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PubMed1996

Effects of an institutional AIDS prevention intervention: moderation by gender.

AIDS risk reduction programs are being conducted in many institutional settings, but rigorous evaluations of their effectiveness are lacking. This is particularly unfortunate in that these programs are expensive, and tend to be of lower intensity than those that have been shown to be effective. Further, risk reduction is generally regarded as entailing greater difficulty for women, who do not use condoms themselves but must negotiate their use with male partners. We used a quasi-experimental design to evaluate an institutional AIDS prevention program on a New Jersey college campus. Sexual behavior was assessed via linked, anonymous mailed surveys at the beginning and end of an academic year among 1st-year students on the campus and others on a nearby control campus. Responses from the spring survey indicated that intervention campus students had been exposed significantly more than control students to intervention components. While MANCOVA analyses indicated no main effect of treatment group on outcome variable, we obtained a significant group by gender interaction, indicating a significant effect on number of risky encounters for men but not for women. In fact, relative to women on the control campus, women on the intervention campus displayed reduced self-efficacy to perform safe sex at the end of the year. These results may indicate that although men can be effectively reached by low-intensity risk reduction programs, women may not be. In fact, interventions without adequate intensity to provide substantial and individualized negotiation skill training may cause women to experience failure in these efforts.

Adolescent↗
PubMed1997

Resolving conflicts surrounding end-of-life care.

Critical care physicians are frequently called on to negotiate issues of medical management with patients, their families, and other physicians. These decisions frequently revolve around end-of-life care. Recent data suggest that such discussions are manageable. In one study, 57% of patients and surrogates agreed immediately to a physician's recommendation to limit intensive care and 90% agreed within 5 days, while multiple treating physicians came to consensus about such limits within 4 days in 92% of cases. If conflicts are rare, they are strongly felt. They arise when any one of the parties to a decision insists on continued care against the considered judgment of another. Since the alternative to aggressive ICU care is usually the death of the patient, it seems difficult to reconcile a physician's refusal to treat with patient autonomy. The concept of a fiduciary offers a model of the physician-patient relationship in which the physician commits himself to the patient's best interests but retains a role in defining those interests. This model offers significant benefits over medical futility in negotiating conflicts over end-of-life care.

Conflict, Psychological↗
PubMed1997

Devolving authority for health care in Canada's provinces: 1. An introduction to the issues.

In 9 of Canada's 10 provinces, much of the decision-making in health care has recently been devolved to local authorities. Provincial governments want this new governance structure to at least contain costs and improve service integration. However, there has been little evaluation of devolution to determine whether these and other goals are being met. Although devolved structures in the provinces vary somewhat with respect to the number of tiers, accountability mechanisms, degree of authority and method of funding, the only structural element that varies substantially is the scope of services under the authority of local boards. The real authority of the boards depends, however, on their negotiated compromises among 3 areas of tension: the provincial government's expectations, the providers' interests and the local citizens' needs and preferences. The boards' abilities to negotiate acceptable compromises will largely determine their effectiveness. This article introduces a survey of the members of 62 boards in 5 provinces for which the response rate was 65%, with 514 of 791 board members responding.

Canada↗
PubMed1997

Perioperative managed care reimbursements.

Providing high quality health care is no longer enough to thrive in the world of managed care. You must first analyze your marketplace and then represent your service in negotiations with managed care companies. Contracting managers can provide valuable information when negotiating for your services or areas.

Contract Services↗
PubMedDate not supplied

A preventive ethics approach to counseling patients about clinical futility in the primary care setting.

Given the current themes of futility and managed care in medicine and bioethics, the primary care setting needs to account for how to address futility. We argue for applying the concept of clinical futility to primary care medicine. A preventive ethics approach directs the primary care physician to explain and counsel against futile interventions, with a negotiation strategy for circumstances of disagreement. These efforts will require primary care physicians to concentrate their efforts on education, negotiation, and enhanced trust in their patient relationships. Using a preventive ethics approach in these circumstances, the physician can better protect the interests of the patient by avoiding nonbeneficial interventions, especially those that also are potentially harmful.

