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PubMed2002

Nurse autonomy as relational.

This article seeks an improved understanding of nurse autonomy by looking at nursing through the lens of what recent feminist scholars have called 'relational' autonomy. A relational understanding of autonomy means a shift away from older views focused on individuals achieving independence, towards a view that seeks meaningful self-direction within a context of interdependency. The main claim made here is that nurse autonomy is, indeed, relational. The article begins with an explanation of the notion of relational autonomy. It then explains both the collective and the individual application of the term 'professional autonomy'. Finally, it argues that both senses of professional autonomy are best understood as relational, and suggests some implications of this conclusion.

Feminism↗
PubMed1997

Research-based planning for change: assessing nurses' attitudes toward governance and professional practice autonomy after hospital acquisition.

OBJECTIVE: This article describes one medical center's experience in using research to plan for nursing staff integration after hospital acquisition. BACKGROUND: Resistance to new policies, procedures, and standards; passive acceptance of new leadership; limited support for management plans; and failure to integrate with new nursing units are common staff reactions after acquisitions. Little has been written regarding which key staff variables to assess after acquisitions and how to use this data to plan for change. Structural contingency and attribution theory were used to guide leadership staff's assessment of acquired staff attributes to determine their congruence with concepts valued by the acquiring organization. METHODS: Qualitative and quantitative data were collected using a survey method. All 141 registered nurses and licensed practical nurses of the acquired medical center received a mailed survey. Sixty-six completed surveys were returned through the U.S. mail. No identifying information was placed on the survey to assure anonymity. RESULTS: The survey results described nurses perceptions of the advantages, concerns, and suggestions for a smooth transition after acquisition. In addition, the results clarified that nurses in the newly acquired hospital preferred a shared governance structure (congruent with the acquiring medical center's values) and the nurses perceived professional nursing autonomy was similar to that of nurses who worked at the acquiring medical center. CONCLUSIONS: By sharing the findings, both staffs were sensitized to the similarities among the staff as well as to their differences. Transition strategies were planned to capitalize on this knowledge. This process may be useful for other nurse executives to replicate as they guide their organizations through similar transitions.

Adult↗
PubMed2005

From autonomy to accountability: the role of clinical practice guidelines in professional power.

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. Based on a systematic evaluation of the available scientific evidence, these guidelines offer recommendations for clinicians about details of patient care and clinical decision making. Because clinical practice guidelines specify how health care should be performed, they could be considered a threat to clinical and professional autonomy. Inspired by the theory of countervailing powers, this article explores how clinical practice guidelines have shifted the focus of professional power from autonomy to accountability. Professional organizations develop clinical practice guidelines as a service to their members but do not require strict adherence to the guidelines. Indeed, implementation studies show at best a modest change in clinical behavior. Such non-adherence might render a profession vulnerable, however, when third parties seize upon guidelines and offer financial incentives to keep clinicians accountable for delivering optimal patient care.

Evidence-Based Medicine↗
PubMed2003

Searching for autonomy.

OBJECTIVE: to gain an understanding of what midwives understand by the term 'autonomy',and to discover whether they consider themselves and their colleagues to be autonomous in practice. PARTICIPANTS: a snowball sample of 27 midwives working in five National Health Service (NHS) trusts within the south west of England, based in both hospitals and in the community. METHOD: within a qualitative research design, semi-structured interviews with participants were tape-recorded and transcribed verbatim, and analysed using thematic content analysis. FINDINGS: most participants did not fully understand the implications of professional autonomy, particularly in terms of interprofessional collaboration and control of their own practice. There were mixed views among respondents about whether they practised autonomously. Although good relationships with medical personnel were found to facilitate midwifery autonomy, the ongoing dominance of the medical profession was still perceived as a major barrier to autonomy. Many participants did not feel that their midwifery education had equipped them for professional autonomy, although midwives educated by the direct-entry route were perceived to be more capable of exercising autonomy in practice than were nurse-trained midwives. Some participants expressed doubts about the possibility of genuine midwifery autonomy within the present system, while others felt that many midwives do not support their own or other midwives' professional autonomy. IMPLICATIONS FOR PRACTICE: midwives need to initiate major change at a collective level, or to consider the creation of obstetric nursing posts, both to afford women the choice of genuinely autonomous midwifery care and to alleviate the stresses of practising within a system that requires the accountability and responsibility of midwifery autonomy, yet neither recognises nor supports it.

