In Western countries the health care system faces numerous challenges. We explore the potential of the normative practice approach to analyze the present system, to provide new insights in the redesign of the health care network, and to offer new concepts to understand the needs and wishes of patients. We present a case study of assistive devices in orthopaedics. This article shows that the Triple I variant of the practice model is very fruitful to understand the organizational embedding of professional practices, to understand the health care system as chains of professional practices, and to understand the influence of stakeholders. In this study we introduce the idea of user practices to investigate the social environment of patients and to make the needs and wishes of patients explicit.
In Western countries the health care system faces numerous challenges. Rising costs make strong demands on the economy, financial reward systems do not support patient-centered treatment, overtreatment increases the suffering of patients, prosperity diseases undermine the health of the population, and the dominant medical approach clashes with the social and spiritual needs of patients. It is generally believed that these problems can only be solved by a fundamental transformation of the whole system. The most often proposed ingredients of that transformation are (i) a major redesign of the health care chain, (ii) a radical focus on the needs and wishes of patients, and (iii) a wide deployment of (internet) technology (Porter and Teisberg 2006; Brownlee 2007; Callahan 2009; Christensen, Grossman, and Hwang 2009; Topol 2012; Gawande 2014; LaRusso, Spurrier, and Farrugia 2015; Topol 2015).
Christian philosophers have contributed to the understanding of professional practices in health care (Jochemsen and Glas 1997; Jochemsen 2006). They have developed the normative practice approach to unravel the complexity of a medical practice and to offer a clue to identifying values and understanding the influence of world views. This approach focuses on the nature of the care process, the influence of the environment, and the basic beliefs that underlie a care practice. Up till now, the normative practice approach has been elaborated for the cornerstone of classical health care: the consulting room as the place where the health care professional sees the patient. However, the redesign of health care will radically change the face of health care, as provocatively expressed by Topol (2015) in the title of his latest book: The Patient Will See You Now.
To date, the potential of the normative practice approach to analyze the challenges of the present health care system has not been explored. Additionally, the potential of this approach to understand ongoing changes and to contribute to a transformation of the health care system has not been investigated either.
This article explores the potential of the normative practice approach. The problem statement of this study is as follows:
- 1.Can the normative practice approach contribute to a deeper insight into the nature of the problems of the present health care system?
- 2.Can the normative practice approach provide new insights into the redesign of the health care chain?
- 3.Can the normative practice approach offer concepts to understand the needs and wishes of patients?
Health care is very diverse. It consists of different disciplines making use of different bodies of knowledge and operating within different organizational structures. In order to address the problem statement of this article fruitfully one needs a lot of contextual knowledge. For that reason we focus on one specialism, to wit, assistive devices in the domain of orthopaedics. This choice is motivated by (i) the specific know-how of one of the authors, (ii) the complexity of this specialism’s care chain, (iii) the important role of technology, and (iv) the relatively high level of dissatisfaction of the users of these orthotic devices.1
This article has the following set-up. In section 2 a case study is presented about the use and satisfaction of orthopaedic devices that illustrates the problems in health care. In section 3 the idea of practices is explored and a distinction is introduced between professional practices and user practices. In section 4 the complexity of the orthopaedic chain is investigated. In section 5 the nature of professional practices is discussed, and in section 6 the character of the newly introduced concept of user practices is investigated. The article closes with a discussion and conclusions.
2 Case Study: Ankle Foot Orthoses
The ankle foot orthosis (afo) is an orthosis or brace that encloses the ankle and foot.2 The orthosis is externally applied and intended to control the position and motion of the ankle. Reasons for the use of afos vary from congenital malformations to diseases and traumas such as poliomyelitis, multiple sclerosis, cerebrovascular accident (stroke), or head injuries resulting in an aberrant gait pattern. An afo is a piece of medical technology that is generally constructed of lightweight polypropylene-based plastic in the shape of the letter L, with the upright part, depending on the function of the afo, behind the calf or in front of the shank, and a lower part running under the foot. They are attached to the calf with a strap, and are made to fit inside accommodative shoes.
