In the face of escalating Medicaid costs and anticipated reductions in federal Medicaid spending, states are increasingly converting from fee-for-service to managed health care systems. The interrelated issues of enrollment and auto-assignment are fundamental to the overall success or failure of Medicaid managed care programs. The purpose of this article is to suggest how policy makers, consumer advocates, and providers should address these issues. My major premise is that implementation of managed care will (...) proceed more smoothly if states adopt enrollment strategies that promote voluntary selection of health plans by Medicaid consumers, minimize the likelihood of auto-assignment, and mitigate the negative consequences of mandatory assignment of consumers to managed care organizations.States seeking to implement Medicaid managed care must apply for a waiver from the secretary of the Department of Health and Human Services. Two different types of waivers are available to implement Medicaid managed care. (shrink)

In the face of escalating Medicaid costs and anticipated reductions in federal Medicaid spending, states are increasingly converting from fee-for-service to managed health care systems. The interrelated issues of enrollment and auto-assignment are fundamental to the overall success or failure of Medicaid managed care programs. The purpose of this article is to suggest how policy makers, consumer advocates, and providers should address these issues. My major premise is that implementation of managed care will (...) proceed more smoothly if states adopt enrollment strategies that promote voluntary selection of health plans by Medicaid consumers, minimize the likelihood of auto-assignment, and mitigate the negative consequences of mandatory assignment of consumers to managed care organizations.States seeking to implement Medicaid managed care must apply for a waiver from the secretary of the Department of Health and Human Services. Two different types of waivers are available to implement Medicaid managed care. (shrink)

During the past decade, Medicaid has experienced extraordinary growth, in both number of beneficiaries and total expenditures. Between 1988 and 1993, the number of Medicaid beneficiaries grew from 22 million to 32 million. While the number of Medicaid beneficiaries increased by 45 percent, expenditures increased by 145 percent, from 51 billion to 125 billion. Expressed in terms of its percentage of state budgets, Medicaid doubled from 10 percent to 20 percent over the same time period, to the point that it (...) is currently the second largest budget item for most states.Faced with unsustainable rates of program budget growth and serious concerns about the level of access and the continuity of care afforded by the Medicaid program, states have turned to managed care. Almost every state has introduced some form of managed care for a subset of their Medicaid beneficiary population. Twenty-three states have gone farther, and implemented, proposed, or are developing section 1115 waivers to overhaul their Medicaid programs. These waivers allow states to develop and introduce nonstandard approaches to benefits, eligibility, service delivery, and financing for the Medicaid beneficiary population. (shrink)

During the past decade, Medicaid has experienced extraordinary growth, in both number of beneficiaries and total expenditures. Between 1988 and 1993, the number of Medicaid beneficiaries grew from 22 million to 32 million. While the number of Medicaid beneficiaries increased by 45 percent, expenditures increased by 145 percent, from 51 billion to 125 billion. Expressed in terms of its percentage of state budgets, Medicaid doubled from 10 percent to 20 percent over the same time period, to the point that it (...) is currently the second largest budget item for most states.Faced with unsustainable rates of program budget growth and serious concerns about the level of access and the continuity of care afforded by the Medicaid program, states have turned to managed care. Almost every state has introduced some form of managed care for a subset of their Medicaid beneficiary population. Twenty-three states have gone farther, and implemented, proposed, or are developing section 1115 waivers to overhaul their Medicaid programs. These waivers allow states to develop and introduce nonstandard approaches to benefits, eligibility, service delivery, and financing for the Medicaid beneficiary population. (shrink)

Diabetes self-management is a crucial part in the management of diabetic patients. Most randomized controlled clinical trials reported significant benefits by diabetes self-management education on DSM behaviors and metabolic control. Although the randomized clinical trials are the gold standard method in assessing the effectiveness of any intervention, including DSME interventions, the outcomes of these studies may reflect exaggerated effects; because in most of these studies, subjects in control group receive usual care with no any DSME. The lack of such (...) education in the control group had many drawbacks: make blindness impossible; at which non blinded studies may result in false-positive findings; it may be unethical to recruit patients for participation in DSME studies as control subjects, most of these studies with long periods of follow up, without any direct benefit to them during the study period; the lack of direct benefit to control subjects in any clinical trial may results in high attrition rate. The high attrition rate in clinical trials especially in the control group can lower the statistical power of the study results; thus, the DSME program would appear to have positive effects even if the program had no real benefit. This problem of the DSME exaggerated effects can be solved partially through providing control subjects with education about some DSM behaviors or comparing the effect of DSME through different educational approaches. (shrink)