Attitude of Health Personnel↗
PubMed1990

Autonomy and professional activities of social workers in hospital and primary health care settings.

Social workers in hospital settings often experience frustration working in the host setting of a hospital. Some hospital social workers may consider a move to a private primary health care setting to gain more autonomy on the job and the opportunity to provide more direct clinical services and less task-oriented ones. In this article, the authors report a study that compared the autonomy and professional activities of social workers in hospital settings and private primary care settings. It was found that social workers in the two settings do not differ in their level of perceived autonomy and that those in private primary care provide more therapy and counseling. The implications of these and other findings are discussed.

Adolescent↗
PubMed2005

The autonomy of professionals and the involvement of patients and families.

PURPOSE OF REVIEW: The involvement of patients/service users and their families/caregivers in the field of mental health has been of interest for several years. It is timely to review what has been learned about involvement; to understand where and how involvement has been implemented; and to explore factors which influence the effectiveness of implementation. Recent literature on user involvement and its implications for professional practice forms the focus of this review. Material is drawn largely from Europe, North America and Australasia, since this reflects where there is most interest in this topic. Papers outside of mental health are included where they further illuminate issues under discussion. RECENT FINDINGS: The involvement of users/patients and their caregivers is an important aspect of the care and treatment of mental illness extending across health and social care. Involvement has implications for professional practice including the negotiation of treatment, the coordination of care and communication strategies. Tensions may emerge during the process of effectively implementing patient/family involvement, but the autonomy of professionals is not usually a factor. SUMMARY: There is no singular definition of involvement. There has been growth in the levels of user/caregiver involvement, particularly in community-based provision and within transition processes from hospital to community-based treatment. There is no suggestion that involvement is widespread. Implementation of involvement should be underpinned by effective communication on the part of professionals and recognition of service users and caregivers as partners in processes of treatment and recovery. Implementation is most effective when supported by appropriate organizational policies and integrated into the education of health professionals.

Journal Article↗
PubMed2006

Client-centred empowering partnering in nursing.

AIM: This paper explores nurses' experiences 1 year after an organization's commitment to providing a client-centred and client-empowering partnering approach to care. BACKGROUND: Historically, nurses' approach to providing care in all nursing contexts has been one of doing for clients, and previous studies have focused more on in-hospital care than on home care. However, the isolation inherent in in-home nursing and nurses' limited professional autonomy and power associated with physician control over patients in home care have been reported, as has their difficulty in finding the meaning and satisfaction of human connectedness and mutuality in nurse-client relationships. Overall, research to date does not inform us about how nurses might make a change toward a more client-centred and client-empowering approach to nursing. METHODS: An interpretive phenomenological design was used to elicit in-depth understanding about Registered Nurses' experiences of providing care using this innovative empowerment model. A purposefully selected sample of eight Registered Nurses participated in in-depth interviews. Data were generated during 2002. Hermeneutic analysis was used to elicit themes and patterns emerging from the data. FINDINGS: Caring, client-centredness and the context of in-home care were important in implementing the new partnering approach. Barriers encountered at system, organizational and personal levels distracted nurses from fully comprehending and enacting the approach. After a year, they had begun to contemplate potential strategies for partnering with clients, but had not yet explored the power of their professional autonomy. CONCLUSION: Nurses are inclined to practise within the expert model of service delivery. They need to work through issues of professional autonomy and rise to the challenge of exercising their autonomy within the current healthcare context if they are to attend more consistently to client-centred empowering partnering. The home care setting offers an excellent environment for achieving these aims.

