Decision-making and nurse case management: a philosophical perspective

Ethical Artificial Intelligence in Nursing Workforce Management and Policymaking: Bridging Philosophy and Practice

Background: Despite artificial intelligence's (AI) transformative potential in healthcare, nursing workforce scholarship lacks a cohesive theoretical foundation and well-established philosophical stances to guide safe yet ethical, effective yet efficient, and sustainable AI integration into nursing workforce management and policymaking. This gap poses significant challenges in leveraging AI's benefits while mitigating potential risks and inequities. Aim: This paper aims to (1) present a philosophical discourse centered on Park's optimized nurse staffing (Sweet Spot) theory and (2) propose a novel theoretical framework with specific methodologies for ethical AI-equipped nursing workforce management and policymaking while providing its philosophical underpinnings. Method: A rigorous philosophical discourse was performed through theoretical triangulation, grounded in Park's Optimized Nursing Staffing (Sweet Spot) Estimation Theory. This approach synthesizes diverse philosophical perspectives to create a robust foundation for ethical AI integration in nursing workforce management and policymaking. Discussion: The novel theoretical framework introduces its well-established philosophical underpinnings, bridging moderate realism with post-positivism and contextualism, for ethical AI-equipped nursing workforce management and policymaking. The framework also provides practical solutions for ethical AI integration while ensuring equity and fairness in nursing workforce practices. This approach consequently offers a groundbreaking pathway toward sustainable AI-equipped nursing workforce management and policymaking that balances safety, ethics, effectiveness, and efficiency. Implication on Nursing Management: This paper is the first to present a theoretical framework for ethically integrating AI into nursing workforce management and policymaking, grounded in its robust philosophical underpinnings. It stands out for its creativity and originality, making a significant contribution by opening new avenues for emerging research and development at the intersection of AI and healthcare. Specifically, the framework serves as a practical and pivotal resource for researchers, policymakers, and healthcare administrators navigating the complex landscape of AI integration in nursing workforce management and policymaking. Above all, it is worthwhile in that this paper contributes to the broader intellectual discourse in a thought-provoking and timely manner by addressing AI's inherent limitations in healthcare through a theoretical framework embedded in human philosophical and ethical deliberation. Unlike the current practice where AI safety and ethical risk assessment are conducted after AI solutions have been developed, this approach provides proactive guidance. Thereby, it lays the crucial groundwork for future empirical studies and practical implementations toward desirable healthcare decision-making.

Decision aids for home and community care: a systematic review

OBJECTIVES

Decision aids (DAs) for clients in home and community care can support shared decision-making (SDM) with patients, healthcare teams and informal caregivers. We aimed to identify DAs developed for home and community care, verify their adherence to international DA criteria and explore the involvement of interprofessional teams in their development and use.

DESIGN

Systematic review reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Six electronic bibliographic databases (MEDLINE, Embase, CINAHL Plus, Web of Science, PsycINFO and the Cochrane Library) from inception to November 2019, social media and grey literature websites up to January 2021.

ELIGIBILITY CRITERIA

DAs designed for home and community care settings or including home care or community services as options.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently reviewed citations. Analysis consisted of a narrative synthesis of outcomes and a thematic analysis. DAs were appraised using the International Patient Decision Aid Standards (IPDAS). We collected information on the involvement of interprofessional teams, including nurses, in their development and use.

RESULTS

After reviewing 10 337 database citations and 924 grey literature citations, we extracted characteristics of 33 included DAs. DAs addressed a variety of decision points. Nearly half (42%) were relevant to older adults. Several DAs did not meet IPDAS criteria. Involvement of nurses and interprofessional teams in the development and use of DAs was minimal (33.3% of DAs).

CONCLUSION

DAs concerned a variety of decisions, especially those related to older people. This reflects the complexity of decisions and need for better support in this sector. There is little evidence about the involvement of interprofessional teams in the development and use of DAs in home and community care settings. An interprofessional approach to designing DAs for home care could facilitate SDM with people being cared for by teams.

PROSPERO REGISTRATION NUMBER

CRD42020169450.

