Original research J Med Ethics: first published as 10.1136/medethics-2019-105865 on 24 January 2020. Downloaded from Communities of practice: acknowledging vulnerability to improve resilience in healthcare teams Janet Delgado ,1,2 Janet de Groot,3 Graham McCaffrey,4,5 Gina Dimitropoulos,6 Kathleen C Sitter,6 Wendy Austin7 1University Institute of Women’s ABSTRact high levels of uncertainty: ‘While caring for patients Studies, University of La Laguna, The majority of healthcare professionals regularly and their families, healthcare professionals share La Laguna, Spain 2NICU, University Hospital of witness fragility, suffering, pain and death in their and reflect on the joys and sorrows that accompany the Canary Islands, La Laguna, professional lives. Such experiences may increase the these interactions. In many ways, they are suffering Spain risk of burnout and compassion fatigue, especially if too’.6 Thus, acquiring a deeper understanding of 3 University of Calgary Cumming they are without self- awareness and a healthy work vulnerability inherent to health professional work is School of Medicine, Calgary, environment. Acquiring a deeper understanding of of crucial importance to face these risks, attending Alberta, Canada 4Faculty of Nursing, University vulnerability inherent to their professional work will be of to professionals’ mental health. Not recognising of Calgary, Calgary, Alberta, crucial importance to face these risks. From a relational the professionals’ vulnerability may come at a cost Canada ethics perspective, the role of the team is critical in the 5 for healthcare staff, patients and their families and University of Cambridge, development of professional values which can help society at larger. Cambridge, UK 6University of Calgary Faculty of to cope with the inherent vulnerability of healthcare The recognition of vulnerability has benefi- Social Work, Calgary, Alberta, professionals. The focus of this paper is the role of cial elements that require greater attention.7 8 For Canada Communities of Practice as a source of resilience, since 7 instance, vulnerability is associated with an inherent Faculty of Nursing, University they can create a reflective space for recognising and openness to the world that supports growth and of Alberta, Edmonton, Alberta, sharing their experiences of vulnerability that arises Canada flourishing. Allowing ourselves to be interdepen- as part of their work. This shared knowledge can be a dent, recognising and accepting our vulnerability, 8 Correspondence to source of strength while simultaneously increasing the is a precondition for creativity. Fineman indicates Dr Janet Delgado, University confidence and resilience of the healthcare team. that our vulnerability presents opportunities for Institute of Women’s Studies, innovation and growth, creativity and fulfilment, University of La Laguna, C/ since it promotes relationship formation. We argue Pedro Zerolo, s/n. Edificio INTRODUCTION that through the recognition and acceptance of Central. Apartado 456. Código Vulnerability is a complex and thought- provoking postal 38200. San Cristóbal our shared vulnerability, better relationships can concept. In a broad sense, there are opposing theo- de La Laguna, S/C de Tenerife, be built within the professional sphere which may Spain; jdelgadr@ ull. edu. es retical approaches on the conception of vulnera- support resilience. For this purpose, it is critical to bility, especially in bioethics, which may result in focus on the relationship between vulnerability and Received 25 September 2019 perceiving it as a largely opaque term. As a result, Revised 19 December 2019 resilience in healthcare settings. there is a huge controversy in bioethics and social Accepted 13 January 2020 In this paper, we aim to explore the relation- sciences about this concept. http://jme.bmj.com/ In this paper we understand vulnerability as a ship between vulnerability and resilience in the 1 framework of Communities of Practice (CoP). We universal, inherent human condition. This essen- 9 tial human condition is an important element in analyse CoP from a relational ethics perspective, bioethics, as well as in the core of healthcare rela- assuming that the role of the team is critical in tionships.2 In this context and following the theo- the development of professional values. An earlier retical framework of vulnerability theory (VT), we project identified the central elements of relational understand vulnerability as ‘the characteristic that ethics as engagement, mutual respect, embodied on January 24, 2020 by guest. Protected copyright. positions us in relation to each other as human beings knowledge, uncertainty/vulnerability and atten- 9 and also suggests a relationship of responsibility tion to an