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PubMedDate not supplied

Primum non nocere and the quality of evidence: rethinking the ethics of screening.

BACKGROUND: Screening is different from investigation, and these differences have important implications in the assessment of screening programs. METHODS: I review the differences between screening and investigation and the implications of these differences derived from a consideration of the four ethical principles of beneficence, nonmaleficence, autonomy, and distributive justice. RESULTS: Because most of the harms of screening fall on the healthy and because screening is initiated by physicians, nonmaleficence takes ethical precedence over beneficence. Issues related to cost and consent are also approached differently in screening compared with investigation, and both take on greater ethical importance. I contend further that these ethical implications require that screening programs be backed up by better evidence than is the usual case for investigative medicine. I suggest an outline for the appropriate assessment of screening programs and for the ethical responsibilities of those involved in screening. CONCLUSIONS: Many current medical screening practices are not concordant with our ethical principles and should be reassessed.

Ethics, Medical↗
PubMed1992

Incorporating an understanding of independent practice physician culture into hospital structure and operations.

The culture values that have dominated the independent practice physician community in the United States include a set of "shared understandings" (individual autonomy, the fact that physicians relate best to other physicians, belief in science, and humanitarian ideals) that affect physician beliefs and values. Given that the current evolution of the health care system inevitably will draw physicians closer to corporate settings, corporate managers will benefit from gaining an explicit understanding of the origins and ramifications of these shared understandings. Managers can then establish organizational environments that effectively reduce the tensions between cultures of the physician and the organization. This article develops a framework of these "shared understandings" and proposes a range of managerial actions to reduce the tensions between the cultures.

Conflict, Psychological↗
PubMedDate not supplied

Job satisfaction among hospice workers: what managers need to know.

The purpose of this study was to investigate the perception of job satisfaction among hospice interdisciplinary team members, which included social workers, nurses, spiritual care providers, and home health aides. Interdisciplinary team members (n = 72) from 4 hospice organizations in the Midwest participated in the study. Results of this study show that job satisfaction as defined by hospice workers includes having task significance, supervisory support, integration, distributive justice, positive affectivity, autonomy, routinization, no role overload, and high levels of work motivation. These same workers also stated that (1) working with patients and families and carrying out the hospice philosophy (task significance), (2) being comfortable with their level of knowledge and skills (competence), and (3) having good relationships with team members (integration) play a significant role in their degree of satisfaction on the job. These results have implications for managers in hospice organizations. Specifically, managers in health care organizations like hospices need to be apprised of what factors result in job satisfaction among employees.

Administrative Personnel↗
PubMed2004

The partners in care approach to ethics outcomes in quality improvement programs for depression.

OBJECTIVE: Patient centeredness and equity are major quality goals, but little is known about how these goals are affected by efforts to improve the quality of care. The authors describe an approach to addressing these goals in a randomized trial of quality improvement for depressed primary care patients. METHODS: For four ethics goals (autonomy, distributive justice, beneficence, and avoiding harm), the authors identify intervention features, study measures, and hypotheses implemented in Partners in Care, a randomized trial of two quality improvement interventions, relative to usual care and summarize published findings pertinent to these outcomes. RESULTS: To implement an ethics framework, modifications were required in study design and in measures and analysis plans, particularly to address the autonomy and justice goals. Extra resources were needed for sample recruitment, for intervention and survey materials, and to fund an ethics coinvestigator. The interventions were associated with improvements in all four ethics areas. Patients who received the interventions were significantly more likely to receive the treatment they had indicated at baseline as their preferred treatment (autonomy goal). Intervention-associated benefits occurred more rapidly among sicker patients and extended to patients from ethnic minority groups, resulting in a reduction in ethnic-group disparities in health outcomes relative to usual care (distributive justice goal). The interventions were associated with improved quality of care and health outcomes (beneficence goal) and with reduced use of long-term minor tranquilizers (goal of avoiding harm). CONCLUSION: S: It is feasible to explicitly address ethics outcomes in quality improvement programs for depression, but substantial marginal resources may be required. Nevertheless, interventions so modified can increase a practice's ability to realize ethics goals.

Culture↗
PubMed2002

Ethics and computer-mediated communication: implications for practice and policy.