Engaging family caregivers and health system partners in exploring how multi-level contexts in primary care practices affect case management functions and outcomes of patients and family caregivers at end of life: a realist synthesis

BACKGROUND

An upstream approach to palliative care in the last 12 months of life delivered by primary care practices is often referred to as Primary Palliative Care (PPC). Implementing case management functions can support delivery of PPC and help patients and their families navigate health, social and fiscal environments that become more complex at end-of-life. A realist synthesis was conducted to understand how multi-level contexts affect case management functions related to initiating end-of-life conversations, assessing patient and caregiver needs, and patient/family centred planning in primary care practices to improve outcomes. The synthesis also explored how these functions aligned with critical community resources identified by patients/families dealing with end-of-life.

METHODS

A realist synthesis is theory driven and iterative, involving the investigation of proposed program theories of how particular contexts catalyze mechanisms (program resources and individual reactions to resources) to generate improved outcomes. To assess whether program theories were supported and plausible, two librarian-assisted and several researcher-initiated purposive searches of the literature were conducted, then extracted data were analyzed and synthesized. To assess relevancy, health system partners and family advisors informed the review process.

RESULTS

Twenty-eight articles were identified as being relevant and evidence was consolidated into two final program theories: 1) Making end-of-life discussions comfortable, and 2) Creating plans that reflect needs and values. Theories were explored in depth to assess the effect of multi-level contexts on primary care practices implementing tools or frameworks, strategies for improving end-of-life communications, or facilitators that could improve advance care planning by primary care practitioners.

CONCLUSIONS

Primary care practitioners' use of tools to assess patients/families' needs facilitated discussions and planning for end-of-life issues without specifically discussing death. Also, receiving training on how to better communicate increased practitioner confidence for initiating end-of-life discussions. Practitioner attitudes toward death and prior education or training in end-of-life care affected their ability to initiate end-of-life conversations and plan with patients/families. Recognizing and seizing opportunities when patients are aware of the need to plan for their end-of-life care, such as in contexts when patients experience transitions can increase readiness for end-of-life discussions and planning. Ultimately conversations and planning can improve patients/families' outcomes.

Sensitivity in ethical decision-making: The experiences of nurse managers

Background

In order to achieve the goals of the healthcare system, nursing managers are required to comply with ethical principles in decision-making. In complex and challenging healthcare settings, it is shown that the managers’ mere awareness of ethics does not suffice and managers need to be sensitive toward making ethical decisions.

Aim

To explore nursing managers and their sensitivity toward ethical decision-making by analyzing their related experiences.

Method

The current study has been conducted in Iran in 2017 through a qualitative content analysis approach. Nineteen nurse managers were selected purposefully from different hospitals in Tehran. Data were collected using semi-structured, in-depth, face-to-face interviews, and after transcription, they were analyzed according to the Graneheim and Lundman method.

Ethical considerations

The research was approved by the ethics committee of Tarbiat Modares University, Tehran, Iran. Participants were informed about the purpose of the study and submitted written informed consents regarding their participation. The principle of autonomy, confidentiality, and anonymity was taken into account in data collection.

Results

Fifteen subcategories, three categories (assertiveness, commitment, and insight), and one theme of excellent decision-making were the results of data analysis.

Discussion

Findings showed that nursing managers’ sensitivity to ethical decision-making allows them to make the best decision by insight, commitment, and assertiveness. Making a morally excellent decision ensures that ethical principles are followed in the healthcare system.

Conclusion

Considering that most managers are committed to making ethical decisions, it is required to develop the scope of their insights even further using a professional management and ethical principles training program. Also, by addressing some of the ethical barriers at personal and organizational levels, the assertiveness in managers can be improved, which in turn can facilitate their ethical decision-making.

Case Manager Work and Workload: Uncovering a Wicked Problem—A Secondary Analysis Using Interpretive Description

