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BIOGRAPHIC-NARRATIVE-BNIM  October 2008

BIOGRAPHIC-NARRATIVE-BNIM October 2008

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Subject:

Re: BNIM and user driven health care reform using IT (automated quasi-BNIM?)

From:

"<Melissa Corbally>" <[log in to unmask]>

Reply-To:

[log in to unmask]

Date:

Thu, 23 Oct 2008 11:36:07 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (559 lines)

Hi There,

Thanks for opening up this discussion - it is very interesting and I'd be
interested in chatting more about this.

In January, I sent a SQUIN via e-mail with a participant who really wanted
to take part in my study but was unavailable to meet (he was travelling to
New Zealand for a long period) that day.  He asked that I e-mail him and
was happy to tell his story to me in this way.  The SQUIN was identical to
what I said to my other face-to face participants.

I was hesitant in doing this, but he was very eager to be involved.

He responded by attaching a word document of his story to me and a photograph.
 He responded to  follow up e-mails, expanding on his story (could this constitute
a second sub-session??). My supervisor was worried about the ethical considerations
of using this medium and asked that he sign a consent to participate. I e-mailed
him a consent form which he downloaded and signed and posted to me (in Ireland).
 

I'm not quite sure about what to do about this case (suggestions welcome!).
However, I wanted to let you know that his response to the 'virtual SQUIN'
via e-mail resulted in a 2700+ account with a pictoral representation of
his experience.  The fact that it was via e-mail did not appear to phase
this particular participant.  I hope this information will prove helpful
to others... 

My background is nursing/health and social care, and I'm undertaking doctoral
study using this method.  I'd be delighted to meet/ communicate with others
with a view of co-investigating health-related issues using this method.
Carmel - if you wanted to meet while you are here - I'd be delighted to.
 I am based in Dublin and you can contact me directly at [log in to unmask]

Best wishes,

Melissa

>-- Original Message --
>Date:         Wed, 22 Oct 2008 23:37:10 +0100
>Reply-To:     tom wengraf <[log in to unmask]>
>From:         tom wengraf <[log in to unmask]>
>Subject: Re: BNIM and user driven health care reform using IT (automated
>quasi-BNIM?)
>To:           [log in to unmask]
>
>
>Hi!
>
> 
>
>An interesting discussion has developed over the last few days between
>myself, Rakesh and Carmel about the possible uses of some variant of BNIM
>in
>fostering (by way of IT) user-driven health care reform. 
>
> 
>
>As you will see from the most recent messages (just below), we've agreed
>that other people on the BNIM e-list might be interested in the discussions
>and also might wish to contribute. 
>
> 
>
>This discussion is obviously only at an early stage, but the notion of
>'doing BNIM interviews by computer' is philosophically interesting and the
>question of how some variant could be 'automated' is also worth thinking
>about.
>
> 
>
>So: do join in if you're interested. I'm putting Rakesh, Carmel and Kevin
>on
>the e-list, so if you do join in, any message to the list will automatically
>go to them as well!
>
> 
>
>Best wishes. Tom.
>
> 
>
>P.S. Almost forgot. As with all such accumulative messages, you need to
read
>from the bottom of this email upwards back to the top.
>
> 
>
>----------------------------------------------------------------------------
>------
>
>FROM  Rakesh
>
> 
>
>Thanks Tom, 
>
> 
>
>Very interesting insights. It would be great if you copy this to your list
>and even better if you make us members of your mailing list.
>
> 
>
