Understanding through experience: information, experience and understanding in clinical rehabilitation practice

Appealing to Tacit Knowledge and Axiology to Enhance Medical Practice in the COVID-19 Pandemic: A Systematic Review and Hermeneutic Bioethical Analysis

Background: The pressure of coronavirus disease 2019 (COVID-19) pandemic, epidemiological and demographic changes, personnel-patient relationship in healthcare, and the development of biotechnologies do not go unnoticed by the healthcare professional. Changes are so wide and at a high rate that guidelines and mere scientific knowledge, which are represented by evidence-based medicine, are not sufficient to lead actions, thus the experiential aspects in the configuration of an ethos present as a fundamental part of the resources to deal with critical scenarios, such as a pandemic. In this regard, the recognition of tacit knowledge as a way of teaching and learning skills related to ethical aspects such as principles, virtues, and values, revealed as a fundamental part of the clinical field. The challenge is to strengthen binomial evidence-based medicine and values-based in order to achieve excellence in the health care of the patients and the well-being of the clinical personnel.

Method: A 2-fold analysis was conducted taking pediatric endocrinology as an example. First, a systematic review was carried out in electronic databases BIREME, PubMed, and PhilPapers following PEO and PRISMA approaches. A total of 132 articles were garnered. After reading their title and abstract, 30 articles were obtained. Quantitative information was arranged in an Excel database according to three themes: ethics, axiology, and tacit knowledge. A quality criterion that meets our research question was assigned to each article and those which had a quality criterion of 3 (9) were taken to carry out the hermeneutic bioethical analysis, which consisted of three stages, namely naïve reading, codification, and interpretation. The results were analyzed in Atlas.ti. to elucidate the relations between the three main themes in accordance with the objective.

Results: Although there was no difference in the frequency of tacit knowledge skills, including cognitive, social, and technical, for medical practice, there is an intrinsic relationship between epistemic and ethical values with cognitive skills, this means that professionals who practice honesty, authenticity and self-control are capable of seeing patients as persons and thus respect their dignity. This suggested that there is a strong partnership between evidence-based medicine and value-based medicine, which reinforced this binomial as the two feet on which medical practice decisions rested. With regard to tacit knowledge in terms of the context of the COVID-19 pandemic, the challenges refer to (1) adapting and learning a new way of establishing trust with the patient and (2) how to capitalize on the new knowledge that new experiences have posed.

Discussion: The analysis of ethical-tacit knowledge in medicine is a recent phenomenon and is in full development. Although no references were found that dealt with any of the main topics in pediatric endocrinology, there is an interest in pediatrics to explore and discuss educational strategies in ethics related to its tacit dimension as a vector of enhancement in the clinical practice. Educational strategies ought to take into consideration the development of skills that promote reflection and discussion of experiences, even more vigorously in the context of the COVID-19 pandemic.

[The Autonomy of Patients in Inpatient Medical Rehabilitation - Aspects of Endangerment and Preservation]

PURPOSE

The aim of the study is to identify aspects within inpatient medical rehabilitation that may endanger or preserve the autonomy of patients.

METHODS

A scoping review was carried out on the basis of the current state of scientific knowledge. The methodological approach was based on the specifications of the Joanna Briggs Institute. The research and generation of findings were logged according to the PRISMA-ScR checklist.

RESULTS

The final study inclusion comprises 39 empirical and normative-theoretical contributions. Autonomy-threatening aspects were assigned to the following domains: Rehabilitation system, rehabilitation clinics, staff, patients and third parties. Aspects potentially preserving the autonomy of patients included the following domains: Rehabilitation clinics, staff, concepts and forms of expression as well as instruments.

CONCLUSION

A large number of heterogeneous aspects can endanger, but can also preserve or promote the autonomy of patients during their stay in inpatient medical rehabilitation. These are located throughout in the entire rehabilitation process and concern the structural, organizational and personal level. The autonomy of patients should not only be treated as an outcome of rehabilitation, but also as a requirement for structures and actors during the rehabilitation stay.

