repeating the line mentally）. Therefore, the degreec. Patientʼs reaction toward the utterance by the healthcare
professional: This patientʼs having to quit drinking seems toof the politeness effect may be ʻneutralʼ, neither positive nor
negative.

constitute a great imposition on him, judging from his act ofGambarimasho [Let us try hard] uttered by the nurse inconcealing his drinking from his nurse. Their social distancecharge here, as a result, can be placed in the ʻformulaic

seems to be moderate, which means neither close nor

expression of greetingsʼ category, because she apparently does

particularly remote. Regarding power, the patient is weaker as

not seem to intend to imply any message. The –masho, which

the nurse is more knowledgeable about health-related matters

also appears in the utterance（43）, is the polite form of volition

and is in a position to control the patientʼs lifestyle.

and may function as a mitigated form of request（Niwa, 2005）.

Considering these three factors, the degree of the face-In this scene, though the nurse will not have to take part directly

threatening act towards this patient seems to be high. Thisin the act of anticancer treatment, she may want to show

patient has continued to drink while being hospitalised, issolidarity or the intention to work together with the patient by

worried and wonders if he will recover; then he says line（78）.

using the polite volitional form.

Even in such circumstances, he says thank you in response to hisnurseʼs utterance（79）. Therefore, this communication succeeds

Hanagoyomi-byoin no Hitobito Vol. 1 Part 3

in providing him with a ʻpositiveʼ politeness effect, creating such

105 Doctor:（letting his patient listen to his heart beating withfeelings as relief and courage. Regarding the type of function,a stethoscope）

this one can be put into ʻvoicing oneʼs thoughtsʼ.

106 Patient:（.................................................）
107 Doctor: I do NOT want to treat any person who does not

Puchi Nurse, p. 163

want to live. （Your heart）wants to die? It surely beats, doesnʼt

88 Nurse: We have done with Adriamycin. Now you areit, NOW.
108 Patient: ............ I do not want to die......

getting Taxol.
89 Patient: Well, how much... more time will it take?

109 Nurse: Together.... Together Gambaro[let us try our best]

90 Nurse: Letʼs see... another hour. Gambarimasho.[Let us... Gambaro[try our best].
110 Patient:（weeping）Yeah...........

try hard.] If something should happen, please call me.
91 Patient:（speaking mentally to herself）it will take anothera. Situation and context of communication: The patient had
found out the name of his disease（cancer）from TV. After that,hour...
a. Situation and context of communication: The patient is now
receiving chemotherapy for her breast cancer.

he desperately removed his intravenous drip as he was sure hewould soon be dead. The communication scene above takes

b. Relationship between the healthcare professional and his/place during the next dayʼs round.

her patients: The patient and the nurse know each other, andb. Relationship between the healthcare professionals and their

their communication goes smoothly. Therefore, they seem topatient: The relationship between the doctor and the patient is anhave a good relationship.

ordinary one and there is no special closeness between them.

c. Patientʼs reaction toward the utterance by the healthcare
professional: The imposition towards the patient seems to be

On the other hand, the patient and the nurse used to beclassmates and their relationship can be considered close.

high as she has to continue her chemotherapy treatment; the

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c. Patientʼs reaction toward the utterance by the healthcareprofessionals: The imposition of the act of accepting he has aʻpraising oneʼs good pointsʼ. The particle ʻnaʼ is for afﬁrming theserious disease seems to be high, as he needs to continue thestatement（Niwa, 2005）.

treatment. The social distance between the patient and the nurse
is close as they were classmates. The power of the nurse may be

Nsʼ Aoi Vol. 5, p.22

stronger than that of her patient because she knows more than

142 Nurse: I think you will be pleased with the wedding. I

the patient. Therefore, the impact of the face-threatening act on

am sure Takeshi will say something like ʻMy grandma has madethe patient may be quite high. However, the social distance isme what I am now. Thank you, grandma.ʼ

much closer than in ordinary cases, so the impact may not be so

143 Patient: I may miss it if I am not attentive enoughvery high.

144 Nurse: I called up Takeshi... and he will be coming on

The nurse in charge gave the utterance（109）while holding
the patientʼs head. Then the patient started to weep and showed

the day of operation... he says ‘he would like to help you any
way he can.

