The multiple faces of practical wisdom in complex clinical practices: An empirical exploration.

RATIONALE, AIMS, AND OBJECTIVES: In recent publications, attention has been drawn to the importance of practical wisdom in order to ensure good, individually attuned care in complex clinical practices. However, what remains insufficiently elucidated is how practical wisdom emerges in the workplace. This study aims to describe manifestations of practical wisdom in medical practices within a general hospital. It also seeks to clarify the interruptions that can be considered as triggers for the emergence of practical wisdom. Furthermore, we searched for figurations, which possibly elicit or constrain the emergence of practical wisdom. METHODS: We used 10 thick descriptions of very distinct patient cases to carry out an explorative qualitative heuristic in-depth analysis. RESULTS: These varied cases enabled us to describe diverse manifestations of practical wisdom; in addition, we were able to discern 10 different "interruptions" that triggered practical wisdom, and finally, we hypothesize that certain infrastructural figurations might facilitate the manifestation of practical wisdom. CONCLUSIONS: We found that practical wisdom frequently emerged in unexpected and diverse guises in these clinical practices, although the "interruptions" that we discovered did not automatically trigger practical wisdom. We have investigated the figurations mentioned only to a limited degree. More empirical research is needed to make the philosophical concept of practical wisdom better manageable for clinical practices and to gain better understanding of the figurations that elicit or obstruct its manifestation.

Nurses' knowledge and deliberations crucial to Barcoded Medication Administration technology in a Dutch hospital: Discovering nurses' agency inside ruling.

This article shows how Barcoded Medication Administration technology institutionally organizes and rules the daily actions of nurses. Although it is widely assumed that Barcoded Medication Administration technology improves quality and safety by reducing the risk of human error, little research has been done on how this technology alters the work of nurses. Drawing on empirical and conceptual strategies of analysis, this qualitative study used certain tools of institutional ethnography to provide a view of how nurses negotiate Barcoded Medication Administration technology. The approach also uses elements from practice theory in order to discern how technology operates as a player on the field instead of being viewed as a 'mere' tool. A literature review preceded participant observation, whereby 17 nurses were followed and data on an orthopaedic ward were collected over a period of 9 months in 2011 and 2012. Barcoded Medication Administration technology relies on nurses' knowledge to mediate between the embedded logics of its design and the unpredictable needs of patients. Nurses negotiate their own professional logic of care in the form of moment-to-moment deliberations which subvert the ruling frame of the barcoded system and its objectified model of patient safety. The logic of Barcoded Medication Administration technology differs from the logic of nursing care, as this technology presumes medication distribution to be linear, even though nurses follow another line of actor-bound safety practices that we characterize as 'deliberations'.

Professional Medical Discourse and the Emergence of Practical Wisdom in Everyday Practices: Analysis of a Keyhole Case.

Recent publications have argued that practical wisdom is increasingly important for medical practices, particularly in complex contexts, to stay focused on giving good care in a moral sense to each individual patient. Our empirical investigation into an ordinary medical practice was aimed at exploring whether the practice would reveal practical wisdom, or, instead, adherence to conventional frames such as guidelines, routines and the dominant professional discourse. We performed a thematic analysis both of the medical files of a complex patient and her daughter's diary. We did find practical wisdom, but only sporadically, whereas it has proved to be essential for professional care. This deficit appeared to result from several factors like: the organization of the practice; established routines; a hierarchical culture; and a traditional medical discourse. Moreover, we discerned various negative consequences. More empirical research into practical wisdom in everyday medical practices is needed for the benefit of professional and morally good care for every patient.

In search of good care: the methodology of phenomenological, theory-oriented 'N=N case studies' in empirically grounded ethics of care.

This paper proposes a new perspective on the methodology of qualitative inquiry in (care) ethics, especially the interaction between empirical work and theory development, and introduces standards to evaluate the quality of this inquiry and its findings. The kind of qualitative inquiry the authors are proposing brings to light what participants in practices of care and welfare do and refrain from doing, and what they undergo, in order to offer 'stepping stones', political-ethical insights that originate in the practice studied and enable practitioners to deal with newly emerging moral issues. As the authors' aim is to study real-life complexity of inevitably morally imprinted care processes, their empirical material typically consists of extensive and comprehensive descriptions of exemplary cases. For their research aim the number of cases is not decisive, as long as the rigorous analysis of the cases studied provides innovative theoretical insights into the practice studied. Another quality criterion of what they propose that should be called 'N=N case studies' is the approval the findings receive from the participants in the practice studied.

HOW BAR CODED MEDICATION ADMINISTRATION TECHNOLOGY AFFECTS THE NURSE-PATIENT RELATIONSHIPS: AN ETHNOGRAPHIC STUDY.

