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PubMedDate not supplied

Reproductive health and blurred professional boundaries.

We recognize that many of the issues raised are not simple. Our proposal calls for the same thoughtful deliberation applied in other settings to be brought to bear on reproductive health care. Some have already tried alternative approaches. In Albuquerque, New Mexico, a university hospital neonatologist and the district attorney have collaborated to create an alternative to sentencing program for women who are arrested for drug-related crimes and found to be both pregnant and drug addicted. Rather than proceed with criminal sanctions, these women are offered entry into a drug treatment program that is geared to families with young children and run by the pediatrics department. Here, the physician and the district attorney collaboratively responded in ways congruent with the professional integrity of each. In another example in Portland, Oregon, physicians, drug treatment providers, and child protective social service representatives cooperatively defeated a legislative proposal to mandatorily test and report pregnant women for illicit drug use and, instead, formed a task force to jointly develop state policy regarding the issue. Drug use, HIV infection, child abuse, and poverty are all cause for alarm. Yet it is critical that our frustration about these difficult problems not be translated into blaming individuals for "deviance," or into short-term inadequate responses. In developing policy we should consider the impact on the legal and ethical rights and obligations of both patient and physician. For every course, we should evaluate both immediate and long-term efficacy, the consequences for the doctor-patient relationship, and the consequences for medical integrity. In the midst of the present regulatory and fiscal turmoil affecting health care, we urge physicians to be careful and deliberate in the policies they embrace and the actions they take.

Confidentiality↗
PubMed2006

Excellence through evidence: the what, when, and where of clinical autonomy.

Despite high valuation and persistent challenges to nurses to function autonomously, neither the structures fostering clinical autonomy nor the relationship between autonomous practice and positive patient outcomes has been empirically established. Much of this is caused by the lack of precision in definition and measurement of the concept and identification of autonomy-enabling structures. The goal of this multisite, evidence-based management practice study is to provide an in-depth analysis of the concept and an articulation of a grounded theory of clinical autonomy preparatory to the identification of structures supporting autonomy. This article describes the research design and methodology and explicates the grounded theory by answering the following questions: What is clinical autonomy? When and where does it occur? Suggestions and recommendations for what could be done to clarify the concept and promote clinical autonomy are provided.

Decision Making↗
PubMedDate not supplied

The medical director as educator: an interview with Elizabeth M. Gallup, MD, JD, MBA. Interview by Richard L. Reece.

Richard L. Reece, MD, interviewed Elizabeth M. Gallup, MD, JD, MBA, on July 9, 1999, to talk about the evolving role of the physician executive. Dr. Gallup discusses how medical directors have evolved from a purely clinical role to participating in the business side of medicine as well. The traditional medical director, a Dr. No who denies treatment and watches clinical performance, is now becoming an educator helping physicians to manage their behavior and change their practices based on comparative data. Her book, How Physicians Can Avoid Surrender and Lead Change: Gaining Real Influence in Your Own Health Care Organization Before It's Too Late, (American College of Physician Executives, 1996) promotes acting together as a group if physicians want to stay independent and not become employed. Independent physicians can form IPAs and act together as a group, avoiding some antitrust laws. Unless physicians get together and act as a group, she says, they are doomed to further and further erosion of their economic interests as well as their clinical autonomy.

Health Maintenance Organizations↗
PubMed2000

Through compacts, health systems and physicians reshape assumptions.

Changing times in healthcare require a rethinking of the premises on which healthcare organizations and physicians have based their relationships. A new compact may call for interdependence, collaboration and other changes that undermine physicians' cherished autonomy, but it may also prove a vital steering mechanism for an organization's future.

Cooperative Behavior↗
PubMed2002

Issues related to staff retention and turnover.

Retention and turnover of staff, particularly highly skilled nurses, are important issues for administrators in the current health care environment. The purpose of this article is to review the literature to improve our understanding of factors related to staff retention. Group cohesion, job stress, manager style, and autonomy are examined. Strategies to improve retention, which focus on these critical factors, are described.

Burnout, Professional↗
PubMedDate not supplied

Empowering nurses in a practical way.

Practical approaches to increasing autonomy and participation will be required to underpin the rhetoric of 'empowerment', says James Buchan in his monthly column.

Humans↗
PubMed1996

Preventing harm and promoting ethical discourse in the helping professions: conceptual, research, analytical, and action frameworks.

The first in a series of 4 articles, this article provides an overview of the concepts and methods developed by a team of researchers concerned with preventing harm and promoting ethical discourse in the helping professions. In this article we introduce conceptual, research, analytical, and action frameworks employed to promote the centrality of ethical discourse in mental health practice. We employ recursive processes whereby knowledge gained from case studies refines our emerging conceptual model of applied ethics. Our participatory conceptual framework differs markedly from the restrictive model typically used in applied ethics. Our research relies on lived experiences of ethics, while our analytical framework draws attention to the multiple levels and contexts in which ethical dilemmas take place. Finally, our action framework is designed to collaborate with research participants and practitioners in making use of our data and interpretations. We demonstrate how the various frameworks inform each other in an integrative fashion. The article sets the stage for 2 case studies presented in subsequent articles.

Administrative Personnel↗
PubMed1997

Clinical specialty and organizational features of acute hospital wards.

Ward clinical specialty is a variable which has been largely ignored in studies of nursing organization and effectiveness. Analysis of data collected from a nationally representative sample of 83 acute medical, surgical and orthopaedic hospital wards demonstrates that while wards had similar staffing resources, differences exist in the likelihood of adopting a nursing organizational system with devolved authority, in nurses' views of prevailing hierarchical attitudes, and their perceived influence over a range of organizational features of the ward. Medical wards were more likely to have developed organizational practices associated with increasing nursing autonomy.

