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PubMed2001

Factors influencing job valuation: a comparative study of critical care and non-critical care nurses.

This study sought to identify the relationship between three predictor variables, perceived collaboration with medical staff, autonomy and independent actions and an outcome, the value hospital nurses placed on their work. In total 189 critical care and 366 non-critical care nurses completed a mailed survey. Critical care nurses perceived themselves to have a more collaborative relationship with the medical staff, described performing actions independent of medical orders more frequently and perceived their jobs to have more value than non-critical care nurses. However the latter group perceived themselves to have more autonomy in their work. Within both groups collaboration and autonomy were significantly, but weak to moderately correlated with job valuation. Simply expanding the work hospital nurses do is unlikely to result in nurses valuing their jobs more, however promoting an environment of respect and sharing between the medical and nursing staff and supporting nurses when they act in an autonomous fashion may positively influence nurses' perceptions of their work.

Adult↗

PubMed2000

Training and education: an analysis of quality assurance in teaching and nursing education.

There is a continuing tension between training and education in vocational higher education courses. The debate in nursing has been heightened by the transfer of courses into higher education and staffing problems in the NHS. Comparisons with other occupations can help prevent introspection in analysis of policy issues in nursing. Teacher training is a particularly useful comparator because it entered higher education before nursing, and teachers have failed to maintain a level of autonomy that nurses would once have envied. This paper compares nursing and teacher training with particular reference to quality assurance. The UK government has adopted a centralized quality assurance and funding system for teacher training. Nursing is included in higher education quality assurance systems but funding is devolved. The tensions between training and education within nursing and teacher training are examined, and implications for the development of nursing considered.

Curriculum↗

PubMedDate not supplied

Physicians' responses to their changing environment.

The loss of physician autonomy, the changing shape of physicians' practices, and efforts to control the cost of health care have left American physicians increasingly dissatisfied with the U.S. health care system. A survey of 300 office and hospital-based physicians shows 59 percent favor reform of the U.S. system; only 31 percent favor retaining the current system. Doctors face increased competition for patients (the supply of physicians has increased three times faster than the population), reduced autonomy because of intervention by government and other third party payers, pressure from patients to provide unnecessary care including expensive new technology, and increased cost containment. Yet a majority of physicians believe the causes of rising health care costs are patient demand for services and the current medical malpractice system. A minority (23 percent) blame hospitals and physicians for rising costs.

Attitude of Health Personnel↗

PubMedDate not supplied

Physician autonomy in the managed care era: the physician-citizen or subject?

Until recently, medicine was one of the few areas in which an individual could practice a profession as a citizen member of the organization. However, in the recent overhauling of medical organizations in search of cost efficiency, physicians have moved from self-governing organizations with the rights of citizen participation to autocratic, centrally controlled organizations with little for physicians to do but provide high-quality manual labor. The principles of prosperity and choice espoused in The Federalist Papers are governance principles that can re-establish citizenship in medical groups.

Managed Care Programs↗

PubMedDate not supplied

Organizational factors influencing nurse practitioners' role implementation in acute care settings.

The purpose of this study was to explore the influence of organizational factors on the Acute Care Nurse Practitioner (ACNP) role implementation. A descriptive correlational design, incorporating quantitative and qualitative methods for data collection was used. The sample of convenience consisted of 57 ACNPs assigned to various medical and surgical programs within acute care hospitals. Ten ACNPs participated in the unstructured qualitative interviews. In addition to the interviews, data pertinent to various organizational factors, including role formalization, receptivity of the role by others, perceived autonomy, role strain, and additional factors that may interfere with role implementation, were collected through a self-report structured questionnaire. A four-diary day was completed to gather data on role implementation. Descriptive and correlational statistics were used to analyze the quantitative data. The qualitative data were content analyzed. The ACNPs engaged most frequently in activities reflective of the clinical practice component of the role and less frequently in the non-clinical components (i.e., education, administration, and research). Results of the quantitative and qualitative analyses indicated that lack of formal clear job description, conflicting demands and expectations, lack of receptivity of the role by others, lack of autonomy, and increased workload were negatively correlated with the ACNP role implementation. The ACNP role implementation varies across practice settings. This variability should be accounted for when examining outcomes of ACNP care.