Canada’s population is aging, and by 2027, it is expected that 22 million people will be older than 65 years. Home care services were used by 2.2 million individuals, or 8% of Canadians 15 years of age and older in 2012. Home care programs are continually expanding to meet the needs of the growing number of clients, and goals include keeping people in their homes for as long as possible, delaying the need for institutional care, and maintaining quality of life. Case managers are the gatekeepers to home care in Canada. They collaborate with families to plan care, coordinate home care services and community supports, as well as monitor client progress and evaluate outcomes. The aim of our study was to conduct a qualitative secondary analysis to understand the factors that influence case manager work and workload in home care. We completed a secondary analysis of four data sets from four primary studies of related concepts that occurred between 2006 and 2013. Our study design was inductively driven using the tenets of interpretive description. Case managers’ work and workloads are messy and affected by interrelated complex structures of home care programs within health care systems. The concept of a wicked problem, which describes a problem that is complex and intractable, is a useful construct we use to gain some clarity around the work and workload problems that case managers face. Case managers aim to make a positive difference in their client’s lives, but are constantly dealing with change, and can experience feelings of being their client’s last resort with the resulting pressure ultimately impacting their workload. In addition, case managers reported health system failures, including a lack of capacity and structural integration within home care programs that increase their work and workload. Case manager work and workload requires further research including the development and refinement of accurate workload measurement tools that consider the multiple aspects of professional responsibilities and case management activities. Workload and workload measurement tools are needed to account for the unplanned and unpredictable nature of case management work and assist with the distribution of more equitable caseloads among case managers and home care teams.

Case Manager Resource Allocation Decision-Making for Adult Home Care Clients: With Comparisons to a High Needs Pediatric Home Care Clients

Home care programs have become integral parts of the overall health service system in Canada and in many other developed nations. Resource allocation decision-making by home care case managers (CM) is a complex task where CMs are challenged to meet the dual responsibilities for clients, in order that they achieve high quality care, and to the system to contain costs. The purpose of this study was to extend what is known about resource allocation decision-making factors identified in a previous systematic literature review and ethnographic study within a high needs pediatric context conducted by the principal investigator in Western Canada. Spradley’s ethnoscience method was used in this research. The study sample consisted of 17 home care CMs, professional practice leads, and their managers from two separate home care offices. All participating CMs had assigned caseloads and were involved in the assessment and implementation of care planning for clients. Purposive sampling methods were employed. In keeping with Spradley’s ethnoscience approach, data collection occurred in three distinct phases or rounds. The first round of data collection began with a series of one-on-one interviews with card sorts, the second round of data collection was another series of one-on-one interviews with CMs who were not interviewed in the prior round, and the third and final round of data collection was a focus group to accomplish further refinement and verification of our established categories. Participants identified five categories of factors that effected their resource allocation decision-making. The categories were related to one of five main areas: the client, the CM, the home care program, community resources, or the health care system. The findings of this study reinforced the complexity of CM resource allocation decision-making in home care. This study provides new insights into CM resource allocation decision-making based on multidisciplinary, integrated home care teams caring for adults, the majority of whom are 65 years and older. This study also provides the comparison of taxonomy that differs between pediatric and adult home care populations that influence resource allocation decision-making.

Home Care Case Managers' Integrated Care of Older Adults With Multiple Chronic Conditions: A Scoping Review

PURPOSE OF STUDY

The purpose of this scoping review was to explore peer-reviewed research and gray literature to examine the extent, range, and nature of available research that describes how home care case managers (HCCMs) provide integrated care for older adults with multiple chronic conditions (MCCs); identify how case management standards of practice correspond with functions of integrated care; identify facilitators and barriers to case management and integrated care delivery; and propose a framework to describe how HCCMs can use case management standards to provide integrated care to older adults with MCCs.

PRIMARY PRACTICE SETTING

Community, home care settings.

METHODOLOGY AND SAMPLE

Scoping review; older adults older than 65 years with MCCs, case managers and health care professionals who provide care for older adults with MCCs.

