Keynotes: Nelly Oudshoorn - Professor of Technology Dynamics and Health Care Department of Science, Technology and Policy Studies, University of Twente e: n.e.j.oudshoorn@utwente.nl w: www.utwente.nl/mb/steps/people/scientific/oudshoorn
Nelly Oudshoorn is a professor of Technology Dynamics and Health Care at the University of Twente, the Netherlands. Her research interests and publications include the co-construction of technologies and users, with a particular focus on medical technologies and information and communication technologies. Her most recent book, Telecare Technologies and the Transformation of Healthcare (Palgrave 2011), has received the Book of the Year Prize 2012 of the Foundation for the Sociology of Health and Illness of the British Sociological Association.
ABSTRACT: How Spaces Matter in Telecare: a Techno-geographical Approach
In the last 15 years, the healthcare sector has witnessed the testing and introduction of an increasing number of telecare applications that enable care at a distance. In this paper I will argue that sociological and philosophical studies of telecare can be enriched by including a focus on place to understand the dynamic interactions between people and things. Adopting insights of human geographers, I will show how places in which technologies are used affect how technologies enable or constrain human actions and identities. Whereas some places may facilitate the incorporation of technologies, others may resist technologies. To capture, and further explore, this changing spatial configuration of healthcare, I introduce the notion of techno-geography of care. This concept provides a useful heuristic to study how spaces matter in healthcare.
Although telecare technologies introduce virtual encounters between healthcare providers and patients, the use of telecare devices is always situated somewhere. In contrast to the rhetoric on telecare, which emphasizes spatially unbounded care practices, telecare technologies still largely depend on locally-grounded, situated care acts. Based on interviews with users of several cardiac telecare applications, I will argue that patients home and public spaces are important places involved in shaping the implementation and use of telecare technologies.
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Professor Davina Allen School of Nursing and Midwifery Studies, Cardiff University e: allenda@cardiff.ac.uk w: www.cardiff.ac.uk/sonms/contactsandpeople/academicstaff/allen-davina-overview_new.html
Davina Allen is a sociologist of healthcare work and has a practice background in adult nursing. A Professor in Cardiff School of Health Sciences, she is currently in receipt of a Health Foundation Improvement Science Fellowship undertaking a programme of research focused on developing a detailed understanding of healthcare coordination.
ABSTRACT: Rethinking holism, rethinking routines: Stretching old labels for a sustainable professional future
The history of modern nursing is marked by a deep-seated tension between the clinical and organisational components of the practice role. Over the last forty years, however, it is the former that has been critical in shaping the professional mandate. Nursings claim to expertise is predicated on a holistic model of patient care informed by a bio-psycho-social approach, with nursing theories and models underlining the importance of therapeutic relationships as the foundation for practice. Yet research demonstrates that nurses not only experience significant material constraints in realising these ideals their contribution to healthcare extends far beyond direct work with patients. Even a cursory glimpse inside healthcare organisations reveals that, for all their appearance of laminated rationality, it is nurses who, in numerous ways, support and sustain the delivery and organisation of health services and the demands and complexity of this work are increasing. In recent history, however, this wider work has generally been regarded as at best an adjunct to the core nursing function, and at worse, responsible for taking nurses away from their real work with patients. Indeed, many of the new clinical governance and improvement technologies in healthcare are promoted on the grounds that they will relieve nurses of such burdens and release time to care.
Arguments about the negative effects of nurses non-clinical functions on their work with patients undoubtedly have credence and interventions which purport to support this activity have a self- evident appeal. But there is a limit to how far organisation can be delegated to non-human actors and the professions ambiguity about these elements of its function may not only be preventing nursing from fulfilling its potential it might also be damaging for the profession and the public. Buttressed by growing societal unease about fundamental care standards (Institute of Medicine 1999; The Mid Staffordshire NHS Foundation Trust Inquiry 2010) and a sense that the profession has lost its way, there is a growing recognition that understanding nursing work exclusively in terms of unmediated patient care is no longer serving the interests of the profession or the public (Chambliss 1997; 2004; Allen 2007; Maben and Griffiths 2008) and that a new model of professionalism is P a g e | 3
required which recasts the nursing role more widely to include nurses contribution to the whole health system (Maben and Griffiths 2008). Studies of professional identity suggest this is highly resilient however, which means it can be slow to change. Nevertheless, over its occupational history the content of nursing work has been remarkably fluid, and the profession has a strong record of accommodating new functions through the extension of old labels (Goodrick and Reay 2010).
Drawing on a wider ethnographic study of nurses organising work and actor network and practice- based theories, in this presentation I consider how we might stretch two fundamental ideas within nursing philosophy holism and routines to redefine the nursing mandate to accommodate the challenges of contemporary healthcare systems.
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Associate Professor Stephen Timmons School of Health Sciences, The University of Nottingham e: stephen.timmons@nottingham.ac.uk w: www.nottingham.ac.uk/healthsciences/people/stephen.timmons
Stephen Timmons studied sociology at the universities of Cambridge and York. After working in the NHS he did his PhD on nursing care planning systems at Anglia Ruskin University. He is now Associate Professor in sociology in the School of Health Sciences, University Of Nottingham. In his research he uses Science and Technology Studies, and sociology of professions to study a variety of issues in healthcare. He is a member of Council of the Royal College of Emergency Medicine.
ABSTRACT: Is there such a thing as nursing technology?
The relationship between nursing and technology remains contested, despite (for instance) Sandelowski and Burnard who show that this is in many ways a false distinction, and the work of theorists like Haraway or Latour who would question whether such a distinction between the human and non-human can ever be drawn. In this paper I will seek to address another issue in nursing and technology. This is the question of whether the technologies that nurses use are distinctively nursing technologies. Drawing on a broadly STS approach, I will argue that often nursing has technology designed for it or imposed upon it. This is possible because of nursings subordinate status, and because of the gendered status of technology. Its striking that neither doctors nor managers seem to have this problem: It appears to be straightforward to know what medical technologies or managerial technologies are.
