Ethnography of "Local Universality": Admission Practices in an Intensive Care Unit Among Guidelines, Routines, and Humour

The article analyses the existing gap between the formal dimension of evidence-based medicine (EBM), as constituted by protocols, procedures, and guidelines, and actual professional practices in relation to a specific issue: the admission of patients to an intensive care unit (ICU). The results of a case study, carried out in the ICU of a hospital in the north of Italy between 2006 and 2007 are reported. The study was performed using ethnographic methods: participant observation, ethnographic interviews, and semi-structured interviews. Empirical data have been analysed using a grounded theory approach. The results show how three dimensions (macrosocial, organisational-interactional, and individual) become intertwined with the operational guidelines that have been drafted on the basis of international evidence. The standardisation process that the guidelines presuppose results in the adoption of a variety of different local styles with respect to the approach that individual doctors take in relation to the admission of a patient to an ICU. These styles can range from strict adherence to the international criteria to a greater compliance with medical–legal, organisational, and individual needs. Furthermore, the results of the study demonstrate how relational knowledge, as a form of situated knowledge, can allow the personnel involved to activate local resources (organisational, professional, and personal) in order to incorporate the formal prescriptions of EBM in professional practice. URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs150226

Etnografía de la "universalidad local": las prácticas de admisión en una unidad de cuidados intensivos entre las directrices, las rutinas y humor

Der Beitrag befasst sich mit der Diskrepanz zwischen der formalen Dimension evidenzbasierter Medizin (EbM), konstituiert durch Protokolle, Verfahren und Richtlinien einerseits und professionellen Praktiken in einem spezifischen Kontext – der Aufnahme von Patent/innen in einer Intensivstation – andererseits. Hierzu werden die Ergebnisse aus einer Fallstudie berichtet, die in einer norditalienischen Intensivstation zwischen 2006 und 2007 durchgeführt wurde. Für die Datenerhebung kamen ethnografische Methoden zum Einsatz (im Besonderen teilnehmende Beobachtung, ethnografische Interviews und teilstrukturierte Interviews); die Daten wurden unter Verwendung von Kodierprozeduren der Grounded-Therory-Methodologie analysiert. Die Ergebnisse veranschaulichen, wie drei Dimensionen (makrosozial, institutionell-interaktional und individuell) sich mit operationalen Richtlinien verflechten, die der internationalen EbM entstammen. Die Standardisierungsprozesse, die die Richtlinien voraussetzen, sind eingebunden in unterschiedliche lokale Stile, die die einzelnen Ärzte und Ärztinnen bei der Aufnahme in der Intensivstation favorisieren. Die Stile changieren zwischen strikter Anpassung an die internationalen Richtlinien auf der einen Seite und der mehr oder weniger weitgehenden Compliance mit je spezifischen medizinischen, rechtlichen, organisatorischen und individuellen Anforderungen auf der anderen Seite. Die Ergebnisse zeigen auch, wie relationales Wissen als Teil situativen Wissens dem Personal erlaubt, lokale (organisatorische, professionelle und persönliche) Ressourcen zu mobilisieren, um die formalen Vorschriften der EbM in die professionelle Praxis zu integrieren.URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs1502261The article analyses the existing gap between the formal dimension of evidence-based medicine (EBM), as constituted by protocols, procedures, and guidelines, and actual professional practices in relation to a specific issue: the admission of patients to an intensive care unit (ICU). The results of a case study, carried out in the ICU of a hospital in the north of Italy between 2006 and 2007 are reported. The study was performed using ethnographic methods: participant observation, ethnographic interviews, and semi-structured interviews. Empirical data have been analysed using a grounded theory approach. The results show how three dimensions (macrosocial, organisational-interactional, and individual) become intertwined with the operational guidelines that have been drafted on the basis of international evidence. The standardisation process that the guidelines presuppose results in the adoption of a variety of different local styles with respect to the approach that individual doctors take in relation to the admission of a patient to an ICU. These styles can range from strict adherence to the international criteria to a greater compliance with medical–legal, organisational, and individual needs. Furthermore, the results of the study demonstrate how relational knowledge, as a form of situated knowledge, can allow the personnel involved to activate local resources (organisational, professional, and personal) in order to incorporate the formal prescriptions of EBM in professional practice.URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs1502261El artículo analiza la brecha existente entre la dimensión formal de la medicina basada en evidencia (MBE), como constituido por protocolos, procedimientos y directrices y prácticas profesionales reales con relación a un tema específico: la admisión de pacientes a la unidad de cuidados intensivos (UCI). Se reportan los resultados de un estudio de caso, llevado a cabo en la UCI de un hospital en el norte de Italia entre 2006 y 2007. El estudio fue realizado usando métodos etnográficos: observación participante, entrevistas etnográficas y entrevistas semiestructuradas. Se han analizado los datos empíricos mediante un enfoque de teoría fundamentada. Los resultados muestran cómo tres dimensiones (macrosociales, organizacional-interaccional e individual) se entrelazan con las directrices operativas que se han redactado sobre la base de evidencia internacional. El proceso de estandarización que presuponen las directrices resultan en la adopción de una variedad de diferentes estilos locales con respecto al enfoque que los médicos individuales adopten en relación con la admisión de un paciente a una UCI. Estos estilos pueden variar desde la estricta observancia de los criterios internacionales hasta un mayor cumplimiento de las necesidades médico – legales, organizacionales e individuales. Además, los resultados del estudio demuestran cómo el conocimiento relacional, como una forma de conocimiento situado, puede permitir al personal involucrado activar los recursos locales (organizacionales, profesionales y personales) con el fin de incorporar las prescripciones formales de la MBE en la práctica profesional.URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs150226

