Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, 150 Kilgour Rd, Toronto, ON, M4G 1R8, Canada.
Department of Physical Therapy, University of Toronto, Toronto, ON, Canada.
Adv Health Sci Educ Theory Pract. 2018 Dec;23(5):867-889. doi: 10.1007/s10459-018-9834-1. Epub 2018 May 24.
For those with chronic, progressive conditions, high quality clinical care requires attention to the human dimensions of illness-emotional, social, and moral aspects-which co-exist with biophysical dimensions of disease. Reflexivity brings historical, institutional, and socio-cultural influences on clinical activities to the fore, enabling consideration of new possibilities. Continuing education methodologies that encourage reflexivity may improve clinical practice and trainee learning, but are rare. We piloted a dialogical methodology with a children's rehabilitation team to foster reflexivity (patient population: young people with Duchenne's or Becker's muscular dystrophy). The methodology involved three facilitated, interactive dialogues with the clinical team. Each dialogue involved clinicians learning to apply a social theory (Mol's The Logic of Care) to ethnographic fieldnotes of clinical appointments, to make routine practice less familiar and thus open to examination. Discourse analyses that preserve group dynamics were completed to evaluate the extent to which the dialogues spurred reflexive dialogue within the team. Overall, imagining impacts of clinical care on people's lives-emphasized in the social theory applied to fieldnotes-showed promise, shifting how clinicians interpreted routine practices and spurring many plans for change. However, this reflexive orientation was not sustained throughout, particularly when examining entrenched assumptions regarding 'best practices'. Clinicians defended institutional practices by co-constructing the metaphor of balancing logics in care delivery. When invoked, the balance metaphor deflected attention from emotional, social, and moral impacts of clinical care on patients and their families. Emergent findings highlight the value of analysing reflexivity-oriented dialogues using discourse analysis methods.
对于患有慢性、进行性疾病的患者，高质量的临床护理需要关注疾病的人文维度——情感、社会和道德方面——这些维度与疾病的生物物理维度并存。反思将历史、制度和社会文化对临床活动的影响突显出来，从而使新的可能性得到考虑。鼓励反思的继续教育方法可能会改善临床实践和学员学习，但却很少见。我们用一种儿童康复团队的对话方法来进行试点，以促进反思（患者人群：患有杜兴氏或贝克氏肌营养不良症的年轻人）。该方法涉及与临床团队进行三次有针对性的互动对话。每次对话都涉及临床医生学习将一种社会理论（莫尔的关怀逻辑）应用于临床预约的民族志实地记录，以使常规实践不那么熟悉，从而可以进行检查。完成了保留群体动态的话语分析，以评估对话在多大程度上激发了团队内部的反思性对话。总的来说，想象临床护理对人们生活的影响——这在应用于实地记录的社会理论中得到了强调——显示出了希望，改变了临床医生对常规实践的解释，并激发了许多变革计划。然而，这种反思性的倾向并没有一直持续下去，尤其是在审视关于“最佳实践”的根深蒂固的假设时。临床医生通过共同构建护理服务中平衡逻辑的隐喻来为机构实践辩护。当平衡隐喻被调用时，它会将注意力从临床护理对患者及其家属的情感、社会和道德影响上转移开。新出现的发现强调了使用话语分析方法分析以反思为导向的对话的价值。