Computer-mediated communication, or email, has become a common workplace practice. Interviews with Army nurse managers (n = 9) and their staff nurses (n = 13) revealed that nurses incorporate the ethical principles of autonomy, beneficence, nonmaleficence, and justice into their computer-mediated communication use, but to varying degrees. Without clearly defined policies to guide computer-mediated communication practices, informal norms evolve that have an impact on both individual and corporate communication. The authors provide insight into the ethical considerations that have an impact on computer-mediated communication use. The spectrum of participant interpretation of appropriate use of this type of communication suggests the need for policies to establish clear boundaries for workplace usage. Policy recommendations are included.

Adult↗
PubMedDate not supplied

Can physicians lead other physicians into the future?

This article reflects upon some of the dynamics that prevent physicians from successfully engaging change. Physicians are enculturated to the competitive and hierarchical, and to value personal autonomy. These traits promote distrust and inhibit the formation of collaborative relationships. At this time of growing complexity, when most other industries are developing styles of work based on teamwork, worker empowerment, cross training, and information sharing, physicians cling to the metaphor of the ship's captain, a lone decision-marker and authoritarian possessor of grand knowledge. And yet, in order to lead, physicians need to learn to work differently and nurture a more collaborative approach. The author's blueprint for change includes: Stop trying to manage consensus; commit to measured accountability; think systemically; don't make the mistake of thinking that people will follow because you are right; and, most importantly, create relationships based on shared purpose and principles.

Decision Making, Organizational↗
PubMed2003

Back in the driver's seat: specialists regaining autonomy.

Between 1997 and 2001, the proportion of specialists reporting more freedom to make clinical decisions that meet their patients' needs increased significantly, much more so than among primary care physicians (PCPs), according to a new study by the Center for Studying Health System Change (HSC). Specialists now are also more likely to believe they can make clinical decisions in the best interest of their patients without reducing their income and can maintain continuing relationships with their patients to promote high-quality care. In contrast, PCPs' views on these issues have changed little. These findings about physicians' perceptions are likely a reflection of recent changes in managed care. Responding to a strong consumer and physician backlash, health plans gave consumers a broader choice of physicians and eased restrictions on care in the late 1990s

Communication↗
PubMedDate not supplied

Changes in pediatric residents' perceptions of their continuity experience during their training: a national study.

OBJECTIVE: To determine how pediatric residents' perceptions of continuity clinic experiences vary by level of training, after controlling for the effect of continuity setting. METHOD: Cross-sectional survey of pediatric and combined pediatric trainees in US residency programs. RESULTS: Survey responses were received from 1355 residents in 36 training programs. Residents' continuity experiences were in hospital-based and community settings. Numbers of patients seen increased between PGY-1 and PGY-3 years, but not in the PGY-4 and PGY-5 years. Compared to PGY-1 residents, PGY-2 and PGY-3 residents were more likely to report more encounters with established patients, but were not more likely to feel like the primary care provider. There were no significant differences by training level in terms of involvement in panel patients' laboratory results, hospitalizations, or telephone calls, although nursery involvement decreased with increasing training level. Autonomy was directly related to training level. The perception of having the appropriate amount of exposure to practice management issues was low for all respondents. CONCLUSIONS: Residents perceived that they had greater autonomy and continuity with patients as they become more senior, yet they were not more likely to feel like the primary care provider. Lack of increased involvement in key patient care and office responsibilities across training years may reflect a need for changes in resident education. These data may be helpful in formulating recommendations to program directors with regard to determining which Accreditation Council for Graduate Medical Education competencies should be emphasized and evaluated in the continuity experience.

Ambulatory Care↗
PubMed1995

Faculty practice in an academic nursing care center model: autonomy, job satisfaction, and productivity.

There were no significant differences in faculty participants and nonparticipants in the center in autonomy, job satisfaction, or productivity. However, nonpracticing faculty members did express a decrease in satisfaction attributed to the tiring, routine job design, and practicing members were generally more often involved in scholarly research and productivity. Based on the results of this investigation, it is recommended that: 1. Studies be conducted that evaluate the effectiveness of academic-based nursing care centers in meeting their goals. 2. Replications of this study occur on a wider scale, looking at a variety of universities and colleges with academic-based nursing care centers. 3. Investigations be done studying the effects of intrinsic and extrinsic factors on the nursing educator's willingness to practice.

