Toward a just healthcare system

The U.S. healthcare delivery system is a patchwork nonsystem full of inequities, whose symptoms include the prolongation of the dying process, a lack of preventive care, and patient dumping. What can be done to make this nation's healthcare delivery system more just? The U.S. healthcare system should be modeled on the same underlying assumptions and justice-related values as the U.S. education system, a system based on need. Americans would find such a model psychologically acceptable because they are familiar with it, even though it is not perfect. Because they have the facilities and resources at their disposal, care givers must experience solidarity with all those who need care. The unity and solidarity of all creation is an explicitly Christian theme and is an appropriate value to emphasize with regard to compassionate healthcare. To establish a fairer healthcare delivery system, providers must consider their own Christian responsibilities and those of the Church, as well as the civic responsibilities of the government. If Catholic healthcare professionals do their part to change the status quo, Americans will be able to enjoy a fair system of healthcare delivery based on need, not on ability to pay.     

Changing the culture of dying. A new awakening of spirituality in America heightens sensitivity to needs of dying persons

Americans increasingly believe there are material solutions to all problems. Though we once accepted death as a part of life, we now think that--with enough technology--death can be controlled and postponed. Throughout this century, we have moved the dying process from the home to institutional settings. But institutions have a tendency to push all care to its logical end, which leads to alienation, fragmentation, and diminishment. Alienation is the result of the isolation and regimentation found in acute and skilled nursing care facilities. When care givers are indifferent to patients' pain, or do not know how to control it, they further impair the ability of dying persons to interact with others. Care for the dying person, "system by system, organ by organ," as is typical in institutional settings, fragments the dying process into a series of medical events. And, finally, institutionalized care often results in a diminishment of respect by care givers, who may come to view the dying person more as an object of academic interest than as a human whose spiritual needs may transcend physical ones. Such behavior has begun to show us the human costs of denying death and is contributing to a reawakening of spirituality in this country. The devastating effects of alienation, fragmentation, and diminishment can be ameliorated by a heightened sensitivity to the dying person's spiritual needs. With the proper supports, the dying process can be relocated from institutions to the home. Specialized training can educate healthcare professionals about palliative care and human needs at the end of life. We can rehumanize dying persons by first rehumanizing their care givers, specifically addressing the issues of stress and burnout on the job. Ultimately, the way we give care at the end of life reflects broader issues in U.S. culture. Only when communitarian values replace individualistic ones will resources be reallocated in a manner that best serves the most people. Only then will physicians, nurses, and other care givers receive rewards for supporting the dying person when tests and treatment are no longer needed.     

Care of the dying: a Catholic perspective. Part I, Cultural context: a CHA document challenges care givers to define appropriate care for the dying

In a society tempted to adopt legalized assisted suicide and euthanasia as appropriate responses to dying, the healthcare community is challenged to nurture positive attitudes toward death among all ages and to help those with terminal illnesses to live well while dying. Whereas family and friends were once the primary care givers, now members of the healthcare professions are. This shift has introduced tensions between medical professionals and patients, including their families, in defining appropriate behavior toward the dying. To enable the terminally ill to live well while dying, we need to allow them to retain as much control as possible within the limits of belonging to a community. Also, we need to secure their network of significant relationships so they can experience the affective bonds of trust and love that support personal dignity and enhance the meaning of life. Medical technology is to be used in service of the total good of the patient. This includes not only the relief or cure that therapy can bring, but also what the patient prefers, values about life, and regards as giving ultimate meaning to life. Catholic healthcare institutions are challenged to promote a sensitivity and respect for cultural diversity as they respond to the needs of the dying and those who care for them.     

Designing a first-line manager development program using organization-appropriate strategies.

First-line managers (head nurses) are increasingly accountable for all aspects of nursing care delivery and resource management on a unit. However, traditional methods of training head nurses may not adequately prepare them to meet their increasing responsibilities. A structured first-line manager development program can help correct this deficiency. However, the successful implementation of such a program requires an understanding of organizational culture as well as substantive knowledge about management. This article describes how a hospital-based first-line manager development program was designed and implemented by using strategies appropriate to the values, norms, and resources within the organization.     

