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2 Risk Induced Professional Caregiver Despair Voices of Nurses Society of Rogerian Scholars Savannah, GA October 22, 2005 Thomas Cox PhD, RN Associate Professor College of Nursing Seton Hall University

3 How Risk Induced Professional Caregiver Despair Developed Mathematics and statistics… Social work Nursing Insurance Planning and research Hobbyist creator of vapid research on PCIR Reflecting on roles, duties, and responsibilities

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5 Risk Induced Professional Caregiver Despair? Changing face of healthcare finance Caregivers manage insurance and clinical risks Is this consistent with quality health care Disrupted bonds between RNs and clients  Character, quality, & rapport of relationships Issues neglected - need new to understand the new HC environment Some RNs experience despair in this ‘new’ environment RNs stories about fiscal constraints & caring

6 Professional Caregiver Insurance Risk Unexamined/undisclosed insurance risk transfers occur between and within organizations Inadequate funding unavoidable with insurance risk transfers Risk transfers cause financial, professional, spiritual, and affective disharmonies to emerge ‘Listening’ to the spiritual, affective, physical, and cognitive wounds of nurses may be critical to the well-being of nurses, nursing, nursing clients, and the health care system as a whole

7 Professional Caregiver Insurance Risk The Statistics Version 1 Insurance, financial, and clinical risks borne by health care providers (PCs) when they accept insurance risks from 'insurers' under capitation, PPS, Managed Care, and fixed operating budgets Aggregate risk reduction by insurance is eliminated when public/private insurers cede insurance risks to PCs PCs have higher risk - adversely affecting PCs, marginalized consumers, and marginalized geographic or social regions, due to limited financial & social capital Fosters HCP consolidations and lower service capacity Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

8 Direction of Risk Transmission The Statistics Version 1 Insurer Client Agent Agency District State Insurer Reinsurer PCIR Insurer Corporation Hospital Department Physician Nurse Client In 'insurance' risk transmission is toward more capable entities In PCIR risk transmission is toward less capable entities We should NOT assume that insurance risk transfers to PCs have no effect on quality until proven otherwise – we should assume that they have an untoward effect until proven otherwise

9 Which Type I and Type II Errors? The Statistics Version 1 Which set of null & alternative hypotheses are most appropriate for evaluating risk transfers? H 0 : Risk transfers to PCs do not affect healthcare quality H a : Risk transfers to PCs do affect healthcare quality OR H 0 : Risk transfers to PCs do affect healthcare quality H a : Risk transfers to PCs do not affect healthcare quality Causality: I am happy to report that the architects of prospective payment systems have embraced acausality… When you are travelling on a curve – there is only forward and backward

10 Steady State Assumptions for PCIR The Statistics Version 1 Large population of potential policyholders IID loss characteristics N(0.85, se = 0.05 for N = 1,000,000) Random sampling by insurers Random sampling by PCs from insurer portfolios (R/T industry, social class, dependency status, and geography) Free, competitive, and efficient insurance markets Free, competitive, and efficient healthcare markets Ratemaking is prospective - not re-coupment of past costs Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

11 Problems Caused by Insurance Risk Assumption The Statistics Version 1 Non-random sampling from Insurer's policyholders Contracts of adhesion between insurers and PCs Inadequate actuarial analysis, underwriting & claims handling Documentation systems inadequate for retrospective audits Lack of liquid capital Service capacity more complex than underwriting capacity Insurers motivated to select cost-minimizing PCs Exposure to conflagration hazards due to non-random selections Exposure to self-selection risks by ill clients Different benefit plans ===> increased inefficiencies Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

12 Risk Premium The Statistics Version 1 Insurance rates must cover: Losses + Loss Adjustment Expenses Expenses Profits Risk Premium Risk premium = F(Population variance, Portfolio size, Financial status, Risk aversiveness) Large Insurers - Small se – Low risk premium v smaller insurers Large insurers - better data, better estimates of loss distribution Small Insurers (PCs) should charge higher risk premiums to manage smaller portfolios PCs are very, very small and extremely inefficient insurers Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

13 Insurance Ratemaking & Reserving Parallels for Professional Caregivers The Statistics Version 1 Class plans – Clients with different benefits, status, geography, age, gender... Credibility weighted rates Expectations for fair rates and equal services PCs cannot provide uniform services – Inefficient operations High benefit clients leave if treated like low benefit clients Impacts all provider-client interactions Ethical and management issues in clinical decisions Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

14 Aristotle's Geocentric Universe The Statistics Version 1 Why not just fix our deficient healthcare finance system with a hodgepodge of financial 'epicycles' – SMSA adjustments, Carve- outs, Wage adjustments, Volume adjustments, Equipment exceptions, Facility size adjustments...