Holtkamp et al. (2015) conducted a questionnaire study to obtain insight in the use and non-use of afos, and the (dis)satisfaction of afo users. The users were also asked to write down any remarks about the delivery, quality, and use of the device. The survey was completed by 211 users (response rate 44%). This survey showed that one out of fifteen participants did not use the afo at all. This result is striking because these people depended on a device for their daily functioning. Evidently, using this device generated more discomfort for them than not using it. Further, this survey showed that three quarters of the afo users were satisfied and one quarter was dissatisfied. Dissatisfied users reported not only dissatisfaction about the design and use of the product but also about the process of delivery and maintenance. The highest level of dissatisfaction was reported with respect to comfort. Finally, a large number of comments were made by the respondents to improve the device or process. Unsatisfied users reported, among other things, pain and hindrance. Even satisfied and very satisfied users reported—to the surprise of the investigators—serious problems in the daily use of the device.
What are the causes of non-use of and dissatisfaction with afos? Why do satisfied and even very satisfied users report serious problems during wear? These problems find their origin in two main causes (Holtkamp et al. 2015, 2016). First, professionals do not manage the care chain as a whole; instead, they are dedicated to their own contribution. Second, orthotic professionals are not adequately focused on the needs and wishes of the users. They do not investigate the environments in which their clients use the device and do not have adequate models to map these environments. The first main cause will be addressed in sections 4 and 5, and the second one in section 6.
3 The Normative Practice Approach
The field of orthopaedic devices is centered on professionals, patients,3 and medical technology. Professionals collaborate to care for patients, professionals and patients meet each other to address a demand for care, and patients are supported by medical technology in their social environment. We interpret all these activities in terms of practices (Nicolini 2012). In this section we explore the idea of practices, give an overview of the normative practice approach, and introduce the idea of user practices to understand the needs and wishes of patients.
3.1 What Is a Practice?
In MacIntyre’s definition four aspects are important: (i) a practice is a “cooperative human activity”: it is not about individuals but about cooperating human beings; (ii) a practice is “socially established”: the activities are related to or rooted in a community; (iii) the practice realizes “goods internal to that form of activity”: the produced goods are characteristic for that practice; and (iv) the practice operates to “standards of excellence”: the activities in this practice meet certain standards of quality.
By a “practice” I am going to mean any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended.
Thus, MacIntyre (1984, 181–203) focuses on practices that meet certain “standards of excellence” and Nicolini (2012, 213–242) limits himself to practices in work and organization. Together, these approaches are well suited to describe the practices of professionals in the field of orthopaedics. In this article we extend the idea of practices by including the social environment of orthopaedic patients in our considerations.
Thus, the study of practices always starts in the middle of action: “In the beginning was the deed”, as proclaimed by Goethe’s Faustus. More clearly, I surmise that to study practice we need to start our investigation by zooming in on practices and approaching them as a knowledgeable accomplishment. Attention should be towards issues such as: what are people doing and saying? What are they trying to do when they speak? What is said and done? How do the patterns of doing and saying flow in time? What temporal sequences do they conjure? With what effect? Through which moves, strategies, methods, and discursive practical devices do practitioners accomplish their work?nicolini 2012, 221
3.2 Professional Practices
Jochemsen, Glas, and Hoogland (Jochemsen and Glas 1997; Hoogland and Jochemsen 2000; Jochemsen 2006) have developed the normative practice approach. This approach is strongly inspired by the ideas of MacIntyre (1984) and focuses on professional practices.4 Originally, the normative practice approach was developed for health care (Jochemsen and Glas 1997) but later on it was elaborated for technology (Verkerk 2014a; Verkerk et al. 2016), the military (Van Burken and De Vries 2012), spirituality at work (Verkerk 2014b), management and organization (Verkerk 2015), policing (Drenth 2016), and government communication (Jansen, Van der Stoep, and Jochemsen 2017).
