A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of MSc (Med) in Bioethics & Health Law Johannesburg, May 2017 / Spiraling health care costs have posed a threat to access to health care for scheme members, as more has to be done with even less. Managed care programmes were introduced to control the health care costs by reducing medical doctors autonomy. My aim was to ascertain the extent to which the managed care processes impede medical doctors’ autonomy. Principled conditions were identified where the limitation of doctors’ autonomy as a result of managed care could be morally justified which include where implementation would result in a just distribution of resources and a limitation of medically futile treatment. However principled conditions where these managed care tools would not ethically be justified included where they would result in adverse patient outcomes, where they result in a loss of medical doctors morale or where they result in reduced trust in the patient doctor relationship. / MT2017

Thesis (Ph. D.)--University of Washington, 2006. / Vita. Includes bibliographical references (leaves 223-240).

Den här studien ämnar undersöka hur lärare uppfattar sin autonomi inom olika områden av deras yrke och fungerar som en förstudie till ett forskningsprojekt. Begreppet autonomi är mångfacetterat, men kontroll över yrket och inflytande över beslutsprocesser utgör en stor del av det. Uppsatsen fokuserar på lärare i grundskolan och gymnasiet. Tre forskningsfrågor formulerades för att fånga in begreppet autonomi. Dessa är: Hur uppfattar lärare sin professionella autonomi?, Hur skiljer sig lärares uppfattningar angående olika dimensioner av autonomi (olika nivåer och olika områden i yrkeslivet)? samt Hur väl korrelerar olika delar av lärares uppfattade autonomi med varandra?. Studiens empiri samlades in genom kvantitativ metod i form av en webbenkät vilken 93 personer svarade på. Merparten av lärarna svarade på enkäten via facebookgrupper även om flera olika kanaler användes för att nå ut till möjliga respondenter. Det teoretiska ramverket består i Frostensons tre nivåer av autonomi, LaCoes sex komponenter gällande lärares yrkesautonomi och Ballous individuella autonomi vilka tillsammans skapar en multidimensionell konstruktion. Tidigare forskning behandlar hur de senaste decenniernas skolreformer i Sverige omformat lärarprofessionen men består också i utländsk forskning gällande lärare och deras autonomi.                       Uppsatsens resultat visar att lärare uppfattar sin autonomi som både stor och liten beroende på vilket område av autonomi som åsyftas. Respondenterna anser sig ha litet inflytande gällande ekonomiska beslut vilka även visar sig vara de beslut de uppfattar är viktigast i skolans verksamhet. Vidare uppfattar lärarna som svarade på enkäten sin autonomi som hög vad gäller sådant som rör deras klassrumsmiljö och undervisning. / This study serves as a pilot study for a research project and aims to investigate how teachers perceive their autonomy in different domains of their profession. Autonomy as a concept is multifaceted but control over the profession and influence in decision-making processes constitute a great part of it. The study focuses on primary, secondary and high school teachers. Three research questions were formed to capture the term autonomy. These are: How do teachers perceive their professional autonomy?, How do teachers perceptions differ in the various dimensions of autonomy (different levels and domains of the worklife)? and How well do various domains of teachers perceived autonomy correlate?. The data of the study was collected by quantitative method via a web-based questionnaire which was answered by 93 persons. The main part of the teachers answered the questionnaire through facebook groups despite having used several other different channels to reach out to possible respondents. The theoretical framework consists of Frostenson’s three different levels of autonomy, LaCoe’s six components of teacher autonomy and Ballou’s themes within individual autonomy which together create a multidimensional construction. Previous research discusses how school reforms of the recent decades in Sweden have reshaped the teaching profession but it also consists of foreign research of teachers and their autonomy.                       The results of the study indicates that teachers perceive their degree of autonomy as both high and low depending on what domain referred to. The respondents consider themselves having a small influence regarding economical decisions which also is considered the most important decisions in school’s activities. Furthermore the teachers who responded perceive their degree of autonomy as high regarding the classroom environment and teaching.