I want to argue that nursing should seize control of the technology that it uses by thinking about and designing new, distinctively nursing technologies. I will draw on the work of Cheryl Crocker and her notion of technology transformed to show how this might be possible. I would contend that the time is right to do this; designing and building new technologies has paradoxically never been easier. As technology plays a key role in defining professions and their scope, this approach could prove fruitful to the nursing profession more widely.
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Dr Alan Barnard School of Nursing, Queensland University of Technology e: a.barnard@qut.edu.au w: http://staff.qut.edu.au/staff/barnard
Dr Alan Barnard is a nurse with a background in philosophy and psychology. Alan is a senior lecturer at Queensland University of Technology, Australia and has extensive academic and clinical experience. He is also a Research Fellow at a major Australian hospital, is the recipient of major research grants and has published extensively on technology and nursing. He is interested in the relationship between person-focused care, technology and nursing practice.
ABSTRACT: The Need for philosophic reflection on nursing, technology and the discourse of difference
Technology is core business in nursing and it continues to impact directly upon nursing practice(s), education and care. Technology is significant to the history and future of nursing yet as nurses we have inadequately understood both its influence upon our practice and how to best address the many challenges associated with it. This presentation will overview a model that broadens explanation of technology to be more than machinery and artifact, in order to argue that technology needs to be understood to include knowledge, skills and a specific way of thinking (technique). Technique is the formation of a system of thinking aimed toward the absolute efficiency of methods and means in every field of human endeavor.
The thesis of the paper is that development of philosophy(ies) of technology and nursing is fundamental to discipline maturity and ultimately our role in enhancing person focused health care. It will be argued that we must further our responsibility and interest in critiquing current and future health care systems through philosophic inquiry into the experience, meaning and implications of technology. Nurses are situated as important contributors to the use and integration of health care technology yet we continue often to advance a discourse of difference between nurses and technology as if we are in opposition to it. The paper argues for philosophy(ies) of technology and nursing, and posits that the cause of experiences related to dehumanisation, or claims of inadequate health care are less a result of the inclusion of machinery and artifacts, then they are about the goals of technique, choices we make in practice, our thinking, and decisions about what is judged to be important in care delivery. Interpretation highlights the influences of popular culture and commonplace assumptions about technology, such as the primacy of progress and presumption of neutrality, as central tenets influencing nursing literature and the construction of nursing evidence.
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The presentation concludes with practice examples of human focused care that occurs even in highly technological environments. It will be demonstrated that what is required is explication of our complicated and changing relationship with technology, which is more than simply about dehumanisation as a logical outcome of technology. Technology is at any moment in time increasingly understood to depend on the eye of the beholder, the hand of the user, and the technological systems that influence integration and use.
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Dr Neema Sofaer Centre of Medical Law & Ethics, King's College London Fellow in Ethics and Health, Harvard University w: www.kcl.ac.uk/prospectus/staff/index/id/1465 w: http://peh.harvard.edu/people/sofaer.html
Dr Neema Sofaer obtained a BA in English and Philosophy, and an M.Phil in Philosophy, from Trinity College, Cambridge. After studying philosophy and classics at Harvard University as a Kennedy Memorial Scholar, she obtained her PhD in Linguistics and Philosophy from Massachusetts Institute of Technology. She then returned to Harvard as a Research Fellow, where she re-trained as a social scientist and worked on some incredibly interesting projects. These included the drafting of Massachusetts Department of Public Healths pandemic flu guidelines, a National Institutes of Health study of people participating in clinical trials to obtain standard healthcare, and a Norwegian government project to describe and evaluate the distribution of HIV drugs in Uganda.
Most recently, Neema was at Kings College London, where she managed her own Wellcome Trust grant on the legal and ethical aspects of post-trial access to trial drugs. There, she designed and carried out a three-year international consultation, which she used to first-author what is now the current Health Research Authority Guidance on post-trial access to trial drugs. She also developed and published (with Daniel Strech) a process for summarising complex debates in medical ethics for medical professionals and policy makers. With Nir Eyal, she won her fields biennial, worldwide prize for work on the ethics of translational health research.
ABSTRACT: Reasons Why Post-Trial Access to Trial Drugs Should, or Need not be Ensured to Research Participants: A Systematic Review
Background: Researchers and sponsors increasingly confront the issue of whether participants in a clinical trial should have post-trial access (PTA) to the trial drug. Legislation and guidelines are inconsistent, ambiguous or silent about many aspects of PTA. Recent research highlights the potential importance of systematic reviews (SRs) of reason-based literatures in informing decision- making in medicine, medical research and health policy.
Purpose: To systematically review reasons why drug trial participants should, or need not be ensured PTA to the trial drug and the uses of such reasons.
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Data sources: Databases in science/medicine, law and ethics, thesis databases, bibliographies, research ethics books and included publications' notes/bibliographies.
Publication selection: A publication was included if it included a reason as above. See article for detailed inclusion conditions.
Data extraction and analysis: Two reviewers extracted and analysed data on publications and reasons.
Results: Of 2060 publications identified, 75 were included. These mentioned reasons based on morality, legality, interests/incentives, or practicality, comprising 36 broad (235 narrow) types of reason. None of the included publications, which included informal reviews and reports by official bodies, mentioned more than 22 broad (59 narrow) types. For many reasons, publications differed about the reason's interpretation, implications and/or persuasiveness. Publications differed also regarding costs, feasibility and legality of PTA.
Limitations: Reason types could be applied differently. The quality of reasons was not measured.
Conclusion: This review captured a greater variety of reasons and of their uses than any included publication. Decisions based on informal reviews or sub-sets of literature are likely to be biased. Research is needed on PTA ethics, costs, feasibility and legality and on assessing the quality of reason-based literature.
