ABSTRACT
AIM: To scope the international literature about registered nurses delegated models of care to unlicenced workers, identify gaps and reflect upon how the evidence relates to nursing in multiple contexts. DESIGN: Scoping review of the peer reviewed literature from the year 2000 onwards, using the PRISMA-ScR checklist. METHODS: The study searched the following databases in February 2022: CINAHL, Medline, ProQuest, and SCOPUS, and included keywords, Boolean operators and subject headings relevant to registered nurses delegating the provision of care to unlicenced workers. RESULTS: A total of 49 articles met the eligibility criteria for this study, and relevant data were extractedThree models of delegation were highlighted within the literature: direct, indirect and a mixture of both. The data highlighted that direct delegation mainly occurred in acute contexts, with delegation decreasing with increasing patient acuity and/or complexity but the threshold of when this would occur was not clear. There was one intervention study that measured patient outcomes which could aid in the determination of what is effective delegation. For studies that did report on it (n = 6), there were few examples of better patient outcomes in cases where care was delegated from registered nurses to unlicenced workers. CONCLUSIONS: The scoping review highlighted heterogeneity in practice areas and methods of delegation practice. A key gap in literature is the absence of studies focusing on patient outcomes, with a clear baseline to measure and identify effective delegation practices. Additionally, the legal and logistical implications presented in both direct and indirect delegation practices is not evident in the literature. IMPLICATIONS FOR THE PROFESSION: Decisions related to delegation are often made at the service level and prescribed to those who work within the service, suggesting that models of indirect delegation are in fact not delegation at all, rather a re-distribution of nurses' work. RELEVANCE TO CLINICAL PRACTICE: Delegation is a vital component of the scope of practice of registered nurses. This review has highlighted unique differences in delegation by practice context, where the proliferation of unlicensed workers in certain contexts places a vastly different professional and legal burden on the registered nurse.
Subject(s)
Nurses , Personnel Delegation , HumansABSTRACT
Resumo O Brasil possui 5.570 municípios e em cada um deles governos eleitos dispõem de um estoque de cargos em comissão disponíveis para nomeação discricionária. É possível observar variações nas estratégias políticas adotadas para essas indicações? Os principais achados deste trabalho permitidos através do uso de estatística descritiva e inferencial foram (1) identificação de diferentes estratégias de nomeação política entre recompensa (escopo elevado/escolaridade baixa) e policy-making (escopo reduzido/escolaridade alta) (2) robusta relação entre IDH e nomeações políticas com perfil de policy-making inferindo menores custos de coordenação e assimetrias informacionais para principais/eleitores e, (3) variáveis partidárias e de competição eleitoral apresentaram resultados modestos como candidatas a explicar a adoção de estratégias de recompensa, da mesma forma que estratégias de recompensa - maior proporção de CCs e menor escolaridade destes - não afetaram as razões de chance de incumbentes nas eleições municipais seguintes.
Resumen Brasil tiene 5.570 municipios y en cada uno de ellos los gobiernos elegidos electos tienen un stock de puestos en comisión disponibles para su nombramiento discrecional. ¿Es posible observar variaciones en las estrategias políticas adoptadas para estas candidaturas? Los principales hallazgos de este trabajo obtenidos mediante el uso de estadísticas descriptivas e inferenciales fueron (1) identificación de diferentes estrategias de nombramiento político entre recompensa (alcance alto/educación baja) y formulación de políticas (alcance reducido/educación alta); (2) relación sólida entre el IDH y los nombramientos políticos con un perfil de hacedor de políticas que infiere menores costos de coordinación y asimetrías de información para los principales/votantes y, (3) las variables de competencia electoral y partidaria mostraron resultados modestos como candidatas para explicar la adopción de estrategias de recompensa, de la misma manera que las estrategias de recompensa -mayor proporción de CC y menor escolaridad de estos- no afectaron las razones de probabilidad de los titulares en las siguientes elecciones municipales.
Abstract Brazil has 5,570 municipalities, and each local government has a stock of appointed positions. This study adopted descriptive and inferential statistics to observe the variations in the political strategies adopted when filling these positions. The research identified (1) different political appointment strategies, from those based on reward (high scope/low education level) to strategies based on policy-making (reduced scope/high education level), (2) a robust relationship between HDI and political appointments with a policy-making profile inferring lower coordination costs and informational asymmetries for principals/voters, and (3) party and electoral competition variables showed modest results as potential explanatory factors to adopting reward-based strategies. Also, the adoption of reward-based strategies - cases where municipalities' employees presented a higher proportion of appointees with lower education levels - did not affect the odds ratios of incumbents in the next municipal elections.
