As a response to the criticisms evidence-based practice currently faces, groups of health care re... more As a response to the criticisms evidence-based practice currently faces, groups of health care researchers and guideline makers have started to call for the appraisal and inclusion of different kinds of knowledge in guideline production (other than randomized controlled trials [RCTs]) to better link with the informal knowledge used in clinical practice. In an ethnographic study, Gabbay and Le May showed that clinicians in everyday practice situations do not explicitly or consciously use guidelines. Instead, they use mindlines: collectively shared, mostly tacit knowledge that is shaped by many sources, including accumulated personal experiences, education (formal and informal), guidance, and the narratives about patients that are shared among colleagues. In this study on informal knowledge, we consider virtual networks of clinicians as representative of the mindlines in the wider medical community, as holders of knowledge, as well as catalysts of knowing. The aim of this study was to...
Journal of evaluation in clinical practice, Jan 16, 2017
Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by man... more Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by many to have modernized health care and brought it from an authority-based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC. In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to "purify" clinical reality into a dichotomy of objective "evidence" from nature and subjective "preferences" from human society and culture. However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition-albeit implicit a...
Journal of health services research & policy, Jan 11, 2016
Funding bodies, policy makers, researchers and clinicians are seeking strategies to increase the ... more Funding bodies, policy makers, researchers and clinicians are seeking strategies to increase the translation of knowledge between research and practice. Participatory research encompasses a range of approaches for clinicians' involvement in research in the hope of increasing the relevance and usability of research. Our aim was to explore how knowledge is translated and integrated in participants' presentations and negotiations about knowledge. Twelve collaboration meetings were observed, and discussions between researchers and clinicians were recorded. The material was examined using the following analytical terms: knowledge object, knowledge form, knowledge position and knowledge tasks. We identified a recurring rhetorical pattern in translational processes that we call 'relevance testing': a strategy by which the participants attempt to create coherence and identify relevance across different contexts. The limitation of this translational strategy was a tendency to...
Proceeding from a phenomenological perspective, this study investigates how physiotherapists' exp... more Proceeding from a phenomenological perspective, this study investigates how physiotherapists' experience-based knowledge acquires significance in their encounters with patients diagnosed as obese. Presenting the thematic accounts of three physiotherapists, this paper illuminates how they make use of experiences from both their own life as well as experiences from learning and doing physiotherapy. This multifaceted experience-based knowledge is significant for making individual adjustments in a group-based programme. In line with these findings, the authors question whether the therapeutic method itself can be given such a prime position in defining best evidence in evidence-based practice. In concluding, they call for a reconsideration of the term evidence. More precisely, it is argued that what will be "effective" therapy for a person diagnosed as obese cannot be reduced to external evidence. Because research is one thing ... but retrieving experiences from my experience box-that has impacted my approach. ... When I started working with this, in the beginning, I was more like this: Now you have come to the right place. I was kind of like that. I felt the need to convince them that I know what I am doing.
The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardiza... more The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research. EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement. In this paper, we argue that the protagonists of EBM position their mission as reducing uncertainty through the use of standardized methods for knowledge evaluation and use. With this drive towards uniformity, standardization and control comes a suspicion towards intuition, creativity and uncertainty as integral parts of medical practice. We question the appropriateness of attempts to standardize professional practice through a discussion of the importance of uncertainty. Greenhalgh's taxonomy of uncertainty is used to inform an analysis of the clinical reasoning occurring in a potentially life threatening emergency situation with a young patient. The case anal...
Objectives: Funding bodies, policy makers, researchers and clinicians are seeking strategies to i... more Objectives: Funding bodies, policy makers, researchers and clinicians are seeking strategies to increase the translation of knowledge between research and practice. Participatory research encompasses a range of approaches for clinicians' involvement in research in the hope of increasing the relevance and usability of research. Our aim was to explore how knowledge is translated and integrated in participants' presentations and negotiations about knowledge. Methods: Twelve collaboration meetings were observed, and discussions between researchers and clinicians were recorded. The material was examined using the following analytical terms: knowledge object, knowledge form, knowledge position and knowledge tasks. Results: We identified a recurring rhetorical pattern in translational processes that we call 'relevance testing': a strategy by which the participants attempt to create coherence and identify relevance across different contexts. The limitation of this translational strategy was a tendency to reinforce a 'two-communities' logic: re-establishing the separated worlds and rationales between clinicians and researchers. The 'translational work' that unfolds during discussions remains implicit. It may be that participants are unable to explicitly address and identify the knowledge translation processes because they lack necessary conceptual tools. Conclusions: Our results contribute to increased awareness about translational processes and provide a language through which barriers to translation can be addressed.
