Practicing Health Care in Modern Society - Essay Example

Discussing and analyzing key sociological and psychological issues which underpin approach to care management I. Introduction Practicing health care in modern society is a challenging task. The increase of population around the world has led the health care industry to a dilemma whether the services provided should be of a lower level in accordance to meet the demands of all the people suffering. On the other hand, such a strategy would be in opposition with the industry’s main mission which is the provision of high quality services (at least of the highest possible) to the people that need medical treatment. It should be noticed that the possible intervention of other factors (such as the family of the patient or his/ her gender, race or educational level) should not be criteria for differentiation from the principles and the ethics that govern the health care sector. In this context Arneson et al. (2003, 35) stated that ‘professional nurses experience increasing workplace demands from inside and outside the hospital; The internal pressures of patient care and a traditional organizational hierarchy are coupled with external factors such as medical reimbursement guidelines and competition from other healthcare providers’. Under the above conditions the intervention of the sector’s leaders for change should be considered as crucial. After examining the particular issue Shelley (2003, 13) stated that leaders in the health care industry should ‘understand that staffs reactions to change vary widely; While change itself isnt good or bad, its relative to whomever is experiencing it. Some will feel motivated and energized by change, others will feel threatened, anxious, fearful, or a sense of loss of the familiar and status quo. Some may even experience a grief reaction’. The application of the above plan should not be regarded as a permanent solution to the problems that appear in the healthcare industry; however it could be characterized as a primary effort that can lead – if applied successfully - to the delivery of high quality health care services in the future. II. Care management – characteristics, ethical and legal framework If we try to identify the particular elements of care management and particular the responsibilities of the care provisioners we will come to the conclusion that although a net of rules and principles exist in the specific area – referring especially to the issues of responsibility and ethical behaviour – in fact the retrieval of evidence for the existence of responsibility regarding the actions of care provisioners can be a very difficult task which in many times is not completed successfully. In this context, Wikler (2002, 48) stated that ‘assessment of the value of invoking personal responsibility for health in health policy would ideally be conducted at multiple levels of abstraction: the notion of personal responsibility for health involves a number of perennial philosophical concerns, including the concepts of freedom of the will, voluntariness, and responsibility itself’. The view of the above researcher in practice verify the assumptions made before that it is rather difficult to identify and prove the existence of responsibility of care provisioners (referring to particular cases) mostly due to the emergent character of their activities – especially when having to deal with critical situations within very narrow time limits. Moreover, in order to understand the behaviour of care provisioners when delivering health care services we should primarily examine the content and the characteristics of ‘ethics’ as the above term is used in modern society. Regarding the specific issue Benn et al. (1996, 228) stated that ‘ethics is the systematic study of moral reasoning in theory and practice clarifying questions about right and wrong, but also demonstrating their complexity: most ethical theories and many moral judgments are contestable while some norms, values or principles are sufficiently widely agreed for codes of professional practice or laws to be based on them; the four most important of these principles are respect for the autonomy of persons, beneficence, non-maleficence and justice’. In the above context, a behaviour that would be differentiated from the framework described above should be criticized as not acceptable particularly in the area of health care industry where the consequences of such behaviour can be crucial even for a person’s life. However, ethics seem to be evaluated differently in accordance with the elements that are used for their identification and their description. For this reason Kohn et al. (1999, 167) is slightly differentiated from the view of Benn et al. (1996) supporting that ‘ethics is about questioning: questioning ourselves, questioning our relationships with others and questioning our place, as humans, in the larger environment; the nature of ethics, specifically health care ethics, is fundamentally a matter of the questioning, which requires openness, deliberation, self-reflection, uncertainty and contemplation; ethical issues encourage the logic of question and answer’. It seems from the above presentation of ethics that the behaviour of health care practitioners can be criticized differently – regarding the existence of ethical motive – in accordance with the conditions of each particular case, the character of the particular carer and the provisions of the professional rules as applied in a specific case. In other words, the interpretation of the carer’s behaviour can vary in accordance with the elements that are going to be used for its support. The