Graham McCaffrey

Rationale: Implementing evidence‐informed healthcare services is typically approached as a structured, time‐limited project, focused largely on what to do. Less well understood is how implementation actually unfolds in practice: the ways in which those involved navigate change and generate solutions in diverse community settings. Without understanding how implementation happens in unique contexts, implementation failure may remain poorly understood. Aim: The aim was to understand what it means for kidney care team providers, information technology staff, and patients to engage in implementing an evolving virtual kidney care service in a large, sparsely populated rural and remote region. Method: We interviewed eight kidney care service providers, two information technology specialists, and 17 patients in northern British Columbia, Canada, for their experiences in implementing, delivering, and receiving virtual kidney care and how their practices changed with COVID‐19. Through an inductive, reflexive process of analysis and hermeneutic interpretation, we identified patterns in how virtual kidney care was implemented. Results: The analysis showed six hermeneutic principles of implementation at work in the everyday practices of the kidney care and information technology teams: acknowledging central concerns, creating new common understandings, collectively acting, surfacing tensions, being responsive to context, and engaging in ongoing dialogue. Rather than discrete, technical, and time‐limited, we found implementation to be an ongoing, evolving, relational, generative, and iterative process that is inextricably connected to its context, and that never fully ends. Conclusion: Attending to the how revealed dimensions of implementation practice that are seldom visible in conventional implementation research. A hermeneutic sensibility, marked by openness, humility, and dialogue, with a commitment to understanding, responsiveness, and relationship‐building, is key to implementation, especially in the ever‐changing contexts of rural and remote areas. The findings point to the value of a hermeneutic approach in implementing, sustaining, and researching innovations in dynamic healthcare systems and rural settings.

Nursing theory should reflect the pluralism inherent in nursing practice. Nurses routinely enact different kinds of knowledge in combination to achieve good nursing care. Nursing theoretical and philosophical literature includes many attempts to engage with epistemological pluralism. In this paper, concepts from the work of Michel Serres are introduced as a contribution to the resources available to think pluralistically about nursing. Serres' work is valuable because he is a pluralist thinker, who uses different conceptual tools to explore the complexity of human life, including topology, isomorphism, and the excluded third. Serres' terms are discussed with examples of application to nursing. An extendeddd example of addictions nursing is used to pull together different concepts applied to a complex and multilayered area of practice.

From Philosophy to Practice (Moules

Background: Virtual health care has transformed health care delivery, with its use dramatically increasing since the COVID-19 pandemic. While it has been quickly adopted for its convenience and efficiency, there has been a relative lack of in-depth exploration of its human impact, specifically how both patients and providers experience clinical encounters. Objective: This analysis aims to identify and explore themes of change in how patients and providers in a geographically dispersed renal service described their experiences with virtual care, including those changes that occurred during the COVID-19 pandemic. Methods: Hermeneutics is an interpretive research methodology that treats human experience as inherently interpretive, generating meaning through interactions with others in specific, historically conditioned, social contexts. A total of 17 patients and 10 providers from various disciplines were interviewed by phone as part of a study on health care implementation in the context of a kidney care service in northern British Columbia, Canada. The interview data were analyzed using a hermeneutic approach, which emphasizes careful attention to reported experiences in relation to the relationships and contexts of care. Results: During analysis, the interdisciplinary team identified themes related to changes in the clinical encounter and how virtual care influenced perceptions of care among both providers and patients. We organized these themes into 2 categories: the structure and content of the encounter. The structure category included the convenience for patients, who no longer had to travel long distances for appointments, as well as changes in care networks. For example, communication between specialist services and local primary care providers became more crucial for ensuring continuity of care. The content category included issues related to trust-building and assessment. Providers expressed concerns about the difficulty in assessing and understanding their patients’ physical and social well-being beyond laboratory results. Conclusions: Patients in the study appreciated the convenience of not needing to travel for appointments, while still having the option for in-person contact with local providers or specialists if their condition changed. Providers were more concerned about the loss of visual cues and sensory data for assessments, as well as the reduced opportunity to build relationships through conversation with patients. Providers also described changes in the locus of control and boundaries, as patients could join phone encounters from anywhere, bypassing traditional privacy and confidentiality boundaries. The study offers a nuanced view of the effects of virtual care on clinical encounters in one setting, seen through the experiences of both patients and providers.

