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PubMed2000

An exemplar of a positive perspective of being dependent on care.

This article is part of an ongoing study which aims at disclosing the meaning of being dependent on care. From a larger data set derived from 10 patients, interviews with one severely ill patient, her daughter and two of her professional nurses were selected to illuminate a "positive" meaning of being dependent on care. The interviews were tape-recorded and transcribed verbatim and followed by interpretation of transcripts using a phenomenological-hermeneutic approach inspired by Paul Ricoeur's philosophy. The interpretation discloses the meaning of being dependent on care as balancing between being free and negotiating when receiving care. Whether or not dependency on care is negotiated about seems to be about how the power that lies in the existing differences in ability is used. When ability, that is, power, is used to compensate inability, the patient appears free to be dependent on care. Dependency on care is accepted for what it is, when it is. When dependency on care is negotiated about, the differences in ability, that is, power, risk setting limits for what dependency on care is to be. There is a risk that dependency on care will be limited within the frame of what is regarded as polite, appealing and pleasing.

Activities of Daily Living↗
PubMed2001

Performance indicators in water and sanitation for developing areas.

There is a move throughout the developed world to introduce benchmarking techniques to the management of water and sanitation systems. The indicators that are being considered for benchmarking purposes tend to cover a broad band of activities that are part of the scope of management of large organisations. Most of the lists that have been prepared do not really cater for the implementation and operation of small rural schemes. The greatest need is the implementation of sustainable schemes for this category of consumer. The implementation of a rural water and sanitation scheme involves the negotiation in the initial stages with the local community representatives of what the community wants and how it will be provided and operated. This may have to be preceded by a period of empowerment so that the negotiations can be conducted by informed people. At the conclusion of the negotiations a business plan can be prepared that should be implemented in association with the community. The project is at this stage mainly in the control of a professional engineer, responsible for the technical interpretation of the business plan and the management of the construction phase. Finally, after commissioning, a water service provider will be responsible for the operation, management and maintenance of the scheme on a sustainable basis. The key actions and activities are identified and performance criteria defined. As communication at the beginning of the project is a critical component, the success of this is confirmed by examination and discussion as to how much has in fact been communicated and understood correctly. Other performance indicators for the operational phase are derived from the conventional ones used in the developed world. Finally, it is important that the participants, do not see the measurement of performance as a threatening situation, but rather a stepping stone to improvement of not only performance, but also of subsequent reward.

Benchmarking↗
PubMedDate not supplied

Beating the odds: reducing the risk of not being paid by HMOs and IPAs.

Physicians are having increasing problems getting paid by HMOs, independent practice associations and other payers. This article discusses what practices should investigate about payers, and guidelines for negotiating protections in contracts with payers. Even if certain clauses cannot be negotiated, it is important that providers be aware of potential traps in the contract. By using these guidelines, physicians will be able to negotiate better contracts or decide that no contract is better than a bad contract.

Guidelines as Topic↗
PubMedDate not supplied

[Analysis of the negotiation/accommodation concepts of M. Leininger's theory].

This work aims at clarifying the method of implementation of the negotiation/accommodation care preconized by Madeleine Leininger's theory concerning the Universality and Diversity of Care. The conceptual analysis technique is used as a tool to analyze the literature. It was verified that the concept of accommodation defines the idea of adaptation, of something passive, whilst in negotiation, each party commands resources and needs to be fulfilled. Among the different works which were analyzed and used Leininger's theory, only one showed to approach negotiation. As a conclusion, accommodation is considered to be different from negotiation, the former being more commonly seen in practice than the latter.

Negotiating↗
PubMed2004

Growing controversy over "wise international water governance".

This article takes the perspective that when political relationships are strained, there seem to be few examples of wise international water resources governance. The Middle East is a striking example. Much effort has been put into policy development and the design of international principles, but very little into the translation of those into concrete and lasting governance. One of the theses of the article is that politics--whether domestic or international--in most cases overrides these principles and standards. Moreover readymade regional co-operation models of water managements are not directly applicable to every geographical, political, economic and social setting. Certain factors are often under-estimated in international water negotiations, such as: the complexity of any hydro-political negotiations, and need to develop commonly accepted standards; the difficulty of translating policy--either politically or legally--into an operational and realistic negotiations strategy; the format of the procedures and meetings; recognition that third parties should have a long-term perspective on any conflict they get involved in. With reservations, the lessons learned indicate that the following factors have an impact on grid locked situations, such as: new substantive information; new trade-offs between the parties; and changed political climate or relationship with external power-brokers.