Ministering to persons who face death. Practical guidance for care givers of persons making end-of-life treatment decisions

It is time care givers learn how to minister effectively and sensitively to those making end-of-life treatment decisions. To do so, care givers need to be aware of the various meanings death and dying hold. Culture, religion, past experiences with death and dying, and current situations can all influence the way persons perceive death and dying. Sensitivity to who the patient and family are, to how they perceive the disease or illness, and to how this perception influences their ability to achieve their life goals is a critical care-giving skill. Sensitivity, however, need not result in value neutrality or tolerance. Care givers should not be mindless executors of patient or family demands. Care givers must learn to talk honestly with patients and families about how a particular disease is most likely to progress and about the types of decisions they are likely to need to make. And then care givers need to present options, remaining sensitive to the patients' beliefs, values, and interests. Persons who care for the dying will face three types of patients, who will require different types of responses. The three types are patients who welcome death, patients who accept death, and patients who fight death. For all types of patients, care givers must keep the care patient centered and responsive to patients' priorities; facilitate informed decision making; promote communication among the patient, family, and healthcare team; support autonomous decision making; mediate conflicts; and offer spiritual counseling.     

The comprehensive organizational plan: how a COP can protect and serve your health care organization

In today's hyperturbulent and competitive health care environment, health care organizations must improve operating efficiency, reduce duplication, and compete effectively in the health care market to survive. The comprehensive organizational plan is a 5-stage development tool for health care organizations that is intended to protect and serve the health care organization in its survival efforts. Through its 5 planning stages-competitive, facilities, financial, human resources, and marketing-the comprehensive organizational plan assists the organization in optimizing the goals of cost containment, quality preservation, and universal access.     

Primary health care delivery and public health departments: a model and simulation

Describes development of a computer simulated design of primary care service delivery within a complex organization. Data for the model was obtained by interview, from financial records, patient charts, personnel files, and by questionnaire. The design regards primary health care need as a variable dependent on population characteristics and disease incidence rates, with delivery of care being determined by community needs. By extension of this line of thought, the most appropriate organizational design for the institution must necessarily be based on the specific environment in which it operates. The model and the simulation of primary health care activity in a health department supported the hypothesis that staff assignment is a function of community need for the service, and is also a function of the resources available. Changes in lag time for feedback regarding goal attainment did not produce any changes in performance, and political support was not found to be directly related to staffing of a particular program. An important conclusion to be drawn from this research is that resource administration and allocation requires skills in community diagnosis and internal management which health administrators would do well to include in their education.     

Care of the dying: a Catholic perspective. Part III: Clinical context--good palliative care eases the dying process. Catholic Health Association

In the midst of a push for legalized euthanasia and assisted suicide in the United States, the Catholic healing tradition should provide good palliative care and support for dying patients. Catholic healthcare institutions can have a counterinfluence on the euthanasia movement if they strive to relieve all forms of pain-physical, psychological, social, and spiritual. Care givers must adapt their pain management methods to diverse groups of patients and their needs. Comprehensive pain management includes not only specialized clinical programs to control physical pain, but also counseling and human support to minimize psychological pain, community support groups to counter social pain, and pastoral care resources to address spiritual pain. Truthful communication lies at the heart of the therapeutic relationship. Healthcare institutions can likewise organize themselves internally to offer optimal support programs for those who are dying, their families, and their care givers. Necessary ingredients for a comprehensive approach include integrated treatment plans, hospitable environments, policies on advance directives and collaborative decision making, ethics committees that are well versed in end-of-life issues, education programs, and a hospice philosophy of care.     

The effect of commitment to the organization on physicians' familiarity with guidelines for diabetes in managed care organizations

Despite continuous efforts, healthcare organizations still find it difficult to influence physicians to follow clinical guidelines. Previous studies have not taken into account the organizational context of the physicians' practice. We conducted a survey of a representative sample of 743 primary care physicians employed in Israel's 2 largest managed care health plans. The findings indicated that "commitment to the health plan" and "perceived monitoring by the health plan" had an independent positive effect on familiarity with guidelines for treating diabetes. We propose that managers of healthcare organizations consider enhancing physicians' commitment to the organization as a means for increasing their adherence with clinical guidelines, thereby improving the quality of care provided to diabetic patients.     

Retooling for community benefit

Healthcare providers today must have a mission of service both to the individual and to the community. In 1990 the Hospital Community Benefit Standards Program (HCBSP) was launched as a demonstration project to begin the process of defining the elements that constitute community benefit. The HCBSP standards are that a hospital (1) evince a significant organizational and operational commitment to a community benefit process, (2) plan and implement projects and activities that address specific community public health needs, (3) cultivate and maintain relationships with other organizations to foster community benefit, and (4) foster an internal environment that encourages everyone in the organization to participate in community benefit programs. The following elements are important to an effective community benefit program: Governing board involvement CEO understanding and commitment A key senior manager to coordinate An explicit commitment of human and financial resources An epidemiologic data base describing a defined community or population A mechanism for bringing together people in the organization interested in community benefit A mechanism for facilitating dialogue between hospital leaders and representatives from the community A method of linking community benefit processes to outcomes     

