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PubMed1991

Shared governance for nursing. Part II: Putting the organization into action.

Shared governance is a major departure from traditional management-drive systems. It requires commitment and investment from all of nursing. It builds on the trust developed in the nursing service between all participants who deliver nursing care. It requires management and clinical teams to work closely and redefine their roles. The need for mutual understanding and support is undeniable. Unfortunately, there has not been much reason for that trust to develop at a rate and a level it should in most health care facilities. As institutions move to higher levels of interaction to compete and survive and as the nursing shortage requires hospitals to address the role of the nurse, hospitals are laying the groundwork for nurses to play a larger role in governance and control. These circumstances, among others, stimulate interest and provide a basis on which nurses can work together, whether in management or clinical positions, to strengthen the accountability and role of nurses in managing their services and their practices. Moving to shared governance affects the way in which nurses work and relate to the organization. The use of collective bargaining strategies, movement of the nurse into areas of control over issues that institutions once considered beyond his or her role or right, and conflict management strategies will have to change to facilitate the move of nurses into the main-stream of decision making. As the institution moves from a hierarchical structure to a multiservice setting and a more responsive market-based organization is created, nurses will have to play a stronger role in marketing and managing their practices. This flexibility extends to moving health care services out of the institution and into the community and the home and requiring nurses to become more invested in processes and mechanisms that affect what they do and how they do it. If nurses are to have a place in creating policies and define their part in unfolding the future of health care, they must be able to reorganize their services, create stronger peer-based governance approaches, and exhibit stronger control in the exercise of their practices. That will not happen by accident, nor will there be many people from other disciplines who will be heralding this cause for nurses. Before others in policy-making positions move over to provide the necessary space for nurses, the practicing nurse will have to operate and manage his or her practice at the same level and in a similar manner as other professional workers who are outside of the typical dependent, vocational employee role.(ABSTRACT TRUNCATED AT 400 WORDS)

Decision Making, Organizational↗
PubMed1995

Dollars and sense--the benefits of membership in the American Urological Association.

OBJECTIVES: To enumerate some of the benefits of being a member in the American Urological Association (AUA) and to request support in promoting membership in our specialty society's parent organization (AUA). METHODS: The benefits of belonging to a medical specialty society are assessed by weighing the costs of membership (financial expenditures, time constraints, society requirements, etc.) against the return one receives (scientific and educational benefit, collegiality, collectively bargained compensation, etc.). From a socioeconomic point of view, many of the benefits cannot be quantified; however, they are real and undoubtedly contribute in a variety of ways to the satisfaction of day-to-day practice. RESULTS: Financial incentives can be quantified, and present times dictate that they be enumerated. Additionally AUA proactively supports the livelihood of its members. Both financial incentives and financial gains are presented. CONCLUSIONS: Membership in AUA continues to be a bargain and the dollars and sense of belonging to AUA represent genuine and unparalleled value.

Education, Medical, Continuing↗
PubMed2000

The future of orthopaedics in the United States: an analysis of the effects of managed care in the face of an excess supply of orthopaedic surgeons.

Recent technological advances in orthopaedic surgery have propelled both the volume of surgical cases and their complexity, resulting in increased costs, which should naturally result in higher incomes for surgeons. However, the transition from a fee-for-service model of physician compensation to a managed care model has resulted in major shifts in economic resource allocation. An economic model of this market based on imperfect competition shows that these changes have shifted market power from surgeons to the managed care organizations. Our model predicts that practicing surgeons will retire earlier, medical students will begin to select other specialties, and innovation will be slowed. Antitrust laws limit surgeons' ability to combat this trend through meaningful collective bargaining, creating the potential for future shortages as the baby boom generation reaches retirement age and the demand for orthopaedic services increases dramatically.

Education, Medical↗
PubMed2004

Competition or coordination in hospital markets with unionised labour.

