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Research question/problem definition This thesis is a philosophical study into the nature of the practice of supervisory boards in care institutions in The Netherlands. I do so from the perspective of ‘practical wisdom’ (phronesis) as coined by Aristotle. The main question of this thesis is: what is wise supervision? What will become apparent is that albeit this is a thesis on supervisory practice, it has a much wider scope. As supervisory practice is oriented to so many organizational and societal aspects, it is also a thesis on governance, institutions, management and ordinary caring practices in civil society in general. The question is explorative: what happens if we reconceptualize supervision as practical wisdom? I have no hypothesis that is tested in the ‘real world’, but rather I install a specific interpretation that sheds light on the practice that has remained in the background in previous research on supervisory work. Relevance The role and position of the supervisory board in Dutch civil society organizations, such as in health care or education, has been discussed intensively but narrowly in the past decade. This narrow view consists of a focus on quality and risk management, corporate governance, professionalization and value-oriented approaches. In this narrow view there is a permanent quest for certainty, unambiguity, clarity and simpleness. This quest paralyzes the debate and practice of governance, and possibly also that of care itself. We need a perspective on supervisory boards and governance that takes ambiguity and equivocality of care and organizing as a point of departure. Theoretical framework The theoretical perspectives in this thesis vary widely. The first overarching theory is from Schön on the reflective practitioner and the difference he makes between the ‘safe high grounds’ and the ‘swampy lowlands’. A second overarching theory is about the difference between system world and lifeworld, and the quest for ‘purpose’. The specific theoretical perspectives that are worked out are from care ethics, critical management studies, hermeneutic-phenomenology, critical modernity analyses and post-foundational political philosophy. These perspectives integrate questions of ambiguity, politics and democracy. Method It is a theoretical philosophical dissertation that does not assume representation, but rather precisely interprets the practice from a particular angle. In order to do so, I have analyzed the practice of supervisory boards in a sensitizing way: I interpreted cases, analyzed popular books on governance and had dialogues with two supervisory boards. Arguments It is argued that care is a political category, and that this is usually denied in practices of quality management. Care, especially institutional care, reflects to some greater or lesser extent our attempts to live together in a decent way. This implies that the question of ‘good care’ is not a mere technical matter, but rather also a moral and political question. The technical approach to care, mainly by quality management, hides the paradoxes that flow from its applications. From this angle, also governance is a political and caring activity. Supervisory board members need to understand their work as being ‘relational’, i.e., between boards and the organization. The supervisory board is on the boundary of concrete everyday care and its political context, the institutional framework, in which care is nested. Conclusion I conceptualize wise supervision as practical wisdom as a form of knowledge that is not a mere individual trait but has a practice aspect and an institutional aspect as well. Supervisory practice is not only about the behavior of its practice members, but also about the interplay between society, supervision, management and organization – as well as the way in which this is institutionally embedded: who has a say, who may take decisions and who can counteract.

Research question/problem definition This thesis is a philosophical study into the nature of the practice of supervisory boards in care institutions in The Netherlands. I do so from the perspective of ‘practical wisdom’ (phronesis) as coined by Aristotle. The main question of this thesis is: what is wise supervision? What will become apparent is that albeit this is a thesis on supervisory practice, it has a much wider scope. As supervisory practice is oriented to so many organizational and societal aspects, it is also a thesis on governance, institutions, management and ordinary caring practices in civil society in general. The question is explorative: what happens if we reconceptualize supervision as practical wisdom? I have no hypothesis that is tested in the ‘real world’, but rather I install a specific interpretation that sheds light on the practice that has remained in the background in previous research on supervisory work. Relevance The role and position of the supervisory board in Dutch civil society organizations, such as in health care or education, has been discussed intensively but narrowly in the past decade. This narrow view consists of a focus on quality and risk management, corporate governance, professionalization and value-oriented approaches. In this narrow view there is a permanent quest for certainty, unambiguity, clarity and simpleness. This quest paralyzes the debate and practice of governance, and possibly also that of care itself. We need a perspective on supervisory boards and governance that takes ambiguity and equivocality of care and organizing as a point of departure. Theoretical framework The theoretical perspectives in this thesis vary widely. The first overarching theory is from Schön on the reflective practitioner and the difference he makes between the ‘safe high grounds’ and the ‘swampy lowlands’. A second overarching theory is about the difference between system world