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PubMed2003

Accreditation of general practices: challenges and lessons.

To flourish, practice accreditation must meet challenges. It needs to manage uncertainty over its effectiveness and cost effectiveness, to address concerns that it erodes professional autonomy, and to promote and elucidate the conditions under which it is appropriate. Lessons from Australia and New Zealand help to focus these challenges. The lessons include the need to reward quality practices, loosen professional control over accreditation, trade some consistency of standards for validity, develop standards that acknowledge cultural diversity, and be transparent. Another lesson is to separate quality control from quality improvement within a coordinated systems based framework, with practices being helped to pay for accreditation and quality improvement. Such assistance is important because, in the presence of unintended variations in practice service delivery, all practices should have to show that they meet or exceed minimum standards while aiming for excellence.

Accreditation↗
PubMed2002

Evaluation of the extended role of the midwife: the voices of midwives.

It is not uncommon for midwives in Australian hospitals to order and interpret tests and initiate medications. The National Health and Medical Research Council only formally acknowledged these practices through recommendations in 1998. Successful extension of the midwife's role is assumed to be advantageous to the health-care system in its ability to satisfy consumer demand for a less medicalized experience and to be cost effective. This paper presents the results of the first phase of a three-phase fourth generation evaluation of the extended role of the midwife in two acute care settings in the Northern Territory, Australia. The results suggest that recognition of the extended role of the midwife has the potential to deliver high level continuous midwifery care to women, to increase work satisfaction for the midwives and to enhance professional autonomy and responsibility in the workplace. However, when compared with their counterparts in the United Kingdom and New Zealand, midwives in Australia continue to practice with considerable limitations placed on their autonomy.

Cost-Benefit Analysis↗
PubMed2001

Professional regulation: determinants and strategies.

This paper discusses the nature of nursing's social contract, in particular the way in which nursing practice is or should be regulated in order to contribute to quality health care. Given that professional autonomy is linked to regulation, registration, education requirements and institutional policy and procedure, setting the limitations of the current model of regulation of entry to practice and disciplinary action for default, are questioned. The concept of personal responsibility for practice is introduced along with possible strategies for the ongoing validation of professional practice.

Australia↗
PubMed2003

National recommendations and guidelines.

Clinical guidelines and recommendations from organizations such as the National Institute for Clinical Excellence provide clinicians with information, based on an appraisal of the current evidence, regarding specific therapeutic interventions and conditions. These are designed to guide practice and to move towards achievement of best practice based on clinical and cost-effectiveness. The provision of such guidelines are potentially beneficial in developing health care practice. However, they also lead to potential problems or dilemmas for nurses. These include the conflict between standardization of service and client choice, the tension between professional autonomy and prescribed actions, and the balance between clinical and cost-effectiveness.

Benchmarking↗
PubMed1995

The implementation of the named nurse concept.

Continuity of care is of central importance to the named nurse concept and the method of care delivery in many clinical areas will have to be reorganised in order to achieve it. Patients are empowered when they contribute to their own care-planning but this is often hindered by traditional attitudes. Nurses must embrace the concept of professional autonomy if they want the initiative to succeed. National-level auditing of the named nurse initiative is required.

Continuity of Patient Care↗
PubMed1992

When the manager encounters "We can't do it!".

This article has described the importance of increasing staff feelings of self-worth, of promoting feelings of personal power, involving staff actively in practice issues, of increasing staff knowledge of the health care and agency system, and of setting limits on negative discussion in a group. When nurses feel power in the health care system, it not only has the benefit of increasing job satisfaction but increases positive responses on the job. On the other hand, nursing staff who are unable to conquer the feeling of powerlessness may respond to assignments with statements signifying the subjective state experienced: "We can't do it!" Such staff are unlikely to experience personal and professional rewards and may ultimately leave the health care field. This negative process may be blocked by the manager who assists staff to develop feelings of worth, professional autonomy, and control and who can appropriately handle negative feelings expressed in a group.

Attitude of Health Personnel↗
PubMed1991

Controlling variation in health care: a consultation from Walter Shewhart.

The control of unintended variation is an objective central to modern industrial quality management methods, based largely on the theoretical work of Walter A. Shewhart. As industrial quality management techniques find their place in health care, professionals may feel threatened by the effort to reduce variation. Understanding may reduce this fear. Variation of the types addressed in quality control efforts erodes quality and reliability, and adds unnecessarily to costs. Such undesirable variation derives, for example, from misinterpretation of random noise in clinical data, from unreliability in the performance of clinical and support systems intended to support care, from habitual differences in practice style that are not grounded in knowledge or reason, and from the failure to integrate care across the boundaries of components of the health care system. Quality management efforts can successfully reduce each of these forms of variation without insult to the professional autonomy, dignity, or purpose of health care professionals. Professionals need to embrace the scientific control of variation in the service of their patients and themselves.