RESULTS

The study findings demonstrated that HCCMs consistently used the case management standards assessment, planning, implementation, and evaluation to provide all professional and clinical integrated care functions, and were least likely to use the standards of identification of client and eligibility for case management and transition to provide professional and clinical integrated care functions. In addition, HCCM use of professional and clinical integrated care functions was inconsistent and varied based on use of case management standards. All case management standards and integrated care functions were found to be both facilitators and barriers, but were more likely to facilitate HCCM work. Interestingly, the standards of assessment, planning, and implementation were more likely to facilitate functional integration, whereas the integrated care functions of intra- and interpartnerships, shared accountability, person centered of care, and engagement for client self-management were more likely to facilitate normative integration. We also found that HCCMs use case management standards and integrated care functions to provide care for older adults with MCCs at the professional (meso) and clinical (micro) levels.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Variations in HCCM practice may impact the delivery of case management standards when caring for older adults with MCCs. This has implications for the comprehensiveness and consistency of HCCM practice, as well as interdisciplinary health professional and the client's awareness of the HCCM role when providing integrated care to older adults with MCCs within home settings. The greatest facilitators and barriers to integrated care are those case management standards and clinical and professional integrated care functions that focus on partnerships, collective and shared responsibility and accountability, coordinated person centered of care for clients, and ensuring engagement and partnership in self-management. This indicates the need for development of case management policies and programs that support the work of HCCMs in the delivery of seamless and collaborative case management and integrated care functions that foster collaboration and partnership-building efforts. The development of a new case management and integrated care conceptual framework that includes case management standards, professional and clinical integrated care functions would guide HCCM integrated care practice, policy and research to support client and family-centered care, and foster shared values for sustainable partnerships across care settings.

Head nurses’ decision-making when managing ethical dilemmas

Purpose

– The purpose of this paper is to characterize issues related to head nurses’ decision making when managing ethical dilemmas.

Design/methodology/approach

– The study is qualitative descriptive, in which researchers stay close to the data. The data were collected in the format of unstructured written reflections. Inductive conventional latent qualitative content analysis was applied to the data.

Findings

– The issues of head nurses’ management of decision making in ethical dilemmas relate to the following aspects: taking risks in deviating from the formalities, balancing power and humaneness, maintaining the professional hierarchy, managing resistance to change, managing with limited options, and experiencing the decline of nurse’s professional and/or human dignity.

Research limitations/implications

– Reflections in written form were preferred to semi-structured interviews and the researchers were unable to contact the participants directly and to ask additional questions. All the reflections were produced in a language other than English.

Practical implications

– The issues of head nurses’ management of decision making in ethical dilemmas reveal the gap between societal expectations and the opportunities to improve nursing leadership in health care organizations.

Social implications

– The issues of head nurses’ decision making when managing ethical dilemmas are related to contexts that reflect the attitudes of society and health care system toward nursing management.

Originality/value

– The study adds to the understanding of issues of the management of decision making in ethical dilemmas. It is an ongoing systematic process that encourages head nurses to learn from practice and manage the quality of care by empowering themselves and nurses to take responsibility for leadership.

Uncovering the Meaning of Home Care Using an Arts-Based and Qualitative Approach

The need for home care is increasing in Canada, yet little is known about the home care experience of clients and their families. Uncovering the meaning of the home care experience is an important step towards developing understanding and public awareness. We explored the experiences of home care using arts-based methods and individual interviews with 11 participants (one client and 10 family caregivers). Participants discussed the numerous ways formal home care and family caregiving affected their lives, how they coped with these effects, their experiences in hospitals or assisted living facilities, and aspects of the home care experience they liked or disliked. Participants agreed that home care facilitated a better quality of life for families and clients, although they acknowledged some challenges with it. The artistic outputs produced by participants facilitated interview dialogue and fostered understanding of key themes within the research team.

An interprofessional approach to shared decision making: an exploratory case study with family caregivers of one IP home care team

BACKGROUND

Within the context of an exploratory case study, the authors assessed the perceptions of family caregivers about the decision-making process regarding relocating their relative and about the applicability of an interprofessional approach to shared decision making (IP-SDM). They also assessed perceptions of health professionals and health managers about IP-SDM.

METHODS

From November 2010 to October 2011, we worked with one IP home care team dedicated to older adults (the case) from a large primary health care organization in Quebec City, Canada. We identified six of their clients who had faced a decision about whether to stay at home or move to a long-term care facility in the past year and interviewed their family caregivers. We explored the decision-making process they had experienced regarding relocating their relative and their perceptions about the applicability of IP-SDM in this context. Attitudes towards IP-SDM and potential barriers to this approach were explored using a focus group with the participating IP home care team, individual interviews with 8 managers and a survey of 272 health professionals from the primary care organization. A hybrid process of inductive and deductive thematic analysis was used and data were triangulated across all sources.

