healthcare management articles

• Research article
• Open access
• Published: 24 April 2019

Priorities and challenges for health leadership and workforce management globally: a rapid review

• Carah Alyssa Figueroa   ORCID: orcid.org/0000-0002-8825-7796 1 ,
• Reema Harrison 1 ,
• Ashfaq Chauhan 1 &
• Lois Meyer 1  

BMC Health Services Research volume  19 , Article number:  239 ( 2019 ) Cite this article

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Health systems are complex and continually changing across a variety of contexts and health service levels. The capacities needed by health managers and leaders to respond to current and emerging issues are not yet well understood. Studies to date have been country-specific and have not integrated different international and multi-level insights. This review examines the current and emerging challenges for health leadership and workforce management in diverse contexts and health systems at three structural levels, from the overarching macro (international, national) context to the meso context of organisations through to the micro context of individual healthcare managers.

A rapid review of evidence was undertaken using a systematic search of a selected segment of the diverse literature related to health leadership and management. A range of text words, synonyms and subject headings were developed for the major concepts of global health, health service management and health leadership. An explorative review of three electronic databases (MEDLINE®, Pubmed and Scopus) was undertaken to identify the key publication outlets for relevant content between January 2010 to July 2018. A search strategy was then applied to the key journals identified, in addition to hand searching the journals and reference list of relevant papers identified. Inclusion criteria were independently applied to potentially relevant articles by three reviewers. Data were subject to a narrative synthesis to highlight key concepts identified.

Sixty-three articles were included. A set of consistent challenges and emerging trends within healthcare sectors internationally for health leadership and management were represented at the three structural levels. At the macro level these included societal, demographic, historical and cultural factors; at the meso level, human resource management challenges, changing structures and performance measures and intensified management; and at the micro level shifting roles and expectations in the workplace for health care managers.

Contemporary challenges and emerging needs of the global health management workforce orient around efficiency-saving, change and human resource management. The role of health managers is evolving and expanding to meet these new priorities. Ensuring contemporary health leaders and managers have the capabilities to respond to the current landscape is critical.

Peer Review reports

Health systems are increasingly complex; encompassing the provision of public and private health services, primary healthcare, acute, chronic and aged care, in a variety of contexts. Health systems are continually evolving to adapt to epidemiological, demographic and societal shifts. Emerging technologies and political, economic, social, and environmental realities create a complex agenda for global health [ 1 ]. In response, there has been increased recognition of the role of non-state actors to manage population needs and drive innovation. The concept of ‘collaborative governance,’ in which non-health actors and health actors work together, has come to underpin health systems and service delivery internationally [ 1 ] in order to meet changing expectations and new priorities. Seeking the achievement of universal health coverage (UHC) and the Sustainable Development Goals (SDGs), particularly in low- and middle-income countries, have been pivotal driving forces [ 2 ]. Agendas for change have been encapsulated in reforms intended to improve the efficiency, equity of access, and the quality of public services more broadly [ 1 , 3 ].

The profound shortage of human resources for health to address current and emerging population health needs across the globe was identified in the World Health Organization (WHO) landmark publication ‘Working together for health’ and continues to impede progress towards the SDGs [ 4 ]. Despite some improvements overall in health workforce aggregates globally, the human resources for health challenges confronting health systems are highly complex and varied. These include not only numerical workforce shortages but imbalances in skill mix, geographical maldistribution, difficulty in inter-professional collaboration, inefficient use of resources, and burnout [ 2 , 5 , 6 ]. Effective health leadership and workforce management is therefore critical to addressing the needs of human resources within health systems and strengthening capacities at regional and global levels [ 4 , 6 , 7 , 8 ].

While there is no standard definition, health leadership is centred on the ability to identify priorities, provide strategic direction to multiple actors within the health system, and create commitment across the health sector to address those priorities for improved health services [ 7 , 8 ]. Effective management is required to facilitate change and achieve results through ensuring the efficient mobilisation and utilisation of the health workforce and other resources [ 8 ]. As contemporary health systems operate through networks within which are ranging levels of responsibilities, they require cooperation and coordination through effective health leadership and workforce management to provide high quality care that is effective, efficient, accessible, patient-centred, equitable, and safe [ 9 ]. In this regard, health leadership and workforce management are interlinked and play critical roles in health services management [ 7 , 8 ].

Along with health systems, the role of leaders and managers in health is evolving. Strategic management that is responsive to political, technological, societal and economic change is essential for health system strengthening [ 10 ]. Despite the pivotal role of health service management in the health sector, the priorities for health service management in the global health context are not well understood. This rapid review was conducted to identify the current challenges and priorities for health leadership and workforce management globally.