Adult↗
PubMed1989

Power and responsibility in the practice of medicine.

The evident power of the medical profession in the contemporary provision of health care requires a careful moral evaluation. The demand for professional autonomy may well lead to misuses of power. To illustrate the dangers of 'clinical freedom' and of the failure of the profession to monitor the actions of its members adequately, a case study is presented based on the recently published findings of a judicial inquiry into inadequate treatment of cervical cancer in Auckland, New Zealand. From this case study there emerge questions concerning professional autonomy, the autonomy of patients, and the need for a patient's advocate. These issues are assessed in light of the application to medical practice of the autonomy/heteronomy distinction in moral theory. Finally, three theological themes are briefly related to the issues which have emerged: the nature of agape, the limitations of human moral authority and the vision for humankind contained in the doctrines of incarnation and redemption.

Christianity↗
PubMed1996

Characteristics of physicians with participatory decision-making styles.

OBJECTIVES: To identify physician and practice characteristics associated with a physician's propensity to involve patients in diagnostic and treatment decisions, or participatory decision-making style. DESIGN: A representative cross-sectional sample of patients participating in the Medical Outcomes Study characterized each physician's style by using a self-reported questionnaire. A single averaged style score was generated for each physician. Style scores were compared among physicians who differed in age, sex, minority status, specialty, primary care training or training in interviewing skills, satisfaction with professional autonomy, and practice volume. SETTINGS: Solo practices, multispecialty groups, and health maintenance organizations in Boston, Chicago, and Los Angeles. PARTICIPANTS: 7730 patients sampled over 9 days from the practices of 300 physicians. Physicians were practicing general internal medicine, family medicine, cardiology, and endocrinology. MEASUREMENTS: Participatory decision-making style was measured using a three-item scale on a questionnaire that was completed by patients after their office visit. Physician and practice characteristics were reported by physicians on self-administered questionnaires. RESULTS: Among patients of physicians who were rated in the lowest (least participatory) quartile, one third changed physicians in the following year; among patients of physicians who were rated in the highest quartile, only 15% changed physicians. Higher scores were associated with greater patient satisfaction. Physicians who had had primary care training or training in interviewing skills scored higher than those without such training. Physicians in higher-volume practices were rated as less participatory than those in lower-volume practices. Physicians who were satisfied with their level of professional autonomy were rates as more participatory than those who were dissatisfied. CONCLUSION: Participatory decision-making style is influenced by physicians' background, training, practice volume, and professional autonomy. Because participatory decision-making style is related to patient satisfaction and loyalty to the physician, cost-containment strategies that reduce time with patients and decrease physician autonomy may result in suboptimal patient outcomes.

Cross-Sectional Studies↗
PubMed2002

Policy and profession: elite perspectives on redefining general practice in Australia and England.

OBJECTIVES: To understand how general (family) practice is being redefined and is redefining itself, from the perspective of policy elites, and to build an analytical framework. METHODS: Politicians, senior bureaucrats and executives of professional organisations were interviewed (1998-2000) about the impact of general practice reforms on the profession. The information gathered was thematically coded and used to advance an understanding of profession from an elite perspective. RESULTS: Four main aspects of profession were discussed by interviewees. These were cultural authority, profession's authority, social authority and professional autonomy. The elites interviewed reported a potential challenge to the cultural authority of general practice in both countries through moves to redefine it as something broader. The profession's authority was seen as having shifted, especially in Australia where new forms of representation for the profession have been established. Medicine was viewed variously as having its social authority challenged, maintained, or extended in the granting of expertise in health, and professional autonomy was regarded as having been restructured through policy change. CONCLUSIONS: Policy elites perceive that the authority and autonomy of general practitioners has changed but reform has not resulted in generalised losses for the profession. The framework developed here, which employed aspects of profession that arose as major themes, proved useful for examining the redefinition of profession and for generating policy insights in regard to possibilities for change and likely impacts.