RESULTS

Family caregivers reported lack of agreement on the nature of the decision to be made, a disconnection between home care services and relatives' needs, and high cost of long-term care alternatives. Factors influencing their decision included their ability to provide care for their relative. While they felt somewhat supported by the IP home care team, they also felt pressured in the decision. Overall, they did not perceive they had been exposed to IP-SDM but agreed that it was applicable in this context. Results from the survey, focus group and interviews with health professionals and managers indicated they all had a favourable attitude towards IP-SDM but many barriers hampered its implementation in their practice.

CONCLUSIONS

The family caregivers in this study did not experience IP-SDM when relocating their relative. Added to results obtained with health professionals and managers, this highlights the need for an effective intervention targeting identified barriers to implementing IP-SDM in this context.

Measuring Home Care Caseloads

In response to caseloads that are increasing in numbers and acuity, Alberta Health Services developed the Caseload Intensity Tool (CIT). The development and testing process led to a valid and reliable tool that connects client clinical condition to clinician response. The CIT allows clinicians to discriminate between levels of client intensity quickly and accurately. The scores for each client are summarized first into a client intensity scale and then a caseload intensity scale. The CIT can facilitate caseload management including matching client needs to resources and improving staff resource management, for example, equitable caseloads. There is potential for the tool to validate the relatively invisible work of case managers making it understandable, measurable, and defensible during times of rising costs and budget restraint.

A nurse-led interdisciplinary primary care approach to prevent disability among community-dwelling frail older people: a large-scale process evaluation

BACKGROUND

The complex healthcare needs of frail older people and their increased risk of disability require an integrated and proactive approach. In the Netherlands, an interdisciplinary primary care approach has recently been developed, involving individualized assessment and interventions (tailor-made care), case management and long-term follow-up. The practice nurse as part of a general practice is case manager and plans, organizes and monitors the care process and facilitates cooperation between professionals. The approach has shown positive indications regarding its feasibility in a small pilot, but its implementation on a large scale had not hitherto been investigated.

OBJECTIVES

To examine the extent to which the interdisciplinary care approach is implemented as planned and to gain insight into healthcare professionals' and frail older people's experiences regarding the benefits, burden, stimulating factors and barriers.

DESIGN

A process evaluation was conducted using a mixed methods design.

SETTINGS

Six GP practices in the south of the Netherlands.

PARTICIPANTS

Practice nurses (n=7), GPs (n=12), occupational therapists (n=6) and physical therapists (n=20) participated in the process evaluation. Furthermore, 194 community-dwelling frail older people (≥ 70 years) were included using the Groningen Frailty Indicator. People who were terminally ill, were confined to bed, had severe cognitive or psychological impairments or were unable to communicate in Dutch were excluded.

METHODS

Quantitative data (logbooks and evaluation forms) were collected from all the participating frail older people and 13 semi-structured interviews with a selection of them were conducted. In addition, data from healthcare professionals were collected through 12 semi-structured interviews and four focus group discussions.

RESULTS

Although some parts of the protocol were insufficiently executed, healthcare professionals and frail older people were satisfied with the care approach, as it provided a useful structure for the delivery of geriatric primary care and increased the attention to preventive treatment. Frail older people felt acknowledged by healthcare professionals and experienced support in handling their problems and fulfilling their wishes.

CONCLUSIONS

The findings of the study revealed several positive aspects of the interdisciplinary primary care approach. Given its complexity, the implementation of the nurse-led interdisciplinary care approach is challenging and some parts of the protocol need special attention.

Rationing home-based nursing care: professional ethical implications

The purpose of this study was to investigate nurses' decisions about priorities in home-based nursing care. Qualitative research interviews were conducted with 17 nurses in home-based care. The interviews were analyzed and interpreted according to a hermeneutic methodology. Nurses describe clinical priorities in home-based care as rationing care to mind the gap between an extensive workload and staff shortages. By organizing home-based care according to tight time schedules, the nurses' are able to provide care for as many patients as possible. Furthermore, legal norms set boundaries for clinical priority decisions, resulting in marginalized care. Hence, rationing care jeopardizes important values in the nurse-patient relationship, in particular the value of individualized and inclusive nursing care. The findings are highly relevant for clinical practice, since they have major implications for provision of nursing care. They revive debates about the protection of values and standards of care, and nurses' role and responsibility when resources are limited.

