Reflections on Caring Practice

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Reflections on Caring Practice

• Patricia Benner, R.N., Ph.D. FAAN
• Thelma Shobe Chair, Ethics and Spirituality in
  Nursing Care,
• University of California, San Francisco,
• Department of Social and Behavioral Sciences

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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

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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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Narratives and Experiential Learning

• Experiential learning - a key to skillful
  ethical comportment.
• Experiential learning can be captured in
  narrativesfirst personexperience near accounts
  of actual clinical situations.
• Experiential learning requires openness and
  learning.

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Practice is a Way of Knowing in its
Own Right.

• Narratives of Learning.
• Constitutive and Sustaining Narratives.
• Narratives of breakdown and error.

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Enhancing Relational Skills

• Skills of involvement are a key to developing
  practical wisdomgood ethical and clinical
  judgment.
• Moral agency is conditioned by skillful ethical
  comportment..
• Good Relationships create different ethical
  perceptions and disclosive spaces.

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The Role of Articulation for Clinical
Knowledge Development

• Articulating what you know in practice
• Naming the silences.
• Describing new practices

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Reflective Practice / Thinking-in-action
Making clinical knowledge cumulative and
collective
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Articulating Clinical Knowledge

• Identify concerns that organize the story.
• Why does the story begin and end where it does?
• Stay within the situated possibilities of the
  actual narrative.
• Identify notions of good.
• Identify areas of skill, new knowledge.
• Identify experiential learning.
• Areas for system re-design.

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Articulating Clinical Knowledge..cont.

• Identify limits of formal knowledge
• The nature of the situation as understood by
  different participants.
• Pattern recognitionintuitive insights?
• Concerns of the patientfamily...nursedoctorothe
  rs?

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Articulation cont..

• Transitions in the clinicians understanding of
  the situation.
• Differences in understanding the situation.

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Naming the Silences

• Are aspects of the situation or concerns
  invisible?
• What actions were central in the story?
• Examine actions in relation to decisions
• How did time or timing influence the situation?
• How was the experiential learning communicated
  (or not) to others?

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Strategies for making experiential learning
collective and cumulative

• Debriefing
• Narratives
• Cross-discipline narratives
• Using experiential learning to re-design the
  system

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Narratives Can Capture

• The particular
• Relational skill/disclosive spaces
• New clinical knowledge
• Qualitative distinctions
• Moral dilemmas articulated