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PubMed1993

Physician satisfaction under managed care.

Data from a survey of young physicians have been analyzed to study the relationship between practicing medicine under managed care and the levels of perceived professional autonomy, practice satisfaction, and career satisfaction. Although practicing under managed care is associated with lower levels of perceived autonomy in patient selection and time allocation, it is associated with higher levels of perceived autonomy in use of hospital care, tests, and procedures. Specialists associated with managed care perceive more autonomy than generalists. Analyses of physicians' satisfaction with their practices and careers show that practicing under managed care is not uniformly associated with lower levels of satisfaction. Overall, managed care does not seem to have had the deleterious impact on medical practice that was forecast for it.

Attitude of Health Personnel↗

PubMed2004

Swedish mental health nurses' responsibility in supervised community care of persons with long-term mental illness.

The aim of the present study was to describe psychiatric nurses' experience of how the changing focus of mental health care in Sweden, from in-patient treatment to community-based care, has influenced their professional autonomy. Eleven psychiatric nurses were interviewed and a qualitative content analysis was used to identify major themes in the data. Three main themes were found: pattern of responsibility, pattern of clinical judgement, and pattern of control through support and supervision. All themes were related to the nurse's identity, moral responsibility and the feelings of loneliness and independence in his/her daily work. Together, the three themes were found to constitute a process. This study shows the complexity involved in nursing care provided in the patient's home. Achieving control over the patient's everyday life through support and supervision does not imply taking over the patient's autonomy, but rather reducing the stigma attached to mental illness and facilitating the process of rehabilitation.

Adult↗

PubMed1997

Primary care--opportunities and threats. The changing meaning of the GP contract.

The meaning of the GP contract has changed since the last major upheaval in the mid-1960s. The government has always dealt with general practitioners as independent contractors, but the way in which it treated them in 1990 was entirely different from the way in which they were treated in 1966. In 1966, the profession's independent contractor status effectively served to protect professional autonomy. In 1990, with the change in the form of government towards a "contract state," general practitioners were treated as independent contractors more in the sense of business entrepreneurs. The article finishes by raising the issue of how general practitioners can gain control over the medicopolitical agenda in the future.

Attitude of Health Personnel↗

PubMed2005

Nursing agency and governance: registered nurses' perceptions.

AIM: To explore registered nurses' perceptions of standards of nursing practice and factors that affect nursing practice standards. BACKGROUND: Nursing governance affects nurses' ability to manage nursing practice standards. Lack of nursing professional autonomy has been associated with occupational dissatisfaction, stress, turnover and low morale, which impact upon care quality. METHOD: Grounded theory was used. Data, gathered by semistructured interviews with 142 nurses, theoretically sampled from three National Health Service hospitals were analysed using constant comparative analysis. FINDINGS: Nurses were dissatisfied with their governance over factors that they believed had most influence on nursing practice standards. Perceived lack of control over factors that affect practice standards generated dissatisfaction, frustration and demoralization. CONCLUSIONS: Nurses' perceived lack of governance over their practice requires investigation and attention if occupational dissatisfaction, stress, turnover and low morale, which impact on quality care, are to be reduced. Dissatisfaction with nursing governance indicates a need to review nurses' professional involvement in clinical governance.

Adult↗

PubMed1995

Is medicine moving to the right?

During the CMA's recent annual meeting in Winnipeg, General Council delegates agreed that as far as Canada's health care system is concerned, maintenance of the status quo is impossible. Some delegates were motivated by the principle of professional autonomy, while others approached the issue from a public-policy perspective. Still others were driven by outrage at what is happening to physicians' incomes. But delegates barely resisted the pull of a vocal group of physicians who favour giving Canadians the right to choose regulated private insurance for all medical services. The compromise position, for now at least, is that delegates want the CMA to lead a public debate on the future of health care.

Canada↗

PubMed2004

Discovering the nature of advanced nursing practice in high dependency care: a critical care nurse consultant's experience.

This paper describes how a critical care nurse consultant's clinical role has evolved within a surgical high dependency unit (SHDU) in a large teaching hospitals trust. In order to provide some background to role development, an overview of the research exploring the nature of advanced nursing practice in the context of critical care will be presented. From the outset, advanced nursing practice was not perceived as the acquisition and application of technical procedures usually undertaken by doctors, but possibly an integration of medicine and nursing where holistic nursing assessment is combined with symptom-focused physical examination. A reflective account of practical problems encountered relating to role integration, professional autonomy, legal and consent issues, non-medical prescribing, and role evaluation will be presented. A model of working that can be applied to high dependency units, integrating the role of the advanced nurse practitioner within the clinical team, will be described.

Activities of Daily Living↗

PubMed1995

The production and reception of scientific papers in the academic-industrial complex: the clinical evaluation of a new medicine.