Subject(s)
Reward , Cities , Personnel Delegation , GovernmentABSTRACT
AIM: To identify the evidence on factors that impact delegation practices by Registered Nurses to Assistants in Nursing in acute care hospitals. DESIGN: An integrative review. DATA SOURCES: Database searches were conducted between July 2011 and July 2021. REVIEW METHODS: We used the 12-step approach by Kable and colleagues to document the search strategy. The (Whittemore & Knafl. 2005. Journal of Advanced Nursing, 52(5), 546-553) integrative review framework method was adopted and the methodological quality of the studies was assessed using Joanna Briggs critical appraisal instruments. RESULTS: Nine studies were included. Delegation between the Registered Nurse and the Assistant in Nursing is a complex but critical leadership skill which is impacted by the Registered Nurse's understanding of the Assistant in Nursing's role, scope of practice and job description. Newly qualified nurses lacked the necessary leadership skills to delegate. Further education on delegation is required in pre-registration studies and during nurses' careers to ensure Registered Nurses are equipped with the skills and knowledge to delegate effectively. CONCLUSION: With increasing numbers of Assistants in Nursing working in the acute care environment, it is essential that Registered Nurses are equipped with the appropriate leadership skills to ensure safe delegation practice.
Subject(s)
Nurses , Nursing Assistants , Personnel Delegation , Humans , LeadershipABSTRACT
Este estudo objetivou descrever a identidade profissional de psicólogos judiciários, partindo do cenário contemporâneo da Psicologia Jurídica brasileira, contexto que envolve crises e conflitos sobre a forma de responder a atribuições e demandas do campo legal. Pela perspectiva da sociologia das identidades profissionais de Claude Dubar, sustenta-se a hipótese de que a identidade profissional do psicólogo judiciário depende de estratégias de compatibilização entre o pertencimento à categoria e as atribuições legais e institucionais. Participaram 95 psicólogos do quadro ativo do Tribunal de Justiça de São Paulo, que responderam a um formulário online sobre a percepção de si e do campo de atuação. Os dados foram submetidos à análise de conteúdo. Os resultados indicam a saliência da avaliação psicológica e da interdisciplinaridade na identidade profissional, e as rupturas identitárias diante de práticas verificatórias. Tais achados apontam a necessidade de participação da categoria na construção de suas atribuições; e dificuldades para o exercício das funções por limitações à autonomia profissional.(AU)
This study aimed to describe the professional identity of forensic psychologists, considering Brazil's Legal Psychology contemporary scenario which relates to a critical issues on how practitioners respond the demands of the legal system. Based on Claude Dubar's sociology of professional identities, we support the hypothesis that forensic psychologists' professional identity depends on strategies of compatibilization between belonging their reference group and the institutional attributions. There were 95 participants, all from the current staff of the Court of Justice of the state of São Paulo, who answered an online form. The data were subjected to content analysis. The results indicate a professional identity with noted salience on psychological assessment and interdisciplinarity, and the identity crises regarding verification practices. Such findings highlight the importance of practitioners taking part on the construction of their own tasks.(AU)
Este estudio tuvo como objetivo describir la identidad profesional de los psicólogos forenses, considerando el escenario de la Psicología Jurídica brasileña, que se relaciona con una crisis sobre si estos profesionales responden a las demandas del sistema legal. Teniendo en cuenta la sociología de las identidades profesionales de Claude Dubar, sostenemos la hipótesis de que la identidad profesional de los psicólogos forenses depende de estrategias de compatibilización entre la pertenencia a su grupo profesional y a instituciones. Participaron 95 psicólogos, quienes actuaban en el Tribunal de Justicia del Estado de São Paulo, a los cuales se aplicó un formulario en línea. Los datos se sometieron a análisis de contenido. Los resultados indican una identidad profesional saliente en cuanto a la evaluación psicológica y la interdisciplinariedad, pero también crisis de identidad en relación con las prácticas de verificación. Tales resultados señalan la importancia de que la categoría participe en la construcción de sus propias atribuciones.(AU)
Subject(s)
Humans , Male , Female , Social Identification , Forensic Psychiatry , Professional Training , Forensic Psychology , Organization and Administration , Philosophy , Professional Practice Location , Psychology , Psychology, Social , Research , Self Concept , Social Desirability , Social Environment , Social Sciences , Social Welfare , Social Work , Socialization , Socioeconomic Factors , Work , Decision Making, Organizational , Health Services Administration , Acting Out , Decision Support Systems, Management , Brazil , Adaptation, Psychological , Career Choice , Child Advocacy , Demography , Mental Health , Epidemiology, Descriptive , Interviews as Topic , Surveys and Questionnaires , Staff Development , Civil Rights , Professional Autonomy , Negotiating , Workplace , Confidentiality , Cultural Diversity , Knowledge , Criminal Law , Culture , Psychosocial Impact , Democracy , Personnel Delegation , Efficiency , Eligibility Determination , Employment , Health Research Evaluation , Workforce , User Embracement , Expert Testimony , Exploratory Behavior , Sociological Factors , Social Capital , Psychosocial Support Systems , Work Engagement , Socioeconomic Rights , Freedom , Psychosocial Functioning , Sociodemographic Factors , Belonging , Clinical Relevance , Diversity, Equity, Inclusion , Population Groups , Working Conditions , Health Promotion , Human Development , Interpersonal Relations , Job Description , Jurisprudence , Knowledge of Results, Psychological , Leadership , Anthropology, CulturalABSTRACT
Festa para comemorar a nomeação de Arouca para presidente da Fiocruz. A felicidade estampada nos rostos era o prenúncio de novos dias para a Fundação.