This review utilised a rapid evidence assessment (REA) methodology structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [ 11 ]. An REA uses the same methods and principles as a systematic review but makes concessions to the breadth or depth of the process to address key issues about the topic under investigation [ 12 , 13 , 14 ]. An REA provides a balanced assessment of what is already known about an issue, and the strength of evidence. The narrower research focus, relative to full systematic reviews, make REAs helpful for systematically exploring the evidence around a particular issue when there is a broad evidence base to explore [ 14 ]. In the present review, the search was limited to contemporary literature (post 2010) selected from leading health service management and global health journals identified from exploring major electronic databases.

Search strategy

An explorative review of three core databases in the area of public health and health services (MEDLINE®, Pubmed and Scopus) was undertaken to identify the key publication outlets for relevant content. These databases were selected as those that would be most relevant to the focus of the review and have the broadest range of relevant content. A range of text words, synonyms and subject headings were developed for the major constructs: global health, health service management and health leadership, priorities and challenges. Regarding health service management and health leadership, the following search terms were used: “healthcare manag*” OR “health manag*” OR “health services manag*” OR “health leader*”. Due to the large volume of diverse literature generated, a systematic search was then undertaken on the key journals that produced the largest number of relevant articles. The journals were selected as those identified as likely to contain highly relevant material based on an initial scoping of the literature.

Based on the initial database search, a systematic search for articles published in English between 1 January 2010 and 31 July 2018 was undertaken of the current issues and archives of the following journals: Asia-Pacific Journal of Health Management; BMC Health Services Research; Healthcare Management Review; International Journal of Healthcare Management; International Journal of Health Planning and Management; Journal of Healthcare Management; Journal of Health Organisation and Management; and, Journal of Health Management. Hand-searching of reference lists of identified papers were also used to ensure that major relevant material was captured.

Study selection and data extraction

Results were merged using reference-management software (Endnote) and any duplicates removed. The first author (CF) screened the titles and abstracts of articles meeting the eligibility criteria (Table 1 ). Full-text publications were requested for those identified as potentially relevant. The inclusion and exclusion criteria were then independently applied by two authors. Disagreements were resolved by consensus or consultation with a third person, and the following data were extracted from each publication: author(s), publication year, location, primary focus and main findings in relation to the research objective. Sixty-three articles were included in the final review. The selection process followed the PRISMA checklist [ 11 ] as shown in Fig. 1 .

PRISMA flow chart of the literature search, identification, and inclusion for the review

Data extraction and analysis

A narrative synthesis was used to explore the literature against the review objective. A narrative synthesis refers to “an approach to the systematic review and synthesis of findings from multiple studies that relies primarily on the use of words and text to summarise and explain the findings of the synthesis” [ 15 ]. Firstly, an initial description of the key findings of included studies was drafted. Findings were then organised, mapped and synthesised to explore patterns in the data.

Search results

A total of 63 articles were included; Table 2 summarizes the data extraction results by region and country. Nineteen were undertaken in Europe, 16 in North America, and one in Australia, with relatively fewer studies from Asia, the Middle East, and small island developing countries. Eighteen qualitative studies that used interviews and/or focus group studies [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ] were identified. Other studies were quantitative [ 33 , 34 , 35 , 36 , 37 , 38 , 39 ] including the use of questionnaires or survey data, or used a mixed-method approach [ 40 , 41 , 42 , 43 , 44 ]. Other articles combined different types of primary and secondary data (key informant interviews, observations, focus groups, questionnaire/survey data, and government reports). The included literature also comprised 28 review articles of various types that used mixed data and bibliographic evidence.

Key challenges and emerging trends

A set of challenges and emerging trends were identified across healthcare sectors internationally. These were grouped at three levels: 1) macro, system context (society, demography, technology, political economy, legal framework, history, culture), 2) meso, organisational context (infrastructure, resources, governance, clinical processes, management processes, suppliers, patients), and 3) micro context related to the individual healthcare manager (Table 3 ). This multi-levelled approach has been used in previous research to demonstrate the interplay between different factors across different levels, and their direct and indirect reciprocal influences on healthcare management policies and practices [ 45 ].

Societal and system-wide (macro)

Population growth, ageing populations, and increased disease burdens are some of the common trends health systems are facing globally. Developing and developed countries are going through demographic and epidemiological transitions; people are living longer with increasing prevalence of chronic diseases requiring health managers and leaders to adjust to shifting healthcare needs at the population level, delivering preventative and long-term care beyond acute care. Countries in Africa, Europe, the Pacific Islands, Middle East, Asia and Caribbean are seeing an increase in number of patients with non-communicable diseases and communicable diseases [ 21 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ].

Although many countries have similar emerging health system concerns, there are some differences in the complexities each country faces. For many small countries, outmigration, capacity building and funding from international aid agencies are affecting how their health systems operate, while in many larger countries, funding cuts, rise in private health insurance, innovations, and health system restructuring are major influences [ 21 , 34 , 50 , 53 , 54 ]. In addition, patients are increasingly health literate and, as consumers, expect high-quality healthcare [ 34 , 53 , 54 ]. However, hospitals and healthcare systems are lacking capacity to meet the increased demand [ 16 , 34 , 43 ].