above assumption is also supported by the view of Churchill (1986, 7) who stated that ‘in its broadest sense, ethics concerns how we live and what choices we make; as a particular professional expression of the larger discipline, medical ethics has to do with how physicians choose values and embody them in professional relationships with patients, families, colleagues, and the general public’. The extended reference to the content, the character and the interpretation of ethics has been made in order to show the level of differentiation that would possibly involve in the evaluation of a carer’s behaviour while delivering health care services. Regarding this view it has been found by Parker (1999, 43) that ‘according to the accepted principles of medical ethics, the patient is to be the ultimate judge of the benefits and burdens of life-extending treatment while the right to make such judgements rests on the principle of patient self-determination’. From a similar point of view, Grumet (1992, 316) stated that ‘ethics can be trivialized by too much enforcement, rather than too little; this approach causes public employees to think that ethics is silly, and diverts time and energy of ethics committee staff from potentially more serious ethical violations’. It seems that the circumstances of a specific event are crucial for the existence of responsibility of a specific carer regarding the obligations set by the ethical rules that govern the health care sector. Moreover, only if a carer’s behaviour is characterized as opposite to the ‘ethical standards’ it can lead to the person’s punishment in accordance with the professional and the legal principles that are applied in the relevant area. On the other hand, the evaluation of the carer’s behaviour has to be based on specific standards. In this context, Kaveny et al. (1995, 142) supported that ‘developing meaningful ways to measure and compare the effectiveness of various clinical interventions is clearly at the heart of managed care’. It is not made clear however whether the evaluation of clinical interventions is different in cases that do not take place within a ‘managed care’ environment (like the fee-for-service medicine). Regarding this issue, Wikler (2002, 48) stated that ‘an important consideration weighing against emphasis on personal responsibility for health is the potential harm that such a view might inflict upon both the enterprise of health care and the making of social policy on health affairs’. In other words, the existence of responsibility for the quality of services offered within a health care environment should be examined in accordance with the general ethical standards applied in the industry (McCullough et al., 2000) and should not be influenced by the character of a specific health care environment (fee-for-service medicine or managed care). Under this view, the influence of the sociological and the psychological principles and theories can be really intense as both the carer and the patient participate in a situation of high pressure which is crucial for both (either for professional, emotional or personal safety reasons). III. Issues of care management that arise in the particular case - psychological and sociological issues According to the facts presented in the case under examination Mrs. Begun is a woman that has left alone to bring her child in life. The assistance of the carers can be considered as the only help existed for the specific woman while her family is totally absent. Moreover, no support seems to exist from the woman’s environment (husband, family, and friends) apart from the help offered by the staff of the specific medical unit. In this case the role of midwife should be regarded as of high importance both for the woman and the child. In the particular occasion, midwife would offer also psychological support to Mrs. Begun taking into account the hostility that the woman faces from her environment. Under the above conditions, the role of midwife would be slightly differentiated from its common form although it can be argued that the provision of psychological support is among the duties of the midwife in any type medical environment (Loewenberg et al. 1992, Scallet et al., 1997). In order to evaluate the behaviour of midwives and that of the patient in the case under examination and particularly as of its sociological and psychological aspects, we could use at a first level the theories that they have developed in the area of nursing. In this context, in accordance with the medical model which was mainly supported by Florence Nightingale (1859) ‘medicine and nursing should be clearly differentiated from each other, as during her time this was indeed the case’ (McKenna, 1997, 85). Other significant theories in this area are the ‘Metatheory’ and the ‘Grand Theory’. The first of the above theories is based on the development of a separate team of theory watchers apart from the theorists already existed in the area. These individuals ‘are called metatheorists and, while they do not formulate theory themselves, they discuss, debate, describe, analyse, categorise, classify and explain what theorists are developing and how practitioners and patients are affected by such developments. Another role for these metatheorists is to examine how changes in the various philosophies of science affect the change in emphasis among nursing theorists; to some extent, therefore, metatheory incorporates the examination of how theory affects and is affected by research and practice within nursing, and philosophy and politics outside nursing’ (McKenna, 1997, 87). The gradual development of life at all