Access to respite breaks for families who have a relative with intellectual disabilities: a national survey

AIMS

This paper reports the findings of a national study of the variations in the provision and correlates of respite breaks to families. Background.  Internationally, respite breaks are a major support service to family carers, demand for which often exceeds supply for persons with an intellectual disability. Hence, the length of breaks available to families has to be rationed. Nurses are often involved in such decisions.

METHOD

National data on the use of respite breaks by over 4000 families in a full calendar year (2008) were analysed to examine the variation within the Republic of Ireland on two indicators: namely the proportion of carers who had any access to breaks and the median number of days they had received.

FINDINGS

Striking differences across health service areas were found on both indicators of usage. These were not solely attributable to the availability of provision but also reflected variations in the criteria local services used to allocate places. However, those persons with more severe disabilities were given priority, whereas carer characteristics were not a major influence. Contact with social workers and community nurses also increased the likelihood of carers receiving respite breaks.

CONCLUSION

Intra-country comparisons of service delivery should assist planners in creating more equitable access to respite breaks and the development of more explicit eligibility criteria for their use. Nurses are well placed to lead on this.

A conceptual framework for interprofessional shared decision making in home care: protocol for a feasibility study

BACKGROUND

Shared decision making (SDM) is fundamental to informed consent and client-centered care. So far, SDM frameworks have been limited to the client-physician dyad, even though care is increasingly delivered by interprofessional (IP) teams. IP collaboration is especially essential in home care, one of health care's most rapidly growing areas. This study will assess whether it is possible to practice SDM in IP home care.

METHODS/DESIGN

We will use a qualitative case study and a quantitative survey to capture the macro, meso and micro levels of stakeholders in home care. The case study will follow the knowledge-to-action process framework to evaluate the work of an IP home care team at a Quebec City health center. Sources of data will include one-on-one interviews with patients, family caregivers or surrogates and significant others, and administrators; a focus group of home care health professionals; organizational documents; and government policies and standards. The interview guide for the interviews and the focus group will explore current practices and clinical problems addressed in home care; factors that could influence the implementation of the proposed IP approach to SDM; the face and content validity of the approach; and interventions to facilitate the implementation and evaluation of the approach. The survey will ask 300 health professionals working in home care at the health center to complete a questionnaire based on the Theory of Planned Behaviour that measures their intentions to engage in an IP approach to SDM. We will use our analysis of the individual interviews, the focus group and the survey to elaborate a toolkit for implementing an IP approach to SDM in home care. Finally, we will conduct a pilot study in Alberta to assess the transferability of our findings.

DISCUSSION

We believe that developing tools to implement IP SDM in home care is essential to strengthening Canada's healthcare system and furthering patient-centered care. This study will contribute to the evaluation of IP SDM delivery models in home care. It will also generate practical, policy-oriented knowledge regarding the barriers and facilitators likely to influence the practice of IP SDM in home care.

Home care nurses' decisions about the need for and amount of service at the end of life

AIMS

We explore home care nurse decision-making about the need for and amount of service by clients and families at the end of life. We identify factors nurses refer to when describing these decisions, situated within contextual features of nursing practice.

BACKGROUND

Home care nurses are often responsible for decisions which have an impact on the access of clients and families to services at the end of life. Understanding how these decisions, are made, factors that are considered, and contextual influences is critical for improving access and enhancing care.

METHODS

Qualitative data were collected between 2006 and 2008 from two samples of home care nurses: the first group (n = 29) recorded narrative descriptions of decisions made during visits to families. The second group (n = 27) completed in-person interviews focusing on access to care and their interactions with clients and families. Data were analysed with thematic coding and constant comparison.

FINDINGS

Participants described assessing client and family needs and capacity. These assessments, at times integrated with considerations about relationships with clients and families, inform predictive judgements about future visits; these judgments are integrated with workload and home health resource considerations. In describing decisions, participants referred to concepts such as expertise, practice ideals and approaches to care.

CONCLUSION

Findings highlight the role of considerations of family caregiver capacity, the influence of relationships and the importance of the context of practice, as part of a complete understanding of the complexity of access to care at the end of life.

