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

The continuing formation of relational caring professionals

Learning to work as a relational caring professional in healthcare and social welfare, is foremost a process of transformative learning, of Building, of professional subjectification. In this article we contribute to the design of such a process of formation by presenting a structured map of five domains of formational goals. It is mainly informed by many years of care-ethical research and training of professionals in healthcare and social work. The five formational domains are: Relational Caring Approach, Perception, Knowledge, Interpretation, and Practical Wisdom. The formation process, described as the recurring detour of a continuing practice, requires ‘exposure’, in-depth learning and learning communities. Relational caring—care consequently resulting from and structured by relational thinking, exploring, and steering—requires ‘inquiry’ as a continuous learning process in practice. The process is ultimately aimed at fostering mature, competent, and practically wise professional caregivers who are able to relationally connect with and attune to care receivers, and adequately navigate existential, moral, and political-institutional tensions in relational caring in complex organizations in Late-Modern society.

Care ethics framework for midwifery practice: A scoping review

Background: As a normative theory, care ethics has become widely theorized and accepted. However, there remains a lack of clarity in relation to its use in practice, and a care ethics framework for practice. Maternity care is fraught with ethical issues and care ethics may provide an avenue to enhance ethical sensitivity.Aim: The purpose of this scoping review is to determine how care ethics is used amongst health professions, and to collate the information in data charts to create a care ethics framework and definition for midwifery practice.Method: The scoping review was conducted according to the Preferred Reporting Items for Scoping reviews (PRISMA-ScR) and Joanna Briggs Institute (JBI) recommendations. The search was applied to the databases CINAHL, MEDLINE, PschInfo and Pubmed which were searched in September 2019 and again in July 2021. The inclusion criteria were guided by the mnemonic for search terms: Participants, Concept, and Context (PCC) and included variations of health care professionals, care ethics and utilization. The search was limited to qualitative studies published in English between 2010 and 2021. A data extraction tool was used to extract and synthesize data into categories. The articles were screened for eligibility by title, abstract and full text review, by two independent reviewers.Ethical Considerations: The scoping review was guided by ethical conduct respecting authorship and referencing sources.Results: Twelve of the initially identified 129 studies were included in the scoping review. Data synthesis yielded four categories of care ethics use by health professionals: relationship, context, attention to power and caring practices. In combination, the evidence forms a framework for care ethics use in midwifery practice.Conclusion: Care ethics use by health professionals enhances ethical sensitivity. A framework and definition for care ethics for midwifery practice is proposed. This review will be of interest to midwives and other health practitioners seeking to enhance ethical sensitivity.

Virtue and care ethics & humanism in medical education: a scoping review

PURPOSE

This scoping review explores how virtue and care ethics are incorporated into health professions education and how these factors may relate to the development of humanistic patient care.

METHOD

Our team identified citations in the literature emphasizing virtue ethics and care ethics (in PubMed, NLM Catalog, WorldCat, EthicsShare, EthxWeb, Globethics.net , Philosopher's Index, and ProQuest Central) lending themselves to constructs of humanism curricula. Our exclusion criteria consisted of non-English articles, those not addressing virtue and care ethics and humanism in medical pedagogy, and those not addressing aspects of character in health ethics. We examined in a stepwise fashion whether citations: 1) Contained definitions of virtue and care ethics; 2) Implemented virtue and care ethics in health care curricula; and 3) Evidenced patient-directed caregiver humanism.

RESULTS

Eight hundred eleven citations were identified, 88 intensively reviewed, and the final 25 analyzed in-depth. We identified multiple key themes with relevant metaphors associated with virtue/care ethics, curricula, and humanism education.

CONCLUSIONS

This research sought to better understand how virtue and care ethics can potentially promote humanism and identified themes that facilitate and impede this mission.

Does midwifery-led care demonstrate care ethics: A template analysis

BACKGROUND

Ethical care in maternity is fundamental to providing care that both prevents harm and does good, and yet, there is growing acknowledgement that disrespect and abuse routinely occur in this context, which indicates that current ethical frameworks are not adequate. Care ethics offers an alternative to the traditional biomedical ethical principles.

RESEARCH AIM

The aim of the study was to determine whether a correlation exists between midwifery-led care and care ethics as an important first step in an action research project.

RESEARCH DESIGN

Template analysis was chosen for this part of the action research. Template analysis is a design that tests theory against empirical data, which requires pre-set codes.

PARTICIPANTS AND CONTEXT

A priori codes that represent midwifery-led care were generated by a stakeholder consultative group of nine childbearing women using nominal group technique, collected in Perth, Western Australia. The a priori codes were applied to a predesigned template with four domains of care ethics.

ETHICAL CONSIDERATIONS

Ethics approval was granted by the Edith Cowan University research ethics committee REMS no. 2019-00296-Buchanan.

FINDINGS

The participants generated eight a priori codes representing ethical midwifery care, such as: 1.1 Relationship with Midwife; 1.2 Woman-centred care; 2.1 Trust women's bodies and abilities; 2.2. Protect normal physiological birth; 3.1. Information provision; 3.2. Respect autonomy; 4.1. Birth culture of fear (midwifery-led care counter-cultural) and 4.2. Recognition of rite of passage. The a priori codes were mapped to the care ethics template. The template analysis found that midwifery-led care does indeed demonstrate care ethics.

DISCUSSION

Care ethics takes into consideration what principle-based bioethics have previously overlooked: relationship, context and power.

CONCLUSION

Midwifery-led care has been determined in this study to demonstrate care ethics, which suggest that further research is defensible with the view that it could be incorporated into the ethical codes and conduct for the midwifery profession.