The original normative practice approach offers three perspectives to understand professional practices: structure, context, and direction (fig. 1). The structure describes the qualitative aspects of a practice, the context describes the influence of the environment in which a practice is developed, and the direction describes the basic beliefs that underlie a practice (Jochemsen and Glas 1997; Jochemsen 2006; Verkerk et al. 2016). These three perspectives can be considered as different points of view in order to understand the nature of a professional practice. Structural, contextual, and directional aspects are not “sold separately” but form an integral part of a specific practice. For example, contextual aspects such as the influence of the culture on health care is not concentrated in one or two isolated procedures but penetrates in all procedures of the medical practice that describe the interactions between professionals, patients, and other stakeholders. The normative practice approach appears to be very fruitful as it unravels the complexity of professional practices, identifies the normative aspect of these practices, and highlights the influence of basic beliefs, world views, and religions.
The normative practice approach as developed for health care focuses on the interaction between the health care professional and the patient in the consulting room. In practice, however, health care is much more complex. Firstly, professional practices are not isolated events in a consulting room, but activities that are embedded in organizations. Secondly, organizations cannot be considered as isolated structures—they function in chains or networks of other care organizations. Thirdly, organizations do not function in an abstract context but in a web of stakeholders that have their own nature and their own interests. In other words, rather than being independent units, professional practices are embedded in care organizations, cooperate in care chains or networks, and interact with stakeholders.
Verkerk (2014a) has developed an organizational variant of the normative practice approach for professional practices that considers “organizations both as the site and the result of work activities” and “as bundles of practices,” and that understands “management as a particular form of activity aimed at ensuring that these social and material activities work more or less in the same direction” (Nicolini 2012, 2). The organizational variant, which is called the Triple I approach, offers three comparable perspectives to understand professional practices; to wit, identity and intrinsic values, interests of stakeholders, and ideals and basic beliefs (fig. 2). The Triple I approach has been used by Verkerk (2014c) in sustainability studies and by Van Hoof et al. (2015) in evidence-based design processes.
The first I refers to the identity and intrinsic values of a practice. For example, the identity of a health care practice is characterized by “caring for.” All activities in the practice have to be focused on the well-being and health of the patient. In Dooyeweerdian terminology: the qualifying function5 of the health care practice is the moral aspect. The intrinsic values of the health care practice are such values as empathy, involvement, altruism, and caring. The relationship between identity and intrinsic values is a reciprocal one. On the one hand, values concretize the identity of the practice; on the other hand, values constitute its identity.
The second I refers to the interests of stakeholders of a practice. Health care practices have their own specific network of stakeholders. Important stakeholders are the insurance companies, patient organizations, professional associations, and authorities. Every stakeholder has its own justified interests. A justified interest of an insurance company, for instance, is the delivery of good care for a reasonable price. A justified interest of a patient organization is that the needs of the patient come first. A justified interest of a professional organization is the development of standards of excellence. And a justified interest of authorities is that professionals comply with the regulations.6
The third I refers to the ideals and basic beliefs that are embedded in or expressed by the professional practice. On the one hand, ideals and basic beliefs co-shape protocols and guidelines, habits and attitudes of the employees, and managerial relationships. On the other hand, protocols and guidelines, habits and attitudes of the employees, and managerial relationships express or reflect certain ideals and basic beliefs.
The original normative practice approach and the Triple I approach have different backgrounds. The former is mainly based on the idea of professional practices as developed by MacIntyre (1984); the latter on an organizational analysis of institutionalized professional practices (Verkerk 2014a). There are similarities between the meaning of the concepts structure, context, and direction, on the one hand, and the concepts identity and intrinsic values, interests of stakeholders, and ideals and basic beliefs, on the other hand. However, the precise interpretation of these concepts is different.
3.3 User Practices
In the last decades, enormous efforts have been made to understand the needs and wishes of the patient. Especially, the International Classification of Functioning, Disability and Health (icf) addresses a multitude of personal and environmental factors (who 2001; Heerkens, Bougie, and Claus 2014). The personal factors include gender, age, coping styles, social background, education, profession, past and current experience, and behavior. The environmental factors include social attitudes, architectural characteristics, and legal and social structures, as well as climate, terrain, and so forth. In practice, however, this approach does not adequately support professionals to understand the different environments in which patients live and act. As a consequence, the needs and wishes of patients are not systematically mapped (Van Hoof et al. 2010a, 2010b, 2015; Sinoo et al. 2014; Holtkamp et al. 2015, 2016).
