Health workforce data needed to minimize inequities associated with health-worker migration

A persistent challenge with health-worker migration is the inequities it creates. To minimize these inequities, systems of global governance of health-worker migration have arisen which include various global codes of practice, agreements and reporting requirements. Reporting that is rigorous, open and transparent, and subject to scrutiny from the public, researchers, civil society organizations and other interested stakeholders, is important. One element of these codes and agreements with perhaps the greatest potential to deal with the impact of health-worker migration is more robust planning of the health workforce to address the goal of self-sufficiency. Open platforms for data sharing enable engagement of the public and stakeholders with data on the distribution and national origin of health workers, and reveal policy strengths and weaknesses related to health-workforce planning. We explore recent policies directed at reducing the inequities from health-worker migration. While many of the examples used focus on nurses and doctors, the issues discussed are relevant to all cadres of internationally trained health workers.

Global evidence of gender equity in academic health research: a scoping review

OBJECTIVES

To chart the global literature on gender equity in academic health research.

DESIGN

Scoping review.

PARTICIPANTS

Quantitative studies were eligible if they examined gender equity within academic institutions including health researchers.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes related to equity across gender and other social identities in academia: (1) faculty workforce: representation of all genders in university/faculty departments, academic rank or position and salary; (2) service: teaching obligations and administrative/non-teaching activities; (3) recruitment and hiring data: number of applicants by gender, interviews and new hires for various rank; (4) promotion: opportunities for promotion and time to progress through academic ranks; (5) academic leadership: type of leadership positions, opportunities for leadership promotion or training, opportunities to supervise/mentor and support for leadership bids; (6) scholarly output or productivity: number/type of publications and presentations, position of authorship, number/value of grants or awards and intellectual property ownership; (7) contextual factors of universities; (8) infrastructure; (9) knowledge and technology translation activities; (10) availability of maternity/paternity/parental/family leave; (11) collaboration activities/opportunities for collaboration; (12) qualitative considerations: perceptions around promotion, finances and support.

RESULTS

Literature search yielded 94 798 citations; 4753 full-text articles were screened, and 562 studies were included. Most studies originated from North America (462/562, 82.2%). Few studies (27/562, 4.8%) reported race and fewer reported sex/gender (which were used interchangeably in most studies) other than male/female (11/562, 2.0%). Only one study provided data on religion. No other PROGRESS-PLUS variables were reported. A total of 2996 outcomes were reported, with most studies examining academic output (371/562, 66.0%).

CONCLUSIONS

Reviewed literature suggest a lack in analytic approaches that consider genders beyond the binary categories of man and woman, additional social identities (race, religion, social capital and disability) and an intersectionality lens examining the interconnection of multiple social identities in understanding discrimination and disadvantage. All of these are necessary to tailor strategies that promote gender equity.

TRIAL REGISTRATION NUMBER

Open Science Framework: https://osf.io/8wk7e/.

Complexities of health and care worker migration pathways and corresponding international reporting requirements

The increasing complexity of the migration pathways of health and care workers is a critical consideration in the reporting requirements of international agreements designed to address their impacts. There are inherent challenges across these different agreements including reporting functions that are misaligned across different data collection tools, variable capacity of country respondents, and a lack of transparency or accountability in the reporting process. Moreover, reporting processes often neglect to recognize the broader intersectional gendered and racialized political economy of health and care worker migration. We argue for a more coordinated approach to the various international reporting requirements and processes that involve building capacity within countries to report on their domestic situation in response to these codes and conventions, and internationally to make such reporting result in more than simply the sum of their responses, but to reflect cross-national and transnational interactions and relationships. These strategies would better enable policy interventions along migration pathways that would more accurately recognize the growing complexity of health worker migration leading to more effective responses to mitigate its negative effects for migrants, source, destination, and transit countries. While recognizing the multiple layers of complexity, we nevertheless reaffirm the fact that countries still have an ethical responsibility to undertake health workforce planning in their countries that does not overly rely on the recruitment of migrant health and care workers.

Teaming up for long-term care: Recognizing all long-term care staff contribute to quality care

When looking to promising international approaches to improve quality care in long-term care, it is necessary to avoid cherry-picking specific dimensions ignoring the integrated nature of what makes these approaches promising in the first place. In looking at promising Scandinavian or Green House models, attention is often paid to the size of facility. This often overlooks the importance of higher level of staffing, mix, and compensation of direct care staff and the integration of dietary, laundry, and housekeeping staff to care teams. Other overlooked considerations include recognition of family and friends and policies supporting care continuity.

