Advanced Practitioners Research Articles

Safe prescribing of oral alendronic acid following hip fracture

In the UK, physiotherapists can train as independent prescribers and are working in increasing numbers as advanced clinical practitioners. This case study examines the safe prescribing of oral bisphosphonates following a fragility fracture of the hip and considers this process in the context of the Royal Pharmaceutical Society's competencies (2021) , which were adopted by the Health and Care Professions Council in 2016. Despite these medications being around since the 1960s, their utilisation in the treatment of osteoporosis remains limited, and low levels of patient adherence continues to present a problem. This case study will look at the ways in which these issues can be addressed and identifies areas for future development. It will also describe the process of bone health assessment, offering non-pharmacological approaches as a way to reduce fracture and falls risks. The shared care nature of osteoporosis management will also be considered, with communication and partnership between primary care and secondary care being key in the provision of this treatment.

Staying Abreast of New Biomarkers in Hematology/Oncology.

There has been an increasing number of approvals for targeted therapies in oncology in the past decade, changing the treatment paradigm for many solid tumors and hematologic malignancies. At JADPRO Live 2023, presenters provided an in-depth review of cancer biomarkers, including testing methodology, recommended therapies, and how advanced practitioners can integrate results into clinical decision-making.

Advancing the voice of women through doctoral education: Proposed models for dental hygienists and dental therapists.

The increase in scientific knowledge, oral healthcare, new dental hygiene workforce models, and the latest clinical skills, have elevated the need for doctoral prepared dental hygienists and dental therapists. These oral care providers need to be empowered with advanced preparation in education, research, and leadership. Therefore, the purpose of this paper is to present two curricular models for a doctorate of philosophy and a doctorate of oral health practice recognizing that students may have different goals and interests in educational pursuits. The doctoral program models support the conduct of research and scholarship, which supports the research infrastructure of the profession and emphasizes the dissemination of scholarly works. Creation of doctoral programs for dental hygienists and dental therapists provides opportunities to broaden choices and strive for autonomy throughout their careers. These programs may support the development of additional scholars and advanced practitioners who can contribute to the scientific body of knowledge and create policies and pathways to improve population oral health.

2022-2023 Drug Updates in Solid Tumors.

At JADPRO Live 2023 in Orlando, Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP, briefed advanced practitioners on key US Food and Drug Administration approvals from late 2022 to late 2023. Dr. Holle described indications, mechanisms of action, and monitoring and management of side effects of new therapies in solid malignancies.

Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study

BackgroundStaff retention in Emergency Medicine (EM) is at crisis level and could be attributed in some part to adverse working conditions. This study aimed to better understand current concerns relating...

Healthcare professionals' experiences of caring for women with false-positive screening test results in the National Health Service Breast Screening Programme.

Understanding healthcare professionals' (HCPs) experiences of caring for women with false-positive screening test results in the National Health Service Breast Screening Programme (NHSBSP) is important for reducing the impact of such results. Interviews were undertaken with 12 HCPs from a single NHSBSP unit, including advanced radiographer practitioners, breast radiographers, breast radiologists, clinical nurse specialists (CNSs), and a radiology healthcare assistant. Data were analysed thematically using Template Analysis. Two themes were produced: (1) Gauging and navigating women's anxiety during screening assessment was an inevitable and necessary task for all participants. CNSs were perceived as particularly adept at this, while breast radiographers reported a lack of adequate formal training. (2) Controlling the delivery of information to women (including amount, type and timing of information). HCPs reported various communication strategies to facilitate women's information processing and retention during a distressing time. Women's anxiety could be reduced through dedicated CNS support, but this should not replace support from other HCPs. Breast radiographers may benefit from more training to emotionally support recalled women. While HCPs emphasised taking a patient-centred communication approach, the use of other strategies (e.g., standardised scripts) and the constraints of the 'one-stop shop' model pose challenges to such an approach. During the study design, two Patient and Public Involvement members (women with false-positive-breast screening test results) were consulted to gain an understanding of patient perspectives and experiences of being recalled specifically in the NHSBSP. Their feedback informed the formulations of the research aim, objectives and the direction of the interview guide.