and lifeworld, and the quest for ‘purpose’. The specific theoretical perspectives that are worked out are from care ethics, critical management studies, hermeneutic-phenomenology, critical modernity analyses and post-foundational political philosophy. These perspectives integrate questions of ambiguity, politics and democracy. Method It is a theoretical philosophical dissertation that does not assume representation, but rather precisely interprets the practice from a particular angle. In order to do so, I have analyzed the practice of supervisory boards in a sensitizing way: I interpreted cases, analyzed popular books on governance and had dialogues with two supervisory boards. Arguments It is argued that care is a political category, and that this is usually denied in practices of quality management. Care, especially institutional care, reflects to some greater or lesser extent our attempts to live together in a decent way. This implies that the question of ‘good care’ is not a mere technical matter, but rather also a moral and political question. The technical approach to care, mainly by quality management, hides the paradoxes that flow from its applications. From this angle, also governance is a political and caring activity. Supervisory board members need to understand their work as being ‘relational’, i.e., between boards and the organization. The supervisory board is on the boundary of concrete everyday care and its political context, the institutional framework, in which care is nested. Conclusion I conceptualize wise supervision as practical wisdom as a form of knowledge that is not a mere individual trait but has a practice aspect and an institutional aspect as well. Supervisory practice is not only about the behavior of its practice members, but also about the interplay between society, supervision, management and organization – as well as the way in which this is institutionally embedded: who has a say, who may take decisions and who can counteract.

Research question/problem definition This thesis is a philosophical study into the nature of the practice of supervisory boards in care institutions in The Netherlands. I do so from the perspective of ‘practical wisdom’ (phronesis) as coined by Aristotle. The main question of this thesis is: what is wise supervision? What will become apparent is that albeit this is a thesis on supervisory practice, it has a much wider scope. As supervisory practice is oriented to so many organizational and societal aspects, it is also a thesis on governance, institutions, management and ordinary caring practices in civil society in general. The question is explorative: what happens if we reconceptualize supervision as practical wisdom? I have no hypothesis that is tested in the ‘real world’, but rather I install a specific interpretation that sheds light on the practice that has remained in the background in previous research on supervisory work. Relevance The role and position of the supervisory board in Dutch civil society organizations, such as in health care or education, has been discussed intensively but narrowly in the past decade. This narrow view consists of a focus on quality and risk management, corporate governance, professionalization and value-oriented approaches. In this narrow view there is a permanent quest for certainty, unambiguity, clarity and simpleness. This quest paralyzes the debate and practice of governance, and possibly also that of care itself. We need a perspective on supervisory boards and governance that takes ambiguity and equivocality of care and organizing as a point of departure. Theoretical framework The theoretical perspectives in this thesis vary widely. The first overarching theory is from Schön on the reflective practitioner and the difference he makes between the ‘safe high grounds’ and the ‘swampy lowlands’. A second overarching theory is about the difference between system world and lifeworld, and the quest for ‘purpose’. The specific theoretical perspectives that are worked out are from care ethics, critical management studies, hermeneutic-phenomenology, critical modernity analyses and post-foundational political philosophy. These perspectives integrate questions of ambiguity, politics and democracy. Method It is a theoretical philosophical dissertation that does not assume representation, but rather precisely interprets the practice from a particular angle. In order to do so, I have analyzed the practice of supervisory boards in a sensitizing way: I interpreted cases, analyzed popular books on governance and had dialogues with two supervisory boards. Arguments It is argued that care is a political category, and that this is usually denied in practices of quality management. Care, especially institutional care, reflects to some greater or lesser extent our attempts to live together in a decent way. This implies that the question of ‘good care’ is not a mere technical matter, but rather also a moral and political question. The technical approach to care, mainly by quality management, hides the paradoxes that flow from its applications. From this angle, also governance is a political and caring activity. Supervisory board members need to understand their work as being ‘relational’, i.e., between boards and the organization. The supervisory board is on the boundary of concrete everyday care and its political context, the institutional framework, in which care is nested. Conclusion I conceptualize wise supervision as practical wisdom as a form of knowledge that is not a mere individual trait but has a practice aspect and an institutional aspect as well. Supervisory practice is not only about the behavior of its practice members, but also about the interplay between society, supervision, management and organization – as well as the way in which this is institutionally embedded: who has a say, who may take decisions and who can counteract.

