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When determining a method of procurement, the purchasing manager must remember his goals. Whether it be by bidding, negotiating, or open-ended contracts, the method chosen is a means of obtaining savings for the hospital and, ultimately, for the patient.
Nurse practitioners (NPs) have an unprecedented opportunity to become key primary health care providers, yet barriers to independent practice still exist. The purpose of this research was to explore and describe the practice of NPs from their perspective. Open-ended, interactive interviews were conducted with 23 NPs. Data analysis using the grounded theory method revealed that NPs attempt to establish their roles from a marginalized position and are often subjected to psychological and structural discounting. To combat discounting, the NPs in this research worked to negotiate the symbolic space required for their acceptance as valued health care providers. They used techniques of cultivating, bargaining, confronting, and disengaging. All of these techniques promote NP role definition by generating and preserving role boundaries, thereby moving NPs toward the symbolic space necessary for them to become part of the national consciousness. This research contributes to clarification of the NP role and the building of a formal theory of advanced nursing practice.
Physicians currently have a major opportunity to help guide the rapid evolution of managed care in the United States. General principles on how physicians can successfully negotiate a managed care contract are discussed.
This article is based on medical literature published in American and British monographs and medical journals in which physician-authors utilized case histories of women's nervous and mental disease and related gynecological complaints. I argue that the interaction of physicians, patients, and families was a relationship in which women patients contributed to the formation of medical knowledge and forged a modern sense of body and self. After an introductory section on reading case studies, I call attention to the ways in which physicians, patients, and patients' families educated each other about wellness and illness, which formed the basis of physicians' interpretation of disease. Next, I point out how the case histories structured an ideal script for doctor, patient, and family, based on physicians' sympathetic authority and patients' willingness to tell and show all. And finally, I suggest that the doctor-patient dialogue encouraged women patients to see themselves as medically manageable bodies and as individuals separate from families.
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This article investigates the uneasy process of integrating midwifery's alternative, women-centered model of childbirth care within the medically-dominated healthcare system in Canada. It analyses the impure processes of rhetorical identification and differentiation that characterized the debate about how to regulate midwifery in Ontario by examining a selection of submissions from diverse health care groups with vested interest in the debate's outcome. In divergent ways, these groups strategically appeal to the value of the "public interest" in order to advance professional concerns. The study considers the implications of this rhetorical process for re-defining midwifery's distinctive professional identity in relation to other health professions, to the state, and to the women for whom midwives care. Likewise, it suggests the relevance of rhetorical analysis for understanding the discursive formation and re-formation of health models, values, and professions in Western culture.
One of the most difficult decisions facing physicians in contemporary medical practice is whether to initiate or withhold cardiopulmonary resuscitation (CPR) for patients who are critically ill. Because of the problems surrounding these decisions, hospital guidelines have recently been developed for the appropriate use of do-not-resuscitate (DNR) orders. Despite the establishment of these guidelines, problems with the application of DNR orders remain. This study examines one strategy used by internal medicine resident physicians to cope with the problematic nature of decisions regarding resuscitation--the use of partial or slow resuscitation attempts, known as 'limited codes.' It analyzes how these code efforts play a role within the context of resident work by enabling residents to circumvent ethical and practical dilemmas created by the circumstances of their clinical practice.
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Living with heart failure (HF) means living with a chronic illness characterized by periods of acute decompensation alternating with periods of relative stability. Improved medical care for patients with cardiovascular diseases, coupled with the aging of the populations in the developed world, has resulted in a steadily increasing prevalence of HF. Rehospitalization rates are high for this patient population. In 20-64% of the cases, poor compliance by patients with the prescribed HF treatment is a contributing factor to hospitalization. This article uses a review of the literature on HF non-compliance, including the prevalence, barriers, consequences, and the long-term outcomes of non-compliance with HF therapy, to illustrate remaining issues and questions. Original studies published in English or German between 1966 and June 2004 identified by combining patient compliance, non-compliance, adherence, self-care, rehospitalization, patient education, and management programs, with heart failure in the search strategy are included. Creative approaches to achieving a true partnership between providers and patients are needed if clinical outcomes are to improve.
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In the two experiments discussed in this paper we quantified obstacle avoidance performance characteristics carried out open loop (without vision) but with different initial visual sampling conditions and compared it to the full vision condition. The initial visual sampling conditions included: static vision (SV), vision during forward walking for three steps and stopping (FW), vision during forward walking for three steps and not stopping (FW-NS), and vision during backward walking for three steps and stopping (BW). In experiment 1, we compared performance during SV, FW and BW with full vision condition, while in the second experiment we compared performance during FW and FW-NS conditions. The questions we wanted to address are: Is ecologically valid dynamic visual sampling of the environment superior to static visual sampling for open loop obstacle avoidance task? What are the reasons for failure in performing open loop obstacle avoidance task? The results showed that irrespective of the initial visual sampling condition when open loop control is initiated from a standing posture, the success rate was only approximately 50%. The main reason for the high failure rates was not inappropriate limb elevation, but incorrect foot placement before the obstacle. The second experiment showed that it is not the nature of visual sampling per se that influences success rate, but the fact that the open loop obstacle avoidance task is initiated from a standing posture. The results of these two experiments clearly demonstrate the importance of on-line visual information for adaptive human locomotion.
This study analyses arguments for and against the notion of healthy lifestyles, and the construction of responsibility for health, in group discussions in Finland. With data from four focus groups, we identified five interpretative repertoires: a strong activity repertoire reflects the dominant cultural value of health and emphasizes self-control. Three other repertoires--illness, external barriers, and weak character--share the underlying values of the activity repertoire, but exemplify situations where the individual lacks control, seeking to justify deviations from the norm of activity. One counter-repertoire, the pleasure repertoire, questions the hegemonic value of health, and discusses other competing values. The discussion of health is an ongoing dialectical process drawing from the different repertoires. In order to avoid stigmatization and to save face in the social situation of a focus group, the subjects strive to balance their accounts of behaviours considered unhealthy by also claiming healthy behaviours. They also strike a balance between extreme rigidity and carelessness, emphasizing the ideal of moderation and harmony. The findings point to a need to consider variations in and underpinnings of a "good life" at the individual level. Encouraging people to specify the meaning and content of moderation in their personal lives could provide a new perspective for health education and health promotion.
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