Artificial Intelligence–Generated Draft Replies to Patient Inbox Messages

The emergence and promise of generative artificial intelligence (AI) represent a turning point for health care. Rigorous evaluation of generative AI deployment in clinical practice is needed to inform strategic decision-making. To evaluate the implementation of a large language model used to draft responses to patient messages in the electronic inbox. A 5-week, prospective, single-group quality improvement study was conducted from July 10 through August 13, 2023, at a single academic medical center (Stanford Health Care). All attending physicians, advanced practice practitioners, clinic nurses, and clinical pharmacists from the Divisions of Primary Care and Gastroenterology and Hepatology were enrolled in the pilot. Draft replies to patient portal messages generated by a Health Insurance Portability and Accountability Act-compliant electronic health record-integrated large language model. The primary outcome was AI-generated draft reply utilization as a percentage of total patient message replies. Secondary outcomes included changes in time measures and clinician experience as assessed by survey. A total of 197 clinicians were enrolled in the pilot; 35 clinicians who were prepilot beta users, out of office, or not tied to a specific ambulatory clinic were excluded, leaving 162 clinicians included in the analysis. The survey analysis cohort consisted of 73 participants (45.1%) who completed both the presurvey and postsurvey. In gastroenterology and hepatology, there were 58 physicians and APPs and 10 nurses. In primary care, there were 83 physicians and APPs, 4 nurses, and 8 clinical pharmacists. The mean AI-generated draft response utilization rate across clinicians was 20%. There was no change in reply action time, write time, or read time between the prepilot and pilot periods. There were statistically significant reductions in the 4-item physician task load score derivative (mean [SD], 61.31 [17.23] presurvey vs 47.26 [17.11] postsurvey; paired difference, -13.87; 95% CI, -17.38 to -9.50; P < .001) and work exhaustion scores (mean [SD], 1.95 [0.79] presurvey vs 1.62 [0.68] postsurvey; paired difference, -0.33; 95% CI, -0.50 to -0.17; P < .001). In this quality improvement study of an early implementation of generative AI, there was notable adoption, usability, and improvement in assessments of burden and burnout. There was no improvement in time. Further code-to-bedside testing is needed to guide future development and organizational strategy.

Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study

BackgroundAdvanced Clinical Practitioners (ACPs) are a new role that have been established to address gaps and support the existing medical workforce in an effort to help reduce increasing pressures on NHS services. ACPs have the potential to practice at a similar level to mid-grade medical staff, for example independently undertaking assessments, requesting and interpreting investigations, and diagnosing and discharging patients. These roles have been shown to improve both service outcomes and quality of patient care. However, there is currently no widespread formalised standard of training within the UK resulting in variations in the training experiences and clinical capabilities of ACPs. We sought to explore the training experiences of ACPs as well as their views on role identity and future development of the role.MethodsFive online focus groups were conducted between March and May 2021 with trainee and qualified advanced clinical practitioners working in a range of healthcare settings, in the North of England. The focus groups aimed to explore the experiences of undertaking ACP training including supervision, gaining competence, role identity and career progression. Thematic analysis of the focus group transcripts was performed, informed by grounded theory principles.ResultsFourteen advanced clinical practitioners participated. Analysis revealed that training was influenced by internal and external perceptions of the role, often acting as barriers, with structural aspects being significant contributory factors. Key themes identified (1) clinical training lacked structure and support, negatively impacting progress, (2) existing knowledge and experience acted as both an enabler and inhibitor, with implications for confidence, (3) the role and responsibilities are poorly understood by both advanced clinical practitioners and the wider medical profession and (4) advanced clinical practitioners recognised the value and importance of the role but felt changes were necessary, to provide security and sustainability.ConclusionsAppropriate structure and support are crucial throughout the training process to enable staff to have a smooth transition to advanced level, ensuring they obtain the necessary confidence and competence. Structural changes and knowledge brokering are essential, particularly in relation to role clarity and its responsibilities, sufficient allocated time to learn and practice, role accreditation and continuous appropriate supervision.

Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care. To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents. This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023. Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually. This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care-sensitive condition. Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (-1.6% [95% CI, -2.5% to -0.8%]), (2) lack of continuity in NHs after hospitalization (-4.8% [95% CI, -6.7% to -3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (-5.8% [95% CI, -10.1% to -1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care-sensitive condition in the last 90 days of life (0.0% [95% CI, -14.7% to 131.7%]). This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

Understanding Team Dynamics and Culture of Safety using Video Reflexive Ethnography during Real-Time Emergent Intubation.

Endotracheal intubation is the third most common bedside procedure in U.S. hospitals. In over 40% of intubations preventable complications attributable to human factors occur. A better understanding of team dynamics during intubation may improve patient safety. To explore team dynamics and safety-related actions during emergent endotracheal intubations in the emergency department (ED) and intensive care unit (ICU), and to engage members of the care team in reflection for process improvement through a novel video-based team debriefing technique. Video-reflexive ethnography involves in-situ video-recording and reflexive discussions with practitioners to scrutinize behaviors and to identify opportunities for improvement. In this study, real-time intubations were recorded in the ED and ICU at Mayo Clinic Rochester and facilitated video-reflexive sessions were conducted with the multidisciplinary procedural teams. Themes about team dynamics and safety-related action were identified inductively from transcriptions of recorded sessions. Between December 2022 and January 2023, eight video-reflexive sessions were conducted with a total of 78 participants. Multidisciplinary members included nurses (n=23), respiratory therapists (n=16), pharmacists (n=7), advanced practitioners (n=5), and physicians (n=26). Video-reflexive discussions identified major safety gaps and proposed several solutions related to the use of a multidisciplinary intubation checklist, standardized communication and team positioning, developing a culture of safety, and routinely debriefing after the procedure. The findings of this study may inform the development of a team supervision model for emergent endotracheal intubations. This approach could integrate key components such as a multidisciplinary intubation checklist, standardized communication and team positioning, a culture of safety, and debriefing as part of the procedure itself.

Established advanced practice roles in radiation therapy: A scoping review.

Advanced practitioners are healthcare professionals that are highly skilled with a particular area of expertise. These roles have been successfully implemented in many healthcare settings, improving efficiency of the service, as well as enhancing the standard of care received by patients. Although advanced practice roles have been implemented in some radiation therapy departments, their implementation have yet to be facilitated in the majority of countries. The purpose of this review is to scope the literature available regarding established advanced practice roles in radiation therapy. The PRISMA strategy for the identification of relevant literature was adhered to. Two data bases, EMBASE and PubMed, were searched using combinations of the key words 'Advanced', 'Practice', 'APRT', 'Radiation', 'Therapy' and 'Radiotherapy'. Exclusion criteria were applied, and citation lists were also screened for additional relevant sources, including grey literature sources. A total of 35 relevant sources were identified that discussed advanced practice radiation therapy roles in the United Kingdom, Singapore, Canada, Australia and the USA. Means of role establishment and scope of practice were defined, and a number of advantages and challenges for advanced practice radiation therapist roles were identified. There are many benefits of implementing advanced practice roles in radiation therapy departments. Though the implementation of these roles can be challenging, the existing evidence indicates that it would be beneficial for the patient, the radiation therapist and the department as a whole. A more systematic approach, including reporting of quantitative outcomes may assist in the more widespread implementation of these roles.

Clinical supervision experience of nurses in or transitioning to advanced practice: A systematic review.

