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Faculty governance can play a central role in modeling professional autonomy to student nurses during their socialization processes. Nurse educators, however, may be more familiar with bureaucratic models of governance than with collegial models of governance. The collegial or shared governance model offers nursing access to enhanced academic maturity, and deserves nursings' close attention and study.
As federal governmental involvement in U.S. health care had become a fact in the mid-1960s, a significant number of contributors to The Journal of the American Medical Association (JAMA) had recommended educational reforms to save an autonomous profession. In the late 1970s, demands for additional professional reforms began to appear in JAMA and The Journal of Medical Education (JME), particularly from contributors who perceived threats to professional autonomy from corporate medicine. The New Oslerian reform agenda is an application of the "humanizing" movement to the clinical phase of medical education. In its most restricted formulation (the inherent ethic argument), proponents simply urged clinicians to permit every student's inborn sense of moral duty to blossom on the wards. Others argued that Sir William Osler's legacy was more complex and involved systematic instruction, especially in ethics, at the bedside (the service ethic argument). Real Flexnerian reforms were based on an assumption that unintended distortions in Abraham Flexner's reform measures had eventuated in stultifying and counterproductive teaching of the biomedical model. Consequently, medical education should be altered to train future physicians in what Flexner had really intended--the capacity to think and problem-solve in a scientific manner. In time, many reformers emphasized the complementarity of Real Flexnerian and New Oslerian curricular proposals. The most comprehensive proposal to date, GPEP (General Professional Education of the Physician), makes a strong case that implementation of these old, turn-of-the-century reform proposals would make physicians in the 21st century well-rounded and competent. But GPEP's proposed changes in medical education are inadequate because the recommendations do little to prepare future physicians to contend with the corporate context in which most of them will be practicing.
Ontario's universal health insurance system has placed few constraints on the clinical and economic autonomy of medical doctors. Although fees are standardized, most physicians remain in private fee-for-service practice and thereby retain control of the mix and volume of services. Utilization review is minimal. While organized medicine has argued that health care is 'under-funded', the government is pressing for better use of extant resources through firmer management of the medical services sector. The Ontario Medical Association (OMA), the major bargaining agent for doctors in the province, has accordingly sought to protect professional autonomy by developing voluntary self-regulatory approaches that obviate the need for external controls over physician practice patterns. Part of this strategy is promulgation of practice guidelines. Tissue plasminogen activator (t-PA), a clot-lysing drug for myocardial infarction, was released in late 1987, and, at C$2950 per treatment, constituted an unforeseen add-on cost for hospitals. The OMA subsequently convened an expert panel to develop guidelines for thrombolysis in myocardial infarction. Among the unanticipated results was the conclusion that insufficient evidence had accumulated to recommend routine use of t-PA instead of streptokinase, an older drug costing C$290. The OMA panel's guidelines were approved by the OMA executive, and led the government to reject special add-on funding for hospitals purchasing t-PA. The OMA's position and government decision provoked negative reactions from the OMA's own cardiology section. Indicative of clinicians' feelings, a follow-up survey of cardiologists and internists showed that only 28% of respondents were indifferent between t-PA and streptokinase, while 64% preferred t-PA. On the other hand, 74% supported clinical policy development by the OMA, while 94% opposed direct government involvement in guideline-setting. The case of the OMA thrombolysis guidelines illustrates a strategic conundrum facing Canadian organized medicine. Professional activism in guideline-setting may in theory protect the individual practitioner's autonomy by offering a voluntary alternative to utilization management by government, and is likely to strengthen the collective influence of organized medicine. However, among the risks are alienation of practitioners who see professional guidelines and government control as two sides of the same regulatory coin, and the transmogrification of voluntary guidelines into parameters for cost control and utilization management by government or hospitals. Future initiatives will depend on how these benefits and risks are weighed.
The importance and satisfaction associated with 21 characteristics of a nurse faculty position were examined, using 1974 questionnaire data from schools of nursing at four major state universities. Teaching, supportive colleagues, keeping clinical knowledge current, and faculty autonomy were seen as the most important aspects of the job by the 154 nursing educators surveyed, while salary, fringe benefits, and other extrinsic rewards ranked substantially lower in importance. Satisfaction with the more important conditions was generally low, with lack of faculty participation in decision making a particularly noteworthy source of dissatisfaction. Importance and satisfaction ranking of the 21 characteristics remained fairly stable across the four schools and across groups broken down by martial status, experience, and other personal attributes. Increased professional autonomy, it was suggested, would benefit faculty morale, recruitment, retention, and overall effectiveness in nursing education.
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The purpose of this study was to determine differences in perceptions of ethical dilemmas and attitudes toward autonomy among four groups of nursing students. A randomly selected sample (n = 130) of students enrolled in associate degree, generic baccalaureate, degree completion, and master's study completed the Judgments About Nursing Decisions (JAND), the Nursing Autonomy and Patient's Rights Scale (NAPRS), and a demographic data sheet. Using one-way analysis of variance procedures, significant differences were found among groups on autonomy, patients' rights, and rejection of traditional role limitations. No significant differences were found on perceptions of idealistic and realistic moral behavior. Additional analysis produced significant findings when student groups were compared by age, RN status, and participation in ethics courses and seminars. Lack of significant differences on perceptions of ethical dilemmas may have resulted from the relatively low level of reliability of the JAND with the groups studied. Differences in attitudes are attributed to experience as a registered nurse, participation in an educational offering, and exposure to the bureaucratic environment of the health-care system.
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The recent resurgence of lay midwifery in the United States has been intimately connected with the establishment of grassroots organizations which address women's health issues and make the reappearance of the lay midwife a different kind of phenomenon than was the case earlier in this century. This paper describes the organizational structure of 32 lay midwives' organizations and compares them to a model of alternative women's health groups as well as more traditional health professional organizations. Are lay midwives' groups the beginnings of new professional organizations which eventually will become part of the dominant system or do they model themselves more closely after alternative women's health groups? Voluntary self-certification in five lay midwives' groups is described in detail as a means of determining how a group handles the question of integration with or separation from the existing medical care system. Certification plays a critical role in promoting acceptance and credibility of midwifery practice and is seen increasingly as a mechanism to preempt regulation by another body.
The purpose of this study was to validate the findings of a previous investigation of differences in perceptions of idealistic and realistic moral behavior and attitudes toward autonomy, patients' rights, and traditional role limitations among four groups of nursing students. A sample of 147 associate, generic baccalaureate, degree completion, and master's students anonymously completed the Judgments About Nursing Decisions (JAND) and the Nursing Autonomy and Patient Rights Scale (NAPRS). Only three findings from the original study were validated: that both age and ethics education have effects on attitudes toward autonomy as measured by the NAPRS and that, overall, there is a consistent lack of significant findings on JAND scores among groups studied.
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