its levels has created the need for a more advanced theoretical basis that could support all the types of behaviour appearing in the nursing area. For this reason from the early twenty-first century nurse theorists began to create a series of grand theories of nursing (actually these theories are well over fifty). Grand theories are differentiated in accordance with the area of nursing practice in which they are going to be applied and the elements of each particular occasion. In general they have followed the following stages of development: ‘there are many borrowed theories which have been used successfully by nurses to influence practice, and more mid-range and practice theories are being formulated each year; others have been developed inductively, from experiences in practice; deductively, from other theories (both borrowed and home grown); or through a retroductive combination of induction and deduction (McKenna, 1997, 93). From another point of view the behaviour of the participants (midwives and patient) in the specific case could be evaluated using the ‘implicit theories’. Regarding the above theories Anderson (1995, 286) stated that ‘people have two main types of implicit theories: entity and incremental. The entity theorists view the world in dispositional terms, believing that stable traits exist, that these traits influence how people behave, and that behaviors reveal the presence or absence of such traits. The incremental theorists view the world in more fluid or dynamic terms, believing less in fixed traits and more in the power of current psychological states-such as needs, goals, and intentions--as the proper way to understand behavior’. On the other hand, Russell (1999) supports the view of Brewin (1988) who stated that ‘the extent to which individuals deal successfully or unsuccessfully with challenging situations is also determined by their personal coping style and their prior experience or expectations’ (Brewin 1988, in Russell, 1999, 55). It has also been stated that ‘emotional and self-esteem support may be offered by the nurse during periods when the patient feels particularly low while those experiencing depression, for example, often feel a sense of worthlessness that can be counteracted by someone spending time listening and talking to them; similarly, the nurse can offer tangible support in the form of practical advice and information that may help to relieve stress by providing the patient with a means to deal with it; whilst this type of support may normally be offered by friends and relatives, it is the quality of support rather than the size of the individual’s network that is the critical factor in helping vulnerable individuals to meet their own needs (Schaefer et al. 1981, in Russell, 1999, 55). Similarly, Calnan et al. (2000, 337) supported that ‘access to, and observation of, the carers’ client group and the activities of caring are essential for the formulation of theory; just as access to and observation of patients was crucial for the development of medical discourse; but technical skills and practical experience are not in themselves sufficient to construct the crucial body of knowledge claimed by a profession’. In the above context ‘the nurse where appropriate, must be able to follow the client and be sufficiently skilled and adaptable to care in any environment, be it the ward, day care unit or community’ (Calnan et al., 2000, 336). From a similar point of view, Inglehart (1991, 317) proposed the application of stage-centered theories in the area of caring and particularly when an issue of psychological support occurs. As the above researcher found ‘stage-centered theories of reactions to critical life events developed in three phases: during the early period of stress research, Selye proposed a stage theory of reactions to noxious stimuli which he called the general adaptation syndrome (Selye 1936, 1956); the second period of stress research in the 1960s was dominated by stage-centered theories focusing on specific events; such writers as Bowlby and Kuebler-Ross studied reactions to specific events such as the separation of a child from its mother (Bowlby 1961) or reactions to facing death and dying (Kuebler- Ross 1969), and formulated stage models to describe these reactions; finally, in a third phase, Klinger (1975) published his incentive-disengagement theory; this theory no longer focused on reactions to specific events, but instead offered a general explanation of reactions to critical life events’ (in Inglehart, 1991, 317). In fact, the development of stage theories as described above in the work of Inglehart, presents also the different forms of their content as the latter has been altered throughout the years in order to meet the constantly changing demands and needs of the care services sector. The existence of responsibility of carers can be based on many ethical and professional rules. However, because of the particular ‘character’ of the specific profession there is always space left for interpretation and personal evaluation (Rhodes, 1991, Meyer, 1983). Regarding specifically the behaviour of nurses when delivering healthcare services, Hunt (1994, 183-184) stated that there are ‘three elements that characterise the caring relationship, and it is in these elements that the attractiveness of the theory for nursing can be found; they are receptivity, relatedness and responsiveness’. Towards the above direction Rumay (2002, 31) who stated that ‘language and perception barriers not only impact patient communication, but also discharge planning and the patients overall ability to maneuver through the health care system