In this definition six elements are important. First, it is about actual activities that a patient does or has to do. So, it is not about what is said but about what is done. Second, these activities form a coherent set, meaning that all activities cohere and can be understood from the nature of the practice. Third, the user uses a medical product to realize the objectives of that practice. It is not about the “abstract use” of a medical product, but about the use of a medical product in a concrete practice. Fourth, a concrete practice has its own objective, and different practices will have different objectives. Fifth, it is about activities that are characteristic of, qualified by, and environmentally conditioned by the practices in which these activities take place. In other words, every practice has its own qualification that determines the nature of its activities. Finally, patients live in different practices, and each practice will put specific demands on medical products.
A user practice is defined as a coherent set of activities that are or have to be performed by patients using medical products to realize the objectives of that practice. These activities are characteristic of, qualified by, and environmentally conditioned by the practice in which these activities take place. In general, patients use these medical products in different practices.
Like professional practices, user practices can be understood from three perspectives (fig. 3). In the Triple I variant these perspectives are identity and intrinsic values, interests of relevant social actors, and ideals and basic beliefs. These perspectives are illustrated and discussed in section 6.
4 Analysis of the Orthopaedic Chain
The patient journey (fig. 4) describes the journey of the patient within the health care system (Curry, McGregor, and Tracy 2007). It is a formal term for the sequence of care events which a patient follows from the point of entry into the system (triggered by an illness or a care question) until the point of exit out of the system (discharge, death). The patient journey of an afo user consists of seven main steps: awareness of the patient or his/her caregiver, assessment by a physician, examination and tests by a physician, specifications made by an orthopaedic engineer, manufacturing of the device, evaluation of the device by the orthopaedic engineer and the patient, and acceptance and use by the patient. Figure 4 describes the process, the actions done, and the expected outcome of every step.
Figure 5 offers an analysis of the patient journey from the perspective of practices. Every main step represents a practice. In this chain four different practices can be distinguished:
- 1. Health Care Practice In the chain two different health care practices are present. The first one is that of the general practitioner: assessment of the complaints and referral to a health care specialist. The second one is that of the health care specialist: examination of the patient, execution of tests, making a diagnosis, prescription, and referral to an orthopaedic engineer. These practices are professional health care practices.
- 2. Engineering Practice The orthopaedic engineer performs two activities. First, he/she translates the diagnosis/prescription into a specification for the assistive device and places an order at the manufacturing company. Second, he/she evaluates the assistive device with the patient during delivery. Orthopaedic engineers have a technical background in the context of health care. Their activities have mainly a technical character. Therefore, this practice is characterized as a professional engineering practice.
- 3. Manufacturing Practice The starting point for the manufacturer is the specification made up by an orthopaedic engineer. The specification describes all relevant parameters to manufacture the device—for instance, design, materials, and dimensions. This practice is a professional manufacturing practice.
- 4. User Practice Last but not least, the whole chain starts and ends with the patient—a patient in the original meaning of the word, to wit, “he/she who suffers.” The whole process starts with a care question (complaint) of the patient, who experiences difficulties in daily movements. The process also ends with the patient; that is, with the acceptance and actual use of a device that supports the patient in functioning related to mobility. As shown below, we should not speak about “the” user practice because several different user practices are involved.
We conclude that the orthopaedic process consists of different practices, to wit, two different professional health care practices, one engineering practice, one manufacturing practice, and several user practices.
5 Professional Practices
In order to understand the whole orthopaedic chain we need not only to explore the nature of the different professional practices as such, but also to investigate the embedding of practices in organizations and the interaction and cooperation between the different professional practices that constitute this chain.
5.1 Layered Structures
Figure 6 gives a general approach of the organizational embedding of professional practices. Most professionals work in a department, which is a part of a larger organization that operates in the external world. It offers a general approach, because some professionals work in flat or horizontal organizations without departments whereas other professionals work in organizations that are part of larger health care organizations.
Figure 6 shows that the organization has a layered structure. The professional practice is at the center of the organization—the “license to operate” lies in the care for the patient. In an ideal world, the department supports the professional practice to realize its objectives, and the organization supports the department in its support of professional practices. In other words, the different layers form a coherent unity. In practice, however, there are often tensions between the different layers. For example, financial decisions at higher organizational levels may put pressure on intrinsic values of the care process.