Fair nursing care when resources are limited: the role of patients and family members in Norwegian home-based services

The purpose of the study was to investigate nurses' priority decisions and the provision of home-based nursing care services. Interviews were conducted with 17 nurses in various positions in this service. The data were interpreted and analyzed according to interpretive hermeneutic methodology. The authors particularly address the nurses' descriptions of the role of the patient and his or her family members for the provision of home-based care. Cooperative patients and family members represent an important resource for care and can make it possible for nurses to provide services for all the patients on an egalitarian basis and to prioritize those who live alone. However, demanding and resourceful patients and family members may "rule" the service at the expense of other patients who also have legitimate care needs--a practice that the nurses describe as unfair. In this article, the authors discuss how a fair and impartial distribution of common benefits can be achieved without some parties being unjustly treated.

Factors that influence case managers' resource allocation decisions in pediatric home care: an ethnographic study

BACKGROUND

Case managers make decisions that directly affect the amount and type of services home care clients receive and subsequently affect the overall available health care resources of home care programs. A recent systematic review of the literature identified significant knowledge gaps with respect to resource allocation decision-making in home care.

METHODS

Using Spradley's methodology, we designed an ethnographic study of a children's home care program in Western Canada. The sample included 11 case managers and program leaders. Data sources included interviews, card sorts, and participant observation over a 5-month period. Data analyses included open coding, domain, taxonomic, and componential analysis.

RESULTS

One of the key findings was a taxonomy of factors that influence case manager resource allocation decisions. The factors were grouped into one of four main categories: system-related, home care program-related, family related, or client-related. Family related factors have not been previously reported as influencing case manager resource allocation decision-making and nor has the team's role been reported as an influencing factor.

CONCLUSION

The findings of this study are examined in light of Daniels and Sabin's Accountability for Reasonableness framework, which may be useful for future knowledge development about micro-level resource allocation theory.

What factors influence case managers' resource allocation decisions? A systematic review of the literature

OBJECTIVE

Case managers' decisions directly affect the amount and type of services individual clients receive, as well as overall home care program available resources. We know little about the resource allocation decision-making processes of case managers. The question guiding this review was, "What factors influence case managers' resource allocation decisions in home care?''

METHODS

The authors did a systematic literature review to answer the above question. After assessing the articles for inclusion, they assessed the quality (internal validity) of each included study. They described the characteristics of the studies and provided a synthesis of the findings of the primary studies.

RESULTS

Five qualitative and 6 quantitative articles met the inclusion criteria for this review. The findings of these studies are equivocal. Despite this, the authors were able to create a preliminary taxonomy of the factors that influence case manager resource allocation decisions. Despite evidence-based decision making receiving so much attention in contemporary health care literature, the authors found a near absence of reference to research use in the context of case manager decision making.

CONCLUSIONS

Currently, there are relatively few studies in the literature on the factors that influence, and how they are used in, case manager resource allocation decisions. Studies are often lacking in terms of conceptual clarity and theoretical framing. They are often not guided by theoretical frameworks and are not situated within the larger field of decision making or even within the clinical decision-making literature. These issues are impeding progress in this area.

The contribution of organization theory to nursing health services research

We review nursing and health services research on health care organizations over the period 1950 through 2004 to reveal the contribution of nursing to this field. Notwithstanding this rich tradition and the unique perspective of nursing researchers grounded in patient care production processes, the following gaps in nursing research remain: (1) the lack of theoretical frameworks about organizational factors relating to internal work processes; (2) the need for sophisticated methodologies to guide empirical investigations; (3) the difficulty in understanding how organizations adapt models for patient care delivery in response to market forces; (4) the paucity of attention to the impact of new technologies on the organization of patient care work processes. Given nurses' deep understanding of the inner workings of health care facilities, we hope to see an increasing number of research programs that tackle these deficiencies.

Nurse case management: negotiating care together within a developing relationship

TOPIC/PROBLEM: The purpose of this study was to explicate the process of nurse case management involving clients afflicted with chronic mental illness.

METHOD

Grounded theory was the method of choice. Interviews were conducted with nurses in inpatient, transitional, and community settings in four cities in southern Ontario, Canada.

FINDINGS

Negotiating care together within a developing relationship emerged as the basic social process. "Building a trusting relationship" was identified as the foundation of case management.

CONCLUSIONS

Salient differences were found between the three settings, yet the basic social process was consistent across settings. This underscores the therapeutic relationship as the basis for nurse psychiatric case management.