The Shoeshine Stand and the Renaissance of Primary Care.

Over the past century, family physicians have moved from small independently owned practices, many of them solo, to being employed by large hospital systems, corporate entities, or health systems. Today, almost three-quarters of all physicians are employed and the highest percentage of employed physicians are family physicians.This essay contrasts the elements of independent practice with employed practice as part of what has been lost in the past half century, but what might be regained if physicians demanded more autonomy and control over their practices.

Ethical challenges in health care during collective hunger strikes in public or occupied spaces.

Public collective hunger strikes take place in complex social and political contexts, require medical attention and present ethical challenges to physicians. Empirical research, the ethical debate to date and existing guidelines by the World Medical Association focus almost exclusively on hunger strikes in detention. However, the public space differs substantially with regard to the conditions for the provision of health care and the diverse groups of healthcare providers or stakeholders involved. By reviewing empirical research on the experience of health professionals with public collective hunger strikes, we identified the following ethical challenges: (1) establishment of a trustful physician-striker relationship, (2) balancing of medico-ethical principles in medical decision-making, (3) handling of loyalty conflicts and (4) preservation of professional independence and the risk of political instrumentalization. Some of these challenges have already been described and discussed, yet not contextualized for public collective strikes, while others are novel. The presence of voluntary physicians may offer opportunities for a trustful relationship and, hence, for ethical treatment decisions. According to our findings, it requires more attention to how to realise autonomous medical decisions in the complex context of a dynamic, often unstructured and politically charged setting, which ethical norms should shape the professional role of voluntary physicians, and what is the influence of the hunger strikers' collective on individual healthcare decisions. Our article can serve as a starting point for further ethical discussion. It can also provide the basis for the development of potential guidelines to support health professionals involved in public collective hunger strikes.

How artificial intelligence is reshaping the autonomy and boundary work of radiologists. A qualitative study.

The application of artificial intelligence (AI) in medical practice is spreading, especially in technologically dense fields such as radiology, which could consequently undergo profound transformations in the near future. This article aims to qualitatively explore the potential influence of AI technologies on the professional identity of radiologists. Drawing on 12 in-depth interviews with a subgroup of radiologists who participated in a larger study, this article investigated (1) whether radiologists perceived AI as a threat to their decision-making autonomy; and (2) how radiologists perceived the future of their profession compared to other health-care professions. The findings revealed that while AI did not generally affect radiologists' decision-making autonomy, it threatened their professional and epistemic authority. Two discursive strategies were identified to explain these findings. The first strategy emphasised radiologists' specific expertise and knowledge that extends beyond interpreting images, a task performed with high accuracy by AI machines. The second strategy underscored the fostering of radiologists' professional prestige through developing expertise in using AI technologies, a skill that would distinguish them from other clinicians who did not pose this knowledge. This study identifies AI machines as status objects and useful tools in performing boundary work in and around the radiological profession.

'We're at war.' Healthcare workers' experience with organisational change, uncertainty and vaccine hesitancy in 2021 and 2022 during the COVID-19 vaccination programe in Poland.

This article analyses the organisation of the mass COVID-19 vaccination programme in Poland and its consequences for various aspects of the social identity of healthcare workers (HCWs). Based on 31 in-depth interviews with HCWs, our study reveals the following: (1) Certain elements of the programme (inclusion of other healthcare professionals like pharmacists and laboratory diagnosticians as vaccinators) and the provision of additional infrastructure (pharmacies and shopping malls) may prompt scepticism and criticism in physicians and nurses who feel challenged about their professional autonomy and hierarchies; (2) Given the high levels of professional uncertainty, the implementation of the COVID-19 vaccination is forcing HCWs to revise their attitude to medical standards, resulting in specific responses and adaptation strategies (ranging from the active involvement in the programme due to the sense of mission, to more or less evident scepticism); and (3) Confronting vaccine hesitancy, both among patients and other HCWs, contributes to the feeling of helplessness, leading to criticism of policymakers.

Nurses' perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents- a qualitative study.