>Would be nice to hear how others would approach this. Yes as Carmel pointed
>out this discussion is partly brainstorming for the NDRC grant proposal.
>We
>have our own list but right now it has been silent and most of the
>discussions have been between the three of us.
>
> 
>
>Would be great if you could meet Carmel and we could have the advantage
of
>your expertise and of your team. 
>
> 
>
>rakesh
>
> 
>
>On 10/22/08, [log in to unmask] <[log in to unmask]> wrote:
>
>
>Tom
>Thanks for your comments. Sure I would be happy to extend our email
>discussion to a wider group. I don't know if you know the back ground to
>our
>discussion. 
>I am writing a grant proposal to the NDRC (www.ndrc.ie <http://www.ndrc.ie/>
>). As it happens, my husband Kevin Smith has moved to NDRC from Canada in
>July this year. I am writing a translational research grant to the current
>ndrc call - see www.ndrc.ie/howitworks.html so that I may hopefully move
>here also. I am an academic family physician and health services researcher
>and we have a wide network of interested co-investigators in Australia,
>Canada, India, ireland.... We are very keen to move beyond reductionist
>models that plague our discipline and health services reform. We have a
>strong interest in complex adaptive systems.... etc. I am currently in
>Dublin for 3 weeks 'holiday' before going back to Canada. I do drop in in
>London quiet regularly. We are also looking for academic and business
>partner for our proposal.
>Carmel 
>
>
>
>
>On Oct 22, 2008 8:12am, tom wengraf <[log in to unmask]> wrote:
> Dear Carmel and Rakesh,
>
> I very much like your 22-10-08 account of your PhD (which I've still to
>read!) and of 'sense-making', Carmel. Especially the notion of
>'understanding situatedness': this connects and amplifies helpfully the
>notion of 'situated subjectivity' (HiSST2) which I suggest in the Guide
to
>BNIM as a default concept for psycho-societal studies in general and for
>BNIM-using research in particular. I would only add that 'understanding
>situated subjectivity' by way of "connections (which can be among people,
>places, and events)" can also be about understanding 'disconnections and
>disjunctions" and I would modify "among people" to read "within
>and among people". 
>
>
>
>As regards your point, Rakesh, where you write "s/he may be able to scale
>up/build upon her own
> story over a period of time", I think this might happen. 
>
> 
>
>However, I think it might just as easily not happen and the person might
>keep repeating what in the Guide I refer to as their "official
>version/Public Relations subsession 1 story" more or less over and over
>again. I have a Dead Sea / water saturated with salt/ model of 'defended
>subjectivity' in which the person avoids more detail, or uncomfortable
>thoughts, or whatever by staying at a certain level at or near the surface.
>They need determined and/or skilfull 'nudging downwards' against that
>propensity to drift up and surfacewards. So I would say that having a
>subsession 1 and 2 is much more likely to produce the Whole Narrative +
>Particular PINs (the goal of BNIM interviewing) than is a long series (whole
>lifetime?) of repeated subsession 1s, even given that experience of a whole
>series of encountering other people's subsession 1s as well!
>
>Any objections if I copy this discussion to the BNIM e-list? I think it
>would be interesting to them and they might well have good ideas to offer?
>
>----------------------------------------------
>
> 
>
> 
>
>FROM Carmel
>
> 
>
>Rakesh/Tom
>
>I think that the BNIM discussion has potential in our proposed work and
it
>is primarily at the level of a formative pattern recognition research tool.
>
>
>My phd identified 3 interwoven patient narratives - the illness/health
>experience (internal); the treatment narrative (internal and external),