Advance Care Planning↗
PubMed2003

Benefits of and barriers to large medical group practice in the United States.

BACKGROUND: For decades, reformers argued that medical groups can efficiently provide high-quality care and a collegial professional environment. The growth of managed care and the movement to improve quality provide additional reasons for physicians to practice in groups, especially large groups. However, information is lacking on recent trends in group size and the benefits of and barriers to group practice. OBJECTIVES: To identify benefits of and barriers to large medical group practice, and to describe recent trends in group size. DESIGN, SETTING, AND PARTICIPANTS: Information on benefits and barriers was obtained from 195 interviews conducted during round 3 (2000-2001) of the Community Tracking Study with leaders of the largest groups, hospitals, and health insurance plans in 12 randomly selected metropolitan areas. Information on recent trends in group size was obtained from more than 6000 physicians in private practice in 48 randomly selected metropolitan areas via Community Tracking Study telephone surveys in 1997-1998, 1998-1999, and 2000-2001. MAIN OUTCOME MEASURES: Benefits of and barriers to large group practice, as perceived by interviewees, and changes in percentages of physicians in groups of varying sizes. RESULTS: Gaining negotiating leverage with health insurance plans was the most frequently cited benefit; it was cited 8 times more often than improving quality. Lack of physician cooperation, investment, and leadership were the most frequently cited barriers. Survey data indicate that 47% of private physicians work in practices of 1 or 2 physicians and 82% in practices of 9 or fewer, and that the percentage of physicians in groups of 20 or more did not increase between 1996 and 2001. CONCLUSIONS: Current payment methods reward gaining size to obtain negotiating leverage more than they reward quality. However, barriers to creating large medical groups are substantial, and most private physicians continue to practice in small groups, although the size of these groups is slowly increasing.

Data Collection↗
PubMed1975

The customer approach to patienthood. Attending to patient requests in a walk-in clinic.

This report conceptualizes the initial psychiatric interview as a process of negotiation between the clinician and patient. Patients are conceived of as appearing with one or more requests, many of which represent legitimate needs. It is the clinician's task to elicit the request, collect the relevant clinical data, and enter into a "negotiation" that should foster a relationship of mutual influence between patient and clinician. We have attempted to show that this approach to patienthood not only improves patient care and patient satisfaction but also leads to improved staff morale. The "customer approach" has special relevance to those clinical settings (walk-in clinics and community mental health centers) in which clinicians see a broad range of patients with a broad definition of psychiatric problems and requests.

Community Mental Health Services↗
PubMed2003

Care of the dying doctor: on the other end of the stethoscope.

The challenges of caring for a dying doctor reflect both common issues in helping the terminally ill and unique problems in working with a physician-patient. The dying doctor must deal with a familiar environment and set of problems from a radically different perspective and must negotiate overlapping and conflicting personal and professional roles. Some of the cardinal virtues of physicians--professional identity, expertise, perfectionism, selflessness, and stoicism--may pose both strengths and liabilities in the patient's role. The treating physicians may also encounter new strains in caring for a colleague. They must guard against both overinvolvement and underinvolvement, and, as with all dying persons, they must serve as a guide through unfamiliar territory for dying patient and family--a companion who is not afraid to listen to or explore the most upsetting matters, a person who can speak frankly when others may be ignoring "the horse on the dining room table." The case of Dr B, an internist dying of myelofibrosis and congestive heart failure, whose son is also a physician, offers the reader the opportunity to reflect on these challenges and to draw lessons about how to best care for fellow physicians at a time of great need. We suggest strategies for negotiating the patient-physician relationship when the patient is also a physician.

Attitude of Health Personnel↗
PubMed2000

Interventions for encouraging sexual lifestyles and behaviours intended to prevent cervical cancer.