Scientific advances have meant more patients are receiving care across the health system. It is imperative to have processes for communication and collaboration between different health professionals for high-quality care. However, health systems are fragmented; increasing specialisation is leading to further fragmentation and disassociation [ 31 , 54 , 55 ]. Adoption of technological innovations also require change management, hospital restructure, and capacity building [ 56 , 57 , 58 ].

Changes in health policies and regulations compound the challenge faced by healthcare managers and leaders to deliver high quality care [ 53 , 54 , 59 ]. Political reforms often lead to health system restructuring requiring change in the values, structures, processes and systems that can constrain how health managers and leaders align their organisations to new agendas [ 24 , 28 , 31 , 60 ]. For example, the distribution of health services management to local authorities through decentralisation has a variable impact on the efficacy and efficiency of healthcare delivery [ 24 , 27 , 35 , 59 ].

Governments’ decisions are often made focusing on cost savings, resulting in budgetary constraints within which health systems must operate [ 16 , 19 , 53 , 61 ]. Although some health systems have delivered positive results under such constraint [ 53 ], often financial resource constraints can lead to poor human and technical resource allocation, creating a disconnect between demand and supply [ 23 , 27 , 40 , 47 , 57 ]. To reduce spending in acute care, there is also a push to deliver health services in the community and focus on social determinants of health, though this brings further complexities related to managing multiple stakeholder collaborations [ 27 , 32 , 34 , 38 , 40 , 49 , 55 ].

Due to an increase in demand and cost constraints, new business models are emerging, and some health systems are resorting to privatisation and corporatisation [ 22 , 48 , 62 ]. This has created competition in the market, increased uptake of private health insurance and increased movement of consumers between various organisations [ 22 , 48 ]. Health managers and leaders need to keep abreast with continuously changing business models of care delivery and assess their impact [ 59 , 62 ]. The evolving international health workforce, insufficient numbers of trained health personnel, and maintaining and improving appropriate skill mixes comprise other important challenges for managers in meeting population health needs and demands (Table 3 ).

Organisational level (meso)

At the organisation level, human resource management issues were a central concern. This can be understood in part within the wider global human resources for health crisis which has placed healthcare organisations under intense pressure to perform. The evidence suggests healthcare organisations are evolving to strengthen coordination between primary and secondary care; there is greater attention to population-based perspectives in disease prevention, interdisciplinary collaboration, and clinical governance. These trends are challenged by the persistence of bureaucratic and hierarchical cultures, emphasis on targets over care quality, and the intensification of front-line and middle-management work that is limiting capacity.

Healthcare managers and leaders also face operational inefficiencies in providing primary health and referral services to address highly complex and shifting needs which often result in the waste of resources [ 49 , 63 , 64 ]. Considering the pace of change, organisations are required to be flexible and deliver higher quality care at lower cost [ 21 , 53 , 65 ]. To achieve this, many organisations in developing and developed countries alike are adopting a lean model [ 17 , 21 ]. However, there are challenges associated with ensuring sustainability of the lean system, adjusting organisational hierarchies, and improving knowledge of the lean model, especially in developing countries [ 17 , 21 ].

Healthcare organisations require various actors with different capabilities to deliver high quality care. However, a dominant hierarchical culture and lack of collaborative and distributed culture can limit the performance of healthcare organisations [ 22 , 36 , 54 ]. In addition, considering high turnover of executive leadership, healthcare organisations often rely on external talent for succession management which can reduce hospital efficiency [ 44 , 66 ]. Other contributors to weakened hospital performance include: the lack of allocative efficiency and transparency [ 24 , 30 , 64 , 67 ]; poor hospital processes that hamper the development of effective systems for the prevention and control of hospital acquired infections (HAIs) [ 53 , 68 ]; and, payment reforms such as value-based funding and fee-for-service that encourage volume [ 18 , 23 , 24 , 61 , 62 , 69 , 70 ].

Managerial work distribution within organisations is often not clearly defined, leading to extra or extreme work conditions for middle and front-line managers [ 29 , 42 , 53 , 70 ]. Unregulated and undefined expectations at the organisation level leads to negative effects such as stress, reduced productivity, and unpredictable work hours, and long-term effects on organisational efficiency and delivery of high quality care [ 22 , 28 , 29 , 37 , 42 , 51 , 71 ]. Furthermore, often times front-line clinicians are also required to take the leadership role in the absence of managers without proper training [ 20 ]. Despite this, included studies indicate that the involvement of middle and front-line managers in strategic decision-making can be limited due to various reasons including lack of support from the organisation itself and misalignment of individual and organisational goals [ 16 , 26 , 31 , 72 ].

