The exclusion of the other: challenges to the ethics of closeness

Abstract There is an ongoing discussion concerning personal vs. impersonal considerations in professional care. In this article, three different positions within the ethics of closeness will be discussed. These are: (a) reserving the ethics of closeness for close experienced others, ‘including the experienced Other’, which is Nortvedt's position; (b) trying to bring the distant, non‐experienced others closer, ‘including the Third’; and (c) finally, an examination of whether a perspective of closeness may lead to the exclusion of various groups in need of help, ‘including the Other at the expense of the Third’. These positions are discussed with a view to clarifying some of the challenges that the ethics of closeness faces when it maintains that greater ethical obligation is associated with personal than with impersonal relations, without discussing the terms on which the obligation is based. Key questions that arise for a nurse or other health professional are: If our primary moral responsibility is for those that are close to us, the experienced others, who is to be responsible for those that are outside the established health services, the non‐experienced others? Is it evident that favouring the experienced others is based on legitimate needs? Can a discussion on the legitimate basis of nursing be avoided in questions relating to closeness and priorities? This discussion touches the heart of our discipline. Is a one‐sided perspective of closeness, rejecting moral responsibility for those with whom we have no relationship, a defensible ethical position?     

从医务人员新型冠状病毒感染思考医疗机构的职业卫生工作

在COVID-19流行期间，医务人员受到新型冠状病毒的影响，让人们再次反思医疗机构的职业防护问题。就医疗机构在紧急（异常）状态下启动职业防护、识别“异常”状态、针对可能的“异常”采取必需的应急准备、个人防护用品的最适化、职业卫生工作常态化以及多学科的融合等话题进行了讨论，期望引起重视整合，推动医疗机构的职业卫生工作。提出政府和职业卫生专业机构要在指导、帮助医疗机构做好相关工作方面发挥重要作用。     

A cyborg ontology in health care: traversing into the liminal space between technology and person‐centred practice

Person‐centred practice indubitably seems to be the antithesis of technology. The ostensible polarity of technology and person‐centred practice is an easy road to travel down and in their various forms has been probably travelled for decades if not centuries. By forging ahead or enduring these dualisms, we continue to approach and recede, but never encounter the elusive and the liminal space between technology and person‐centred practice. Inspired by Haraway's work, we argue that healthcare practitioners who critically consider their cyborg ontology may begin the process to initiate and complicate the liminal and sought after space between technology and person‐centred practice. In this paper, we draw upon Haraway's idea that we are all materially and ontologically cyborgs. Cyborgs, the hybridity of machine and human, are part of our social reality and embedded in our everyday existence. By considering our cyborg ontology, we suggest that person‐centred practice can be actualized in the contextualized, embodied and relational spaces of technology. It is not a question of espousing technology or person‐centred practice. Such dualisms have been historically produced and reproduced over many decades and prevented us from recognizing our own cyborg ontology. Rather, it is salient that we take notice of our own cyborg ontology and how technological, habitual ways of being may prevent (and facilitate) us to recognize the embodied and contextualized experiences of patients. A disruption and engagement with the habitual can ensure we are not governed by technology in our logics and practices of care and can move us to a conscious and critical integration of person‐centred practice in the technologized care environments. By acknowledging ourselves as cyborgs, we can recapture and preserve our humanness as caregivers, as well as thrive as we proceed in our technological way of being.     