whereas gender, age, ethnicity, race, sexual orientation, and disabilities create challenges for health care providers’. Regarding this issue, Riley (2000, 9) stated that assertiveness could be the key to ‘successful relationships for the client, the family, the nurse, and other colleagues; the assertive nurse appears confident and comfortable; assertive behavior is contrasted with nonassertive or passive behavior, in which individuals disregard their own needs and rights, and aggressive behavior, in which individuals disregard the needs and rights of others’. There is also the issue of the patient’s race and gender, which in the particular case may be regarded as having an impact on the midwife’s behaviour. In many cases the issues of race and gender have been proved to be crucial for the development of a specific behaviour by the carers in the healthcare industry (Banyard et al., 1998, Rawls, 1971). Regarding this problem, Rumay (2002, 33) came to the conclusion that in order ‘to offer quality care for all patients, health care service and support systems should inherently recognize that: a) each culture defines the family as the primary support system and preferred intervention; b) most racial and ethnic minority populations speak more than one language and that this may create a unique set of mental health issues to which the system must be equipped to respond; c) patients and their families make different choices based on cultural forces; d) culturally preferred choices, not culturally blind or culturally free interventions, drive practice in the service delivery system; e) all cross-cultural interactions offer dynamics that require acknowledge went, adjustment, and acceptance; f) health care systems must sanction or mandate the inclusion of cultural knowledge into practice and policy making’. The application of the above views in the specific case can lead to the assumption that although midwife had an ethical responsibility to support the patient – Mrs. Begum – in fact it was a responsibility related more to the general social and ethical rules and not so much the ethical and professional standards regarding the midwife’s responsibility. This assumption is supported by the fact that midwife has offered to Mrs. Begum all the necessary support and the demands that followed should be regarded as ‘supplementary’ although socially necessary. On the other hand, although the baby’s life or Mrs. Begun’s life were not in danger and even if there was no specific problem of health, the provision of ‘supplementary’ health services can be considered in certain cases as ‘obligatory’ and – if follow this interpretation – the midwife should be considered as responsible for not offering the specific services (Beshorov et al., 1987, Cournoyer, 1991). Barnett et al. (1995, 117) tried to resolve the above issue and for this reason they conducted an empirical research in which ‘undergraduate subjects were asked to write an essay describing the one experience they considered as having been the most important in their moral development; in addition, they were asked to (a) rate the extent to which various moral lessons had been learned as a result of the experience and (b) complete the Bem Sex-Role Inventory’. In the above research ‘no relation was found between subjects scores on the two lessons learned factors and their sex-role classification as determined by scores on the BSRI’ (Barnett et al., 1995, 137). The reference to the above research is made in order to show that in the case under examination the midwife would possibly be friendlier towards Mrs. Begun taking into account her gender and her experiences in the particular sector of healthcare services. However, it seems that in the specific case the results of the above research are not verified proving that even if the personal behaviour is expected to be formulated in accordance with specific standards there is always the issue of personal views and thoughts that can lead to different reactions. IV. Conclusion The examination of the issues related with the specific case show that the behaviour of carers within a healthcare services environment should be evaluated differentially in accordance with the conditions applied in each particular case. Generally, the duties and the responsibilities of carers are set by the relevant Professional and Legal Bodies however in many cases the support that need to be offered to a patient cannot be categorized or included in a particular piece of text. Moreover, it is often an issue of moral obligation for providing a particular type of service which it is not even included on the specific carer’s obligations. However, in cases that the necessity for an out-of-duties medical service cannot be denied then a severe ethical dilemma is being arisen which is related with the carer’s responsibility for providing this service. In the case under examination the midwife would not be considered as professionally obligated to offer to Mrs. Begun a series of particular medical services however taking into account the conditions of the specific cases it cannot be doubted that the midwife was morally obligated to provide the medical services requested and even more to provide psychological support to the patient in order for the latter to be able to respond to her increased responsibilities and the lack of support from her environment. References Anderson, C. (1995) ‘Implicit Theories in Broad Perspective’ Psychological Inquiry, 6(4): 286-295 Arneson, P., Carroll, L. A. (2003). Communication in a Shared Governance Hospital: Managing Emergent Paradoxes. 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