How should a nurse approach truth‐telling? A virtue ethics perspective

Abstract Truth‐telling is a key issue within the nurse–patient relationship. Nurses make decisions on a daily basis regarding what information to tell patients. This paper analyses truth‐telling within an end of life scenario. Virtue ethics provides a useful philosophical approach for exploring decisions on information disclosure in more detail. Virtue ethics allows appropriate examination of the moral character of the nurse involved, their intention, ability to use wisdom and judgement when making decisions and the virtue of truth‐telling. It is appropriate to discuss nursing as a ‘practice’ in relation to virtue ethics. This is achieved through consideration of the implications of arguments made by Alasdair MacIntyre who believes that qualities such as honesty, courage and justice are virtues because they enable us to achieve the internal goods of practices.     

The excesses of care: a matter of understanding the asymmetry of power

The aim of the article is to illustrate concrete problems in the asymmetrical nurse–patient power relationship. It is an ethical demand that the nurse is faced with the challenges that the power in the relation is administered so that the patient's room for action is expanded and trust maintained. It is an essential message in care philosophy, but in clinical practice, success is not always achievable. A hidden and more or less unconscious restriction of the patient's room for action may result in the excesses of care. Three selected aspects: dependence, trust, and power described by the Danish philosopher K.E. Løgstrup and the Norwegian nursing philosopher Kari Martinsen's care philosophy has inspired this empirically based examination of some current barriers in the asymmetrical nurse–patient relationship. On the basis of qualitative interviews with six patients and six nurses, the research thus provides an identifying and problem‐exploratory examination of some current obstacles in which the handling of trust and power reflects the excesses of care. The findings develop three themes. ‘Being a burden’ acknowledges that the balance of power will always tip to the nurse's advantage. The second theme, ‘Doing only what's absolutely necessary’, shows how a fixation with ‘technicalism’ creates a distance between people that may constrain the patient's room for action. The last theme is concerning the nurse's ability to navigate between closeness and distance is essential in avoiding ‘the excesses of care’, paternalism, and overprotectiveness. A situation in which distance takes the upper hand and care turns into paternalism. A different situation would arise if the nurse's emotions became sentimental or intimate with the result that closeness gets the upper hand. To avoid a harmful exercise of power and the excesses of care, the findings have demonstrated that a relationship‐based caring is a demand for situation‐specific sensitive attention skills.     

Citizens, their agents and health care rationing: an exploratory study using qualitative methods

This paper considers the application of the theoretical notion of a principal-agent relationship to societal health care decision making. Current literature sheds little light upon whether a citizen-agent relationship exists in health care, with ambiguity about whether citizens want agents to make rationing decisions on their behalf, and if so, who these societal agents might be. A qualitative approach, using semi-structured interviews as the main instrument of data collection and analysis by constant comparison, was used to explore these issues with groups of both citizens and their potential agents. The findings of the research suggest that citizens vary considerably in the extent to which they want to be directly involved in making rationing decisions. Important influences on this issue appear to be knowledge and experience, objectivity and the potential distress that denying care may cause. Agents, in contrast, view citizens as needing agents to make decisions for them and suggest that it is primarily the health authority's role to act in this capacity. It is, however, apparent that the citizen-agent relationship in health care is both imperfect and complex, with final decisions resulting from the interaction between the utility functions of the various actors in the health care system. In practice a system of equivocation can be envisaged in which different groups collude as they attempt to avoid the disutility associated with denying care, with the consequence that the impact of decisions taken on an explicitly societal or citizen basis may be relatively small.     

Locating the lived body in client–nurse interactions: Embodiment,intersubjectivity and intercorporeality

The practice of nursing involves ongoing interactions between nurses' and clients' lived bodies. Despite this, several scholars have suggested that the “lived body” (Merleau‐Ponty, 1962) has not been given its due place in nursing practice, education or research (Draper, J Adv Nurs, 70, 2014, 2235). With the advent of electronic health records and increased use of technology, face‐to‐face assessment and embodied understanding of clients' lived bodies may be on the decline. Furthermore, staffing levels may not afford the time nurses need to be as “present” with their clients in embodied ways. The failure to attend to the lived body may contribute to missed opportunities for care and decreased quality of life for both clients and healthcare practitioners. In this paper, we undertake an analysis of selected aspects of the work of Maurice Merleau‐Ponty. The aim is to advance understanding of the affordances this work may offer to enhancing client–nurse interactions within the practice of nursing. Merleau‐Ponty's notions of embodiment, intersubjectivity and intercorporeality as articulated in his seminal texts The Phenomenology of Perception (New York, NY: Routledge, 2012) and The Visible and the Invisible (Evanston, IL: Northwestern University Press, 1968) are examined. These three constructs are discussed as they relate to the lived body in client–nurse interactions in nursing practice and education. Finally, implications of how attention to “the lived body” could shape interactions and have the potential to foster increased quality of life of clients and nurses are considered.     

