A review of the implementation and research strategies of advance care planning in nursing homes.

BACKGROUND: Nursing home (NH) patients have complex health problems, disabilities and needs for Advance Care Planning (ACP). The implementation of ACP in NHs is a neglected research topic, yet it may optimize the intervention efficacy, or provide explanations for low efficacy. This scoping review investigates methods, design and outcomes and the implementation of ACP (i.e., themes and guiding questions, setting, facilitators, implementers, and promoters/barriers). METHODS: A systematic search using ACP MESH terms and keywords was conducted in CINAHL, Medline, PsychINFO, Embase and Cochrane libraries. We excluded studies on home-dwelling and hospital patients, including only specific diagnoses and/or chart-based interventions without conversations. RESULTS: Sixteen papers were included. There were large variations in definitions and content of ACP, study design, implementation strategies and outcomes. Often, the ACP intervention or implementation processes were not described in detail. Few studies included patients lacking decision-making capacity, despite the fact that this group is significantly present in most NHs. The chief ACP implementation strategy was education of staff. Among others, ACP improved documentation of and adherence to preferences. Important implementation barriers were non-attending NH physicians, legal challenges and reluctance to participate among personnel and relatives. CONCLUSION: ACP intervention studies in NHs are few and heterogeneous. Variation in ACP definitions may be related to cultural and legal differences. This variation, along with sparse information about procedures, makes it difficult to collate and compare research results. Essential implementation considerations relate to the involvement and education of nurses, physicians and leaders.

Medical women -- towards full integration? An analysis of the specialty choices made by two cohorts of Norwegian doctors.

In Norway, as in most Western countries, doctors' choice of specialty has been strongly gendered. Female physicians have tended both to specialise to a lesser degree and to enter other specialties than male colleagues. In spite of the increase of women in medicine, previous studies have not managed to show any changes in this pattern. Comparing data from two cohorts of Norwegian doctors, authorised in 1970-73 and 1980-83 respectively, this article demonstrates that changes are in fact taking place. The changes are, however, not unequivocal. Firstly, women in these cohorts specialise to a very high degree and just as much as their male colleagues. Secondly, women doctors of the 1980s cohort spread their choice of specialisation over more fields than their predecessors did. They have, for example, started to enter surgery, although still not as often as men. Thirdly, proportionally more doctors of the 1980s cohort than the 1970s cohort have chosen general practice as their main specialty, and this applies to both women and men. Fourthly, there are tendencies towards an increasing concentration of women in some disciplines such as obstetrics and gynaecology, as well as paediatrics. These changes in doctors' pattern of specialisation are discussed as consequences of socially shaped individual preferences, structural aspects of the Norwegian health system and the existence of gendered closure mechanisms within specific medical fields. Although the medical profession still appears as a gender differentiated community, the article gives a more dynamic and in some respects a more optimistic picture than earlier studies.

The doctor-nurse relationship: how easy is it to be a female doctor co-operating with a female nurse?

The doctor-nurse relationship has traditionally been a man-woman relationship. However, in recent years, the number of women studying medicine has increased in all West-European countries, and in 1997, 29% of active Norwegian doctors were women. The doctor-nurse relationship has often been described as a dominant-subservient relationship with a clear understanding that the doctor is a man and the nurse is a woman. This article examines what happens to the doctor-nurse relationship when both are women: how do female doctors experience their relationship to female nurses? It is based on two sets of data, qualitative interviews with 15 doctors and a nationwide survey of 3589 doctors. The results show that in the experience of many doctors, male and female, the doctor-nurse relationship is influenced by the doctor's gender. Female doctors often find that they are met with less respect and confidence and are given less help than their male colleagues. The doctors' own interpretation of this is partly that the nurses' wish to reduce status differences between the two groups affects female doctors more than male, and partly that there is an "erotic game" taking place between male doctors and female nurses. In order to tackle the experience of differential treatment, the strategies chosen by female doctors include doing as much as possible themselves and making friends with the nurses. The results are considered in light of structural changes both in society at large and within the health services, with emphasis on the recent convergence of status between the two occupational groups.

[Positive feedback for good medical work--a short-supply commodity?]. / Anerkjennelse for godt legearbeid--en mangelvare?