BACKGROUND: Over the years, caring has been explained in various ways, thus presenting various meanings to different people. Caring is central to nursing discipline and care ethics have always had an important place in nursing ethics discussions. In the literature, Joan Tronto's theory of ethics of care is mostly discussed at the personal level, but there are still a few studies that address its influence on caring within the nursing context, especially during the provision of end-of-life care. This study aims to explore nurses' perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. METHODS: This study has a qualitative descriptive design. Data were collected by conducting five individual interviews and one focus group during a seven-month period between April 2022 and September 2022. Nine nurses employed at four Norwegian nursing homes were the participants in this study. Data were analysed by employing a qualitative deductive content analysis method. RESULTS: The content analysis generated five categories that were labelled similar to Tronto's five phases of the care process: (i) caring about, (ii) caring for, (iii) care giving, (iv) care receiving and (v) caring with. The findings revealed that nurses' autonomy more or less influences the decision-making care process at all five phases, demonstrating that the Tronto's theory contributes to greater reflectiveness around what may constitute 'good' end-of-life care. CONCLUSIONS: Tronto's care ethics is useful for understanding end-of-life care practice in nursing homes. Tronto's care ethics provides a framework for an in-depth analysis of the asymmetric relationships that may or may not exist between nurses and nursing home residents and their next-of-kin. This can help nurses see and understand the moral dimension of end-of-life care provided to nursing home residents during their final days. Moreover, it helps handle moral responsibility around end-of-life care issues, providing a more complex picture of what 'good' end-of-life care should be.

The impact of a nutrition course on self-epistemic authority, professional meaning as mediating factors on professional identity among nursing students.

BACKGROUND: The professional competence of nursing personnel is integral to the efficacy of nursing procedures. Educational endeavors, especially those encompassing professional training programs, are critical in fostering a professional identity among nurses. The role of nurses within a multi-disciplinary nutrition team has the potential to enhance professional identity and improve the quality of care provided. OBJECTIVE: This study aimed to explore the potential impact of knowledge acquisition and practical nutrition education on the development of professional identity among nursing school students. Furthermore, we hypothesize that professional autonomy and self-epistemic authority mediated the relationship between a sense of meaning, professional mission, and professional identity. DESIGN: A cross-sectional survey compared nursing students who had completed a practical nutrition course with those who had not. The study measured professional identity, professional autonomy, self-epistemic authority, and sense of meaning. Data collection was conducted using validated questionnaires, with questions tailored to suit the study demographic. Mediation analysis was conducted on the combined sample of both groups. PARTICIPANTS: The study included 98 nursing students, divided into a study group (57 students who completed a nutrition course) and a control group (41 students who did not complete the course). RESULTS: Significant differences were found between the groups in measures of professional identity (t = 3.42, p < .001), professional autonomy (t = 2.93, p < .005), and self-epistemic authority (t = 2.78, p < .007). There was no significant difference in the sense of meaning (t = 1.45, p = .150). Mediation analysis on the combined sample revealed that self-epistemic authority mediated the relationship between professional meaning and professional identity, while professional autonomy did not. CONCLUSION: The findings suggest that practical nutrition education enhances nursing students' professional identity, autonomy, and self-epistemic authority. Future studies should include larger and more diverse samples to further explore these relationships.

Organizational characteristics of nursing practice environments related to registered nurses' professional autonomy and job satisfaction in two Finnish Magnet-aspiring hospitals: structural equation modeling study.

BACKGROUND: Nurses are leaving their profession because of poor personal job satisfaction, heavy workload, and unfavorable work environments with low professional autonomy. Professional autonomy involves the possibility to influence one's work and have a sense of control - the ability to contribute to a workplace culture and influence how decisions are made. This study explores registered nurses' perceptions of the nursing practice environment, using the Nursing Work Index-Revised (NWI-R), and its relationships with professional autonomy and job satisfaction. METHODS: A cross-sectional study along with instrument re-validation was conducted using a web-based survey for nurses in two Magnet-aspiring hospitals in Finland in September 2021 (n = 586). Structural equation modeling was used to find out the relationships of the NWI-R components with professional autonomy and job satisfaction. RESULTS: Principal component analysis and confirmatory factor analysis supported seven components with 34 items. Collegial nurse-doctor relationships, organization's quality standards, and nursing involvement and expertise sharing (means of 3.23, 2.96, and 2.66, respectively) demonstrated a favorable nursing practice environment; professional nursing standards, nurse management and leadership, staffing and resource adequacy, and professional advancement (means of 2.38, 2.18, 2.15, and 2.13, respectively) demonstrated an unfavorable nursing practice environment. The presented model (RMSEA 0.068, CFI 0.987, TLI 0.946) indicated that nursing involvement and expertise sharing, organization's quality standards, nurse management and leadership, and collegial nurse-doctor relationships were related to professional autonomy. Nurse management and leadership, staffing and resource adequacy, and organization's quality standards were related to job satisfaction. Moreover, professional autonomy was related to job satisfaction. CONCLUSION: Nurses' professional autonomy is important due to its relationship with job satisfaction. When factors that increase professional autonomy are taken into account and attention is paid to the promotion of autonomy, it is possible to improve nurses' job satisfaction. These issues cannot be solved at the unit level; investment is needed at the organizational and political levels. The results introduce nurses, managers, researchers, and stakeholders to improvements in the nursing practice environment toward an organizational culture where nurses may utilize their professional autonomy to its full potential.