O modelo de assistência ao parto o Brasil está fortemente relacionado à atuação do médico e a maioria dos partos é realizada em ambiente hospitalar: em 2004, 94% dos partos foram hospitalares e 43% dos nascimentos ocorreram por cesariana, uma atividade estritamente médica. Na rede privada de serviços de saúde do município de São Paulo, o percentual de cesarianas gira em torno de 84%. A partir do final da década de 1990, vêm sendo formuladas políticas públicas para promover mudanças nesse modelo. Algumas dessas proposições favorecem a inserção de enfermeiras obstétricas e obstetrizes (EO) na assistência ao parto, reconhecendo sua importância para promover o parto normal. Nesse contexto, a autonomia profissional da EO na atenção de baixo risco e o trabalho colaborativo na assistência ao parto são elementos fundamentais para uma atenção qualificada. Por sua vez, a atuação da EO na assistência ao parto é definida não exclusivamente pelas políticas de saúde oficiais, mas também pela organização da assistência praticada nas instituições. A forma como a EO atua na assistência ao parto e como vivencia a autonomia profissional e o trabalho colaborativo dependem do local de atuação, das regras e normas da instituição, da divisão técnica do trabalho e da relação hierárquica estabelecida na equipe obstétrica. O objetivo deste estudo foi descrever como a enfermeira obstétrica percebe sua inserção na equipe obstétrica e sua autonomia profissional na assistência à mulher durante o parto, em instituições de saúde privadas. Foi utilizada a metodologia qualitativa e o estudo foi realizado com EO que atuavam em instituições de saúde privadas da cidade de São Paulo, que atendem exclusivamente pacientes particulares ou usuários de seguros ou planos de saúde. Os dados foram coletados por meio de entrevista semi-estruturada, como uso do gravador. Foram incluídas 15 EO que atuavam no centro obstétrico de nove instituições de saúde privadas. A análise de conteúdo foi utilizada para sistematizar os dados qualitativos e a discussão foi realizada considerando os seguintes temas: Autonomia; Confiança e cumplicidade: principais facilitadores da autonomia; Outros aspectos facilitadores da autonomia; Dificuldades para a autonomia; Facilitadores do trabalho colaborativo; Barreiras para o trabalho colaborativo; Percepção da inserção da enfermeira obstétrica na equipe; Composição e coordenação da equipe de assistência ao parto; Reflexões sobre a atuação da enfermeira obstétrica nas instituições de saúde privadas. Identificamos que apesar do apoio legal e do reconhecimento dos órgãos oficiais e organizações internacionais da importância da EO assistência à mulher no parto, sua atuação nas instituições privadas do município de São Paulo é muito restrita e aquém das competências estabelecidas para esta profissional. As EO apontaram o não reconhecimento de suas atribuições pelos médicos obstetras como um dos principais fatores para a restrição de sua autonomia e para a falta de trabalho colaborativo no cuidado da parturiente / The model of healthcare during labor in Brazil is strongly associated to the physician care, and the majority of deliveries occur in hospitals: in 2004, 94% of the deliveries took place in hospitals and 43% of them were cesarian sections, something that implies medical care. In the private health system in the city of São Paulo, the incidence of cesarian section deliveries reaches around 84%. Since the end of the 1990-decade, some political initiatives have been trying to change this model. Some of the proposals favor the insertion of nurse-midwives in the assistance team, recognizing the importance of this professional in the promotion of normal delivery. In that context, the professional autonomy of the nurse-midwife and collaborative work in the delivery assistance are essential for a qualified care. However, the role of the nurse-midwife in the delivery assistance is defined not only by official guidelines, but also by the institutions\' policies. The way she can live professional autonomy and collaborative work depends on the type of hospital, its rules and norms, on the distribution of work among the team\'s members and on the hierarchical relationships. This study had the objective of describing the nurse-midwife\'s perception of her insertion in the assistance team and of her professional autonomy in private hospitals. This was a qualitative study, with nurse-midwives working in private institutions in São Paulo that assist members of health care insurance plans. Data were collected by means of semi-structured interviews, registered in a tape recorder, with 15 nurse-midwives who work in 9 private hospitals. Content analysis was used and the qualitative data collected was discussed based on the themes: autonomy, factors that facilitate autonomy or factors that make autonomy more difficult, facilitators of collaborative work and factors that make it more difficult, the composition and coordination of the delivery health care team and the perception of the nurse-midwife of her insertion in the team. We observed that, despite the legal support and the recognition of official and international organizations about the role of the nurse-midwife, her actual work in the private hospitals in São Paulo is restricted and are not in accordance with her competence and skills. The nurse-midwives pointed out that obstetricians do not recognize their responsibilities in the health care team, and this restricts her autonomy and plays against the collaborative work in the patient\'s benefit