Enactivism is a branch of embodied cognition theory that argues for a highly distributed model of cognition as a sense‐making process involving brain, body, environment, and subjective experience. It is a theoretical framework with potential value for nursing since it offers an integrated framework for human sense‐making that includes physiological and psychological factors as well as the primary experience of subjective perceptions. This paper presents an introduction to the background and main tenets of enactivist theory. These are discussed in relation to nursing, and mental health nursing to argue for the relevance of enactivism in nursing knowledge.

This paper was originally written for a hermeneutic research course where I interpreted Yojiro Takita’s (2008) film Departures. I outline an interpretation of death that I came to after viewing the film, discussing death as a form of “unsettling.” Death unsettles by revealing life’s impermanence which is often concealed in everyday life. We may be reminded of it through the death of another. As per Heidegger, when we are perturbed by life’s finitude, we may be driven to action. Subsequently, death discloses life’s grotesqueness. Hidden within the vitality of life is the inevitable decay of the flesh. For some, this may trigger a sense of disgust. As people who work closely with death, nurses learn ways to manage their disgust. However, this experience may not apply to mental health nurses. I end this paper by reflecting on my own experience as a mental nurse, questioning if my choice of specialty is perhaps related to the avoidance of death and the flesh. Keywords: death, hermeneutics, interpretation, film, mental health nursing, existential, disgust

BACKGROUND Virtual health care has transformed health care delivery, with its use dramatically increasing since the COVID-19 pandemic. While it has been quickly adopted for its convenience and efficiency, there has been a relative lack of in-depth exploration of its human impact, specifically how both patients and providers experience clinical encounters. OBJECTIVE This analysis aims to identify and explore themes of change in how patients and providers in a geographically dispersed renal service described their experiences with virtual care, including those changes that occurred during the COVID-19 pandemic. METHODS Hermeneutics is an interpretive research methodology that treats human experience as inherently interpretive, generating meaning through interactions with others in specific, historically conditioned, social contexts. A total of 17 patients and 10 providers from various disciplines were interviewed by phone as part of a study on health care implementation in the context of a kidney care service in northern British Columbia, Canada. The interview data were analyzed using a hermeneutic approach, which emphasizes careful attention to reported experiences in relation to the relationships and contexts of care. RESULTS During analysis, the interdisciplinary team identified themes related to changes in the clinical encounter and how virtual care influenced perceptions of care among both providers and patients. We organized these themes into 2 categories: the structure and content of the encounter. The structure category included the convenience for patients, who no longer had to travel long distances for appointments, as well as changes in care networks. For example, communication between specialist services and local primary care providers became more crucial for ensuring continuity of care. The content category included issues related to trust-building and assessment. Providers expressed concerns about the difficulty in assessing and understanding their patients’ physical and social well-being beyond laboratory results. CONCLUSIONS Patients in the study appreciated the convenience of not needing to travel for appointments, while still having the option for in-person contact with local providers or specialists if their condition changed. Providers were more concerned about the loss of visual cues and sensory data for assessments, as well as the reduced opportunity to build relationships through conversation with patients. Providers also described changes in the locus of control and boundaries, as patients could join phone encounters from anywhere, bypassing traditional privacy and confidentiality boundaries. The study offers a nuanced view of the effects of virtual care on clinical encounters in one setting, seen through the experiences of both patients and providers.

Hermeneutic methods have been widely used in health research. Through conducting a scoping review of hermeneutic studies related to implementation in healthcare, we identified various approaches and common strengths across studies. The review was part of a larger study exploring how hermeneutics could contribute fresh perspectives to implementation science. We looked at a large number of studies that reported some use of hermeneutics with a focus on what they had to say about processes of implementation in health care environments. While meeting our primary goal of identifying what was salient to implementation, we came up against the question of what made for a strong hermeneutic study. Through an extensive process of evaluation and discussion, several common elements emerged across studies that used hermeneutics: participatory conversations, reflective spaces, attention to alterity, and close-up granular detail. In this article, we outline the review process, then focus on six articles that met our criteria for relevance to implementation and hermeneutic strength. We discuss how some or all the common elements appeared in the articles, despite wide variations in topic and in how hermeneutics was applied. We argue that strength in hermeneutic research stems from a dialectic between applied principles and outcomes.