Individual level (micro)

Worldwide, middle and front-line health managers and leaders are disproportionately affected by challenges at the system and organisational level, which has contributed to increasing and often conflicting responsibilities. Some countries are experiencing a growth in senior health managers with a clinical background, while in other countries, the converse is apparent. Indistinct organisational boundaries, increasing scope of practice, and lack of systemic support at policy level are leaving healthcare managers with undefined roles [ 28 , 59 ]. Poorly defined roles contribute to reduced accountability, transparency, autonomy, and understanding of responsibilities [ 24 , 30 , 31 , 67 ]. Studies also indicate a lack of recognition of clinical leaders in health organisations and inadequate training opportunities for them as such [ 20 , 67 ].

The number of hybrid managers (performing clinical and managerial work concurrently) in developed countries is increasing, with the perception that such managers improve the clinical governance of an organization. In contrast, the number of non-clinical managers in many developing countries appears to be increasing [ 63 , 73 , 74 , 75 ]. Included studies suggest this approach does not necessarily improve manager-clinical professional relationships or the willingness of clinicians becoming managers, limiting their participation in strategic decisions [ 28 , 70 , 71 , 74 ].

This rapid review highlights the current global climate in health service management, the key priority areas, and current health management approaches being utilised to address these. The multitude of issues emerging demonstrate the complex and evolving role of health service management in the wider complex functioning of health systems globally in a changing healthcare landscape. Key themes of achieving high quality care and sustainable service delivery were apparent, often evidenced through health reforms [ 5 ]. The influence of technological innovation in both its opportunities and complexities is evident worldwide. In the context of changing healthcare goals and delivery approaches, health management is seeking to professionalise as a strategy to build strength and capacity. In doing so, health managers are questioning role scope and the skills and knowledge they need to meet the requirements of the role.

Global challenges facing health management

Understanding how the features of the macro, meso and micro systems can create challenges for managers is critical [ 19 ]. With continual healthcare reform and increasing health expenditure as a proportion of GDP, distinct challenges are facing high-income Organisation for Economic Co-operation and Development (OECD) countries, middle-income rapidly-developing economies, and low-income, resource-limited countries. Reforms, especially in OECD countries, have been aimed at controlling costs, consolidating hospitals for greater efficiencies, and reconfiguring primary healthcare [ 1 , 76 ]. The changing business models for the delivery of care have wider implications for the way in which health managers conceptualise healthcare delivery and the key stakeholders [ 59 ], for example, the emerging role of private healthcare providers and non-health actors in public health. Changes to the business model of healthcare delivery also has implications for the distribution of power amongst key actors within the system. This is evident in the evolved role of general practitioners (GPs) in the UK National Health Service as leaders of Clinical Commissioning Groups (CCGs). Commissioning requires a different skill set to clinical work, in terms of assessing financial data, the nature of statutory responsibilities, and the need to engage with a wider stakeholder group across a region to plan services [ 77 ]. With new responsibilities, GPs have been required to quickly equip themselves with new management capabilities, reflecting the range of studies included in this review around clinician managers and the associated challenges [ 18 , 28 , 53 , 63 , 70 , 71 , 74 , 75 ].

Central to the role of healthcare managers is the ability to transition between existing and new cultures and practices within healthcare delivery [ 59 ]. Bridging this space is particularly important in the context of increasingly personalized and technologically-driven healthcare delivery [ 54 ]. While advances in knowledge and medical technologies have increased capability to tackle complex health needs, the integration of innovations into existing healthcare management practices requires strong change management [ 73 ]. Health leaders and managers need to be able to rapidly and continually assess the changes required or upon them, the implications, and to transform their analysis into a workable plan to realise change [ 10 ]. Focusing only on the clinical training of health professionals rather than incorporating managerial and leadership roles, and specifically, change management capability may limit the speed and success of innovation uptake [ 22 ].

Implications

Our findings highlight the implications of current priorities within the health sector for health management practice internationally; key issues are efficiency savings, change management and human resource management. In the context of efficiency approaches, health system and service managers are facing instances of poor human and technical resource allocation, creating a disconnect between demand and supply. At the service delivery level, this has intensified and varied the role of middle managers mediating at two main levels. The first level of middle-management is positioned between the front-line and C-suite management of an organisation. The second level of middle-management being the C-suite managers who translate regional and/or national funding decisions and policies into their organisations. Faced with increasing pace of change, and economic and resource constraints, middle managers across both levels are now more than ever exposed to high levels of stress, low morale, and unsustainable working patterns [ 29 ]. Emphasis on cost-saving has brought with it increased attention to the health services that can be delivered in the community and the social determinants of health. Connecting disparate services in order to meet efficiency goals is a now a core feature of the work of many health managers mediating this process.