The normative practice approach gives a deeper insight into tensions within the organization that have a negative influence on quality and costs of care. These tensions can be caused by differences in identity or intrinsic values at microlevel (practice), mesolevel (department), and macrolevel (organization). They also can be caused by stakeholders at micro-, meso-, or macrolevel who do not respect the identity or intrinsic values of the professional practice. Finally, tensions can be caused by differences in ideals and basic beliefs between individuals, professionals, and management, and between professionals, management, and stakeholders.
In the orthopaedic chain or network professional practices are connected to each other.10 In general, the layered structure is present in every organization in the orthopaedic chain. We focus on the microlayer—i.e., the professional practice. Every practice has an identity and intrinsic values. The identity of a health care practice is a moral one: it is all about the care for the patient. The intrinsic values of the health care practice are values such as empathy, involvement, altruism, and caring. All activities executed by care professionals have a moral character. The identity of the engineering profession is also a moral one. After all, the engineer has to use all his/her knowledge and skills to design a device for a patient. The engineering practice will also be based on values such as empathy, involvement, altruism, and caring. Finally, the identity of the manufacturing practice is a technical or formative one. The intrinsic values of the manufacturing practice are values such as discipline, cleanliness, quality, and control. A manufacturing process consists of a number of different formative steps. Every step has to be controlled in detail (e.g., materials, process, conditions, and quality) so that the final product (i.e., the assistive device) meets the specifications.
Every professional practice has its own specific network of stakeholders. In general, the different professional practices—health care, engineering, and manufacturing—have different stakeholders. For example, every professional practice has its own disciplinary association and its own suppliers. On the other hand, the professional practices in the chain share some stakeholders—for instance, the insurance company.
It can be expected that different professional practices have different ideals and basic beliefs. These practices consist of different individuals and are embedded in different organizations, with different company values; as a result, they have different identities and intrinsic values, and they have different sets of stakeholders.
The analysis on the microlevel of the health care chain shows various mechanisms that can cause an increase in costs or quality problems. The Triple I approach shows that these mechanisms find their origin in the misfit between identities and intrinsic values, interests of stakeholders, and ideals and basic beliefs. Similar analyses can be done for the meso- and macrolevel.
The normative practice approach reveals some important characteristics of the orthopaedic chain, namely, different practices, different organizations, and layered structures. Coordination problems between different levels in the organization or between different professional practices in the chain will have a negative influence on the performance. Conflicts between identities, intrinsic values, interests of stakeholders, ideals, and basic beliefs may induce the problems mentioned in the introduction.
We give two examples in the field of orthopaedics. The first example is about the influence of stakeholders. Orthopaedic manufacturing companies need to have a contract with a health care insurance company. In recent times, the insurance companies decided one-sidedly that the prices have to be lowered. In the pursuit of delivering cheaper devices, the orthopaedic manufacturers reduced the number of different devices that can be produced in their factories. As a consequence, the orthopaedic engineer’s freedom in his/her choice in design is reduced, resulting in a suboptimal solution that does not fully meet the needs and wishes of the patient. In this example, economic decisions taken by the insurance company result in less optimal solutions for the patient.
The second example is about hampered communication due to different organizational embeddings. A medical specialist referred a patient to an orthopaedic shoe engineer because she/he believed that the current device—an afo—was not the best solution. The orthopaedic shoe engineer examined the patient, took measurements, and made a custom-made pair of orthopaedic shoes. Afterwards it became obvious that, rather than making a new shoe, the shoe engineer should have referred the patient back to the aforementioned medical specialist because some functional needs could not be incorporated in the shoe design. In the end, a newly designed afo turned out to be the perfect solution.
6 User Practices
We coined the word user practice to highlight the specific character of the different social environments in which patients use medical devices. In the field of orthopaedics it is always about “activities in context”—therefore, the different contexts or social environments of the patients have to be mapped.