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Concurrent sessions Transforming Caring into Bytes: An Institutional Ethnography examining the impact of the Electronic Health Record on Care deliveryThe patient record has evolved greatly in the past century. From its initial purpose of being a record of the individual patients health condition it has evolved to a tool used for institutional risk management, financial, and quality assurance purposes. Even though the Electronic Health Record (EHR) is widely being implemented and it has a become central part of care delivery, little is known about how the work of everyday patient care and specifically the patient provider relationship, has been impacted by the use of it. This Institutional Ethnography examines how the electronic health record has impacted healthcare delivery. Findings of this study included: This study demonstrated that the use of the electronic health record has led to a sense of proletariatization and alienation of healthcare providers, particularly nurses. This study yielded a large amount of data. These rich data offered a good insight in how the EHR is changing the healthcare delivery system. Key findings included: The implementation of the EHR has led to significant changes in care delivery. Healthcare providers work is being directed by the documentation requirements. Institutions are aware of how they can change care delivery and use this new gained capability readily. Caregivers have seen a proletariatization of their work. The work of assessing a patients, meaning, that they try obtain comprehensive understanding of the condition of the patient is being replaced with data collection. Data collection, in contrary to assessment, is focused on pulling apart a patient in separate data points. E.g. level of pain, numeric value for the level of falling. The move to the EHR has led to a sense of Alienation with the Care providers. This study showed how Karl Marxs theory on the impact of technology is current. This study demonstrates 4 levels of Alienation: o Alienation of the product of the Caregivers labor o Alienation of a sense of professional o Alienation of personal identity. o Alienation from others (Patients and Colleagues) This findings of study are linked to the work of works of Martin Heidegger, Michel Foucault, Andrew Feenberg and Albert Borgman . Hans-Peter de Ruiter PhD, RN Minnesota State University, Mankato 7700 France Ave S Suite 360 Edina, MN 55435 507-389-6812 deruih@mnsu.ed P a g e | 10
How should we search the literature? Evidence based practice and nurse education
Nursing dissertations often take the form of a literature review and post registration/licensure, it can be argued that search and assessment skills are necessary prerequisites for the successful performance of evidence based practice. To meet academic and professional requirements (and putting assessment to one side), educators introduce literature searching skills to students and this introduction makes use of texts that, it is argued, are problematic. Using work by Helen Aveyard to illustrate recommended practice, this paper explores some of the assumptions that permeate thinking about literature searching. It is proposed both that the number and types of sources that need to be located remain indeterminate and open to contestation and, also, that an overly narrow interpretation of the purpose and structure of nursing literature searches is frequently presumed. Thus it is commonly supposed that the search process should and can begin with the formulation of an answerable question and, to address the question posed, unhelpful or limiting conventions about what counts as evidence are assumed. Students and registered nurses are however, properly and legitimately interested in subjects that cannot easily be collapsed or framed in a way that allows answerable questions to be set and targeted answering evidence sought. If the purpose of literature searches is interpreted broadly rather than narrowly, alternative conceptions of search construction deserve consideration. Thinking about how students are introduced to search strategies provides a useful vehicle for investigating important aspects of evidence based practice and nurse education. Unresolved questions about the meaning and purpose of evidence in or for nursing practice underpin the way we approach and read the literature. Martin Lipscomb PhD, RN University of the West of England Faculty of Health and Life Sciences Department of Nursing and Midwifery Alexandra Warehouse West Quay Gloucester Docks Gloucester GL1 2LG
email: Martin.Lipscomb@uwe.ac.uk
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Clinical Labor Optimization: Managing Supply and Demand in a Dynamic Environment
Healthcare organizations continue to be challenged by the conflicting priorities of deploying scarce nursing resources. Cost constrained organizations, shortages of professional nurses, and the need to drive retention by meeting staffs schedule preferences are often in conflict as leaders strive to create staffing and scheduling protocols. The traditional approaches to this activity are not systems based and often involve a point solution whereby a single component of the system is improved, often to the detriment of the system as a whole. Because the systems of staffing and scheduling are dynamic, complex and non-linear, the traditional algebraic approaches serve a single dimension of the system; i.e. staff preference or cost effectiveness. Optimization modeling, which has been identified as best practice in other logistics intensive industries can be applied in the solution of these problems in complex adaptive systems. These models find the best solution when balancing complex work rules, union contracts, staff preference, budget requirements, and various models of care. Fitzpatrick will present several hospital case studies describing Two specific best practices from the logistics industry have been applied to the system of staffing and scheduling; Lean production operations strategies and the use of linear programming to model the complexities of the staffing processes. : The quantitative as well as qualitative components of the model The importance of interpretation and implementation of the staffing strategy The need for process improvement to actualize the financial results Achieving the business objectives of adequate coverage for demand, lowest cost solutions, and satisfied staff Therese Fitzpatrick, PhD, RN Assistant Professor, The University of Illinois-Chicago, USA Department of Health System Science, College of Nursing Contact Information: 822 West Golf Road Libertyville, Illinois 60048 USA 312.401.2738 (mobile) Email: therese@uic.edu or ThereseAFitzpatrick@gmail.com P a g e | 12
Phenomenology, Evidence-Based Practice and the Study of Family Presence in Critical Care Units
Patient-centered care rather than disease-centered care with treatment recommendations and decision making tailored to patients preferences and beliefs is emphasized in todays healthcare. Guidelines for evidence-based best practices for support of families in the delivery of patient- centered care in critical care have been established but only a number of institutions have policies on family presence. Reliable, well-designed, high-quality research studies attending to family- centered care will strengthen the level of evidence and document why family presence is not incorporated in institutional polices. At the same time, evidence must extend beyond the current emphasis on random controlled trials as the criterion standard in inquiry, which thereby devalues or excludes qualitative studies. Qualitative studies like phenomenology are also most often ranked lower in hierarchy of evidence, along with descriptive, evaluative, and case studies as weaker forms of evidence compared with other research designs that examine interventions. From the findings of two phenomenological studies, this paper aims to instill an evidence-based mindset into qualitative research and a need to balance scientific knowledge gained through empirical research and evidence from qualitative studies. The sheer proliferation of qualitative health research has made qualitative findings difficult to dismiss and has generated urgent calls to incorporate them into the evidence- based practice process. Qualitative questions are meaning questions influenced by a focus in understanding of human experiences and the contexts of which the experiences occur. These types of questions are asked to determine meaning, to provide insight and scope to a phenomenon, and to appreciate a specific populations experience. Brigitte S. Cypress, EdD, RN, CCRN (Assistant Professor) Institutional affiliation: Lehman College, City University of New York Contact address: P. O. Box 2205 Pocono Summit, PA 18346 USA email: brigitte.cypress@lehman.cuny.edu
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What kind of robot might merit acceptance as an authentic companion?
