Every day, India sees the addition of 5,000 new cases of diabetes to its current diabetic population of 65 million people. This number is projected to cross the 100 million mark in 15 years. The emerging pandemic scale of diabetes growth is straining India's already-overburdened public healthcare resources. India is home to several well-established native and adapted foreign traditions of medicine that are widely practiced. These traditions include Ayurveda, yoga and naturopathy, unani, siddha, and homeopathy. The modern and traditional medicine approaches are extensively used as independent systems. The purpose of this qualitative research case study was to evaluate the use of an integrative approach to address the multiple challenges posed by diabetes in India. The research design for the case study was based on the theoretical framework of participatory action research. The research questions evaluated how the modern and traditional medicine systems can be jointly used to contain the spread, scale, and immensity of diabetes in India and examined the barriers and challenges in combining various systems of medicine. Data were collected from interviews with 30 modern and traditional medical practitioners and 6 policy makers identified through a stratified purposeful sampling process. The transcribed data were coded thematically and objectively analyzed. The trustworthiness of interpretations was bolstered with triangulation through records from notes and observations. In evaluating the feasibility of a synergistic and integrative approach, the study filled a gap in scholarly literature. The study contributes to social change by adding to the existing body of knowledge available to physicians and patients in preventing and containing the diabetes pandemic.

Libyan citizens who can afford private health care are opting out of the public health care system. They have a perception that the quality of public health care has deteriorated. The negative perceptions have resulted in a lack of trust by many of Libyan's citizens in the Libyan public health care system and consequently to unequal access to quality health care. The purpose of this study was to identify the factors that have led to the negative perceptions and mistrust. The conceptual support for the study was based on a construct of trust that defines trust as the state of readiness for unguarded interaction with someone or something. Key research questions examined the role Libyan cultural values and privatization of healthcare might have played in creating the negative perceptions and mistrust of the healthcare and its delivery and whether the perceptions and mistrust varied between the patients and healthcare providers. The research methodology used for this study was a qualitative exploratory single-case study. Fifty participants were interviewed during a one-month period. Responses were coded using ATLAS.ti. Study results provided an understanding of the cultural considerations, the impact of privatization, and the respondents' perceptions of Libyan public health care. Results indicated that respondents demonstrated the capacity to trust but did not consistently have positive perceptions of competence and intention of administrators of the public health care system. The findings suggest that patients view the behavior of providers as an indication of their level of skill. Additionally, respondents perceived that they will have a higher level of service if they have a personal recommendation. The social change implication for this study is that overcoming these negative perceptions and improving trust can lead to equal access to quality health care.

Medical errors occur despite precautionary measures. Limited research has focused on intuition in preventing medical errors. The problem addressed in this study explored the role of intuition by health care team members in preventing medical errors from reaching hospitalized patients. The research questions focused on the differences in response to medical errors by health care team members from 3 West Coast hospitals. The theoretical framework included human error, personality typing, skill acquisition, and a model of intuition. In this exploratory mixed method study 1,836 unusual occurrence reports submitted over 6 months were analyzed. Of the 710 health care team members surveyed, 201 (28%) completed an intuitive score instrument. Eight health care team members were interviewed, with responses analyzed for themes of knowledge management implicit to intuition. The unusual occurrences results were categorized as near miss or adverse event and analyzed using t tests. There were no differences in a comparison of mean intuition scores for type of error and levels of intuition by participant age or gender. Differences were found in the number of documented constructs of intuition by type of error and discipline in the comparison of pharmacy to nursing and diagnostic imaging. Interview excerpts were compiled for use by managers to role model through storytelling how intuition can prevent medical errors. Research is needed to understand how to incorporate skills of tacit recognition and intuition. Preventing costly and potentially life-threatening medical errors is fundamental to addressing the societal need to lower costs and provide safer patient care.

