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PubMed1994

Autonomy of audiologists in educational settings.

Professional autonomy continues to be an issue of major concern for practicing audiologists. Members of the Educational Audiology Association completed a written survey covering the amount of independence and authority they experience when employed in an educational setting. Four areas were explored: scope of practice; referral procedures; assessment and management activities; and employment conditions. Responses indicated that educational audiologists have a great deal of autonomy in matters relating to the scope of their practice and the implementation of daily activities. Autonomy in the area of employment conditions was much less widespread. This report provides a detailed description of the survey responses, conclusions, and implications for future training needs for audiologists who may be employed in an educational setting.

Audiology↗
PubMed1998

Autonomy in practice: are nurse practitioner students being prepared for reality?

This article reports on a study examining the relationship between nurse practitioner students' expectations of future professional autonomy and the level of autonomy experienced by certified nurse practitioners. The findings indicate that practicing nurse practitioners experience a greater sense of autonomy than student nurse practitioners perceive. As autonomy is an issue of continuing importance in nursing, and for advanced practice, further research is needed to assist schools of nursing in devising reality-based curricula for nurse practitioner programs.

Attitude of Health Personnel↗
PubMed1993

A challenge to the rhetoric of emancipation: recreating a professional culture.

This paper explores the notion that nursing education is a political process which reproduces traditional practices. There is evidence to suggest that dominant ideologies, embedded in the social processes of education and health care, shape the consciousness of nurse teachers and students towards conformity and compliance with established practices in hegemonic institutions. Traditional practices or 'common sense' reinforces the structural arrangements which contribute to the contradictions that students experience between knowledge they are 'given' in the classroom and knowledge they derive from their clinical learning experiences. It is clinical placements which bring students face to face with their position in the established hierarchy of knowledge, professional relationships and routinized practices. In this sense students may experience their classroom education as a denial of their lived experience in clinical settings. They may learn to negotiate among the different meanings and explanations they encounter and learn to act in ways that are personally and professionally 'safe', thereby reproducing traditional nursing culture. Project 2000 in Great Britain and the calls for a 'curriculum revolution' from North America promise transformation of traditional practice. But it is the political processes of teaching and learning and their practical effects which must be revealed for critique and transformation if professional ideals of reflective practice, emancipatory knowledge and professional autonomy are to play an integral part in transforming professional nursing practice within hegemonic institutions.

Attitude↗
PubMed1996

[Trying to save themselves: nurses' choices in difficult situations].

This study was originated in the interest to understand the nurse's autonomy. We accomplished individual interview with 8 nurses, which works in a hospital unit, and the focus of the interviews was their experiences in making choices in her settings. The analysis of the data, through fenomenologic analysis, results in the identification of 4 themes which explain the meanings that guidance the nurse's actions in work's situations, when she makes a choice. They are: "OBLIGATIONS AND RESTRICTIONS DEFINE THE INSTITUTIONAL ROLE OF THE NURSE", "IDENTIFY RESOURCES THAT SUPPORT HER ACTS", "TO FEEL WEAK FOR MAKE CHOICES", "TO TRY PRESERVE HERSELF". The internal autonomy was identified as a condition to the nurse's professional autonomy.

Choice Behavior↗
PubMed1992

Medicine and the health professions: issues of dominance, autonomy and authority.

Medical dominance of health care has traditionally been the organising principle in health care delivery. Medical power is manifested through the professional autonomy of doctors, through their pivotal role in the economics of health services, through dominance over allied health occupational groups, through administrative influence, and through the collective influence of medical associations. Using Friedson's four factor definition of medical dominance, a structured interview schedule was developed to examine one aspect of medical dominance, that is, doctors' control over the allied health professions. Ninety interviews were carried out with a sample of nurses, physiotherapists, occupational therapists, speech pathologists and psychologists working in various health care settings in metropolitan Sydney, seeking their perceptions on the way in which the medical profession interacts with their occupational group. The findings indicate that a significant proportion (73%) of health professionals did not feel regarded as professional equals by doctors. Nor did they feel that doctors had an adequate knowledge and understanding of their professions (73%). However, the majority (74%) felt that they had sufficient autonomy and were able to discuss doctors' instructions and offer advice or suggestions to doctors. Length of service significantly contributed to perceptions of professional autonomy amongst allied health professionals. These results support the view that the increased autonomy of the allied health professions has not impinged on medical dominance in the health care delivery system. Recommendations for further research and the training of medical and allied health professionals are made.

Allied Health Personnel↗
PubMed2006

Commitment to nursing: results of a qualitative interview study.