The pathway from mental health, leaves of absence, and return to work of health professionals: Gender and leadership matter

Health professions are ranked among the most stressful occupations and have a much higher likelihood of absenteeism from work. In this article, we present findings from four health professional case studies in our Healthy Professional Worker partnership, involving surveys with 1,860 respondents and 163 interviews with nurses, physicians, midwives, and dentists conducted between December 2020 and April 2021. We found that the pathway from mental health experiences through to the decision to take a leave of absence and return to work differed between the health professions and that both gender and leadership matter greatly. There is a need to de-stigmatize mental health issues and encourage greater awareness and support from supervisors and colleagues. Leadership can play an important role in mitigating mental health issues, and as such investment in both leadership training and mentorship are important first steps in acting upon our research findings.

Leadership for quality in long-term care

Leadership in long-term care is a burgeoning field of research, particularly that which is focused on enabling point of care staff to provide high-quality and responsive healthcare. In this article, we focus on the relatively important role that leadership plays in enabling the conditions for high-quality long-term care. Our methodological approach involved a rapid in-depth ethnography undertaken by an interdisciplinary team across eight public and non-profit long-term care homes in Canada, where we conducted over 1,000 hours of observations and 275 formal and informal interviews with managers, staff, residents, family members and volunteers. Guiding our analysis post hoc is the LEADS in a Caring Environment framework. We mapped key promising leadership practices identified by our analysis and discuss how these can inform the development of leadership standards across staff and management in long-term care.

Mapping the peer-reviewed literature on accommodating nurses' return to work after leaves of absence for mental health issues: a scoping review

BACKGROUND

The complexity of nursing practice increases the risk of nurses suffering from mental health issues, such as substance use disorders, anxiety, burnout, depression, and posttraumatic stress disorder (PTSD). These mental health issues can potentially lead to nurses taking leaves of absence and may require accommodations for their return to work. The purpose of this review was to map key themes in the peer-reviewed literature about accommodations for nurses' return to work following leaves of absence for mental health issues.

METHODS

A six-step methodological framework for scoping reviews was used to summarize the amount, types, sources, and distribution of the literature. The academic literature was searched through nine electronic databases. Electronic charts were used to extract code and collate the data. Findings were derived inductively and summarized thematically and numerically.

RESULTS

Academic literature is scarce regarding interventions for nurses' return to work following leaves of absence for mental health issues, and most focused on substance use concerns. Search of the peer-reviewed literature yielded only six records. The records were primarily quantitative studies (n = 4, 68%), published between 1997 and 2018, and originated in the United States (n = 6, 100%). The qualitative thematic findings addressed three major themes: alternative to discipline programs (ADPs), peer support, and return to work policies, procedures, and practices.

CONCLUSIONS

While the literature supports alternative to discipline programs as a primary accommodation supporting return to work of nurses, more on the effectiveness of such programs is required. Empirical evidence is necessary to develop, maintain, and refine much needed return to work accommodations for nurses after leaves of absence for mental health issues.

Is attending birth dying out? Trends in obstetric care provision among primary care physicians in British Columbia

OBJECTIVE

To examine trends in and sociodemographic predictors of the provision of obstetric care within the primary care context among physicians in British Columbia (BC).

DESIGN

Population-based, longitudinal cohort study using administrative data.

SETTING

British Columbia.

PARTICIPANTS

All primary care physicians practising in BC between 2005-2006 and 2011-2012.

MAIN OUTCOME MEASURES

Fee-for-service payment records were used to identify the provision of prenatal and postnatal care and deliveries. The proportions of physicians who attended deliveries and who included any obstetric care provision in their practices were examined over time using longitudinal mixed-effects log-linear models.

RESULTS

The proportion of physicians attending deliveries or providing any obstetric care declined significantly over the study period (deliveries: odds ratio [OR] of 0.92, 95% CI 0.89-0.95; obstetric care: OR = 0.92, 95% CI 0.89-0.95), and obstetric care provision accounted for a smaller proportion of overall practice activity (OR = 0.96, 95% CI 0.94-0.99). Female physicians had higher odds of including obstetric care in their practices (OR = 1.46, 95% CI 1.27-1.69), and by 2011-2012 had significantly higher odds of attending deliveries (OR = 1.22, 95% CI 1.05-1.38). Older physicians and those located in metropolitan centres were less likely to provide obstetric care or attend deliveries.