his understanding by saying yeah（110）. This process indicates

145 Patient:（starts to weep）

that the nurseʼs utterance of encouragement（110）obtained thea. Situation and context of communication: While the doctor

desired effect of giving comfort. The form of Gambaro inwas explaining to the patient that she needs to have an operation,（109）is a plain version of Gambarimasho in（43）and（90）,the nurse in charge stopped by the patientʼs room.

and shows more closeness to her patients. The plain form has ab. Relationship between the healthcare professionals and theirstronger function of volition than the polite form（Niwa, 2005）.

patient: The nurse in charge and the patient are on good terms

Also, ʻtogetherʼ with Gambaro in（109）clariﬁes the function ofwith each other and they sometimes talk about small things suchoffering assistance. Therefore, this encouragement may well beas their hobbies. Also, that the nurse refers to the patientʼscategorised as ʻoffering assistanceʼ.

grandson as Takeshi-san（144）implies they have a good
relationship, as the nurses may well say ʻyour grandsonʼ instead

Puchi Nurse, p. 172

of using his ﬁrst name when they have not established a close

134 Physiotherapist: Hey, Gambare [keep it up]. Just a bit

relationship. In the Japanese contexts, calling each other byoneʼs ﬁrst name shows people have established a close enoughmore.
135 Patient（Child）: Wow, doctor. I made it!

relationship as individuals.

136 Physiotherapist: GREAT! Gambattana [you DID great!]c. Patientʼs reaction toward the utterance by the healthcare
professional: The imposition of the face-threatening act towards

Hang in there.
137 Patient（Child）: Sure!

the patient seems low as the nurse is just relaying the message toa. Situation and context of communication: The rehabilitation

the patient from her grandson. The social distance between thepatient and the nurse is quite close. The power of the nurse

aimed at making this patient walk again has just ﬁnished.
b. Relationship between the healthcare professionals and theirseems, as in other cases, stronger than that of the patient as shepatient: The relationship between the patient and theis in charge of her hospital life. Taking these three factors into

physiotherapist has not been described in the comic story, so it isaccount, the impact of the face-threatening act on the patient is

difﬁcult to judge. However, the elicited communication above

considered low. Also, the patientʼs reaction of starting to weepsuggests there exists good communication between them.

after hearing the nurseʼs utterance（145）may be interpreted asc. Patientʼs reaction toward the utterance by the healthcare

showing that the patient feels happy and relieved. After thisprofessional: The imposition of the act（trying hard）on thecommunication, in the comic story, the patient decides to have

patient seems low as he has received a compliment, and thean operation that she had been afraid of. Therefore, thissocial distance between the patient and the physiotherapist

communication of encouragement（144）succeeds in providing

seems to be appropriate. Regarding power, the physiotherapist is

the patient with the positive politeness effect. With regard to thein the position of instructing the patient. Taking these threetype, this encouragement can be classiﬁed in the type of ʻrelaying

factors into account, the impact of the face-threatening act

the offer of assistance from the patientʼs familyʼ.

towards the patient is low. Also, judging from the situation
where the patient nodded and smiled at the utterance of（137）,

The taxonomy of functions and politeness effects

the communication succeeded in achieving a positive politenessIn order to clarify the overall results of discourse analysis andeffect in both cases. The function of encouragement in（134）to discuss the relationship between the functions and politenesscan be categorised in the type of ʻcheering upʼ ; and（136）as

effects, the taxonomy for functions and politeness effects of− 37 −J Nurs Studies N C N J Vol. 8 No. 1 2009