The production and reception of scientific papers in the academic-industrial complex have been neglected in sociology. In this article the social processes which influence the nature of the scientific paper in that complex are explored in depth by taking a number of controversial medical papers as case studies. The empirical evidence is collected and discussed in the light of sociological theories of normative ethos, paradigm development, reward-induced conformity and social interests in science. It is concluded that within the medical-industrial complex conformity to industrial interests can be a major criterion in defining the kind of reception given to a scientific paper and the professional autonomy of the authors in the paper's production, rather than an ethos of scientific scepticism or commitment to paradigmatic conventions. This is seen to have implications for the production of scientific knowledge - implications that might be in conflict with the public interest. Consequently, the desirability of current British Government proposals to intensify its policy of making science more responsive to the needs of industry may have significant drawbacks, hitherto unacknowledged in official circles, and in need of more extensive sociological investigation.

Clinical Trials as Topic↗

PubMed1994

Implementing continuous quality improvement in primary care: implications for preventive services.

The implementation of CQI must be done in a manner that capitalizes on the challenges of primary care, including the professional autonomy of the physician, the availability of data, issues of cost and efficiency of service, and the expanding role of patient expectations in quality care. Analysis of these factors is based on an ongoing study designed to help community-based primary care practices increase the utilization of prevention and early detection services offered to patients.

Cost-Benefit Analysis↗

PubMed2006

Medical staff organizations: a persistent anomaly.

Medical staff organizations (MSOs) originated to reconcile hospitals' hierarchical management structure with the professional autonomy demanded by physicians. MSOs' primary purpose is to hold physicians collectively accountable for patient safety and clinical performance. However, in an era of declining hospital activity, most physicians no longer understand this. More often, they view the MSO as a political body whose purpose is to foster physicians' interests with the hospital's administration and board of trustees. In many hospitals, it is difficult to determine whether the MSO is the key to clinical improvement or the biggest barrier.

Decision Making, Organizational↗

PubMed1994

The impact of outcomes measurement on the hospital-physician relationship.

Hospitals and physicians have a mutually dependent relationship. Although both are responsible for patient care, conflicts arise as physicians attempt to maintain professional autonomy and hospitals attempt to maintain organizational stability. In recent years the outcomes measurement movement has influenced this relationship in a variety of ways. This review chapter traces the major sociological, historical, theoretical, and political influences that have contributed to these conflicts. Additionally, based on an analysis of these trends, speculation is offered on the future of the hospital-physician relationship as society increasingly holds both groups responsible for outcomes of care.

Conflict, Psychological↗

PubMed2002

Evidence-based practice in health and social care: where are we now?

This paper explores evidence-based practice (EBP) in health and social care in the UK from the individual perspectives of professionals in physiotherapy, midwifery, nursing and social care. The present interest in EBP emerges as a natural derivative of contemporary economic, social and political trends and concerns. There is optimism and broad acceptance of the overall philosophy of EBP and each profession demonstrates a concerted organisational attempt to bridge the research--practice divide. This includes the interpretation of research outcomes in the form of practice guidelines, protocols and standards. However, adherence to these is poor and resistance to EBP is growing. This is attributed to practical and philosophical tensions common to all of the professions. These include the continued dominance of randomised controlled trials (RCTs) in the hierarchy of evidence. RCTs often fail to capture the multi-faceted individualistic nature of health and social care interactions or the development of qualitative methodologies within the professions. Concern is expressed that professional autonomy and the art of practice will be eroded by the enforcement of guidelines and protocols. EBP is currently located within individual professions rather than the broader context of interprofessional practice. The future of EBP is dependent, at least in part, on educational initiatives, organisational commitment and support, patient/client involvement and the development of a broader interprofessional perspective.

Attitude of Health Personnel↗

PubMed1997

Swedish physicians' perspectives on the introduction of the Stockholm model.

Reports findings on the perspectives of Swedish physicians since the introduction of the Stockholm model. Subjects were asked to describe their work, how long they had been working and whether they were familiar with the Stockholm model. Questions also focused on professional autonomy, use of diagnostic related groups (DRGs), quality of care and competition among health-care providers. Most of the physicians interviewed reported that the Stockholm model had the advantage of increasing efficiency and productivity, that economic incentives influenced their medical decisions, and medical treatment appears more patient-focused than before. Finally, primary care physicians report an enhanced status within the medical profession.

Aged↗

PubMed1992

Freidson then and now: an "internalist" critique of Freidson's past and present views of the medical profession.

Freidson is a foremost analyst of the medical profession. Most recently Freidson attacks those who claim that medicine is declining in power. He insists that medicine has not lost the core elements that make it a powerful, indeed, the dominant, health profession. The author compares Freidson's early writings on medicine with his most recent ones, and shows that there are critical confusions in Freidson's central concepts of professional autonomy and dominance. This difficulty is illuminated by viewing dominance, autonomy, and subordination as on a continuum of control. Using this continuum, the author argues that Freidson implicitly admits what he set out to deny (that medicine has not declined in power) by shifting his focus from medical dominance to that of autonomy. Freidson also now rejects valid parts of his earlier work (that which emphasizes social structural determinants of behavior over socialization). In equating medicine in the United States with teaching in that country, Freidson's contention of "little change in medical power" meets its own refutation. Finally, despite his derogation of others, Freidson's lack of an adequate framework to explain the dynamics and not simply the structure of health care produces purely normative, utopian (and unhelpful) policy recommendations.