'Two sides of the coin'--the value of personal continuity to GPs: a qualitative interview study

BACKGROUND: Continuity is thought to be important to GPs but the values behind this are unknown. OBJECTIVES: To explore the values that doctors working in general practice attach to continuity of patient care and to outline how these values are applied in practice. METHODS: In-depth qualitative interview with 24 GPs in England. Participants were purposefully sampled according to personal and practice characteristics. Analysis was thematic, drawing on the constant comparative method. RESULTS: The majority of doctors valued doctor-patient, or personal, continuity in their everyday work. It was most valued in patients with serious, complex or psychological problems. GPs believed that through their personal knowledge of the patient and the doctor-patient relationship, personal continuity enabled them to provide higher quality care. However, the benefits of personal continuity were balanced against problems, and GPs identified personal, professional and external constraints that limited its provision. GPs seemed to have resolved the tension between the benefits, limits and constraints they described by accepting an increased reliance on continuity being provided within teams. CONCLUSION: Personal continuity may offer important benefits to doctors and patients, but we do not know how unique its values are. In particular, it is not clear whether the same benefits can be achieved within teams, the level at which continuity is increasingly being provided. The relative advantages and limits of the different means of delivering continuity need to be better understood, before further policy changes that affect personal continuity are introduced.     

Rethinking nursing education and investing in persons: various contributions to the gestalt approach

Despite the widespread emphasis on human wholeness, the training of health professionals has privileged technical competence, desconsidering the need to strengthen the person's process of inner growth. The purpose of this article is to reflect on the importance of a person's development as a basic tool of one's own work. The authors consider that there is no way to separate the personal from the professional dimension since each person interacts as a totality. Thus, the person exists in the professional Being or, dialectically speaking, the professional integrates the human being that it really is. These considerations, which are fundamental to each one's development, usually are not part of one's life, personal or professional learning. It is necessary to make this an essential part of nursing training, broadening the possibilities of integrating and transcending either side of the person, by introducing an holistic approach which contemplates the human being development in an integral and integrated way.     

Family responsibilities and domestic activities of US women physicians

BACKGROUND: Women physicians may have a multiplicity of domestic roles (eg, cook, housekeeper, child care provider) that are of inherent interest and that may affect their professional lives, but are largely unstudied. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES: We report data from respondents (N = 4501) to the Women Physicians' Health Study, a cross-sectional, questionnaire-based study of a stratified random sample of US women MDs. RESULTS: Women physicians with children aged 0 to 17 years spent a median of 24.4 hours per week on child care. Women physicians typically spent half an hour per day cooking, and another half-hour per day on other housework. Little time was spent on gardening: a median of 0.05 hours (3 minutes) per week. Those performing more domestic tasks are likely to work fewer hours outside the home and to be on call less often. Women physicians who are married or widowed, have more children, have lower personal incomes, and have more highly educated and higher-earning spouses perform more domestic activities. We found no significant adverse relationship between time spent on any domestic activity and career satisfaction or mental or physical health. CONCLUSIONS: Women physicians spend little time on domestic activities that can be done for them by others, including cooking, housework, and especially gardening. Women physicians spend somewhat less time on child care and substantially less time on housework than do other US women. Despite abundant editorializing about role conflicts of women physicians, our measures of career satisfaction and mental health were not adversely affected by time spent on domestic obligations.     

Hormonal contraception,breastfeeding and bedside advocacy: the case for patient-centered care

Postpartum contraceptive decision making is complex, and recommendations may be influenced by breastfeeding intentions. While biologically plausible, concerns about the adverse impact of hormonal contraception on breast milk production have not been supported by the clinical evidence to date. However, the data have limitations, which can lead providers with different priorities around contraception and breastfeeding to interpret the data in a way that advances their personal priorities. Discrepancies in interpretations can lead to divergent recommendations for individual women and may cause conflict. Furthermore, providers must recognize that decision making about contraception and breastfeeding takes place in complex cultural, historical and socioeconomic contexts. Implicit bias may influence a provider's counseling. Unrecognized biases toward one patient or another, or one practice or another, may influence a provider's counseling. It is crucial for providers to strive to recognize their own biases. Providers need to respectfully recognize each patient's values and preferences regarding hormonal contraception and breastfeeding. Developing a patient-centered decision tool or implementing patient-centered interview techniques specifically around breastfeeding and contraception could help to minimize provider-driven variability in care.     