In an attempt to gain some control over ever escalating health care cost, many organizations have moved to a managed care concept of health benefits. Managed care health benefit strategies account for well over 90 percent of all employer sponsored health benefit programs.In essence, managed care coverage usually demands, at a minimum, some form of utilization review in regard to provider services. Thus the privacy of the traditional doctor patient relationship must inevitably (...) be modified when managed care enters the picture. (shrink)

In this article we describe the successes of Aetna’s Compassionate Care Program in providing case management services for people with advanced illnesses.

This commentary describes limitations of mental health parity requirements in ensuring access to insurance coverage for mental health treatment and surveys regulatory options employed by states in Medicaid managed care programs as supplements to parity that can further reduce the risk of inappropriate denials of coverage.

The increased prevalence of advanced‐stage chronic diseases has augmented the need for palliative care teams. In Colombia, although the legislation promotes palliative care development, people still die without receiving management from a palliative care team. In addition, judiciary regulations regarding euthanasia have generated public confusion and ethical conflicts among members of the palliative care teams. Therefore, this study aimed to perform a bioethical reflection on the relationship between palliative care and euthanasia supported by data on (...) euthanasia requests in a palliative care program. This reflection is based on retrospective and descriptive observational data, collected in two highly complex hospitals in Bogotá, Colombia. A total of 50 euthanasia requests were identified, of which 62% met the defined criteria, 16% did not, and 22% were not considered by the interdisciplinary committee for the right to die with dignity due to early death. All patients were treated and followed up by a palliative care team until their death. This study considered that palliative care could be a complement management for patients requesting euthanasia based on their experience by supporting the decision‐making, alleviating suffering, and providing emotional support in the last days of life. (shrink)

Within the past few years, managed care health insurance programs have become commonplace. With managed care programs, however, physicians are facing increasing ethical pressures. This paper examines the relationship between physicians'' behavior intentions with respect to four managed care ethical scenarios and their responses to Forsyth''s (1980) Ethics Position Questionnaire (EPQ). This is one of the first papers to compare this scale to behavioral intentions in the workplace. We provide a literature review (...) of the ethical dilemmas that doctors face under a managed care system and conduct a national random sample of general practitioners and surgeons regarding the four managed care ethical dilemmas. The results show that the doctors surveyed are significantly more idealistic than relativistic. In relating the EPQ to the ethical scenarios, however, there was no support for the proposition that ethical ideology was related to the ethical behavioral intentions. This suggests more research is needed to establish the links between ethical positions, attitudes, and behavioral intentions. Finally, there were little differences in EPQ scores by practice or demographic variables, the only significant result being that general surgeons are significantly more idealistic than family practitioners. (shrink)

BackgroundAs hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs (HCEPs) that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.MethodsBased on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.ResultsAmong 372 hospitals whose informants responded to an (...) online survey, 97% of hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership (35.7%), regulatory compliance (29.0%), business ethics (26.2%), and research ethics (12.6%). HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff (77.0%), nurses (59.9%), staff physicians (49.0%), hospital leadership (44.2%), medical residents (20.3%) and the community/general public (18.4%). HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents’ strategies for managing challenges include staff training and additional funds.ConclusionsWhile this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs. (shrink)

The effectiveness of a quality management program of medical care has to meet not just the quality management standards, but also has to be flexible, taking into account the features of a medical organization and the existing problems in the medical care support. The effectiveness of a quality management program is based on feedback, so the quality control of medical care is so important. The study of problems in medical care gives us the ability to improve (...) both, the quality management program of medical care and the quality and scope of medical services constantly. (shrink)

The assessment and management of pain is a significant public health problem in the United States. Long-term care facilities face unique barriers and challenges to pain management due to the large population of cognitively impaired residents, little physician contact and poor pain education for nurses and nurse assistants. In addition, common misconceptions about pain and pain treatment in the elderly along with health professional and resident fears of addiction and drug toxicity, add to the problem of pain management. The (...) basic principles of pain treatment in long-term care are identical to all other health care settings – utilizing a combination of drug and non-drug treatments. Recent efforts to institutionalize improved pain management practices, through assessment procedures and defined pain management policies, standards and education programming, is a promising venue for systemically improving pain treatment in long-term care settings. (shrink)

