A meta-regression of the impact of policy on the efficacy of individual placement and support.

OBJECTIVE: Individual placement and support (IPS) has shown consistently better outcomes on competitive employment for patients with severe mental illness than traditional vocational rehabilitation. The evidence for efficacy originates from few countries, and generalization to different countries has been questioned. This has delayed implementation of IPS and led to requests for country-specific RCTs. This meta-analysis examines if evidence for IPS efficacy can be generalized between rather different countries. METHODS: A systematic search was conducted according to PRISMA guidelines to identify RCTs. Overall efficacy was established by meta-analysis. The generalizability of IPS efficacy between countries was analysed by random-effects meta-regression, employing country- and date-specific contextual data obtained from the OECD and the World Bank. RESULTS: The systematic review identified 27 RCTs. Employment rates are more than doubled in IPS compared with standard vocational rehabilitation (RR 2.07 95% CI 1.82-2.35). The efficacy of IPS was marginally moderated by strong legal protection against dismissals. It was not moderated by regulation of temporary employment, generosity of disability benefits, type of integration policies, GDP, unemployment rate or employment rate for those with low education. CONCLUSIONS: The evidence for efficacy of IPS is very strong. The efficacy of IPS can be generalized between countries.

Priority dilemmas in dialysis: the impact of old age.

AIM: This study explores priority dilemmas in dialysis treatment and care offered elderly patients within the Norwegian public healthcare system. BACKGROUND: Inadequate healthcare due to advanced age is frequently reported in Norway. The Norwegian guidelines for healthcare priorities state that age alone is not a relevant criterion. However, chronological age, if it affects the risk or effect of medical treatment, can be a legitimate criterion. METHOD: A qualitative approach is used. Data were collected through semistructured interviews and analysed through hermeneutical content analysis. The informants were five physicians and four nurses from dialysis wards. FINDINGS: Pressing priority dilemmas centre around decision-making concerning withholding and withdrawal of dialysis treatment. Advanced age is rarely an absolute or sole priority criterion. It seems, however, that advanced age appears to be a more subtle criterion in relation with, for example, comorbidity, functional status and cognitive impairment. Nurses primarily prioritise specialised dialysis care and not comprehensive nursing care. The complex needs of elderly patients are therefore often not always met. CONCLUSIONS: Clinical priorities should be made more transparent in order to secure legitimate and fair resource allocation in dialysis treatment and care. Difficult decisions concerning withholding or withdrawal of dialysis ought to be openly discussed within the healthcare team as well as with patients and significant others. The biomedical focus and limitations on comprehensive care during dialysis should be debated.

Clinical prioritisations of healthcare for the aged--professional roles.

BACKGROUND: Although fair distribution of healthcare services for older patients is an important challenge, qualitative research exploring clinicians' considerations in clinical prioritisation within this field is scarce. OBJECTIVES: To explore how clinicians understand their professional role in clinical prioritisations in healthcare services for old patients. DESIGN: A semi-structured interview-guide was employed to interview 45 clinicians working with older patients. The interviews were analysed qualitatively using hermeneutical content analysis. PARTICIPANTS: 20 physicians and 25 nurses working in public hospitals and nursing homes in different parts of Norway. RESULTS AND INTERPRETATIONS: The clinicians struggle with not being able to attend to the comprehensive needs of older patients, and being unfaithful to professional ideals and expectations. There is a tendency towards lowering the standards and narrowing the role of the clinician. This is done in order to secure the vital needs of the patient, but is at the expense of good practice and holistic role modelling. Increased specialisation, advances and increase in medical interventions, economical incentives, organisational structures, and biomedical paradigms, may all contribute to a narrowing of the clinicians' role. CONCLUSION: Distributing healthcare services in a fair way is generally not described as integral to the clinicians' role in clinical prioritisations. If considerations of justice are not included in clinicians' role, it is likely that others will shape major parts of their roles and responsibilities in clinical prioritisations. Fair distribution of healthcare services for older patients is possible only if clinicians accept responsibility in these questions.

In quest of justice? Clinical prioritisation in healthcare for the aged.

BACKGROUND: A fair distribution of healthcare services for older patients is an important challenge, but qualitative research exploring clinicians' consideration in daily clinical prioritisation in healthcare services for the aged is scarce. OBJECTIVES: To explore what kind of criteria, values, and other relevant considerations are important in clinical prioritisations in healthcare services for older patients. DESIGN: A semi-structured interview-guide was used to interview 45 clinicians working with older patients. The interviews were analysed qualitatively using hermeneutical content analysis and template organising style. PARTICIPANTS: 20 physicians and 25 nurses working in public hospitals and nursing homes in different parts of Norway. RESULTS AND INTERPRETATIONS: Important dilemmas relate to under-provision of community care and comprehensive approaches, and over-utilisation of certain specialised services. Overt ageism is generally not reported, but the healthcare services for the aged seem to be inadequate due to more subtle processes, for example, dominating considerations and ideals and operating conditions that do not pay sufficient attention to older patients' needs and considerations of justice. Clinical prioritisations are described as being dominated by adapting traditional biomedical approaches to the operating conditions. Many of the clinicians indicate that there is a potential for improving end of life decisions and for reducing exaggerated use of life-prolonging treatment and hospitalisations. CONCLUSION: The interviews in this study indicate that considerations of justice and patients' perspectives should be given more attention to strike a balance between specialised medical approaches and more general and comprehensive approaches in healthcare services for older patients.