Deconstructing the ailment: one health care professional's experience as the patient.

This essay explores an illness in a health care professional through lenses of role flexibility and professional accountability. It highlights the process of contemplation about the dual identifications implicit in the experience of being both a professional and a patient within one health care delivery system. This can be a position of standing on the borders of possibility. Thus, the dilemma of a "wounded healer" may challenge some assumptions inherent in the giving and receiving of care as well as grant us some regard for the power shifts within the management of our patients and of ourselves. The experience that one's ailment can be an opportunity-to explore notions of sickness and health or to help to tease out the limits or the potential impact of our responsibility toward that which we name disease and cure-may be the more salient message.     

Efforts,rewards and professional autonomy determine residents’ experienced well-being

The well-being of residents, our future medical specialists, is not only beneficial to the individual physician but also conditional for delivering high-quality patient care. Therefore, the authors further explored how residents experience their own well-being in relation to their professional and personal life. The authors conducted a qualitative study based on a phenomenological approach. From June to October 2013, 13 in-depth interviews were conducted with residents in various training programs using a semi-structured interview guide to explore participants’ experience of their well-being in relation to their professional life. The data were collected and analyzed through an iterative process using the thematic network approach. Effort–reward balance and perceived autonomy were dominant overarching experiences in influencing residents’ well-being. Experiencing sufficient autonomy was important in residents’ roles as caregivers, as learners and in their personal lives. The experienced effort–reward balance could both positively and negatively influence well-being. We found two categories of ways that influence residents’ experience of well-being; (1) professional lives: delivering patient care, participating in teamwork, learning at the workplace and dealing with the organization and (2) personal lives: dealing with personal characteristics and balancing work–life. In residents’ well-being experiences, the effort–reward balance and perceived autonomy are crucial. Additionally, ways that influence residents’ well-being are identified in both their professional and personal lives. These dominant experiences and ways that influence well-being could be key factors for interventions and residency training adaptations for enhancing residents’ well-being.     

Hospital restructuring: positioning social work to manage change.

In the shifts to programmatic hospital organizations, social workers are having to learn to reframe their work, reorganize their thinking, and restructure their professional disciplines in order to survive. The experience is frequently one of frustration, anger, and impotence. Yet, social workers are masters of systems thinking in hospitals, and are well positioned to effect change. The beauty of shifting to a flattened hierarchy that is patient focused, is that it endorses change consistent with the social work mission in health. The challenge for social work is to grapple with the big issues: our belief in ourselves; defining our roles and functions and priorities; defining our vision in programmatic hospital organizations; being critical of what we do; and articulating what we have to offer. This paper identifies ways social workers can position themselves to effect positive change in hospitals undergoing restructuring.     

Professional participation in organizational decision making: Physicians in HMOs

Although it has been suggested that participation by physicians in administrative and policy decisions is linked to outcomes in health care organizations, there is little research on this subject. Using Shortell's framework this paper considers relationships between perceived participation and three intermediate organizational outcomes: physician work satisfaction, perceived staff consensus about day-to-day activities, and attitudes toward patients. Also considered are situational, professional, and personal characteristics which may be related to participation. Data were collected from four staff model health maintenance organizations (HMOs) in 1978 and 1979 through physician questionnaires, administrator interviews, and documents. Physicians who reported greater participation were more satisfied with work, perceived greater staff consensus, and had more favorable attitudes toward patients. Greater participation was associated with full-time employment status and more years in the HMO (but not with the physicians' professional or personal characteristics). Implications of these findings are discussed, and it is proposed that the findings suggest mechanisms by which participation in organizational decision making may affect ultimate outcomes of the organization.     