Subject(s)
Photograph , Famous Persons , Personnel DelegationABSTRACT
Resumo O objetivo deste trabalho é discutir as possíveis transformações das representações sociais sobre a loucura que circulam em um jornal impresso brasileiro, tomando como marco a Reforma Psiquiátrica Brasileira. Foram analisadas 1.385 matérias publicadas em formato eletrônico no período de janeiro de 1978 a dezembro de 2015, que tinham como tema central a loucura. As matérias foram analisadas por meio do software IRAMUTEQ, a partir de três corpora, cada um dos quais foi analisado separadamente e gerou um dendrograma de Classificação Hierárquica Descendente. A análise dos resultados nos permitiu verificar os movimentos de mudança e resistência das representações sociais ao longo do tempo. Os diversos nomes atribuídos à figura do louco sofreram mudanças no período analisado, de forma que algumas categorias foram mais suavizadas do que outras. Destaca-se a dinâmica social que levou a uma mudança e a forma como essa mudança foi incorporada, reorganizada e ressignificada sem provocar ruptura. Do ponto de vista metodológico, os dados dessa pesquisa nos chamam a atenção para as escolhas de descritores realizadas no percurso do trabalho e as consequências dessas escolhas nos resultados obtidos.(AU)
Abstract Based on the Brazilian Psychiatric Reform, this work aims to discuss possible transformations in the social representations of madness in a Brazilian printed newspaper. To this end, 1.385 media articles addressing the theme of madness published in electronic format from January 1978 to December 2015 were separately analyzed using three corpora with the support of IRAMUTEQ software, generating three dendrograms of different hierarchical classification. The results allow us to verify the changes and resistance movements of the social representations over time. Throughout the analyzed period, the several names attributed to the figure of the madman have undergone changes, with some categories having been softened more than others. This work highlights the social dynamics driving a change and the means through which it is incorporated, reorganized, and reframed without causing a rupture. From a methodological point of view, this research data call attention to the choices of descriptors and their consequences on the obtained results.(AU)
Resumen El objetivo de este trabajo es discutir las posibles transformaciones en las representaciones sociales que circulan en un periódico impreso brasileño sobre la locura, tomando como marco la Reforma Psiquiátrica Brasileña. Se analizaron 1.385 materias publicadas electrónicamente en el período de enero de 1978 a diciembre de 2015, cuyo tema central fue la locura. Las materias fueron analizadas con el apoyo del software Iramuteq a partir de tres corpus, analizados separadamente, lo que generó tres dendrogramas de la Clasificación Jerárquica Descendente. El análisis de los resultados nos permitió verificar los movimientos de cambio y resistencia de las representaciones sociales a lo largo del tiempo. Los distintos nombres atribuidos a la figura del loco a lo largo de los años han sufrido cambios, habiéndose suavizado algunas categorías más que otras. Se señalan las dinámicas sociales que propiciaron el cambio y la forma en que ese cambio se está incorporando, reorganizando y reformulando sin provocar una ruptura. Desde un punto de vista metodológico, los datos de esta investigación llaman nuestra atención sobre las elecciones de descriptores realizadas en el curso del trabajo y las consecuencias de estas elecciones sobre los resultados obtenidos.(AU)
Subject(s)
Humans , Psychiatry , Psychology, Social , Personnel Delegation , Mass Media , Mental Disorders , Social Medicine , Unified Health System , Mental Health , Community Psychiatry , Comprehensive Health Care , Delivery of Health Care , Social Interaction , Health Policy , Human Rights , InstitutionalizationABSTRACT
BACKGROUND: Emergency departments (EDs) in New Zealand are experiencing growing demand because of rising attendances, and this is having a negative effect on patients, staff and organisations. The expansion of traditional nursing roles is one solution that has been explored internationally to ameliorate the adverse effects of increasing patient attendances. AIM: To explore the attitudes of registered nurses and physicians employed in emergency medicine towards an expanded role for registered nurses in the ED setting. METHOD: A mixed-methods approach was adopted, in which data were collected in two phases, using interviews and questionnaires. Semi-structured, face-to-face interviews were held with clinical and non-clinical staff employed in emergency medicine, and questionnaires were distributed to 140 physicians and nurses employed in one ED. The data were analysed to identify themes and to determine the differences between nurse and physician respondents. FINDINGS: Ten ED staff were interviewed, including non-clinical managers (n=4), physicians (n=2) and nurses (n=4). Analysis of the interviews identified five themes: driving change; expanded nurse role; optimal environment; facilitating change; and optimising outcomes for patients. A total of 70 questionnaires were returned, with 63 from nurses and seven from physicians. Nurse respondents were more supportive than their physician colleagues of the need to expand the nursing role in the ED. CONCLUSION: The existing New Zealand nursing scope of practice has the capacity to develop roles, with nurses supporting this change more than physicians. If role expansion is undertaken, serious consideration needs to be given to developing clear professional boundaries to maintain patient safety and department flow.