Acute Disease↗

PubMed2001

Health care workforce for the twenty-first century: the impact of nonphysician clinicians.

For many years, nonphysician clinicians (NPCs) have participated in the care of patients. However, their numbers were small and their licensed prerogatives were narrow. Over the past decade, these characteristics have changed in three important ways. First, training in many of the NPC disciplines has increased substantially, and the growth of these disciplines is accelerating. Second, state laws and regulations have expanded both the practice prerogatives of NPCs and their autonomy from physician supervision. Third, payers have increased their access to reimbursement. As a consequence, NPCs are undertaking many elements of care that previously were provided by physicians. Their participation is generally cost-effective and is met with a high degree of patient satisfaction. This presents both opportunities and challenges to physicians as they forge new relationships with NPCs and as their own spectrum of responsibilities evolves.

Chiropractic↗

PubMed1992

Unconventional cancer treatments: professional, legal, and ethical issues.

A significant number of patients with cancer use or seriously consider using unconventional treatments. When patients or their families seek or use unproven treatment methods, the oncology nurse may face complex professional, legal, and ethical issues. This article addresses the possible reasons why patients and families may choose unconventional treatments. Oncology nurses are challenged to become aware of their many and varied nursing responsibilities. These responsibilities are examined in light of applicable codes and nursing practice standards, the clinical situation, and the values that are unique to each patient and family. Guidelines are offered for the oncology nurse to assist patients and families in choosing among treatment options.

Beneficence↗

PubMedDate not supplied

Research supporting the congruence between rehabilitation principles and home health nursing practice.

A grounded-theory study of 30 home health nurses conducted in the Washington, DC, metropolitan area used unstructured audiotaped interviews to elicit data as to how home health nurses define their practice. The purpose of the study was to develop a beginning substantive research-based theory of home health nursing practice. The model that emerged consists of three stages by which nurses attain autonomy in their practice. Adaptation was found to be the core category, in that nurses cannot function effectively or successfully in the home health arena unless they are or learn to be adaptable. Data also revealed that home health nurses either knowingly or unknowingly use rehabilitation nursing principles in their practice, thereby lending credence to the supposition that home health nursing practice is congruent with rehabilitation nursing principles.

Adult↗

PubMed1995

Fighting fire with fire: physicians blazing new paths to autonomy.

Thousands of physicians around the country have stopped complaining about being burned by the system and have started reengineering their destinies. They're building super IPAs, forming and operating HMOs, and joining unions to represent their rights in a growing grassroots physician effort to regain control. These physicians have thumbed their noses at managed care companies they say have drastically cut reimbursements, arbitrarily dropped them from panels, dictated utilization, and cost them patients. They're tired of working harder and earning less and frustrated by sacrificing quality in the name of cost reduction. And they have learned that there are ways to prevail.

Health Maintenance Organizations↗

PubMed2003

The American College of Obstetricians and Gynecologists and the evolution of abortion policy, 1951-1973: the politics of science.

The autonomy granted to physicians is based on the claim that their decisions are grounded in scientific principles. But a case study of the evolution of the American College of Obstetricians and Gynecologists' abortion policy between 1951 and 1973 shows that decisions were only secondarily determined by science. The principal determinant was the need to preserve physician autonomy over the organization and delivery of services. As a result, the organization representing physicians who specialized in women's reproductive health was marginal to the struggle for legalized abortion. But, the profession was central to decisions about whether physicians would perform abortions and how they would be done. This case study finding has implications for understanding the role that organized medicine might take in the ongoing debates about national health policy.

Abortion, Legal↗

PubMedDate not supplied

Nurse practitioners and physician assistants as primary care providers in institutional settings.

This paper describes the scope of primary care practice and autonomy of nurse practitioners (NPs) and physician assistants (PAs) at nine health maintenance organizations (HMOs) and multispecialty clinics (MSCs). We found that the larger an institution's managed care population, the greater the NPs' and PAs' scope of practice and autonomy, although patients with complex illnesses or multisystem problems usually were referred directly to a physician. Alternative policies to increase the number of primary care physicians might slow the growth in hiring new NPs and PAs, but are unlikely to reduce their primary care role in managed care settings. Further research is needed to consider whether these results are applicable to a broader range of practice settings.

