1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. 3 ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. 4 ICPs can be effective in improving physician agreement about treatment options. 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide. 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. 7 Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established. 10 Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others. 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. 13 ICP documentation can introduce scope for new kinds of error. Conclusions ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.
In a recent paper in Sociology of Health and Illness, Svensson (1996) makes the case for adopting the negotiated order perspective as the most appropriate theoretical framework for understanding patterns of doctor-nurse interaction. Analysing interview data with nursing staff from surgical and medical wards in five Swedish hospitals, Svensson identifies key changes in the health care context which he suggests have created 'negotiation space' for nurses, leading to the evolution of new working relationships with doctors. In examining the relationship between negotiation processes and the wider structural context, Svensson addresses a theme that has remained an enduring interest of critics and supporters of the negotiated order perspective alike. Drawing on data generated on a surgical and a medical ward in a UK District General Hospital, this paper attempts to make a further contribution to this debate and also to sociological understanding of doctor-nurse relationships, by analysing some features of hospital work which inhibited face-toface inter-occupational negotiations but which nevertheless resulted in the modification of the formal division of labour between nursing and medicine. The imphcations of these findings for the negotiated order perspective are considered, and the question is raised as to what researchers working within this tradition understand by 'negotiation' and how it can be studied.
This article examines field studies of nursing work published in the English language between 1993 and 2003 as the first step towards an empirically based reformulation of the nursing mandate. A decade of ethnographic research reveals that, contrary to contemporary theories which promote an image of nursing work centred on individualised unmediated caring relationships, in real-life practice the core nursing contribution is that of the healthcare mediator. Eight bundles of activity that comprise this intermediary role are described utilising evidence from the literature. The mismatch between nursing's culture and ideals and the structure and constraints of the work setting is a chronic source of practitioner dissatisfaction. It is argued that the profession has little to gain by pursuing an agenda of holistic patient care centred on emotional intimacy and that an alternative occupational mandate focused on the healthcare mediator function might make for more humane health services and a more viable professional future.
This article re-examines insider-outsider relationships in nursing ethnographies of healthcare settings as a case study in the wider sociological debate around reflexivity in field research. It focuses on the practices through which the fieldwork role is accomplished and the "identity work" of nurse ethnographers. Insights derived from ethnomethodology are utilized in order to analyse selected aspects of real-life field experiences in order to enhance our understanding of this relatively neglected dimension of the research process. The article is offered as a contribution to an emerging body of scholarship that is directed at promoting a more rigorous and theoretically informed understanding of the conduct and reportage of ethnographic fieldwork.
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