Good Care in Ongoing Dialogue. Improving the Quality of Care Through Moral Deliberation and Responsive Evaluation

Recently, moral deliberation within care institutions is gaining more attention in medical ethics. Ongoing dialogues about ethical issues are considered as a vehicle for quality improvement of health care practices. The rise of ethical conversation methods can be understood against the broader development within medical ethics in which interaction and dialogue are seen as alternatives for both theoretical or individual reflection on ethical questions. In other disciplines, intersubjectivity is also seen as a way to handle practical problems, and methodologies have emerged to deal with dynamic processes of practice improvement. An example is responsive evaluation. In this article we investigate the relationship between moral deliberation and responsive evaluation, describe their common basis in dialogical ethics and pragmatic hermeneutics, and explore the relevance of both for improving the quality of care. The synergy between the approaches is illustrated by a case example in which both play a distinct and complementary role. It concerns the implementation of quality criteria for coercion in Dutch psychiatry

Realizing autonomy in responsive relationships

The goal of this article is to augment the ethical discussion among nurses with the findings from empirical research on autonomy of older adults with type 2 diabetes mellitus. There are many factors influencing autonomy. These include: health conditions, treatment, knowledge, experience and skills, personal approach as well as familial patterns, type of relationship, life history and social context. Fifteen older adults with type 2 diabetes mellitus were interviewed in a nurse-led diabetes clinic. These participants perceive three processes which support autonomy in responsive relationships: preserving patterns of concern and interaction, nurturing collaborative responsibilities and being closely engaged in trustful and helpful family relations. People with diabetes realize autonomy in various responsive relationships in their unique life context. Next, we performed a literature review of care ethics and caring in nursing with regard to relational autonomy. We classified the literature in five strands of care: attitude-oriented, dialogue-oriented, activity-oriented, relationship-oriented and life-oriented. According to our respondents, autonomy in responsive relationships is fostered when patient, nurses, professionals of the health team and family members carry out care activities supported by a relational attitude of care. They can best realize autonomy in relationships with others when several essential aspects of care and caring are present in their lives. Therefore, we advocate a comprehensive approach to care and caring

Clinical and cost-effectiveness of computerised cognitive behavioural therapy for depression in primary care: Design of a randomised trial

<p>Abstract</p> <p>Background</p> <p>Major depression is a common mental health problem in the general population, associated with a substantial impact on quality of life and societal costs. However, many depressed patients in primary care do not receive the care they need. Reason for this is that pharmacotherapy is only effective in severely depressed patients and psychological treatments in primary care are scarce and costly. A more feasible treatment in primary care might be computerised cognitive behavioural therapy. This can be a self-help computer program based on the principles of cognitive behavioural therapy. Although previous studies suggest that computerised cognitive behavioural therapy is effective, more research is necessary. Therefore, the objective of the current study is to evaluate the (cost-) effectiveness of online computerised cognitive behavioural therapy for depression in primary care.</p> <p>Methods/Design</p> <p>In a randomised trial we will compare (a) computerised cognitive behavioural therapy with (b) treatment as usual by a GP, and (c) computerised cognitive behavioural therapy in combination with usual GP care. Three hundred mild to moderately depressed patients (aged 18–65) will be recruited in the general population by means of a large-scale Internet-based screening (<it>N </it>= 200,000). Patients will be randomly allocated to one of the three treatment groups. Primary outcome measure of the clinical evaluation is the severity of depression. Other outcomes include psychological distress, social functioning, and dysfunctional beliefs. The economic evaluation will be performed from a societal perspective, in which all costs will be related to clinical effectiveness and health-related quality of life. All outcome assessments will take place on the Internet at baseline, two, three, six, nine, and twelve months. Costs are measured on a monthly basis. A time horizon of one year will be used without long-term extrapolation of either costs or quality of life.</p> <p>Discussion</p> <p>Although computerised cognitive behavioural therapy is a promising treatment for depression in primary care, more research is needed. The effectiveness of online computerised cognitive behavioural therapy without support remains to be evaluated as well as the effects of computerised cognitive behavioural therapy in combination with usual GP care. Economic evaluation is also needed. Methodological strengths and weaknesses are discussed.</p> <p>Trial registration</p> <p>The study has been registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).</p

Dialogue in Evaluation: A Hermeneutic Perspective

Dialogue is crucial to evaluation. Through dialogue, people are invited to develop new, shared ways of seeing and acting. From a hermeneutic perspective, dialogue implies consensus, based upon shared meanings and oriented towards reaching agreement. Dialogue also implies disagreement, in the form of a conflict between different, rival stories. The role of the evaluator is to enter into dialogue with people participating in practice. It is also to stimulate a dialogue between participants. This requires support for marginalized voices, but also attention to the voices of those who are in power. Only if the evaluator tries to understand the values endorsed in a practice and is prepared to listen to the stories of all parties involved, can evaluation become a practice to which all participants contribute

Handlung und Struktur - Überlegungen zu einer handlungstheoretischen Gesellschaftstheorie

If action theory is to be relevant for the study of social phenomena, its scope has to be enlarged so as to include social structures. A hermeneutic theory of action, which draws on the thoughts of Gadamer, Merleau-Ponty, Ricoeur and Giddens, can meet this requirement. The hermeneutic concept of action, which emphasises the importance of tradition, style and rituals, demonstrates that action and structure presuppose and explain each other. The mutual relationship between action and structure is particularly clear in theories of human development in the domain of psychology, psychotherapy and education. These theories can be used to construct a theory of social evolution, as has been developed by Habermas. By integrating structural, theoretical and critical points of view, a hermeneutic theory of action opens a perspective in which action theory and social theory might be successfully combined

Moral deliberation in psychiatric nursing practice

Moral deliberation has been receiving more attention in nursing ethics. Several ethical conversation models have been developed. This article explores the feasibility of the so-called CARE (Considerations, Actions, Reasons, Experiences) model as a framework for moral deliberation in psychiatric nursing practice. This model was used in combination with narrative and dialogical approaches to foster discourse between various stakeholders about coercion in a closed admission clinic in a mental hospital in the Netherlands. The findings demonstrate that the CARE model provides a substantial framework for structuring moral deliberations. Narratives and dialogue are useful tools for broadening issues in conversations, to engage various stakeholders (including patients), and to gain shared understandings