This dissertation examines the development and implementation of a new care model in Dutch forensic psychiatry called Forensic High and Intensive Care (FHIC). FHIC aims to foster the transition from control-based care to contact-based care in forensic psychiatry. A new care model in acute psychiatry, High and Intensive Care (HIC), serves as an example. By analogy, Forensic High and Intensive Care (FHIC) has been developed for forensic psychiatry. However, the question is how the HIC model can be translated to forensic psychiatry. To gain insight into this, three research questions have been formulated: A. What can be learned from complex situations at HIC wards? B. What are the characteristics of FHIC and how can implementation be measured? C. How can FHIC be implemented? Chapter 2 presents a study of difficult situations in HIC wards to see what can be learned regarding the development of FHIC. At HIC wards, care professionals sometimes encounter difficult situations. Interviews and a focus group were organized with care professionals from HIC wards. Taking into account the situation, and not focusing only on the patient, can be helpful in the detection of (early) signals or even prevent aggression. Chapter 3 describes the development and core elements of FHIC. The model was developed in expert meetings, using the results of scientific research and experiences from practice. The FHIC model consists of various interventions to reduce coercive measures and increase safety by working on the basis of contact. There are five core elements; care ethics, stepped care, the premise that a crisis is relational, safety in contact and peer expertise. Chapter 4 describes a mixed methods study validating the FHIC monitor. The FHIC monitor is a model fidelity scale of the FHIC model. Audits by trained FHIC care professionals provided the basis for the assessment of the measurement properties of the instrument. After revisions and adjustments, the FHIC monitor proved to be a useful tool to measure the implementation of the FHIC model and to support institutions in the implementation process. Chapter 5 presents a study of two Communities of Practices (CoPs), one for HIC and one for FHIC. The CoPs for HIC and FHIC consist of auditors, project leaders and care professionals working with HIC and FHIC, respectively. Based on qualitative research, various lessons were formulated for the development of CoPs and perceived effects were identified. The audits served as an important vehicle to activate the CoPs and stimulated the implementation of HIC and FHIC. Chapter 6 shows that working on the basis of contact can result in moral questions and dilemmas. A specific form of clinical ethics support is moral case deliberation (MCD). The chapter describes a MCD in a forensic psychiatric clinic about the relationship between contact and safety. MCD can also contribute to a change in culture. Chapter 7 concludes with the general discussion and conclusion. The research in this thesis confirms that FHIC is a promising development. Many forensic healthcare institutions are in the process of implementing FHIC and this process contributes to the intended transition to contact-based care. The thesis also shows that the implementation of FHIC is not easy because it requires a transition at the level of culture, structure, and practices within a complex care practice. Three lessons were formulated for initiatives aimed at shifting from control to contact-based care in complex care practices: 1) pay attention to complexity, 2) use reflection for dealing with complexity, and 3) foster collaboration in complex care. For future research it is recommended to gain more insight into the further implementation of FHIC and the effects of FHIC on (perceived) safety.