Table 2 Taxonomy of functions and positive politeness effect
Functions

Frequency

Positive politeness effectCheering up

10（22.0%）8（80.0%）

Relieving from anxiety

7（17.1%）3（42.9%）

Voicing oneʼs thoughts

5（12.2%）3（60.0%）

Formulaic expression of greetings4（9.76%）0（0.0%）

Offering assistance4（9.76%）2（50.0%）

Giving advice

4（9.76%）3（75.0%）Praising patientʼs good points

3（7.32%）

1（33.3%）

Relaying the offer of assistance from the patientʼs family2（4.88%）1（50.0%）Empathising2（4.88%）2（100.0%）

Joking1（1.44%）1（100.0%）

Total

42（100%）25（58.5%）

achieving positive politeness effects is praising their good

encouragement was arranged as follows:

points.
Functions of encouragement
Ten functions were identified amid the communication of

Gambaru expressions vs. other verbal encouragements

encouragement from the studied healthcare scenes using the

In order to ﬁnd out the differences between Gambaru and its

approach of discourse analysis, in reference to the prior study on

inflected forms, and other verbal encouragement such asencouragement（Kurokawa, 2001）as described in the previous

Daijobu in terms of their functions and effects [researchsection about methods. They are a）cheering up, b）relieving

question c）], Gambaru and its inﬂected forms and other verbal

from anxiety, c）voicing oneʼs thoughts, d）formulaic expression

encouragement were arranged separately.

of greetings, e）offering assistance, f）giving advice, g）

Table 3 indicates the frequencies of functions and positive

praising the patientsʼ good points, h）relaying the offer ofpoliteness effects that Gambaru has. They are in descending

assistance from a family member, i）empathising and j）joking.

order of frequency with the number of frequencies in

It must be repeated, however, that utterances may carry pluralparentheses: a）cheering up（5）; b）offering assistance（4）; c）

functions.

formulaic expression of greetings（4）; d）praising the patientʼs

The first numbers in Table 2 show the frequency of thesegood points（3）; e）relaying the offer of assistance from thefunctions from the 41 scenes. There were forty-two utterances

patientʼs family（2）, and f）voicing oneʼs thoughts（1）.

of encouragement, as in one scene two encouragement

Gambaru expressions did not provide the functions of relieving

utterances were found. The most frequent function is a）

from anxiety, empathising, and joking. In other words, thecheering up, the second most frequent is b）relieving fromhealthcare professionals use Gambaru expressions as cheering-anxiety, and ranked third is c）voicing oneʼs thoughts.

up, as a formulaic expression of greeting and as offering
assistance, in the data for this study. Regarding the positive

Politeness effect of encouragement

politeness effects, Gambaru expressions achieved seven positive

The right-hand column of politeness effect in Table 2
indicates the effects of each function of encouragement. The

politeness effects from seventeen cases of encouragement, whichcount as 41.2%.

percentage means the ratio of positive politeness effects in the

In contrast to the result shown in Table 3, verbal

patientʼs response to encouragement from the healthcare

encouragement, other than Gambaru expressions, as found in

professionals. The encouragements with the function of boththe example of Daijobu, provided seven functions and the mostempathising and joking achieve one hundred percent in positivefrequent function was found to be relieving from anxiety（seeresponses from the patients, despite the small number ofTable 4）
, which Gambaru expressions did not provide（seefrequency and/or the small number of denominators. On the

Table 3）. It must be noted here that the function of being aother hand, the encouragement with the function of formulaic

formulaic expression of greeting, did not even exist as a function

expression of greeting has zero percent in positive responses

in other encouragement expressions such as Daijobuyo, unlikefrom the patients. The second least successful function of

Gambaru expressions, which showed the most frequency in a

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2009 年− 38 −

Table 3 Functions and positive politeness effects of Gambaru and its inﬂected forms
Functions

