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Each manager holds the key to promoting job satisfaction. Through increased autonomy, staff are empowered to control the destination of their clinical practice. Control over your own clinical practice increases autonomy and therefore leads to greater retention in the work area.
Shared Governance is the administration and deployment of the organization's services through a partnership model of managers and staff. A system is said to "live" where it provides service. In a health care organization this is the point of service known as the patient care unit. In that arena staff nurses engaged in a partnership model of governance should be acknowledged as the rightful owner of their clinical practice and the systems that support the delivery of patient care. This manuscript describes an acute care hospital's experience in the evolution of its governance structure that enabled staff nurses to assume greater levels of autonomy and control over their practice.
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Studies were undertaken to assess the practice prerogatives of nonphysician clinicians (NPCs) in 10 disciplines that, collectively, are the major nonphysician contributors to the delivery of medical and surgical services. These disciplines include nurse practitioners, physician assistants, nurse-midwives, chiropractors, acupuncturists, naturopaths, optometrists, podiatrists, nurse anesthetists, and clinical nurse specialists. Marked differences were found in the practice prerogatives that states granted NPCs in the various disciplines. For most disciplines, the magnitude of their prerogatives correlated with the numbers of NPCs practicing in each state. At their maximal levels, state practice prerogatives authorized a high degree of autonomy and a broad range of authority to provide discrete levels of uncomplicated primary and specialty care. The recent growth in these prerogatives is fostering new opportunities for NPCs; however, it also is creating a pluralism that has the potential to further fragment the US health care system. It is time for regulatory integration and professional collaboration so that a health care workforce that includes a diversity of disciplines can be assured of providing a coherent set of patient care services in the future.
Knowledge of the work climate is important in all organizations since the this climate can either contribute to or limit the development and sense of fulfillment of those working within the workplace. The aim of this study was to describe the nurses' perception of the working environment in a university hospital. Two-hundred and thirteen nurses completed a self-administered questionnaire which included the Work Environment Scale (WES) translated to Spanish. The nurses perceived that involvement and cohesion among colleagues was high. The support of the supervisor as well as the autonomy given to nurses in their work was considered moderate. The nurses also highlighted organizational aspects, i.e. planning and efficiency at work and the clarity of what was expected of them in their daily activities. The perception of the work environment differed among the various nursing units. In general, nurses with the fewest years of professional experience perceived the work environment more positively. This study has enabled the determination of a work environment profile of a group of nurses in a university hospital. Moreover, guidance is offered to nurse managers of the nursing units on the positive aspects of the work environment which should be reinforced and on the negative aspects which should be modified in order to create an optimal work environment.
BACKGROUND: Changing patterns of patient referral, decreasing payments for service provision, confusing network participation and reimbursement, as well as challenges to autonomous clinical decision-making jeopardize the traditional role of the oncologist in delivering cancer care. The cancer patient also may be at risk with unproven cancer delivery systems that displace the oncologist as decision-maker and care provider. The authors have constructed a model that preserves the oncologist's clinical and financial autonomy while meeting marketplace demands for improved access, decreasing costs and preserved quality of care. METHODS: During a 4-year period, a group of private practice medical oncologists initiated a formal business plan to evaluate marketplace needs, then designed and implemented a novel cancer care delivery model. The model required reconfiguring the practice into an integrated Joint Commission on Accreditation of Healthcare Organizations-certified cancer service corporation, providing medical, radiation, and gynecologic oncology. Palliative care, pain management, psychologic, and nutritional services were instituted as well as the vertical integration of home health and hospice care. Clinical pathways and treatment protocols were designed to enhance patient care and facilitate cost-of-care projections in designated populations using a cancer incidence forecasting model. Outcomes analysis are performed as part of ongoing continuous quality improvement, which continues to change this health care delivery system. RESULTS: In the 3 years since implementation of the model, the practice has increased from 16 to 24 physicians, and the number of offices has increased from 12 to 17. Patient encounters, both new and established, have doubled. Cost of services, specifically hospitalization, have been reduced by 50%. Clinical research referrals have increased 300%. Physician compensation has improved >20%. CONCLUSIONS: The model created a low cost, high value provider not burdened by allocated overhead. Decentralized care enhanced community access, which improved patient compliance, enhanced patient satisfaction, decreased hospitalization, and thereby decreased cost. The horizontal structure permited the flexibility for varied purchaser products and politically sensitive physician and hospital provider panels. Consensus-based protocol and pathway determination achieved maximum physician participation, which preserved clinical and financial autonomy, decreased variance, and facilitated clinical research.