Creating android and humanoid robots to furnish companionship in the nursing care of older people continues to attract substantial development capital and research. Some people object, though, that machines of this kind furnish human-robot interaction characterized by inauthentic relationships. In particular, robotic and artificial intelligence (AI) technologies have been charged with substituting mindless mimicry of human behavior for the real presence of conscious caring offered by human nurses. When thus viewed as deceptive, these robots also have prompted corresponding concerns regarding their potential psychological, moral, and spiritual implications for people who will be interacting socially with the machines. Such objections and concerns can be assessed quite differently, depending upon ones ambient culture and metaphysical presuppositions. The complaints may be set aside as unnecessary, for example, within religious traditions for which robots relying exclusively upon classical computation still can be viewed as presenting spiritual aspects. Elsewhere, largely post-religious cultures may reject the misgivings simply as outdated superstition, holding that the machines eventually will enjoy a consciousness described purely in behaviorist terms. The present essay, in contrast, proposes that the heart of the foregoing objections and concerns actually may be assessed scientifically and with results recommending fundamental revisions in AI modeling of human mental life. Specifically, there now are considerations that favor introduction of AI models using interactive classical and quantum computation. Development of such hybrid computational architecture could provide credible reasons for people at least to countenance accepting this advanced kind of robot as an authentic companion. Dr. Ted Metzler Oklahoma City University Petree College of Arts and Sciences 2501 N. Blackwelder Oklahoma City, Oklahoma 73106-1493 USA (405) 208-5511 tmetzler@okcu.edu
Dr. Lundy Lewis Department of Computer Information Technology Southern New Hampshire University 2500 N. River Road Manchester, New Hampshire 03106 USA P a g e | 14
(603) 668-2211 x3061 l.lewis@snhu.edu
The Rev. Linda Pope Senior Pastor, Hunter & Garber United Methodist Churches P.O. Box 137 Hunter, Oklahoma 74640 USA (580) 684-7775 lindacpope@aol.com
Nursing as body care is precisely contradictory to a vision of nursing as a healing practice. Our conference announcement begins with the following: Body care is at the centre of nursing practice. For someone with my philosophical bent this represents a challenge and a contradiction. There may be some caregivers who see themselves caring for bodies, but, with the exception of the morgue, this is a limited and inadequate view. Even those who care for patients in a persistent vegetative state do not just care for bodies. I would argue they are caring for persons; persons who are matter/form unities in the language of Aristotle and Aquinas. The materials of their bodies may not allow expression of their rational form (soul), but they are still persons within community. The contemporary philosopher, Norris Clarke (Person and Being, 1993) will address the phenomenological understanding of humans as substantial and relational, having transcendence. This paper will consider(1) the meaning of being human within classical philosophy, (2) Descartes distinction between humans and machines as he argues that we will always be able to tell the difference, and (3) Nursing as a healing practice. Nursing as body care is precisely contradictory to a vision of nursing as a healing practice. This later will address my own thought borrowing from the work of William A. Wallace, Edmund Pellegrino and Imogene King. Beverly J. Whelton, Ph.D. MSN Associate Professor of Philosophy Wheeling Jesuit University 316 Washington Avenue Wheeling, Wv 26003 P a g e | 15
Surveillance and the looking glass: a Foucaldian perspective on changing behaviours to promote best practice in nursing
Traditionally defined as close observation (Marx, 2002:10), surveillance has long been used as a powerful tool to protect social values (Dawson et al, 2005). However, in healthcare, as in wider society, how surveillance is implemented is likely to be viewed negatively (Cooper, 2013). Whilst a disembodied form of surveillance threads through peoples lives in the social world, the word still implies a form of management control (Lyon, 2001). This presentation will report on the findings from a nursing study, conducted in the United Kingdom, which examined the impact of different intermediaries (a range of people who link between policy, evidence and individuals in clinical areas) to promote best practice in infection control. The findings showed that the ways in which intermediaries watched over practice meant that frontline staff were stimulated through guilt or shame to practice correctly, so that evidence based habitual behaviours were promoted. However, how intermediaries watched over practice also triggered staff to believe they were being individually supported, and promoted an atmosphere of collegiality in clinical areas. Being subjected to surveillance enhances self -awareness and influences behaviour (Henderson et al, 2010), and the theme observed in this study was constructive and caring, as opposed to the more punitive connotations of surveillance. The potential impact of promoting self-surveillance and amongst nursing and other clinical staff is magnified by this study. To consider the implication for future policy and the organisation and delivery of nursing and healthcare practice, the findings are explored in this presentation through a Foucaldian lens. Dr Lynne Williams Cymrawd Ymchwil Ysgol Gwyddorau Iechyd lynne.williams@bangor.ac.uk Prifysgol Bangor Gwynedd, LL57 2EF
Dr Lynne Williams Research Fellow, School of Healthcare Sciences lynne.williams@bangor.ac.uk Bangor University,Gwynedd, LL57 2EF P a g e | 16
Health technologiesfor better or for worse? A critical theory of standardization and instrumental thinking within contemporary health care
The goal of market-oriented public health care reforms has been to find a balance between affordability, high quality, and universal access. Health technologies, such as devices, techniques, and procedures, are a great asset in achieving this. Undeniably, the quality of health care has improved, to the extent that they have made earlier diagnosis, more effective and less invasive treatments, and shorter hospital stays possible. However, for better or worse, the increasing use of technologies also standardizes care. This raises the question whether there could be any adverse effects on the ethical relationship between patients and professionals?