Frequency

Positive politeness effectCheering up

53（60.0%）

Relieving from anxiety

0

Voicing oneʼs thoughts

1

1（100%）

Formulaic expression of greetings

40（0.0%）

Offering assistance42（50.0%）

Giving advice0

Praising patientʼs good points

3

Relaying the offer of assistance from patientʼs family

0Empathising0

Joking0

Totals171（33.3%）7（41.2%）

Table 4 Functions and positive politeness effects of other verbal encouragement
Functions

Frequency

Positive politeness effectCheering up

5

5（100.0%）

Relieving from anxiety

73（42.6%）

Voicing oneʼs thoughts

42（50.0%）

Formulaic expression of greetings

0

Offering assistance0

Giving advice

4

Praising patientʼs good points

03（75.0%）

Relaying the offer of assistance from patientʼs family21（50.0%）Empathising22（100.0%）

Joking11（100.0%）

Totals25

18（72.0%）

formulaic expression of greeting. Regarding both frequencies

the discourse analysis, Gambaru expressions that are frequently

and positive politeness effects, these other expressions exceeded

used in daily verbal interaction in Japanese were compared withGambaru expressions, by eight cases in frequency and by 30.8

other expressions of encouragement.

（72 – 41.2）in percentages of positive politeness effects. These

For instance, verbal encouragement was found to be used

results suggests that other encouragement expressions are more

frequently in the scenes of ʻcheering upʼ, and its politeness effecteffective than Gambaru expressions, though Gambaru

was 80.0 percent. Examining the verbal encouragement used in

expressions may provide some inevitable functions in thethe scenes of ʻcheering upʼ, ʻGambaruʼ and its inflected forms

Japanese socio-cultural contexts, such as being a formulaic

were used with the same frequency as other verbal

expressions that occupy some verbal spaces as a discourse

encouragement. However, as Tables 3 and 4 indicate, themarkers.

percentage of the positive politeness effects achieved by
Gambaru expressions gained was 60 percent, while other verbal
encouragement achieved 100 percent; therefore, it is likely thatConcluding remarks

other verbal encouragement may be more successful in
The present study was conducted in order to examine howachieving in the politeness effect of cheering patients up.

healthcare professionals use verbal encouragement with their

Moreover, the other verbal encouragement has functions ofpatients. First the functions and politeness effects that may berelieving patients from anxiety, giving advice and empathising,produced by verbal encouragement, were evaluated, using thewhile Gambaru and its inflected forms do not have theseapproach of discourse analysis applied to the data from Japanesefunctions. Therefore, when healthcare professionals need tohealthcare comic books. Then, based on the results gained fromrelieve their patients from anxiety, Gambaru and its inflected− 39 −J Nurs Studies N C N J Vol. 8 No. 1 2009

■ References

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impact of face-threatening acts on patients in healthcare settings[People in Hanagoyomi Hospital]. Tokyo: Kodansha.

is generally high. In other words, there are three important

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threatening acts, and to provide the politeness effect.
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Manga ni mirareru kitsuen byoshabamen nitsuiteno

effective communication and sometimes even fails to provide

chosa [Study on scenes of smoking in healthcare comic

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Kurita, R.（2003）. Puchi Nurse [Petit Nurse]. Tokyo: Kodansha.

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The present study may have two limitations. First, the authors
chose seven comic series titles and 41 scenes of encouragement
were elicited. Therefore, for the future studies, the data from thehealthcare comic series titles that were not available or were not

Japanese native speakers]. http://sekky.tripod.com/
0105kurokawa.html
Maynard, S. K.（2004）. Discourse linguistics. Tokyo: Kuroshio
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chosen for this present study should be included so that the

Maynard, S. K.（2005）. Danwahyogen Handbook [Handbook

analysis can make a thorough and in-depth examination offor discourse expressions]. Tokyo: Kuroshio Shuppan.

healthcare encouragement communication for more rigorous

Miura, T.（2006）. Gambare toiu kotoba [Word of ʻGambareʼ].

transferability. Data from doctor-centered comic series or othermedia such as TV dramas or movies would also enhance theresearch into communication. The second limitation concerns