6.1 Activities in Context
At first glance, some activities do not seem to need an explanation. Consider, for example, an afo that is placed around the ankle in order to reduce a mobility problem. Now, walking seems to be a well-defined activity that needs no further specification. However, from the perspective of the designer of the assistive device there are different types of walking, such as walking through a large room, walking inside a small bathroom, walking on slippery floors, walking in the street, walking in the office, walking in the field, walking in the mountains, walking in the dark, and so on. The specific type of walking depends on the environment in which the walking activity is performed. Our conclusion is that activities should always be specified and understood in relation to the practice in which they take place.
6.2 Different User Practices
Holtkamp et al. (2016) showed that the following four general user practices can be identified in the field of afos: daily life at home, transport, work, and leisure.
Daily life at home consists of activities that are performed in the user’s home, such as walking indoors, maneuvering in the kitchen, walking the stairs, passing thresholds, and using the bathroom. The activities in the home have a social character: they serve the purpose of daily living with other people. Orthopaedic engineers need to understand the specific home situation of the user, the movements in the home, and the support that the afo has to give to maintain social relationships.
Transport forms quite a different set of activities containing, for instance, walking, cycling, public transport, and driving. These movements are required to realize social goals (cycling with one’s partner), economic goals (car driving for an account manager), and juridical goals (walking of a police agent).
Work consists of differently qualified sets of activities. Work in health care is morally qualified, work in a factory is technically qualified, and work in a sales department is economically qualified. Assistive devices have to support their users to realize the goals of their work environment. The nature and qualification of the work practice co-determine the specifications for the afo. The work environment is often characterized by specific conditions such as temperature, humidity, bumpiness of the floor, and so on.
Finally, leisure spans quite a wide range of different activities in various environments. For every environment the activities, movements, and conditions have to be analyzed. For example, the activities, movements, and conditions involved in playing bridge are quite different from those involved in such hobbies as mountain hiking.
Assistive devices have to support patients in their daily life. Our analysis shows that patients live and act in the context of different user practices. The nature and qualification of these user practices co-determine the specifications for the afo. The specific user practices also define such specific conditions as temperature, humidity, and so on.
Holtkamp et al. (2016) showed that orthopaedic engineers do not explore in depth the activities of the patient during the interview. They do not systematically map the environments in which their patients live, and do not analyze the various sets of activities that take place within these environments. This observation explains why some patients do not use the afo at all, why others are not satisfied, and why even very satisfied patients express complaints about its use and comfort.
6.4 Case Study
In this section we present a case study to show the importance and fruitfulness of the idea of user practices. John (62) lives with his wife in a two-story family house. They have two children who live on their own. John has been an experienced mechanic in plumbing and central heating systems for more than 30 years. He regularly drives his car and sometimes rides a bike. In his spare time, he enjoys fishing, especially on the North Sea shore. He is also a regular church-goer. As a result of a trauma, John has what is called a drop foot. This impairment hinders John during walking on a daily basis because of the lack of control over his foot and the likelihood of stumbling. Therefore, he has an afo that is mainly worn inside his shoes. The fact that John uses an afo makes it plausible to think that the problems are solved, that John is satisfied and supported in daily life. In this particular case, he is not.
The description of John’s case reveals a set of five different user practices: daily life at home, transportation by bike and car, working as a mechanic, religious activities in church, and his hobby, fishing. Each user practice has its own identity and intrinsic values, its own relevant social actors, and its own ideals and basic beliefs. Therefore, each user practice has specific demands with respect to function, performance, look, and feel of the device.
Daily Life at Home Daily life at home is a social practice. Its most important intrinsic values are cooperation, mutual support, and togetherness. John has to be able to move independently in and around the house, walk up and down the stairs, maneuver in the kitchen, sit on the couch and chairs, and visit the bathroom. The most important social actor is his wife. The ideals and basic beliefs that influence their living together have a Christian background. These considerations have a large influence on the specifications of the afo: it must support movements, fit perfectly around foot and ankle for maneuvering in the small bathroom, be usable in any type of footwear, and have easy closures that do not damage clothes or furniture.