This paper study labour market responses to hospital mergers. The market consists of two hospitals providing horizontally and vertically differentiated services. Hospitals compete either in price and quality or just in quality (non-price competition). To provide medical care, hospitals employ health care workers (e.g., physicians, nurses). The workers collectively bargain wages either at a central level, firm level or plant level. Anticipating wage responses, hospitals decide whether or not to merge. The main finding is that the bargaining structure, the nature of competition and the patient copayment rate have a crucial impact on the profitability of hospital mergers.

Economic Competition↗
PubMedDate not supplied

Strategies to minimize risks and exploitation in phase one trials on healthy subjects.

Most of the literature on phase one trials has focused on ethical and safety issues in research on patients with advanced cancer, but this article focuses on healthy, adult subjects. The article makes six specific recommendations for protecting the rights and welfare of healthy subjects in phase one trials: 1) because phase one trials are short in duration (usually 1 to 3 months), researchers should gather more data on the short-term and long-term risks of participation in phase one studies by healthy subjects; 2) researchers should develop strict inclusion/exclusion criteria that exclude unhealthy or vulnerable subjects, such as decisionally impaired people, in phase one studies; 3) subjects should not participate in more than one phase one study at the same time and should wait at least 30 days between participating in different studies; 4) researchers should develop a database to keep track of phase one participants; 5) subjects should be guaranteed a minimum wage equivalent to the equivalent type of unskilled labor, but there should be no upper limits on wages; and 6) subjects should be allowed to engage in collective bargaining with research sponsors.

Adult↗
PubMed1993

Litigation involving medical faculty and academic medical centers, 1950-1991.

An analysis is presented of 240 cases of litigation involving medical faculty, medical schools, and academic medical centers reported over the period 1950-1991. The number of reported cases increased dramatically over the study period in association with the expansion of the national medical educational enterprise. These cases can be conveniently divided by the issues they dealt with into three broad areas: general administration (89 cases), clinical affairs (108 cases), and research issues (43 cases). Cases of litigation related to general administration were most often concerned with the hiring, promotion and/or tenure, and discharge of faculty, with nearly half of these alleging discrimination. General administrative disputes also arose over allocation of departmental resources and responsibilities, faculty conduct, Veterans Affairs, relationships, employee benefits, system-wide discrimination, and collective bargaining. Courts generally supported the exercise of administrative discretion, yet examined procedures carefully. Litigation related to clinical affairs increased dramatically in recent years. Issues litigated reflect the complexity of the existing academic health care system and environment: sovereign immunity and/or malpractice, practice plans, staff privileges, indemnification, access to peer review records or other records, and conduct of practice. Outcomes of clinically related litigation through 1991 indicate substantial leeway for medical faculty, medical schools, and academic medical centers to innovate and advance their patient mission. Litigation related to medical research also accelerated recently. Issues litigated involved grants and/or personnel management, research risks, commercialization, research funding, ethics, and research animals. Litigation has paralleled (1) federal policy initiatives designed to stimulate collaboration between industry and academia and (2) the growth of regulations designed to monitor policy areas affecting research. The exposure of academic medical administrators and faculty to litigation has increased in the last 40 years. Medical schools and academic medical centers should take active steps to reduce future risks of litigation.

Academic Medical Centers↗
PubMed1984

Occupational health and safety. The Swedish model.

Occupational health and safety legislation has found greater acceptance in Sweden than in the United States. Since both countries share many similar socioeconomic values, occupational health professionals in the United States may profit from knowledge of the Swedish system. The Swedish Work Environment Act is a frame law, the details of which are determined by collective bargaining. Employers are responsible for complying with standards but have greater flexibility than their American counterparts. Methods of compliance require the agreement of the plant safety committee or the safety delegates. Safety delegates and safety committees are required by law in almost all places of work. Their responsibilities are supported by adequate training, the right to know, and the authority to stop work in the face of imminent or perceived imminent danger. Consensus and cooperation are emphasized.