Subject(s)
Clinical Competence , Emergency Nursing , Emergency Service, Hospital/organization & administration , Nurse's Role , Personnel Delegation , Physicians/psychology , Adult , Career Mobility , Female , Humans , Interviews as Topic , Male , New Zealand , Organizational Innovation , Quality Assurance, Health Care , Surveys and QuestionnairesABSTRACT
Physicians and all health professionals need to find an appropriate balance between the interests of individual patients and their organization's bottom line. Corporatization in health care has complicated such efforts. More and more health professionals function as employees of health care organizations, some of which value leaders' and shareholders' interests over those of patients. When faced with such conflicts, physicians bear a responsibility to put patients first and to advocate for their profession.
Subject(s)
Commerce , Delivery of Health Care/ethics , Employment/ethics , Job Description , Physicians/ethics , Professional Role , Workload , Conflict, Psychological , Delivery of Health Care/economics , Delivery of Health Care/organization & administration , Efficiency , Ethics, Medical , Humans , Leadership , Moral Obligations , Organizational Culture , Organizations , Personnel Delegation , Physician Assistants , Physicians/psychology , Quality of Health CareABSTRACT
Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.
Subject(s)
Delivery of Health Care/methods , HIV Infections/drug therapy , Health Services Accessibility , Antiretroviral Therapy, Highly Active , Comorbidity , Delivery of Health Care/organization & administration , Family Planning Services , HIV Infections/diagnosis , Humans , Medication Adherence , Noncommunicable Diseases/therapy , Peer Group , Personnel Delegation , Research , Retention in Care , Self-Help Groups , World Health OrganizationABSTRACT
BACKGROUND: General practitioner (GP) shortages and increasing demand for care led to the introduction of nurse practitioners (NPs) to primary care. Many concepts for task sharing among health professionals feature complexity. The aim of this narrative review was to examine how complexity is used as a factor for task allocation between GPs and NPs. METHODS: According to the PRISMA statement, PubMed and CINAHL were searched systematically, and eligibility criteria were applied to detect literature concerning GPs and NPs in primary care and complexity in the context of task allocation. Relevant information was extracted, and a narrative analysis was performed. RESULTS: Thirty-seven studies from seven countries were included, comprising quantitative, qualitative, and mixed methods. Complexity was used to describe patients, their needs, and health professionals' tasks. The understanding of the use of complexity as a factor for task allocation between NPs and GPs was based on the patient population (specific vs. unspecific), the setting (specific vs. unspecific), the numbers of health professionals involved (two vs. more than two), and the NP role (distinct model of care vs. no model). Despite similarities in these areas, the tasks which NPs perform range from providing minor to complex care. However, there is a slight trend towards NPs treating socially complex patients and GPs focusing on medically complex cases. CONCLUSION: Complexity as a concept is prominent in primary care but remains broad and inconsistent as a factor for task allocation between NPs and GPs. This review can be used as a point of reference when practitioners are seeking methods for task allocation in a collaborative primary care setting.
Subject(s)
General Practitioners , Nurse Practitioners , Personnel Delegation , Primary Health Care , Humans , Professional RoleABSTRACT
Resumo Objetivo Comparar o número de horas da demanda de cuidados de enfermagem ao paciente no pós-operatório de transplante renal, por meio dos instrumentos de Sistema de Classificação de Pacientes (SCP) e do Escore de Atividade de Enfermagem (NAS). Métodos Estudo de Coorte Prospectivo. A população foi composta pelos pacientes submetidos ao transplante renal com doador falecido no Hospital São Lucas da PUCRS, a avaliação ocorreu de 6 a 24 horas no pós-operatório imediato, nos dias subsequentes até a alta da UTI Cirúrgica e no 15º dia pós-operatório ou no dia da alta (o que tenha ocorrido primeiro). Resultados Completaram o estudo 73 pacientes, a média do SCP na primeira avaliação foi de 31,6 (cuidado intermediário), já no NAS a média foi de 86,5% (cuidado intensivo). Na última avaliação a pontuação encontrada no SCP foi de 15,5 (cuidado mínimo), no NAS a mediana foi de 50,1% (cuidado semi-intensivo). Não houve diferença significativa quando comparadas as pontuações obtidas na alta da UTI cirúrgica e na alta hospitalar. Conclusão Os achados deste estudo sugerem que há diferença entre o número de horas da demanda de cuidados ao transplantado renal no pós-operatório quando comparados os instrumentos SCP e NAS, e isso repercute também no tipo de cuidado.