Transport John uses both a car and a bike. The identity of the transport user practice is social when he and his wife visit family or friends, and economic when he is working for his employer. The intrinsic values are ease and reliability, and the most important relevant actors are the other road users. The most important ideals and basic beliefs have to do with safety and environmental pollution. Because John drives a car and also rides a bike, the afo has to meet the highest level of reliability, wearability, and comfort. For example, when he is riding a bike, the afo should not rub against the popliteal and cause irritation.
Work The identity of John’s work setting can be described as a technical one. During his work he has to perform many movements; e.g., sitting on his knees, crawling under machines, turning in small rooms, and so on. The most important social actor is his employer. He expects that John works efficiently and delivers high-quality work. One of the most important values is safety. From a social perspective it is preferred that the afo is invisible to prevent any negative reactions. Finally, the conditions at work can vary: e.g., high and low humidity, warm or cold. The design of the afo has to meet all the needs and wishes of this user practice.
Religious Activities John has a Roman Catholic background. Every Sunday he and his wife attend Holy Mass. In a religious user practice, movement and maneuvering are important—John has to sit on a bench, walk to the altar, and kneel on a bench. The most important values are respect and dignity. Especially, the requirement of kneeling puts extra demands on the afo, such as identifying the areas where the pressure of the body weight will be while kneeling, taking into account a proper fit and reduction of sounds. In this setting the priest is one of the most important social actors.
Hobby: Fishing Fishing is a social activity. The core value is to enjoy each other’s company at the water side. Moving on the shoreline sets special conditions for the afo: it means walking in loose sand, walking on hard wet sand, and clambering over rocks. In addition, the used materials should be salt-proof because of corrosion. Above all, especially in the mornings and evenings there is a change in ambient temperature. His friends expect that John can come along easily.
This case study shows that patients live in different environments or user practices. The movements that are executed are characteristic for each user practice. The needs and wishes of patients can only be explored when the different user practices are mapped and the different activities of these practices are analyzed. A user practice can only be understood from its identity and intrinsic values, its relevant social actors, ideals, and basic beliefs.
7 Discussion and Conclusions
7.1 Research Questions
In this article we explored the potential of the normative practice approach in view of the present challenges in the health care system. We start with the first research question of this paper: Can the normative practice approach be used to understand the problems in health care? In this article we used the Triple I variant of the normative practice approach. We showed (i) that the orthopaedic device chain consists of different professional practices, (ii) that each practice is embedded in an organization, and (iii) that these different practices form a chain. We showed that coordination problems between different organizational levels or between different professional practices in the chain have a negative influence on the performance of health care. This phenomenon is well known in the literature (Porter and Teisberg 2006). Our analysis also showed that stakeholders can have a negative influence on the quality of health care. This phenomenon is also well known in health care (Callahan 2009). However—and this is new—our analysis showed that identity and intrinsic values have a layered structure and that tensions can arise between the different levels of this structure. The same holds for ideals and basic beliefs. In addition—and this is also partly new—our analysis indicated why the lack of a thorough understanding of a patient’s daily life results in quality problems.
Our second research question was: Can the normative practice approach provide new insights in the redesign of the health care chain? Our investigations showed that the complexity of the care chain is one of the root causes of the problems in Western health care. The Triple I approach invites scholars to integrate professional practices and to consider the organizational embedding of professional practices. A transformation can be realized by changing the overall organization model, namely, organizing care around patients instead of organizing care around professional practices (fig. 7). In addition, this research invites organizations to reflect on the layered structure of their identity and intrinsic values, and to organize dialogues between representatives of the different layers to prevent tensions. The same holds for the influence of ideals and basic beliefs.
Our third research question was: Can the normative practice approach offer concepts to understand the needs and wishes of patients? Investigations have shown that in the field of orthopaedics, the daily life of the patient is not systematically investigated. Our analysis suggests that one of the reasons for this observation is that the widely accepted icf approach is not specific enough to help orthopaedic engineers analyze their patients’ social environments. To fill this gap, we developed the idea of user practices, inspired by the normative practice approach, the theory of individuality structures developed by philosopher Herman Dooyeweerd (1969), and the icf model. We described user practices roughly as the practices of a patient in which the products of professional medical practices are used to realize the objectives of the practices of the patient. This approach lays the foundation for a new methodology in orthopaedics to map all relevant practices in which patients live and act, to analyze all relevant activities in these practices, and to specify the conditions in these different practices, so that a complete list of specifications for an afo can be composed.