Gekkan Gengo, 2, 76-79.
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the section about discourse analysis, discourse or communicationof modern Japanese grammar]. http://www.geocities.jp/

may carry multiple meanings and functions, influenced, forniwasaburoo/index.html

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politeness theory: Focusing on the concept of relative

医療漫画における励まし表現の談話分析
Rieko Matsuoka1
Ian Smith2
Mari Uchimura3
1 国立看護大学校；〒 204-8575 東京都清瀬市梅園 1-2-1

2 イーストアングリア大学

3 東京医科歯科大学【要旨】 本論文では，効果的な励ましを患者に提供するためにはいかなる励まし表現が推奨されるかを見つけ出すことを目的に，看護師を中心に医療専門家がどのように励まし表現を用いているかを考察する。日本語の「がんばる」という典型的な励まし表現に焦点をあてながら，医師がコミュニケーションの中心になっているものを除いた医療漫画のデータから 41 の場面を抜き出し，それぞれの場面について，コミュニケーションが行われている背景，患者との関係，励ましに対する患者の反応，という 3 つの視点から分析する。特に患者の反応に注目し，ブラウンとレビンソン（1987）によるポライトネス理論から「フェイスを脅かす行為の負荷量」「社会的距離」「相対的力関係」によって患者がフェイスを脅かされる程度を，ウサミ（2006）によるディスコース・ポライトネス理論から「ポライトネスの効果」の程度を評価し考察する。 さらに，それらの場面において抽出した励まし表現を機能に従って「元気づける」や「安心させる」など 10 個のカテゴリーに分類し，機能とポライトネス効果の関係を考察する。また，
活用形を含めた「がんばる」とそれ以外の「励まし」を比較検討し，その結果に基づき，医療コミュニケーションの質を高めるた
めにはいかなる励まし表現が望まれるであろうかについて提案する。