Resumen Objetivo Comparar el número de horas de la demanda de cuidados de enfermería al paciente en posoperatorio de trasplante renal, por medio de los instrumentos de Sistema de Clasificación de Pacientes (SCP) y de la escala Nursing Activities Score (NAS). Métodos Estudio de cohorte prospectivo. La población fue formada por pacientes sometidos a trasplante renal con donante fallecido en el Hospital São Lucas de la universidad PUCRS. La evaluación se llevó a cabo de 6 a 24 horas en el posoperatorio inmediato, en los días subsiguientes hasta el alta de la UCI Quirúrgica y en el 15° día del posoperatorio o el día del alta (lo que haya sucedido primero). Resultados El estudio lo completaron 73 pacientes, el promedio del SCP en la primera evaluación fue 31,6 (cuidado intermedio) y en el NAS el promedio fue 86,5% (cuidado intensivo). En la última evaluación, la puntuación del SCP fue 15,5 (cuidado mínimo) y en el NAS la mediana fue 50,1% (cuidado semintensivo). No hubo diferencia significativa al comparar las valoraciones obtenidas en el alta de la UCI Quirúrgica y en el alta hospitalaria. Conclusión Los resultados de este estudio sugieren que hay diferencia entre el número de horas de la demanda de cuidados al trasplantado renal en el posoperatorio al comparar los instrumentos SCP y NAS, y eso repercute también en el tipo de cuidado.
Abstract Objective To compare the number of hours of nursing care demand for patients in the postoperative period after kidney transplantation, using the Patient Classification System (SCP) and Nursing Activity Score (NAS) tools. Methods a prospective cohort study. The population consisted of patients who underwent deceased donor kidney transplantation at PUCRS São Lucas Hospital. Assessment was carried out from 6 to 24 hours in the immediate postoperative period, on the days following discharge from the Surgical ICU and on the 15thpostoperative day or on the day of discharge (whichever occurred first). Results A total of 73 patients completed the study. The mean SCP in the first assessment was 31.6 (intermediate care), while in NAS the mean was 86.5% (intensive care). In the last assessment, the score found in the SCP was 15.5 (minimum care); In the NAS, the median was 50.1% (semi-intensive care). There were no significant differences when comparing the scores obtained at discharge from surgical ICU and discharge from hospital. Conclusion The findings of this study suggest that there is a difference between the number of hours of postoperative kidney transplant care demand when compared to the SCP and NAS tools, and this affects the type of care.
Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Kidney Transplantation/nursing , Personnel Delegation , Health Services Needs and Demand , Cohort Studies , Observational Studies as Topic , Nursing CareABSTRACT
Resumo Quantos são e a quais partidos estão filiados os nomeados para os cargos do alto e médio escalão da burocracia federal brasileira? Há diferenças entre mandatos presidenciais? Para responder essas perguntas, construímos uma base de dados inédita referente aos filiados a partidos políticos em cargos de direção e assessoramento superior (DAS). Nossa análise descritiva aponta que a proporção de filiados aumentou nos governos do Partido dos Trabalhadores (PT) e é maior entre nomeados sem vínculo com o setor público. A concentração de poder entre os partidos - principalmente entre o partido presidencial e os demais - variou de modo significativo entre presidentes. O controle partidário sobre os nomeados filiados é mais brando nos cargos de nível intermediário e maior nos níveis superiores. Entretanto, os filiados são minoria, mesmo nos cargos de mais alto poder político-administrativo. Por isso, sugerimos que, possivelmente, as redes de conexão política que definem os quadros da burocracia decisória também se constroem por meios extrapartidários e compreendê-las se mostra decisivo para dimensionar o peso da política partidária na burocracia ministerial e reinterpretar como o Poder Executivo constrói e gerencia a coalizão de governo e seu apoio no Poder Legislativo.
Resumen ¿Cuántos son y a qué partidos están afiliados los nominados para los puestos de rango superior y medio de la burocracia federal brasileña? ¿Hay diferencias entre los mandatos presidenciales? Para responder a estas preguntas, construimos una base de datos inédita referente a los afiliados a partidos políticos que ocupan cargos directivos y de asesoramiento superior (DAS). Nuestro análisis descriptivo muestra que la proporción de afiliados aumentó en los gobiernos del Partido de los Trabajadores (PT) y es mayor entre los nominados sin vínculo con el sector público. La concentración de poder entre los partidos -principalmente entre el partido presidencial y los demás- varió de modo significativo entre presidentes. El control del partido sobre los nominados afiliados es más moderado en los cargos de nivel medio y mayor en los rangos superiores. Sin embargo, los afiliados son minoría, incluso en los puestos de mayor poder político-administrativo. Por lo tanto, sugerimos que posiblemente las redes de conexión política que definen a los cuadros de la burocracia decisoria también se construyan por medios extrapartidarios, y comprenderlas es decisivo para dimensionar el peso de la política partidaria en la burocracia ministerial y reinterpretar cómo el Poder Ejecutivo construye y administra la coalición de gobierno y su apoyo en el Poder Legislativo.