Employment, unemployment, occupation, and smoking

This study analyzes the relationships of cigarette smoking and smoking histories to employment status and occupation. Data from a large, representative sample of U.S. adults in 1985 were analyzed separately for white men, white women, black men, and black women, with controls for age, education, and marital status included in all analyses. It has been hypothesized that women who adopt traditional male roles are more likely to become smokers. However, our data indicate that participation of women in the labor force or employment of women in male-dominated occupations have had little or no effect on women's smoking adoption or cessation. Unemployed men and women (those who were not employed but were seeking work) were substantially more likely than employed men and women to be smokers. Among employed whites, the percentage of smokers was high for industrial manual workers and service workers and low for professionals and farmers. Similar differences were observed in the proportion who had ever adopted smoking. These differences in smoking adoption had begun at young ages, before most people have adopted adult roles, which suggests that the differences in smoking adoption were not caused by unemployment or occupation. Rather, it appears that certain personal characteristics or early experiences influenced both smoking adoption and adult unemployment or occupation. In addition, unemployment may decrease smoking cessation, and employment in professional occupations may increase smoking cessation.     

The perceptions of the personal and professional factors influencing social workers in Saudi hospitals: a qualitative analysis

The perceptions of 10 social workers regarding the personal and professional characteristics influencing their practice at Saudi hospitals were examined using semi-structured interviews. A qualitative analysis employing a thematic approach informed by grounded theory was undertaken and produced three broad interrelated themes: "skills upgrading," "departmental support," and "personal experience in the workplace," which subsequently informed the development of the overarching theme of "personal and professional factors." The discussion illustrates social work practitioners are inhibited from effectively performing their roles. These include: (a) Deficiencies related to job training and professional skills updating where there is a lack of efficient and accessible inservice training programs, especially in relation to practical issues. Further, these perceptions relate to a lack of long-term educational opportunities that impact on individual practitioner's currency of skills, techniques and pedagogy enabling/disenabling him/her to excel at his/her job, (b) Obvious bureaucracy within the controlling hierarchy and difficulty with the dissemination of information between the social workers were perceived to detrimentally impact on a practitioner's ability to attend to one's work demands, and (c) Personal day to day work experiences, including counterproductive emotional feelings (high stress), increased dissatisfaction with the job, and ineffective communication within the workplace were seen as limiting the social workers' professional potential. This article will focus on how these themes were addressed in terms of qualitative interview data.     

Critical complexity in environmental health practice: simplify and complexify

The magic word 'complexity' has been buzzing around in science, policy and society for quite some time now. There seems to be a common feel for a 'new way' of doing things, for overcoming the limits of tradition. From the combined perspective of critical complexity thinking and environment and health practice we want to contribute to the development of alternative routines that may help overcome the limitations of traditional environment and health science. On the one hand traditional environment and health science is too self-confident with respect to potential scientific insight in environment and health problems: complexity condemns us to limited and ambiguous knowledge and the need for simplification. A more modest attitude would be more realistic from that point of view. On the other hand from a problem solving perspective more boldness is required. Waiting for Godot (perfect undisputed knowledge) will not help us with respect to the challenges posed to society by environment and health problems. A sense of urgency is legitimate: the paralysis by traditional analysis should be resolved. Nevertheless this sense of urgency should not withhold us from investing in the problem solving quality of our endeavour; quality takes time, fastness from a quality perspective often leads us to a standstill. We propose the concept of critical complexification of environment and health practice that will enable the integration of relevant actors and factors in a pragmatic manner. We will illustrate this with practical examples and especially draw attention to the practical complexities involved, confronting us not only with fundamental questions, but also with fundamental challenges.     