Accident Prevention↗
PubMed2000

Occupationally related hydrogen sulfide deaths in the United States from 1984 to 1994.

Alice Hamilton described fatal work injuries from acute hydrogen sulfide poisonings in 1925 in her book Industrial Poisons in the United States. There is no unique code for H2S poisoning in the International Classification of Diseases, 9th Revision; therefore, these deaths cannot be identified easily from vital records. We reviewed US Occupational Safety and Health Administration (OSHA) investigation records for the period 1984 to 1994 for mention of hazardous substance 1480 (hydrogen sulfide). There were 80 fatalities from hydrogen sulfide in 57 incidents, with 19 fatalities and 36 injuries among coworkers attempting to rescue fallen workers. Only 17% of the deaths were at workplaces covered by collective bargaining agreements. OSHA issued citations for violation of respiratory protection and confined space standards in 60% of the fatalities. The use of hydrogen sulfide detection equipment, air-supplied respirators, and confined space safety training would have prevented most of the fatalities.

Adolescent↗
PubMed1997

Future of the nurse labor market according to health executives in high managed-care areas of the United States.

PURPOSE: To understand how the work environment of nurses is changing in states with high enrollment in health maintenance organizations (HMOs), the underlying forces driving change, and how these forces are expected to affect employment and earnings of nurses in the future. Financing and delivery systems that have developed in some states with high enrollment in HMOs are generally regarded as indicative of the future for all the United States. DESIGN: Survey in 1995 of a convenience sample of 62 health executives in 11 states with high enrollment in HMOs. Executives included officials in state governments, state and metropolitan hospital associations, professional and nonprofessional nursing associations, state boards of nursing, community and public health, home health care, nursing homes, other non-acute care associations, and leading HMOs. METHODS: Through structured telephone interviews, executives were asked about changes in nurse employment, earnings, collective bargaining, fringe benefits, nurses' roles, substitution of licensed practical nurses (LPNs) and aides for RNs, patient severity, quality of patient care, and expectations for nurse employment during the remainder of the decade. FINDINGS: Executives perceive a mostly positive and fast-changing nurse labor market but they are concerned about the aging RN work force, possible development of an RN shortage, and linking quality of patient care to the provision of nursing services. They doubt the ability of nurse educators to respond quickly to the need to prepare nurses for rapidly changing employer requirements. CONCLUSIONS: Public and private forces are causing rapid, profound changes in health care delivery and throughout the nurse labor market. These changes are most evident in the shift in employment of nurses from hospitals to home health. Despite anxiety associated with these changes, no evidence of an "employment disaster" exists in the views of health executives.

Administrative Personnel↗
PubMed1983

State and development of dental care for employees in Finland.

The aim of this study was to analyze the present state of occupational dental care in Finland. In addition, the viewpoints of employees and employers concerning possibilities for developing occupational dental care were evaluated. Five percent of employers had arranged dental services for their employees. Twenty-four firms either had their own dentist or had made an agreement with a dentist about dental care for their employees. Most of these dentists delivered all kinds of dental treatment to employees, and the costs of treatment were usually paid from the worker's sickness benefit funds. Many such funds also subsidized the costs of dental treatment delivered in other dental offices. In 1978 about 49% of the workers covered by such funds received subsidies for their dental expenses. The most important means of developing adult dental care in Finland was considered to be widening the scope of public dental care. The second means was widening the scope of the national health insurance system. In third place, the employers supported development of private dentistry. Employees, however, preferred to include dental care in agreements made by collective bargaining.

Adult↗
PubMed1997

Using quality and cost for employee incentives in a reengineered hospital setting.