>the
>life trajectory school, work, social networks internal and external). 
>
>My theoretical and operational approach to patient narratives today is that
>of sense making in the following context. 
>
>"Chronicity" implies ongoing asynchronous and heterogeneous journeys of
>individuals through disease, illness and care encompassing health promotion,
>preventative care, diagnosis, self management, disease management and
>control, treatment and palliation.1
>
>
>"IT interventions in chronic care need to be flexible, adaptive and above
>all useful and empowering to patients, caregivers, clinicians and learners
>(users) at the point of care." 2
>
>
>Sensemaking is the ability or attempt to make sense of an ambiguous
>situation. More exactly, sensemaking is the process of creating situational
>awareness <http://en.wikipedia.org/wiki/Situational_awareness>  and
>understanding <http://en.wikipedia.org/wiki/Understanding>  in situations
>of
>high complexity or uncertainty in order to make decisions. It is "a
>motivated, continuous effort to understand connections (which can be among
>people, places, and events) in order to anticipate their trajectories and
>act effectively" (Klein et al, 2006a). 
>
>Carmel
>
> 
>
>FROM: Rakesh
>
>
>For a robust operational clinical system we need to develop pattern
>recognition programs that are informed and monitored by BNIM type processes
>in the background. 
>
>2008/10/21 Rakesh Biswas <[log in to unmask]>
>
> 
>
>I agree it would be definitely more useful to have the sub session 2 to
>extract the narrative out of the person (I too have experienced this
>difficulty of not being able to get a proper story in one session). 
>
> 
>
>However my idea was that with multiple sessions where the individual gets
>feedback from others and also reviews her own story s/he may be able to
>scale up/build upon her own story over a period of time (which means a life
>time since s/he gets hooked).
>
> 
>
>I would also like to hear what Carmel thinks about this. Great to keep this
>discussion alive.
>
> 
>
>rakesh
>----------------------------------------------------------------------------
>-------------
> 
>
>On 10/21/08, tom wengraf <[log in to unmask]> wrote: 
>
>OK. The advantages of your proposal is that it is very straightforward.
The
>disadvantage is that there is no sub-session 2. Our experience is that most
>people need the 'pushing for PINs' in subsession 2 for the narratives to
>become very felt, very rich, and very informative... The question would
be,
>how to do it. The subsession 1 'initial poured out heart/narrative' is in
>BNIM that which sets the agenda for further questioning. Sometimes it can
>be
>very rich; more often it isn't. I think the best thing would be to run a
>pilot in the way you suggest but perhaps have a sub-sample of that pilot
>with some arrangement for (a phone) subsession 2. You would get some idea
>of
>the difference then and decide whether you do or don't need the default
mode
>to include a sub-session 2. If you thought that it might worth trying to
>mak
>the default mode one of both subsession 1 and  subsession 2, you could
>explore whether this was technically possible - as per my note (1) in my
>original email below.
>
>Best wishes
>
>Tom 
>
>
>  _____  
>
>
>From: Rakesh Biswas [mailto: <mailto:[log in to unmask]>
>[log in to unmask]] 
>Sent: 21 October 2008 17:22
>To: tom wengraf
>Cc: Carmel Martin 
>
>
>Subject: Re: BNIM and user driven health care
>
>All right...this is how I believe it may work (the feedback part comes at
>the end): 
>
>Just imagine your basic mobile handset into which you simply dial a number
>(toll free) and pour out your heart into it (particularly when you have
the
>time...waiting in a que to see a physician or sulking after a tiff with
>spouse/partner). 
>
>All this data that you entered (mostly consisting of the story of your life)
>could now be transcribed into a web based platform equipped with web 2.0
>tools that immediately scoop out similar stories based on your story (you
>can be given the option of entering the keyword tags yourself even on the
>voice mail box or let the web software decide like google does for its gmail
>ads). 
>
>Eventually you get addicted to entering voice data through your mobile
>because you immediately get to hear stories that are similar to yours and
>yet have different insights to offer.
>
>rakesh
>
> 
>----------------------------------------------------------------------------
>---
>
>On 10/21/08, tom wengraf <[log in to unmask]> wrote: 
>
>Dear Rakesh,
>
>I have only had time to scan the two articles you sent me superficially,
>but
>I found them really interesting. I look forward to reading them properly
>later. 
>
>A couple of thoughts as to how BNIM might enter in. 
>
>1) The interview. A key function of BNIM is to ask in subsession 1 for
>'whole Story' of some period of time defined by the researcher. Then in
>subsession 2, the interviewer picks out certain items mentioned in
>subsession 1 and asks for 'more detailed story' about them, often pushing
>several times (over several rounds) for such 'more story'. The formulations
>of the questioning for subsession 2 are rather standard. However the
>selection of items for asking such 'more story' questioning are not
>well-formalised. The Guide discusses selection crtiteria and criteria for
>'following up or not' in subsession 2. The giving of 'further questioning
>feedback on initial responses', how might this be done? 
>
>2) Interpretation. The default BNIM model for 'interpretation' is quite
>complex and time-consuming, and I doubt whether you would find it relevant
>or useful. It lends itself to use in a very small number of cases, not a
>large N. Of course, you might at some point want to use a small
>theory-generating sub-sample. The 'giving of feedback on the entered data'
>that you mention. How is this/would this be done?
>
>Anyway, if you have time to look at the relevant parts of the Guide, I would
>lov e to hear about any thoughts you may come to have about BNIM's
>usability. 
>
>Tom
>
>