Physician-nurse collaboration in the relationship between professional autonomy and practice behaviors.

BACKGROUND: Nurses and physicians are key members of healthcare teams. While physicians are responsible for the diagnosis and treatment of patients, nurses are part of the treatment and the primary practitioners of patient care. Nurses' professional autonomy, collaboration with physicians, and practice behaviors in treatment and patient care practices are interrelated. OBJECTIVES: In the present study, we examined the mediating effect of physician-nurse collaboration on the relationship between nurses' practice behaviors and their professional autonomy. DESIGN: The present study utilized a cross-sectional survey design following quantitative methods. METHODS: This study was conducted in the Istanbul Province of Turkiye from September to October 2022. The sampling method used was a convenience sampling strategy to provide easier access to participants when selecting nurses from different health institutions. The mean age of the 295 nurses was 31.23 years, with ages ranging from 21 to 59 years. The data analysis was conducted using IBM's SPSS 24.0 software package and the Process Macro 4.0 plug-in. ETHICAL CONSIDERATION: Research ethics approval was obtained from the researcher's university. RESULTS: Physician-nurse collaboration is positively associated with practice behaviors and professional autonomy. Nurses' professional autonomy in practice behaviors through physician-nurse collaboration is significant (95% CI [0.043, 0.135]). DISCUSSION: Our results revealed the relationships among physician‒nurse collaboration, professional autonomy, and practice behaviors among nurses. CONCLUSION: Our results provide evidence on the underlying factors of nurses' practice behaviors in patient care and guide the development of an intervention program to enhance this collaboration. Hospital managers can contribute to a collaborative physician‒nurse working environment.

The relationship between attitudes towards professional autonomy and nurse-nurse collaboration: A cross-sectional study.

AIM: This study aimed to determine the relationship between attitudes towards professional autonomy and nurse-nurse collaboration among nurses. BACKGROUND: Professional autonomy is crucial for nurses in today's complex and ever-changing healthcare environment. Therefore, attitudes towards professional autonomy may result in effective collaboration among nurses, one of the nursing roles and responsibilities. METHODS: This descriptive, cross-sectional study was conducted with 685 nurses in four private hospitals affiliated with a university. Descriptive tests, correlation analysis and hierarchical regression analysis were used. An ethics committee approved this study, and the STROBE Statement guidelines for cross-sectional studies were followed. RESULTS: Significant predictors for nurse-nurse collaboration were identified as job-related independence, autonomous clinical judgement and working unit from control variables. CONCLUSION: This study's results provided valuable insights for nurse managers to enhance nurses' attitudes towards professional autonomy and foster collaborative work environments. IMPLICATIONS FOR NURSING: Nurse managers can increase nurses' participation in decision-making processes and allow them to recognize their autonomy and that of their colleagues.

Enhancing Physicians' Autonomy through Practical Trainings.

Background: In medical emergencies adherence to standardized clinical protocols is crucial to ensure a better outcome for patients. Newly qualified physicians may play several roles in serving the National Health Service (substituting general practitioners, on-call duty, working in emergency rooms, etc.) in Italy. In these situations, the physician may have to manage critical patients autonomously. Moreover, newly qualified physicians may show a considerable deficiency in routine medical activities. In fact, many universities do not provide a practical simulation training programme, which is why a substantial number of students only face clinical emergencies when they start working after graduation. Study design: A cross-sectional study was performed by engaging medical doctors. Both experienced physicians and newly licensed physicians (graduated less than 24 months ago) were included in the study. Methods: A questionnaire was distributed to each participant during SIMED's Courses from June 2021 to December 2022. The questionnaire consisted of two sections. The first one analyzed participation in standardized practical courses on medical emer-gencies (Basic Life Support, Advanced Cardiac Life Support, International Trauma Life Support and a course on Advanced Airway Management). The second section analyzed the perceived autonomy of health professionals in the management of five different work settings, using a 5-point likert scale. Results: 2,168 questionnaires were analyzed, of which 68.7% were from newly qualified doctors and 31.3% from more experienced doctors. The highest rate of physicians who undertook training courses was achieved for the basic life support course (77.5%) and the lowest rate for the advanced trauma course (15.9%). Physicians perceive themselves the highest autonomy in Primary Care setting (63.1%), while in the Emergency Department they perceive themselves with less autonomy (24.0%). In the analyzed sample, experienced physicians show a higher percentage of autonomy than newly qualified doctors (31.4% vs 8.1%) in all scenarios.