In their critique of culture industry, Horkheimer and Adorno argue that the adverse effects of technology should not be attributed to their internal laws but rather to its function within the economy today. From this I argue that the benefit of technology may turn against itself if the fiscal conditions within public services do not allow sufficient time for professionals to properly consider the use of technologies in each care situation. The intrinsic logic of making dissimilar things comparable by reducing them to abstract quantities also validates technology use. If they are taken for granted and applied blindly, merely as method and not as means towards understanding, they become the sole instrument of thought: *t+he standardization of the intellectual function through which the mastery of the senses is accomplished, the acquiescence of thought to the production of unanimity, implies an impoverishment of thought no less than of experience; the separation of the two realms leaves both damaged. This is bound to reflect the way the care relationship is conceptualised. Max Horkheimer and Theodor W. Adorno, Dialectic of Enlightenment (Stanford, CA: Stanford University Press, 2002) 95.
Anna Ilona Rajala, MA, research student Institutional affiliation: University College London / University of Brighton (from Oct 2014) Contact address: 6 Cliff Close, Seaford, East Sussex, BN25 1BN, UK email address: a.rajala.12@ucl.ac.uk
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Are patient care technologies impeding the therapeutic quality of nurse-patient relationships?
Increasingly, technologies are being used to facilitate care of patients in healthcare organisations with the aim of controlling hospital costs, and improving professional staff performance and patient safety. When used by nurses, technologies become part of the nurse-patient relationship and intrinsic to the therapeutic context within which nursing practice takes place. It is important to examine whether technologies, by virtue of their mechanical character, are impeding the therapeutic quality of nurse-patient relationships. The purpose of this paper is to consider this issue with regards to the use of medication dispensing technology.
This paper draws on findings from recent case study research in New Zealand that explores professional nursing values in contemporary hospital practice. An argument will be presented using interview and observation data from medical wards across three hospital sites together with MacIntyres philosophical arguments of internal and external goods. It will be proposed that use of medication dispensing technology (dispensing robots) requires nurses to spend significant time away from the patients thereby impeding the therapeutic quality of nurse-patient relationships. Taking the position of patient care technologies acting as barriers to, rather than enablers of, a therapeutic nurse-patient relationship, MacIntyres arguments of excellence/internal goods and effectiveness/external goods are used to understand how technological advances in healthcare influence the therapeutic nurse-patient relationship. Tensions between organisational and technological objectives good of effectiveness and the intentions of practice goods of excellence will be demonstrated.
Helen Rook1, Kay De Vries2 and Therese Meehan3 4 5 Institutional affiliation 1 Lecturer, Programme Director, Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington New Zealand. 2 Senior Lecturer, Head of School, Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington New Zealand. 3Honorary Fellow of the Faculty of Nursing, Royal College of Surgeons in Ireland. 4Adjunct Senior Lecturer in Nursing at University College Dublin. 5Adjunct Professor, Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, New Zealand.
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Contact Details Helen Rook Lecturer in Nursing, Programme Director MNS Graduate School of Nursing, Midwifery & Health Te Kura Tapuhi Hauora, Victoria University of Wellington, PO Box 7625, Newtown, Wellington 6242. New Zealand. Email: helen.rook@vuw.ac.nz
Making technology work for people: Self-testing technology and patient autonomy This paper presents the empirical findings of a PhD study exploring the patient experience of autonomy in engagement with self-testing technology. The proliferation of home-based self-testing technology provides a contextualised example of an ideological shift towards greater patient autonomy. The assumption underpinning these technologies is that they facilitate patient autonomy through self-management. The study explored that assumption and the wider reverence to autonomy in healthcare, in the clinical context of individuals with diabetes who self-test their blood glucose levels. Heideggerian phenomenology provided the overarching philosophy for the research. The study adopted an empirical ethics research design that integrates philosophical analysis and empirical enquiry in a cyclical fashion. Empirical data from key stakeholders: patients, healthcare professionals and the scientific community was analysed collectively in accordance with a hermeneutic approach. Empirical findings revealed an understanding of Autonomy as lived: The interdependent phenomenon of autonomy in self-testing, whereby the patient experience of autonomy was underpinned by three inter-reliant relationships - Relationship with self-testing device, Relationship with illness and Relationship with healthcare provider. The paper explores the key implications of this contextualised understanding of technology use for all stakeholders. While technology can facilitate greater patient autonomy this can only occur in tandem with a variety of interdependent factors and supporting structures. The value of reflection on the ethics of emerging healthcare technologies is also explored. The paper concludes by introducing some normative implications of the empirical work for operationalising autonomy, both in the context of technology use and in the wider healthcare context. Anna-Marie Greaney RGN, RNT, MA Department of Nursing and Healthcare Sciences Sls Building Institute of Technology Tralee Co. Kerry Email: Anna.Marie.Greaney@staff.ittralee.ie P a g e | 19
Athena Swan: Philosophy in Action
There are powerful philosophical reasons for fully embracing the recent Athena Swan initiative, which go well beyond the usual utilitarian justifications. This paper argues that there is a deeper set of values at issue, which, if not addressed, will expose our discipline to the possibility of embedding bad science rather than nursing science. Women in STEMM are under-represented, especially at senior levels. Even in Health Sciences and Academic Nursing (where there is a much higher proportion of women than in many STEMM subjects), there is a leaky pipeline feeding the upper echelons. The odds of rising (from undergraduate to Professor) within Schools of Nursing are still much better for men (who are first onto the glass lift). As well as a gender pay gap, there is unconscious bias against women at all levels, and especially those in leadership roles. Athena Swan is a national initiative to recognise organisational commitment to advancing womens careers in STEMM. Prof Dame Sally Davies, Chief Medical Officer, has announced that NIHR and CLAHRC funding bodies will no longer shortlist any NHS/University partnership unless the academic department holds at least a Silver Award from the Athena Swan Charter for Women in Science. This means Athena Swan now has a few teeth. All funding councils are following suit, and instantiating a requirement for academic organisations to demonstrate a commitment to equality and diversity. For many, this kind of initiative demonstrates a welcome, if belated, commitment to social justice. Missing, so far, is a thorough-going commitment to equality and diversity, in combination with a full recognition of the scientific importance of women as nurses and nurses as women. Alison Edgley Associate Professor of Social Sciences in Health Room D87 Queen's Medical Centre Nottingham NG7 2UH UK Email: alison.edgley@nottingham.ac.uk
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Mixed methods in rehabilitation of the older person: a clinical and research paradigm
The demographic is aging and with this presents an increasingly nebulous and complex arrangement of clinical problems. Clinical interventions have long been served by the reductionism of Descartes and Newton: cause leads to a linear effect. This traditional positivistic model faces challenges within rehabilitation of the older person. Conversely, these challenges can only be partially met through an interpretivistic paradigm. Thus, Nurses and Allied Health Professionals need to progress away from either a positivistic quantitative model or an interpretivistic qualitative model. A move toward the mixed methods paradigm is justified in order that the strengths of both quantitative and qualitative paradigms are integrated and embraced.