To systematically explore the clinical supervision (CS) experience for nurses transitioning to advanced practice. A qualitative systematic review using Joanna Briggs Institute meta-aggregation following an a priori protocol published on PROSPERO (CRD42023426658). Qualitative studies obtained from Medline, CINAHL, PsycINFO, Scopus, Emcare and ERIC databases and ProQuest dissertations and theses for peer-reviewed, published and unpublished studies from inception to July 2023. Two authors conducted data screening and abstraction. Quality was appraised using the Critical Appraisal Skills Programme tool and reporting followed the Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist for systematic reviews. Sixteen studies contributed to five synthesized findings: CS that is beneficial requires structure and commitment, trusting relationships are foundational for learning, lifting burdens and preventing burnout, learning through reflection, critical thinking and feedback and barriers to CS. This review provides a meaningful exploration of CS to support nurses transitioning to advanced practice. Well-structured supervision offers a safe space to share work-related concerns and develop an advanced practitioner identity. Sharing experiences helps alleviate work-related burdens and reduce professional isolation and burnout. Peer-support networks are vital for successful transition to advanced practice. This review highlighted the impact of effective supervisory relationships in forming professional identity and possible links with nursing retention. No direct patient contributions are included as it forms part of a research degree.

Lorna Breen Heroes' Foundation announces partnership to address physician burnout and MH

Dr. Lorna Breen Heroes' Foundation, the only nonprofit organization exclusively focused on health worker mental health and well‐being, on Feb. 27 announced an exclusive partnership with Jackson + Coker Locum Tenens to focus on physician and advanced practitioner burnout and well‐being, the Foundation annouced. Through this strategic alliance and as part of the Dr. Lorna Breen Heroes' Foundation's “ALL IN: Caring for Caregivers Program,” the two organizations are uniting around a mission to eliminate the stigma and barriers associated with physicians and advanced practitioners seeking support for mental health, burnout and related issues that can occur in the high‐paced, pressure‐filled environments in which they provide critical and transforming care to those in need. In addition to helping make it professionally safe to seek support, the partnership champions and advocates for work environments in which physicians and advanced practitioners feel valued and supported, cultures that embrace their whole health and well‐being, and settings that enable them to deliver safe, quality patient care. Through this relationship, Jackson + Coker reinforces its commitment to physician and advanced practitioner well‐being and positive outcomes for all. By participating in the “ALL IN: Caring for Caregivers Program,” Jackson + Coker commits to.

Saving ambulance resources: a service evaluation of the identification of non-viable out-of-hospital cardiac arrest in London by advanced paramedic practitioners in critical care.

Advanced paramedic practitioners in critical care (APPCCs) are advanced clinical practitioners focused on the delivery of pre-hospital critical care. While working in an ambulance control room setting, APPCCs seek to identify emergency calls appropriate for operational APPCCs to attend. These would include out-of-hospital cardiac arrest (OHCA). Through interrogation of incoming emergency calls they are also able to identify OHCA calls where resuscitation may be futile. In these cases, and within a governance framework, they stand down multiple ambulance responders, leaving only the closest responding resource to attend, thereby 'saving resources' that can be re-directed to other waiting emergency calls. It is believed that this is the first initiative of this nature in the United Kingdom. A three-year retrospective service evaluation of data was undertaken. The aim was to quantify the number of 'saved resources', including both double crewed ambulances (DCAs) and solo (single-person) responders, and furthermore to equate those savings into potential hours saved, using average known job cycle times (JCTs). Additionally, safety was assessed by searching all mandated incident reports for occasions where, despite cancellation of resources by an APPCC, resuscitation was commenced by the first response to scene. A total of 13,356 ambulance resources were saved. Of these, 6593 (49.4%) were DCAs and 6763 (50.6%) were solo responders. Using the average JCT for deceased patients of 104.8 minutes, the total time saving equated to 23,328.48 hours of work or 1944.04 12-hour shifts. When considering DCAs alone, the average JCT for obviously deceased patients was 110.9 minutes. This equates to 12,186.1 hours of work or 1015.5 12-hour shifts. A total of 15 incident reports were identified. All had been investigated, revealing appropriate decision making in cancelling ambulance resources. No patient harm was identified. APPCCs working within a governance framework safely saved a significant number of ambulance resources over a three-year period. Perceived benefits include 'freeing up' DCA and solo responders, allowing them to be redirected to other emergency calls, leading to potential improvement in response times for patients waiting for an ambulance resource.