Costs and Cost Analysis↗

PubMed2004

Ulysses directives in The Netherlands: opinions of psychiatrists and clients.

In this article we present a study on the opinions of Dutch psychiatrists and clients on Ulysses directives. In-depth interviews were conducted with 18 clients and 17 psychiatrists. Most respondents were proponents of Ulysses directives. The most frequently mentioned objective of these directives was to secure timely admission to hospital, although a large minority was mainly interested in giving patients influence on treatment decisions. Psychiatrists differed on how much autonomy they preferred with regard to decisions about the moment of admission and kind of treatment. Clients also differed in this respect. Pressure from others to execute a Ulysses directive, and premature admission to the hospital were mentioned as risks of Ulysses directives. Crisis cards were seen as an alternative by many psychiatrists and some clients. Recommendations are made for a good functioning of Ulysses directives, and the appropriateness of crisis cards as an alternative for a number of patients is discussed.

Adult↗

PubMed2004

A dimensional analysis of role enactment of acute care nurses.

PURPOSE: To identify dimensions of the role enactment process of acute care nurses. DESIGN: Dimensional analysis, rooted in grounded theory methodology, was used to analyze the role enactment process. METHODS: Twenty-eight articles related to acute care staff nurse roles were selected for analysis. Articles were from eight countries and were published between 1995 and 2002. Significant phrases or themes from each document were categorized to identify themes. FINDINGS: Initial analysis of the articles indicated 37 separate dimensions in the role enactment process of acute care nurses. The final, integrative analysis reduced the initial 37 to 7 core dimensions: care delivery, autonomy, culture management, information management, leadership, psychologic management, and relationship management. The analysis showed a role that is rooted in management processes. CONCLUSIONS: The multidimensional nature of the role of acute care nurses was indicated in the dimensional analysis. The findings have implications for the administration and education of nurses, as well as for human resource development of nurses in many parts of the world.

Acute Disease↗

PubMed1995

Ethical issues in discharge planning for vulnerable infants and children.

Discharge planning for vulnerable infants and children is a collaborative, interdisciplinary, decision-making activity that is grounded in the ethical complexities of clinical practice. Although it is a psychosocial intervention that frequently causes moral distress for professionals and has the potential to inflict harm on children and their families, the process has received little attention from ethicists. An ongoing study of the transition of technology-dependent children from hospital to home suggests that the ethical issues embedded in the discharge-planning process may be concealed by dominant cultural values, institutional policies, clinical standards, historical precedents, and legal regulations.

Adolescent↗

PubMed2001

Values identified in different groups of Air Force nurses.

Fundamental personal values are reflected in the choices and decisions made in every aspect of our lives. This descriptive study identified values held by a convenience sample of 224 Air Force nurses stationed at four U.S. Air Force medical facilities. Study participants identified seven of eight literature-supported values in the categories "important" or "very important" across the demographic factors of age, gender, educational level, military rank, marital status, and years of Air Force or civilian nursing experience. These seven values were ability utilization, achievement, altruism, autonomy, economic reward, economic security, and personal development. Personnel using this information may ease the transition process to military nursing, facilitate job placement to positions reflecting personally held values, and provide valuable insight for Air Force nurse recruiters who have limited knowledge of the nursing profession. In all, this would promote job satisfaction and Air Force nurse retention.

Aerospace Medicine↗

PubMed2002

An empirical test of the Nursing Role Effectiveness Model.