TKA) or total hip arthroplasty (THA) (4,5). Our initial intention was to examine the effect of th... more TKA) or total hip arthroplasty (THA) (4,5). Our initial intention was to examine the effect of the programme in a strict RCT design, and consequently describe the intervention in a standardized manner, with number of repetitions or time to target muscle strength, joint fl exibility or balance during ambula-tion. Over the course of the training programme, and as the physiotherapists conducting the intervention, we became increasingly aware that the programme was highly individualized and contained various elements that we had not included in the RCT reports. These individualizations included a variety of adjustments in both the exercises that were performed and how the tasks were approached. We started questioning whether the individual adjustments were crucial for the patients ' ability to pursue with the programme (6). We therefore concluded that Abstract A walking skill intervention was reported by two randomized controlled trials (RCTs) to be effective in improving walking fo...
In youth theory of the 90s, one frequently encounters the terms i~adi2~ieltialisation, risk, and ... more In youth theory of the 90s, one frequently encounters the terms i~adi2~ieltialisation, risk, and reflexivity. More than in previous social systems, youth scenes in post-industrial societycan be characterised by terms such as dissolving traditions, diversity, individual solutions, ...
We studied resilience related to childhood experiences of famine in Ethiopia. We sought an unders... more We studied resilience related to childhood experiences of famine in Ethiopia. We sought an understanding of how young Ethiopians survived and coped with the devastating effects of famine. Participant observations and in-depth interviews at an orphanage in Addis Ababa with eight boys and girls (ages 18 to 23), survivors from famine catastrophe in Ethiopia 1984-1985, were conducted. Significant resilience factors identified were faith and hope, having a living relative, and having memories of one's past roots. Exposure to famine and multiple early losses may have long-term effects on an individual's capacity to maintain resilience. We discuss how an understanding of resilience can be applied in different cultural settings. Future research on resilience in Africa is suggested to increase our knowledge base of this concept.
To explore what patients that had completely recovered from fibromyalgia (FM) experienced as bein... more To explore what patients that had completely recovered from fibromyalgia (FM) experienced as being important for their recovery. Five women, aged between 37 and 49 were interviewed individually. The interviews were aimed at finding out about the recovery process and the women's daily lives at the time of the interview and before and after their diagnosis, with a special emphasis on social relationships and obligations. The interviews were analysed by qualitative thematic content analysis. These five women reported that they recovered irrespective of specific treatment. The study shows that resistance to the unpleasantness of the sick role and the stigmatization associated with the uncertain nature of the FM diagnosis promoted recovery. Instead of adapting their activities to pain, they used pain as a warning signal of too much stress in life. This significantly developed their ability to alter their life goals and everyday obligations. At the same time they managed to maintain a social role they considered to be consistent with their self-image. Patients can recover from FM. The information from these informants suggests that to struggle against a role of chronic patient and keep up with their social obligations and goals were of great importance.
Empowerment and user participation represents an ideal of power with a strong position in the hea... more Empowerment and user participation represents an ideal of power with a strong position in the health sector. In this article we use text analysis to investigate notions of power in a program plan for health workers focusing on empowerment. Issues addressed include: How are relationships of power between users and helpers described in the program plan? Which notions of user participation are embedded in the plan? The analysis is based on Foucault’s idea that power which is made subject to attempts of redistribution will re-emerge in other forms. How this happens, and with what consequences, is our analytical concern. The analysis is contrasted with ‘snapshots’ from everyday life in a nursing home. The program plan communicates empowerment as a democracy-building instrument that the users need. It is a tool for providing expert assistance to the user’s self-help. User participation is made into a tool which is external to the user him-/herself. Furthermore, the analysis shows that the plan’s image of empowerment presupposes an ‘élite user’ able to articulate personal needs and desires. This is not very applicable to the most vulnerable user groups, who thereby may end up in an even weaker position. By way of conclusion, we argue that an exchange of undesirable dominating paternalism for a desirable empowerment will not abolish power, but may result in more covert and subtle forms of power that are less open to criticism. The paper offers insights that will facilitate reflections on the premises for practising empowerment-oriented health care.