CONCLUSION

The provision of obstetric care by primary care physicians in BC declined over this period, suggesting the possibility of a growing access issue, particularly in rural and remote communities where family physicians are often the sole providers of obstetric services.

Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia

PURPOSE

Providing care in alternative (non-office) locations and outside office hours are important elements of access and comprehensiveness of primary care. We examined the trends in and determinants of the services provided in a cohort of primary care physicians in British Columbia, Canada.

METHODS

We used physician-level payments for all primary care physicians practicing in British Columbia from 2006-2007 through 2011-2012. We examined the association between physician demographics and practice characteristics and payment for care in alternative locations and after hours across rural, urban, and metropolitan areas using longitudinal mixed-effects models.

RESULTS

The proportion of physicians who provided care in alternative locations and after hours declined significantly during the period, in rural, urban, and metropolitan practices. Declines ranged from 5% for long-term care facility visits to 22% for after-hours care. Female physicians, and those in the oldest age category, had lower odds of providing care at alternative locations and for urgent after-hours care. Compared with those practicing in metropolitan centers, physicians working in rural areas had significantly higher odds of providing care both in alternative locations and after hours.

CONCLUSION

Care provided in non-office locations and after office hours declined significantly during the study period. Jurisdictions where providing these services are not mandated, and where similar workforce demographic shifts are occurring, may experience similar accessibility challenges.

In British Columbia, The Supply Of Primary Care Physicians Grew, But Their Rate Of Clinical Activity Declined

Reports of a primary care shortage are ubiquitous in Canada and the United States. We used a population-based, retrospective cohort study to examine the extent to which the feminization and aging of the primary care physician workforce and secular trends may contribute to changes in the availability of primary care services. We used billing data for all primary care physicians in British Columbia for the period 2005-12. We used multivariate linear mixed-effects models to study physician remuneration and activity levels. We found limited change in per physician remuneration over the study period. However, numbers of patient contacts and practice sizes (numbers of unique patients) declined by 14 percent and 10 percent, respectively. Although the feminization of the workforce-and, to a lesser extent, its aging-contributed to this decline, the primary driver appears to be a broad trend toward reduced clinical activity over time. To the extent that similar trends are occurring in the United States, the implications of our study for the availability of primary care services beyond Canada are potentially significant.

Canada's evacuation policy for pregnant First Nations women: Resignation, resilience, and resistance

BACKGROUND

Aboriginal peoples in Canada are comprised of First Nations, Métis, and Inuit. Health care services for First Nations who live on rural and remote reserves are mostly provided by the Government of Canada through the federal department, Health Canada. One Health Canada policy, the evacuation policy, requires all First Nations women living on rural and remote reserves to leave their communities between 36 and 38 weeks gestational age and travel to urban centres to await labour and birth. Although there are a few First Nations communities in Canada that have re-established community birthing and Aboriginal midwifery is growing, most First Nations communities are still reliant on the evacuation policy for labour and birthing services. In one Canadian province, Manitoba, First Nations women are evacuated to The Pas, Thompson, or Winnipeg but most - including all women with high-risk pregnancies - go to Winnipeg.

AIM

To contribute scholarship that describes First Nations women's and community members' experiences and perspectives of Health Canada's evacuation policy in Manitoba.

METHODS

Applying intersectional theory to data collected through 12 semi-structured interviews with seven women and five community members (four females, one male) in Manitoba who had experienced the evacuation policy. The data were analyzed thematically, which revealed three themes: resignation, resilience, and resistance.

FINDINGS

The theme of resignation was epitomized by the quote, "Nobody has a choice." The ability to withstand and endure the evacuation policy despite poor or absent communication and loneliness informed of resilience. Resistance was demonstrated by women who questioned the necessity and requirement of evacuation for labour and birth. In one instance, resistance took the form of a planned homebirth with Aboriginal registered midwives.

CONCLUSION

There is a pressing need to improve the maternity care services that First Nations women receive when they are evacuated out of their communities, particularly when understood from the specific legal and constitutional position of First Nations women in Manitoba.