AIMS OF THE STUDY: This study investigated the propositions depicted in the Nursing Role Effectiveness Model, in which nurse and patient structural variables were expected to influence nurses' role performance, which, in turn was expected to affect patient outcome achievement. RATIONALE/BACKGROUND: Increasingly, nurses are expected to demonstrate their contribution to patient outcome achievement as a basis for evaluating practice and for monitoring improvements in practice. A model was developed that describes nursing practice in relationship to the roles nurses assume in health care, and links patient and system outcomes to nurses' role functions (Nursing Economics 1998: 16, 58-64, 87). RESEARCH METHODS: A cross-sectional design was used to collect data on the structure, process, and outcome variables. Data were collected through structured questionnaires and chart audit, involving a total of 372 patients and 254 nurses from 26 general medical-surgical units in a tertiary care hospital. Patient structural variables included medical diagnosis, age, gender and education. Nurse structural variables included educational preparation and length of hospital experience. The unit structural variables included the adequacy of time to provide care, autonomy, and role tension. The quality of nurses' independent role performance was assessed by collecting data from patients on their perception of the quality of nursing care. Nurses' interdependent role performance was assessed by collecting data from nurses on the quality of nurse communication and co-ordination of care. Patient outcomes were assessed through self-report and consisted of the patients' therapeutic self-care ability, functional status, and mood disturbance at the time of hospital discharge. Structural equation modelling was used to test the hypothesized relationships among the structural, process, and outcome variables. RESULTS: Patients viewed nurses' independent role performance more effective on units where nurses reported less autonomy but more time to provide care. The quality of nurse communication was higher on units where nurses had higher education, more autonomy, less hospital experience, and lower role tension. However, the co-ordination of care was more effective on units where nurses had higher education, greater hospital experience, less autonomy and role tension. The three role performance variables were associated with patients' therapeutic self-care ability at hospital discharge. Nurses' independent role performance was associated with better patient functional status and less mood disturbance at hospital discharge. The role performance variables fully mediated the effect of the structural variables on patient outcomes, lending support for the proposition that nurses' role performance explains the relationship between structural variables, such as nurse education and autonomy, and patient outcome achievement. DISCUSSION: The Nursing Role Effectiveness Model provides a well-defined conceptual framework to guide the evaluation of outcomes of nursing care. For the most part the hypothesized relationships among the variables were supported. However, further work is needed to develop an understanding of how nurses engage in their co-ordinating role functions and how we can measures these role activities.

Adult↗

PubMed1995

Towards a just, courageous, and honest resolution of the futility debate.

This essay discusses the history of the "futility debate" and the motives that sometimes prompt health care professionals, health care providers, patients, and surrogates to take different sides in it. Changes in the health care system, financial responsibility shifts, technical medical advances, and medical care rationing are analyzed as contributors to the futility debate. So too are variations in the definition of futility examined as part of the current controversy. The respective attitudes of professionals, providers, patients, and surrogates in accepting the goals, capabilities, and limits of medicine are also explored. In particular, the lack of honest communication between health care professionals/health care providers on the one hand and patients/surrogates on the other is acknowledged as a major roadblock in the building of care-focused futility policies. Finally, various initial attempts of hospitals to create futility guidelines are evaluated in order to detect problem areas and to suggest lines of improvement.

Aged↗

PubMed2004

Nurse prescribers' experiences of prescribing.

BACKGROUND: Nurse prescribing has advanced rapidly over the previous decade and is clearly on the agenda for the future. Previous research considers nurse prescribing from the patient's perspective, the medical professions' stance and the legal and ethical implications. However, there is a paucity of literature that explores the experiences of nurse prescribers' within their current role. These experiences need investigating to ensure nurse prescribing is able to advance in ways that provide benefit to nurses and thus provides the impetus for the study. AIM: To explore and review nurse prescribers' experiences of prescribing. DESIGN METHODS: A purposeful sample of seven nurse prescribers currently prescribing within a West Midlands Community Trust underwent minimally structured interviews in this qualitative study. Transcribed interviews were analyzed using thematic analysis. FINDINGS: Four themes were generated from analysis of the interviews, 'patient centred care', 'benefits of nurse prescribing', 'support and role satisfaction' and finally 'prescribing difficulties'. CONCLUSIONS: Nurse prescribers' perceive prescribing as a predominantly positive experience, frequently asserting the advantages that prescribing saves the patient and nurse time, is more convenient for the patient and increases the nurses' autonomy and role satisfaction. However, negative experiences of restrictions to practice as a result of nurse prescribers' formulary limitations and duplication of documentation were also described. RELEVANCE TO CLINICAL PRACTICE: Nurse prescribing is a rapidly evolving area of practice with the potential to advance nursing roles. This research aims to provide an insight into the experiences of current nurse prescribers that may then be disseminated and applied to future practice.

Attitude of Health Personnel↗