Greenway Julie Catherine, Entwistle Vikki Ann, terMeulen Ruud
Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
Prim Health Care Res Dev. 2013 Apr;14(2):200-11. doi: 10.1017/S1463423612000400. Epub 2012 Aug 10.
To explore whether and how health visitors experience ethical tensions between the public health agenda and the need to be responsive to individual clients.
Current health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This may generate tensions.
A total of 17 semi-structured individual interviews covering participants' experiences of implementing public health interventions and perceptions of the ethical tensions involved were conducted. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach.
Health visitors raised a number of ethical concerns, which they attributed to organisational resource allocation and the introduction of protocols and targets relating to public health goals. They did not always regard it as appropriate to raise topics that employing organisations had identified as public health priorities with particular clients for whom they were not priorities, or who had other more pressing needs. They noted that resources that were allocated towards reaching public health targets were unavailable for clients who needed support in other areas. Organisational protocols designed to monitor performance put pressure on health visitors to prioritise achieving targets and undermined their ability to exercise professional judgement when supporting individual clients. This had implications for health visitors' sense of professionalism. Health visitors saw trusting relationships as key to effective health visiting practice, but the requirement to implement public health priorities, combined with a lack of resources in health visiting, eroded their ability to form these. Policies need to be evaluated with regard to their impact upon a broader range of processes and outcomes than public health goals. The erosion of health visitors' professional values and ability to develop relationships with clients could have numerous adverse implications.
探讨健康访视员是否以及如何在公共卫生议程与回应个体客户需求之间体验到伦理困境。
英国当前的卫生政策赋予健康访视员在实施政府公共卫生议程方面的关键作用。其职业准则还要求健康访视员回应个体客户与健康相关的关切和偏好。这可能会产生紧张关系。
总共进行了17次半结构化个人访谈，内容涵盖参与者实施公共卫生干预措施的经历以及对其中涉及的伦理困境的看法。访谈进行了录音、转录，并采用框架法进行主题分析。
健康访视员提出了一些伦理问题，他们将其归因于组织资源分配以及与公共卫生目标相关的方案和指标的引入。他们并不总是认为向特定客户提及雇主确定为公共卫生优先事项但对这些客户并非优先事项或有其他更紧迫需求的话题是合适的。他们指出，用于实现公共卫生目标的资源无法用于其他需要支持的客户。旨在监控绩效的组织方案给健康访视员带来压力，要求他们优先实现目标，并在支持个体客户时削弱了他们行使专业判断力的能力。这对健康访视员的专业感产生了影响。健康访视员认为信任关系是有效开展健康访视工作的关键，但实施公共卫生优先事项的要求，再加上健康访视资源的缺乏，侵蚀了他们建立这些关系的能力。需要对政策在公共卫生目标之外对更广泛的过程和结果的影响进行评估。健康访视员专业价值观的侵蚀以及与客户建立关系的能力可能会产生许多不利影响。