Conflict, Psychological↗
PubMed2006

Family impact and influence following severe traumatic brain injury.

Negotiating is the core variable or central concern of families who have a close relative in a state of post-comatose unawareness or minimal responsiveness following a severe traumatic brain injury. Family members negotiate with each other, with members of the health care team, and with others such as insurance agents, case managers, and representatives of the justice system on behalf of the injured individual. Family members also negotiate the intricacies of the health care system. These are the findings of a 16-month grounded theory study conducted on two acute neurosurgical units in Toronto, with 25 family members from 11 families who had a close family member who suffered a severe traumatic brain injury and who was in a state of post-comatose unawareness or minimal responsiveness. An extensive review of the scholarly literature related to family research methodology and family research related to families following the brain injury of a family member is also provided in this paper.

Adaptation, Psychological↗
PubMedDate not supplied

Arming your practice with the payer's data.

Negotiation of the most favorable managed rates may be the best opportunity you have to meet the revenue goals of the practice. When participating in a negotiation you should arm yourself with all the knowledge and tools available. This article discusses some of the public filings made annually by payers and how to use the data, the payer's own data, to enhance your negotiating position.

Managed Care Programs↗
PubMed2001

An analysis of physician antitrust exemption legislation: adjusting the balance of power.

Current antitrust law restricts physicians from joining together to collectively negotiate. However, such activities may be approved by state laws under the so-called state action immunity doctrine and by federal legislation under an explicit antitrust exemption. In 1999, Texas became the first state to pass physician antitrust exemption legislation allowing physicians, under certain defined circumstances, to collectively negotiate fees with health plans. Last year, similar legislation was introduced in the US Congress, in 18 state legislatures, and in the District of Columbia. This legislation was passed only in the District of Columbia where its implementation was blocked by the city's financial control board. Nonetheless, legislation permitting physicians to collectively negotiate fees with managed care plans has been introduced in 10 state legislatures this year, and there is continued interest in introducing similar legislation in the US Congress. This analysis examines the basic features of this legislation and its potential impact on the balance of power between physicians and managed care plans.

Antitrust Laws↗
PubMed2003

Effect of communications training on medical student performance.

CONTEXT: Although physicians' communication skills have been found to be related to clinical outcomes and patient satisfaction, teaching of communication skills has not been fully integrated into many medical school curricula or adequately evaluated with large-scale controlled trials. OBJECTIVE: To determine whether communications training for medical students improves specific competencies known to affect outcomes of care. DESIGN AND SETTING: A communications curriculum instituted in 2000-2001 at 3 US medical schools was evaluated with objective structured clinical examinations (OSCEs). The same OSCEs were administered to a comparison cohort of students in the year before the intervention. PARTICIPANTS: One hundred thirty-eight randomly selected medical students (38% of eligible students) in the comparison cohort, tested at the beginning and end of their third year (1999-2000), and 155 students in the intervention cohort (42% of eligible students), tested at the beginning and end of their third year (2000-2001). INTERVENTION: Comprehensive communications curricula were developed at each school using an established educational model for teaching and practicing core communication skills and engaging students in self-reflection on their performance. Communications teaching was integrated with clinical material during the third year, required clerkships, and was supported by formal faculty development. MAIN OUTCOME MEASURES: Standardized patients assessed student performance in OSCEs on 21 skills related to 5 key patient care tasks: relationship development and maintenance, patient assessment, education and counseling, negotiation and shared decision making, and organization and time management. Scores were calculated as percentage of maximum possible performance. RESULTS: Adjusting for baseline differences, students exposed to the intervention significantly outperformed those in the comparison cohort on the overall OSCE (65.4% vs 60.4%; 5.1% difference; 95% confidence interval [CI], 3.9%-6.3%; P<.001), relationship development and maintenance (5.3% difference; 95% CI, 3.8%-6.7%; P<.001), organization and time management (1.8% difference; 95% CI, 1.0%-2.7%; P<.001), and subsets of cases addressing patient assessment (6.7% difference; 95% CI, 5.9%-7.8%; P<.001) and negotiation and shared decision making (5.7% difference; 95% CI, 4.5%-6.9%; P<.001). Similar effects were found at each of the 3 schools, though they differed in magnitude. CONCLUSIONS: Communications curricula using an established educational model significantly improved third-year students' overall communications competence as well as their skills in relationship building, organization and time management, patient assessment, and negotiation and shared decision making-tasks that are important to positive patient outcomes. Improvements were observed at each of the 3 schools despite adaptation of the intervention to the local curriculum and culture.