AIM: The aims of the study were to explore opportunities to undergo continuing professional education, family friendly policy and holding an innovative or traditional post on nurses' job satisfaction and professional and organizational commitment. BACKGROUND: Qualified nurses have become a scare resource in the National Health Service. Managers need to be aware of the work-related factors most likely to secure nurses' professional and organizational commitment which will contribute to the retention. Commitment is thought to be increased if opportunities for continuing professional education are good. Family friendly policy is also important. Less is known about the relationship between type of nursing work and commitment. METHODS: An in-depth, exploratory approach to data collection were taken, employing an interview guide with open-ended questions. Data were collected with 27 nurses in clinical grades in two contrasting trusts. RESULTS: Family friendly policies emerged as most important in securing nursing commitment. Those in innovative posts whose work entailed social hours and greater professional autonomy also displayed greater levels of job satisfaction. Opportunities for continuing professional education had less influence on professional and organizational commitment. CONCLUSION: Providing flexible or social working hours appears to be more influential than providing opportunities for continuing professional education in securing nursing commitment in this exploratory study.

Adult↗
PubMed2005

Factors contributing to the decision to leave nursing care: a study among Swedish nursing personnel.

BACKGROUND: An ageing nursing workforce raises questions of recruitment strategies and how to prevent nursing personnel from leaving their jobs. AIM: The aim of this study was to examine factors contributing to the decision to leave nursing care with special reference to work conditions related to nursing care. METHODS: This paper is based on data from a survey of nursing personnel who were employed at various county hospitals in Sweden from 1992 to 1995 (n = 1507). A self-administered questionnaire was used to identify those who had left nursing care voluntarily (n = 158) and to examine factors contributing to their decision to leave. RESULTS: Results showed that unsatisfactory salary contributed most to the nursing personnel's decision to leave, followed by lack of professional opportunities and restricted professional autonomy. CONCLUSION: The fact that nursing personnel leave because of unsatisfactory salary and lack of professional opportunities underpins the importance of making nursing more attractive in terms of financial and professional development. However, the sample size of this study was relatively small and larger studies are thus required to further investigate the importance of these factors in the decision to leave nursing care.

Adult↗
PubMed2001

Developments in nursing practice in primary health care in Hong Kong: opportunities and challenges.

The significance of primary health care to the health of individuals and communities has been well established but the development of primary health care and nursing practice within the context of primary health care remains varied in different countries and settings. This paper focuses on developments in nursing practice in primary health care in Hong Kong, using three community-based research projects to identify the opportunities and challenges created for nurses working in these settings. The projects were established in response to identified health needs and to target cancer education, HIV/AIDS and chronic health problems. Opportunities include the development of professional autonomy, innovative approaches to clinical practice, and developing skills in working with a diverse range of professionals and communities. Challenges include managing uncertainty and the development of evaluation systems to demonstrate health gains from nursing interventions.

Attitude to Health↗
PubMed2003

Reform and autonomy: perceptions of the Australian general practice community.

Reforms in health care in the 1990s across industrialised nations have had profound consequences for the autonomy of general/family practitioners (GPs). Research suggests that the professional autonomy of GPs is declining across countries, related to policy reform processes and to challenges from other actors. Important questions remain, however, around appropriate ways to conceptualise autonomy, and about the perceptions that GPs themselves have of their autonomy. It is these questions in the context of more than a decade of general practice reform in Australia that are the focus of this paper. Using a multi-component model of autonomy, which separates out micro, meso and macro dimensions of autonomy, we undertook an analysis of 343 items on autonomy and reform collected from 3 key general practice journals. We argue that members of the GP community profess an enjoyment for general practice, and operate with an ideal of what it means to be a GP. However, the reform process is perceived to challenge this enjoyment and the ideal of professional practice. In particular, there exists uncertainty as to what it means to be a GP, with members of the GP community expressing a loss of control across important dimensions of autonomy. While numerically most discussion focused on control over earnings, the intensity of feeling was most evident around control over clinical practice. Our results suggest the importance of using a multi-component model of autonomy, as it allows for a nuanced analysis of the relationship between the reform process and autonomy. At the same time, however, our analysis indicates that it is also crucial to recognise autonomy is constituted by the interaction of these components.

Attitude of Health Personnel↗
PubMed1995

[How can the patient's home be changed into a work place for the nurse? Interaction theoretical note on the role of the professional nurse in ambulatory care].

In home-care-situations nurses are confronted with the special problem of changing the house of the patients into a nurse's place of work and to play at this "stage" the role of professional nurses. The role-theory of Goffman is the background to outline some structural barriers for the performance of this role. In such and other care-giving-situations the nurse must be able to keep a necessary amount of role-distance, to regain professional autonomy.

Ambulatory Care↗
PubMed1994

Compliance with practice guidelines: clinical autonomy revisited.

The development of practice guidelines is gaining popularity in both North America and Europe. This review article explores the different reasons behind guideline development, the methodologies used and the effects assessed so far. Experience since 1982 with a guideline development programme at CBO is discussed in more detail. The consequences guidelines have for professional autonomy are discussed, and it is concluded that guidelines can enforce professionalization as well as accountability and efficiency when developed within the framework of a consistent goal-method-effect scheme and applied as an integral part of professional quality assurance activities.

Attitude of Health Personnel↗
PubMed1993

Patient control over dying: responses of health care professionals.