If the United States is turning to consumer-driven health plans to control costs and improve access, research is needed regarding the perception of such plans among small businesses. Nearly half of Americans are employed by small businesses where access to health insurance has declined most rapidly. Reviews of the literature revealed solid theoretical bases for high expectations regarding the diffusion of consumer-driven health plans among small businesses, but relatively little information was found regarding the attitudes of small businesses toward emerging health plan models. Qualitative case studies of 6 small employers in the Ogden, Utah, area were conducted to address this problem. Data were collected from documents, archival records, and participant interviews and analyzed using memoing, coding, and iterative pattern matching. Key findings were that leaders of these firms did not believe employees could or would find adequate information about the quality and cost of health care services and alternative providers that would allow them to make effective choices. As a result of this belief, all firms maintained managed care controls on available providers and access to expensive services. The results imply that despite policy assumptions about the attractiveness of consumer-driven plans for small business, such plans may in actuality not be offered by small businesses as an alternative or replacement for managed care. Rather, high deductibles may simply be layered on top of managed care controls without a corresponding expansion of choice for employees. Some employees of participating firms engaged in both passive and active resistance to the imposition of high deductibles. Policy and plan designers will benefit from enhanced understanding of ways to diffuse consumer-driven plans in small businesses that will reduce employee resistance.

Background There is a relative dearth of information regarding transgender patient perceptions of healthcare provider interactions and experiences. Previous studies have examined the experiences of transgender patients across multiple generations. Purpose This research focuses on understanding the lived experience of transgender college-aged students receiving healthcare. The goal of this research is to help inform the practices of healthcare providers in order to improve care experiences. Methods Hermeneutic phenomenology was utilized to illuminate the lived experiences of three college-aged transgender patients receiving healthcare. Interviews were conducted with research participants. After transcription, interview content was read and re-read for significant statements. Significant statements were then grouped to identify themes. Results Theme 1: provider knowledge. Study participants noted that provider knowledge was associated with several behaviors and impacted their feelings regarding the experience and willingness to seek future healthcare. The trans-friendly provider was identified as a provider who uses preferred language, shares decision-making, and is aware of medical treatments. Theme 2: being defined. Study participants felt defined through a variety of provider interactions. These included experiences wherein providers question timelines of transition and question the patient regarding their identity using static terminology. Theme 3: loss of power. Participants noted the experience of loss of control when receiving healthcare. Loss of control was felt in a variety of ways including: loss of control over naming, identity, and care decisions. Conclusions This research begins to identify emerging themes expressed by transgender college-aged patients. By identifying these themes, future research can be conducted to further clarify patient feelings associated with their experiences in seeking healthcare in order to inform provider behaviors. More research is needed regarding transgender patient experiences receiving healthcare and whether these experiences impact health outcomes.

This research developed and tested a conceptual model to explain why higher volumes of certain surgical procedures lead to better patient outcomes. The model incorporated hospital structural characteristics and process of care indicators to explain the volume-outcome relationship. The volume-outcome relationship was further examined longitudinally to determine stability over time and to substantiate the causality implied by the conceptual model. A sample (n=1752) of acute-care, general hospitals was selected from hospitals that performed, in 1990, at least one surgical procedure on Medicare patients of the following: reduction of hip fracture, cholecystectomy, hip replacement, carotid endarterectomy, and pacemaker insertion. For the longitudinal analysis, the sample size was reduced to 1582 hospitals that performed all five surgical procedures in 1988 and in 1990. The conceptual model was specified as a structural equation model, and was analyzed using LISREL 7. The cross-sectional analysis examined interrelationships among volume, resource availability, average length of stay, structure, process, and outcome. Panel data were used to examine the stability of volume and outcome from 1988 to 1990. The hypothesized volume-outcome relationship existed for hip fracture and cholecystectomy, and the effects of structure and process on outcome were significant for hip fracture and hip replacement. No volume effects were detected for hip replacement, carotid endarterectomy, and pacemaker insertion. In all cases, volume, average length of stay, and resource availability had significant influence on the hospital's structure and process of care. Panel data were relatively stable for volume, but unstable for outcome. The volume-outcome relationship is procedure-specific. For hip fracture and cholecystectomy, the direct effect of volume on outcome is small after taking into account structure and process. The indirect effect of volume leads to inefficient care processes and attenuates the beneficial, direct effects of high volume.