Further, when investigating low intervention adherence rates in the older population, clarity of the underlying reasons is required. A critical realist worldview is set within the middle-ground: phenomena are not reduced to a positivistic linear order (Reagon et al, 2009); truth values are not placed on human behavioural perspectives (DeForge & Shaw, 2011). Critical realisms ontology is stratified (Walsh & Evans, 2013): highly suited to impaired intervention adherence levels investigations within older people.
An example is found in those who are at risk of injurious falls: Empirical (the observed): Injurious falls rates Actual (the known but unseen): Exercise adherence levels Real (the hidden precondition): Bio-psychosocial phenomena (historical and contemporary)
The authors therefore argue that the philosophical stance point when performing clinical research should be directed toward that of mixed methods.
Kevin Anthony MSc MCSP MA Research Methods Fellow, University of Nottingham / Nottingham CityCare Partnership Stephen Timmons PhD Associate Professor, University of Nottingham
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Fatalism and the fundamental attribution error. On not trivialising social psychology
Philip Darbyshire has responded to my editorial in Nurse Education Today. He gained the impression, he says, that I used social psychology to absolve poor or negligent practice from any hint of personal responsibility and accountability. I propose to comment on this view.
The paper has two sections. First, I discuss the fundamental attribution error, an idea which Darbyshire trivialises as the fundamental arrogance error, and a piece of linguistic puffery. In fact, the evidence for correspondence bias, which is logically antecedent to the FAE, is rock solid. We constantly invoke traits, attitudes and values, even when behaviour is manifestly constrained by circumstance. We over-emphasise dispositions, and under-emphasise context. The FAE is a theory of attribution. It says: we over-attribute behaviour to character. Darbyshire, however, imagines that it is a theory of behaviour. He thinks it says: situations explain behaviour, character doesnt come into it. He does not see the difference between saying situations matter (more than we think) and only situations matter.
This error is compounded by a nave view of causation, discussed in the second section. According to Darbyshire, claiming that behaviour is constrained by situations makes me a fatalist, unable to account for nurses who do not all behave and respond identically. In the same way, not all those who smoke develop cancer, a fact which on Darbyshires logic refutes the fatalistic claim that cancer is caused by smoking. I explain why this conception of cause (as a sufficient condition) is mistaken. However, I also argue that situations-as-causes do set limits to responsibility, even if Darbyshire finds this morally inconvenient. John Paley 8 Farm Place Henton Chinner OX39 4AD 01844 351905
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Ways of improving health outcomes Antimicrobial resistance and Telehealth agendas Within the health policy field we identified two generative socio-technical imaginaries Telehealth and antimicrobial resistance (AMR) agendas that aim to reconfigure the existing socio-technical regime its technologies, cultural practices, institutions in such a way as to improve health outcomes. Each agenda tackles a specific wicked health problem: the increased burden on healthcare resources presented by patients with chronic long term conditions (Telehealth), and the challenge of managing and treating infectious disease against a backdrop of increased prevalence of multi-drug resistant strains of pathogenic bacteria (AMR). Although these diverse agendas occupy different territory within the health policy field they both attend to wicked problems that impact on health outcomes. The purpose of this paper is to interrogate the extent that these agendas are complementary and/or competing in terms of their means and ends with regards to achieving improved health outcomes. For instance, whilst both agendas introduce technological fixes, via closer monitoring for early detection of health complications (Telehealth) and better diagnostic equipment for targeted antibiotic use (AMR), which if responsive to each other could provide complementary means. The overarching Teleheath aim of reducing emergency hospital admissions through measures such as increased prophylactic antibiotic use may be unintentionally blind to the AMR agendas goal of preventing overuse of antibiotic treatments. We conclude by highlighting the need for responsiveness between agendas to ensure early co-operative agenda-shaping to ensure the emergence of compatible socio-technical imaginaries, that once emerged and embedded socio-technical regimes, do not require costly retro- manipulation to address potentially foreseeable conflicts. Ms Josephine Go Jefferies Mr Richard Helliwell (presenter) University of Nottingham Nottingham University Business School University of Nottingham Institute of Science and Society School of Sociology and Social Policy Room B42 Business School (South) Jubilee Campus Nottingham NG8 1BB P a g e | 23
Email: lixjg21@nottingham.ac.uk Room B24 Law and Social Science University Park Nottingham NG7 2RD Email: lqxrh2@nottingham.ac.uk
Productivity and professional identities in healthcare exploring governance and the governed
The performance of healthcare systems has come under increasing scrutiny as global trends mean that both demand and costs escalate. Compounded by austere times, improving productivity is deemed a universal challenge. In the UK a number of contemporary reforms and strategies have advocated improved healthcare productivity as a political panacea for the long term future of the NHS. As such, productivity improvement has been framed as a fundamental objective of both policy and professional work. This study broadly aims to explore the ontological relationship between professional healthcare work and identity. Specifically, it seeks to examine how austerity (in particular the call for improved productivity) influences professional subjectivities, and how Emergency Department (ED) nurses and doctors mediate their responses to dominant productivity discourses and modes of governance. Using empirical data from a longitudinal ethnographic case study conducted in one of the UKs largest EDs, this work uses a theoretical framework based on Foucaults technologies of power and technologies of the self to expose and explore two co-existing modes of professional productivity governance one of authoritarian control and one of self-governance. The interplay between these modes of governance is considered and the resultant professional subjectivity presented not as a negotiated balance or hybrid position, but rather a complex and dynamic state characterised by near continuous constitution and reconstitution. The significance of this state of flux is discussed with reference to professionalism, practice and implications for future policy and productivity improvement strategies.
