A hermeneutical rapprochement framework for clinical ethics practice

2017 ◽  
Vol 26 (3) ◽  
pp. 674-687 ◽  
Author(s):  
Franco A Carnevale
Keyword(s):  
Clinical Practice ◽  
Moral Philosophy ◽  
Clinical Ethics ◽  
Charles Taylor ◽  
Local Context ◽  
Ethical Practice ◽  
Educational Preparation ◽  
Normative Development

Background: A growing number of frameworks for the practice of clinical ethics are described in the literature. Among these, hermeneutical frameworks have helped highlight the interpretive and contextual nature of clinical ethics practice. Objectives: The aim of this article is to further advance this body of work by drawing on the ideas of Charles Taylor, a leading hermeneutical philosopher. Design/Findings: A Hermeneutical Rapprochement Framework is presented for clinical ethics practice, based on Taylor’s hermeneutical “retrieval” and “rapprochement.” This builds on existing hermeneutical approaches for the practice of clinical ethics by articulating a framework with interpretive and reconciliatory scope that extends beyond the presenting “local” context. A Hermeneutical Rapprochement Framework considers broader socio-historical horizons and imaginaries grounded on Taylor’s expansive work in epistemological, ontological, political, and moral philosophy. Discussion: The framework is discussed in terms of how it can be operationalized for clinical practice as well as normative development. Implications for the educational preparation of clinical ethicists are also discussed. Although this work is directly relevant for clinical ethicists, it can also help inform the ethical practice of all clinicians.

scholarly journals Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework

2021 ◽  
Author(s):  
Jing Li ◽  
Susan S. Smyth ◽  
Jessica Miller Clouser ◽  
Colleen A. McMullen ◽  
Vedant Gupta ◽  
...  
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Family Caregivers ◽  
Implementation Strategy ◽  
Care Pathway ◽  
Implementation Strategies ◽  
Mobile App ◽  
Care Plan ◽  
Local Context ◽  
Successful Implementation

Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, study suggested that the current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guideline (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders’ inputs. We then co-designed with patients and frontline teams, developed and tested specific strategies. Results: 114 clinicians completed surveys and 32 clinicians and stake-holders participated in interviews. Results from the surveys and interview indicated low awareness of syncope guidelines, and communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change were recognized as major barriers. Thirty-one patients and their family caregivers participated in interviews and ex-pressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. After identifying change methods to address those barriers, the multilevel, multicomponent implementation strategy, MISSION, included pa-tient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and corresponding Mobile App, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Con-clusions: Effect multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs.

scholarly journals Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice

2020 ◽  
pp. 026921632097427
Author(s):  
Guy Schofield ◽  
Mariana Dittborn ◽  
Richard Huxtable ◽  
Emer Brangan ◽  
Lucy Ellen Selman
Keyword(s):  
Systematic Review ◽  
Palliative Care ◽  
Clinical Practice ◽  
Ethical Issues ◽  
Clinical Care ◽  
Ethical Principles ◽  
Original Research ◽  
Specialist Palliative Care ◽  
Ethical Challenges ◽  
Ethical Practice

Background: Ethical issues arise daily in the delivery of palliative care. Despite much (largely theoretical) literature, evidence from specialist palliative care practitioners about day-to-day ethical challenges has not previously been synthesised. This evidence is crucial to inform education and adequately support staff. Aim: To synthesise the evidence regarding the ethical challenges which specialist palliative care practitioners encounter during clinical practice. Design: Systematic review with narrative synthesis (PROSPERO registration CRD42018105365). Quality was dual-assessed using the Mixed-Methods Appraisal Tool. Tabulation, textural description, concept mapping and thematic synthesis were used to develop and present the narrative. Data sources: Seven databases (MEDLINE, Philosopher’s Index, EMBASE, PsycINFO, LILACS, Web of Science and CINAHL) were searched from inception to December 2019 without language limits. Eligible papers reported original research using inductive methods to describe practitioner-reported ethical challenges. Results: A total of 8074 records were screened. Thirteen studies from nine countries were included. Challenges were organised into six themes: application of ethical principles; delivering clinical care; working with families; engaging with institutional structures and values; navigating societal values and expectations; philosophy of palliative care. Challenges related to specific scenarios/contexts rather than the application of general ethical principles, and occurred at all levels (bedside, institution, society, policy). Conclusion: Palliative care practitioners encounter a broad range of contextual ethical challenges, many of which are not represented in palliative care ethics training resources, for example, navigating institutional policies, resource allocation and inter-professional conflict. Findings have implications for supporting ethical practice and training practitioners. The lack of low- and middle- income country data needs addressing.