Abstract How many are the top and middle-level Brazilian federal bureaucracy appointees, and to which party are they affiliated? Are there differences among presidential mandates regarding the number of these professionals and their party affiliation? This study seeks to answer these questions, by building a new database that gathers the number of party-affiliated public officials that were appointed to Cargos de Direção e Assessoramento Superior (DAS) (position of director and high level consultant). Descriptive analysis found that the proportion of party-affiliated among appointees increased during the Workers' Party (PT) governments and higher among appointed professionals that were not civil servant. The power-sharing among parties - mainly between the party of the president and the others - varies significantly according to the government. The partisan control over appointees is milder in middle-level and stronger at top-level positions. However, a minority of appointees are party members, even among the top-level bureaucracy. Therefore, we suggest that the political networks go beyond the party affiliations. To understand these networks it is necessary to reassess the role of party politics in shaping the executive agenda and enable reinterpretation of how presidents build and manage the government coalition and the support to their agenda in the legislative arena.
Subject(s)
Politics , Executive , Personnel Delegation , GovernmentABSTRACT
OBJECTIVE: Although many contextual factors can facilitate or impede primary care managers' work with quality and safety, research on how these factors influences the managers' continuous improvement efforts is scarce. This study explored how primary care managers experience the impact of a variety of contextual factors on their daily quality and safety work. DESIGN: The study has a qualitative design. Nine semistructured qualitative interviews were conducted at the participants' workplaces. Systematic text condensation was used for analysis. SETTING: Five nursing homes and three home care services in Norway. PARTICIPANTS: Female primary care managers at different levels, working in different units and municipalities varying in size and location. RESULTS: The participants cited the lack of time and money as a significant impediment to quality and safety, and these resources had to be carefully allocated. They emphasised the importance of networks and competence for their quality and safety work. Delegation of responsibility among employees helped create engagement, improved competence and ensured that new knowledge reached all employees. External guidelines and demands helped them to systematise their work and explain the necessity of quality and safety work to their employees, if they were compliant with daily clinical practice in the organisation. CONCLUSIONS: Numerous contextual factors influence the managers by determining the leeway that they have in quality and safety work, by setting the budgetary constraints and defining available competence, networks and regulation. At first glance, these factors appear fixed, but our findings underscore the importance of primary care managers acting on and negotiating the environment in which they conduct their daily quality and safety work. More research is needed to understand how these managers strategise to overcome the impediments to quality and safety.
Subject(s)
Home Care Services/standards , Nursing Homes/standards , Patient Safety/standards , Primary Health Care/standards , Quality Assurance, Health Care/standards , Adult , Clinical Competence/standards , Female , Home Care Services/organization & administration , Humans , Middle Aged , Norway , Nursing Homes/organization & administration , Personnel Delegation/organization & administration , Primary Health Care/organization & administration , Qualitative Research , Quality Assurance, Health Care/organization & administrationABSTRACT
Clinical guidelines (GLs) are widely adopted in order to improve the quality of patient care, and to optimize it. To achieve such goals, their application on a specific patient usually requires the interventions of different agents, with different roles (e.g., physician, nurse), abilities (e.g., specialist in the treatment of alcohol-related problems) and contexts (e.g., many chronic patients may be treated at home). Additionally, the responsibility of the application of a guideline to a patient is usually retained by a physician, but delegation of responsibility (of the whole guideline, or of a part of it) is often used\required (e.g., delegation to a specialist), as well as the possibility, for a responsible, to select the executor of an action (e.g., a physician may retain the responsibility of an action, but delegate to a nurse its execution). To manage such phenomena, proper support to agent interaction and communication must be provided, providing agents with facilities for (1) treatment continuity (2) contextualization, (3) responsibility assignment and delegation (4) check of agent "appropriateness". In this paper we extend GLARE, a computerized GL management system, to support such needs. We illustrate our approach by means of a practical case study.
Subject(s)
Alcohol-Related Disorders/therapy , Continuity of Patient Care/organization & administration , Practice Guidelines as Topic , Therapy, Computer-Assisted , Humans , Information Dissemination , Interdisciplinary Communication , Personnel DelegationABSTRACT
Resumen: En el presente artículo el autor analiza los presupuestos y límites del principio de confianza como criterio de concreción del cuidado debido exigible a los médicos. Para ello, se distingue entre división horizontal y vertical del trabajo. En el ámbito de la división horizontal, se destaca la relevancia que tiene una clara delimitación de ámbitos de responsabilidad para la vigencia del principio de confianza. En el plano de la división vertical, se explica la delegación de actividades médicas en enfermeras y auxiliares paramédicos (contemplada en el inc. 2º del art. 113 del Código Sanitario), así como los deberes de elección, instrucción y supervigilancia que han de cumplirse para que los facultativos puedan confiar en la correcta ejecución de las tareas delegadas.