Clinical Competence↗
PubMed2000

Framing the Game: Examining Frame Choice in Bargaining.

This article introduces the study of frame choice in negotiation. Here, the selection of a procedural frame is treated as a dependent variable-a choice that bargainers make in addition to determining their offers. The empirical focus of the article is on whether, when given a choice between two alternative versions of the ultimatum bargaining game, negotiators choose the description that maximizes their expected payoffs. For example, in one frame-choice task, negotiators assigned to the Player 1 role were asked to select between framing the game as "Player 1 proposes a division and Player 2 accepts or rejects it" or "Player 1 makes a claim from a common pool and Player 2 makes a counterclaim." Past research has shown that the second frame leads to higher expected payoffs for Player 1 than does the first. Across four studies and three established framing effects, it is found that participants consistently fail to select the procedural frames that optimize monetary outcomes. Subsequent analyses suggest that this tendency is due to two factors: (a) nonmonetary motivations, such as fairness and respect, that influence frame-choice preferences and (b) cognitive limitations that inhibit the ability to accurately predict the effect of alternative procedural frames on opponents' responses Copyright 2000 Academic Press.

Journal Article↗
PubMed2002

Conflict and post-conflict behavior in a small group of chimpanzees.

Chimpanzee research plays a central role in the discussions of conflict negotiation. Reconciliation, or the attraction and affiliation of former opponents following conflict, has been proposed as a central element of conflict negotiation in chimpanzees and various other taxa. In an attempt to expand the database of chimpanzee conflict resolution, conflict and post-conflict behavior were recorded for a small group of socially housed chimpanzees at the Chimpanzee and Human Communication Institute, at Central Washington University. Data were collected over six 6-week periods between 1997 and 2000, for a total of 840 hours of observation, resulting in a substantial post-conflict (PC) and matched control (MC) data set. The data demonstrate this group's tendencies to maintain visual contact and closer proximity after conflicts. Dyadic corrected conciliatory tendencies ranged between 0 - 37.5% and averaged 17.25% across all dyads. Individual corrected conciliatory tendencies ranged between 5.8 and 32%. The results of this study combined with recent publications on captive and free-ranging chimpanzee post-conflict behavior suggest that variation in post-conflict behavior may be important to our understanding of chimpanzee conflict negotiation, and may also have implications for the design and management of captive chimpanzee enclosures and social groups, respectively.

Aggression↗
PubMed2006

The art and science of integrating Undoing Racism with CBPR: challenges of pursuing NIH funding to investigate cancer care and racial equity.

In this nation, the unequal burden of disease among People of Color has been well documented. One starting point to eliminating health disparities is recognizing the existence of inequities in health care delivery and identifying the complexities of how institutional racism may operate within the health care system. In this paper, we explore the integration of community-based participatory research (CBPR) principles with an Undoing Racism process to conceptualize, design, apply for, and secure National Institutes of Health (NIH) funding to investigate the complexities of racial equity in the system of breast cancer care. Additionally, we describe the sequence of activities and "necessary conflicts" managed by our Health Disparities Collaborative to design and submit an application for NIH funding. This process of integrating CBPR principles with anti-racist community organizing presented unique challenges that were negotiated only by creating a strong foundation of trusting relationships that viewed conflict as being necessary. The process of developing a successful NIH grant proposal illustrated a variety of important lessons associated with the concepts of cultural humility and cultural safety. For successfully conducting CBPR, major challenges have included: assembling and mobilizing a partnership; the difficulty of establishing a shared vision and purpose for the group; the problem of maintaining trust; and the willingness to address differences in institutional cultures. Expectation, acceptance and negotiation of conflict were essential in the process of developing, preparing and submitting our NIH application. Central to negotiating these and other challenges has been the utilization of a CBPR approach.

Breast Neoplasms↗
PubMed2005

Mechanical load on the upper extremity during wheelchair activities.

