The social determinants of child health

Social determinants of health have long been recognised but their importance is often overlooked. Globally social determinants are responsible for most childhood illness and death. In the UK, conditions which constitute a large part of paediatric practice are socially patterned. Social determinants exert their influence on child health through a complex inter-relationship of more distal social factors such as income and education with more proximal factors such as health behaviours.The pathways by which the social determinants exert their influence operate over time and across generations. Socially related risk and protective factors cluster in different social groups and accumulate over time. Social determinants are profoundly influenced by social and political decisions which are beyond the control of parents and individual paediatricians. Societies can protect children against the adverse effects of social disadvantage. National paediatric societies have a key role in promoting policies which protect children. This brief review summarises the impact of social determinants on children's health in the UK and considers the role of paediatricians in reducing the health inequities generated by these determinants.     

Advocacy in nursing: perceptions and attitudes of the nursing elite in the United Kingdom

Advocacy in nursing: perceptions and attitudes of the nursing elite in the United Kingdom ¶In recent years, patient advocacy has been claimed as an integral part of the nurse’s role in health care delivery in the United Kingdom (UK). Support from the nursing leadership/elite is seen as important in the promulgation and diffusion of any ‘new’ role in nursing. This paper explores the perceptions and attitudes of nurse leaders in the UK to the adoption of the patient advocate role as an ‘innovation’ in nursing. Using a qualitative methodology, semi-structured interviews with six of nursing’s ‘elite’ were conducted over a period of 5 months. Results revealed contradictions and paradoxes within the views of the elite. Although leaders recognized patient advocacy as a role integral to the moral value system in nursing enhanced by the nurse–patient relationship, they objected to the professionalization of the role, seeing an exclusive claim to patient advocacy as intensifying interprofessional conflicts in health care. It is argued that unless professionalized, the individual nurse will continue this potentially risky activity without adequate authority or support systems. The results overall question the role of the nursing leadership in the diffusion of innovations in nursing.     

Patient advocacy: a role for nurses?

There is much controversy surrounding the issue of nurses in the role of patient advocate. Cancer patients are vulnerable due to their diagnoses, the anxiety that it generates, the nature of the disease and subsequent treatment and may have diminished autonomy as a result. It is questionable whether the nurse is able to promote the best interests of the patient in this situation. Models of advocacy and the nurse-patient relationship are discussed. The main arguments for taking on the role of patient advocate include: reference to long periods of time spent with the patient and the chance to build a relationship; the duty to care and the duty to do no harm. Criticisms of the appropriateness of the advocacy role for nurses include: inability for the patient to choose his or her nurse; promotion of self interests; charges of paternalism; challenges from other health care professionals and multiple and/or conflicting obligations. It is concluded that perhaps the most ethical way of caring is by empowering patients and promoting selfadvocacy. This concept needs to be further explored.     

Ritual action and its effect on the role of the nurse as advocate

Problems related to the ability of the nurse to act as advocate for patients have caused dilemmas in the profession over recent years. This paper seeks to address the issue from the aspect of ritual action which pervades the day-to-day activities of nurses and could therefore have an effect on nurse–patient relations. By looking at a short study based on data from nurses working with dying patients, part of work in progress on the subject, it is possible to draw some conclusions about the effect that such rituals and routines have on practice. Examination of the work of Douglas leads to speculation about the ways that rituals associated with restricted language can undermine the nurse's ability to advocate successfully. Results from the study are limited given the small sample, but they give some indication of trends and possibilities that more exhaustive research may confirm.     

Parents and families as partners in the care of pediatric cardiology patients

The concept of patient- and family-centered care has its roots deep in the movement to improve care for special-needs children and in the tradition of pediatricians working with the families of their patients. Parents of pediatric cardiology patients can play a significant role in their children's care and often act as quarterbacks by coordinating multiple specialists and treatments in a system that can be fraught with hazards and poor communication. The medical system provides few tools to aid parents in this “partnership” process. We propose that parents be given specific resources to help them navigate the healthcare system and thereby provide better support for their children, and that pediatric cardiologists and their staffs use the principles of patient- and family-centered care to help parents become more effective advocates for their children.     

