Autonomy and integrity : Drivers of health care professionals dealing with multiple obligations

Detta är en avhandling från Stockholm : Karolinska Institutet, Department of Learning, Informatics, Management and Ethics (Lime)

Sammanfattning: The medical services have undergone substantial changes over the past decades, and the design and content of health care have been determined by economic programmes, streamlining, and rationalization. The calls to cut costs and implement reorganizations have come largely from politicians and have been handled by middle and high-level managers. Advances in medicine and technology have led to heavier burdens on staff, and another challenge concerns having to deal with patients who are more knowledgeable and demanding than was previously the case. Therefore, health care professionals are required to carry out more tasks simultaneously, and they also have to contend with additional obligations to different stakeholders. The main objective of the research underlying this thesis was to gain a better understanding of how medical and health care personnel are affected by having multiple obligations, which can even be conflicting in relation to these professionals themselves, their patients, and their employers. To identify and elucidate the experiences of care personnel in this context, data were collected by use of an open interview form in the first study and by performing in-depth interviews in the three subsequent investigations. The gathered data were assessed by content analysis in Study 1, by grounded theory in Studies 2 and 3, and by modified analytic induction in Study 4. All of the participants in the four investigations had in common the fact that they were licensed practitioners in various fields of medicine and health care, and thus they were responsible their own professional conduct. The first study included 42 resident physicians, and the results showed that these professionals were highly engaged in their work and were satisfied with their career choice, but they had mixed emotions about their work situation. It was clear they needed confirmation, more support, and greater opportunity for reflection under stressful working conditions. The eight participants in the second study represented all levels in one psychiatric care organization, which was being reorganized with respect to the authorities in charge, as well as the treatment strategies in use. It became apparent that a change in a theoretical frame of reference or a revision of internal obligations proceeded according to a completely different timetable compared to a more technical transformation of a method or an external change in the organization. Professional autonomy and authority were threatened, and professional identity was shaken. Ten middle managers took part in the third study. They had developed strategies and above all a personalprofessional maturity that gave them non-negotiable independence and authority. They were guided by their basic values, respect, and integrity in relation to how they perceived themselves, their personnel, and their patients, and even with regard to their own superiors and the organization in which they worked. The fourth study included 13 clinicians who served as both teachers and researchers, and had several formal commissions and different employers. These individuals had an extremely complicated and demanding work situation, but they felt that the various tasks they performed enhanced each other. They got feedback on their work, and their authority was not questioned. Furthermore, the work they did was stimulating and challenging, and led to self-development. The medical and health care services will be continually restructured to meet the demands of patients and society. One of the most important challenges is to make this an attractive area of work, so that the personnel will not want to leave. Health care professionals are not going to stand idly by while their autonomy and authority are undermined, rendering them a mere cog in an industrialized health care system. They want to contribute their expertise, and when they feel they are appreciated and treated with respect, they become involved in and committed to both the organization and their original mission to give their patients the best possible care.

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