“A Lot of Things I Hide”: Understanding Disclosure in the Care of HIV-Positive Bisexual Men

Objective: To improve access to health care for HIV-positive bisexual men it is necessary to characterize the relationship between their identity and their health care experience. Methods: This qualitative study of 10 HIV-positive bisexual men utilized grounded theory. Taped interviews elicited information on experiences with (a) health care delivery, (b) antiretroviral therapy, (c) social identity, and (d) social environments. In response to data from the first interview, an additional prompt on childhood sexual experiences was added to the remaining interviews. Results: These bisexual men believed they had experienced discrimination or exclusion because of homophobic interactions with the health care system which often led to avoiding the health system. These experiences included being considered homosexual, breaches of confidentiality about sexual orientation, and being judged. The majority said they would not disclose sexual identity (9/10) to health providers due to prevailing attitudes in health care toward bisexuality and addiction. These participants reported injection drug use (9/10) and had experienced childhood sexual abuse (9/10). Only 3 persons took antiretroviral therapy, for which all participants qualified. Implications: When dealing with HIV-positive bisexual men (who may have histories of childhood assault), health practitioners need to be aware of the sensitive issues surrounding disclosure of sexual identity. Addressing psychosocial issues would improve care-seeking and improve adherence.     

Governance mechanisms in the physician–patient relationship: a literature review and conceptual framework

Background

The physician–patient relationship is a critical component of the integrated approach to excellence in health‐care delivery. Although commonly modelled within the boundaries of the agency theory and regarded as synonymous to an agent–principal interaction, there exists only a sparse understanding about the most effective ways of governing it.

Objective

This article undertakes a selective review of the growing body of research on the governance of the physician–patient relationship to discuss the current state of the knowledge in the field and suggest promising avenues for further exploration.

Findings

On the basis of an extensive analysis of the relevant literature, we identify two emerging streams of inquiry on the trust‐based (i.e. trust and ethical oversight) and distrust‐based (i.e. patient information‐empowerment and decision‐making authority) governance mechanisms of the physician–patient relationship and discuss the key findings within each stream.

Discussion

To conciliate the on‐going scholarly debate concerning the efficacy of trust‐ and distrust‐based mechanisms, we draw the foundations of a conceptual framework which might serve as a guide for more integrative research endeavours on the governance of the physician–patient relationship.     

Patients’ perceptions of safety if interpersonal continuity of care were to be disrupted

Objective  To determine if patients vary in perceptions of safety if interpersonal continuity were to be disrupted. If so, which characteristics are associated with feeling unsafe? Background  The extent to which patients’ preference for continuity with a personal physician is due to perceptions of safety is unclear. Design  Observational study (Wisconsin Longitudinal Study Graduate and Sibling Survey). Setting and participants  A total of 6827 respondents (most aged 63–66 years) who completed the 2003–06 survey round. Main variables studied  Age, gender, marital status, education, health insurance type, illnesses, medications, length of relationship with provider and place, personality type, decision‐making preference and trust in physician deliberation. Main outcome measures  Safety perception when visiting another doctor or clinic if own doctor were not available. Results  Twelve percent of respondents felt unsafe. After adjustment, as compared to those who felt safe, those who felt unsafe were more likely to be women (Odds ratio = 1.65, 95% confidence interval = 1.35–2.01), have more chronic conditions (1.27, 1.08–1.50) and have a longer relationship with a usual provider: 5–9 years (1.53, 1.11–2.10) 10–14 years (1.41, 1.02–1.95) and 15 or more years (1.62, 1.20–2.17) compared to 0–4 years. Those who preferred active participation in decision making and had trust in their physician were less likely to feel safe (1.63, 1.10–2.41). Conclusions  Certain older adults perceive being unsafe if not seeing their usual physician. Further research should investigate reasons for perceptions of safety if continuity were disrupted and any implications for care.     

Development and psychometric testing of the patient participation in bedside handover survey

IntroductionWhen handover is conducted at the patient''s bedside, active patient participation can be encouraged, which may improve the safety and quality of care. There is a need for valid and reliable tools to measure patient perceptions of participation in bedside handover, to ensure the rising number of implementation and improvement efforts are consistently and effectively evaluated. The aim of this study is to systematically develop and evaluate the psychometric properties of a self‐report survey to measure patients'' perceptions of participation in bedside handover.MethodsIn Phase 1, our team developed a conceptual framework and item pool (n = 130). In Phase 2, content validity was assessed with four health consumers, four nurses and four researchers. Next, 10 current hospital inpatients tested the survey for end‐user satisfaction. In Phase 3, 326 inpatients completed the survey, allowing exploratory factor analysis, reliability analyses and convergent/divergent validity analyses to occur.ResultsPhase 1 and 2 resulted in a 42‐item survey. In Phase 3, 321 surveys were available for analysis. Exploratory factor analysis revealed a three‐factor solution, with 24 items, which matched our conceptual framework. The three factors were: ‘Conditions for patient participation in bedside handover’, ‘Level of patient participation in bedside handover’ and ‘Evaluation of patient participation in bedside handover’. There was strong evidence for factor reliability and validity. Additionally, the correlation between factors was strong.ConclusionThis study furthers our conceptual understanding by showing that nurse facilitating behaviours are a strong precursor for patient participation and perceived handover outcomes, justifying the need for nursing training. A robust survey has been developed to measure patient perceptions of participation in bedside handover, which can effectively evaluate this approach to care. Engaging consumers and nurses as research team members was invaluable in ensuring that the survey is acceptable for end‐users.Patient or Public ContributionA health consumer and nurse partnered as members of the research team from study inception to dissemination.     