Our findings also have implications for the conceptualisation of healthcare management as a profession. The scale and increasing breadth of the role of health leaders and managers is evident in the review. Clarifying the professional identity of ‘health manager’ may therefore be a critical part of building and maintaining a robust health management workforce that can fulfil these diverse roles [ 59 ]. Increasing migration of the healthcare workforce and of population, products and services between countries also brings new challenges for healthcare. In response, the notion of transnational competence among healthcare professionals has been identified [ 78 ]. Transnational competence progresses cultural competence by considering the interpersonal skills required for engaging with those from diverse cultural and social backgrounds. Thus, transnational competence may be important for health managers working across national borders. A key aspect of professionalisation is the education and training of health managers. Our findings provide a unique and useful theoretical contribution that is globally-focused and multi-level to stimulate new thinking in health management educators, and for current health leaders and managers. These findings have considerable practical utility for managers and practitioners designing graduate health management programs.

Limitations

Most of the studies in the field have focused on the Anglo-American context and health systems. Notwithstanding the importance of lessons drawn from these health systems, further research is needed in other regions, and in low- and middle-income countries in particular [ 79 ]. We acknowledge the nuanced interplay between evidence, culture, organisational factors, stakeholder interests, and population health outcomes. Terminologies and definitions to express global health, management and leadership vary across countries and cultures, creating potential for bias in the interpretation of findings. We also recognise that there is fluidity in the categorisations, and challenges arising may span multiple domains. This review considers challenges facing all types of healthcare managers and thus lacks discrete analysis of senior, middle and front-line managers. That said, managers at different levels can learn from one another. Senior managers and executives may gain an appreciation for the operational challenges that middle and front-line managers may face. Middle and front-line managers may have a heightened awareness of the more strategic decision-making of senior health managers. Whilst the findings indicate consistent challenges and needs for health managers across a range of international contexts, the study does not capture country-specific issues which may have consequences at the local level. Whilst a systematic approach was taken to the literature in undertaking this review, relevant material may have been omitted due to the limits placed on the rapid review of the vast and diverse health management literature. The inclusion of only materials in English language may have led to further omissions of relevant work.

Health managers within both international and national settings face complex challenges given the shortage of human resources for health worldwide and the rapid evolution of national and transnational healthcare systems. This review addresses the lack of studies taking a global perspective of the challenges and emerging needs at macro (international, national and societal), meso (organisational), and micro (individual health manager) levels. Contemporary challenges of the global health management workforce orient around demographic and epidemiological change, efficiency-saving, human resource management, changing structures, intensified management, and shifting roles and expectations. In recognising these challenges, researchers, management educators, and policy makers can establish global health service management priorities and enhance health leadership and capacities to meet these. Health managers and leaders with adaptable and relevant capabilities are critical to high quality systems of healthcare delivery.

Abbreviations

Clinical Commissioning Groups

General practitioners

Hospital acquired infections

Organisation for Economic Co-operation and Development

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Rapid evidence assessment

Sustainable Development Goals

Universal health coverage

World Health Organization

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Figueroa, C.A., Harrison, R., Chauhan, A. et al. Priorities and challenges for health leadership and workforce management globally: a rapid review. BMC Health Serv Res 19 , 239 (2019). https://doi.org/10.1186/s12913-019-4080-7

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Healthcare Management: A Bibliometric Analysis Based on the Citations of Research Articles Published between 1967 and 2020

Oana păduraru.

1 Doctoral School, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; moc.oohay@17tserofanao

Alina Moroșanu

2 Department of Social Sciences and Humanities, Institute of Interdisciplinary Research, Alexandru Ioan Cuza University, 700506 Iasi, Romania

Călin Ștefan Păduraru

3 Doctoral School of Biomedical Sciences, Dunărea de Jos University, 800008 Galati, Romania; moc.liamg@urarudapnafetsnilac

Elena Mihaela Cărăușu

4 Department of Public Health and Management, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; moc.oohay@usuaracaleahim

Associated Data

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to restrictions, e.g., privacy or ethical.

The purpose of this study is to analyse the trends manifested in research literature from the field of healthcare management, with emphasis on bibliometric features and different influencing factors. For this, a search was conducted of nine academic databases between January and May 2021. Article features were registered in our database after first applying the validation criteria used for their inclusion. Then, data regarding the publication of the included articles were collected. The analysis focused on trends over time, topic, and journals in which they were published. Moreover, the effect of some factors on the citation of articles was analysed. Our results showed that the 250 analysed articles were published in 139 journals, and many of were by researchers affiliated with universities in the United States. Over time, the publication of analysed articles and their number of citations registered a continuous increase. The most common topics of focus were healthcare management systems and their challenges. In our study, we identified factors that significantly affect citation number, such as number of years since publication, the number of words in the title, and the number of authors of an article. In addition, major gaps were identified, as were new unresolved challenges that can trigger new research ideas.