One barrier to optimal pain management in the neonatal intensive care unit is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are vulnerable to pain and harm, and completely dependent (...) on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate’s family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers. (shrink)

Malpractice lawsuits serve as a great source of pain, consternation and loss for physicians and patients alike, usually leaving all parties involved in the process with a sense of betrayal. A significant number of physicians will be sued at least once in their career, especially if they practice in some of the more vulnerable specialties. In addition, there is some evidence that the threat of malpractice lawsuits changes the practice style of many physicians, leading to the practice of “defensive medicine” (...) and raises the total cost of health care. Clearly, the prevention of medical malpractice is an issue that deserves considerable attention from physicians and from those who train them.Empirical evidence suggests that medical negligence may play a relatively minor role in malpractice lawsuits. As demonstrated by Localio, et al., one in thirty-five cases of negligence or incompetence actually results in a lawsuit. (shrink)

Malpractice lawsuits serve as a great source of pain, consternation and loss for physicians and patients alike, usually leaving all parties involved in the process with a sense of betrayal. A significant number of physicians will be sued at least once in their career, especially if they practice in some of the more vulnerable specialties. In addition, there is some evidence that the threat of malpractice lawsuits changes the practice style of many physicians, leading to the practice of “defensive medicine” (...) and raises the total cost of health care. Clearly, the prevention of medical malpractice is an issue that deserves considerable attention from physicians and from those who train them.Empirical evidence suggests that medical negligence may play a relatively minor role in malpractice lawsuits. As demonstrated by Localio, et al., one in thirty-five cases of negligence or incompetence actually results in a lawsuit. (shrink)

Hospice is the premiere end of life program in the United States, but its requirement that patients forgo disease-directed therapies and that they have a prognosis of 6 months or less means that it serves less than half of dying patients and often for very short periods of time. Palliative care offers careful attention to pain and symptom management, added support for patients and families, and assistance with difficult medical decision making alongside any and all desired medical treatments, but (...) it does not include a comprehensive system of care as is provided by hospice. The practice of palliative care and hospice is filled with sometimes overt (requests for hastened death in an environment where such acts are legally prohibited) and other times covert (the delay in palliative care referral because the health care team believes it will undermine disease directed treatment) ethical issues. The contributors to this volume use a series of case presentations within each chapter to illustrate some of the palliative care and hospice challenges with significant ethical dimensions across the three overarching domains: 1) care delivery systems; 2) addressing the many dimensions of suffering; and 3) difficult decisions near the end of life. The contributors are among the most experienced palliative care, hospice and ethics scholars in North America and Western Europe. Each has been given relatively free reign to address what they feel are the most pressing ethical challenges within their domain, so a wide range of positions and vantage points are represented. As a result, the volume provides a very diverse ethical exploration of this relatively young field that can deepen, stretch, and at times confront any simple notion of the challenges facing patients, their families, professional caregivers, and policy makers. (shrink)

Compassion, as an indicator for quality care, is highly valued by patients and healthcare professionals. Compassionate care is considered a moral dimension of nursing practice and an essential component of high quality care. This study aimed to answer these questions: What are the facilitators and barriers of providing compassionate nursing care in the clinical setting? Which strategies do nurses use to provide compassionate care? What is the specific model of compassionate care for the nursing (...) context? A grounded theory approach was used in this study. A total of 21 nurses working in diverse clinical settings participated in the study. Purposive and theoretical sampling was used to select the participants. Data were collected by in-depth face to face interviews and analyzed by the constant comparative method. Ethical approval was gained from the Ethical Review Board of Tabriz University of Medical sciences. The analysis resulted in the development of three main themes: contextual factors affecting compassionate care, the compassionate care actions, and the consequences of compassionate care. The main dimensions of compassionate care are demonstrated in a Compassionate Nursing Care Model. Nurses’ ability on providing compassionate care is influenced by individual and organizational factors that may facilitate or inhibit this type of care. Leadership and nurse managers should remove the barriers which diminish the nurses’ ability to provide compassionate care and support them to engage in compassionate care programs. Identifying and recruiting compassionate nurses, developing their compassionate capacity, and providing role models of compassion could improve the flourishing of person-centered and compassionate care in clinical settings. The Compassionate Nursing Care Model provides a model to guide nursing care and research. (shrink)