Many health plans are shifting to less-restrictive managed care options that increase provider and consumer autonomy. Although intended to improve satisfaction and quality, the effect of these changes on utilization and expenditures is not yet known. Evidence from changes increasing clinical autonomy in a statewide workers' compensation system may be illustrative for managed health care plans as to how these changes may result in costly and unintended consequences.
This article explores doctors' experience of the role of clinical director in a large National Health Service (NHS) teaching Trust. The advent of doctors in management, as a relatively new phenomenon in the NHS, is reviewed to provide a contextual setting for the case study. The empirical findings are presented as a 'clinical diamond' which emerged as a form that captured the multifaceted nature of the role. The research demonstrates that, for a doctor, being a clinical director potentially threatens the professional identity, collegiality and autonomy of both the individual and the professional group the directorate represents. Moreover, stress that emanates from the structural tension inherent in the role is displaced into personal and professional stress. Clinical directors embody the tensions and conflicts of different managerial and professional cultures, whilst attempting to reconcile the demands of purchasers with the views of disparate and difficult professional colleagues. The argument concludes that there is an urgent need to recognize the demands being placed upon doctors who take on this role, and identifies the benefits and challenges that the role creates in leading health care. The final section identifies the issues that need to be considered to sustain this role in future and the recognition that it has substantially increased the power base of the medical profession, but often at a high price for the individuals involved.
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The authors examined employee development and its relationship with Conscientiousness and person-environment fit (in terms of needs and supplies of autonomy). They hypothesized that Conscientiousness would be positively associated with development but only when employees felt that the autonomy supplied by the organization did not fit their needs. In other words, whereas Conscientiousness could supply the dispositional resources for development, misfit was needed to create the need for development. The results supported the authors' predictions. Conscientiousness was positively related to development but only when employees were misfits with respect to autonomy. Employee involvement in development activities was then linked to subsequent fit.
The perception of contemporary nursing as being subordinate and subservient to medicine can be compared to the role of chloroform, which in its day served the purpose intended. However, like nursing, today's anesthetic agents require greater expertise to maximize their effectiveness. As nursing enters a new era in its struggle for autonomy, androgynous approaches promise increased independent thinking, action and self-esteem. Nurses possessing these qualities can address effectively, many of the challenges today's nursing practice poses.
BACKGROUND: Nursing autonomy has been associated with better patient-outcomes; therefore, it is a priority for critical care nursing management. Low authority has been a persistent complaint of Hellenic intensive care unit nurses; however, issues of nursing autonomy have not been previously addressed empirically in Hellas. PURPOSE: To investigate: (1) the perceived contribution to clinical decision-making, (2) the degree of autonomy in technical tasks, and (3) factors related to practice autonomy in critical care nurses in Hellas. Additionally, because of the lack of sufficient tools, this study also aimed to construct and to validate a new tool for assessing practice and clinical decision-making autonomy among Hellenic intensive care unit nurses. MATERIALS AND METHODS: A Hellenic intensive care nursing autonomy scale, focused on technical aspects of care, was developed through literature review, a panel of experts and a pilot study in a random sample of 120 respondents. Items were refined by factor analysis, which revealed three major conceptual categories of autonomy: (1) basic technical, (2) advanced technical, and (3) clinical decision. Hellenic intensive care nursing autonomy (Likert 4, range: 38-152), was distributed to all nurses employed in intensive care units in Hellas (n = 807; attrition: 27%). Comparisons, correlation and multivariate regression were employed. RESULTS: The Hellenic intensive care nursing autonomy scale exhibited appropriate reliability (Cronbach's alpha = 0.86) and validity properties. Autonomy scores were moderate (mean: 105.24 +/- 9.58). Highest autonomy was attributed to basic technical tasks, followed by advanced technical tasks and decision-making. Male gender and higher education were predictors of higher overall, advanced technical and decision-making autonomy (P = 0.01). Bachelor degree graduates scored higher in decisional autonomy (P = 0.03). Intensive care unit experience and type of intensive care unit were also important determinants of decisional autonomy (P = 0.02). CONCLUSIONS: The results revealed moderate autonomy in technical tasks and low decisional autonomy among Hellenic intensive care unit nurses. Factors related to the educational preparation of nurses, gender issues and institutional characteristics might hinder intensive care unit nurses' autonomy in Hellas.