O modelo de assistência ao parto o Brasil está fortemente relacionado à atuação do médico e a maioria dos partos é realizada em ambiente hospitalar: em 2004, 94% dos partos foram hospitalares e 43% dos nascimentos ocorreram por cesariana, uma atividade estritamente médica. Na rede privada de serviços de saúde do município de São Paulo, o percentual de cesarianas gira em torno de 84%. A partir do final da década de 1990, vêm sendo formuladas políticas públicas para promover mudanças nesse modelo. Algumas dessas proposições favorecem a inserção de enfermeiras obstétricas e obstetrizes (EO) na assistência ao parto, reconhecendo sua importância para promover o parto normal. Nesse contexto, a autonomia profissional da EO na atenção de baixo risco e o trabalho colaborativo na assistência ao parto são elementos fundamentais para uma atenção qualificada. Por sua vez, a atuação da EO na assistência ao parto é definida não exclusivamente pelas políticas de saúde oficiais, mas também pela organização da assistência praticada nas instituições. A forma como a EO atua na assistência ao parto e como vivencia a autonomia profissional e o trabalho colaborativo dependem do local de atuação, das regras e normas da instituição, da divisão técnica do trabalho e da relação hierárquica estabelecida na equipe obstétrica. O objetivo deste estudo foi descrever como a enfermeira obstétrica percebe sua inserção na equipe obstétrica e sua autonomia profissional na assistência à mulher durante o parto, em instituições de saúde privadas. Foi utilizada a metodologia qualitativa e o estudo foi realizado com EO que atuavam em instituições de saúde privadas da cidade de São Paulo, que atendem exclusivamente pacientes particulares ou usuários de seguros ou planos de saúde. Os dados foram coletados por meio de entrevista semi-estruturada, como uso do gravador. Foram incluídas 15 EO que atuavam no centro obstétrico de nove instituições de saúde privadas. A análise de conteúdo foi utilizada para sistematizar os dados qualitativos e a discussão foi realizada considerando os seguintes temas: Autonomia; Confiança e cumplicidade: principais facilitadores da autonomia; Outros aspectos facilitadores da autonomia; Dificuldades para a autonomia; Facilitadores do trabalho colaborativo; Barreiras para o trabalho colaborativo; Percepção da inserção da enfermeira obstétrica na equipe; Composição e coordenação da equipe de assistência ao parto; Reflexões sobre a atuação da enfermeira obstétrica nas instituições de saúde privadas. Identificamos que apesar do apoio legal e do reconhecimento dos órgãos oficiais e organizações internacionais da importância da EO assistência à mulher no parto, sua atuação nas instituições privadas do município de São Paulo é muito restrita e aquém das competências estabelecidas para esta profissional. As EO apontaram o não reconhecimento de suas atribuições pelos médicos obstetras como um dos principais fatores para a restrição de sua autonomia e para a falta de trabalho colaborativo no cuidado da parturiente / The model of healthcare during labor in Brazil is strongly associated to the physician care, and the majority of deliveries occur in hospitals: in 2004, 94% of the deliveries took place in hospitals and 43% of them were cesarian sections, something that implies medical care. In the private health system in the city of São Paulo, the incidence of cesarian section deliveries reaches around 84%. Since the end of the 1990-decade, some political initiatives have been trying to change this model. Some of the proposals favor the insertion of nurse-midwives in the assistance team, recognizing the importance of this professional in the promotion of normal delivery. In that context, the professional autonomy of the nurse-midwife and collaborative work in the delivery assistance are essential for a qualified care. However, the role of the nurse-midwife in the delivery assistance is defined not only by official guidelines, but also by the institutions\' policies. The way she can live professional autonomy and collaborative work depends on the type of hospital, its rules and norms, on the distribution of work among the team\'s members and on the hierarchical relationships. This study had the objective of describing the nurse-midwife\'s perception of her insertion in the assistance team and of her professional autonomy in private hospitals. This was a qualitative study, with nurse-midwives working in private institutions in São Paulo that assist members of health care insurance plans. Data were collected by means of semi-structured interviews, registered in a tape recorder, with 15 nurse-midwives who work in 9 private hospitals. Content analysis was used and the qualitative data collected was discussed based on the themes: autonomy, factors that facilitate autonomy or factors that make autonomy more difficult, facilitators of collaborative work and factors that make it more difficult, the composition and coordination of the delivery health care team and the perception of the nurse-midwife of her insertion in the team. We observed that, despite the legal support and the recognition of official and international organizations about the role of the nurse-midwife, her actual work in the private hospitals in São Paulo is restricted and are not in accordance with her competence and skills. The nurse-midwives pointed out that obstetricians do not recognize their responsibilities in the health care team, and this restricts her autonomy and plays against the collaborative work in the patient\'s benefit