Life or death. The social impact of paramedics and first responders in landmine-infested villages in northern Iraq.

INTRODUCTION: Landmines are indiscriminate weapons that mainly injure poor populations in the developing world. Pre-hospital treatment by village-based paramedics and first responders has reduced mortality, but little is known about the social impact of paramedic and first responder training in villages. The aim of this study was to understand how villagers in socially deprived, mine-infested villages experience the establishment of paramedic and first responder chains of survival. METHODS: The study used focus-group interviews conducted in four villages in northern Iraq, to explore villagers' perceptions of the impact of paramedic and first responder training. The material was analyzed using grounded theory, with the main category identified entitled 'life or death', with three subcategories: 'living on the edge', 'demanding equal rights', and 'adapting to new needs'. RESULTS: The paramedics were perceived by the villagers as having a large impact on the social life of the village, first as an emergency medical resource, and also as a prerequisite for the villages' continued existence. The system represented one of the few services offered by outside society to villages that lacked health care, schools, electricity, roads, and clean water. Despite an improved economic situation in the larger society, conditions in the villages had deteriorated. Although originally intended as an emergency care system for land mine victims, the system was adapted to include the role of a general medical resource in the villages. This adaptation was perceived as useful by the villagers, and necessary for their continued trust in the system. A prerequisite for this adaptation was that the program coordinator was a villager himself, and that the program deviated from its originally fixed time period. This flexibility depended on very close cooperation between expatriate and local program managers. CONCLUSIONS: Our findings indicate that the paramedic system made a wider impact than just the provision of emergency health care. The program earned trust through a strong local anchor, and by adapting to the needs of the population served.

Ethical decision making in neonatal units--the normative significance of vitality.

This article will be concerned with the phenomenon of vitality, which emerged as one of the main findings in a larger grounded theory study about life and death decisions in hospitals' neonatal units. Definite signs showing the new-born infant's energy and vigour contributed to the clinician's judgements about life expectancy and the continuation or termination of medical treatment. In this paper we will discuss the normative importance of vitality as a diagnostic cue and will argue that vitality, as a sign perceived by doctors and nurses, has moral significance and represents a legitimate contribution to clinical decision-making in difficult cases where the child's life is at stake. We will argue that these clinical intuitions can be justified on a moral basis but only with certain qualifications that accounts for a certain objectivity and intersubjective reliability in the therapeutic judgements.

'They have to show that they can make it': vitality as a criterion for the prognosis of premature infants.

In this article, the vitality of premature infants will be described and discussed. Vitality was one of the main factors in a grounded theory study in which the aim was to generate knowledge concerning the ethical decision-making processes with which nurses and physicians are faced in a neonatal unit. Which assessments underlie decisions about whether to start, continue or stop medical treatment of very sick premature babies? A descriptive study design, including 120 hours of field observations and 22 qualitative in-depth interviews with doctors and nurses, was chosen. Strauss and Glaser's comparative method was used to analyse the field observations and interviews. The findings indicate that life-and-death decisions are somewhat ambivalent; experience does not always make them easier. In situations of ambiguity, decisions also seem to be based upon the vitality of the babies concerned.

[Vitality as a criterion of the prognosis in the treatment of premature children?]. / Livsgnist som prognostisk tegn i behandlingen av premature barn?

The aim of this study was to generate knowledge about the ethical decision-making processes nurses and physicians are faced with in a neonatal unit. What are the ethical assessments underlying decisions about whether to start, continue or stop medical treatment of very sick premature babies? The theoretical framework was deontological ethics, utilitarianism, Aristotelian virtue ethics theory and an ethics of proximity. A descriptive study design with 120 hours of field observations and 22 qualitative in-depth interviews was chosen. Strauss & Glaser's comparative method, grounded theory, was used to analyze the field observations and interviews. The findings seem to indicate that ethical decisions are somewhat ambivalent. Experience does not always make these decisions easier. There are indications that nurses and physicians use elements from all the different ethical positions. In situations of ambiguity, decisions are also based upon the vitality of the babies.

When the home becomes a prison: living with a severely disabled child.

The aim of this study was to generate knowledge about how parents who have been part of an ethical decision-making process concerning a son or daughter in a neonatal unit experience life with a severely disabled child. A descriptive study design was chosen using 30 hours of field observations and seven in-depth interviews, carried out over a period of five months with parents who had been faced with ethical decisions concerning their own children in a neonatal unit. Strauss and Glaser's constant comparative method was used for the analysis. The findings seem to indicate that these parents have an extremely tough life. Their relationships with their children are somewhat ambivalent. The children are very dependent on their parents, who in some ways both love and hate them. Too little rest and sleep and feeding the children are the most serious problems. The parents require respite facilities. The home can seem like a prison, from which it is impossible to escape. It is like having a baby who never grows up.