Interactional practices in person‐centred care: Conversation analysis of nurse‐patient disagreement during self‐management support

BackgroundPerson‐centred care implies a change in interaction between care professionals and patients where patients are not passive recipients but co‐producers of care. The interactional practices of person‐centred care remain largely unexplored.ObjectiveThis study focuses on the analysis of disagreements, which are described as an important part in the co‐production of knowledge in interaction.DesignA qualitative exploratory study using conversation analysis.Setting and participantsData were collected from a nurse‐led person‐centred intervention in a hospital outpatient setting. Interactions between adult patients with irritable bowel syndrome (n = 17) and a registered nurse were audio‐recorded. COREQ guidelines were applied.ResultsDisagreements were found after demonstration of the nurse''s or patients’ respective professional or personal knowledge. Disagreements were also evident when deciding on strategies for self‐management. Although negotiations between opposing views of the nurse and patient were seen as important, the patient generally claimed final authority both in knowing how IBS is perceived and in the right to choose self‐management strategies. The nurse generally oriented towards patient authority, but instances of demonstration of nurse authority despite patient resistance were also found.Discussion and conclusionsThis study provides information on how co‐production of knowledge and decisions occur in the context of a person‐centred care intervention. Negotiations between nurse and patient views require a flexible approach to communication, adapting interaction to each context while bearing in mind the patients having the final authority. To facilitate co‐production, the patient''s role and responsibilities in interaction should be explicitly stated.     

The physician-patient relationship: the impact of patient-obtained medical information

We investigate the impact of patient-obtained medical information (POMI) on the physician-patient relationship when patients, as a group, are heterogeneously informed and a physician's interests do not coincide with those of her patients. Introducing additional well-informed patients to the population discontinuously affects the physician's strategy, having no effect unless a sufficient quantity is added. When few patients are well informed, increasing the precision of their information level has no effect on the physician's strategy. Alternately, when a sufficient number of well-informed patients exists, increasing the precision of their information allows all patients to free-ride by receiving more appropriate treatment recommendations.Counterintuitively, we also identify circumstances under which increasing the general level of information may potentially harm patients.     

The influence of medical cost controls implemented by Taiwan's national health insurance program on doctor–patient relationships

To prevent medical costs from rising, the National Health Insurance administration implemented the global budget system for financial reform, effective 1 July 2004. Since the implementation of this system, patients have been required to pay for some medicines to limit costs to the system. More recently, as they have faced constant increases in health insurance fees and also faced an increase in the number of medical expenses they must pay during an economic recession and a rise in unemployment, would the economic burden on the people of Taiwan not be increased? Even though National Health Insurance is a form of social insurance, does it guarantee social equality? The value of the healthcare industry is irreplaceable, so the most critical concern is whether worsening doctor–patient relationships will worsen healthcare quality. In short, while the global budget system saves on National Health Insurance costs, whether its implementation has affected healthcare quality is also worth exploring. This commentary also hopes to serve as a reference for the implementation of national health insurance in the United States. Copyright © 2014 John Wiley & Sons, Ltd.     

余姚市2008—2010年手足口病流行病学分析

目的了解浙江省永嘉县手足口病病例及病原分布情况,为预防保健工作提供科学依据。方法采用永嘉县疾病监测信息报告管理系统收集2008—2016年该县手足口病例资料,分析手足口病发病的时间、年龄、性别及病原体的分布特点。结果2008—2016年累计报告手足口病病例27 815例,发病时间呈双峰变化,以春末夏初季节及秋季为多;男性发病人数高于女性;年龄集中于1 ~5岁孩子,尤以1 ~3岁幼儿发病最多;各年份检出病原体除2011年EV71占优势(59.62%)外,近几年均以其他肠道病毒为主,2015和2016年EV71病毒在检出病原中已经下降到10%以下。结论该县手足口病呈一定的季节性,1 ~5岁孩子高发,近年EV71构成比呈下降趋势。     

2005—2014年江苏省卫生人力资源配置现状及公平性

目的评价分析2005—2014年江苏省卫生人力资源配置现状及公平性,为区域卫生人力资源规划提供实证依据。方法采用统计描述、洛伦兹和基尼系数以及卫生人力资源密度(HRDI)等方法对江苏省卫生人力资源的配置现状及公平性程度。结果各类卫生人力资源人口分布、地理分布以及按HRDI计算的基尼系数在分别在0.02~0.16、0.12~0.24、0.05~0.25之间。人口分布公平性优于地理分布公平性。在各类卫生人力资源中,注册护士的公平性最差。结论江苏省卫生人力资源配置总体上处于高度公平状态,但应继续优化卫生人力资源的区域配置,改善卫生人力资源的内部结构,以此提高卫生人力资源配置公平性。