1. Introduction

In recent years, there has been constant concern in the field of healthcare, considering the risks to the health of the population caused by severe pandemics, the most recent example being the COVID-19 pandemic [ 1 , 2 ]. The COVID-19 pandemic has shown more than ever that the most valuable source for generating innovation in the healthcare management field is concern and not only information. To increase the chances of generating innovations, the amount of useful information must also increase [ 3 ]. Evidence of this is the provision and rapid sharing of scientific data and information. Since the beginning of the pandemic on platforms such as GISAID or Nextstrain, the amount of data shared has increased significantly. Moreover, 117 organisations (including journals, funding agencies, disease prevention centres) signed a statement entitled “Sharing relevant data and research findings for the new coronavirus outbreak (COVID-19)” [ 3 ]. Thus, a series of practices related to the elimination of payment for accessing scientific documents and the use of preprint servers were initiated [ 4 ]. Researchers and practitioners from all over the world have continued this initiative, encouraging people to make their work available to help in fighting the COVID-19 pandemic [ 3 ]. Programs, such as CORD-19 (CORD-19, 2020), MOBS Lab, MIDAS, ELIXIR, COVID-19 Data Portal, or COVID-19 High-Performance Computing Consortium, can provide a variety of resources as well for scientific research [ 4 ]. In addition to sharing data and research tools, the rapid dissemination of research results played an important role in building an objective dialogue that helped to facilitate the process of generating new research directions [ 3 ].

Thus, researchers and academia have a key role to play in developing and promoting the highest level of healthcare [ 5 , 6 ]. The results of research in several fields contribute significantly to the identification and adoption of important solutions that help to achieve future objectives. Many of the organisations that provide healthcare services face the existence of quite serious problems that can be solved through research and innovation [ 5 ]. In other words, researchers are best placed to propose genuine innovative solutions that actively contribute to solving national and international problems [ 5 ]. Given this context, local and international authorities are free to implement research results and academic recommendations. They could provide a practical agenda that would strengthen the partnership with all stakeholders and help to accelerate the steps towards its fulfilment. On the other hand, the plurivalence of the research field is a way of understanding the fact that there is a non-linearity, and behaviours are the factors that determine the set rules [ 7 ]. They have developed through academic customs in the fields of exact sciences and humanities. The diversity and complexity of systems can be understood by identifying common traits and behavioural patterns that are based on distinct units [ 8 ]. In the areas related to health and healthcare, this diversity is provided by the multitude of involved categories (health professionals, health authorities, beneficiaries, non-governmental organisations) and the interactions between them [ 9 ]. This approach was initiated with the dissemination and publication of the results of studies and research debating the application of scientific plurivalence in the healthcare [ 10 , 11 , 12 ] or education [ 13 ] domains.

Global warming also presents a risk to the population through the rapid transmission of infectious diseases [ 11 ]. Conflicts in different geographical areas of the world have also led to the mass migration of refugees, with this category of people benefiting from minimal healthcare services [ 12 , 13 ]. Lack of well-being, cleanliness, access to medicines and healthcare services has increased the risk of spreading diseases to the most exposed categories of the population (children, women, and the elderly) [ 13 ]. The global onset of health challenges, in general, and healthcare imposed by spontaneous and unpredictable pandemics, conflicts, climate change, and the lack of economic growth have impacted welfare and the fulfilment of development goals.

Taking in consideration this context, the ability of research to understand and address some of the biggest challenges in healthcare delivery was observed. An edifying example is provided by [ 14 ], in which complexity theory is used to highlight and analyse how nurses in the United States make decisions. Another team of researchers [ 15 ] conducted a case study evaluating how decisions were made regarding the financing of hospitals in Kenya.

Therefore, in the specialised literature, there are indications according to which the study of the field of healthcare reaches a certain depth. They come as a complement to what is already known, and an examination of the influence and extent of this literature is even more beneficial. Bibliometric analysis offers an objective image of the publications from a certain area of the specialised literature. On the other hand, as specified above, bibliometric analyses cannot escape the intellectual properties contexts whereby researchers and policymakers (and funders) strive for innovative solutions in healthcare management and beyond.

Background and Objectives

Bibliometric analysis can be used to identify many papers from the recent literature that provide a general overview regarding different aspects of healthcare management. For example, some authors [ 16 ] have presented a view of healthcare-related research and the directions of future work to benefit patients and healthcare providers. Others [ 16 , 17 , 18 , 19 ] highlight dynamic trends in publications and have identified the most influential authors, institutions, countries, and research teams for a certain journal case. However, those studies are limited to broad directions on the development of healthcare. Another limitation they have is in regard to the definitions of the healthcare management field. Because some additional terms (for example, “sustainability” or “artificial intelligence”) were used to identify papers that treat aspects of healthcare management, there was a high risk of including sample documents on topics related to other fields, such as innovation, environment, or sociology. For this reason, we consider it necessary to have a clearer definition of healthcare management. In addition, a limitation of some papers that present a bibliometric analysis of healthcare management is the data source used [ 20 , 21 ]. An article search can be performed using other additional databases (for example, Scopus or Google Scholar), as suggested in another study [ 22 ].