Adult↗
PubMed1999

Advanced practice nursing and the role of the pediatric critical care nurse practitioner.

Advanced practice nursing, since its inception in the early 1960s, has constantly changed in an effort to establish standardized core graduate education, specialization of practice, and autonomy, now common in the 1990s. Nurse practitioners, nurse midwives, and certified registered nurse anesthetists have followed in the footsteps of the clinical nurse specialist by enhancing their practice through advanced education. Nurses in these advanced areas are graduating from established programs with a master's of science in nursing and a specialty in their chosen field. The pediatric critical care nurse practitioner is one such specialty. This article highlights the results of a national survey that described pediatric critical care nurse practitioner practice over a broad geographic area. With change as a constant, nurses will look to the future of advanced practice roles, which are ever changing, and continue to provide safe, quality care to patients.

Certification↗
PubMed1999

Measuring physician job satisfaction in a changing workplace and a challenging environment. SGIM Career Satisfaction Study Group. Society of General Internal Medicine.

BACKGROUND: Changes in the demographic, specialty, and employment sector composition of medicine have altered physicians' jobs, limiting autonomy and reducing morale. Because physician job satisfaction has been linked to clinical variables, better measurement might help to ameliorate conditions linked to medical disaffection, possibly improving health care. OBJECTIVE: To document conceptual development, item construction, and use of content experts in designing multidimensional measures of physician job satisfaction and global satisfaction scales for assessing physicians' job perceptions across settings and specialties. DESIGN: Using previous research, physician focus groups, secondary analysis of survey data, interviews with physician informants, and a multispecialty physician expert panel, distinct job facets and statements representing those facets were developed. RESULTS: Facets from previously validated instruments included autonomy, relationships with colleagues, relationships with patients, relationships with staff, pay, resources, and status. New facets included intrinsic satisfaction, free time away from work, administrative support, and community involvement. Physician status items were reconfigured into relationships with peers, patients, staff, and community, yielding 10 hypothetical facets. Global scales and items were developed representing satisfaction with job, career, and specialty. CONCLUSIONS: A comprehensive approach to assessing physician job satisfaction yielded 10 facets, some of which had not been previously identified, and generated a matching pool of items for subsequent use in field tests.

Attitude of Health Personnel↗
PubMedDate not supplied

The managed care world order. The revolution is here.

What are the belief clashes caused by the shift from a fee-for-service medical setting to a managed care environment? Right now, most physicians are enculturated in the old world order that emphasizes physician autonomy, control, security, and specialness. Physicians feel squeezed--by third-party payers wanting to be involved in the decision-making process of care delivery and by a new focus on teams versus the captain of the ship role. When traditional expectations clash with a changing reality, most people feel stressed. Physicians are no exception. If physicians have clear and realistic expectations, they can better cope with the uncertainties they face. And, the only realistic expectation in the medical profession is increasing uncertainty. Here are 10 predictions of what is happening in the health care industry--a list of the belief clashes that are so unsettling to those practicing medicine.

Attitude to Health↗
PubMedDate not supplied

Internal practice barriers for non-physician practitioners in the veterans healthcare system.

As a consequence of the re-engineering of the veterans healthcare system initiated in 1995, non-physician clinicians are functioning with new levels of autonomy and expanded scopes of practice, but they are not consistently being utilized to their optimal potential. A work group appointed by the Under Secretary of Health in 1996 found various barriers to improving this situation: 1) lack of clarity regarding the roles of the non-physician clinicians; 2) lack of understanding of the basis of their credentialing; 3) lack of uniformity of their credentials; 4) non-acceptance by physicians and managers; 5) rigidity of administrative policies; and 6) salary, benefit, and career-advancement issues. The authors recommend ongoing management attention to addressing these barriers both within and outside the VHA system.

Allied Health Personnel↗
PubMedDate not supplied

Value-based health care. Part I: Physicians reestablishing clinical autonomy.