As a response to the criticisms evidence-based practice currently faces, groups of health care re... more As a response to the criticisms evidence-based practice currently faces, groups of health care researchers and guideline makers have started to call for the appraisal and inclusion of different kinds of knowledge in guideline production (other than randomized controlled trials [RCTs]) to better link with the informal knowledge used in clinical practice. In an ethnographic study, Gabbay and Le May showed that clinicians in everyday practice situations do not explicitly or consciously use guidelines. Instead, they use mindlines: collectively shared, mostly tacit knowledge that is shaped by many sources, including accumulated personal experiences, education (formal and informal), guidance, and the narratives about patients that are shared among colleagues. In this study on informal knowledge, we consider virtual networks of clinicians as representative of the mindlines in the wider medical community, as holders of knowledge, as well as catalysts of knowing. The aim of this study was to...
Journal of evaluation in clinical practice, Jan 16, 2017
Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by man... more Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by many to have modernized health care and brought it from an authority-based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC. In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to "purify" clinical reality into a dichotomy of objective "evidence" from nature and subjective "preferences" from human society and culture. However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition-albeit implicit a...
Journal of health services research & policy, Jan 11, 2016
Funding bodies, policy makers, researchers and clinicians are seeking strategies to increase the ... more Funding bodies, policy makers, researchers and clinicians are seeking strategies to increase the translation of knowledge between research and practice. Participatory research encompasses a range of approaches for clinicians' involvement in research in the hope of increasing the relevance and usability of research. Our aim was to explore how knowledge is translated and integrated in participants' presentations and negotiations about knowledge. Twelve collaboration meetings were observed, and discussions between researchers and clinicians were recorded. The material was examined using the following analytical terms: knowledge object, knowledge form, knowledge position and knowledge tasks. We identified a recurring rhetorical pattern in translational processes that we call 'relevance testing': a strategy by which the participants attempt to create coherence and identify relevance across different contexts. The limitation of this translational strategy was a tendency to...
Proceeding from a phenomenological perspective, this study investigates how physiotherapists' exp... more Proceeding from a phenomenological perspective, this study investigates how physiotherapists' experience-based knowledge acquires significance in their encounters with patients diagnosed as obese. Presenting the thematic accounts of three physiotherapists, this paper illuminates how they make use of experiences from both their own life as well as experiences from learning and doing physiotherapy. This multifaceted experience-based knowledge is significant for making individual adjustments in a group-based programme. In line with these findings, the authors question whether the therapeutic method itself can be given such a prime position in defining best evidence in evidence-based practice. In concluding, they call for a reconsideration of the term evidence. More precisely, it is argued that what will be "effective" therapy for a person diagnosed as obese cannot be reduced to external evidence. Because research is one thing ... but retrieving experiences from my experience box-that has impacted my approach. ... When I started working with this, in the beginning, I was more like this: Now you have come to the right place. I was kind of like that. I felt the need to convince them that I know what I am doing.
The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardiza... more The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research. EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement. In this paper, we argue that the protagonists of EBM position their mission as reducing uncertainty through the use of standardized methods for knowledge evaluation and use. With this drive towards uniformity, standardization and control comes a suspicion towards intuition, creativity and uncertainty as integral parts of medical practice. We question the appropriateness of attempts to standardize professional practice through a discussion of the importance of uncertainty. Greenhalgh's taxonomy of uncertainty is used to inform an analysis of the clinical reasoning occurring in a potentially life threatening emergency situation with a young patient. The case anal...
Objectives: Funding bodies, policy makers, researchers and clinicians are seeking strategies to i... more Objectives: Funding bodies, policy makers, researchers and clinicians are seeking strategies to increase the translation of knowledge between research and practice. Participatory research encompasses a range of approaches for clinicians' involvement in research in the hope of increasing the relevance and usability of research. Our aim was to explore how knowledge is translated and integrated in participants' presentations and negotiations about knowledge. Methods: Twelve collaboration meetings were observed, and discussions between researchers and clinicians were recorded. The material was examined using the following analytical terms: knowledge object, knowledge form, knowledge position and knowledge tasks. Results: We identified a recurring rhetorical pattern in translational processes that we call 'relevance testing': a strategy by which the participants attempt to create coherence and identify relevance across different contexts. The limitation of this translational strategy was a tendency to reinforce a 'two-communities' logic: re-establishing the separated worlds and rationales between clinicians and researchers. The 'translational work' that unfolds during discussions remains implicit. It may be that participants are unable to explicitly address and identify the knowledge translation processes because they lack necessary conceptual tools. Conclusions: Our results contribute to increased awareness about translational processes and provide a language through which barriers to translation can be addressed.