Research question/aim/objectives Providing care for hospitalized children causes moral distress to nurses. Employee participation in discovering and solving the everyday problems of the workplace is one of the ways to hear the voices of nurses. This study aimed to evaluate the effect of participatory management programs on perceived organizational support and moral distress in pediatric nurses. Research design A quasi-experimental study. Participants and research context The present study was conducted on 114 pediatric nurses in Iran. Data were collected (...) using the Perceived Organizational Support Scale and the Moral Distress Scale of nurses. The intervention included implementing a participatory management program in three treatment departments that were randomly selected and it lasted 4 months. Participatory management was at the level of problem-solving with a focus on investigating, solving, and correcting issues and problems of work shifts and departments concerning the physical environment, equipment of the department, improvement of work processes, and team cooperation. In the control group, ordinary organizational approaches to problem-solving were used. Ethical considerations This study was approved by the Ethics Committee of Mashhad School of Nursing and Midwifery. Informed consent was obtained from the study participants. Findings/results Based on the results, both groups were homogenous before the intervention in terms of moral distress and perceived organizational support. The results showed that the moral distress mean scores in the intervention group decreased from 1.45 (0.52) to 1.03 (0.37) after the intervention. Also, the score of the perceived organizational support was 2.12 (1.2) increased after the intervention to 2.68 (1.10) in the intervention group. Conclusions It was found that the participation of nurses in the problem-solving process to solve daily workplace issues can be effective in increasing their perceived organizational support and reducing their moral distress. (shrink)

This essay examines a special program developed by the international Canadian mining firm, Placer Dome, to help recently laid-off workers find remunerative work in southern Africa. Shortly after it bought a 50% interest in the Deep South gold mine in South Africa, the mine laid off nearly 2600 workers. The firm gave redundant miners token serverance pay and offered them opportunity to participate in training and counseling services at the mine site. Overwhelmingly, the miners came from homes all over southern (...) Africa at great distance from the mine to which homes they chose to return. In addition, many had become ill from the HIV virus. Placer Dome soon realized that something more was required, given the very high rates of unemployment in the region. After securing grants from USAID and CIDA, and working with NGOs representing both the unions and mining companies in South Africa, the firm developed Project CARE. The project contacted workers where they lived and offered them or another proxy member of their households a variety of training, coaching, and consultative services. Within 2 years 65% of those contacted had either found new employment or started their own business. The project helped those households with HIV-affected ex-miners care for their affected family members. While describing the case, the essay raises more general ethical questions about the responsibilities of mining firms in particular for their redundant workers. (shrink)

Managed care is evolving in ways that pose unique ethical challenges to those interested in the intersection of clinical and organizational ethics. For example, Disease Management is a form of managed care that has emerged in response to chronic illness. DM is a healthcare management tool that coordinates resources across an entire health care delivery system and throughout the life cycle of chronic disease. Health Maintenance Organizations have reduced some costs in the delivery of acute (...) care, but real cost savings will result only with greater efficiencies in the delivery of costly chronic care. DM is a systematic, population-based approach that identifies persons at risk of chronic ailment, intervenes with specific programs of care, measures clinical and other outcomes, and provides continuous quality improvement. Characterized as a movement to patient-driven services, DM involves a complex web of provider relations. (shrink)

Managed care is evolving in ways that pose unique ethical challenges to those interested in the intersection of clinical and organizational ethics. For example, Disease Management is a form of managed care that has emerged in response to chronic illness. DM is a healthcare management tool that coordinates resources across an entire health care delivery system and throughout the life cycle of chronic disease. Health Maintenance Organizations have reduced some costs in the delivery of acute (...) care, but real cost savings will result only with greater efficiencies in the delivery of costly chronic care. DM is a systematic, population-based approach that identifies persons at risk of chronic ailment, intervenes with specific programs of care, measures clinical and other outcomes, and provides continuous quality improvement. Characterized as a movement to patient-driven services, DM involves a complex web of provider relations. (shrink)

