Initiatives to engage the public in health policy decisions have been widely endorsed and used, yet agreed upon methods for systematically evaluating the effectiveness of these initiatives remain to ...be developed. Dukhanin, Topazian, and DeCamp have thus developed a useful taxonomy of evaluation criteria derived from a systematic review of published evaluation tools that might serve as the basis for systematic evaluation. In considering the application of such a taxonomy, it is important to appreciate the political space in which health policy decisions occur. In this context, public engagement initiatives are likely to have a modest and unpredictable impact on policy decisions. Other goals, aside from influencing policy decisions, such as informing the public about issues, identifying the public's values, enhancing public support for decisions, and promoting public discourse, are likely to be more feasible. While Dukanan and colleagues did not aim to do so, future efforts to align guidance for planning public engagement initiatives with evaluation tools would be useful to promote the success of public engagement initiatives.
A 1999-2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we ...administered a 105-item survey to "best informants" in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC.
To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have ...overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners' opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive perceptions of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted.
ulrich c.m., taylor c., soeken k., o’donnell p., farrar a., danis m. & grady c. (2010) Everyday ethics: ethical issues and stress in nursing practice. Journal of Advanced Nursing 66(11), 2510–2519.
...Aim. This paper is a report of a study of the type, frequency, and level of stress of ethical issues encountered by nurses in their everyday practice.
Background. Everyday ethical issues in nursing practice attract little attention but can create stress for nurses. Nurses often feel uncomfortable in addressing the ethical issues they encounter in patient care.
Methods. A self‐administered survey was sent in 2004 to 1000 nurses in four states in four different census regions of the United States of America. The adjusted response rate was 52%. Data were analysed using descriptive statistics, cross‐tabulations and Pearson correlations.
Results. A total of 422 questionnaires were used in the analysis. The five most frequently occurring and most stressful ethical and patient care issues were protecting patients’ rights; autonomy and informed consent to treatment; staffing patterns; advanced care planning; and surrogate decision‐making. Other common occurrences were unethical practices of healthcare professionals; breaches of patient confidentiality or right to privacy; and end‐of‐life decision‐making. Younger nurses and those with fewer years of experience encountered ethical issues more frequently and reported higher levels of stress. Nurses from different regions also experienced specific types of ethical problems more commonly.
Conclusion. Nurses face daily ethical challenges in the provision of quality care. To retain nurses, targeted ethics‐related interventions that address caring for an increasingly complex patient population are needed.
Nurses and social workers are fundamental to the delivery of quality health care across the continuum of care. As health care becomes increasingly complex, these providers encounter difficult ethical ...issues in patient care, perceive limited respect in their work, and are increasingly dissatisfied. However, the link between ethics-related work factors and job satisfaction and intent-to-leave one's job has rarely been considered. In this paper, we describe how nurses and social workers in the US view the ethical climate in which they work, including the degree of ethics stress they feel, and the adequacy of organizational resources to address their ethical concerns. Controlling for socio-demographics, we examined the extent to which these factors affect nurses and social workers’ job satisfaction and their interest in leaving their current position. Data were from self-administered mail questionnaires of 1215 randomly selected nurses and social workers in four census regions of the US. Respondents reported feeling powerless (32.5%) and overwhelmed (34.7%) with ethical issues in the workplace and frustration (52.8%) and fatigue (40%) when they cannot resolve ethical issues. In multivariate models, a positive ethical climate and job satisfaction protected against respondents’ intentions to leave as did perceptions of adequate or extensive institutional support for dealing with ethical issues. Black nurses were 3.21 times more likely than white nurses to want to leave their position. We suggest several strategies to reduce ethics stress and improve the ethical climate of the workplace for nurses and social workers.
Out-of-pocket health expenditures can pose major financial risks, create access-barriers and drive patients and families into poverty. Little is known about physicians' role in financial protection ...of patients and families at the bedside in low-income settings and how they perceive their roles and duties when treating patients in a health care system requiring high out-of-pocket costs.
Assess physicians' concerns regarding financial welfare of patients and their families and analyze physicians' experiences in reducing catastrophic health expenditures for patients in Ethiopia.
A national survey was conducted among physicians at 49 public hospitals in six regions in Ethiopia. Descriptive statistics were used.
Totally 587 physicians responded (response rate 91%) and 565 filled the inclusion criteria. Health care costs driving people into financial crisis and poverty were witnessed by 82% of respondants, and 88% reported that costs for the patient are important when deciding to use or not use an intervention. Several strategies to save costs for patients were used: 37-79% of physicians were doing this daily or weekly through limiting prescription of drugs, limiting radiologic studies, ultrasound and lab tests, providing second best treatments, and avoiding admission or initiating early discharge. Overall, 75% of the physicians reported that ongoing and future costs to patients influenced their decisions to a greater extent than concerns for preserving hospital resources.