Networks as systems

Purpose The purpose of this paper is to present a case study of the World Health Organization's Global Healthcare Workforce Alliance (GHWA). Based on a commissioned evaluation of GHWA, it applies network theory and key concepts from systems thinking to explore network emergence, effectiveness, and evolution to over a ten-year period. The research was designed to provide high-level strategic guidance for further evolution of global governance in human resources for health (HRH). Design/methodology/approach Methods included a review of published literature on HRH governance and current practice in the field and an in-depth case study whose main data sources were relevant GHWA background documents and key informant interviews with GHWA leaders, staff, and stakeholders. Sampling was purposive and at a senior level, focusing on board members, executive directors, funders, and academics. Data were analyzed thematically with reference to systems theory and Shiffman's theory of network development. Findings Five key lessons emerged: effective management and leadership are critical; networks need to balance "tight" and "loose" approaches to their structure and processes; an active communication strategy is key to create and maintain support; the goals, priorities, and membership must be carefully focused; and the network needs to support shared measurement of progress on agreed-upon goals. Shiffman's middle-range network theory is a useful tool when guided by the principles of complex systems that illuminate dynamic situations and shifting interests as global alliances evolve. Research limitations/implications This study was implemented at the end of the ten-year funding cycle. A more continuous evaluation throughout the term would have provided richer understanding of issues. Experience and perspectives at the country level were not assessed. Practical implications Design and management of large, complex networks requires ongoing attention to key issues like leadership, and flexible structures and processes to accommodate the dynamic reality of these networks. Originality/value This case study builds on growing interest in the role of networks to foster large-scale change. The particular value rests on the longitudinal perspective on the evolution of a large, complex global network, and the use of theory to guide understanding.

Acculturation and nutritional health of immigrants in Canada: a scoping review

Although recent immigrants to Canada are healthier than Canadian born (i.e., the Healthy Immigrant Effect), they experience a deterioration in their health status which is partly due to transitions in dietary habits. Since pathways to these transitions are under-documented, this scoping review aims to identify knowledge gaps and research priorities related to immigrant nutritional health. A total of 49 articles were retrieved and reviewed using electronic databases and a stakeholder consultation was undertaken to consolidate findings. Overall, research tends to confirm the Healthy Immigrant Effect and suggests that significant knowledge gaps in nutritional health persist, thereby creating a barrier to the advancement of health promotion and the achievement of maximum health equity. Five research priorities were identified including (1) risks and benefits associated with traditional/ethnic foods; (2) access and outreach to immigrants; (3) mechanisms and coping strategies for food security; (4) mechanisms of food choice in immigrant families; and (5) health promotion strategies that work for immigrant populations.

The implications of the feminization of the primary care physician workforce on service supply: a systematic review

There is a widespread perception that the increasing proportion of female physicians in most developed countries is contributing to a primary care service shortage because females work less and provide less patient care compared with their male counterparts. There has, however, been no comprehensive investigation of the effects of primary care physician (PCP) workforce feminization on service supply. We undertook a systematic review to examine the current evidence that quantifies the effect of feminization on time spent working, intensity and scope of work, and practice characteristics. We searched Medline, Embase, and Web of Science from 1991 to 2013 using variations of the terms 'primary care', 'women', 'manpower', and 'supply and distribution'; screened the abstracts of all articles; and entered those meeting our inclusion criteria into a data abstraction tool. Original research comparing male to female PCPs on measures of years of practice, time spent working, intensity of work, scope of work, or practice characteristics was included. We screened 1,271 unique abstracts and selected 74 studies for full-text review. Of these, 34 met the inclusion criteria. Years of practice, hours of work, intensity of work, scope of work, and practice characteristics featured in 12%, 53%, 42%, 50%, and 21% of studies respectively. Female PCPs self-report fewer hours of work than male PCPs, have fewer patient encounters, and deliver fewer services, but spend longer with their patients during a contact and deal with more separate presenting problems in one visit. They write fewer prescriptions but refer to diagnostic services and specialist physicians more often. The studies included in this review suggest that the feminization of the workforce is likely to have a small negative impact on the availability of primary health care services, and that the drivers of observed differences between male and female PCPs are complex and nuanced. The true scale of the impact of these findings on future effective physician supply is difficult to determine with currently available evidence, given that few studies looked at trends over time, and results from those that did are inconsistent. Additional research examining gender differences in practice patterns and scope of work is warranted.