TKA) or total hip arthroplasty (THA) (4,5). Our initial intention was to examine the effect of th... more TKA) or total hip arthroplasty (THA) (4,5). Our initial intention was to examine the effect of the programme in a strict RCT design, and consequently describe the intervention in a standardized manner, with number of repetitions or time to target muscle strength, joint fl exibility or balance during ambula-tion. Over the course of the training programme, and as the physiotherapists conducting the intervention, we became increasingly aware that the programme was highly individualized and contained various elements that we had not included in the RCT reports. These individualizations included a variety of adjustments in both the exercises that were performed and how the tasks were approached. We started questioning whether the individual adjustments were crucial for the patients ' ability to pursue with the programme (6). We therefore concluded that Abstract A walking skill intervention was reported by two randomized controlled trials (RCTs) to be effective in improving walking fo...
In youth theory of the 90s, one frequently encounters the terms i~adi2~ieltialisation, risk, and ... more In youth theory of the 90s, one frequently encounters the terms i~adi2~ieltialisation, risk, and reflexivity. More than in previous social systems, youth scenes in post-industrial societycan be characterised by terms such as dissolving traditions, diversity, individual solutions, ...
We studied resilience related to childhood experiences of famine in Ethiopia. We sought an unders... more We studied resilience related to childhood experiences of famine in Ethiopia. We sought an understanding of how young Ethiopians survived and coped with the devastating effects of famine. Participant observations and in-depth interviews at an orphanage in Addis Ababa with eight boys and girls (ages 18 to 23), survivors from famine catastrophe in Ethiopia 1984-1985, were conducted. Significant resilience factors identified were faith and hope, having a living relative, and having memories of one's past roots. Exposure to famine and multiple early losses may have long-term effects on an individual's capacity to maintain resilience. We discuss how an understanding of resilience can be applied in different cultural settings. Future research on resilience in Africa is suggested to increase our knowledge base of this concept.
To explore what patients that had completely recovered from fibromyalgia (FM) experienced as bein... more To explore what patients that had completely recovered from fibromyalgia (FM) experienced as being important for their recovery. Five women, aged between 37 and 49 were interviewed individually. The interviews were aimed at finding out about the recovery process and the women's daily lives at the time of the interview and before and after their diagnosis, with a special emphasis on social relationships and obligations. The interviews were analysed by qualitative thematic content analysis. These five women reported that they recovered irrespective of specific treatment. The study shows that resistance to the unpleasantness of the sick role and the stigmatization associated with the uncertain nature of the FM diagnosis promoted recovery. Instead of adapting their activities to pain, they used pain as a warning signal of too much stress in life. This significantly developed their ability to alter their life goals and everyday obligations. At the same time they managed to maintain a social role they considered to be consistent with their self-image. Patients can recover from FM. The information from these informants suggests that to struggle against a role of chronic patient and keep up with their social obligations and goals were of great importance.
Empowerment and user participation represents an ideal of power with a strong position in the hea... more Empowerment and user participation represents an ideal of power with a strong position in the health sector. In this article we use text analysis to investigate notions of power in a program plan for health workers focusing on empowerment. Issues addressed include: How are relationships of power between users and helpers described in the program plan? Which notions of user participation are embedded in the plan? The analysis is based on Foucault’s idea that power which is made subject to attempts of redistribution will re-emerge in other forms. How this happens, and with what consequences, is our analytical concern. The analysis is contrasted with ‘snapshots’ from everyday life in a nursing home. The program plan communicates empowerment as a democracy-building instrument that the users need. It is a tool for providing expert assistance to the user’s self-help. User participation is made into a tool which is external to the user him-/herself. Furthermore, the analysis shows that the plan’s image of empowerment presupposes an ‘élite user’ able to articulate personal needs and desires. This is not very applicable to the most vulnerable user groups, who thereby may end up in an even weaker position. By way of conclusion, we argue that an exchange of undesirable dominating paternalism for a desirable empowerment will not abolish power, but may result in more covert and subtle forms of power that are less open to criticism. The paper offers insights that will facilitate reflections on the premises for practising empowerment-oriented health care.
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Papers by Kristin Heggen