The Mount Sinai Hospital is reengineering its inpatient services to increase the quality of patient care and achieve greater operational efficiency. The central component of this redesign has been the establishment of "care centers," which are administratively and fiscally separate "hospitals within the hospital." To promote quality and financial goals set for each care center, a novel employee incentive compensation program was created. Performance on both quality and financial indicators determines the level of bonus payments to hourly employees. The incentive compensation plan was initiated in the first quarter of 1996. By achieving two of the three performance targets, employees earned a bonus of 6% of base salary for the first two quarters. Nurses and pharmacists did not accept bonus payments because of collective bargaining agreements. The early experience of the Cardiac Care Center has been highly favorable. Changes are planned to improve the process further.

Academic Medical Centers↗
PubMed1997

Nurses and strikes: a perspective from the United States.

In the United States, there has been a continuous debate between those who favour collective bargaining for nurses and those who believe it is not professional. Likewise, the controversy over whether nurses should strike has been longstanding and continues today. Those who oppose the idea of nurses striking often state that they are abandoning their patients, and that it is not ethical, even though federal legislation requires a 10-day strike notice so that management can make patient care arrangements. The American Nurses Association (ANA) has supported the right of nurses to strike, as a last resort and after careful consideration of every factor. This support has divided the membership of ANA and the nursing profession, even though the strikes have been used sparingly and effectively by nurses in this country; and so the debate continues.

American Nurses' Association↗
PubMed2006

Chinese workers and labor conditions from state industry to globalized factories: how to stop the race to the bottom.

This article discusses administrative obstacles in China that hinder the full integration of the rural population into the mainstream of development during a period of rapid industrialization. The Chinese household registration only for urban residents with its golden contents of cradle-to-grave security has become a formidable stumbling block that perpetuates the status of rural migrants as second-class citizens in their own country. Rural migrant workers are excluded from certain types of jobs and are not eligible for many benefits that urbanites have, such as health, education, and unemployment protection. These workers must also pay a number of fees and work for lower minimum wages than the local residents. With a precarious legal existence in urban areas, they are easy prey to unscrupulous officials and employers. Because they are not allowed to form independent trade unions, their best option is to vote with their feet and leave the firms with the worst conditions; this is exactly what they did from 2004. Given this situation, the debate on Corporate Social Responsibility (CSR) took a new turn with not only nongovernmental organizations (NGOs) pushing it but with a wider range of employers and, of late, Chinese officials promoting their version of CSR. In the campaign to promote minimum labor standards, the norms set down in the Social Accountability 8000 were included in the CSR, recognizing the right to free collective bargaining and free trade unions but were excluded in the Chinese version even though the World Trade Organization (WTO) agreements recognized these rights.

Journal Article↗
PubMed1992

Residential care for the elderly.

This article maps variations in a standardized way in residential care for elderly people in three Western nations. Measured by the number of available places per person aged sixty-five and over and by the number of staff members per bed in nursing homes, the United Kingdom has the most highly developed standards. The United States ranks second, with Germany lagging considerably behind. The variations are explained by four variables: the pressure of the problem, as defined by the percentage of the population aged sixty-five and over; the caretaker potential in the family system, which alleviates this pressure; the structure and financing of the supply of residential care; and decision-making procedures in health care policy-making. My analysis emphasizes the last two variables. In the United Kingdom and the United States, the public and private providers who supply care have either political or market incentives to expand their services. Germany's mix of public and private, by contrast, is dominated by voluntary associations that are neither responsible to an electorate nor allowed to make profits. Thus, their clients do not have opportunities to articulate their needs. Health care decision making in Germany takes place through a collective bargaining process between the sickness funds and the providers. In such a system, the interests of groups who are not represented at the negotiation table--such as the elderly--tend to be neglected. A national health system of the British type links political decision makers via the election mechanism more closely to the concerns of the public. As older people represent growing proportions of the electorate, their needs find more adequate consideration in the policy process. In the United States, political officeholders also have to pay attention to the needs of increasingly organized older people, since the tax-financed and federally regulated Medicaid system is largely responsible for financing long-term care for the elderly.

Aged↗
PubMed2005

Labor and the tobacco institute's labor management committee in new york state: the rise and fall of a political coalition.