OBJECTIVE: To determine the net moments on the glenohumeral joint and elbow joint during wheelchair activities. DESIGN: Kinematics and external forces were measured during wheelchair activities of daily living (level propulsion, riding on a slope, weight-relief lifting, reaching, negotiating a curb) and processed in an inverse dynamics biomechanic model. SETTING: Biomechanics laboratory. PARTICIPANTS: Five able-bodied subjects, 8 subjects with paraplegia, and 4 subjects with tetraplegia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Net moments on the glenohumeral joint and elbow joint. RESULTS: Peak shoulder and elbow moments were significantly higher for negotiating a curb and weight-relief lifting than for reaching, level propulsion, and riding on a slope. Overall, the elbow extension moments were significantly lower for subjects with tetraplegia than for those with paraplegia. CONCLUSIONS: The net moments during weight-relief lifting and negotiating a curb were high when compared with wheelchair propulsion tasks. Taking the effect of frequency and duration into account, these loads might imply a considerable risk for joint damage in the long term.

Acceleration↗
PubMed2005

Gait termination: a review of experimental methods and the effects of ageing and gait pathologies.

The study of human gait has expanded and diversified to the extent that it is now possible to identify a substantive literature concerning a variety of gait tasks, such as gait initiation [Halliday SE, Winter DA, Frank JS, Patla AE, Prince F. The initiation of gait in young, elderly, and Parkinson's disease subjects. Gait Posture 1998;8:8-14; Mickelborough J, van der Linden ML, Tallis RC, Ennos AR. Muscle activity during gait initiation in normal elderly people. Gait Posture 2004;19:50-57], stepping over and across obstacles [Patla AE, Prentice SD, Robinson C, Newfold J. Visual control of locomotion: strategies for changing direction and for going over obstacles. J Exp Psych 1991;17:603-34; Chen, HC, Ashton-Miller JA, Alexander NB, Schultz AB. Effect of age and available response time on ability to step over an obstacle. J Gerontol 1994;49:227-33; Sparrow WA, Shinkfield AJ, Chow S, Begg RK. Gait characteristics in stepping over obstacles. Hum Mov Sci 1996;15:605-22; Begg RK, Sparrow WA, Lythgo ND. Time-domain analysis of foot-ground reaction forces in negotiating obstacles. Gait Posture 1998;7:99-109; Patla AE, Rietdyk S. Visual control of limb trajectory over obstacles during locomotion: effect of obstacle height and width. Gait Posture 1993;1:45-60] negotiating raised surfaces such as curbs and stairs [Begg RK, Sparrow WA. Gait characteristics of young and older individuals negotiating a raised surface: implications for the prevention of falls. J Gerontol Med Sci 2000;55A:147-54; Mcfayden BJ, Winter DA. An integrated biomechanical analysis of normal stair ascent and descent. J Biomech 1988;21:733-44]. In addition, increasing research interest in age-related declines in gait that might predispose individuals to falls has engendered a very extensive literature concerning ageing effects on gait. While rapid locomotor adjustments are common in the course of daily activities there has been no previous review of the findings concerning gait adaptations when walking is terminated both rapidly and unexpectedly. The aims of this review were first, to summarise the key research findings and methodological considerations from studies of termination. The second aim was to demonstrate the effects of ageing and gait pathologies on termination with respect to the regulation of step characteristics, lower-limb muscle activation patterns and foot-ground reaction forces.

Aging↗
PubMed2004

Foreign direct investment and trade in health services: a review of the literature.

Globalization is a key challenge facing health policy-makers. A significant aspect of this is direct trade in health services, a result of the rise of transnational corporations, challenges in health care financing, porous borders and improved technology creating the scope for increased 'foreign direct investment' (FDI) in health care. This has gathered momentum with the General Agreement on Trade in Services (GATS), which aims to further liberalize trade in services, and within which FDI has been noted as perhaps the most critical area for trade negotiation. Given the rapid development of this area, there are little empirical data. This paper therefore seeks to provide the first comprehensive and systematic review of evidence concerning FDI and health services. This process included electronic bibliographic database searches, website searches and correspondence with experts in the area of trade in health services, from which 76 papers, books and reports were reviewed. Perhaps due to the rapid developments in this area, most of the literature is speculative, polarized between those arguing for the benefits of liberalization and those arguing against. However, there seem to be three issues which emerge as of most importance: (i) the extent to which a national health system is commercialized per se is of more significance than whether investment in it is foreign or domestic; (ii) the national regulatory environment and its 'strength' will significantly determine the economic and health impact of FDI, the effectiveness of safeguard measures, and the stability of GATS commitments; and (iii) any negotiations will depend upon parties having a common understanding of what is being negotiated, and the interpretation of key definitions is thus critical. Each of these issues is explored in some depth, with the overall conclusion that countries should take a step back and first think through the risks and benefits of commercialization of their health sector, rather than being sidetracked in to considering the level of foreign investment.