Given these limitations, which we found by consulting the research literature, the aim of our paper is to perform a bibliometric analysis of the literature dealing with healthcare management by analysing the effect of different factors such that other researchers can then use the results in further studies. Moreover, another part of our goal is to identify aspects of healthcare management research that require further attention from researchers. This would serve to encourage future research in the areas of need, which would benefit this field of research.

In achieving this goal, we attempt to provide answers to the following questions:

• ▪ Is there variability between journals regarding the number of citations received by academic articles?
• ▪ Does the number of citations of an article vary depending on the journal in which it is published?
• ▪ Does the number of citations of an article vary depending on its topic?
• ▪ Are discrepancies in the citations of articles between areas due to dissimilarities in the level of developed research infrastructure?

Taking into consideration the proposed goal and the research questions, the following research objectives were established:

• O1: Analysis of the dynamics of scientific “production” related to healthcare management field.
• O2: Highlighting scientific progress as well as identifying the most prolific researchers, institutions, and countries in which research in this field is carried out [ 23 ].
• O3: The study of the influence of some factors upon which the citations of the articles dealing with this topic are dependent.

2. Materials and Methods

2.1. international literature search, 2.1.1. databases.

To identify articles dealing with the topic of healthcare management, international databases, such as JAMA Network, JSTOR, PMC, PubMed, SAGE, ScienceDirect, Springer, Taylor & Francis, and Clarivate, were consulted. This activity took place between January and May 2021. Our approach involved the use of keywords that relate to healthcare management. No limits have been imposed for identifying articles, research reports, reviews, or books. In addition, the number of citations was used in cases where it was necessary to identify papers of high scientific relevance. In total, by searching the nine international databases, 1594 articles were identified. They were downloaded into an Excel spreadsheet, and duplicates were then removed. After this stage, 943 articles remained, and their details were saved in another spreadsheet in Excel with the purpose being to examine them so that only those titles that met the requirements specified above are retained for analysis. For those 943 articles, the titles/abstracts were checked, and 651 of them were excluded on the basis that their content was strongly related to other fields. We wanted to ensure that we would only consider articles that are not related to other fields for analysis and that there were no other compelling reasons for exclusion. Thus, we obtained 292 articles for which another evaluation was conducted, and other reasons for exclusion were identified in the case of another 42 articles ( Table 1 ).

Other reasons for excluding articles from the analysis.

After this stage, 250 articles were retained and subjected to analysis, although another 1344 had already been excluded in earlier stages because they did not meet the inclusion criteria during verification.

Of the 250 articles considered eligible for analysis, the full text in English was accessed for 223 articles, thus making it possible to achieve a more detailed and clear classification of the content. In the case of an additional 20 articles that were included in the bibliometric analysis and were published in journals in English, their text was only partially accessible, and in the case of the final 7 articles, the text was not available in English. Figure 1 presents a summary of the details concerning the search strategy.

Research strategy applied for the selection of articles included in analysis.

2.1.2. Keywords

To identify the most appropriate keywords to use in identifying articles dealing with healthcare management topic, it was necessary to first define this concept. Thus, in some sources [ 24 ], healthcare management is defined as “the profession that provide leadership and direction to organizations that deliver personal health services, and to divisions, departments, units, or services within those organisations”. Based on this definition, we can consider that healthcare management involves the planning and coordination of nonclinical activities within healthcare systems, organisations, and networks.

Database searching was conducted using “healthcare management” OR “healthcare hospital” OR “health system” OR “primary care” OR “clinical management” OR “acute care” OR “healthcare practice” OR “medical practice” OR “healthcare networks” OR “nursing management”. Those keywords must occur in the article’s title.

References identified using these keywords were managed using EndNote. Thus, duplicates were much more easily found and then removed from our list. All references that met our criteria were retained for analysis. In the next step, all data were exported to an Excel spreadsheet in which variables represent each of the researched aspects were created. For example, to quantify the number of authors of an article, the variable “Author” was created. To include an article in a certain category that designates the research area, the variable “Topic” was created. To identify the journal in which the article was published, the variable “Journal” was created, or to see the country from which most articles came, the variable “Country” was created. After the database was created, the statistical program R was used to obtain the results.

2.1.3. Criteria Used to Include Articles in the Analysis

The analysis will include articles published in academic journals with impact factors indexed in international databases and referring to healthcare management. It was also intended that these articles include results obtained not only by specialists who provide medical assistance (nurses, doctors) or specialised websites of institutions (such as hospitals, retirement homes) but also people specialised in other fields related to health (for example, education, ethics, policies, research).