Nutrition and Dietetics Professionals Sustainable Food Systems Knowledge Seeking Behaviour

ABSTRACT Sustainable food system (SFS) competence is a new and recognized knowledge area for nutrition and dietetics professionals (NDP). This research seeks to describe the SFS knowledge seeking behavior of NDP. Secondary data analysis of 231 anonymous self-assessments collected between September 2020 to December 2021 indicate a high proportion (41%) of self-assessed “beginners” in this topic at a mixture of career stages. There was a preference for learning about topics that already have significant public attention globally. More advanced practitioners sought more applied information. These results are informative for updating education and professional development tools for NDP.

Use of a handheld real-time ultrasound unit in post-prostatectomy incontinence rehabilitation

Following surgery for prostate cancer, a 56-year- old man self-referred to a specialist pelvic health physiotherapist working in private practice. An assessment was performed, and a holistic treatment programme was implemented. The patient was an advanced clinical practitioner who concurrently employed real-time ultrasound as a biofeedback tool. This was part of a wider, physiotherapist-supervised programme of pelvic floor muscle training and overall rehabilitation. An early return to continence was achieved. While recognizing the limitations of the unique circumstances described, this case report discusses the possibilities that it raises with regard to: male pelvic health rehabilitation; the use of biofeedback tools; and access to information or adjuncts that might be usefully employed by physiotherapists working in this field.

Antibiotic Prescribing Patterns for Urinary Tract Infections and Pneumonia by Prescriber Type and Specialty in Nursing Home Care, 2016–2018

ObjectiveTo identify whether differences in antibiotic prescribing practices by prescriber type and specialization in nursing home (NH) care exist for urinary tract infection (UTI) and pneumonia. DesignRetrospective cohort. Setting and ParticipantsThis national study included antibiotic dispensings to traditional Medicare beneficiaries aged ≥65 years with UTI or pneumonia infections residing long-term (≥100 days) in US NHs between 2016 and 2018. MethodsMinimum Data Set assessment data were linked to Medicare data [Part D prescription drug, inpatient hospital (MedPAR), prescriber characteristics, and enrollment]. We compared antibiotic prescribing patterns by prescriber type [physician vs advanced practice practitioner (AP)] and NH specialization (≥90% vs <90% of all associated medication dispensings to NH residents). Antibiotic dispensing measures included the total number of dispensings and duration of therapy (median number of days supplied) by antibiotic class. ResultsThere were 264,735 antibiotic dispensings prescribed by 32,437 prescribers for 140,360 residents in 14,035 NHs. NH specialists were less likely to prescribe fluoroquinolones for UTI (22.9% NH specialist physician, 23.9% non-NH specialist physician, 21.3% NH specialist AP, 24.2% non-NH specialist AP), but more likely to prescribe fluoroquinolones for pneumonia (38.9%, 37.8%, 38.8%, 37.3%, respectively). Over time, NH specialists reduced fluoroquinolone prescribing for pneumonia to a greater extent than non-NH specialists. The duration of therapy was similar across prescriber groups for UTI, but longer among non-NH specialist APs for several antibiotic classes for pneumonia, including tetracyclines, glycopeptides and lipoglycopeptides, and metronidazole. Conclusions and ImplicationsThere were differences in antibiotic prescribing patterns by prescriber type and specialization in NH care between 2016 and 2018. Understanding how antibiotic prescribing differs based on prescriber characteristics is essential to inform antibiotic stewardship efforts. Tailoring antibiotic stewardship efforts to prescribers by NH specialization is rational given differences in antibiotic prescribing patterns based on NH specialization.