Resumo: No presente artigo o autor analisa os pressupostos e limites do princípio da confiança como critério de materialização do cuidado devido exigido dos médicos. Para isso se distingue entre divisão horizontal e vertical do trabalho. No âmbito da divisão horizontal se destaca a relevância que tem uma clara delimitação de âmbitos de responsabilidade para a vigência do princípio da confiança. No plano vertical se explica a delegação de atividades médicas para enfermeiras e auxiliares paramédicos (contemplada no parágrafo 2º do artigo 113 do Código Sanitário), assim como os deveres de eleição, instrução e supervigilância que se tem de cumprir para que os médicos possam confiar na correta execução das tarefas delegadas.
Abstract: In the present article, the author analyzes the pre-requisites and boundaries of the principle of reliance as a criterion for determining the due care that can be demanded from physicians. For that purpose, a distinction is made between horizontal and vertical division of labour. Regarding horizontal division, the relevance of a clear delimitation of scopes of responsibility for the principle of reliance to apply is highlighted. Regarding vertical division, an explanation about delegation of medical activities to nurses and paramedic auxiliaries (contemplated in indent 2 of article 113 of the Sanitary Code) is offered, as well as one about the duties of selection, instruction and supervision that must be fulfilled for the physicians to be allowed to trust in the correct execution of the delegated tasks.
Subject(s)
Humans , Physicians , Criminal Liability , Trust , Personnel DelegationABSTRACT
BACKGROUND: Resident work hour restrictions and required protected didactic time limit their ability to perform clinical duties and participate in structured education. Advanced practice providers (APPs) have previoulsy been shown to positively impact patients' outcomes and overall hospital costs. We describe a model in which nurse practitioners (NPs) improve resident education and American Board of Surgery In Training Examination (ABSITE) scores by providing support to our trauma and acute care surgery (ACS) service thereby protecting resident didactic time. MATERIALS AND METHODS: A new educational model aimed to improve ABSITE scores was created, increasing protected resident didactic time. The addition of three full-time NPs to the ACS service allowed implementation of this redesigned academic curriculum to be put into effect without neglecting patient or service-related responsibilities that were previously fulfilled by resident staff. Resident ABSITE results including standard score, percent correct, and percentile were compared before and after the educational changes were instituted. RESULTS: Eleven residents' scores were included. For each ABSITE score, we used a mixed model with time and postgraduate year (PGY) level as fixed effects and subject ID as a random effect. The interaction term between PGY level and time was not significant and removed from the model. A significant main effect of PGY level and of time was then observed. A statistically significant improvement in ABSITE scores after intervention was observed across all the PGY levels. Standard score increased 77.3 points (P-value = 0.001), percent correct increased 5.9% (P-value = 0.002), and percentile increased 23.8 (P-value = 0.02). Following the educational reform, no residents scored below the 35th percentile. CONCLUSIONS: Utilization of NPs on our ACS service provided adequate service coverage, allowing the implementation of an educational reform increasing protected resident education time and improved ABSITE scores.
Subject(s)
General Surgery/education , Internship and Residency/methods , Models, Educational , Nurse Practitioners/organization & administration , Workload/standards , Educational Measurement/statistics & numerical data , Hospitals, Teaching/organization & administration , Hospitals, Teaching/standards , Humans , Internship and Residency/standards , Internship and Residency/statistics & numerical data , Personnel Delegation/organization & administration , Retrospective Studies , Time Factors , Trauma Centers/organization & administration , Trauma Centers/standards , United StatesSubject(s)
Contract Services/legislation & jurisprudence , Interdisciplinary Communication , Intersectoral Collaboration , National Health Programs/legislation & jurisprudence , Physician-Patient Relations , Quality Assurance, Health Care/legislation & jurisprudence , Radiology/legislation & jurisprudence , Germany , Humans , Patient Care Team/legislation & jurisprudence , Personnel Delegation , Referral and Consultation/legislation & jurisprudenceABSTRACT
BACKGROUND: Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles. OBJECTIVES: (1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review. SEARCH METHODS: We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed. SELECTION CRITERIA: We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively. DATA COLLECTION AND ANALYSIS: We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness. MAIN RESULTS: We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses. AUTHORS' CONCLUSIONS: Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.