OBJECTIVES: This study aims to assess how care is mediated through technology by analyzing the interaction between nurses, patients, and a Bar Coded Medication Administration (BCMA) system. The objective is to explore how patients experience care through medication technology, with the main focus of our observations and interviews on nurses rather than patients. METHODS: A qualitative ethnographic study was conducted in an orthopedic ward of a Dutch general hospital. RESULTS: After analyses, the following two themes were discerned: (i) the use of bar code medication technology organizes double institutionalization, and (ii) nurses frequently need to work around the BCMA, as the system is not always supportive of patient needs. CONCLUSIONS: The results of this study indicate that BCMA is not merely a neutral tool, but an active component within the nurse-patient relationship, as it influences medication administration and profoundly affects patient participation in the care process.

A qualitative study assessing patient perspectives in the process of decision-making on disease modifying therapies (DMT's) in multiple sclerosis (MS).

BACKGROUND: Physicians commonly advise patients to begin disease modifying therapies (DMT's) shortly after the establishment of a diagnosis of Multiple Sclerosis (MS) to prevent further relapses and disease progression. However, little is known about the meaning for patients going through the process of the diagnosis of MS and of making decisions on DMT's in early MS. OBJECTIVE: To explore the patient perspective on using DMT's for MS. Methods: Ten participants with a recent (< 2 years) relapsing-remitting MS diagnosis were interviewed. Seven of them were using DMT's at the time of the interview. All interviews were transcribed and analyzed using a hermeneutical-phenomenological approach. RESULTS: The analysis revealed the following themes: (1) Constant confrontation with the disease, (2) Managing inevitable decline, (3) Hope of delaying the progression of the disease, and, (4) The importance of social support. The themes show that patients associate the recommendation to begin DMT's (especially injectable DMT's) with views about their bodies as well as their hopes about the future. Both considering and adhering to treatment are experienced by patients as not only matters of individual and rational deliberation, but also as activities that are lived within a web of relationships with relatives and friends. CONCLUSION: From the patient perspective, the use of DMT's is not a purely rational and individual experience. More attention to the use of DMT's as relational and lived phenomena will improve the understanding of the process of decision-making for DMT's in MS.

Rethinking critical reflection on care: late modern uncertainty and the implications for care ethics.

Care ethics as initiated by Gilligan, Held, Tronto and others (in the nineteen eighties and nineties) has from its onset been critical towards ethical concepts established in modernity, like 'autonomy', alternatively proposing to think from within relationships and to pay attention to power. In this article the question is raised whether renewal in this same critical vein is necessary and possible as late modern circumstances require rethinking the care ethical inquiry. Two late modern realities that invite to rethink care ethics are complexity and precariousness. Late modern organizations, like the general hospital, codetermined by various (control-, information-, safety-, accountability-) systems are characterized by complexity and the need for complexity reduction, both permeating care practices. By means of a heuristic use of the concept of precariousness, taken as the installment of uncertainty, it is shown that relations and power in late modern care organizations have changed, precluding the use of a straightforward domination idea of power. In the final section a proposition is made how to rethink the care ethical inquiry in order to take late modern circumstances into account: inquiry should always be related to the concerns of people and practitioners from within care practices.

Tinker, tailor, deliberate. An ethnographic inquiry into the institutionalized practice of bar-coded medication administration technology by nurses.

AIM: Explore the practice of nurses working with bar-coded medication administration technology, to gain insight in the impact it has on their work. BACKGROUND: The widespread presumption of using Barcoded Medication Administration Technology (BCMA) is that it will effectively reduce the number of errors in the dispensing of medication to patients. However, it remains unclear whether this is the case in actual practice. METHOD: Two distinct but overlapping research methodologies of Institutional Ethnography and Praxeology were combined as a means to uncover the highly complex practice of BCMA by nurses. RESULTS: The implementation of BCMA creates a series of problems leading to nurses constantly tinkering with the technology. At the same time they are continuously deliberating the best ways of tailoring the BCMA to each of their patients. CONCLUSION: Although working with BCMA is often misconstrued as being mindless and automatic, conforming to the technology, this tinkering with BCMA in fact always entails thorough deliberation by nurses.

Multiple sclerosis (MS) in the life cycle of the family: An interpretative phenomenological analysis of the perspective of persons with recently diagnosed MS.