Decisions concerning how, when and where patients should die have traditionally been the exclusive domain of health care professionals. More recently, patients and their families are demanding increasing control over these decisions. This paper reports on the responses of 20 physicians and 20 nurses in a major teaching hospital regarding the desire of patients to exert more control over the circumstances of their dying. The findings, based on in-depth, semi-structured interviews, suggest that while health care professionals are generally in favour of the principle of patient control over dying, they have reservations about accommodating patients' wishes in actual clinical situations. Key factors that underly their ambivalence on this point are: (1) specific patient circumstances, such as age, severity of illness and mental competence; (2) moral and legal concerns; and (3) the type of intervention requested by patient. The results indicate that patient control over dying represents a challenge to the clinical judgement of health care professionals; that it runs counter to their perception of their role as healers and supporters; that it raises crucial concerns about their personal ethics and legal liability and that it poses a challenge to their professional autonomy and power. It is likely that health care practitioners will increasingly be pressured to concede their autonomy and enter into a partnership with patients in the decision-making process.

Adult↗
PubMed1997

Joint working. Local differences.

The interface between social care and primary healthcare remains underdeveloped. Where joint working is effective, it is the result of co-operation, trust and mutual respect. Successful local networks take account of professional autonomy.

Cost-Benefit Analysis↗
PubMed2004

Mineral wealth and medical opportunity.

With the increase in population and in colonial revenues after the discovery of diamonds and gold in the last quarter of the nineteenth century, public and private hospitals proliferated, particularly in larger centres such as Cape Town. The numbers of practitioners engaged in public health also increased. Perhaps as important, doctors were now accepted as skilled professionals and remunerated accordingly. At the same time there was also a greater demand for doctors in the employment of business and industry, particularly the insurance industry and the railways. These opportunities for salaried employment somewhat reduced doctors' professional autonomy and occasionally encouraged intra-professional squabbles. Yet they also provided a springboard for general professional regulation, growing professional status in specialisms like psychiatry, and a solid base for the economic survival of country doctors.

Colonialism↗
PubMed1996

Managerialism and professionalism in general practice: teamwork and the art of "pulling together".

Considers the impact of recent government policy on the organization of primary care in England and Wales. Discusses the notion and practice of "teamworking" currently in vogue, and analyses implications for doctors, nurses and managers working in/attached to general practices. Draws on the findings of a study of primary care team building which took place in a UK health authority (here referred to as "Weston"), and focuses on the experience of four general practices as they have attempted to develop as multidisciplinary partnerships. Gives consideration to the "new managerialism" evident in the NHS and its attempt to redefine professionalism and professional autonomy.

Family Practice↗
PubMedDate not supplied

Medical professionalism under managed care: the pros and cons of utilization review.

We contend that the full consequences of managed care for American medicine and health care professionals can be more fully understood if strategies for managing care are identified-in particular, strategies for the administrative oversight of professional decision making. In this paper we apply this perspective to the study of third-party utilization review, making use of a national survey of firms contracting to provide prior authorization for hospitalization in 1992. Survey data suggest that (1) existing approaches to utilization review differ greatly among review firms; (2) review practices that might improve agency and accountability seem to be overlooked by most review firms; and (3) a large number of review firms employ practices that undermine professional autonomy in seemingly inappropriate ways.

Data Collection↗
PubMed2002

Themes in the history of medical professionalism.

Professionalism in medicine is an ambiguous term. Discussions are hampered by understandings of the past that are counterproductive to today s debates. Three decades of criticism of physicians as self-interested and arrogant, and of professional organizations as unfairly monopolistic have shaken the confidence of professional leaders and their constituents in their ability to act as a positive social force, and left the concept of professional autonomy without a useful meaning. Inherited assumptions about conflict between the profession, government and the market have encouraged organizational policies to fight familiar enemies for short-term gains, rather than reinvent professionalism as a social force or seek new strategic alliances. This article stresses the importance of distancing the present from the past in re-inventing professionalism for the future, and lists eight fundamental goals.

Clinical Medicine↗
PubMed2005

"Saying no is no easy matter" a qualitative study of competing concerns in rationing decisions in general practice.

BACKGROUND: The general practitioner in Norway is expected to ensure equity and effectiveness through fair rationing. At the same time, due to recent reforms of the Norwegian health care sector, both the role of economic incentives and patient autonomy have been strengthened. Studies indicate that modern general practitioners, both in Norway and in other countries are uncomfortable with the gatekeeper role, but there is little knowledge about how general practitioners experience rationing in practice. METHODS: Through focus group interviews with Norwegian general practitioners, we explore physicians' attitudes toward factors of influence on medical decision making and how rationing dilemmas are experienced in everyday practice. RESULTS: Four major concerns appeared in the group discussions: The obligation to ration health care, professional autonomy, patient autonomy, and competition. A central finding was that the physicians find rationing difficult because saying no in face to face relations often is felt uncomfortable and in conflict with other important objectives for the general practitioner. CONCLUSION: It is important to understand the association between using economic incentives in the management of health care, increasing patient autonomy, and the willingness among physicians to contribute to efficient, fair and legitimate resource allocation.

Attitude of Health Personnel↗