This dissertation examines the development and implementation of a new care model in Dutch forensic psychiatry called Forensic High and Intensive Care (FHIC). FHIC aims to foster the transition from control-based care to contact-based care in forensic psychiatry. A new care model in acute psychiatry, High and Intensive Care (HIC), serves as an example. By analogy, Forensic High and Intensive Care (FHIC) has been developed for forensic psychiatry. However, the question is how the HIC model can be translated to forensic psychiatry. To gain insight into this, three research questions have been formulated: A. What can be learned from complex situations at HIC wards? B. What are the characteristics of FHIC and how can implementation be measured? C. How can FHIC be implemented? Chapter 2 presents a study of difficult situations in HIC wards to see what can be learned regarding the development of FHIC. At HIC wards, care professionals sometimes encounter difficult situations. Interviews and a focus group were organized with care professionals from HIC wards. Taking into account the situation, and not focusing only on the patient, can be helpful in the detection of (early) signals or even prevent aggression. Chapter 3 describes the development and core elements of FHIC. The model was developed in expert meetings, using the results of scientific research and experiences from practice. The FHIC model consists of various interventions to reduce coercive measures and increase safety by working on the basis of contact. There are five core elements; care ethics, stepped care, the premise that a crisis is relational, safety in contact and peer expertise. Chapter 4 describes a mixed methods study validating the FHIC monitor. The FHIC monitor is a model fidelity scale of the FHIC model. Audits by trained FHIC care professionals provided the basis for the assessment of the measurement properties of the instrument. After revisions and adjustments, the FHIC monitor proved to be a useful tool to measure the implementation of the FHIC model and to support institutions in the implementation process. Chapter 5 presents a study of two Communities of Practices (CoPs), one for HIC and one for FHIC. The CoPs for HIC and FHIC consist of auditors, project leaders and care professionals working with HIC and FHIC, respectively. Based on qualitative research, various lessons were formulated for the development of CoPs and perceived effects were identified. The audits served as an important vehicle to activate the CoPs and stimulated the implementation of HIC and FHIC. Chapter 6 shows that working on the basis of contact can result in moral questions and dilemmas. A specific form of clinical ethics support is moral case deliberation (MCD). The chapter describes a MCD in a forensic psychiatric clinic about the relationship between contact and safety. MCD can also contribute to a change in culture. Chapter 7 concludes with the general discussion and conclusion. The research in this thesis confirms that FHIC is a promising development. Many forensic healthcare institutions are in the process of implementing FHIC and this process contributes to the intended transition to contact-based care. The thesis also shows that the implementation of FHIC is not easy because it requires a transition at the level of culture, structure, and practices within a complex care practice. Three lessons were formulated for initiatives aimed at shifting from control to contact-based care in complex care practices: 1) pay attention to complexity, 2) use reflection for dealing with complexity, and 3) foster collaboration in complex care. For future research it is recommended to gain more insight into the further implementation of FHIC and the effects of FHIC on (perceived) safety.

This dissertation examines the development and implementation of a new care model in Dutch forensic psychiatry called Forensic High and Intensive Care (FHIC). FHIC aims to foster the transition from control-based care to contact-based care in forensic psychiatry. A new care model in acute psychiatry, High and Intensive Care (HIC), serves as an example. By analogy, Forensic High and Intensive Care (FHIC) has been developed for forensic psychiatry. However, the question is how the HIC model can be translated to forensic psychiatry. To gain insight into this, three research questions have been formulated: A. What can be learned from complex situations at HIC wards? B. What are the characteristics of FHIC and how can implementation be measured? C. How can FHIC be implemented? Chapter 2 presents a study of difficult situations in HIC wards to see what can be learned regarding the development of FHIC. At HIC wards, care professionals sometimes encounter difficult situations. Interviews and a focus group were organized with care professionals from HIC wards. Taking into account the situation, and not focusing only on the patient, can be helpful in the detection of (early) signals or even prevent aggression. Chapter 3 describes the development and core elements of FHIC. The model was developed in expert meetings, using the results of scientific research and experiences from practice. The FHIC model consists of various interventions to reduce coercive measures and increase safety by working on the basis of contact. There are five core elements; care ethics, stepped care, the premise that a crisis is relational, safety in contact and peer expertise. Chapter 4 describes a mixed methods study validating the FHIC monitor. The FHIC monitor is a model fidelity scale of the FHIC model. Audits by trained FHIC care professionals provided the basis for the assessment of the measurement properties of the instrument. After revisions and adjustments, the FHIC monitor proved to be a useful tool to measure the implementation of the FHIC model and to support institutions in the implementation process. Chapter 5 presents a study of two Communities of Practices (CoPs), one for HIC and one for FHIC. The CoPs for HIC and FHIC consist of auditors, project leaders and care professionals working with HIC and FHIC, respectively. Based on qualitative research, various lessons were formulated for the development of CoPs and perceived effects were identified. The audits served as an important vehicle to activate the CoPs and stimulated the implementation of HIC and FHIC. Chapter 6 shows that working on the basis of contact can result in moral questions and dilemmas. A specific form of clinical ethics support is moral case deliberation (MCD). The chapter describes a MCD in a forensic psychiatric clinic about the relationship between contact and safety. MCD can also contribute to a change in culture. Chapter 7 concludes with the general discussion and conclusion. The research in this thesis confirms that FHIC is a promising development. Many forensic healthcare institutions are in the process of implementing FHIC and this process contributes to the intended transition to contact-based care. The thesis also shows that the implementation of FHIC is not easy because it requires a transition at the level of culture, structure, and practices within a complex care practice. Three lessons were formulated for initiatives aimed at shifting from control to contact-based care in complex care practices: 1) pay attention to complexity, 2) use reflection for dealing with complexity, and 3) foster collaboration in complex care. For future research it is recommended to gain more insight into the further implementation of FHIC and the effects of FHIC on (perceived) safety.