Clinical decision-making was once the sole purview of physicians, but no longer. Medical judgment has been usurped by third parties in the name of cost control. To reestablish this rightful authority, physicians must organize to assume the financial risks for their patients' health, using objective, clinical information to deliver superior quality outcomes. To successfully manage their patients' clinical and financial risks, physicians need to: (1) establish a structure independent of the hospital medical staff for outpatient contracting; (2) secure a capital partner that supports their independent, clinical decision-making; and (3) be leaders in acquiring and effectively using clinical information that accurately risk-adjusts and integrates both inpatient and outpatient data for all episodes of care. Physicians who acquire these skills will secure premium contracts from purchasers who are demanding value-based health care delivery.

Capital Financing↗
PubMed2004

A categorization and analysis of the criticisms of Evidence-Based Medicine.

The major criticisms and limitations of Evidence-Based Medicine (EBM) appearing in the literature over the past decade can be summarized and categorized into five recurring themes. The themes include: reliance on empiricism, narrow definition of evidence, lack of evidence of efficacy, limited usefulness for individual patients, and threats to the autonomy of the doctor/patient relationship. Analysis of EBM according to these themes leads to the conclusion that EBM can be a useful tool, but has severe drawbacks when used in isolation in the practice of individual patient care. Modern medicine must strive to balance an extremely complex set of priorities. To be an effective aid in achieving this balance, the theory and practice of EBM must expand to include new methods of study design and integration, and must adapt to the needs of both patients and the health care system in order to provide patients with the best care at the lowest cost.

Attitude to Health↗
PubMed1988

Ethical or legal perceptions by dental practitioners.

Perplexing ethical and legal concerns cross health professions and reach into many professions and vocations. Confidentiality is crucial not only to the health professional and the patient, but also to the lawyer and client, and the investigative reporter and the source. Reporting poor work or whistleblowing is a dilemma not only for dentists and other health care professionals, but also for the engineer, architect, and federal employee, among others. This survey of the ethical or legal perceptions of the dental practitioner supports two conclusions: perplexing situations are perceived as predominantly ethical rather than legal problems and the factor of age (number of years in practice) might affect this trend toward the ethical consideration of complicated issues. Understanding the nature of these and other perplexing situations requires that dental practitioners step beyond the confines of their practice and the boundaries of the dental profession to search for more effective ways of dealing with, and therefore living with, the realities of their practice.

Age Factors↗
PubMed1997

Ethical decision-making in intensive care: are nurses suitable patient advocates?

According to the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) code of conduct (1992), nurses in Britain are expected to act as patient advocates. An advocate is someone who 'pleads for another' (Concise Oxford Dictionary 1982). However, it has been shown that advocacy is a complex issue and it is debatable as to whether or not it is a legitimate attribute of the role of the nurse (Gates 1995). Mallik (1997) also finds that advocacy can be a risky career option. Professional codes of conduct spell out duties, but do not give moral guidance. Phrases such as 'promote and safeguard the well-being of the patient' (UKCC 1992) are used, but although undoubtedly well-intentioned, this is platitudinous and these codes commonly shed little light on how to define an action that is to the patient's benefit or detriment. It is tempting to suggest that they are used as a drunken man uses a street lamp; more for support than illumination. Castledine (1981) identified a number of factors that would make a nurse an inappropriate advocate and these will be discussed within the context of intensive care units (ICUs).

Critical Care↗
PubMed1989

The role of the nurse on hospital ethics committees.

Sound decisions are characterized by assurance of adequate information, multiple perspectives, sufficiently deliberate thought, emotional support for all decision makers, and legal acceptability. Each of these features can be enhanced by appropriate involvement of the nurse on an ethics committee. As a result, the nurse will be helping to assure patient, family, and professional participants that they have done their best under difficult constraints. Serving as a member of a hospital ethics committee is time consuming and challenging. Yet, it is one of the most important ways nurses can function in the role of patient advocate. The ethics committee can be the answer to the frustration that nurses confront every day when faced with increased technology, legislative inaction, and medical paternalism. Even competent patients are often manipulated when they want to refuse treatment. Patients and families frequently have the illusion of choice but no real choice at all. If an ethics committee can provide some meaningful avenue for the exercise of patients' and families' rights, then they are worth the effort.

Ethics↗