scholarly journals Designing a customized clinical practice guideline regarding antibiotic prophylaxis for Iranian general dentists

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Najmeh Savadi ◽  
Omid Barati ◽  
Hossein Mirhadi ◽  
Ali Golkari
Keyword(s):  
Clinical Practice ◽  
Antibiotic Prophylaxis ◽  
Content Validity ◽  
Expert Panel ◽  
Joint Infection ◽  
Developed Countries ◽  
Local Context ◽  
Dental Procedures ◽  
Validity Indices ◽  
General Dentists

Abstract Background Clinical practice guidelines produced by developed countries seemed to be not completely feasible for developing countries due to their different local context. In this study, we designed a customized guideline about antibiotic prophylaxis before dental procedures for Iranian general dentists. Methods This study was conducted of two parts, including a qualitative part and a cross-sectional analytic part. A multidisciplinary team searched for related guidelines and other documents, selected the most updated and high quality ones, customized their recommendations based on available antibiotics in Iran, prepared a draft adapted guideline and summarized its recommendations in 3 flowcharts. An expert panel (20 specialists of four Iranian dental universities) participated in a consensus process, afterwards to determine the relevance and clarity of the flowcharts and their items. Then the Content Validity Indices (CVIs) were calculated and any items with CVI higher than 0.79 remained. Results The adapted recommendations were summarized in flowcharts A to C. Two separate groups of patients who need antibiotic prophylaxis were presented in flowchart A; including those with high risk for distant-site infection (infective endocarditis and prosthetic joint infection) and those at risk for poor healing and orofacial infection (due to impaired immunologic function). Flowcharts B and C described antibiotic regimen and also the dental procedures where antibiotic prophylaxis was needed for mentioned groups. The content validity indices and the percentages of agreement between the expert panel members were considerably high. Conclusions A localized, clear and straight forward guideline that addresses all groups of dental patients who need antibiotic prophylaxis has been produced for Iranian general dentists.

scholarly journals Constrained Physical Therapist Practice: An Ethical Case Analysis of Recommending Discharge Placement From the Acute Care Setting

2010 ◽  
Vol 90 (6) ◽  
pp. 939-952 ◽  
Author(s):  
Ernest Nalette
Keyword(s):  
Clinical Practice ◽  
Acute Care ◽  
Physical Therapists ◽  
Physical Therapist ◽  
Moral Agent ◽  
Moral Dilemma ◽  
Case Analysis ◽  
Ethical Practice ◽  
Best Interest ◽  
Systematic Analysis

Background and PurposeConstrained practice is routinely encountered by physical therapists and may limit the physical therapist's primary moral responsibility—which is to help the patient to become well again. Ethical practice under such conditions requires a certain moral character of the practitioner. The purposes of this article are: (1) to provide an ethical analysis of a typical patient case of constrained clinical practice, (2) to discuss the moral implications of constrained clinical practice, and (3) to identify key moral principles and virtues fostering ethical physical therapist practice.CaseThe case represents a common scenario of discharge planning in acute care health facilities in the northeastern United States.MethodsAn applied ethics approach was used for case analysis.ResultsThe decision following analysis of the dilemma was to provide the needed care to the patient as required by compassion, professional ethical standards, and organizational mission.Discussion and ConclusionsConstrained clinical practice creates a moral dilemma for physical therapists. Being responsive to the patient's needs moves the physical therapist's practice toward the professional ideal of helping vulnerable patients become well again. Meeting the patient's needs is a professional requirement of the physical therapist as moral agent. Acting otherwise requires an alternative position be ethically justified based on systematic analysis of a particular case. Skepticism of status quo practices is required to modify conventional individual, organizational, and societal practices toward meeting the patient's best interest.