Beatrice Dorothy Wade: Philosopher, Administrator, and Advocate.

Occupational therapist, Beatrice D. Wade, contributed to occupational therapy through her interest in the philosophy of professional autonomy, in educational program administration and curriculum design, in mental health advocacy and in service to the profession as an office holder during her occupational therapy career spanning the years 1925-1971. The purpose of this article is to document her life, work, and contributions and to summarize her impact on current professional autonomy, and philosophy of education and practice.

Nurse managers' perceptions of nurses' professional autonomy-A qualitative interview study.

AIMS: To describe nurse managers' perceptions of nurses' professional autonomy in hospitals and their role in promoting it. DESIGN: A qualitative descriptive approach. METHODS: Fifteen nurse managers participated in semi-structured focus group interviews in two university hospitals in Finland between May and June 2022. The data were analysed using inductive content analysis. RESULTS: Nurses' professional autonomy in hospitals is perceived according to three themes: individual qualities behind independent actions, limited influencing opportunities in the organization and physicians' central effect. The nurse managers perceive that they enhance nurses' professional autonomy by promoting the nurses' independence at work, their sufficient and up-to-date competence, their expert role in multi-professional cooperation and joint decision-making and an open and appreciative work community. CONCLUSIONS: Nurse managers can enhance nurses' professional autonomy with shared leadership. However, there are still gaps in nurses' equal possibilities to influence multi-professional work, especially outside of patient care. Promoting their autonomy requires commitment and support from leadership at all levels of the organization. The results advise nurse managers and the administration of the organization to maximize the potential of nurses' expertise, along with encouraging nurses towards self-leadership. IMPACT: This study provides an innovative approach to nurses' roles through their professional autonomy from the perspective of nurse managers. These managers have an important role in enhancing nurses' professional autonomy, empowering and supporting them in their expertise, enabling necessary advanced training, and maintaining an appreciative work community where all have equal participation opportunities. Thus, nurse managers have the opportunity to strengthen high-quality multi-professional teams' ability to jointly develop the patient's care for better outcomes through their leadership. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Professional autonomy among nurses in Saudi Arabian critical care units.

BACKGROUND: Professional autonomy is essential in expanding the scope of nursing practice and has been recognized as a top nursing priority. OBJECTIVE: This study aims to assess Saudi nurses' autonomy level in critical care settings and examine the influence of sociodemographic and clinical characteristics on their autonomy level. METHODS: A correlational design and a convenience sampling approach were used to recruit 212 staff nurses from five Saudi governmental hospitals in Jouf region of Saudi Arabia. The data were collected through a self-administered questionnaire composed of two sections, including sociodemographic characteristics and the Belgen autonomy scale. The Belgen autonomy scale used in this study measures nurses' autonomy levels and consists of 42 items rated on an ordinal scale. The scale's minimum score of 1 indicates nurses with no authority, while the maximum score of 5 indicates nurses with full authority. RESULTS: Descriptive statistics revealed that nurses in the sample had a moderate overall work autonomy (M = 3.08), with higher autonomy in patient care decisions (M = 3.25) compared to unit operations decisions (M = 2.91). Nurses had the highest level of autonomy in tasks related to preventing patient falls (M = 3.84), preventing skin breakdown (M = 3.69), and promoting health activities (M = 3.62), while they had the lowest level of autonomy in ordering diagnostic tests (M = 2.27), determining the day of discharge (M = 2.61), and planning the unit's annual budget (M = 2.22). The multiple linear regression model (R2 = 0.32, F (16, 195) = 5.87, p < .001) showed that education level and years of experience in critical care settings were significantly related to nurses' work autonomy. CONCLUSION: Saudi nurses in acute care settings have moderate professional autonomy, with higher autonomy in making patient care decisions than unit operations decisions. Investing in nurses' education and training could increase their professional autonomy, leading to improved patient care. Policymakers and nursing administrators can use the study's results to develop strategies that promote nurses' professional development and autonomy.