Analysis of Variance↗
PubMed2005

Justifications of physicians' choice of action.

OBJECTIVE: To compare choice of actions and justifying reasons among the general public, GPs and oncologists. DESIGN: A postal questionnaire using four vignettes: a healthy patient reluctant to quit smoking and one demanding an X-ray, a pulmonary cancer patient reluctant to quit smoking and one demanding immunotherapy. Subjects A random sample of the general public (n = 1000), GPs (n = 200), and oncologists (n = 200). MAIN OUTCOME MEASURES: The respondents' choice of how the physician should act (general public)/would act (physicians), and, with reference to their choice of action, their justifying reasons. RESULTS: A majority answered that the physician should/would bring up the question about smoking cessation with the reluctant patient, justified by promotion of medical benefit and protection from harm. With reference to the reluctant cancer patient every second oncologist and every third GP would not mention smoking cessation, justified by respect for self-determination and enhancement of the relationship. Facing the patient demanding a new X-ray the general public was more in favour while the physicians rejected it. One-third of the general public answered that the seriously ill patient's demand for immunotherapy should be granted and referred to respect for self-determination and enhanced relationship. A majority of the physicians rejected such a demand, justified by promotion of a fair distribution of resources. CONCLUSION: The fear of infringing the patient's right to self-determination and harming the relationship is exaggerated by physicians. They are mostly expected to bring up smoking cessation with a reluctant patient. How to manage demanding patients is more controversial.

Adult↗
PubMed2005

A path analytic model of ethical conflict in practice and autonomy in a sample of nurse practitioners.

The purpose of this study was to test a causal model of ethical conflict in practice and autonomy in a sample of 254 nurse practitioners working in the primary care areas of family health, pediatrics, adult health and obstetrics/gynecology in the state of Maryland. A test of the model was conducted using a path analytic approach with LISREL 8.30 hypothesizing individual, organizational and societal/market factors influencing ethical conflict in practice and autonomy. Maximum likelihood estimation was used to estimate the parameters most likely to have generated the data. Forty-five percent of the total variance in ethical conflict was explained by the variables of ethical environment and ethical concern. Ethical concern, idealistic philosophy, ethics education in continuing education, percentage of client population enrolled in managed care, and market penetration explained 15% of the total variance in autonomy. The findings of this study indicate that the causal model of ethical conflict in practice and autonomy is consistent with the data and contributed to a fuller understanding of clinical decision making associated with practicing in a managed care environment. The final model supported a conceptual framework that is inclusive of three domains: individual, organizational and societal/market variables.

Adult↗
PubMed2002

Technological medicine and the autonomy of man.

Is technology value-free or is it value-laden? How does technology affect human autonomy? These questions, viewed within the context of medicine, are the focus of attention in this article. The central argument is that we need neither to subscribe to the value-neutrality dictum nor to the all-encompassing value-ladenness thesis to explain the pertinent position of technology in medicine. Technology is constitutive of and strongly implicated in difficult questions of value. This, however, does not mean that technology is identical to (or neutral to) these value-laden questions. Technology poses issues of value, but only some of these relate to technology qua technology. Hence, it makes a difference whether we discuss general questions of value posed by technology or whether we discuss the value-ladenness of technology. Admitting technological value-ladenness does not imply that we are subject to a technological imperative that reduces our autonomy, on the contrary, it explains how technology increases our responsibility. This is particularly prominent in medicine.

Ethics, Medical↗
PubMed2004

Diversity and consistency: the challenge of maintaining quality in a multidisciplinary workforce.

Non-physician clinicians have become prominent providers of patient services within the practice of medicine. They include nurse practitioners and clinical nurse specialists, physician assistants, the alternative and complementary disciplines (chiropractic, naturopathy and acupuncture), mental health providers (psychologists, clinical social workers, counsellors and therapists) and specialty disciplines (optometrists, podiatrists, nurse anaesthetists and nurse-midwives). Although these various disciplines have differing histories and philosophic frameworks, which create distinctive approaches to patient care, they have shared a struggle to obtain recognition and autonomy through state licensure, to expand their state-granted practice prerogatives and to achieve broader reimbursement from third-party payers and managed care. Most entered into a growth spurt beginning in the early 1990s. All now provide care that not only overlaps that of physicians but that complements and supplements that care. The central question is, how does their care contribute to quality? The evidence thus far shows that non-physician clinicians throughout the range of disciplines can produce high-quality outcomes under particular circumstances. However, the strongest body of evidence is derived from care that is at the least complex end of the clinical spectrum or that is provided under the umbrella of physicians. Unfortunately, few studies have critically examined the outcomes of non-physician clinicians at the leading edge of their practice prerogatives and under conditions that are free of physician oversight. Thus, while the principle that they can deliver high quality care within the practice of medicine is unequivocally true, more research is needed to test this principle under conditions of greater clinical complexity and autonomy, and, pending the results of such research, caution must be exercised in applying this principle too broadly.

Humans↗
PubMedDate not supplied

[The role of nursing in the current health and social health system: nursing management in Italy].

The objects can substantially synthesizes: 1. To reflect on the evolution of the organizational configuration of the nursing function based on the various theoretical contributions; 2. To make a picture of the organizational configurations of nursing function that more frequently appear in the immense and heterogeneous health system; 3. To formulate future hypotheses that concur on nursing autonomy in the comparisons with new and old professions and to strengthen out direct responsibility.

Delivery of Health Care↗