Conflicts and con-fusions confounding compassion in acute care: Creating dialogical moral space

2017 ◽  
Vol 26 (1) ◽  
pp. 116-123 ◽  
Author(s):  
Jenny Jones ◽  
Petra Strube ◽  
Marion Mitchell ◽  
Amanda Henderson
Keyword(s):  
Moral Philosophy ◽  
Theoretical Foundation ◽  
Essential Element ◽  
Charles Taylor ◽  
Human Condition ◽  
Sense Making ◽  
Moral Space ◽  
A Value ◽  
Shared Understandings ◽  
Spiritual Suffering

Background: Compassion, understood as empathy for another who is experiencing physical, mental, emotional and/or spiritual suffering, is an essential element of our shared understandings of nursing and the constitution of the professional nurse. Theoretical foundation: Charles Taylor account of ethics which concerns ‘what or who is it good to be’ rather than the predominant analytical moral philosophy approach which concentrates on ‘what ought one to do’ is the core concern of this discussion. An ontological appreciation of our shared human condition is the premise upon which the discussion is based. Discussion: This article proposes that concept by opening a dialogical space, nurses can engage in reflection and sense making wherein they explore individually and collectively the conflicts and confusions encountered in their day-to-day work. Through their dialogues, nurses – individually and collectively – orient and reorient themselves and each other towards what they see as meaningful and purposeful in their lives and in doing so they are well positioned to reaffirm their commitment to compassion as a value which both anchors and orients their day-to-day work. Implications: The provision of opportunities in the workplace, in the form of dialogue, to articulate often unspoken assumptions and frameworks in which nursing work is carried out can not only initiate the building of pathways of support but also assist nurses reaffirm their compassion – arguably the essence of their nursing practice.

scholarly journals Adapting clinical practice guidelines to local context and assessing barriers to their use

2009 ◽  
Vol 182 (2) ◽  
pp. E78-E84 ◽  
Author(s):  
M. B. Harrison ◽  
F. Legare ◽  
I. D. Graham ◽  
B. Fervers
Keyword(s):  
Clinical Practice ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Local Context

scholarly journals Ethical issues in optometric practice

2010 ◽  
Vol 69 (2) ◽  
Author(s):  
H. L. Sithole
Keyword(s):  
Health Care ◽  
Clinical Practice ◽  
Unethical Behavior ◽  
Ethical Decision ◽  
Ethical Decision Making ◽  
Ethical Issues ◽  
Health Care Practitioner ◽  
Ethical Practice ◽  
Ethical Concerns ◽  
Legal Constraints

Ethics as a discipline is the study and analysis of values and standards related to duty, responsibility, and right and wrong behavior. The ethical obligations of optometry toward patients are similar to those of other health professionals. These obligations generally require optometrists to recognize, respect, and protect the rights of their patients. This approach encourages patients to participate actively in their care and allows them to develop arelationship with their optometrist based on trust. The ethical codes which contain guiding principles serve to help practitioners in their decisions and in practicing in accordance with a set of standards that are expected of a health care practitioner. There are four major ethical principles in health care, namely; beneficence, non-maleficence, and respect for autonomy and justice. Because these principles are easily recognized as being among the primary ethical goals of health care, using them as the basis for ethical analysis may help to explain the moral justification for certain professional actions as well as to identify unethical behavior. However, in clinical practice, the specific demands and rationales of these broad principles may be difficult to apply. This illustrates the paradox that whilst these principles are essential tools for ethical practice, if applied too rigidly, they can be problematic. How-ever, the goal of ethical decision making in optometry should be to identify one or more courses of action that will honor the profession’s essential values while minimizing conflict with other values and professional standards. Every profession, every practice and every practitioner is governed by not only legal constraints, but also by the ethical concerns of ensuring that the patient is properly served. Considering our practices from a patient’s perspective can help optometrists understand the multiple responsibilities of clinical practice. (S Afr Optom 2010 69(2) 93-99)

Moral Distress

2018 ◽  
Author(s):  
Alisa Carse ◽  
Cynda Hylton Rushton
Keyword(s):  
Clinical Practice ◽  
Patient Care ◽  
Moral Distress ◽  
Ethical Practice ◽  
Moral Resilience