Full practice authority and burnout among primary care nurse practitioners.

BACKGROUND: Full practice authority (FPA) improves clinical autonomy for nurse practitioners (NPs). Autonomy may reduce burnout. PURPOSE: Estimate the effect of changing from reduced or restricted practice authority to FPA on NP burnout. METHODS: In this quasi-experimental study, we compared NP burnout before (2016) and after (2018) a Veterans Health Administration (VHA) regulation authorized NP FPA. Burnout proportions were estimated for VHA facilities by aggregating responses to the VHA's All Employee Survey from 1,352 primary care NPs. DISCUSSION: Seventy-seven percent of facilities changed to FPA postregulation. Burnout was six points lower among NPs in facilities that changed to FPA compared to facilities that had FPA prior to the regulation; however, this association was not statistically significant. CONCLUSION: NPs are increasingly working under independent practice. While changing to FPA did not reduce NP burnout, this association may vary by health care setting or when burnout is measured for individuals or teams.

The effect of cognitive flexibility in nurses on attitudes to professional autonomy.

BACKGROUND: Professional autonomy, which directly affects the quality of professional nursing in patient care, and cognitive flexibility, which is an important factor for adaptation to change and developing nursing roles, are important concepts for nursing. RESEARCH OBJECTIVES: This research was carried out to determine the effect of cognitive flexibility on attitudes towards professional autonomy in nurses. RESEARCH DESIGN: This was a descriptive study. PARTICIPANTS AND RESEARCH CONTEXT: The research was conducted with 415 nurses working in a city hospital of a province, meeting the inclusion criteria and agreeing to participate in the study. A questionnaire form, The Cognitive Flexibility Inventory (CFI), and the Attitude Toward Professional Autonomy Scale for Nurses (APASN) were used to collect data. ETHICAL CONSIDERATIONS: Ethical approval was obtained from the university ethics committee before starting the study. Institutional permission was obtained from the city hospital where the study was conducted. Electronic informed consent was obtained from the nurses included in the study. FINDINGS: In the study, the mean CFI score was 80.62 ± 11.55 and the mean APASN score was 70.42 ± 18.79. There was a weak positive correlation (r = 0.270; p < 0.05) between CFI and APASN scores. Moreover, the effect of the CFI mean score on the APASN mean score was found to be statistically significant (ß = 0.278; p < 0.001). Furthermore, CFI explains 7.7% of APASN. CONCLUSION: In the study, nurses' attitudes towards professional autonomy and cognitive flexibility scores were found to be at a good level. Cognitive flexibility has a positive effect on attitudes towards professional autonomy. Interventional studies that will increase the level of cognitive flexibility are recommended in the development of nurses' attitudes towards professional autonomy.

Italian midwives in Europe: a qualitative study on the experiences of professional migration.

Aim: To explore the reasons for Italian midwives' decision to migrate, and their lived professional and emotional experiences. Methods: A descriptive phenomenological study was conducted recruiting Italian midwives who were working abroad in European countries. We offered a telephone or web interview. Two researchers conducted, audio-recorded, and fully transcribed the interviews and other two researchers, independently, performed a content analysis. Results: Thirty-two midwives having professional experiences in the UK, Ireland, Germany, Switzerland, and Spain were interviewed. Five themes emerged: 1) Education, 2) Migration decision-making, 3) Professional experience abroad, 4) Midwives' perceptions of their role, 5) Satisfaction versus desire to return. Our findings show a general dissatisfaction with Italian job opportunities in terms both of access to employment and work conditions. This scenario is complicated by the status of the professional midwifery in Italy. Conclusion: Stakeholders should ensure that the migration of Italian midwives is not synonymous with dispersion but is a channel of professional growth and mutual exchange.

Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study.

BACKGROUND: Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor-patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed. OBJECTIVE: To explore Norwegian GPs' perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider 'unreasonable'. METHODS: A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation. RESULTS: The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an 'unreasonable' patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs' gatekeeping role among peers and from authorities. CONCLUSION: Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required.