Attitude of Health Personnel↗
PubMedDate not supplied

Decentralization as a determinant of autonomy, job satisfaction, and organizational commitment among nurse managers.

The purpose of this study was to test a theoretical model of the following variables, decentralization, professional autonomy, job satisfaction, and organizational commitment. Data were collected through a comprehensive survey of first-line nurse managers (N = 200) in acute care hospitals with more than 100 beds in British Columbia, Canada. The final model excluded all explored personal characteristics of the nurse manager-gender, health or vitality status, marital status, age, education, and years of supervisory or management experience. Job satisfaction was found to be an important predictor of organizational commitment. However, decentralization was most important because it affected organizational commitment directly, as well as indirectly, through professional autonomy and job satisfaction.

Adult↗
PubMedDate not supplied

Marketing: a flawed concept when applied to health care?

Since the introduction of a marketing orientation to the NHS in 1990, arguments continue to abound as to the extent and success of the internal market. This article identifies where and how the market is operating and explores the inherent difficulties of using this model, both ethically and economically. The dangers of increasing inequality, social manipulation, continuing cost pressures, loss of professional autonomy and restricted professional collaboration have to be balanced against the potential value of marketing on performance measures and a more responsive service. The article concludes that marketing needs to be tailored to the particular culture of the NHS rather than copied from the private sector and should emphasize client needs, integrated planning, good communication and the development of agreed quality indicators.

Ethics, Medical↗
PubMed1998

Primary nursing--an alternative approach for midwives.

In task allocation and team nursing systems the least complex task is given to the least trained staff member and the most complex task is given to a more skilled worker, registered nurses often do no more than checking up on others. Primary nursing is a way of thinking and working with patients that challenges outdated and traditional nursing hierarchies and supports the way forward for professional nurses. Primary nursing allows nurses to provide consistent individualised care and encourages the nurse to practice with greater professional autonomy. Task allocation, team nursing and even patient allocation methods of nursing are not wholly supportive of individualised and humanistic care. In contrast, primary nursing presents a structure in which the care planner and principle care giver are the same person. With the focus on helping the client to make her own decisions and greater professional autonomy for nurses, primary nursing is an ideal method of patient care delivery for the specialty of post-natal nursing. The way nursing activities are organised reflects the attitude towards holistic care of the patient and primary nursing is an unconditional patient-centred method of nursing care delivery and the way forward for the professionalism and autonomy of nurses.

Humans↗
PubMed2006

Application of concentration ratios to analyze the phenomenon of "next-door" pharmacy in Taiwan.

BACKGROUND: In Taiwan, a policy of separation of prescribing and dispensing practices of practitioners at Western medical and dental clinics was implemented on an incremental basis in 1997. The purpose of this policy was to promote pharmacists' autonomy and increase the transparency and safety of prescribing medications. To avoid profit loss from no longer being able to dispense prescription medications, some clinics opened pharmacies located under the same roof as the clinic ("next-door" pharmacies) or hired an on-site pharmacist. This practice might compromise pharmacists' professional autonomy and patients' benefit in pharmaceutical care. OBJECTIVE: The aim of the current study was to clarify the relationship between practicing pharmacies and clinics that resulted from contracts between pharmacies and the Bureau of National Health Insurance from 1996 to 2004. METHODS: The National Health Research Institutes database in Taiwan supplied the complete claims data sets of practicing pharmacies from 1997 to 2004. The prescribing source of every dispensed prescription was used to calculate the 1-firm concentration ratio (CR-1) (ie, the proportion of prescriptions issued by the largest prescribing clinic/hospital in the total number of dispensed prescriptions of a pharmacy in each year). Similar processing was applied to the clinics. We identified each clinic's largest cooperating pharmacy and compared their CR-1s. Pharmacies that dispensed >900 prescriptions/mo during the study period were considered thriving. Pharmacies with a CR-1 > or =0.99 and whose largest cooperating clinic had a CR-1 > or =0.99 were considered to have a close business relationship, possibly indicating a next-door pharmacy. RESULTS: The total number of prescriptions dispensed at all pharmacies in the database grew from 226,901 in 1996 to 59,785,039 in 2004, and the number of pharmacies, from 481 to 3529. An increasing number of pharmacies had a higher CR-1 after 1999. We found that most prescriptions could be dispensed at only 1 pharmacy during the study period. In 2004, 1429 clinics had >900 prescriptions/mo dispensed externally and a CR-1 > or =0.99. They had released 75.8% of all prescriptions to be dispensed at practicing pharmacies; 811 of these clinics had a cooperating pharmacy with a CR-1 > or =0.99. CONCLUSIONS: In this data analysis in Taiwan, most prescriptions from practitioners at Western medical and dental clinics could be dispensed at only 1 pharmacy during the study period, suggesting that pharmacists' professional autonomy and the patients' benefit in pharmaceutical care might be compromised in Taiwan.