15 PC Risks The Statistics Version 1 Insurance risk assuming PCs face concatenated losses: Costs of clinical services Bonus plans often reward low costs – not high costs High costs jeopardize future contracts High referral rates/costs trigger more reviews & retrospective audits Prior year losses non-random selection losses uncompensated if other contracting PCs didn't have them High prior losses & high current risks jeopardize PC financial stability Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

16 Clinical Constraints The Statistics Version 1 Insurance risk transfers move, through organizations, ever closer to clients: Variability in costs/service demands r/t small samples increases Financial risks increase – not necessarily organizational – “personal” Risk aversive behavior increases Risk premium adequacy decreases Scrutiny of clinician’s decisions increases as costs increase Breakdown in provider-consumer relationships Lack of clinician consciousness about their claims management role Parallels to insurance – Sales agents not held liable for ‘bad’ risks – clinicians are held responsible for ‘high cost’ clients Ex post facto auditing – reduced reimbursements Clinical efficacy decisions are instantaneous – reviews are ‘referent to infinity’ High costs Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

17 Reinterpeting the Standard Error The Statistics Version 1 Normally the standard error relates to the accuracy of the insurer’s estimate of the true loss ratio for the population of all potential policyholders based on past insurer sampling/underwriting In PCIR, there are critically important additional meanings: Measure of PC’s ability to analyze/price/select renewal contracts Measures reduced service capacity/delivery levels needed to maintain PC bankruptcy risk at pre-set level Measures lost insurance risk aggregation benefit due to insurance risk cessions to PCs Indirectly measures loss in health system capacity Measure of disparity between 'pure premium' and service capacity Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

18 Insurer v PC Standard Errors The Statistics Version 1 Ideally, both the insurer and the provider portfolios are random selections from the population of all possible policyholders: Population SD = sigma Insurer standard error LR Target P( Insolvency ) se*2*sqrt(5)seVariability ,000Number Provider 1,000s Insurer 1,000s Population 1,000s Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

19 Risk Induced Professional Caregiver Despair RNs experiences, perceptions and expressions of despair about their careers and working environments Reasons for despair - not biological/chemical/Rx deficiency Unmet expectations, unfulfilled hopes & dreams, opportunities lost, challenges too hard to meet, harsh and uninviting futures, and a past impossible to replicate or resurrect Many RNs created new meanings of their experiences by blending art, science, perception, feeling, and intuition into organic and meaningful wholes, representing and revealing their unique constructions of the world

20 Correlates and Corollaries of Professional Caregiver Despair BurnoutDepression UnhappinessAnomie AngstDissatisfaction AlienationSuffering Stress Poor Attitude Ethical ConflictMoral Distress

21 Correlates and Corollaries of Professional Caregiver Despair BurnoutDepression UnhappinessAnomie AngstDissatisfaction AlienationSuffering Stress Poor Attitude Ethical ConflictMoral Distress

22 Correlates and Corollaries of Professional Caregiver Despair BurnoutDepression UnhappinessAnomie AngstDissatisfaction AlienationSuffering Stress Poor Attitude Ethical ConflictMoral Distress

23 Correlates and Corollaries of Professional Caregiver Despair BurnoutDepression UnhappinessAnomie AngstDissatisfaction AlienationSuffering Stress Poor Attitude Ethical ConflictMoral Distress

24 Correlates and Corollaries of Professional Caregiver Despair BurnoutDepression UnhappinessAnomie AngstDissatisfaction AlienationSuffering Stress Poor Attitude Ethical ConflictMoral Distress

25 Correlates and Corollaries of Professional Caregiver Despair BurnoutDepression UnhappinessAnomie AngstDissatisfaction AlienationSuffering Stress Poor Attitude Ethical ConflictMoral Distress

26 Correlates and Corollaries of Professional Caregiver Despair BurnoutDepression UnhappinessAnomie AngstDissatisfaction AlienationSuffering Stress Poor Attitude Ethical ConflictMoral Distress

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28 Unitary Appreciative Inquiry I Theory generating, practice and research method Appreciation of humans and human phenomena as wholes Co-researchers shared experiences, perceptions & expressions, from their unique vantage point and without the need to justify themselves, their thoughts, beliefs, actions, or decisions Goal – Appreciation of co-researchers' experiences of RIPCD Researcher sought a ‘healing appreciation of co-researchers’ not just data capture

29 Practicing Unitary Appreciative Inquiry Acceptance and validation Empathic and appreciative See through the eyes of participant Gain deeper understanding of/with participants as wholes Healing intention - assisting participants toward freer expression, greater insight, and greater integration Dwell in preconceptions and assumptions favorable to participants Foster rapport and promote harmony and mutuality Participants may not yet feel themselves to be wholes Researcher: Assists participants in healing appreciation of their own wholeness Facilitating insight, growth, and transformation Not just data collection – IRB issues

30 RIPCD – A Unitary Appreciative Inquiry Experiences, intuitions, reflections of RNs RIPCD experiences Collaborative, theorogenic, research, and ‘healing’ journey Opportunity to reveal, explore, and represent effects of HC financing experiments, adding substance, humanity, faces, and feeling to the soulless explications dominating the landscape 8 Participants shared experiences of the impact of risk transfers on nursing care and nurses: OPERATING ROOM ONCOLOGY MATERNITY AND PEDIATRICS PSYCHIATRY and MEDICAL-SURGICAL RNs