Dr Fiona Moffatt University of Nottingham Division of Physiotherapy Education, University of Nottingham, Clinical Sciences Building, City Hospital Campus, NG5 5PB P a g e | 24
fiona.moffatt@nottingham.ac.uk
Does blended learning need a third element for stabilisation within nurse education? Blended learning offers not only face to face sessions within higher education, but the use of technological interventions to provide a combined support for student learning (Driscoll, 2002; Garison and Vaughan, 2008). Many forms of blended learning can be used to enable students to supplement and support their learning journey. You tube, videos quizzes, reusable Learning objects, exams, online discussion forums and debates were embedded into an existing course at the University of Nottingham for post registration nurses. This provided an innovative blended learning platform for nursing students (Kelly et al, 2009, Clifton and Mann, 2011; Blake, 2010). Lecturers and students often remain reserved in supporting this approach and question if blended learning is the new pedagogical breakthrough we hail it as. Lecturers expectations of the use of such a course may not be supported by student engagement within the process (Philips, 2005). The student acceptance of the virtual world may be considered as removing them from the foundations of caring and compassion which is traditionally taught through clinical exposure ( Meyer, 2005; Lopez-Perez et al., 2011 ) When reflecting upon the delivery of blended learning courses, a third component should be considered. The introduction of clinical skills would support existing blended learning courses, providing a triad of educational approaches in the delivery of such an eclectic programme (Lenister, 209; Watson, 2001) Therefore, the development of a three pronged approach to nurse education may offer a stabilisation from which further educational innovations can be offered .
Nichola Ashsby School of Health Sciences Derby Education Centre Royal Derby Hospital Uttoxeter Road Derby DE22 3DT UK Email: Nichola.Ashby@nottingham.ac.uk P a g e | 25
Mill, advocacy and the tobacco endgame.
Though its stricture has not been universally followed in modern liberal states, Mills harm principle remains important in public health ethics. Banning an individual from doing something because its bad for him requires stronger reasons than banning it because it harms others. In England, justification for smoking bans in enclosed spaces was firmly presented in terms of preventing harms to others, even if its subsequent evaluation also included health gains to smokers. The legal ban did not cover smoking outside where harms to others are less. Care homes and hospices were granted exemption but in mental health units this was temporary, so that when they expired, the ban became de facto a complete ban where patients cannot go outside. During legal challenges in England, justification for the ban was sought in health gains for patients, including regarding the habit as self-harm. Recent NICE guidelines recommend total smoking bans inside and outside hospital for the benefit of smokers. For smokers, Mills principle has been overturned. The supremacy of personal autonomy is central to nursing ethics, though less so in public health ethics. Smoking bans and their effect on individual patients is one area where these disciplines collide. Nursing claims (or requires) a role for patient advocacy but this can be variously interpreted and nursing can no longer prevaricate. It must choose to advocate for patients health (in favour of a ban) or for patients choice (against a ban), and the direction it takes clearly identifies where the professions values lie.
Paul Snelling Senior Lecturer in Adult Nursing University of Worcester Institute of Health and Society Henwick Grove Worcester WR2 6A P a g e | 26
p.snelling@worc.ac.uk
http://worc.academia.edu/PaulSnelling
Development and evaluation of a computer based e-learning tool to enhance knowledge of workplace wellness in a healthcare setting Background: Workplace health promotion is important for maintaining a healthy public health workforce, and is an important settings approach to improving population health, yet is infrequently included within formal training for healthcare professionals. Aim: To develop an interactive e-learning tool on Workplace Wellness covering six key workplace health promotion areas including work-related stress, musculoskeletal disorders, physical activity, diet and nutrition, smoking and alcohol consumption. To assess the use of the tool in improving knowledge of workplace health issues in NHS employees and healthcare students. Methods: E-learning resource was developed by a nurse and health psychologist in an iterative peer- reviewed process involving 14 expert reviewers. 194 participants (129 healthcare students, 91 healthcare employees; 26 of which-were both employee and student) completed the tool. Change in knowledge was assessed using an online knowledge questionnaire before (n=188) and immediately after (n=88) exposure to the e-learning tool. Participant perceptions towards use of the tool were assessed (n=88). Results: Baseline knowledge of workplace wellness was poor (n=188; mean accuracy 47.60%, s.d. 11.94%). Knowledge significantly improved from baseline to post-intervention (t(75)=-14.801, p < 0.0005, n=75, mean accuracy 77.96%, s.d. 14.08%), with improvements in knowledge evident for all sub-topics. 90.5% of participants felt their knowledge of workplace wellness was improved, with 86.9% of participants stating they would recommend the resource to others. Conclusion: E-learning has potential to improve knowledge of workplace wellness in healthcare staff and students. The impact of improved knowledge on the health of employees, or their delivery of patient care requires further exploration.