Attitude of Health Personnel↗
PubMed1994

Physician burnout: recommendations for HMO managers.

If HMOs are to remain viable, they will have to control and eliminate conditions that contribute to the burnout of their physicians. Based on the belief that interventions should be based on a thorough understanding of how an HMO affects burnout, physicians in a large, prepaid group practice were asked to respond to objective and open-ended questions about their background and career, work conditions, professional autonomy, patient care, and stress and well-being. Findings about burnout prevalence, factors related to burnout, and burnout outcomes are presented and used as a starting point for a discussion of possible interventions.

Adult↗
PubMed1994

Professional oligarchy in medical group practice: toward the development of a middle-range theory.

The article presents the findings from a study of 27 large, multi-specialty medical groups that suggests a new middle range theory that the governance of medical groups is evolving away from professional autonomy due to environmental changes resulting from the expansion of managed care. The article takes a contingency theory approach to the governance of medical groups to determine the locus-of-control for strategic and management decision making. The findings support the contention that successful medical groups limit decision making at the highest level in the organization to a small number of physician leaders, thereby creating a new organizational form, professional oligarchy.

Data Collection↗
PubMed2005

An exploratory study of complementary and alternative medicine in hospital midwifery: models of care and professional struggle.

Complementary and alternative medicine (CAM) is increasingly popular amongst midwives in Australia. A growing number of hospital midwives are personally integrating one or a range of CAM within their midwifery practice. Despite this trend we still know little about CAM in midwifery, particularly at a grass-roots level. This paper reports findings from one section of a larger exploratory study examining grass-root practitioners' understandings and experiences of complementary therapies in nursing and midwifery. Thirteen in-depth interviews were conducted with midwives working in New South Wales public hospitals and currently integrating CAM within their general midwifery practice. Analysis illustrates how midwives' explanations of, and affinity claims regarding, CAM feed into wider ongoing issues relating to professional autonomy and the relationship between midwifery and obstetrics.

Attitude of Health Personnel↗
PubMedDate not supplied

[Nursing and its practice: thinking and experiences of nurses at the St. Francis of Assisi Teaching Hospital].

This research is of qualitative nature and it aims at studying nurse's social representations towards nursing and its professional practice and the way they effectively accomplish this practice at Rio de Janeiro Federal University San Francisco de Assisi School Hospital (HESFA/UFRJ). Data were collected from interview, campus observations and documents. Data analysis reveal contradictions and conflicts experienced by nurses in their professional praxis. They are beginning a process of reflection on their professional autonomy: they are sorry for the lack of structure is assisting clients properly; they do believe that researching and political participation are essential for profession development.

Attitude of Health Personnel↗
PubMed2005

From the doctor's workshop to the iron cage? Evolving modes of physician control in US health systems.

As national health systems pursue the common goals of containing expenditure growth and improving quality, many have sought to replace autonomous modes (systems) of physician control that rely on initial professional training and subsequent peer review. A common approach has involved extending bureaucratic modes of physician control that employ techniques such as hierarchical coordination and salaried positions. This paper applies concepts from studies of professional work to frame an empirical analysis of emergent bureaucratic modes of physician control in US hospital-based systems. Conceptually, we draw from recent studies to update Scott's (Health Services Res. 17(3) (1982) 213) typology to specify three bureaucratic modes of physician control: heteronomous, conjoint, and custodial. Empirically, we use case study evidence from eight US hospital-based systems to illustrate the heterogeneity of bureaucratic modes of physician control that span each of the ideal types. The findings indicate that some influential analysts perpetuate a caricature of bureaucratic organization which underplays its capacity to provide multiple modes of physician control that maintain professional autonomy over the content of work, and present opportunities for aligning practice with social goals.

Contracts↗
PubMedDate not supplied

Powerlessness, control, and complexity: the experience of family physicians in a group model HMO.