This study examined hospital characteristics that affected the differential in hospital mortality, while controlling for the effect of community attributes. Analytical models for the determinants of hospital mortality were formulated and validated through an empirical examination of 243 hospitals that had higher or lower mortality rates than expected for Medicare beneficiaries. The dependent variable for this study was death rates for 1984 Medicare patients in united states hospitals released in 1986 by the Health Care Financing Administration. Structural equation models that portray the causal relation between organizational constructs and hospital mortality rate were formulated. This causal model was empirically validated. The findings suggest that the "size" effect on hospital mortality is a spurious one. Specialization was found to be negatively related to hospital mortality when the effects of other variables were simultaneously controlled. Hospitals having a higher degree of specialization tended to have a lower mortality rate. The effect of service intensity on hospital mortality was statistically significant when control variables were added into the equation. Thus, a hypothesized positive relationship between service intensity and hospital mortality was confirmed; the greater the service intensity, the higher the mortality. Ownership and crude death rate both had a negligible effect on hospital mortality. The only control variable that was statistically significant is "teaching status". The teaching hospitals had a lower mortality rate than nonteaching hospitals did when other organizational factors were controlled.

Nursing shortage is a growing problem in the healthcare industry as hospital leaders are experiencing difficulties recruiting and retaining nurses. Guided by the PESTEL framework theory, the purpose of this case study was to explore strategies healthcare leaders use to overcome a nursing shortage. Participants were 5 healthcare leaders who have the knowledge and experience in recruitment and retention of registered nurses in a healthcare facility in Seattle, Washington. Data were collected through audio-recorded semistructured interviews and document review of the Hospital Employee Education and Training Program. Data analysis consisted of documenting the data, organizing and categorizing the data, connecting of the data, corroborating and legitimizing the findings, and reporting the findings. After data were transcribed, participants reviewed the transcripts for accuracy. Analysis of the data revealed 5 themes: development of communication programs, increased employee engagement, investments in nursing education, positive work environment, and improving the healthcare system through new policies and regulations. The implications for positive social change include the potential to alleviate pain, reduce deaths rates, and create a healthier community by overcoming nursing shortage.

The rates of mental health issues in the lesbian, gay, bisexual, and transgender (LGBT) communities are twice that of individuals who identify as heterosexual. Research in urban communities show lower mental health services utilization rates for LGBT individuals compared to their heterosexual counterparts. The purpose of the study was to examine how rural environmental factors affect the use of mental health services by LGBT individuals and provide information to improve mental health outcomes. Andersen's healthcare utilization model and the minority stress theory were the foundations of this study. This study examined the association of mental health providers' availability/characteristics and utilization of mental health services and the association of perceived sexual discrimination and mental health services utilization in rural LGBT communities. Questionnaires were used to collect data from a random sample of 121 LGBT participants in Virginia, and linear and multiple regression was used to analyze the data. The findings for the associations between environmental factors and mental health service use were p < .84 for perceived discrimination, p < .04 for fear of provider insensitivity, p < .02 for provider availability, p < .000 for provider insensitivity and hostility, and p < .003 for provider insensitivity and ridicule. The results showed a need for specialized and sensitivity training in the health community and the need for improved access for LGBT health consumers in rural communities. The results of this study might lead to social change by encouraging improvement in mental health services and mental health outcomes for the LGBT community.

Business leaders are challenged with sustaining an engaged workforce to achieve economic prosperity in their organizations. The implementation of effective strategies to increase employee engagement can mitigate the challenges of employee disengagement. The purpose of this qualitative, single case study was to explore the strategies that department store managers used to increase employee engagement. The conceptual frameworks selected for the research were Vroom's expectancy theory of motivation and Kahn's engagement theory. The research participants consisted of 5 department store managers, from the northeastern United States, who successfully used strategies to increase employee engagement. Data were collected from the participants in semistructured interviews and from company archival documents about the strategic efforts that department store managers used to increase employee engagement. Data analysis consisted of compiling the data, coding for emergent themes, disassembling the data into common codes, reassembling the data into themes, interpreting the meaning, and reporting the themes. The 9 themes that emerged from the data were manager and employee relationship, employee motivation, rewards and incentives, expressing appreciation, ensuring employee wellbeing, health and safety, employee empowerment, employee feedback, and establishing employee expectations. The study results could contribute to positive social change by providing department store managers with strategies to increase employee engagement, which may reduce employee turnover and create community-wide employment opportunities for community members.