This special issue is a follow-up on a previous issue in this journal on self-management in psychiatry and psychosomatic medicine. It is the concluding chapter of a research project that sought to unpack and develop the implications of an understanding of self-management in psychiatry and psychosomatic medicine as “management of the self.”Over the last, 20 years, self-management has gained a central place in treatment programs across various medical disciplines. It positions patients as “expert-clients,” who share knowledge, responsibilities and expertise (...) with health professionals, and it actively involves them in the management of their own care (Crawford, Lee, May, & Active Self-Care... (shrink)

The United States, unlike all other industrialized nations, does not have a comprehensive public system for financing health care. Nevertheless, the magnitude of America's public health care financing effort is remarkable. Of the one trillion dollars the United States spent on health care in 1996, almost half, $483.1 billion, was spent by public programs. In 1995, Medicare—our social insurance program for persons over sixty-five and the long-term disabled—overed 37.5 million Americans; Medicaid—our program for indigent elderly and (...) disabled persons and indigent children and their families—covered 36.3 million. In 1996, Medicare and Medicaid spent $203.1 and $147.7 billion, respectively. The payment policies of these massive public health care programs have a profound effect on the provision of health care.Many of the recipients of Medicare and Medicaid suffer pain. In 1994, 376,200 Americans over age sixty-five died of cancer. Virtually all of these would have been Medicare recipients, and as many as 70 percent of them died in unrelieved pain. Nearly four million Americans over sixty-five endured the pain of inpatient surgery in 1995, again nearly all of whom were Medicare recipients. (shrink)

The United States, unlike all other industrialized nations, does not have a comprehensive public system for financing health care. Nevertheless, the magnitude of America's public health care financing effort is remarkable. Of the one trillion dollars the United States spent on health care in 1996, almost half, $483.1 billion, was spent by public programs. In 1995, Medicare—our social insurance program for persons over sixty-five and the long-term disabled—overed 37.5 million Americans; Medicaid—our program for indigent elderly and (...) disabled persons and indigent children and their families—covered 36.3 million. In 1996, Medicare and Medicaid spent $203.1 and $147.7 billion, respectively. The payment policies of these massive public health care programs have a profound effect on the provision of health care.Many of the recipients of Medicare and Medicaid suffer pain. In 1994, 376,200 Americans over age sixty-five died of cancer. Virtually all of these would have been Medicare recipients, and as many as 70 percent of them died in unrelieved pain. Nearly four million Americans over sixty-five endured the pain of inpatient surgery in 1995, again nearly all of whom were Medicare recipients. (shrink)

Patient self-management programs have become increasingly popular and are now also receiving official endorsements. This paper analyses two possible types of positive justifications for promoting patient self-management: evidence-based and patient-centred justifications. It is argued that evidence-based justifications, although important politically are deficient and that the primary justification for patient self-management must be a patient-centred justification focusing on the patient’s privileged access to his or her own lived body.

Background Care is the basis of the nursing profession and nurse’s caring behavior is one of the important factors in patient satisfaction. On the other hand, psychological empowerment can improve the provision of care services, and leaders have a significant impact on the behavior of followers. This study determined the correlation between ethical leadership, psychological empowerment, and caring behavior from nurses’ perspective. Methods This cross-sectional descriptive study was conducted in 2019. A total of 200 nurses were selected by (...) stratified random sampling. Data were collected with ethical leadership, caring behavior and psychological empowerment questionnaires and analyzed with descriptive statistics and inferential statistics using SPSS20. Results The findings showed a significant correlation between ethical leadership, psychological empowerment and caring behavior of nurses. Also, there was a significant correlation between psychological empowerment and nurses’ caring behavior. The regression analysis showed that ethical leadership and psychological empowerment are a predictor of caring behavior of nurses. Conclusion Applying an ethical leadership style by nursing managers can lead to nurses’ improved psychological empowerment and caring behaviors and ultimately, patient care quality. Thus, considering guidelines at the team and organizational levels and programs such as providing workshops and periodic counseling to cultivate ethical nurse leadership can lead to better caring behavior. (shrink)