Participatory Health Research (PHR) continues to grow in popularity, based on the normative idea that people, whose life or work is the subject of research, have the right to participate in it. Many scientists recognize the importance of involving people with experiential knowledge in research, but there is limited attention to ethical participation in practice. To address the complexity of participatory research, the ICPHR – an international collaboration of academics – drew a set of ethical principles for participatory researchers for the ECBs and participatory research teams. But what does it mean to practice PHR ethically? And, how can we strengthen the ethical nature of participatory research work? These questions were the start of a reflective journey for Barbara Groot, as a participatory researcher, aiming to understand and improve ethics in participatory research. In my journey, I continuously reflected on ethical issues and the moral challenges I encountered; in action, as I call it in this thesis. This study shows that ethical issues arise at the everyday level in PHR, especially in partnership, power, and collaboration. Dealing with these moral dilemmas requires much invisible work that is often not described in a research proposal, budgeted for, or seen as an official role or responsibility of a traditional scientific researcher. Reflections from me, an academic co-researcher, and co-researchers with lived experiences, illustrate that this ethics work is crucial for ethical practice. The study findings show that the ethical work in PHR mainly focuses on two types of ethics: emotion work and relationship work. First, emotion work is about being caring, compassionate, and empathetic, dealing with your own and others’ emotions, building trust, and responding to others’ feelings. This study showed that emotion work, inspired by the theory of care ethics, is a shared responsibility in a team of co-researchers. Sharing the responsibility to care for, care that, and care of, is essential, including self-care. Creating communicative spaces and arts-based methods contributes to emotion work and increases ethical practice in PHR. Second, relationship work involves forming, connecting, facilitating, and forging partnerships and maintaining them for the long term. The most crucial lesson in this study is that a creative and arts-based approach to research can create, deepen, strengthen relationships, and support them in relationship work. Although the academics who worked on the studies included in this thesis aimed to work most ethically, this study showed several examples of experienced epistemic injustice in co-researchers with experiential knowledge. Epistemic injustice is a well-known pitfall in involving people with experiential knowledge but can also occur in PHR – sometimes subtly and sometimes overtly. Epistemic injustice means that co-researchers with experiential knowledge are not always heard or that their knowledge is not valued or used. The underlying cause is in prejudices and frames about what valuable knowledge is and who has it. Putting epistemic injustice on the agenda in research, and creating platforms that contribute to epistemic justice, can be seen as a critical step towards ethical practice. In sum, ethics is an everyday issue in PHR, not only ECB approval obtained at the start of an investigation. The current master's or PhD curriculum pays little attention to the ethics of PPI or participatory research. Becoming aware of the ethical issues of participatory work, and in PHR specifically, is essential to achieve the main goals of inclusion and empowerment. Finally, Communities of Practices (CoPs), such as the Centre for Client Experience and International Collaboration of Participatory Health Research (ICPHR), provide a safe place to learn about ethics and PHR and encourage reflection and action.