BACKGROUND: Cervical cancer is one of the most common cancers affecting women world-wide. Prevention falls into two main categories - primary and secondary. Primary prevention is characterised by health promotion to promote lifestyles and behaviours minimising risk of cervical cancer. Interventions to promote the use of condoms for sexual intercourse (especially early intercourse amongst young women), sexual partner reduction, and negotiated safer sex strategies has been recommended as one approach to limit the spread of Human Papilloma Virus (HPV), one of the major risk factors for cervical cancer. OBJECTIVES: To determine the effectiveness of health education interventions to promote sexual risk reduction behaviours amongst women in order to reduce transmission of HPV. SEARCH STRATEGY: Electronic searching of EMBASE, ERIC, MEDLINE, PsycLIT, Social Science Citation Index and the CCTR were undertaken using a highly sensitive search strategy. Hand-searching took place of selected journals and reference lists. SELECTION CRITERIA: Studies were included if they evaluated educational interventions targeting women only, and measured the impact on : either a behavioural outcome such as condom use for sexual intercourse, partner reduction, or abstinence; or a clinical outcome such as incidence of a sexually transmitted disease (STD). DATA COLLECTION AND ANALYSIS: Data were extracted and methodological quality was assessed independently by two reviewers and any discrepancies were resolved between them. Ten per cent of the total number of studies were reviewed additionally by a third reviewer as a quality check and differences in judgement were resolved accordingly. MAIN RESULTS: Thirty trials met the inclusion criteria for the review. All of them had the primary aim of preventing HIV and other STDs rather than cervical cancer. Four core methodological qualities were present in 10 of the 30 studies and constitute the subset from which potentially reliable conclusions may be drawn. Each of the 10 studies showed a statistically significant positive effect on sexual risk reduction, typically with increased use of condoms for vaginal intercourse. This positive effect was generally sustained up to three months after intervention. REVIEWER'S CONCLUSIONS: Educational interventions targeting socially and economically disadvantaged women in which information provision is complemented by sexual negotiation skill development can encourage at least short-term sexual risk reduction behaviour. This has the potential to reduce the transmission of HPV, thus possibly reduce the incidence of cervical carcinoma.

Female↗
PubMedDate not supplied

Child abuse and the balance of power in parental relationships: an evolved domain-independent mental mechanism that accounts for behavioral variation.

Previous studies use zero-order analyses to show a link between child abuse and exposure to "stepfathers." These studies rest on a proposed evolved, domain-specific cognitive mechanism that induces adult males to abuse or kill offspring not their own and, so, contribute directly to reproductive success. However, child abuse may reflect an evolved neurological mechanism that creates behavioral plasticity and adaptability by assigning emotional weights (which in consciousness appear rationalized as costs and benefits) to choice alternatives in all behavioral domains. This mechanism should act as a selective mechanism to create enhanced ability to avoid predation (social exploitation) and to obtain access to resources, given the properties of specific ecosystems, and should control behavioral responses to variation in the balance of power in social relationships. Power equalities should elicit good treatment for both parties; power inequalities, by contrast, should elicit exploitative and coercive behavior on the part of those who hold the balance of power. This paper reports a test of both hypotheses simultaneously, controlling for a standard social science risk factor (growing up in poverty). Once we control for the balance of power in parental relationships, exposure to a stepfather and growing up in poverty show no effect on the intensity of child abuse. Powerful women negotiated affectionate behavior from their partners for both themselves and their children; powerless women's negotiations with partners usually left both themselves and their children open to violence.

Adult↗
PubMed2005

The needs of terminally ill cancer patients versus those of caregivers for information regarding prognosis and end-of-life issues.

BACKGROUND: The difficulty of negotiating the concerns of family members while also respecting the needs of the patient adds complexity to the task of discussing prognosis and end-of-life (EOL) issues with terminally ill cancer patients. The informational needs of caregivers may be different from those of the patients themselves with regard to these topics. However, to the authors' knowledge, this issue has received relatively little research attention. METHODS: The authors conducted focus groups and individual interviews with 19 patients with far advanced cancer and 24 caregivers from 3 palliative care (PC) services in Sydney and 22 PC health professionals (HPs) from around Australia. The focus groups and individual interviews were audiotaped and fully transcribed. Additional focus groups or individual interviews were conducted until no additional topics were raised. The participants' narratives were analyzed using qualitative methodology. RESULTS: The participants had varying views regarding whether patients and caregivers should be told different information concerning prognosis and EOL issues. Three themes were identified from the transcripts regarding meeting the informational needs of both the patients and caregivers: 1) the importance of consistency and openness, 2) the specific information needed to care for the patient, and 3) the value of having separate discussions with the patient and caregiver. A desire to restrict the patient's access to information by the caregiver or vice versa was reported by the HPs to be one of the most challenging issues when discussing prognosis and EOL issues. Three themes were identified with regard to this issue: 1) autonomy versus protection, 2) negotiating family dynamics, and 3) difficulty using interpreters. CONCLUSIONS: The results of the current study emphasized the importance of considering the distinct informational needs of caregivers, as well as those of the patient, when discussing prognosis and EOL issues.