Comparing approaches to integrating refugee and asylum-seeking healthcare professionals in Canada and the UK

In this paper, we examine barriers to the integration of refugee doctors and nurses in Canada and the United Kingdom. Key obstacles impeding the integration of internationally trained health professionals are well documented, but less attention has been paid to the integration of refugee health professionals, particularly in Canada. Based on documentary analysis and semi-structured interviews with 46 Canadian and 34 UK stakeholders, our research shows that there are no simple solutions to mitigating the core obstacles that prohibit the professional integration of refugee doctors and nurses into host countries. The targeted approach adopted in parts of the UK does provide some promising practices for Canada, which has yet to develop policies and initiatives specific to health professional refugees. This study is intended to contribute to our understanding of how immigration and health human resources policies have shaped the economic integration of refugee healthcare professionals in the UK and Canada in distinct ways.

The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis

OBJECTIVE

To estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States.

DESIGN

Human capital cost analysis using publicly accessible data.

SETTINGS

Sub-Saharan African countries.

PARTICIPANTS

Nine sub-Saharan African countries with an HIV prevalence of 5% or greater or with more than one million people with HIV/AIDS and with at least one medical school (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), and data available on the number of doctors practising in destination countries.

MAIN OUTCOME MEASURES

The financial cost of educating a doctor (through primary, secondary, and medical school), assuming that migration occurred after graduation, using current country specific interest rates for savings converted to US dollars; cost according to the number of source country doctors currently working in the destination countries; and savings to destination countries of receiving trained doctors.

RESULTS

In the nine source countries the estimated government subsidised cost of a doctor's education ranged from $21,000 (£13,000; €15,000) in Uganda to $58,700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn (95% confidence interval 2.13bn to 2.21bn), with costs for each country ranging from $2.16m (1.55m to 2.78m) for Malawi to $1.41bn (1.38bn to 1.44bn) for South Africa. The ratio of the estimated compounded lost investment over gross domestic product showed that Zimbabwe and South Africa had the largest losses. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m).

CONCLUSIONS

Among sub-Saharan African countries most affected by HIV/AIDS, lost investment from the emigration of doctors is considerable. Destination countries should consider investing in measurable training for source countries and strengthening of their health systems.

Canadian family physicians and complementary/alternative medicine: the role of practice setting, medical training, and province of practice

The present study sheds some light on how and why Canadian family physicians offer complementary and alternative medicine (CAM) services to their patients. Our results suggest that organizational settings discourage physicians from offering CAM, while solo clinics are most conducive. Physicians trained in French-language medical schools are less likely than their English-language trained colleagues to offer CAM services, and those in British Columbia are the most likely to do so. Provincial differences do not appear to be related to the presence or absence of "negative proof" legislation that is considered to facilitate CAM provision by physicians.

Actions speak louder than words: mainstream health providers' definitions and behaviour regarding complementary and alternative medicine

The purpose of this paper is to explore how mainstream practitioners define and categorize complementary and alternative medicine (CAM) as one component of assessing their views. The following themes emerged from interviews with Canadian physicians, midwives and nurses: epistemological, evidence-based, medical domain, political-regulatory, funding-based, and role-based definitions of CAM. We also assess any possible links to their behaviour vis-à-vis CAM. We found that classifying something as CAM does not appear to inhibit most providers from recommending, referring for, or supporting their patients' use of these treatments. In conclusion, we highlight that despite their clear definitional boundaries around CAM, providers tend to evaluate each individual therapy on its own merits, taking other situational factors into consideration.

Conceptualizing mainstream health care providers' behaviours in relation to complementary and alternative medicine

There has been an explosion of literature on the attitudes of a variety of health care providers, particularly physicians, to the growing utilization of complementary and alternative medicines and modalities (CAM). What is most seriously lacking is a conceptual framework that helps to distill this mountain of literature into a manageable and more understandable amount. In this paper, we address these important issues by examining the literature that surveys the attitudes and behaviour of providers regarding CAM comparatively across the professions of medicine and nursing and across settings. We do so by drawing upon existing, more general theoretical contributions to the area of CAM in order to propose a comparative conceptual framework with which to interpret the diverse and at times discrepant results of this body of research.