Life in Suspension with Death: Biocultural Ontologies, Perceptual Cues, and Biomarkers forthe Tibetan Tukdam Postmortem Meditative State.

This article presents two cases from a collaborative study among Tibetan monastic populations in India on the postdeath meditative state called tukdam (thugs dam). Entered by advanced Tibetan Buddhist practitioners through a variety of different practices, this state provides an ontological frame that is investigated by two distinct intellectual traditions-the Tibetan Buddhist and medical tradition on one hand and the Euroamerican biomedical and scientific tradition on the other-using their respective means of inquiry. Through the investigation, the traditions enact two paradigms of the body at the time of death alongside attendant conceptualizations of what constitutes life itself. This work examines when epistemologies of these two traditions might converge, under what ontological contexts, and through which correlated indicators of evidence. In doing so, this work explores how these two intellectual traditions might answer how the time course and characteristics of physiological changes during the postmortem period might exhibit variation across individuals. Centrally, this piece presents an epistemological inquiry delineating the types of valid evidence that constitute exceptional processes post-clinical death and their potential ontological implications.

International survey of equine orthopaedic specialists reveals diverse treatment strategies for horses with overriding spinous processes.

Overriding spinous processes, also known as 'kissing spines', are one of the most common causes of back pain in horses. The aim of this study was to investigate which options for diagnosis and treatment are preferred by equine orthopaedic specialists and assess which techniques are used for local injection. An online survey was distributed among members of the European/American College of Veterinary Surgeons, the European/American College of Veterinary Sports Medicine and Rehabilitation, the International Society of Equine Locomotor Pathology and nationally recognised advanced equine orthopaedic practitioners. The survey was completed by 353 respondents. The injection techniques most commonly used involve placing two needles abaxial to the interspinous space (42%) under ultrasonographic guidance (32%) or one needle in the midline (35%) between two spinous processes. The most popular combination for overriding dorsal spinous process therapy was local injection (26.7%) combined with controlled exercise (25.5%). Manual therapy was considered by 42% of European and 25% of American specialists (p = 0.01). Surgical intervention as a first-line treatment was recommended mainly by specialists working in the United States, the UK or Ireland (p = 0.001). Overall, most equine orthopaedic veterinarians (71%; n = 201) preferred conservative management and recommended surgery only for horses that did not respond to conservative therapy. Respondents' personal bias may have skewed the findings. Despite a growing body of evidence, the therapeutic approach to 'kissing spines' in horses is influenced by professional specialisation and regional preferences. Variations in injection techniques and differing criteria for surgical intervention warrant further investigation.

Mindfulness Traps and the Entanglement of Self: An Inquiry into the Regime of Mind

Mindfulness meditation can provide salutary therapeutic benefits, as well as lead advanced practitioners to states of calm and equanimity. In this paper, we argue that such forms of meditation may subtly entrap practitioners in circular, self-reflexive feedback loops. Because these meditation traps fail to clearly discern the operations of mind, they offer a temporary oasis of peace within an unaltered dualistic realm of mind that leaves the root delusion of self-identity intact. Drawing upon Tarthang Tulku’s seminal book Revelations of Mind, we present what he refers to as the “regime of mind,” the processes of cognition, identification and re-cognition in which body, mind and language work in unison to maintain a persuasive experience of a self that knows an external world. Because these very same mechanisms are operative in meditation, the states of silence, no-thought, peace, calm, and mental blankness that can occur deceive practitioners into interpreting such experiences as signs of progress and spiritual attainment. By developing an understanding of how the regime of mind operates, such clarity can function as a corrective to the common traps of meditative practice fueled and obscured by subtle dualistic structures of self-identification and self-grasping. This clear ground of understanding can reveal how reflexively dualistic structures of knowing are constructed, opening up wider focal-settings that go beyond dualistic mind, offering more liberating options for exercising human freedom and intelligence.