受付日 2008 年 9 月 18 日

− 41 −

採用決定日 2009 年 2 月 6 日

J Nurs Studies N C N J Vol. 8 No. 1 2009

Appendix Healthcare related comic books（ * shows ʻchosenʼ for the study）
Title of Series
Author
1* A Vessel of Life [Inochi no utsuwa]
Uehara, Kimiko
2 With Light [Hikari to tomoni]
Tobe, Keiko
3 Urologist Ippongi Mamoru [Hinyokikai Ippongi Mamoru!]
Takakura, Atsuko
4 Black Jack [Black Jack]
Tezuka, Osamu
5 Diagnoses of Surgeon Tomori Akira [Gekai Tomori Akira no shoken]
Ikeda, Satomi
6 Doctor Chichibu-yama [Doctor Chichibu-yama]
Tanaka, Keiichi
7 I am not an Angel [Tenshi ja nainoyo]
Fujita, Shoko
8 Say hello to BJ [BJ ni yoroshiku]
Sato, Hideki
9 Dr. Kumahige [Dr. Kumahige]
Fumimura, Sho
10 Dr. Harley [Dr. Harley]
Uda, Manabu
11* Nurse Aoi [Nsʼ Aoi]
Koshino, Ryo
12* Open Mind [Open mind]
Yoshizaki, Seimu
13 Blue Sky Clinic [Aozora clinic]
Karube, Junko
14 Glittering [Kirakira hikaru]
Goda, Mamora
15 Doctor Kumano [Kumano sensei]
Yatsuki, Hiroshi
16 Psycho Doctor [Psycho doctor]
Agi Tadashi
17 Psycho Doctor, Kai Kyosuke [Psycho doctor, Kai Kyosuke]
Agi Tadashi
18 Super Doctor, K [Super doctor K]
Mafune, Kazuo
19 Letter to the Sky [Sora eno tegami]
Fukuda, Motoko
20* Petit Nurse [Puchi nurse]
Kurita, Ryo
21 Booking Life [Booking life]
Takada, Yuzo
22 I Live in a Doctorless Village [Ware muison ni ikiru]
Kawai, Hidenori
23 Nine-nine-nine Doctor（Kyu-kyu-kyu doctor）
Barmie Soroku
24 The Sun in Downtown [Shita-machi no taiyo]
Yashima, Masao
25 Jin: Hitoshi [JIN − Hitoshi − ]Murakami, Motoka
26 Dr. Blue Beard is Coming [Aohige wa iku]
Ogane, Toshihiko
27 Operation [Operation]
Kagami, Joji
28 Resident Dr. Kenichi Furutani [Kenshu-i Furutani Kenichi]
Nagai, Akira
29 Here is OB Doctor Tsubaki [Kochira Tsubaki Sanfujin-ka]
Amane, Kazumi
30 The Resident [The resident]
Ogane, Toshihiko
31 Sports Doctor [Sports-i]
Terajima, Yu
32* Nurse Station [Nurse station]
Shimazu, Kyoko
33 Popping in a White Robe [Hakui de pon]
Takasaki, Momoko
34 Scalpel, Glitter! [Mesuyo, kagayake!!]
Ogane, Toshihiko
35* Stupid Nurse [Otankonaasu]
Sasaki, Michiko
36 Love of Kobayakawa Nobuki [Kobayakawa Nobuki no koi]
Saimon, Fumi
37 Living, Dying, and Life [Sei-shi-mei]
Inamoto, Masayuki
38 Very Much Clinic [Tottemo-iin]
Hanai, Hiroshi
39 Doctorʼs Ofﬁce is Closed Today Again[Honjitsu mo kyushin]
Mikawa, Taizan
40 Whisper of Quack [Yabuisha no tsubuyaki]
Morita, Isao
41 Advanced Lifesaving Medical Center [Kodokyumei kyukyu center]
Higuchi, Masakazu
42 Budding Angel [Tenshi no tamago]
Kishi, Kaori
43 A Doctor Living off Another Person [Isoro]
Tsuchiya, Shigeru
44 Hear Sward Doctor: Earnest Doctor [Shinken-i]
Kaminishi, Kazunori
45 Artless and Flawless Doctor [Tenimuho]
Izuki, Keigo
46 Doctor Deﬁant [Doctor Hankotsui]
Kagami, Joji
47 Entrust a Doc. [Doc ni makasero]
Mizutani, Ryuji
48 Fugitive Doctor in Dark [Yami no toboi]
Takayama, Noriyoshi
49 In the Glittering Season [Kagayaku kisetsu no nakade]Okada, Megumi
50 Nursesʼ Jobs [Nurse no oshigoko]
Egashira, Michiru
51 Wiping Tears [Namida wo fuite]
Tsurugina Mai
52 Tomorrow is a Good Day [Asu wa iihida]
Maeda, Kazuo
53 Only Lives are Equal [Seimei dakewa byododa]
Maeda, Kazuo
54 Female Doctor Reika [Joi Reika]
Tsurugina, Mai
55 Great to Have Met You[Anata ni aete yokatta]
Moritsu, Junko
56* People in Hanagoyomi Hospital [Hanagoyomi-byoin no hitobito]
Aimoto, Mizuki

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2009 年− 42 −

Publisher
Akita Shoten
Akita Shoten
Akita Shoten
Akita Shoten
Asahi Shimbun Shuppan
AspectKiri Shobo
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Kodansha
Jitsugyo-no-nihonsha
Jitsugyo-no-nihonsha
Shueisha
Shueisha
Shueisha
Shueisha
Shueisha
Shueisha
Shueisha
Shueisha
Shueisha
Shueisha
Shogakukan
Shogakukan
Shogakukan
Shogakukan
Shogakukan
Shogakukan
Hakusensha
Seishun shuppansha
Nihon Bungeisha
Nihon Bungeisha
Nihon Bungeisha
Nihon Bungeisha
Nihon Bungeisha
Nihon Bungeisha
FusoshaFusoshaBungeishunjusha
Michi shuppan
Michi shuppan
Riidosha
Koike Shoten
Kodansha