As resources in health care are scarce, managers and clinicians must make difficult choices about what to fund and what not to fund. At the level of a regional health authority, limited approaches to aid decision makers in shifting resources across major service portfolios exist. A participatory action research project was conducted in the Calgary Health Region. Through five phases of action, including observation of senior management meetings, as well as two sets of one-on-one interviews and two focus groups, (...) an approach to priority setting at the macro level within the health region was developed and implemented. The resulting macro level approach builds on the program budgeting and marginal analysis (PBMA) framework. Using a multi-disciplinary expert panel, about $45M (CAN) was released for the 2002/03 fiscal year and made available for re-allocation to service growth areas and the deficit. Important qualitative themes from the managers and clinicians informed both process development and refinement. The approach developed here not only facilitated re-allocation of resources, but also drew in both clinicians and managers to work together on this challenging task. The approach is pragmatic, transparent and evidence based, and should have application elsewhere. (shrink)

The ELSI Program: Closing the Loop was an interpretive policy study undertaken to identify how the research and the researchers funded through the program to study the ethical, legal, and social implications of mapping the human genome contributed to the construction of a public policy agenda. The stated goals of this federal grant program, known as ELSI and administered through the National Center for Human Genome Research within the National Institutes of Health, was to maximize the benefits and minimize the (...) harms of the genetic information developed as a result of the government supported genomic research. The purpose of the research project was to generate meaning and understanding regarding the social constructions of this community of researchers. Specifically, identifying themes in the process and outcomes of the research activity was intended to inform future public policy actions, thereby, closing the loop on the reflexive activity generated by the ELSI Program. The activities of the sixty-four researchers granted awards between 1990 and 1993 comprised the core sample for the study. The research process was embedded in a constructivist philosophy and the design included participant observation and an analysis of textual materials generated by the grantees. Data included periodical articles, authored and edited books, videos, popular print and visual media materials, conference papers and presentations, forum reports, interviews, and materials generated by the researcher in the process of the research--notes and analytic memos. Data analysis was an interpretive synthesis of a content analysis, contextual analysis, grounded theory coding categories, and the reflexive process of the researcher. ;The phenomena under investigation were the interactional activities of the ELSI group of researchers through which meaning was shaped on the ethical, legal, and social implications of genomic mapping. A theoretical model of the constructions of the researchers as developed included two core categories: "Framing Academic Constructions" and "Institutionalizing the Myth". The ELSI researchers used a variety of strategies, including rhetorical questioning, professional blocking and impersonalizing, plying a trade, and academic time in generating constructions. The research and researchers contributed to institutionalizing a myth of a genome through strategies that included being the expert, narrowing the focus, and marveling. The consequence of these social interactions was a process of "Making Points Not Meaning", participation in symbolic activities that generated few issues for the public policy agenda. The constructions of the policy study were then situated in the context of the discipline of public administration and policy studies. Significant to the impact of the research findings was understanding how the cooptation of these researchers might effect an health care delivery system dominated by commercial interests such as biotechnology and managed care organizations. The study concluded with a discussion of how situated knowledge constructions, social epistemology, interdisciplinarity, and interpretive research methods might contribute to enhanced credibility in public policy actions. (shrink)

Matters of hospital management do not figure prominently on the medical ethics agenda. However, management decisions that have to be taken in the area of hospital care are in fact riddled with ethical questions and do have significant impact on patients, staff members, and the community being served. In this decision making process evidence based medicine plays an increasingly important role as a tool for rationalising as well as rationing health care resources. In this article, ethical issues of (...) hospital management and the role of EBM will be explored, with particular reference to disease management programs, diagnosis related groups, and clinical pathways as recent developments in the German health care system. (shrink)

ArgumentRaspail’s domestic medicine method, popularized in 1840s France, has similarities with the practices of nineteenth century non-academic healers. His mass marketing of camphor as a universal treatment echoes the practices of “charlatans” and their circles. But Raspail is also very original in this history of popular care. As a scientist, a popularizer of encyclopedic knowledge and a political activist, he managed to blur traditional distinctions between science and politics and between popular and learned medicine. Raspail was a constant (...) thorn in the side of academic institutions and professional organizations, which were struggling to gain legitimacy. His work took a political turn when he combined, within a single project, his approach to treatment and his call for democratizing medical care. Raspail’s method challenged institutional norms by acknowledging the importance of the patient’s contribution to the healing process, and recognizing the necessity of thwarting the occasionally deleterious effects of monopolistic medicalization. (shrink)

Max Weber, the grandfather of organizational theory, recognized the close association between health care organizations and law. When he introduced the concept of a legallaw-saturated,rational bureaucracies, healthcare organizations have highly formalized rules and procedures. They pay a great deal of attention to legal criteria in decisionmaking, and some have entire departments devoted to legal risk management.