31 Why UAI Was Important Wholeness & healing occur with free unstructured expression Most participants thankful for opportunity to discuss their experiences until THEY were satisfied, citing prior inabilities to achieve closure Some feel others prematurely react, designing interventions to ‘fix’ them or see them as ‘problem employees’ Appreciative profiles may be helpful to nursing and other disciplines and settings - fundamental features of modern life and mismatches between expectations and capacities in the face of unanticipated and unplanned variability and unpredictability

32 How The Research Unfolded RNs who wanted to share stories RNs provided new insights about how difficult bedside nursing had become for them Research question: “What does risk induced professional caregiver despair mean to you” Stories about effect on nurses and clients of risk assumption and declining nursing capacity - the organized, synergistic, capacity to provide high quality nursing care

33 The Participant - Carol OR Nurse Self-identified as experiencing RIPCD Volunteer 20+ years as a nurse Revealing stories about corporate response to finance changes: Desire to practice more independently Loss of control over work environment Recycled equipment and supplies – failures in service Supplies come from over 100 miles away Therapeutic to discuss RIPCD

34 Some Thoughts on the Research Process I IRB – Difficult to explain ‘praxis’ to panels focused on risk reduction in ‘designed experiments’ How does one distinguish between ‘healing intent’ and ‘intervention’ aimed at specific outcomes? Not interventive in the same sense as a RCT No objective goals beyond revelation, insight, growth, healing, transformation – the ‘small effects’

35 Work Products? Dissertation Many presentations on research findings, method, PCIR, financial and risk management… Development of tools for monitoring and forecasting nursing capacity needs in risk assumption Collaborations with other nurses, researchers, practitioners, educators, & administrators Greater insight into the impact of managed care and capitation on organizational and professional behavior Better refined theory of PCIR

36 Practical and Theoretical Insights Allowed to freely consider, explore, and express the essence of their experiences, most of the RNs developed new ideas and attitudes about themselves and their experiences Researcher gained important insights into how RNs respond to environmental impediments to caring practice New theories and strategies for preparing RNs in their roles have emerged – greater need to understand how to deal with insurers, how to read and understand budgets and management reports, ethical reasoning regarding quality of care issues New ideas about healing for individuals, groups, and systems

37 Some Guiding Principles of Healing Synoptic Narrative Construction Allegorical – Metaphors encompass past, present, and future Collaborations, incorporating multiple methods of cognitive, affective, aesthetic interpretation, and representation A reaching forward, grounded in the past, present, and alternative possible futures Researcher as guide, reference point, healer, and co-inquirer, journeying with co-researchers Embrace contradiction, dissimilarity, and incoherence as birthing the future

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39 Some Guiding Principles of Risk Induced Professional Caregiver Despair RIPCD is rhythm, flowing in & out of despair, hope, joy, and pessimism RIPCD not ‘observable’ - must engage co-researcher Naturalistic setting - where people are comfortable RIPCD isn’t binary, emerging, shifting, changing, reforming coherence from time to time as different patterns form with an ever-changing environment – Most loved jobs, peers, and nursing For some, flooding their experiences out, seemed to dramatically alter their lives, impelling them to action

40 An Experiment in Data Summarization Data collection and management Interviews digitally recorded Digital files  encrypted mp3 files mp3 files sent via secure internet connection for transcription Text for Carol – including two face-to-face interviews, several s, review of two appreciative profiles – 160+ pages Target length of appreciative profile ~ 7 pgs Wanted participant ‘voice’ – own words

41 An Experiment in Data Summarization The Solution Data saturation Initial appreciative profile construction Breaking raw data into significant vignettes Ranking of vignettes in terms of representativeness of the whole appreciated during data saturation Data summarization and formatting Appreciative profile construction

42 Carol - 1a operating room is really costly… supplies… we exist on supplies we use to do the surgery operating room… negotiate their own contracts… different companies… different types of supplies what has changed is, it’s not {our surgery}, it’s {parent corporation} big contract … one company… lower rates.

43 Carol - 1b don’t know whether it’s… going back to school… getting older, being so long… But I’m starting to feel that I want to go beyond what I’m doing now

44 Carol - 2 Frustration… anxiety… out and out fear about the quality of nursing... Not being able to provide things for my patients not being able to… protect my patients... not being adequately protected myself

45 Carol - 3 We even have the times… had to send a courier to another hospital to get one... one or two instances… in the middle of things… not good for the patient

46 Carol - 4a another thing that has changed… last six months… used to get our case cart; the rolling carts… filled with all the sterile supplies the packs, the towels, the basin, everything used to come from {Medical Supply}… right here in Richmond they would deliver the case carts to the OR

47 Carol - 4b either evenings or nights {shift}… have a list of instruments… to be picked attendants are supposed to have a list of equipment… microscopes, headlights… they should be brought to every room… in a perfect world, everything would be there when you walked in

48 Carol - 4c because of {Parent Corp}… contract dropped… gone to {Other state} So, they drive down the truck every day make do as best you can… pull from what you have there in the hospital run and borrow things… make do with something else

49 Carol - 5 It’s been very therapeutic It does help to talk and to vent about your frustrations with someone sometimes it just really does help you… to get these things off your chest verbalize them

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