Using self-determination theory in research and evaluation in primary care.

BACKGROUND: Multimorbidity (the co-existence of two or more long-term conditions within an individual) is a complex management challenge, with a very limited evidence base. Theories can help in the design and operationalization of complex interventions. OBJECTIVE: This article proposes self-determination theory (SDT) as a candidate theory for the development and evaluation of interventions in multimorbidity. METHODS: We provide an overview of SDT, its use in research to date, and its potential utility in complex interventions for patients with multimorbidity based on the new MRC framework. RESULTS: SDT-based interventions have mainly focused on health behaviour change in the primary prevention of disease, with limited use in primary care and chronic conditions management. However, SDT may be a useful candidate theory in informing complex intervention development and evaluation, both in randomized controlled trials and in evaluations of 'natural experiments'. We illustrate how it could be used multimorbidity interventions in primary care by drawing on the example of CARE Plus (a primary care-based complex intervention for patients with multimorbidity in deprived areas of Scotland). CONCLUSIONS: SDT may have utility in both the design and evaluation of complex interventions for multimorbidity. Further research is required to establish its usefulness, and limitations, compared with other candidate theories. PATIENT OR PUBLIC CONTRIBUTION: Our funded research programme, of which this paper is an early output, has a newly embedded patient and public involvement group of four members with lived experience of long-term conditions and/or of being informal carers. They read and commented on the draft manuscript and made useful suggestions on the text. They will be fully involved at all stages in the rest of the programme of research.

Job satisfaction in midwives and its association with organisational and psychosocial factors at work: a nation-wide, cross-sectional study.

BACKGROUND: Midwives report a challenging work environment globally, with high levels of burnout, insufficient work resources and low job satisfaction. The primary objective of this study was to identify factors in the organisational and psychosocial work environment associated with midwives' job satisfaction. A secondary objective was to identify differences in how midwives assess the organisational and psychosocial work environment compared to Swedish benchmarks. METHODS: This nation-wide, cross-sectional web survey study analysed midwives' assessment of their organisational and psychosocial work environment using the COPSOQ III instrument. A multivariable, bi-directional, stepwise linear regression was used to identify association with job satisfaction (N = 1747, 99.6% women). A conventional minimal important score difference (MID ± 5 as a noticeable difference with clinical importance) were used to compare midwives' results with Swedish benchmarks. RESULTS: A multivariable regression model with 13 scales explained the variance in job satisfaction (R2 = .65). Five scales, possibilities for development, quality of work, role conflict, burnout and recognition, explained most of the variance in midwives' job satisfaction (R2 = .63) and had ß values ranging from .23 to .10. Midwives had adverse MID compared to Swedish benchmarks with higher difference in mean values regarding quantitative demands (8.3), work pace (6.0) emotional demand (20.6), role conflicts (7.9) and burnout (8.3). In addition, lower organisational justice (-6.4), self-rated health (-8.8), influence (-13.2) and recognition at work (-5.8). However, variation and meaning of work showed a beneficial difference in mean values with 7.9 and 13.7 respectively. CONCLUSIONS: Midwives reported high levels of meaningfulness in their work, and meaningfulness was associated with job satisfaction. However, midwives also reported adversely high demands and a lack of influence and recognition at work and in addition, high role conflict and burnout compared to Swedish benchmarks. The lack of organisational resources are modifiable factors that can be taken into account when structural changes are made regarding organisation of care, management and resource allocation. Midwives are necessary to a high quality sexual, reproductive and perinatal health care. Future studies are needed to investigate if job satisfaction can be improved through professional recognition and development, and if this can reduce turnover in midwives.

The Ethics of Algorithms in Healthcare.

The amount of data available to healthcare practitioners is growing, and the rapid increase in available patient data is becoming a problem for healthcare practitioners, as they are often unable to fully survey and process the data relevant for the treatment or care of a patient. Consequently, there are currently several efforts to develop systems that can aid healthcare practitioners with reading and processing patient data and, in this way, provide them with a better foundation for decision-making about the treatment and care of patients. There are also efforts to develop algorithms that provide suggestions for such decisions. However, the development of these systems and algorithms raises several concerns related to the privacy of patients, the patient-practitioner relationship, and the autonomy of healthcare practitioners. The aim of this article is to provide a foundation for understanding the ethical challenges related to the development of a specific form of data-processing systems, namely clinical algorithms.