Self-management develops through doing of everyday activities-a longitudinal qualitative study of stroke survivors during two years post-stroke

Background

A description of the complexity of the process of self-management and the way stroke survivors give meaning to their process of self-management post-stroke is lacking. This study explores how stroke survivors managed their lives, gave meaning to their self-management post-stroke and how this evolved over time.

Methods

Data was generated through participant observations and interviews of 10 stroke survivors at their homes at 3, 6, 9, 15 and 21 months post-discharge. A constant comparative method was chosen to analyse the data.

Results

‘Situated doing’ was central in stroke survivors’ simultaneous development of self-management and their sense of being in charge of everyday life post-stroke. Doing everyday activities provided the stroke survivors with an arena to explore, experience, evaluate, develop and adapt self-management and being in charge of everyday activities and daily life. The influence of stroke survivors’ partners on this development was sometimes experienced as empowering and at other times as constraining. Over time, the meaning of self-management and being in charge changed from the opinion that self-management was doing everything yourself towards self-managing and being in charge, if necessary, with the help of others. Moreover, the sense of self-management and being in charge differed among participants: it ranged from managing only at the level of everyday activities to full role management and experiencing a meaningful and valuable life post-stroke.

Conclusions

The findings of this study indicate the doing of activities as an important arena in which to develop self-management and being in charge post-stroke. Stroke self-management programs could best be delivered in stroke survivors’ own environment and focus on not only stroke survivors but also their relatives. Furthermore, the focus of such interventions should be on not only the level of activities but also the existential level of self-management post-stroke.

Negotiating role management through everyday activities: narratives in action of two stroke survivors and their spouses

PURPOSE

To manage social roles is a challenging part of self-management post-stroke. This study explored how stroke survivors act as role managers with their spouses in the context of everyday activities.

METHOD

Two stroke survivors with a first time stroke living at home with a spouse were included. Data were generated through participant observations at their own environment at 3, 6, 9, 15 and 21 months post-discharge. The narrative analysis focused on the actions of participants.

RESULTS

Daily activities can be understood as an arena where role management and a meaningful live is negotiated and co-constructed with others. Everyday activities gave stroke survivors and their spouses insight into stroke survivors' capacities in daily situations. This was sometimes empowering, and other times conflicting when a spouse had negative perceptions of the abilities of the stroke survivors.

CONCLUSION

The findings add to the current understanding of self-management and role management with regard to how these are situated in everyday activities. Daily activities can help both spouses to reflect and understand about self-management, role management and comanagement in daily life. Moreover, observing stroke survivors in everyday situations provides professionals with concrete pictures of stroke survivors' performance and self-management in interaction with their spouses. Implications for Rehabilitation Self-management is a dynamic process in which individuals actively manage a chronic condition and finally live a meaningful life with a long-term chronic condition; self-management can be divided into medical, role, and emotional management; comanagement is when individuals activate resources and use the capacities of other persons to manage a situation together. Self-management is situated in everyday activities. Everyday activities give stroke survivors ánd their partners impressions about stroke survivors' self-management abilities post-stroke in an everyday context. Everyday activities give stroke survivors ánd their partners an arena where role management and a meaningful life are negotiated and coconstructed through doing. Observing stroke survivors in everyday situations provides professionals a concreter picture of stroke survivors' self-management and comanagement with their partners than can be obtained from an informal interview.

Could Ethical Tensions in Oral Healthcare Management Revealed by Adults with Intellectual Disabilities and Caregivers Explain Unmet Oral Health Needs? Participatory Research with Focus Groups

BACKGROUND

Cognitively impaired patients often present poor oral health status that may be explained by ethical tensions in oral healthcare management. This participatory study explored such tensions among adults with intellectual disabilities and with caregivers. The second objective was to specify, with caregivers, the points that should be developed in a future study among dentists.

MATERIALS AND METHODS

Three focus groups involving adults with intellectual disabilities, family caregivers and professional caregivers were organized in France in 2013.

RESULTS

The thematic content analysis identified discrepancies between experiences and expectations, which were particularly marked for the dentist's competence and attitudes, the dentist's role in decisions, the dental care management and the French socio-political context.

CONCLUSIONS

These discrepancies could partly explain multiple attempts to find the 'right' dentist or the fact that care was abandoned, and could at least contribute to oral health needs being unmet.