Adult↗
PubMedDate not supplied

Understanding the central-local relationship in health care: a new approach.

One of the basic assumptions of governmental health planning policy is that the government can effectively take final responsibility for the development of the health care system. Failure to reach policy goals is explained in terms of inadequate planning technology and instruments to control implementation. In this article an alternative explanation is offered, based on the theory of strategic organizational behavior. According to this theory, the government must be seen as but one actor in a complex interorganizational network. From this, a different perspective on effective health planning policy is developed. Policies will fail if they are not based on a valid analysis of the policy space of health care institutions and the interdependencies between government and health care organizations. This article starts with an outline of the nature of the central-local relationship as seen from the perspective of strategic organizational behavior theory. Next, this theory is used to frame two cases in which Dutch health care institutions successfully pursued their own strategies that ran counter to the existing health planning policies. The article ends with a discussion of the implications of the theory of strategic organizational behavior for the development of effective central health care policies. This development starts with a thorough analysis of the policy space and interdependencies of all relevant actors in the health system, the government included. Following, policy makers can set the governmental goals and then have to start negotiations with health care institutions about mutual adaptation of their strategies and the governmental goals. The result is a negotiated health care order.

Decision Making, Organizational↗
PubMedDate not supplied

Activity-based resource allocation: a system for predicting nursing costs.

As hospital-based managers are being confronted with changing patterns of reimbursement, ranging from revenue generating to cost management, it is imperative that hospitals know the exact nursing costs associated with the actual care delivered to specific patients. Nursing care has traditionally been bundled into the room rate for patients. This approach is extremely limiting when facilities are negotiating per diem rates and capitated rate contracts. At Braintree Hospital Rehabilitation Network, the nursing department has developed and implemented an activity-based management system to determine the actual cost of nursing care provided to each patient. This approach, which differentiates nursing costs accurately by diagnostic group and by intensity of nursing care, has contributed to the hospital's success in negotiating individual patient contracts with insurers in the managed care environment that increasingly focuses on costs and outcomes. Another result has been to enhance the accuracy of the network's cost accounting system.

Cost Allocation↗
PubMed1996

Food choice: a conceptual model of the process.

Interviews examining the food choice process were conducted with 29 adults, primarily individuals making grocery store food choice decisions, who were sampled for their diversity. These people were asked about how they chose foods when shopping and in other settings, and what influenced their choices. Verbatim transcripts of the interviews were analysed using qualitative methods that included constant comparison, concept mapping, and case summaries, and a conceptual food choice process model was developed. Data from the interviews are presented to illustrate the structure of this conceptual model. People's life course experiences affected major influences on food choice that included ideals, personal factors, resources, social contexts and the food context. These influences informed the development of personal systems for making food choices that incorporated value negotiations and behavioral strategies. Value negotiations weighed sensory perceptions, monetary considerations, health and nutrition beliefs and concerns, convenience, social relationships and quality of food choice decisions. Strategies employed to simplify the food choice process developed over time. The conceptual food choice process model represents the rich and complex bases of food practices, and provides a theoretical framework for research and practice in nutrition.

Adult↗
PubMed1999

A new technique for performing Syed template interstitial implants for anterior vaginal tumors using an open retropubic approach.