7.2 Broader Meaning
Our analysis of the problems in Western health care was based on a case study in assistive devices in orthopaedics. In our view, it can be generalized to the entire health care sector because this sector is characterized by complex processes, different professional practices, layered structures, and different organizations. Additionally, everywhere in health care the social environment of patients is not at all or only partly investigated. Therefore, we conclude that the normative practice approach, especially the Triple I variant, deepens the insight into the challenges in Western health care.
Our analysis in the field of orthopaedics has revealed a couple of building blocks for the transformation of health care. In our view, these insights can also be generalized to the entire health care sector. Firstly, the performance of health care will strongly improve when care is organized around the patient instead of around the professional. Secondly, health care performance will further improve when dialogues are organized to handle the layered structures of identity and intrinsic values, and ideals and basic beliefs. Thirdly, the idea of user practices offers a new means to understand the daily life of patients and to make an inventory of their needs and wishes.
Verkerk (2014c) has used the Triple I approach in the field of sustainability, and Van Hoof et al. (2015) in the field of architecture. In this study we have used the Triple I approach fruitfully in health care; in the orthopaedic engineering practice, in particular. All these studies suggest that the Triple I variant deserves a valuable position in the normative practice approach.
Finally, in this article we have focused on the analysis of professional practices and user practices. However, we have shown that the normative practice approach, especially the Triple I variant, can also be used to guide change processes. It offers “change agents” and “recipients of change” a tool for asking questions about the identity of a practice and its intrinsic values, the justified and unjustified interests of stakeholders, and the desirable and undesirable influences of ideals and basic beliefs.
7.3 Improvements and Extensions
In this article we presented a case study in the field of orthopaedics. Our philosophical analysis was guided by the Triple I variant of the normative practice approach. This study shows that the following improvements and extensions of the original approach are required:
- 1.Understanding the organizational embedding of professional practices. This article has given a first exploration of this matter.
- 2.Understanding the health care system as chains or networks of professional practices. This article has given a first exploration of this topic.
- 3.Understanding the influence of stakeholders. In the Triple I variant this influence has been made explicit, and we have introduced the idea of justified interests of stakeholders.
- 4.Understanding the practices in which patients use the products of professional medical practices. In this field the Triple I approach is preferable due to the idea of interests of relevant social actors.
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Up till now, internet technology has not strongly changed the landscape of assistive devices in orthopaedics. Therefore, we will focus on “classical” technologies.
For definitions, see the International Organization for Standardization’s standards iso 8549-3:1989 and iso 13404:2007.
Patients may also be referred to as clients or users, depending on their role or position within the health care system.
The normative practice approach focuses on professional practices but acknowledges that this approach is broader applicable (e.g., Jochemsen 2006, 102).
The qualifying function characterizes the nature or character of a thing or whole. For example, the qualifying function of a museum of modern art is the esthetic aspect, because museums are designed to experience the beauty of art. The qualifying function of a courthouse is the juridical aspect, because courthouses are used for the administration of justice. See also n. 7 below.
The theory of individuality structures as developed by Dooyeweerd (1969, vol. 3) describes the structure of things, or wholes. A thing, or whole, functions in all fifteen aspects of our reality. The nature (or character) of a thing is characterized by its qualifying function, and its origin is described by the foundational function. For example, a church is a thing, or a whole. It functions in the spatial aspect (shape), physical aspect (materials), economic aspect (economic value), and in the esthetic aspect (beauty), among others. Its qualifying function is the pistic aspect (its destination is religious activities) and its foundational function is the formative aspect (it is man-made).
This formulation only states that many professional practices produce goods that are used by consumers, clients, or patients in their daily life. It does not suggest that all professional practices have user practices as a complement, or that all goods of a particular professional practice have user practices as counterparts.
Theoretically, there is a large difference between a health care chain and a health care network. In a health care chain the patient follows the fixed order in which the different organizations are linked together from the beginning to the end. In a health care network the care question of the patient determines both the choice of the relevant organizations and the required order. In this article we will use the words chain and network as synonyms.