Justice and Care: The power of communities of care in healing' In honor of Dr' Gloria Smith, R'N' Ph

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Justice and Care The power of communities
of care in healing.In honor of Dr. Gloria Smith,
R.N. Ph.D., FAAN, FRCN

• Patricia Benner, R.N. Ph.D., FAAN, FRCN
• University of California, San Francisco
• Thelma Shobe Endowed Chair in Ethics and
  Spirituality

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Reconnecting the social, spiritual in health care

• The Cartesian separation of the social and the
  medicalthe division of mind, body, soul and
  world is a powerful force for scientific
  discovery.
• Please, no surgery without anesthesia and heavy
  draping
• No Code..FULL MAKEUP

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Descartes Bargain with the Church

• You care for the soulmedicine will care for the
  body in exchange for absolution for sickness
  found in the body.
• What medicine cant cure must be the fault of the
  soulmind.
• A built in moral contract between the responsible
  mind and the passive mechanical body.

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Success sometimes creates new problems.

• Medicine is parasitic upon the social and
  spiritual lifeworld.
• Nursing and doctoring as caring practices
  informally fit the lifeworld and the person into
  the equation with little language or
  acknowledgement of the role of the person and
  lifeworld in health promotion or health.

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Social needs/ Care needs are marginalized in
Cartesian medicine.

• System design and economic pressures prohibit
  access to the person except through medical
  problems.
• Social admits are covered up.
• Visiting nurses are sometimes grateful to find a
  pressure sore to treat.

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Descartes vision from the window-the
spectator-Levin, 1999

• spectators observation of our relationship with
  others becomes paradigmatic. Descartes stands at
  the window, silently looking out. Even though he
  is prepared to recognize the speech of the other
  as an irrefutable evidence of the others
  humanity, he makes no attempt to go outside, to
  meet the men he seems to see, to talk with
  them. The philosopher prefers the distance of
  vision, even when this distance means
  uncertaintyeven when it means dehumanization.

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Three aspects of the social and spiritual
related to effectiveness of health care

• 1. The relationship and the mood or emotional
  climate of the nurse or physician-patient
  encounter determines what aspects of the
  patients ailments and suffering can or will be
  disclosed.

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• 2. Knowing the patient and family in their
  lifeworld uncovers the contributions and
  restraints on recovery that a particular persons
  world makes or could make.

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• 3. The nurses or physicians caring practices
  and rhetorical skills determine how and what
  information the patient will hear from the
  physician about diagnosis and treatment and how
  those may or may not help reintegrate the person
  in his or her world.

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Care has ontological privilege.

• Care structures being human, what and how
  something matters to one and what can be
  encountered (noticed) and known.

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From a Care perspective

• Any symptom must be heard and attended to in its
  own right and not just as evidence for an
  accurate diagnosis.

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Cartesian, Allopathic Medicine

• Passes over patients human lifeworlds and their
  social, sentient embocied existence in order to
  treat the physical bio-chemical aspects of
  diseases and injuries.
• But when the social and spiritual lifeworld break
  downthis cannot work.

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Genomics and Genetics Research create a
disclosive space in society.

• Science is embedded in our social worlds, and is
  imbued with meanings and goals that are social.
• We have scientific folk beliefs in atomistic
  explanations, and single factor theories.
• If asked to choose between 5 environmental causes
  and 2-3 genetic causes we will choose the simpler
  explanation.

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Skillful Ethical Comportment

• Notions of the good and clinical judgments are
  linked
• Separation of fact/value--- a myth in good
  clinical practice
• Moral agency, skill, and character go hand in
  hand---MINIMAL ARROGANCE
• Skills of involvement, boundary work

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Mistakes and errors are in inevitable

• Actions dont start out mistaken, but become
  mistaken.
• We live our lives forwards, but understand them
  backwards.
• Responsible ethical comportment and
  self-improving practice depend on correction, of
  systems and flawed judgmentlearning from our
  mistakes, rather than covering them over.

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Monitoring and managing quality of performance.

• Prevention of accidents, reliable performance,
  recovery from a near miss, and managing the
  unexpected are the meaningful outcomes of
  positive organizing. Karl Weick, p. 68.
  Organizational tragedy.

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The language of mistakes is a limited Language
Marianne Paget

• It structures thought in terms of right and its
  polar opposite wrong leaving out or denying
  moments of randomness, unguidedness, and
  accidentalness in human conduct. P. (14) Medical
  Mistakes a Complex Sorrow.
• Chance, luck, random accident and fortuitous
  timing can be mined (replicated, designed for
  future) only if noticed.

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Reflection and articulation on practice.

• The trick is to overcome hindsight bias
• And to prevent a negative evaluation of the
  outcomes or a positive evaluation from coloring
  the search backward for conditions that are
  consistent with that outcome.

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Learning Vs. Competence and Failure

• Preventing and shoring up breakdown, actions of
  recovery, monitoring, repair, updating, making do
  and improvisation, recombining tools and
  strategies from different situations/ asking for
  feedback and help are required in settings where
  there is high variability and frequent unexpected
  events.

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Wisdom comes from experiential learning

• Experiential learning comes from failed
  expectations or failure.
• Focusing on learning and on the issues at hand
  rather than on competent performance enhances
  experiential learning.

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Wisdom

• John Meacham (1990) The essence of wisdomlies
  not in what is known but rather in the manner in
  which that knowledge is held and in how that
  knowledge is put to use. (p. 185-187)
• Appreciates that knowledge is fallible, in the
  balance between knowing and doubtingstaying
  curious rather than acting in hubris and
  arrogance.

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Karl Weick2003

• Positive organizing is about enabling people
  collectively to wade into a rich unknowable world
  and build rich experiencesuch organization
  enhances attention, resilience, wisdom and
  reliability.

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Truth, knowledge, method and history.

• This practical wisdom must stay in dialogue with
  science so that it continues to be
  self-improving.
• Articulating clinical knowledge makes it
  cumulative and collective, but it must not rely
  on the old decontexualizing strategies and
  language for formalization.
• Art, ethics and science of practice are
  inter-related and interdependent.

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Envisioning a New Future

• Where interactions with environments are noticed.
  
• Where complex biological social systems and
  lifeworlds are studied.
• This will require enlarging our scientific
  methods in all realms.
• Articulating the knowledge and wisdom in
  practice.
• Where we are honest about our interdependencies
  and connection to our social and spiritual
  lifeworld.

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Creating Healing EnvironmentsONora ONeill

• The fabric of feeling, culture and convention
  which sustains trust and communication is always
  fragile and vulnerable. It not only has to be
  preserved from damage and destruction, but to be
  shielded from mere indifference of neglect. It
  has constantly to be created and sustained,
  recreated and renewed, to preserve the food for
  future generations and of the present generation.

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ONeill cont.

• That food will be reduced, and capacities and
  capabilities will fail at least for some, when
  nobody maintains and contributes to sustainable
  practices of communication, of toleration and
  confidence-building, of loyalty and engagement,
  of educating and encouraging, that will enable
  action, interaction and the development of human
  potential and culture

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ONeill cont.

• The social conditions for human life and
  interaction can be sustained and supported among
  connected agents only by attitudes and action
  that educate new generations, that develop
  individual characters and their capacities and
  capabilities and that foster and seek to improve
  civilizing institutions. To sustain and build
  confidence and trust, and with them the social
  fabric.

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ONeill cont.

• We must not merely act justly, so refrain from
  destroying them, but help to breathe life both
  into current and into new practices and ways of
  life.