Integrating lay and nurse-midwifery into the U.S. and Canadian health care systems

The integration of midwifery into the health care systems in the U.S. and Canada has invoked scholars to speak of a "rise of midwifery". Despite the gains that the profession of midwifery has made in both countries, there are some interesting differences in how midwifery is organized and practised in these two settings. Briefly, in the U.S. midwifery currently exists as a profession divided between nurse- and non-nurse-midwives, or "lay" midwives, with greater acceptance and legitimacy garnered by the former, whereas midwifery in some jurisdictions in Canada has gained legitimacy as a unified profession separate from nursing. An analysis of the differences in the development and organization of lay and nurse-midwifery in Canada and the U.S. highlights the importance of differences in the system of health professions in these two countries, the role of the state in this system, and the relationship between feminism, midwifery and the state on the outcome of efforts to integrate midwifery.

Physicians' attitudes toward patients' use of alternative cancer therapies

OBJECTIVES

To determine physicians' attitudes and reactions to their patients' use of alternative cancer therapies, factors that affect these reactions and physicians' views of how the use of such therapies affects the physician-patient relationship.

DESIGN

Qualitative study involving in-depth semistructured interviews.

SETTING

Toronto.

PARTICIPANTS

Nineteen oncologists and 35 general practitioners (GPs) were selected by means of purposive sampling; 18 oncologists and 12 GPs agreed to participate.

OUTCOME MEASURES

Attitudes and reactions to patients' use of alternative cancer therapies; factors affecting physicians' reactions to such use; and physicians' views of how the use of such therapies affects the physician-patient relationship.

RESULTS

Many physicians perceived themselves to be unfamiliar with available alternative cancer therapies and indicated that their main sources of information were their patients and the lay press. Although most of the physicians viewed the efficacy of such therapies as scientifically unproven, they would respect their patients' decision to use them and encourage them to continue with standard treatment. Factors found to influence the physicians' reactions included the prognosis with standard treatments, the exclusivity of the use of alternative therapies and whether the alternative therapies were harmful. Although many of the participants felt that a patient's use of alternative cancer therapies did not affect the physician-patient relationship, a few indicated that it did cause some tension.

CONCLUSION

Because many physicians lack information on alternative cancer therapies and most of these therapies have not been scientifically proven, physicians' attitudes and reactions to their use by patients are influenced to a greater degree by the efficacy or inefficacy of standard treatment and the invasiveness of the alternative therapy than by the efficacy of the alternative therapy used.

Regulation and legislation of the dying process: views of health care professionals

Because of radical changes that have been effected by medical advances in the process of dying, it is now frequently necessary for patients to make an explicit decision on whether to forego life-prolonging medical therapies. We report physicians' and nurses' perceptions of the need for, feasibility of, and value of regulations and legislation to govern the dying process. In-depth, semistructured interviews were conducted with a sample of 20 physicians and 20 nurses at a large teaching hospital. There was little unanimity in their attitudes toward whether it is advisable or feasible to devise adequate legal safeguards for physicians and nurses who assist patients to hasten their deaths. Some believed such regulations were needed, but others believed they would seriously compromise good patient care. There was also disagreement as to who should develop guidelines. There was, however, clear opposition among most participants to the involvement of lawyers in the process of clarifying the content of regulations and legislation on the dying process.

Advance directives: the views of health care professionals

OBJECTIVES

This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care.

DESIGN

The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques.

MAIN RESULTS

Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients' instructions, the absence of legal status for directives, the possible interference with a practitioner's clinical judgement, the adequacy and appropriateness of patients' information about their circumstances, and the type of intervention (passive or active) requested by patients.

CONCLUSIONS

New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.

Patient control over dying: responses of health care professionals

Decisions concerning how, when and where patients should die have traditionally been the exclusive domain of health care professionals. More recently, patients and their families are demanding increasing control over these decisions. This paper reports on the responses of 20 physicians and 20 nurses in a major teaching hospital regarding the desire of patients to exert more control over the circumstances of their dying. The findings, based on in-depth, semi-structured interviews, suggest that while health care professionals are generally in favour of the principle of patient control over dying, they have reservations about accommodating patients' wishes in actual clinical situations. Key factors that underly their ambivalence on this point are: (1) specific patient circumstances, such as age, severity of illness and mental competence; (2) moral and legal concerns; and (3) the type of intervention requested by patient. The results indicate that patient control over dying represents a challenge to the clinical judgement of health care professionals; that it runs counter to their perception of their role as healers and supporters; that it raises crucial concerns about their personal ethics and legal liability and that it poses a challenge to their professional autonomy and power. It is likely that health care practitioners will increasingly be pressured to concede their autonomy and enter into a partnership with patients in the decision-making process.