I focus group: cultura e pratiche collaborative

Negli ultimi decenni il tema della collaborazione inter-professionale è diventato sempre più centrale nelle strategie di management delle organizzazioni sanitarie italiane a causa della crescente complessità delle configurazioni dei servizi sociosanitari e della eterogeneità dei profili professionali impegnati a diverso titolo nelle pratiche di cura. Il libro intende proporre un inedito approccio alla comprensione delle relazioni collaborative in ambito sanitario, illustrando un percorso di ricerca-azione realizzato nel triennio 2010-12 presso l'Azienda Ospedaliero-Universitaria di Parma. L'esperienza di ricerca-azione ha portato alla luce quelle che gli autori hanno definito pratiche di collaborazione resiliente. In ambito psicologico, la resilienza è la capacità di una persona di reagire a un trauma o a una crisi. Anche i legami sociali possono avere una propria resilienza. Si tratta di quelle pratiche ordinarie e reiterate, di cui è intessuta la quotidianità del lavoro di cura, che vedono i professionisti della salute, afferenti a comunità professionali e strutture organizzative differenti, coordinarsi secondo modalità prevalentemente informali e spesso mettendo in gioco le regole organizzative per raggiungere specifici obiettivi di cura. Il volume fornisce un resoconto sociologico della ricerca-azione, fatta di tentativi ed errori, aggiustamenti e approssimazioni, sopraluoghi e interrogazioni, per cogliere l'urgenza di valorizzare i molteplici sforzi che rendono possibile la tenuta d'insieme di un'organizzazione compless

Etnografia partecipativa e comunità di pratica: metodi formativi e risorse professionali per il nuovo welfare

Etnografia partecipativa e comunità di pratica: metodi formativi e risorse professionali per il nuovo welfare – Riassunto. Gli ultimi decenni sono stati caratterizzati da profondi processi di ridefinizione delle pratiche in ogni settore del welfare, soprattutto negli ambiti sanitario e socio-sanitario. Le cause attengono a tre ordini di fenomeni: la crescente densità scientifico-tecnologica degli interventi; il diffondersi di strategie manageriali che enfatizzano la rilevanza dei meccanismi di controllo degli outcome e della customer satisfaction; infine, le trasformazioni demografiche e socioculturali che vanno ridisegnando le interazioni tra persone e servizi. Il saggio illustra le potenzialità formative del metodo dell’etnografia partecipativa come strumento per affrontare le inedite sfide poste dalle esigenze di welfare attuali. Lo sguardo etnografico diventa una risorsa professionale efficace per il coordinamento delle comunità di pratica in un’ottica di valorizzazione delle competenze tacite e delle pratiche situate, elementi costitutivi della vita organizzativa nella società della conoscenza.Participatory ethnography and community of practice: training methods and professional resources for the new welfare (Article in Italian) – Summary. Last decades have been characterized by processes of redefinition of practices of welfare, especially in health and social care. The causes are related to three orders of phenomena: the increasing scientific-technological density of the interventions; the spread of managerial strategies that emphasize the relevance of mechanisms for managing outcome control and customer satisfaction; finally, the demographic and sociocultural transformations that are shaping the interactions between people and services. The article illustrates the educational potential of the community of practice paradigm to face the unprecedented challenges posed by current welfare needs. The ethnographic gaze, stimulated through the participatory ethnography method, becomes an effective professional resource for the coordination of the community of practice and for enhancing tacit knowledge and situated practice, strategic assets for organizational and professional success in the knowledge society

Making visible the invisible and vice versa. Bodies and organisational arrangements in the Intensive Care Unit

Background and aims: The effectiveness of the treatments carried out in the Intensive Care Unit (ICU) is guaranteed by a socio-technical ensemble where material resources, scientific knowledge, technological artefacts, social norms, spatial dispositions, and professional practices coexist and constantly interact. This paper intends to penetrate such an ensemble for analysing the moral order produced and maintained in everyday medical practice. Method: The results of a case study, carried out in the ICU of a hospital in the north of Italy between 2006 and 2007 are reported. The study was performed using ethnographic methods: participant observation, ethnographic interviews, and semi-structured interviews. Results: I illustrate how ward organisation and professional practices of medical and nurse staff create and reproduce two dispositions of body centred on the staff’s perception of the therapeutic appropriateness of patients. On one side, there are the bodies that staff expect to get better, and these bodies are exposed through a series of organisational devices and activities in order to make them immediately accessible and available for every type of treatment; on the other side, the bodies of chronic and terminal patients tend to become invisibles in the working practice of the unit. This process does not follow any guideline or protocol but is embodied in informal routine and communicative interactions. Conclusions: The invisibility surrounding certain patients can be seen as strategies for the management of professional conflict and bioethical issues that stem from different interpretations of the degree of severity of the patients’ conditions

El prólogo del Lazarillo y la obra de Luis Vives

Le prospettive del processo di cura vedono oggi un conflitto significativo tra un modelli tecnico-procedurale e un modello simbolico-relazionale