Taking steps to build a more dementia‐friendly society is essential for addressing the needs of people experiencing dementia. Initiatives that improve the quality of life for those living with dementia are needed to lessen controllable factors that can negatively influence how people envision a future trajectory of dementia for themselves. Programs that provide better funding and better coordination for care support would lessen caregiver burden and make it more possible to imagine more people being able to live what (...) they might consider a “good life” with dementia. Specific proposals, such as payment for dementia care managers and new systems to support high‐quality, symptom‐based palliative care beyond the hospice benefit of only six months, would improve and reframe how many people in the United States experience a dementia illness. Such changes should be incorporated into discussions about improving and respecting preferences in the later stages of dementia. (shrink)

Nurses’ experiences in, and the overall effectiveness of, widely used alternative‐to‐discipline programs to manage nurses’ substance‐use problems have not been adequately scrutinized. We uncovered the conflicted official and experiential ways of knowing one such alternative‐to‐discipline program in a Canadian province. We explicated this conflict through an institutional ethnography analysis. Ethnographic data from interviews with 12 nurses who were enrolled in an alternative‐to‐discipline treatment program and three program administrators, as well as institutional texts, were analyzed to explore how institutional practices (...) and power relations co‐ordinated and managed nurses’ experiences. Analysis revealed the acritical acceptance of a standardized program not based on current norms of practice. Potential and actual conflicts of interest, power imbalances, and prevailing corporate interests were rife. Nurses were not afforded the same rights to quality ethical health care as other citizens. ‘Expert’ physicians’ knowledge was privileged while nurses’ knowledge was subordinated. Conclusions were that regulatory bodies cannot rely on the taken‐for‐granted standardized treatment model in widespread use. Individualized treatment alternatives reflecting current, scientific evidence must be offered to nurses, and nurses’ knowledge, expertise, and experiences need to be included in decision‐making processes in these programs. (shrink)

How management philosophy is conceived depends on if pragmatism is acknowledged or not! After having been under the main domination of management science both research and education has until recently widened its scope from a decision-making to an action-perspective. It seems to be a recent reconnection to pragmatism that makes the 2011 Carnegie report propose to rethink management in liberal arts terms, whilst the vastly influential 1959 Carnegie Pierson report distanced itself from American pragmatism thus focusing on decisions and forgetting (...) actions. Actions may contain decisions and choices but contain more than that. A decision-perspective explains by causal inference modelling choices as calculated or programmed. The action-perspectives strive at understanding intentions of agents by philosophical interpretations of action stories. It is less limited to finding the logics for constructing worlds, to paraphrase Herbert Simon’s favorite philosopher Rudolf Carnap, than embarking on plausible, although not certain, reconstructions of intentions giving meaning to action stories. This can be illustrated by turning to Elizabeth Anscombe’s Wittgensteinian investigation of intentions as Aristotelian syllogistic reasoning. Her constant analytical care to defend a philosophy of action against metaphysical assumptions and taken-for-granted “psychologisms” shows that an action-perspective is as analytic as ever one of decision-making. What differs is that the latter seems constantly attracted by programming inquiry by “scientific methodology” whilst the latter is charmed by philosophical approaches to action welcoming fascinating conundrums, enigmas and human goofs in the reality of managerial practice. Management science wants to reduce management to logics, programs and models for formal decision making whereas management philosophy is closer to spotting the artfully entrepreneurial in actions. The latter points in the direction of engineering tools, the former to appreciate the toys of management as artwork. Finally the argument of Georg Henrik von Wright helps us see that the two are philosophically compatible; for in a pragmatically inspired management philosophy actions may well contain decisions. (shrink)

Initiated almost four decades ago in the form of an 11-bed clinic in Madurai, Aravind Eye Care System with its large network of hospitals, vision centres and community outreach programs is now recognized in India and beyond as a major actor of health care. This paper upholds the view that Aravind’s innovative characteristics call for the creation of a specific category: transformational entrepreneurship. It first clarifies what may be called the ‘Aravind paradox’: Aravind achieves compassion through Taylorism, (...) providing free eye care to poor patients while expanding its robust entrepreneurial model. It then analyses the social, cultural and policy implications of Aravind’s success, notably from the perspective of its contribution to the common good. Finally, the paper identifies the definitional components of transformational entrepreneurship. (shrink)