INTRODUCTION: In this study the authors explored how people with recently diagnosed multiple sclerosis (MS) experience their disease within their family lives. Ten people in various stages of the cycle of family life (leaving home, finding a partner, raising children, parenting adolescents, launching children) who had been diagnosed with MS were interviewed in half-structured conversational interviews. METHOD: Transcriptions were analyzed following a phenomenological approach. RESULTS: Five themes were found: (a) dwindling capacity for housekeeping and childcare (b) struggling to ask for or to accept help, (c) countering awkward attitudes toward my illness, (d) suspecting family members of concealing their, and (e) watching family members wrestle with your illness. DISCUSSION: The participants described that their illness affected their ability to care for their family and home as they used to. Only a couple of studies have addressed the first person perspective of patients on family and MS. The study expands on these studies by exploring not previously examined perspectives on leaving home, finding a partner, parenting adolescents, and launching children. The findings on family and MS, approached as elements of the first person perspective of MS patients, may guide future research. Given the pivotal role of worries on family in patient experience of MS, we argue that acknowledgment of family as a constitutive element of the patient perspective should be integrated in regular MS care. The authors suggest that the clinical handling of MS as a family issue needs to be done thoughtfully and with attention to the specifics of each unique family situation. (PsycINFO Database Record

Is technology the best medicine? Three practice theoretical perspectives on medication administration technologies in nursing.

Even though it is often presumed that the use of technology like medication administration technology is both safer and more effective, the importance of nurses' know-how is not to be underestimated. In this article, we accordingly try to argue that nurses' labor, including their different forms of knowledge, must play a crucial role in the development, implementation and use of medication administration technology. Using three different theoretical perspectives ('heuristic lenses') and integrating this with our own ethnographic research, we will explore how nursing practices change through the use of medication technology. Ultimately, we will argue that ignoring (institutional) complexity and the various types of important knowledge that nurses have, will seriously complicate the implementation of medication administration technology.

The MS@Work study: a 3-year prospective observational study on factors involved with work participation in patients with relapsing-remitting Multiple Sclerosis.

BACKGROUND: Multiple Sclerosis (MS) is the most common cause of neurological disability in young and middle-aged adults. At this stage in life most people are in the midst of their working career. The majority of MS patients are unable to retain employment within 10 years from disease onset. Leading up to unemployment, many may experience a reduction in hours or work responsibilities and increased time missed from work. The MS@Work study examines various factors that may influence work participation in relapsing-remitting MS patients, including disease-related factors, the working environment and personal factors. METHODS/DESIGN: The MS@Work study is a multicenter, 3-year prospective observational study on work participation in patients with relapsing-remitting MS. We aim to include 350 patients through 15-18 MS outpatient clinics in the Netherlands. Eligible participants are 18 years and older, and either currently employed or within three years since their last employment. At baseline and after 1, 2 and 3 years, the participants are asked to complete online questionnaires (including questions on work participation, work problems and accommodations, cognitive and physical ability, anxiety, depression, psychosocial stress, quality of life, fatigue, empathy, personality traits and coping strategies) and undergo cognitive and neurological examinations. After six months, patients are requested to only complete online questionnaires. Patient perspectives on maintaining and improving work participation and reasons to stop working are gathered through semi-structured interviews in a sub-group of patients. DISCUSSION: Prospective studies with long-term follow-up on work participation in MS are rare, or take into account a limited number of factors. The MS@Work study provides a 3-year follow-up on various factors that may influence work participation in patients with relapsing-remitting MS. We aim to identify factors that relate to job loss and to provide information about preventative measures for physicians, psychologists and other professionals working in the field of occupational health.

Ethical sensitivity in practice: finding tacit moral knowing.

AIM: This article presents a discussion of the conceptual model of ethical sensitivity. BACKGROUND: Recent research pays little attention to the tacit dimension of ethical knowledge. We focus on care practices, drawing a distinction between explicit moral knowledge and tacit moral knowing. This focus has far-reaching methodological consequences, influences the research design of empirical research and enables healthcare workers to discern both explicit and tacit knowing. DATA SOURCES: This article draws on literature about tacit knowledge, practices and ethical sensitivity, covering publications from 1958-2011. Data used in the illustrative cases were gathered in 2009 during the phenomenological phase of a multiple-case study. DISCUSSION: Taking practices as the point of entry for exploring ethical sensitivity makes it possible to study empirically both explicit moral knowledge and tacit moral knowing. Given how relevant practical knowledge is, we aim to put forward a theoretical framework that leaves room for the discernment of this tacit moral knowing. IMPLICATIONS FOR NURSING: Creating opportunities to reflect on daily ethical concerns in an inter-professional team can contribute to improvement on quality of care. CONCLUSION: The broadened perspective on ethical sensitivity can be used as a heuristic device to discern what both explicit and implicit moral knowledge in care are about. This empirical way of looking at care practices can enhance the awareness of the moral knowing of the professional caregiver.

Conditions for religious discourse in secularized ethical health care deliberation.

Religious discourse is no longer self-evident in professional health care ethical deliberation in the North Atlantic cultural sphere. However, in a world of pluralism, care professionals still seek substantive views of good care. Religious and non-religious beliefs should not be excluded from ethical deliberation. They offer patients and professionals a helpful language for expressing values and beliefs. Chaplains have a role to play as allies in sense-making processes and resourcing care.