The 1992 membership survey, authorized by the Executive Board of NAPNAP as part of an ongoing plan to survey members every 4 years, had three foci: (a) demographic characteristics of NAPNAP members, (b) practice characteristics of NAPNAP members, and (c) opinions of NAPNAP members related to health care issues. Information gathered from this membership survey will be used to assist in planning NAPNAP programs and direction, to advocate for pediatric nurse practitioners and for NAPNAP, and to inform health professionals, policy makers, and the general public about characteristics of a pediatric nurse practitioner and the work pediatric nurse practitioners do. NAPNAP members received the survey during the summer 1992, and 65% of the random sample of 800 were returned, a clear indication of strong interest on the part of NAPNAP members to be heard. This article, the second of two describing survey results, presents data describing characteristics of members' practice and the clients they serve.
This article points out the foundation elements of the nursing education, the way covered till now, the status of the art and what has to be achieved in order to attain Nursing Degree objectives. The different aspects concerning the curricula organization and the model of care are examined. The request of getting nursing teaching and nursing chairs for nurses are an aim not yet met, but they are the basis objectives of the professional engagement. Another important subject concerns the leadership that will allow nurses to be administrators and managers in every respect, also from a juridical point of view, and to express their professionality in a really autonomous way.
AIM OF THE STUDY: The first aim of this study was to examine differences in work characteristics (autonomy, social support and workload) and work reactions (emotional exhaustion and job involvement) between general and mental health nurses. The second aim was to validate whether a specific pattern of relationships between work characteristics and reactions was the same for mental health and general nurses. BACKGROUND: Nurses are generally being considered as an above risk group regarding work stress. However, health care is a diverse sector and literature suggests important differences regarding the work of different categories of nursing, such as general and mental health nurses. In addition, little empirical evidence exists about these differences. In order to improve their work situation, more insight is needed regarding differences and similarities in the work of general and mental health nurses. The demand-control-support (DCS) model was used as a research framework. We hypothesized that autonomy, job involvement, and emotional exhaustion are higher in mental health nursing, whereas social support is expected to be lower. Next, in line with the propositions of this model and several recent studies, we hypothesized that emotional exhaustion is primarily predicted by workload and social support, whereas job involvement is primarily predicted by autonomy. In addition, we investigated whether this pattern of relationships was similar in both groups. DESIGN/METHODS: Questionnaires were distributed to nurses working in a general and a psychiatric hospital in the Netherlands. We used MANOVA and MSA (by means of LISREL) to analyse the data. RESULTS AND CONCLUSIONS: Regarding the differences in work characteristics and work reactions between mental health and general nurses, our hypotheses were confirmed, except for social support and job involvement. Autonomy and emotional exhaustion were higher among mental health nurses, whereas their job involvement proved to be significantly lower. Emotional exhaustion was primarily predicted by workload and lack of social support. Contrary to our expectations, the relationship between autonomy and job involvement was not significant in both samples. Finally, we found that the proposed pattern of relationships appeared to be invariant across the two samples.
Smoking cessation counseling by practitioners occurs at low rates in spite of strong evidence that counseling increases quit rates and reduces patient mortality. In a preliminary study, 1060 New York State physicians completed a survey concerning use of the Agency for Health Care Policy and Research (AHCPR) Guidelines, perceived autonomy and perceived competence for counseling, perceived autonomy support from insurers, and barriers to counseling. Considered together, perceived autonomy, perceived competence and perceived autonomy support predicted time devoted to counseling and use of the AHCPR guidelines. The primary, longitudinal study of 220 health care practitioners who attended a smoking cessation workshop predicted change in the practitioners' perceived autonomy and perceived competence for counseling as a function of the degree to which they experienced the workshop instructor as autonomy-supportive. In turn, change in perceived autonomy predicted change in time spent counseling and change in use of the AHCPR guidelines.
As managed care changes medical practice organization, Individual or Independent Practice Associations (IPAs) have theoretically superior attributes as compared with the more centralized large integrated multispecialty group on the one hand, and the less centralized "direct gatekeeper" model on the other. IPAs preserve the small, entrepreneurial, efficient, personal practice model of care delivery, while grafting on necessary business, informational, and care rationalizing functions at the collective level. The IPA also offers practitioners political leverage against the centralizing forces, particularly if the IPA establishes multiple HMO and PPO relationships. Physician autonomy will be best served if practices are allowed multiple IPA memberships. Competition in this model will be multicentric.
Foundation trusts offer the potential for substantial local autonomy. Their governance arrangements raise concerns. Lay non-executives in primary care trusts will face difficulties holding hospitals to account.