Ms Emily Gartshore RN MNurSci
51 Thorpe Road, Melton Mowbray, LE13 1SE 07507863988 emily.gartshore1@gmail.com P a g e | 27
The philosophical issues in the promotion of Financial Capability as a Public Health measure
The World Bank defines Financial Capability as people's internal capacity to act in their own best financial interest given their socioeconomic conditions. The focus of this paper is on its association with health. There is a well-established link between individuals' financial and health states (e.g. Marmot Review). There is also evidence of beneficial effects on mental health and stress levels from interventions that help people in financial difficulty. In the UK since the 1990s, various organisations have attempted to enhance people's Financial Capability; some now do so with an explicit Public Health aim. If successful, the interventions could help meet two objectives, improving Public Health and reducing health inequality. However, those undertaking such interventions need to address a number of philosophical issues, particularly relating to Political Philosophy. This short paper will outline and defend an approach based on Sen and Nussbaum's Capability Approach to social justice.
Dr Peter Allmark Centre for Health and Social Care Research Sheffield Hallam University 32 Collegiate Crescent Sheffield S10 2BP
0114 225 5727
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The Ontology of Spirituality: Implications for Nursing Practice
Spirituality is a domain of human experience which, while accounted for in many nursing models and theories, is poorly addressed in practice. Many reasons have been suggested for this discrepancy, largely focusing on the extent to which nurses are educated on, or feel comfortable engaging with, spirituality. However, the obstacles to effective spiritual care run far deeper than this, stemming from the long-standing obsession of nursing theory with the packaging and labelling of need-types and the prescription of specific approaches to their fulfilment. This compulsion to 'define and conquer', a flaw which pervades nursing theory through the evidence based practice movement and its deification of quantitative research, forms fundamental barriers to nursing's engagement with spirituality, and sets up healthcare professionals to fail where they might otherwise succeed. This paper takes a critical view of the prevailing characterisations of spirituality in nursing theory. I will challenge the assumptions upon which these characterisations are based and argue that they have been a major contributing factor in the under-addressment of spiritual concerns and underperformance in spiritual care within nursing. Finally, I will propose a different, more flexible approach to defining spirituality which might remove some of the barriers to effective spiritual care by allowing nurses to engage with spirituality on their own and their patients' terms.
Daniel Knight Affiliation: University of Nottingham Contact: E: ntyddkn@nottingham.ac.uk
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Believe and care. Study about Spanish midwives Evidence Based Nursing beliefs from Michel de Certeau's anthropology of believe
Evidence-Based Nursing is the major scientific paradigm of our time in the field of nursing care and perinatal care from midwives. However, their implementation by professionals is deficient, which may have significant negative effects on the health of the population and the sustainability of the Health System. This paper proposes a research project on the Spanish midwives beliefs about Evidence Based Nursing, from the fundamental premises of Michel de Certeaus anthropology of believe. Michel de Certeau was a French jesuit thinker who wrote a large and amazing work in differents fields of human sciences. His anthropology of believe have two key ideas: first, belief is one of the key drivers of human action; second, beliefs affect both the epistemic dimension and the social dimension in peoples life. The aim of this research is to identify the core beliefs of Spanish midwives about this paradigm, in order to design interventions which modify those beliefs, thus improving the implementation of Evidence Based Nursing. This research will be conducted in different centres of the Spanish Public Health System. Ad hoc survey will be designed through expert consultation and will be pass to a sample of Spanish midwives. Results may be an important aid in the evaluation of Evidence-Based Nursing implementation in Spain, improving the correction of mistakes and generally the implementation of Evidence Based Nursing.
Juan-Diego Gonzlez-Sanz, PhD, RM, RN.
Health Sciences Education Master (Subdirector) Dp. 70, Fac. Enfermera 21071 Campus El Carmen University of Huelva (Spain) www.uhu.es/edusalud www.uhu.es/juan.diego
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Please note that there will be a special issue of Nursing Philosophy based on the theme of this conference: Details below.
Nursing Philosophy: Call for papers for Special Issue Brave new world? Health, technology and evidence based practice Guest Editor: Stuart Nairn Submission deadline 1st June 2015 Body care is at the centre of nursing practice but the nature of that care has been extended beyond the personal, human-to-human contact, and is increasingly refracted through the medium of technological/scientific interventions. The way these technologies interact with the human dimension does, and should, require critical analysis, particularly for nurses who are increasingly expected to adopt methods and approaches that change the nature of the nurse patient relationship. Added to this is the way that clinicians/academics/researchers interact with healthcare issues, locally as well as globally. There is an established debate and tension within the evidence based practice literature that illustrates a deep ambivalence about how a holistic approach to clinical practice relates to, enhances, or is undermined by the new health technologies. These include care pathways, systematic reviews of knowledge, the enabling/disabling effects of technology and the putative implication of an empiricist and dehumanising process inherent in these developments. For example, what happens to the complexity of ethical debates when shaped in the form of arguments based on literature reviews? These may wittingly or unwittingly serve as a means of translating complex moral issues into usable clinical regimes that partially mimic meta-analyses. Furthermore we may ask what place narrative knowledge and qualitative experiences may have in this new world of implementation technologies? And how do the new interventions of telemedicine and other policy drivers that emphasise the "hospital-at-home" impact on the ways that nurses carry out healthcare? Papers are now invited for consideration for a special issue of Nursing Philosophy that develops this theme. Manuscripts should be prepared and submitted in accordance with the journal author guidelines and will be subject to the usual peer-review process. When submitting your manuscript please state that the article is for the special issue: Brave new world? Health, technology and evidence based practice. The deadline for submission of manuscripts is 1st June 2015. Authors who would like to discuss their ideas for a paper to be considered for this themed issue are welcome to contact stuart.nairn@nottingham.ac.uk