Take forth your human resource agenda--manage performance and reward

Suggests that managing performance should not just be a once-a-year appraisal of people, but should be a dynamic process integrating the various aspects of organizational and human resource management, including staff appraisal and development, as well as quality, standards, targets and outcomes, etc. Points out that the best route to organizational success is through people, and that service industries particularly are highly dependent on people to achieve the business goal. States that managing performance is achieved by managing change and communication, motivating and developing, and equipping the organization with the skills needed to move forward successfully. Integrating into the overall strategy, performance links inextricably with reward, job design, workforce profiling, competences and development. To be a learning company needs commitment to employee development--this, in turn, means commitment to managing human resources effectively, therefore managing reward and performance.     

Older people's views of a good death in heart failure: implications for palliative care provision

Palliative care in the UK has been developed to meet the needs of predominantly middle aged and younger old people with cancer. Few data are available regarding the extent to which services respond to the specific needs of an older group of people with other illnesses. This paper draws on in-depth interviews conducted with 40 people (median age 77) with advanced heart failure and poor prognosis to explore the extent to which older people's views and concerns about dying are consistent with the prevalent model of the 'good death' underpinning palliative care delivery. That prevalent model is identified as the "revivalist" good death. Our findings indicate that older people's views of a 'good death' often conflict with the values upon which palliative care is predicated. For example, in line with previous research, many participants did not want an open awareness of death preceded by acknowledgement of the potential imminence of dying. Similarly, concepts of autonomy and individuality appeared alien to most. Indeed, whilst there was evidence that palliative care could help improve the end of life experiences of older people, for example in initiating discussions around death and dying, the translation of other aspects of specialist palliative care philosophy appear more problematic. Ultimately, the study identified that improving the end of life experiences of older people must involve addressing the problematised nature of ageing and old age within contemporary society, whilst recognising the cohort and cultural effects that influence attitudes to death and dying.     

创造与社会共享的价值——公立医院社会责任、发展战略与价值链

医院在高效运营的同时要创造与社会共享的价值,这是实现社会责任的标志。公立医院在制定发展战略时,要将社会责任有机地融入其中,在价值链的每一个环节上体现对社会的关注。卓越的社会责任承担者会得到更多的社会资源和资本投入,最终,实现医院和社会的可持续共同发展。     

A nursing shortage: building organizational commitment among nurses

As a major nursing shortage threatens healthcare organizations, the views of 30 staff nurses are examined to determine factors that contribute to their commitment, or lack of commitment, to their employing hospital. Content analysis identified that organizational commitment is most related to personal factors, opportunities for learning, job satisfaction, plan for retirement, monetary benefits, patient care, coworkers, cultural factors, and job security, in that order. Lack of organizational commitment is most related to conflict with personal needs. However, lack of learning, lack of appreciation and fairness, inadequate monetary benefits, patient care situations, poor relations with coworkers, career developmental stage, and lack of job security are also discussed. Application of these findings to healthcare administration is discussed, with strategies for building organizational commitment among nurses.     

Care of the dying: a Catholic perspective. Part II: Social and political context--Catholic providers must exemplify a caring community. Catholic Health Association

Fears of abandonment and isolation in an institution have increased the public demand for euthanasia and assisted suicide. To quell this movement, Catholic healthcare providers must provide a caring community where patients and care givers enable each other to confront the fear of death and find support in living with human limitation. To begin to address the social and political dimensions of issues about the end of life, Catholic healthcare providers must use clear and consistent definitions of the terms used to describe these issues, such as death with dignity, right to die, euthanasia, allowing to die, and assisted suicide. By acknowledging the influence of the media in forming attitudes and opinions, healthcare institutions can seize opportunities for public education on fundamental human and religious values. The first effort has to be directed toward educating members of the media. The Catholic Church supports the concept of advance directives, which provide an opportunity for people to express their values and the ways they would expect those values to be honored in decisions about medical treatment. Courts' role in resolving decisions about treatment should be limited. Patient self-determination is best exercised when a patient (or surrogate), in consultation with a physician, decides what is best. Catholic healthcare institutions should advocate for legislation that fosters an appropriate balance between protecting a patient's right to self-determination and the state's interests to protect life. At the same time, institutions' advocacy efforts should demand sufficient resources for holistic care for the dying.     