In a nationwide survey of the working environment of Norwegian physicians every second respondent reported seldom or never being appreciated or praised for good work by their superiors. Nurses, colleagues and auxiliaries are more frequent sources of such appreciation. Very little of the variance in doctors' experience of positive feedback is explained by job variables: a doctor who does not receive supportive feedback cannot attribute this to unwise choice of specialty or type of employer, or to age, sex or position in the hierarchy. The experiences of male and female doctors are very much the same. Whether the doctors are appreciated and praised for good work seems to depend rather on certain traits of their personality.

[Time stress among Norwegian physicians]. / Tidspress blant norske leger.

In this paper perceived stress at work is examined in a nationwide representative sample of Norwegian physicians. Four questions were asked about how often the doctors experienced their working conditions as hectic and bothersome, that the work load was unacceptable, that the large number of duties prevented them form working effectively and that they had difficulty in working reasonably undisturbed. 28% of the respondents stated that their work load was often or fairly often unacceptable, while 43% often or fairly often found it difficult to carry out various tasks without being disturbed. While 19% of the physicians perceived their working situation as often hectic and bothersome, the corresponding figure among other academics was 5%. When the four questions were combined to form a measure of stress, about one fifth of the doctors proved to be highly stressed. In a multiple linear regression analysis (N = 2,304) the physician's perceived autonomy was the strongest predictor of stress, i.e. doctors who feel they can substantially influence the planning and organization of their work achieve the lowest scores for stress. Heads of hospital departments are more stressed than physicians who work outside hospital. Stress also increases with increasing frequency of overtime and with increasing amounts of voluntary overtime.

[Physicians' own control of their working situation--a myth?]. / Legers kontroll over egen arbeidssituasjon--en myte?

The idea that physicians have more autonomy than others in regard to their work does not match the physicians' own experience. In 1993, Norwegian physicians experienced less control over their own work than other professionals and employees in Norwegian society did. However, large variations exist between groups of physicians. Hospital doctors report less autonomy than other physicians do. Among specialists, surgeons report the lowest degree of job control. Female physicians report having less autonomy than their male colleagues, regardless of where or with what they work. Job control increases with age, both for female and for male physicians.

[Good quality in nursing home services? An analysis based on assessments by the head nurse]. / God kvalitet i sykehjemstjenesten? En analyse av virksomheten basert på avdelingsledernes vurderinger.

Until quite recently few systematic studies have been carried out to determine quality in Norwegian nursing homes. Contrary to the negative pictures depicted in the media, 212 head nurses in a sample of 116 nursing homes assessed the overall quality as fairly good. However, the results show a clear potential for improvement at some nursing homes. About 3/5 of the residents have single rooms, and the results confirm that this fraction should be increased. In several nursing homes the normal every day life of non-demented residents is strained; one third of the head nurses characterize the social environment of this group as unsatisfactory. Many residents are in need of medical care and most head nurses are pleased with the medical service. However, too few hours and lack of continuity cause dissatisfaction at one out of ten units. The study demonstrates a need for more frankness and for possibilities for the residents to express their views about life in the nursing home.

[Is gender of significance for specialization of physicians? An analysis of specialization degree among female and male physicians]. / Har kjønn betydning for om legen blir spesialist? En analyse av spesialiseringsgrad blant kvinnelige og mannlige leger.

Although there has been a substantial increase in the number of women in medicine, we still find strong gender differences in career patterns. Female physicians specialize to a lower degree than their male colleagues do, although the percentage who do so has increased in recent years. The gender difference in frequency of specialization is not an effect of female physicians' spending a longer time on specialist training. Our results indicate that female physicians, to a greater extent than their male colleagues have to choose between family and career. A larger percentage of female than of male physicians live alone, perhaps indicating that career demands a higher price for the former. However, the percentage of singles is, larger among older than among younger female physicians. We interpret this as indicating that the necessity to choose between career and family is not as strong as it used to be.

[Physicians' working hours]. / Legers arbeidstid.

Data from an extensive survey among Norwegian doctors conducted in 1993 shows that, on average, doctors work 52.8 hours a week. Their work-load thus exceeds that of the average occupationally active Norwegian by about 40%, and that of the average academic by about 25%. Male doctors work significantly more hours per week than female. Doctors in the age groups 35-44 and 45-54 years work significantly more hours than their younger or older colleagues. Certified specialists work more hours than non-specialists. General practitioners, privately practising specialists and hospital doctors all work more hours per week than municipally employed doctors in the primary health service. Female do very much more housework than male doctors do. Measured in terms of the sum of hours of medical work, housework and caring for children and elderly relatives, female doctors work more hours per week than their male colleagues.