Living in an 'ordinary' neighborhood? A care-ethical exploration of the experiences of young adults with mild intellectual disabilities

Care ethics considers the moral good as arising within practices and in people's experiences in these practices. This contribution applies a care-ethical approach to inquire into the effects of a major change in the social domain policy in The Netherlands. The new policy is based upon the expectation that young adults with Mild Intellectual Disabilities (MID) become 'active citizens, participating in their neighborhood', with the support of care organizations and local municipalities. Accordingly, care responsibilities were transferred to the local level (municipalities). On this level, however, basic insights were lacking concerning the needs and wishes of the young adults with Mild Intellectual Disabilities, and concerning the possibilities for local collaboration. Research was performed by taking Joan Tronto's definition of care as a starting point and applying a method adequate to capture young adults' experiences in one municipality. We conclude that this neighborhood is not an environment wherein they can participate. Points of interestThis article offers new insight into the effects of a major change in long-term care policy in the Netherlands that emphasizes participation.Care ethics focusses on practices, in which more than two people are involved, that help meet needs of care (or fail in this respect).The article presents an inquiry into the experiences and needs of six participants living in a Dutch facility where youths and young adults with Mild Intellectual Disability are supported to participate in society, as expressed by themselves in photos and interviews and as observed through the method of shadowing.The results of this inquiry are three aerial photos that show how the participants live in supporting networks with gaps, underscoring their experiences of being displaced and feeling unacknowledged in the vicinity of their home.Different organizations directed at care for young adults with Mild Intellectual Disability can learn from the care needs that result from this way of organizing care.

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.

Fear, fight, familiarize: the experiences of people living with relapsing-remitting multiple sclerosis and taking oral medication

Purpose: In addition to becoming familiar with the life changing event of having a chronic illness and exploring its meaning in daily life, people with relapsing-remitting Multiple Sclerosis (RRMS) are faced with important decisions about immunomodulating treatment. Biomedical research on the use of Disease Modifying Therapies (DMTs) mostly focuses on adherence, conceptualized and understood as a behavioral act leading to a desired outcome. Less attention has been paid to the meaning for a person with RRMS of starting and continuing the use of DMTs. Studies on the experiences of people with RRMS taking orally administered DMTs are lacking. The aim of this phenomenological study was to examine the experiences of people with RRMS taking oral medication. Methods: The study was guided by Interpretative Phenomenological Analysis (IPA) and Phenomenology of Practice. 25 persons with RRMS participated in in-depth interviews. Results: In general, participants of this study find themselves in alternating phases that vary by degree of experienced unfamiliarity or familiarity with concern to one's illness, one's changing body, and one's new life. The meaning of taking medication is closely related to these phases. Conclusions: Adherence serves a purpose in the lifeworlds of participants. Medication is the embodiment of this purpose. The pill has inherent meaning.

(In)visible materialities in the context of dementia care

Seemingly mundane materialities are intertwined with important, but often neglected, care interactions. It has been argued that if healthcare professionals paid more attention to the roles materialities can have, everyday routines could become important occasions for care. In response to such proposals, we argue that it is relevant to examine how materialities are currently understood. In this article, we explore materialities as part of work in a dementia unit. Using abstracted illustrations of everyday materialities to elicit reflections, we conducted 11 individual interviews with certified nursing assistants. Through phenomenographic analysis we explain our findings as three different categories conceptualising understandings of materialities as: 'tools for care', 'a set of principles for care' and 'caring relationships'. Our analysis indicates that understanding materialities as instruments was reinforced and made visible through the healthcare organisation while understanding materialities as part of specific relationships with residents appeared informal and less visible. How materialities were understood seemed to have several implications for residents. While care practices could benefit from nursing assistants' abilities to alternate between ways of understanding materialitites, such competence seemed dependent on how professional care was organised, structured and materialised.

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.

Practical wisdom in complex medical practices: a critical proposal

In recent times, daily, ordinary medical practices have incontrovertibly been developing under the condition of complexity. Complexity jeopardizes the moral core of practicing medicine: helping people, with their illnesses and suffering, in a medically competent way. Practical wisdom (a modification of the Aristotelian phronèsis) has been proposed as part of the solution to navigate complexity, aiming at the provision of morally good care. Practical wisdom should help practitioners to maneuver in complexity, where the presupposed linear ways of operating prove to be insufficient. However, this solution is unsatisfactory, because the proposed versions of practical wisdom are too individualistic of nature, while physicians are continuously operating in varying teams, and dealing with complicated technologies and pressing structures. A second point of critique is, that these versions are theory based, and thus insufficiently attuned to the actual context of everyday medical practices. Now, our proposal is to use an approach of practical wisdom that enables medical practices to counter the complexity issue and to re-invent the moral core of medical practicing as well. This implies a practice oriented approach, as thematized by practice theory, qualitative empirical research from the inside, and abduction from actual performed practical wisdom towards an apt understanding of phronèsis.

The Mindful Body: A Phenomenology of the Body With Multiple Sclerosis

For people living with multiple sclerosis (MS), one's own body may no longer be taken for granted but may become instead an insistent presence. In this article, we describe how the body experience of people with MS can reflect an ongoing oscillation between four experiential dimensions: bodily uncertainty, having a precious body, being a different body, and the mindful body. People with MS can become engaged in a mode of permanent bodily alertness and may demonstrate adaptive responses to their ill body. In contrast to many studies on health and illness, our study shows that the presence of the body may not necessarily result in alienation or discomfort. By focusing the attention on the body, a sense of well-being can be cultivated and the negative effects of MS only temporarily dominate experience. Rather than aiming at bodily dis-appearance, health care professionals should therefore consider ways to support bodily eu-appearance.