Participatory Health Research (PHR) continues to grow in popularity, based on the normative idea that people, whose life or work is the subject of research, have the right to participate in it. Many scientists recognize the importance of involving people with experiential knowledge in research, but there is limited attention to ethical participation in practice. To address the complexity of participatory research, the ICPHR – an international collaboration of academics – drew a set of ethical principles for participatory researchers for the ECBs and participatory research teams. But what does it mean to practice PHR ethically? And, how can we strengthen the ethical nature of participatory research work? These questions were the start of a reflective journey for Barbara Groot, as a participatory researcher, aiming to understand and improve ethics in participatory research. In my journey, I continuously reflected on ethical issues and the moral challenges I encountered; in action, as I call it in this thesis. This study shows that ethical issues arise at the everyday level in PHR, especially in partnership, power, and collaboration. Dealing with these moral dilemmas requires much invisible work that is often not described in a research proposal, budgeted for, or seen as an official role or responsibility of a traditional scientific researcher. Reflections from me, an academic co-researcher, and co-researchers with lived experiences, illustrate that this ethics work is crucial for ethical practice. The study findings show that the ethical work in PHR mainly focuses on two types of ethics: emotion work and relationship work. First, emotion work is about being caring, compassionate, and empathetic, dealing with your own and others’ emotions, building trust, and responding to others’ feelings. This study showed that emotion work, inspired by the theory of care ethics, is a shared responsibility in a team of co-researchers. Sharing the responsibility to care for, care that, and care of, is essential, including self-care. Creating communicative spaces and arts-based methods contributes to emotion work and increases ethical practice in PHR. Second, relationship work involves forming, connecting, facilitating, and forging partnerships and maintaining them for the long term. The most crucial lesson in this study is that a creative and arts-based approach to research can create, deepen, strengthen relationships, and support them in relationship work. Although the academics who worked on the studies included in this thesis aimed to work most ethically, this study showed several examples of experienced epistemic injustice in co-researchers with experiential knowledge. Epistemic injustice is a well-known pitfall in involving people with experiential knowledge but can also occur in PHR – sometimes subtly and sometimes overtly. Epistemic injustice means that co-researchers with experiential knowledge are not always heard or that their knowledge is not valued or used. The underlying cause is in prejudices and frames about what valuable knowledge is and who has it. Putting epistemic injustice on the agenda in research, and creating platforms that contribute to epistemic justice, can be seen as a critical step towards ethical practice. In sum, ethics is an everyday issue in PHR, not only ECB approval obtained at the start of an investigation. The current master's or PhD curriculum pays little attention to the ethics of PPI or participatory research. Becoming aware of the ethical issues of participatory work, and in PHR specifically, is essential to achieve the main goals of inclusion and empowerment. Finally, Communities of Practices (CoPs), such as the Centre for Client Experience and International Collaboration of Participatory Health Research (ICPHR), provide a safe place to learn about ethics and PHR and encourage reflection and action.

Dit artikel gaat in op twee benaderingen om een zinvol leven te leiden: levenskunst en zorgethiek.

Dit artikel gaat in op twee benaderingen om een zinvol leven te leiden: levenskunst en zorgethiek.

Nowadays, partly due to legislation, decision-making competence is playing an ever-increasing role in psychiatry. So far, however, there are no clear criteria for evaluating the actual competence of the procedure. AIM: To develop a relational ethical model, including criteria and methodology, which can be used to assess and enhance decision-making competence mainly from a relational and ethical perspective. METHOD: Combination of a review of the literature and ethical reflection. First of all, a limited study was made of the literature relating to the concept of and criteria for decision-making competence. On the basis of the literature and relational ethical reflection, ten criteria were developed for decision-making competence and a method was devised for assessing the procedure. RESULTS: The criteria that have to be satisfied can be summarised as follows: the persons involved must understand the information, and must be able to apply it to their own situation. They must be able to gain insight into their own situation and be able to weigh up the available options, and be able to estimate consequences for themselves, as well as for others. They must be able to motivate choices in a sensible and comprehensible manner without being subject to coercive influences coming from internal and external sources. Participants' choices should be motivated on the basis of their own personal values. The decision-making competence is assessed and enhanced by giving a score to the individual criteria and by making an overall evaluation. This is achieved by a dialogue including all the persons involved: the care seeker (as far as possible), close relatives and the care-providers. CONCLUSION: The persons involved can attain greater objectivity by exchanging views orally on the ten proposed criteria for decision-making competence. ispartof: Tijdschrift voor Psychiatrie vol:60 issue:1 pages:29-36 ispartof: location:Netherlands status: published