BACKGROUND: I wanted to explore family physicians' perceptions of working in a group model health maintenance organization participating in ongoing quality improvement initiatives. METHODS: I undertook a qualitative study using semistructured interviews with 24 family physicians in which there was specific inquiry about informants' perceptions of organizational and team functionality. RESULTS: Three main themes emerged from the data: lack of control, strategies for coping, and valuing the practice of primary care. More than one half of the physicians interviewed expressed a sense of powerlessness to change or control their working environment. Some physicians managed to retain a sense of control or at least to mitigate the impact of their powerlessness by employing a range of different strategies for coping. Maintaining a sense of specialist skill in the complex art of family practice was important to many of the physicians interviewed. This sense of specialization across the broad and varied canvas of family practice was not always attainable, however. CONCLUSIONS: Retaining the family physician's enthusiasm means both acknowledging what is difficult about family practice and considering how the experience of being a family physician can be improved. To achieve these ends probably means not only finding ways of restoring to family physicians a sense of professional autonomy and control over their immediate working environment but also assigning greater value to the skills in managing clinical and organizational complexity that are particular to family practice.

Adaptation, Psychological↗
PubMedDate not supplied

[Dentistry in Argentina: The history of a subordinated profession].

Approaching from the perspective of social and historical construction, the article addresses the professionalization of dentistry in Argentina from the late nineteenth century to 1940. The study analyzes the weight of different actors and dimensions, particularly the introduction of dentistry studies into Argentinean universities and the conflicts between dentists and those in related fields (especially physicians, mecánicos dentales, and informal practitioners like barbers and bleeders) as well as conflicts with the State. The article explores the union, political, and academic strategies developed in an effort to define a space for exclusive intervention, and also looks at the earliest successes in tracing out a specific domain that would ensure professional autonomy and monopoly in the practice of dentistry. A review of documentation reveals the weight of craftsmanship and the mercantile tradition in dental practice, very limited collective participation in the union environment and the field's weak commitment to public health.

Argentina↗
PubMedDate not supplied

Biosciences on the margin.

As nursing has striven to acquire professional autonomy, the biological sciences have been marginalized in the teaching and practice of nursing. The authors of this article argue that with the expected expansion of nursing roles--including nurse prescribing--the need to consider the place of the biosciences in nursing has become more acute.

Biological Science Disciplines↗
PubMed2006

Magnet hospital characteristics and northern Canadian nurses' job satisfaction.

Retention of health professionals is a serious problem in northern and rural Canada. Magnet hospital factors are known to increase job satisfaction, which contributes to retention. The purpose of this paper is to examine the extent to which magnet hospital characteristics (management support, nurse-doctor and nurse-manager relationships, professional autonomy and responsibility) contribute to northwestern Canadian hospital nurses' job satisfaction. Participants were 123 nurses from 13 hospitals in western Canada. They completed a survey and structured interview that provided data on their attitudes and perspectives about their hospital jobs. We found that some magnet hospital characteristics apply in northern and rural western Canadian hospitals. Our findings indicate that management support and nurse-manager relations are important to nurses' job satisfaction, but participants' views of management were fairly negative, an issue that management needs to address. Nurses' ability to work professionally and autonomously is also important to their satisfaction. There are indications that nursing supervisory skill sets need to be upgraded in some instances.

Accreditation↗
PubMed1998

Mediating conflict and control: practice challenges for nurses working in palliative care.

A work-based professional development program was offered to a group of registered nurses working in palliative care. The goal of the program was to improve skills in psychosocial care (Yates et al., 1996). Participants were encouraged to reflect critically on their practice experience within a group setting. The focus of the group discussion and reflection were shared practice incidents. Each participant was given the opportunity to identify and describe an incident from their professional practice that presented a challenging issue within palliative nursing. This paper explores the themes of conflict and control, evident within the collection of fifteen practice incidents and discusses the nurses' role as mediator. The concepts of patient advocacy and professional autonomy are challenged through the nurses' experience of providing care within a hierarchical and bureaucratic health service. The outcome of reflection for the organization is most effective when shared experience and collective action (rather than individual practice) are the focus.

Adult↗
PubMed2006

Client-centered home care: balancing between competing responsibilities.

This study explores and describes the perceptions of nurses with respect to everyday client-centered care. A grounded theory study was conducted with 10 Dutch nurses and auxiliary nurses giving home care to chronically ill clients. Participatory observations and semistructured interviews were held. Nurses perceived roles and responsibilities competing with the role as a responsive professional to the client demand: a critical professional, developer of client competencies, individual, and employee. Strategies in balancing between competing responsibilities were distinguished: pleasing, dialoguing, directing, and detaching. Directing (related to impaired client competencies) and detaching (related to organizational barriers) were also used as second choice strategies. Effectively balancing between competing responsibilities was seen in dialoguing and directing as second choice. Conditions identified related to these strategies are awareness of, and responsibility taking for competing responsibilities. Recommendations for practice concern a care relationship and a dialogue with the client, critical ethical reflection, professional autonomy, self-assertiveness and organizational support.

Adaptation, Psychological↗