interdependent environment. We focus between the state and their institutions and the indi- on the paradox that vulnerability is an essential vidual’.3 In the context of healthcare, professionals characteristic to building resilience in health- regularly witness the fragility, suffering, pain and care teams. One way that has been developed to death of others more commonly than most people understand how vulnerability can be transformed do in daily life. In addition to witnessing, health into a strength is to train for resilience, seeking to professionals may also experience vulnerability as improve the psychosocial functioning of members 10 pain and suffering in response to the limits of and of a therapeutic community. We focus on how a © Author(s) (or their CoP in healthcare team can be an essential element employer(s)) 2020. No uncertainty associated with healthcare. Navigating commercial re- use. See rights the differing values of patients, their family and on building resilience. and permissions. Published the healthcare team may also lead to distress and a We argue that CoP may be a source of resilience, by BMJ. sense of helplessness in caring for complex patients through the creation of a reflective space for recog- and supporting their families. These factors, among nising and sharing experiences of vulnerability that To cite: Delgado J, 11 de Groot J, McCaffrey G, et al. others, may increase healthcare professionals’ risk arise as part of CoP members’ work. This shared J Med Ethics Epub ahead of of burnout and compassion fatigue, when not paired knowledge can be a source of strength and benefit print: [please include Day with self-awareness, self- compassion and a healthy to increase the confidence and resilience of the Month Year]. doi:10.1136/ 4 5 healthcare team and its individual members. Our medethics-2019-105865 work environment. Each day healthcare profes- sionals interact with human health and illness and assumption is that resilience can be fostered within Delgado J, et al. J Med Ethics 2020;0:1–6. doi:10.1136/medethics-2019-105865 1 Original research J Med Ethics: first published as 10.1136/medethics-2019-105865 on 24 January 2020. Downloaded from the professional team through ethical values and strategies that This conception is linked to the possibility of suffering that is arise from shared practical wisdom. inherent to human beings. In these approaches, vulnerability is Focusing on CoP, we maintain that a relational turn is at the linked to being fragile, susceptible to damage and suffering and heart of professionalism. Relationships throughout the health- is an ontological, anthropological, inherent and shared condi- care field have profound effects on healthcare professionals as tion for all human beings. These perspectives consider vulner- well as on the patients and their families. Relationship- focused ability in relation to the fact of our inherent interdependency. care brings with it potential emotional demands and stressors We argue that it is necessary to deeply face the notion of that themselves need careful attention. This set of concerns shared and inherent vulnerability within the healthcare field. refers to how daily work can undermine the personality, the Reflections on the universal notion of vulnerability in philos- mood and well- being of professionals and should of necessity be ophy have been guided by Levinas,27 28 MacIntyre,29 Nusbaum,30 taken into account in professionalism reflections. In this regard, Butler,31 32 Ricoeur,33 Turner,34 Fineman1 3 8 and Pelluchon,35 we recommend that a deeper understanding of vulnerability among others. The common feature of all these philosophical within healthcare relationships can be of great value to health- approaches on the concept of vulnerability is that all of them care practice and education. emphasise that being vulnerable is being fragile, susceptible to For our purpose, we will start with a brief introduction to damage and suffering and it is an ontological, inherent, shared VT and to the understanding of vulnerability as a human condi- condition. Emmanuel Levinas’ ethics of alterity can be consid- tion, indicating why this recognition of our vulnerability is ered the most radical approach to universal vulnerability. For important in healthcare. Next, we will continue with an analysis Levinas,27 the relationship that arises in the ethical encounter of the relationship between vulnerability and resilience, linking with the Other, who is vulnerable, is given in the face- to- face these two concepts with the relational ethics framework. This encounter. It is an asymmetrical relationship because the self analysis will allow us to introduce the concept of CoP, and to must respond to the Other’s demands. This implies that one (the