'Profession' and 'professional' are shifting signifiers that have taken on a range of new meanings in the past two decades as professional occupations have been reshaped by moves to 'flexible' (deregulated and decentred) work processes and work practices. The role of modern professions was significant in terms of the democratic elements of the professionalising project. But how do moves away from the modern bureaucratically-structured professions, and a professional ideal based on the concept of universal service, impact on graduates currently entering professional employment domains in which new 'performativity-based' management regimes are replacing the older control structures? This study draws on a range of sociological literature to explore both the structural and discursive changes in the meaning of profession practice. The study also draws on a number of research projects, including materials from focus group interviews of final year undergraduate students, recruitment brochures, ABS (Australian Bureau of Statistics) statistical analyses and DEST (Australia: Department of Employment, Science and Training) graduate destination studies, and policy documents. These materials are used to argue that the employment destinations of those with professional qualifications and credentials are now more stratified and more diverse and no longer necessarily coupled with a lifelong career. In addtion, the new management regimes that accompany the move to more flexible work processes and work practices are changing how those in professional work locations construct their sense of themselves as professional practitioners. Changes in the nature of professional work, and in the structural and discursive location of professional workers, have implications for education and training institutions. These institutions not only prepare workers for these occupational domains but are the main conduits through which access to work in the restructured labour markets is mediated. The study concludes by drawing attention to the need for educational research to be anchored in a 'sociology of employment' that is able to provide a more critical account of the relationship between education and training and entry into high status/low status employment domains.

<p>Financial incentives have become important in health care all over the world. This thesis compares one council implementing a new payment system based on performance based reimbursement (PBR) with ten councils retaining an annual budget system. </p><p>The aim of this thesis was to study the effects of PBR on physicians’ attitudes and behaviours, that may affect the conditions for cost effective care. Aspects highlighted are efficiency, cost awareness, quality of care, professional autonomy and power, job satisfaction and leadership.</p><p>This thesis is based on data from seven studies, questionnaires, interviews and register based studies. One instrument, Incentive, Effectiveness, Environment (IEE) was developed within the framework of this thesis. It measures self-reported behavioural changes related to daily clinical work, judgements about work environment factors and the quality of care, and attitudes towards and existence of financial incentives.</p><p>Physicians in the council with PBR experienced a greater pressure to improve their efficiency and they did so. The average length of stay decreased more both in relative and absolute numbers. Much of the efficiency increase, however, seems to emanate from "running faster", not from working more rationally. Cost awareness increased in all councils studied although more so in the council with PBR. PBR was found to create a different financial incentive than an annual budget, stronger and more positive. Effects on quality of care were judged to be negative. Financial reductions were claimed to be the main reason for quality losses, but PBR was found to be more time consuming and therefore contributed to the negative outcome. Work environment factors, especially professional autonomy and power were judged to have deteriorated in all councils studied although more so in the council with PBR. Good leadership was shown to make a difference for quality of care as well as for professional autonomy and job satisfaction, regardless of context.</p><p>The results seem, at least partly, to depend on the new payment system, creating an increased efficiency pressure. Additional reasons discussed in this thesis are financial reductions, repeated organisational changes and a size effect.</p>

Financial incentives have become important in health care all over the world. This thesis compares one council implementing a new payment system based on performance based reimbursement (PBR) with ten councils retaining an annual budget system. The aim of this thesis was to study the effects of PBR on physicians’ attitudes and behaviours, that may affect the conditions for cost effective care. Aspects highlighted are efficiency, cost awareness, quality of care, professional autonomy and power, job satisfaction and leadership. This thesis is based on data from seven studies, questionnaires, interviews and register based studies. One instrument, Incentive, Effectiveness, Environment (IEE) was developed within the framework of this thesis. It measures self-reported behavioural changes related to daily clinical work, judgements about work environment factors and the quality of care, and attitudes towards and existence of financial incentives. Physicians in the council with PBR experienced a greater pressure to improve their efficiency and they did so. The average length of stay decreased more both in relative and absolute numbers. Much of the efficiency increase, however, seems to emanate from "running faster", not from working more rationally. Cost awareness increased in all councils studied although more so in the council with PBR. PBR was found to create a different financial incentive than an annual budget, stronger and more positive. Effects on quality of care were judged to be negative. Financial reductions were claimed to be the main reason for quality losses, but PBR was found to be more time consuming and therefore contributed to the negative outcome. Work environment factors, especially professional autonomy and power were judged to have deteriorated in all councils studied although more so in the council with PBR. Good leadership was shown to make a difference for quality of care as well as for professional autonomy and job satisfaction, regardless of context. The results seem, at least partly, to depend on the new payment system, creating an increased efficiency pressure. Additional reasons discussed in this thesis are financial reductions, repeated organisational changes and a size effect.

Thesis (Ph.D. in Nursing) -- University of Colorado, 2005. / Typescript. Includes bibliographical references (leaves 225-249). Free to UCDHSC affiliates. Online version available via ProQuest Digital Dissertations;

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