Moral distress, a response to moral adversity that imperils integrity under conditions of constraint, has been studied for more than three decades. The context of clinical practice, the complexities of healthcare, clinicians’ roles, and broader society, alongside exponential advances in technology and treatment, create circumstances that regularly imperil integrity. These circumstances create the conditions for burnout, disengagement, and imperiled patient care. Specifically, they foster powerlessness, frustration, anger, diminished moral responsiveness, disillusionment, and shame. The cumulative dynamic of moral distress results in myriad detrimental consequences affecting the bodies, emotions, minds, and souls of clinicians. Transforming these experiences requires a shift in orientation toward restoring and preserving integrity by cultivating capacities of moral resilience and strategies to foster systemic ethical practice.

scholarly journals Clinical practice guideline adaptation methods in resource-constrained settings: four case studies from South Africa

2019 ◽  
Vol 25 (6) ◽  
pp. 193-198 ◽  
Author(s):  
Michael McCaul ◽  
Dawn Ernstzen ◽  
Henk Temmingh ◽  
Beverly Draper ◽  
Michelle Galloway ◽  
...  
Keyword(s):  
South Africa ◽  
Clinical Practice ◽  
Case Studies ◽  
South African ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Local Context ◽  
Prehospital Emergency Care ◽  
The South ◽  
High Quality

Developing a clinical practice guideline (CPG) is expensive and time-consuming and therefore often unrealistic in settings with limited funding or resources. Although CPGs form the cornerstone of providing synthesised, systematic, evidence-based guidance to patients, healthcare practitioners and managers, there is no added benefit in developing new CPGs when there are accessible, good-quality, up-to-date CPGs available that can be adapted to fit local needs. Different approaches to CPG development have been proposed, including adopting, adapting or contextualising existing high-quality CPGs to make recommendations relevant to local contexts. These approaches are attractive where technical and financial resources are limited and high-quality guidance already exists. However, few examples exist to showcase such alternative approaches to CPG development. The South African Guidelines Excellence project held a workshop in 2017 to provide an opportunity for dialogue regarding different approaches to guideline development with key examples and case studies from the South African setting. Four CPGs represented the topics: mental health, health promotion, chronic musculoskeletal pain and prehospital emergency care. Each CPG used a different approach, however, using transparent, reportable methods. They included advisory groups with representation from content experts, CPG users and methodologists. They assessed CPGs and systematic reviews for adopting or adapting. Each team considered local context issues through qualitative research or stakeholder engagement. Lessons learnt include that South Africa needs fit-for-purpose guidelines and that existing appropriate, high-quality guidelines must be taken into account. Approaches for adapting guidelines are not clear globally and there are lessons to be learnt from existing descriptions of approaches from South Africa.

scholarly journals How to adapt existing evidence-based clinical practice guidelines: a case example with smoking cessation guidelines in Canada

BMJ Open ◽  
2017 ◽  
Vol 7 (11) ◽  
pp. e016124 ◽  
Author(s):  
Peter Selby ◽  
Katie Hunter ◽  
Jess Rogers ◽  
Kelly Lang-Robertson ◽  
Sophie Soklaridis ◽  
...  
Keyword(s):  
Smoking Cessation ◽  
Clinical Practice ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Knowledge Exchange ◽  
Local Context ◽  
High Quality ◽  
Level Of Evidence ◽  
Topic Area ◽  
Independent Expert

ObjectiveTo develop and encourage the adoption of clinical practice guidelines (CPGs) for smoking cessation in Canada by engaging stakeholders in the adaptation of existing high-quality CPGs using principles of the ADAPTE framework.MethodsAn independent expert body in guideline review conducted a review and identified six existing CPGs, which met a priori criteria for quality and potential applicability to the local context. Summary statements were extracted and assigned a grade of recommendation and level of evidence by a second expert panel. Regional knowledge exchange brokers recruited additional stakeholders to build a multidisciplinary network of over 800 clinicians, researchers and decision-makers from across Canada. This interprofessional network and other stakeholders were offered various opportunities to provide input on the guideline both online and in person. We actively encouraged end-user input into the development and adaptation of the guidelines to ensure applicability to various practice settings and to promote adoption.ResultsThe final guideline contained 24 summary statements along with supporting clinical considerations, across six topic area sections. The guideline was adopted by various provincial/territorial and national government and non-governmental organisations.ConclusionsThis method can be applied in other jurisdictions to adapt existing high-quality smoking cessation CPGs to the local context and to facilitate subsequent adoption by various stakeholders.

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