Applying the principles of adaptive leadership to person‐centred care for people with complex care needs: Considerations for care providers,patients, caregivers and organizations

BackgroundHealth systems in many countries see person‐centred care as a critical component of high‐quality care but many struggle to operationalize it in practice. We argue that models such as adaptive leadership can be a critical lever to support person‐centred care, particularly for people who have multiple complex care needs.ObjectiveTo reflect on two concepts: person‐centred care and adaptive leadership and share how adaptive leadership can advance person‐centred care at the front‐line care delivery level and the organizational level.FindingsThe defining feature of adaptive leadership is the separation of technical solutions (ie applying existing knowledge and techniques to problems) from adaptive solutions (ie requiring shifts in how people work together, not just what they do). Addressing adaptive challenges requires identifying key assumptions that may limit motivations for change and the behaviours influenced by these assumptions. Thus, effective care for patients, particularly those with multiple complex care needs, often entails helping care providers and patients to examine their relationships and behaviours not just identifying technical solutions. Addressing adaptive challenges also requires a supportive and enabling organizational context. We provide illustrative examples of how adaptive leadership principles can be applied at both the front line of care and the organization level in advancing person‐centred care delivery.ConclusionsAdvancing person‐centred care at both the clinical and organizational levels requires a growth mindset, a willingness to try (and fail) and try again, comfort in being uncomfortable and a commitment to figure things out, in partnership, in iterative ways. Patients, caregivers, care providers and organizational leaders all need to be adaptive leaders in this endeavour.     

Bio-psycho-social-spiritual needs of adolescents and young adults with life-threatening illnesses: Implications for social work practice

ABSTRACT

This paper explores the biopsychosocial and spiritual needs of adolescents and young adults (AYA) with life-threatening or terminal illnesses. AYA are situated between childhood and adulthood (ages 15–25) and have distinct biopsychosocial and spiritual needs unique to their developmental stage. Having a life-threatening or terminal illness directly challenges normal AYA developmental tasks and identity formation. AYA experience more troubling physical symptoms during the dying process compared to other age groups, which leads to significant psychological distress and an increased need for pharmacological treatments. In general, AYA desire to be fully informed and involved in the health care decision-making process, leading to ethical dilemmas when the AYA is a minor and their wishes differ from the wishes of their legal guardian(s). Social workers are especially well-equipped to serve this population due to aligning professional standards and ability to advocate for holistic care within interdisciplinary teams. Additional research is needed to tailor holistic interventions to meet the needs of this population.     

On reflection: doctors learning to care for people who are dying

Humane care is an essential component of the doctor's role at the end of life. Over the last 20 years, there has been a steady global increase in the extent and variety of medical teaching about the care of people who are dying. In some countries, palliative medicine is now recognised as a discrete medical specialty. Rightly, much emphasis has been placed on symptom management, communication skills and ethical issues. But rarely does the concept of care, or how doctors learn to care, emerge in the medical literature. The concept of "care" is usually defined as a professional behaviour: attending to a patient's needs. Yet, the concept of care also requires a professional commitment on a more holistic level. To care is to be receptive to and responsible for others. This is care motivated by true empathy: a concern for the patient's well-being that comes from a sensitive identification with the patient's situation. This paper reports some of the findings from an interpretive phenomenological study involving 10 doctors and their experiences of learning to care for people who were dying. The doctors came from differing medical disciplines and had varying levels of experience. During the interviews the doctors retrospectively identified "turning points" at which they first perceived some notion of what it means to care for someone who is dying. The doctors often used poignant language when recollecting the strong feelings associated with these critical incidents. They felt that their training had been inadequate in preparing them for such care. The article asks whether their medical education had adequately prepared these doctors for this key element of their work. It recommends ways in which practitioners may be better prepared to care for people who are dying.     

Team dynamics and team empowerment in health care organizations

BACKGROUND: Despite the growing pervasiveness of team-based job designs in health care organizations, there is a degree of uncertainty and ambiguity about the process through which teams affect outcomes. PURPOSE: This research adds to our understanding of the process by which team dynamics affects team member attitudes. It investigates the role of team empowerment as a mediator in the relationships between team context, team atmosphere, job satisfaction, and organizational commitment. METHODOLOGY: Multiple regression analysis is used to test for the mediating effect of team empowerment in the relationships that team context and team atmosphere have with job satisfaction and organizational commitment. FINDINGS: Team empowerment mediates the relationships of team context and team atmosphere with job satisfaction and organizational commitment. PRACTICE IMPLICATIONS: Although adopting team-based job designs is an important first step, attention must also be paid to the context and atmosphere of such teams. Better outcomes will be achieved when team members perceive a supportive team atmosphere and an empowering team context with clear and jointly developed goals, an appropriate mix of skills and expertise, and rewards linked to team performance.