Communism↗

PubMed2001

Professional integrity in the age of managed care: views of physicians.

At the end of 1997, one quarter of the American public used health maintenance organizations. This paper reports findings on physicians' perspectives on the role of managed care in their professional practices. The research data come from mailed surveys to physicians who are selected from the Cigna Directory of Physicians practicing in the State of Ohio. Subjects were asked to explain what managed care meant to them, and how long they have been practicing medicine. Questions also focused on professional autonomy, quality of care and career aspirations for the future. The results from the study suggest that managed care has had a negative impact on how physicians practice medicine. Several of our respondents reported that they are playing the role of a "double agent" and feel a sense of frustration in doing so. The degree of antipathy toward managed care differs between primary care physicians and specialists.

Age Factors↗

PubMed2003

Evaluations of health interventions in social insurance-based countries: Germany, the Netherlands, and Austria.

Health Technology Assessment (HTA) in social insurance-based, or so-called 'Bismarck' health care systems (Germany, Austria, and the Netherlands) has taken a different course than in either taxed-based (Sweden, Norway, United Kingdom, and Spain) or private health care systems (such as the United States). The culture of informed decisions supported by transparent and evidence-based evaluations of health interventions was hindered by the strong professional autonomy and sectoral interests in Germany and Austria for a long time. On the other hand, HTA has a long-standing tradition in the Netherlands. In all three countries sickness funds play an important role in implementing evaluations-as a policy tool-by linking reimbursement to explicit proof of effectiveness in both new and established interventions. This article focuses on the obstacles and opportunities for HTA in Germany, Austria and the Netherlands as countries with insurance-based health care systems.

Austria↗

PubMedDate not supplied

Creating a culture of service excellence: empowering nurses within the shared governance councilor model.

Through the shared governance council model, staff nurses at Delnor Community Hospital were empowered in an organization that encouraged professional autonomy over practice, effective communication, and development of leadership skills. Nursing strategic plans were carefully designed and specifically structured to lead to successful implementation of a shared governance model and a new nursing culture of excellence. The shared decision-making structure was the vehicle used to integrate the 14 standards of Magnet Nursing to create a culture of high-quality nursing practice to achieve optimal outcomes. Nursing excellence was further verified by achieving outstanding results in patient, physician, and nurse satisfaction scores and nurse retention.

Benchmarking↗

PubMed1997

Gestures of resistance: the nurse's body in contested space.

This paper is based on a one-year ethnographic study that focused on nurse-patient relationships on a ward where therapeutic nursing and professional autonomy were explicit nursing goals. Through participant observation and semi-structured interviews, it was found that nurses, as a team, adopted a highly relaxed form of posture. Their informal and open stance served to emphasize their 'closeness' with patients, supporting nurses' claim of a special role in the healthcare team, and making flesh some of the differences between nursing and medical roles. The interpretation of nurses' bodily practice rested in part on the meanings given to the ward space patients felt the ward to be a private domain in which nurses' informality endorsed their sense of being cared for as if by family, while for medical staff the ward remained a public space in which female nurses tacitly challenged their authority as men through the adoption of a masculine bodily praxis. The paper thus looks at links between the gendered body, the gendered professions of medicine and nursing, and the gendered nature of space. It argues that work on occupational closure has previously privileged the discursive, and suggests that understanding how nurses arbitrate professional boundaries in everyday practice will benefit from consideration of the nurse's body as a point of political resistance.

Adult↗

PubMed2003

Magnet hospital nurses describe control over nursing practice.

Staff nurses describe control over nursing practice (C/NP) as a professional nursing function made up of a variety of activities and outcomes. Greater acclaim, status, and prestige for nursing in the organization are viewed as a result, not a precursor, of C/NP. Interviews with 279 staff nurses working in 14 magnet hospitals indicated that effective C/NP requires some kind of empowered, formal organizational structure, extends beyond clinical decision making at the patient care interface, and is the same as or highly similar to what the literature describes as professional autonomy. From constant comparative analysis of nurses' descriptions of C/NP activities, five ranked categories of this real-life event emerged. The basis for the categories and ranking was "who owned the problem, issue, and solution" and the "degree of effectiveness of control" as reflected in visibility, viability, and recognition of a formal structure allowing and encouraging nurses' control over practice. Hospital mergers and structural reorganization were reported to negatively affect the structure needed for effective C/NP. Almost 60% of these magnet hospital staff nurses stated and/or described little or no C/NP.

Health Knowledge, Attitudes, Practice↗