In 1984 the Tobacco Institute and the Bakery, Confectionary and Tobacco Workers Union formed a Labor Management Committee. From the mid-1980s to the mid-1990s, this LMC worked to elicit labor support in New York by framing issues in terms that made them salient to unions: tobacco excise taxes as regressive taxation, workplace smoking restrictions as an intrusion into collective bargaining. By the late 1990s, however, most of labor in New York had shifted to support for anti-tobacco policies. The reasons for this shift include the growing size and influence of public-sector unions, and their generally favorable stances on tobacco control issues; the policy-making autonomy of the unions; the growing body of scientific knowledge concerning the dangers of tobacco use; and the rise in public awareness of such dangers. Nevertheless, for two decades, the LMC contributed to mutual suspicion between labor and tobacco control advocates that prevented collaboration between them.

Journal Article↗
PubMed1992

More in sorrow than in anger: the British nurses' strike of 1988.

In early 1988 the nurses of Britain's National Health Service reached a peak of frustration. They took unprecedented industrial action to bring the state of nursing, and problems within the Health Service, to the attention of the nation. Throughout the crisis there was acrimonious debate between the Royal College of Nursing, which acts as both a professional association and a negotiating unit and opposed the strike, and the trade unions, which organized it. Their conflict undermined the nurses' solidarity and highlighted deep and complex tensions within the profession. On the day of action, labor withdrawal was widespread but inconsistent. In the end, the nurses made some gains, but most of their concerns were ignored. The government promoted the divisions between nursing unions; the media were critical of the nurses' actions; however, the labor movement supported them, and the British Medical Journal voiced the merits of the nurses' case. The struggle of the British nurses exemplifies issues and dilemmas facing nurses throughout the world. The increasing militancy of nurses in many countries reflects their dissatisfaction with pay, working conditions, and career opportunities. Many nurses are torn between the ideals of professionalism and the realities of their workplace and are ambivalent about the principles of collective bargaining. This article addresses these ambivalences and stresses the need to find creative solutions to match nurses' unique place in the political economy of health care.

Career Mobility↗
PubMed1994

Manufacturing poverty: the maquiladorization of Mexico.

Based on interviews with social workers, attorneys, feminists, union activists, and factory workers, the author argues that the maquiladora free trade zone of Northern Mexico portends developments under the North American Free Trade Agreement. Today some 500,000 Mexican workers labor in 2,000 factories for $4.50 a day in Mexico's maquiladoras. Two-thirds of the workers are women, many single women who head their households. These women work in the new, modern manufacturing plants in industrial parks, but live in squalid shantytowns without adequate water, sewage, or electricity. On the job, workers face exposures to toxic chemicals and dangerous work processes. The Mexican government does not have the political will, the trained personnel, or the equipment to monitor these occupational health problems. While Mexico's Constitution and labor laws guarantee workers the right to organize, bargain collectively, and strike, in practice the state controls the unions and opposes worker activism. In the face of employer and state repression workers are forced to organize secretly to fight for higher wages and safer conditions.

Female↗
PubMed1999

The unwritten story of women's role in the birth of occupational health and safety legislation.

Women's role in the formation of trade unions and development of collective bargaining, as well as in labor's historical struggle to improve day-to-day working conditions, has been conspicuously underplayed, if not ignored. Yet, when one reviews the history of the reduction of working hours, prohibition of child labor, elimination of homework in tenement slums, reform of factory legislation, and investigations into accidents precipitating early workers' compensation legislation, the literature is rich with women's investigative reports and studies on unhealthy and unsafe working conditions. This was the case from the late 19th century in North America up until the 1950s and the Cold War. The women's movement and political activities requiring factory reforms then seemed to go underground, re-emerging in full force during the 1960s. Women's involvement in the environmental movement, especially in the United States, has been significant in politicizing occupational health as well. Their efforts led to the 1970 passage of the U.S. Occupational Health and Safety Act.

Canada↗