Commerce↗
PubMed2006

Living without labels: the interactional management of diagnostic uncertainty in the genetic counselling clinic.

In the genetic counselling setting it is not uncommon for a client and genetic counsellor to be faced with uncertainty surrounding the exact diagnostic label to be assigned to the client's symptoms. The huge range of possible conditions/syndromes and the lack of definitive evidence available often combine to create diagnostic uncertainty or non-diagnosis (the assessment given where a genetic diagnosis of the client's symptoms cannot be confirmed at that point). This paper aims to explore the interactional management and negotiation of diagnostic uncertainty in the genetic counselling clinic in the UK. Through the application of discourse analytic tools (including reported speech, contrast and hedging) to transcripts of actual clinical interactions, the participants' use of evidence, and professional and client expertise, are examined and found to be key in the negotiation of diagnostic uncertainty. The complete data set for this research consists of transcripts of 18 clinical encounters between genetic counsellor and client. Two client cases are identified and analysed in detail in order to follow the pattern of interactional management of diagnostic uncertainty throughout the whole interaction. The findings suggest that, unlike other medical settings, clients within genetic counselling are able to actively participate in talk about diagnosis allowing, for the extent of non-diagnosis to be negotiated. This is particularly so during two moments in the interaction: the beginning of the clinic where the agenda is set, and towards the end of the clinic when a form of diagnostic assessment must be made. By providing an insight into the problematic interactional activity of giving a non-diagnosis this paper can contribute to discussions on genetic counselling practice. The analysis in this paper demonstrates how a genetic counsellor can manage the balance between accurate information-giving and empathy towards individual client needs for a diagnosis.

Communication↗
PubMed2000

Endogenous carriers and ligands in non-immunogenic site-specific drug delivery.

Targeted drug delivery has gained recognition in modern therapeutics and attempts are being made to explore the potentials and possibilities of cell biology related bioevents in the development of specific, programmed and target oriented systems. The components which have been recognized to be tools include receptors and ligands, where the receptors act as molecular targets or portals, and ligands, with receptor specificity and selectivity, are trafficked en route to the target site. Although ligands of exogenous or synthetic origin contribute to the selectivity component of carrier constructs, they may impose immunological manifestations of different magnitudes. The latter may entail a continual quest for bio-compatible, non-immunogenic and target orientated delivery. Endogenous serum, cellular and extracellular bio-ligands interact with the colloidal carrier constructs and influence their bio-fate. However, these endogenous bio-ligands can themselves serve as targeting modules either in their native form or engineered as carrier cargo. Bio-regulatory, nutrient and immune ligands are sensitive, specific and effective site directing handles which add to targeted drug delivery. The present review provides an exhaustive account of the identified bio-ligands, which are not only non-immunogenic in nature but also site-specific. The cell-related bioevents which are instrumental in negotiating the uptake of bio-ligands are discussed. Further, a brief account of ligand-receptor interactions and the set of biological events which ensures ligand-driven trafficking of the ligand-receptor complex to the cellular interior is also presented. Since ligand-receptor interaction is a critical pre-requisite for negotiating cellular uptake of endogenous ligands and anchored carrier cargo, an attempt has been made to identify differential expression of receptors and bio-ligands under normal and etiological conditions. Studies which judiciously utilized bio-ligands or their analogs in negotiating site-specific drug delivery have been reviewed and presented. Targeted delivery of bioactives using endogenous bio-ligands offers enormous options and opportunities through carrier construct engineering and could become a future reality in clinical practice.

Animals↗
PubMed2003

Food choices among newly married couples: convergence, conflict, individualism, and projects.

Individuals entering marriage merge their personal food systems to create a joint spousal food system. This investigation examined newly married couples' food choices. Qualitative interviews conducted with 20 couples as they entered marriage and again 1 year later revealed that some reported initial food homogamy, while others had varying degrees of compatibility in food preferences and tolerances. All couples reported some dietary convergence. Convergence was initially symmetrical (similar merging for both partners) or asymmetrical (one partner changed more), and sometimes convergence patterns evolved further. Unresolved food choice negotiations led to food conflicts. Prior food broadening experiences, initial dietary congruity, health/weight philosophies, foodwork, and commensal patterns were conditions shaping couples' food choice negotiations and dietary convergence patterns. Some food individualism persisted for most partners, helping to alleviate food choice conflicts. Food projects occurred when one partner was committed to molding the other's food choices. Overall, food choice negotiations involving both convergence and conflict were important components of marital adjustments that may have later health consequences.

Adult↗