>  _____  
>
>
>From: Rakesh Biswas [mailto:[log in to unmask]] 
>Sent: 20 October 2008 04:09
>To: tom wengraf; [log in to unmask]; Carmel Martin
>Subject: Re: BNIM and user driven health care
>
>Hi Tom, 
>
>Good to hear from you. I hope you may have received Carmel's thesis by now.
>She has reached Dublin. 
>
>I have attached some preliminary models we devised earlier and are still
>building upon to collect patient narratives that would constitute valuable
>information flow which would in turn drive work flow in health care. 
>
>As you pointed out the best way to utilize the BNIM method would be to
>utilize some of its principles in generating a user driven narrative
>preferably through a mobile phone interface. I believe It would be possible
>to drive the whole interview process in bits and pieces through an IVR
>(interactive voice recording) system. This collected voice data in turn
>could be transcribed/translated on to a text based web interface where
>thematic field analysis could be done using available qualitative analysis
>software. 
>
>I believe the greatest driver to this whole process would be the feedback
>individual users receive on their own entered data and this would be
>essentially asynchronous yet meaningful (again derived from extracting
>themes from the patient user's entered data). 
>
>The problem with a chat/message room mode is that it would become
>synchronous and could introduce a lot of unwarranted noise into the system.
>
>Look forward to building on this discussion.
>
>regards,
>
>rakesh
>
> -----------------------------------------------------
>
>I'm afraid that - due to a cookie problem - I couldn't follow your prequel
>suggestion. Could you send some material in some other way, perhaps - like
>a
>WORD or PDF. I would be really interested in knowing about your project.
>
>I would be very interested to see how an experiment with BNIM with 'internet
>users' worked out. As far vas I know, nobody has tried this out and this
>would be a 'first'. What are my first thoughts about it?
>
>BNIM is designed to provoke and to interpret improvised narrative
>interviews.  It is therefore more likely to work well with telephone
>interviews than with written interviews, since writing allows for more
>deliberation and correction.  It may be that there is a way in which the
>deletions and rewritings of the chat room can themselves be recorded.  This
>would be ideal.
>
>Consequently I think you would get better results if you worked on the
>Internet with a message room or chat room mode.  This would to some extent
>at least preserve the observed improvisation aspect that is central to BNIM.
>
>As I say, I don't think anybody has explored yet what can be done with BNIM
>interviewing via the Internet.  If you do experiment with this, I would
love
>to be involved in one way or another. 
>
>Best wishes
>
>Tom
>
> 
>
>Thanks Tom, 
>
> 
>
>I did download this earlier but good to have the recent update. 
> 
>
>Carmel is on her way to Dublin from Ottawa at the moment and will reply
>soon. 
>
> 
>
>We are particularly interested in utilizing the BNIM in a large population
>sample of internet users who would be contributing to their personal health
>records by telling the story of their lives from which different health
care
>themes effecting mutiple dimensions of a patient's illness will be
>extracted. 
>
> 
>
>Do let us know how feasible do you think this would be as a transformative
>health care model.
>
> 
>
>Here is a prequel to the operational model: 
>
> 
>
>http://www3.interscience.wiley.com/journal/118001064/abstract?CRETRY=1
><http://www3.interscience.wiley.com/journal/118001064/abstract?CRETRY=1&SRET
>RY=0> &SRETRY=0
>
> 
>
>Do let me know if you would like to read more.
>
> 
>
>warm regards,
>
> 
>
>rakesh
> 
>
> 
>
>  _____  
>
>From: Rakesh Biswas [mailto:[log in to unmask]] 
>Sent: 17 October 2008 12:40
>To: Carmel Martin
>Cc: [log in to unmask]; Kip Jones
>Subject: Re: interviewing for lived experience BNIM method
>
>Hi Carmel
>
>A few quotes: Hunter (in Mishler 1995) reminded us that medicine is filled
>with stories and is, in fact, dependent on narrative, is essentially
>case-based knowledge and practice and that clinical judgement is
>"fundamentally interpretative" (1995:112-113).
>
>The BNIM from what I understand after reading this is essentially a free
>flow of narrative from the patient's end followed by multiple
>interpretations by a team (perhaps a health care network? like we have been
>contemplating/conceptualizing). At the moment the health care network has
>consistently interrupted a free flow of the patient's story and this is
what
>is paramount in salvaging at the moment. 
>
>I guess a free flow might even best come out of a patient web user's
>keyboard or any other input device that may encourage expression without
>interruption (rather than a human interviewer as is the present BNIM
>method). 
>
>I am also copying this to Tom and Kip who are prominent practitioners of
>the
>BNIM method for their comments (if any) on our comments/interpretations.
>
>
>rakesh
>
> 
>----------------------------------------------------------------------------
>----------------------
>
>On 10/17/08, Carmel Martin <[log in to unmask]> wrote: 
>
>Rakesh
>yes - thanks for this, it looks good for an update. 
>Note that that is what many of us are doing every day in general practice.
>
>my phd was heavily qualitative as well as quantitative - the care of chronic
>illness in general practice. chris peterson - new to you - works closely
>with the chronic illness alliance in australia
>http://www.chronicillness.org.au/  and the health issues centre
>my phd worked with chronic illness self-help groups across the 1990's
>glad that we are finally getting to translate some of these types of work
>into influencing health care and systems through IT.
>
>carmel
>
>2008/10/16 Rakesh Biswas <[log in to unmask]> 
>

Melissa Corbally
Lecturer in Nursing
Dublin City University,
Glasnevin,
Dublin 9

Tel. 01 700 8432

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