Subject(s)
Health Services Needs and Demand , Personnel Delegation , Primary Health Care/standards , Qualitative Research , Quality of Health Care , Humans , Nurse Practitioners , Nurses , Primary Health Care/organization & administrationABSTRACT
BACKGROUND: Clinical practice guidelines (CPGs) in medicine are recommendations supported by systematic review of evidence to facilitate optimal patient outcomes. Primary care practices are expected to implement more than 200 CPGs, overwhelming many practices. This qualitative study elucidated the perspectives and priorities of family medicine physicians and office managers in grouping CPGs to facilitate implementation. METHODS: A qualitative study was performed using individual, semistructured interviews. During the interviews the participants completed an open card-sort exercise grouping 20 CPGs. Purposive sampling was used to identify family medicine physicians and office managers practicing in medically underserved zip codes listed in the local medical society directory. Seven physicians and 6 office managers were interviewed. The interviews were transcribed and analyzed using thematic analysis and compared with the card-sort results. RESULTS: Thematic content analysis identified priorities and perspectives of office managers and physicians when grouping multiple CPGs for implementation: delegation, personalization, triggers, and change management. The card sort exercise revealed grouping by standardized preventive care visit, standardized rooming and discharge processes, and chronic illness. Chronic illness-based groupings and personalization of guidelines were recognized as presenting barriers to delegation of CPGs to the care team. Development of standardized preventive exams, standard rooming and discharge processes and chronic disease management were identified as promoting CPG adherence through team-based care. Standardized workflows provided opportunities for task delegation through predicable roles. Medicalization of CPG implementation relied heavily on the physician alone to remember to adhere to CPGs and inhibited task sharing by not giving office staff clear disease-based protocols to follow. CONCLUSIONS: This study identified priorities and perspectives of office managers and physicians when grouping multiple CPGs for concomitant implementation: delegation, personalization, triggers, and change management. Successful implementation was perceived to be associated with standardized preventive exams, standard rooming and discharge processes, and chronic disease management.
Subject(s)
Attitude of Health Personnel , Office Management , Physicians, Family , Practice Guidelines as Topic , Workflow , Adult , Ambulatory Care/organization & administration , Chronic Disease , Female , Humans , Implementation Science , Male , Middle Aged , Nurses , Patient Discharge , Personnel Delegation , Preventive Medicine , Professional Role , Qualitative Research , Young AdultABSTRACT
Este artigo baseia-se em pesquisa doutoral realizada (Silva, 2017) e objetiva discutir o ato classificatório dos ditos transtornos mentais, a partir da abordagem de teóricos situados na perspectiva social-estruturalista, na Antropologia e na Sociologia da Saúde, no sentido de compreender como são utilizados os manuais nosológicos atuais como formas de configuração clínica das doenças psíquicas. A problemática compõe as seguintes questões norteadoras: Como explicar o ato de classificar? De onde vem essa prática humana? É comum a todas as culturas? Faz parte de uma lógica apriorística da mente humana ou é uma habilidade baseada na realidade empírica e social? O que revela dos mecanismos de distinção e de distribuição de poder num grupo? Para responder a essas questões foi realizada uma pesquisa de abordagem qualitativa, com uso de pesquisa documental, observação sistemática e entrevistas abertas com escuta de narrativas de docentes de ensino básico no Estado do Amapá, com experiências de sofrimento e adoecimento psíquico, atendidos em uma unidade de atendimento psicossocial, lócus da pesquisa. Assim, foram consultados 822 prontuários, entrevistados 40 docentes, 10 técnicos da equipe multidisciplinar e 10 gestores escolares. Com base em discussões teóricas e em dados construídos, entendemos que a tendência classificatória, em saúde mental, pode ser útil como instrumental técnico-cientifico para facilitar o processo de tratamento, porém se realizado com muito cuidado e parcimônia, caso contrário, poderá fornecer bases para a estigmatização social de pessoas
This article is based on a doctoral research (Silva, 2017) and aims to discuss the classificatory act of the so-called mental disorders, from the approach of theorists situated in the social-structuralist perspective, Anthropology and Health Sociology, in the sense of understanding how the current nosological manuals are used as forms of clinical configuration of psychic diseases. The problem composes the following guiding questions: How to explain the act of classifying? Where does this human practice come from? Is it common to all cultures? Is it part of an a priori logic of the human mind or is it a skill based on empirical and social reality? What does it reveal about the mechanisms of distinction and distribution of power in a group? In order to answer these questions, a qualitative research was carried out using documentary research, systematic observation and narratives of teachers of basic education in the State of Amapá, who have experienced suffering and psychic illness, and who attended in a unit of psychosocial care, locus of our research. Thus, 822 medical charts were consulted, 40 teachers were interviewed, 10 multidisciplinary team technicians and 10 school managers were interviewed. Based on theoretical discussions and constructed data, we understand that the classification tendency in mental health may be useful as a technical-scientific instrument to facilitate the treatment process, since it is performed with great care and parsimony, otherwise it may provide bases for the social stigmatization of people