Moral distress (MD) has received considerable attention in the nursing literature over the past few decades. It has been found that high levels of MD can negatively impact nurses, patients, and their family and reduce the quality of patient care. This study aimed to investigate the potentially effective interventions to alleviate MD in critical care nurses. In this systematic review, a broad search of the literature was conducted in the international databases including PubMed/MEDLINE, Web of Science, and Scopus, (...) as well as Google Scholar search engine using keywords such as moral distress, intensive care unit, ICU, nurses, and critical care nurses from 1984, when the concept of MD was first introduced in the nursing literature, up to 29 October 2020. Studies focusing on the interventions for managing MD in critical care nurse were evaluated. The quality of eligible papers was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 8 studies fulfilled the eligibility criteria. Three studies had RCT design and five studies had quasi-experimental design. All studies were conducted in the United States or Iran. Educational workshop, moral empowerment program, social work intervention, nursing ethics huddles, and multifaceted resiliency bundle intervention were effective interventions for managing of MD among critical care nurses. There is limited but promising research evidence evaluating the efficacy of educational interventions for managing of MD among critical care nurses. Although some positive results have been reported, there is limited generalizable evidence due to the variability of interventions. These findings highlight the need for further studies to validate the efficacy of these interventions or develop more potent and efficient interventions for reducing MD in critical care nurses. (shrink)

Managing non-communicable diseases in crisis-affected and fragile humanitarian contexts requires special attention because primary health care systems often collapse or become compromised in such settings. As a result, addressing and managing these diseases become more challenging. Humanitarian organizations that intervene in crisis situations are increasingly including NCD management in the services they support and provide; however, they encounter a range of issues such as ensuring the quality of care, sustainability of programs, and the possibility of unintended harms. (...) This case study explores ethical considerations raised by a mobile NCD program run by an international humanitarian organization in a country affected by a protracted civil war. (shrink)

The program provides psycho-social support to foster adolescents during both their placement in foster families and in transitional period of leaving care, until they manage to cope with independent living. It is concieved as a direct answer to the needs of young people disturbed by the insecure patterns of attachment, who needed an opportunity to explore and modify negative experiences and acquire more successful models on how to build and maintain relationships, how to integrate the past, develop self-esteem and (...) successfully enter the world of adults. It is based on the principles of community psychology, the concept of the group as the transitional object and group dynamics. It was created through interaction with the beneficiaries, with emphasis on their participation and linking with all relevant players on the local level. Applied methods: self-support groups, psychological workshops, supportive activities in socialization and social integration, trainings, educational courses, counselling service, co-operation with foster parents, schools, local community and participation activities with focus on campaigning for development of aftercare services. The Manual, which resulted from the programme, is prompting professionals to develop new services entitled to children and youth and to involve users themselves in the reforms of the system. (shrink)

The passing of the Patient Protection and Affordable Care Act is a triumph for the field of public health. Its inclusion of many provisions intended to prevent illness and promote health endorses the core belief of public health as expressed by Dr. Georges Benjamin, the long-time executive director of the American Public Health Association, in a Washington Post opinion piece praising ACA for “provid[ing] care as far upstream as possible… [in order to] reduce costs by identifying problems early (...) and then managing them to reduce or eliminate the need for more costly care in the future.” In this article, I consider the conflict between ACA’s adoption of public health goals seeing population health and societal interests in protecting individuals from discrimination based on their health. The article focuses on one aspect of ACA which seeks to lower the costs to employers who provide health insurance for their employees by making it easier for them to offer their employees substantial incentives for participating in and meeting the goals of employer-sponsored Wellness Programs. (shrink)

“Female sexual dysfunction” is the type of contested disease that has sparked concern about the role of the pharmaceutical industry in medical science. Many policies have been proposed to manage industry influence without carefully evaluating whether the proposed policies would be successful. We consider a proposal for incorporating citizen stakeholders into scientific research and show, via a detailed case study of the pharmaceutical regulation of flibanserin, that such programs can be co-opted. In closing, we use Holman’s asymmetric arms race (...) framework as a tool for evaluating policies in industry-funded science. (shrink)