In Ethiopia, a low-income country aiming to move towards universal health coverage, physicians view themselves as both stewards of public resources, patient advocates and financial protectors of patients and their families. Their high concern for family welfare should be acknowledged and the economic and ethical implications of this practice must be further explored.
Ethical dilemmas are part of medicine, but the type of challenges, the frequency of their occurrence and the nuances in the difficulties have not been systematically studied in low-income settings. ...The objective of this paper was to map out the ethical dilemmas from the perspective of Ethiopian physicians working in public hospitals.
A national survey of physicians from 49 public hospitals using stratified, multi-stage sampling was conducted in six of the 11 regions in Ethiopia. Descriptive statistics were used and the responses to the open-ended question "If you have experienced any ethical dilemma, can you please describe a dilemma you have encountered in your own words?" were analyzed using a template analysis process.
A total of 587 physicians responded (response rate 91,7%), and 565 met the inclusion criteria. Twelve of 24 specified ethically challenging situations were reported to be experienced often or sometimes by more than 50% of the physicians. The most frequently reported challenge concerned resource distribution: 93% agreed that they often or sometimes had to make difficult choices due to resource limitation, and 83% often or sometimes encountered difficulties because patients were unable to pay for the preferred course of treatment. Other frequently reported difficulties were doubts about doing good or harming the patient, relating to conflicting views, concern for family welfare, disclosure issues and caring for patients not able to consent. Few reported dilemmas related to end-of-life issues. The 200 responses to the open-ended question mirrored the quantitative results.
Ethiopian physicians report ethical challenges related more to bedside rationing and fairness concerns than futility discussions and conflicts about autonomy as described in studies from high-income countries. In addition to the high report of experienced challenges, gravity of the dilemmas that are present in their narratives are striking. Recognition of the everyday experiences of physicians in low-income settings should prompt the development of ethics teaching and support mechanisms, discussion of ethical guidelines as well as increase our focus on how to improve the grave resource scarcity they describe.
Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefit from management by critical care physicians, but evidence of this benefit is scant.
To ...examine the association between hospital mortality in critically ill patients and management by critical care physicians.
Retrospective analysis of a large, prospectively collected database of critically ill patients.
123 ICUs in 100 U.S. hospitals.
101,832 critically ill adults.
Through use of a random-effects logistic regression, investigators compared hospital mortality between patients cared for entirely by critical care physicians and patients cared for entirely by non-critical care physicians. An expanded Simplified Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for differences in the probability of selective referral of patients to critical care physicians.
Patients who received critical care management (CCM) were generally sicker, received more procedures, and had higher hospital mortality rates than those who did not receive CCM. After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not. The difference in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM.
Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized.
In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.
Background
Achieving universal health coverage (UHC) in the context of limited resources will require prioritising the most vulnerable and ensuring health policies and services are responsive to ...their needs. One way of addressing this is through the engagement of marginalised voices in the priority setting process. Public engagement approaches that enable group level deliberation as well as individual level preference capturing might be valuable in this regard, but there are limited examples of their practical application, and gaps in understanding their outcomes, especially with rural populations.
Objective
To address this gap, we implemented a modified priority setting tool (Choosing All Together—CHAT) that enables individuals and groups to make trade‐offs to demonstrate the type of health services packages that may be acceptable to a rural population. The paper presents the findings from the individual choices as compared to the group choices, as well as the differences among the individual choices using this tool.
Methods
Participants worked in groups and as individuals to allocate stickers representing the available budget to different health topics and interventions using the CHAT tool. The allocations were recorded at each stage of the study. We calculated the median and interquartile range across study participants for the topic totals. To examine differences in individual choices, we performed Wilcoxon rank sum tests.
Results
The results show that individual interests were mostly aligned with societal ones, and there were no statistically significant differences between the individual and group choices. However, there were some statistically significant differences between individual priorities based on demographic characteristics like age.
Discussion
The study demonstrates that giving individuals greater control and agency in designing health services packages can increase their participation in the priority setting process, align individual and community priorities, and potentially enhance the legitimacy and acceptability of priority setting. Methods that enable group level deliberation and individual level priority setting may be necessary to reconcile plurality. The paper also highlights the importance of capturing the details of public engagement processes and transparently reporting on these details to ensure valuable outcomes.
Public Contribution
The facilitator of the CHAT groups was a member from the community and underwent training from the research team. The fieldworkers were also from the community and were trained and paid to capture the data. The participants were all members of the rural community‐ the study represents their priorities.
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