Isolation, flexibility and change in vocational training for general practice: personal and educational problems experienced by general practice registrars in Australia

BACKGROUND: GP registrars, in common with other doctors, frequently experience high levels of stress; however, little is known about the nature and outcomes of personal and educational problems experienced during vocational training for general practice. OBJECTIVES: The purpose of our study was to elicit the nature, causes and effects of more severe problems experienced during vocational training for general practice from the registrar's viewpoint and put these into the context of their personal circumstances and background. METHODS: This qualitative study used detailed semi-structured telephone interviews with a selected subgroup of 33 of the 1999 entry cohort of general practice registrars in Australia who had reported serious self-defined problems during an earlier longitudinal questionnaire study. Registrars were asked about the nature, antecedents and outcomes of problems experienced during GP training, actions taken to resolve the problem, and their perceptions of what might have helped prevent or minimize the problem. RESULTS: Problems reported by registrars fell into five major themes: isolation (structural isolation, social isolation and professional isolation); flexibility and choice (administrative issues and balancing work with personal life); change and uncertainty (within general practice and training, intergenerational changes); teaching problems; and work conditions. Actions taken and effects of problems are also discussed in the light of workforce imperatives. Results have been used to develop a list of suggestions for the providers of general practice training. CONCLUSIONS: Registrars commonly experience problems during vocational training. These may be related to structural, social and professional isolation, or a lack of flexibility in training arrangements and balancing work and other commitments. Some of these problems may be amenable to relatively simple solutions involving term placements, selection of training practices and administrative adjustments.     

The road to the winner's circle begins at the ASHRM Annual Conference!

The saying “Time flies when you're having fun” is a time‐honored expression that is part of our vernacular. Sometimes we say it in jest, tongue in cheek, when it seems a long day will never end! However, when we celebrate professional or personal anniversaries, when we look at our growing kids, or especially, when we look in the mirror, we marvel at how fast the years have flown by!     

Sharing the agenda: pondering the politics and practices of occupational therapy research

AIMS: Occupational therapists espouse a client-centred philosophy of practice, yet little attention has been given to pondering the politics or client-centred practices of occupational therapy research. The aim of this paper is thus to foster reflection on occupational therapy's commitment to client-centredness in the practice of occupational therapy research. MAJOR FINDINGS: Occupational therapy research is not consistently undertaken in a collaborative manner. Power resides in control of the research agenda and participants' priorities can be supplanted by those of researchers. However, examples from the literature and from the authors' research suggest that study participants may wish to influence the research agenda such that their needs and priorities are addressed. PRACTICE CONCLUSION: Client-centred principles appear to require occupational therapists to undertake collaborative research and to ensure that research agendas are informed by clients' priorities. Commitment to client-centred principles demands concerted efforts to identify and address potential barriers to meaningful client participation in the occupation of research. However, it is argued that if researchers and disabled people collaborate, and pool their knowledge and expertise, they may achieve research that is more philosophically compatible with espoused professional values; and that collaborative research may also inform more relevant and useful client-centred clinical practices.     

The Perceptions of the Personal and Professional Factors Influencing Social Workers in Saudi Hospitals: A Qualitative Analysis

The perceptions of 10 social workers regarding the personal and professional characteristics influencing their practice at Saudi hospitals were examined using semi-structured interviews. A qualitative analysis employing a thematic approach informed by grounded theory was undertaken and produced three broad interrelated themes: “skills upgrading,” “departmental support,” and “personal experience in the workplace,” which subsequently informed the development of the overarching theme of “personal and professional factors.” The discussion illustrates social work practitioners are inhibited from effectively performing their roles. These include: (a) Deficiencies related to job training and professional skills updating where there is a lack of efficient and accessible inservice training programs, especially in relation to practical issues. Further, these perceptions relate to a lack of long-term educational opportunities that impact on individual practitioner's currency of skills, techniques and pedagogy enabling/disenabling him/her to excel at his/her job, (b) Obvious bureaucracy within the controlling hierarchy and difficulty with the dissemination of information between the social workers were perceived to detrimentally impact on a practitioner's ability to attend to one's work demands, and (c) Personal day to day work experiences, including counterproductive emotional feelings (high stress), increased dissatisfaction with the job, and ineffective communication within the workplace were seen as limiting the social workers' professional potential. This article will focus on how these themes were addressed in terms of qualitative interview data.