The Syed template (Alpha-Omega Services, Bellflower, CA) has been established as an advance in interstitial gynecologic brachytherapy. Unfortunately, enthusiasm for the technique is often tempered by certain tumor geometries which require blind insertion of the interstitial needles, potentially risking inaccurate placement of the radioactive sources and viscus perforation. These concerns arise particularly in the management of anterior vaginal tumors where difficulties in negotiating the pubic arch can prevent optimal needle placement. In answer to this problem, a technique utilizing an open retropubic approach for Syed template interstitial implants in anterior vaginal tumors under direct visualization is described. To date, six procedures have been performed. The disease entities include advanced cervical squamous cell carcinoma, clear cell carcinoma of the vagina, recurrent vaginal carcinoma, recurrent endometrial carcinoma, and urethral adenocarcinoma. Complete response was noted in five of six patients but persistent local control of disease was achieved in only one of five complete responses over a relatively short follow-up interval. Complications included paravaginal abscess (n = 1), postoperative deep venous thrombosis (n = 1), abdominal incision cellulitis (n = 1), and radiation enteritis (n = 1). An open retropubic approach allows direct visualization of the bladder and urethra during interstitial implantation of anterior vaginal malignancies and facilitates negotiation of the pubic arch. In our experience, this technique results in improved needle positioning and is thus intuitively likely to aid in avoiding injury to surrounding normal tissues. Additional accrual of a larger cohort will be necessary to arrive at any meaningful objective conclusions regarding the technique's benefit over current modalities.

Adult↗
PubMed1998

Effects of Practice Conditions and Supplemental Training Method on Cognitive Learning and Interpersonal Skill Generalization.

Organizational expenditures for interpersonal-skills training have been rising. However, little is known about the translation of cognitive learning into skilled interpersonal-task performance, or about the mechanisms through which interpersonal skills in one domain generalize to other interpersonal tasks. This study used a 2 x 2 experimental design to examine the effectiveness of neutral versus stressful practice conditions and mastery-versus performance-oriented supplemental training for improving cognitive learning and interpersonal-skill transfer to a novel task. Participants who experienced stressful salary-negotiation practice conditions, followed by mastery-oriented supplemental training, showed greater skill transfer when performing a novel task (i.e., contract negotiations). Results showed that superior cognitive learning (i.e., recall, comprehension, and synthesis) and greater time on task were the mechanisms that supported interpersonal-skill transfer for trainees in the stressful practice/ mastery-oriented training condition when compared with the other experimental groups. Copyright 1998 Academic Press.

Journal Article↗
PubMed1988

A functional analysis of the collicular output pathways: a dissociation of deficits following lesions of the dorsal tegmental decussation and the ipsilateral collicular efferent bundle in the Mongolian gerbil.

Mongolian gerbils received either lesions of the superior colliculus, small lesions of the uncrossed efferents of the superior colliculus, knifecuts of the dorsal tegmental decussation, or sham operations. The animals were subsequently tested for avoidance of overhead visual threat, orientation and locomotion toward small targets, and negotiation of a large barrier in order to reach a small target. Animals with collicular lesions showed no responses to overhead threat and had severe deficits in orienting to small targets. Animals with lesions of the uncrossed tectal efferents showed diminished responses to overhead threat but had no deficits in orienting to targets. Animals with lesions of the dorsal tegmental decussation showed only slight reductions in responses to overhead threats but clear impairments in the orientation tasks. The impairments in orientation, however, were less severe than those seen in collicular animals. Animals in all groups were able to negotiate barriers efficiently. These results suggest that separate output pathways of the superior colliculus mediate different types of visuomotor behaviours. The results further suggest that visual orientation to small targets does not depend completely on output through the predorsal bundle, but must also involve other collicular outputs.

Animals↗
PubMed1977

Innovative programming in school mental health. Search for a methodology.

Entering a system it often regarded as the most difficult aspect of consultation, especially when entry is initiated by the consultant. Issues involved in seeking entry into a school system are considered from the perspective of a university-based consultant interested in developing, delivering, and evaluating innovative approaches to school mental health problems. Experience with a number of school systems leads to several conclusions about the entry process. Foremost is the existence of a difficult, time-consuming period of negotiations involving various school personnel; because of their varying perspectives and different interests, problems emerge and must be resolved successfully in the course of negotiations if a consultation project is to develop. Often this is not possible, and it is therefore suggested that the consultant seeking a school setting approach several systems concurrently.

Attitude↗