Ambulatory Care Facilities↗
PubMed1999

Perceived financial incentives, HMO market penetration, and physicians' practice styles and satisfaction.

OBJECTIVE: To estimate the effects of physicians' personal financial incentives and other measures of involvement with HMOs on three measures of satisfaction and practice style: overall practice satisfaction, the extent to which prior expectations about professional autonomy and the ability to practice good-quality medicine are met, and several specific measures of practice style. DATA SOURCES: A telephone survey conducted in 1997 of 1,549 physicians who were located in the 75 largest Metropolitan Statistical Areas in 1991. Eligible physicians were under age 52, had between 8 and 17 years of post-residency practice experience, and spent at least 20 hours per week in patient care. The response rate was 74 percent. STUDY DESIGN: Multivariate binomial and multinomial ordered logistic regression models were estimated. Independent variables included physicians' self-reported financial incentives, measured by the extent to which their overall financial arrangements created an incentive to either reduce or increase services to patients, the level of HMO penetration in the market, employment setting, medical specialty, exposure to managed care while in medical training, and selected personal characteristics. PRINCIPAL FINDINGS: About 15 percent of survey respondents reported a moderate or strong incentive to reduce services; 70 percent reported a neutral incentive; and 15 percent reported an incentive to increase services. Compared to physicians with a neutral incentive, physicians with an incentive to reduce services were from 1.5 to 3.5 times more likely to be very dissatisfied with their practices and were 0.2 to 0.5 times as likely to report that their expectations regarding professional autonomy and ability to practice good-quality medicine were met. They were also 0.2 to 0.6 times as likely to report having the freedom to care for patients the way they would like along several specific measures of practice style, such as sufficient time with patients, ability to hospitalize, ability to order tests and procedures, and ability to make referrals. These effects were generally reinforced by practicing in an area with a high level of HMO penetration and were offset to some extent by having had exposure to HMOs and the practice of cost-effective medicine while in medical training. CONCLUSIONS: Although financial incentives to reduce services are not widespread, there is a legitimate reason to be concerned about possible adverse affects on the quality of care. More research is needed to investigate directly whether changes in patients' health are affected by their physicians' financial incentives.

Health Maintenance Organizations↗
PubMedDate not supplied

Autonomy in practice.

When the nurse practitioner (NP) role was first described in the early 1960s it was clear that important dimensions had been added to the role of the nurse. One of these dimensions was the increased professional autonomy. As the NP role continued to evolve, autonomy became a characterizing feature of the role. the purpose of this paper is to present basic assumptions concerning automony and its relationship to the definition of profession; to examine the implications of autonomy to the individual NP, to the nursing profession, and to the health care system; and to offer a model for considering professional autonomy in relation to the NP role.

Humans↗