Paediatrics and the doctor-soldier

Sick and injured children, like combatants wounded by shot and shell in war, are disproportionately represented in the tallies of both man-made and national disasters. Paediatricians have a particularly proud heritage of military service, a nexus dating in Australia from the early 19th century. This paper traces this link between service to children in peacetime and the care of servicemen, women and children in times of war and disaster. The extraordinary record of Australian 'paediatric' doctors who also served in the Gallipoli Campaign (1915) is documented as an illustration of this duality. Paediatricians who serve in the Defence Reserves and in civilian non-government organisations which respond to disasters and civil wars have special credentials in their advocacy for the protection of children enmeshed in conflict or disaster. Such applies particularly to the banning of the recruitment and use of child soldiers; support for children caught up in refugee and illegal immigrant confrontations; and continued advocacy for greater international compliance with the Ottawa Convention to ban the use of anti-personnel landmines. Volunteering for such service must occur in cold 'down time', ensuring that paediatricians are trained in disaster and conflict response, when such challenges inevitably confront the paediatricians of the future.     

Nursing advocacy: how is it defined by patients and nurses,what does it involve and how is it experienced?

THE STUDY'S RATIONALE: Advocacy is an integral part of nursing. However, there is a scarcity of empirical evidence on nursing advocacy process and most of that evidence concerns nurses' views on the care of certain vulnerable patient groups in acute care settings. Before nursing practice can truly adopt advocacy as an inherent and natural part of nursing, a clearer understanding is needed of how it is defined and what activities are needed to accomplish advocacy. AIMS AND OBJECTIVES: The aim was to describe the way that nursing advocacy is defined, the activities through which nursing advocacy is accomplished and the way that nursing advocacy is experienced by patients and nurses. METHODOLOGICAL DESIGN AND JUSTIFICATION: Based on a qualitative approach, the study was limited to adult patients experiencing procedural pain in somatic care. Interviews were conducted in a convenience sample of patients (n = 22) and nurses (n = 21) from four medical and four surgical wards in Finland. A qualitative content analysis of the tape-recorded data was then carried out. ETHICAL ISSUES AND APPROVAL: The appropriate ethical principles were followed. All the participants gave their informed consent and formal approval for conducting the research was obtained according to national and local directives. RESULTS: Nursing advocacy seems to integrate aspects of individuality, professionalism and experiences of empowering, exceptional care. It is not a single event, but a process of analysing, counselling, responding, shielding and whistleblowing activities in clinical nursing practice. CONCLUSIONS: In nursing practice the abstract concept of nursing advocacy finds expression in voicing responsiveness, which integrates an acknowledged professional responsibility for and active involvement in supporting patients' needs and wishes.     

Putting Complex Older Persons First: How the Centers for Medicare and Medicaid Services 2019 Payment Proposal Fails Older Americans

In July 2018, the Centers for Medicare and Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule rule for calendar year 2019 (MPFS2019). The proposal sets forth CMS‐recommended updates to Medicare payment policies, payment rates, and quality provisions for services provided in the next calendar year. From year to year, the rule also can serve as a vehicle for soliciting input on new payment proposals and changes to existing policies. Among the payment and quality proposals in the MPFS2019 proposal, CMS proposed extensive changes to Current Procedural Terminology codes that are the framework for documentation and payment for office‐based evaluation and management (E/M) services. The American Geriatrics Society (AGS) believes the proposed payment methodology changes for E/M services would have had a significant negative impact on care for older Americans. On September 10, 2018, the AGS submitted its comments on this proposal and other aspects of the rule, and the AGS also submitted a comment letter signed by 41 organizations from an AGS‐led multispecialty coalition. The coalition also worked collaboratively on outreach to Congress, which included visits to Capitol Hill and a coalition letter stressing our collective support for reducing the burden of documentation for clinicians and our opposition to the proposed changes in payment methodology. In all letters, we noted that the AGS and members of our coalition hoped to work collaboratively with CMS and other stakeholders to develop a refined approach that would achieve the best possible outcomes for patients, particularly frail older Americans with multiple chronic conditions. In releasing their final MPFS2019, CMS postponed the E/M coding collapse for at least two years, a decision that speaks to the hard work of the AGS, its members, and the multi‐specialty coalition, and which opens the door for further discussions about the future of payment for E/M services so critical to older people. J Am Geriatr Soc 67:145–150, 2019.