Articles that, through their published results, promote aspects of reference to healthcare management, in general, were initially included in our archive. Following this action, some were removed because it was later found that they did not refer to healthcare and care platforms, the profession, or issues related to the provision of medical care services. Those articles referring to interventions or health promotion issues carried out at the population level were not included.

Editorial works, books, chapters, and articles published in volumes of certain correlations were also excluded because it was considered that the information regarding them was either not available or incomplete. This includes articles that, although initially not published in English, have a summary in English based on which it can be verified that they meet our criteria.

2.2. Bibliometric Analysis

2.2.1. searching bibliometric data.

The bibliometric data (year of publication, number of authors, the journal in which it was published, the country of residence of the main author) of each article were recorded from the text of the paper, from the journal that published the article, or from the database in which the journal was indexed. In some cases, it was found that the full text was not available, was inaccessible to the public in its entirety, or was not written in English.

2.2.2. Articles Content Evaluation

At this stage, the articles were grouped together, considering their content, the type, and the topic. This involved classifying articles as empirical or non-empirical. The articles that, through the published results, refer to a certain conceptual framework, methods of data analysis, or ways of interpreting some results were considered empirical. Included in the category of non-empirical works were case studies, reviews, editorials, and debates on conceptual criteria.

Another important aspect refers to the analysis of the content of the registered articles. Thus, a code was assigned to each article and comparisons were conducted, and changes were then made to the codes to identify the most frequently encountered research topics. These details were identified from the title of the articles or their abstract. These were also identified for articles in which the summary did not provide sufficient detail. In those cases, the full verification of the article content was carried out where the text was available in English.

2.2.3. Determination of Articles Influence

To determine the influence that an article has in the literature of the healthcare management field, the number of citations received over time was considered. For this purpose, Google Scholar was consulted. In addition, the references of each article whose text could be accessed and viewed in full version were considered. An essential condition was that the reference should not be made by a publication evaluated by fellow authors, which allowed ensuring greater objectivity in terms of considering other types of academic results. It is also important to mention that no patients or other categories of the population were involved in this research.

2.3. Evaluation of Article Influence

It is known that the number of citations received by an article is associated with his scientific quality. The impact factor (IF), Hirsch index (H index), crown indicator, and other appropriate metrics that take the citation number into consideration were calculated. In addition, scientific search engines used for finding references (such as Google Scholar) show the list of results according to the number of citations [ 25 ]. For these reasons, the number of citations that a scientific paper in the field of healthcare management receives is an important element used to assess the impact of research. However, the number of citations of an article may be influenced by different factors. According to [ 26 , 27 , 28 ], the number of citations of an article is affected by factors such as their length, author number, number of institutions at which the authors are affiliated, number of words in the title, number of cited references, topic, or time since publication.

Articles length (the number of pages) could be a factor that can significantly affect the citations received. A large article can reflect a greater scientific complexity and a higher quality of used methodology; in addition, a lengthier article is expected to contain a greater amount of information, increasing the possibility that it can be appropriated to be cited by other researchers [ 29 ]. In other words, in articles with a larger number of pages compared to those with a smaller number, the research methodology and the obtained results could be presented and discussed more clearly and in detail. Therefore, their impact on citation number could be higher.

The number of authors attracts citation because it is considered that the higher number of authors of an article can determine more traffic for the paper, and so the chances of obtaining more citation are increased [ 30 , 31 ]. On the other hand, articles that cite more references and more publications referenced in different research platforms get a fairly large number of citations.

The number of institutions at which the authors of an article are affiliated is also important. Multiple affiliation is increasingly considered as stimulating knowledge exchange. An individual scientist may seek affiliations to obtain access to research resources, research infrastructure, or career opportunities. Co-authorship can be an efficient way of developing the competencies of a research group, and co-affiliation may be a way of forming stronger connections between researchers and institutions [ 32 ].

Articles title length is perceived as having an important role in the strategy of attracting audience and citations [ 33 ]. Longer titles contain more words and, therefore, more potential keywords, increasing the chances of an article being found easier. On the other hand, longer titles may be harder to digest and thus less attractive [ 34 ].

The number of references in healthcare management articles is another factor that can affect the citation. The reason may be related to the reason researchers from this field cite other’s work. From a theoretical perspective, a reference list of high quality is a comprehensive and well-balanced selection of papers, which can support the content presented in a certain article. Researchers usually reach this by performing a retrospective search and selection of papers with content that is pertinent to that of their article, to be read and cited. Well-chosen and mentioned bibliographic references can support the novelty, value, and visibility of an article. Citations can link a study to other studies, thus creating a network of knowledge that allows other researchers to identify studies that are relevant in general and relevant to them.

Commonly, articles published recently have a limited number of citations, an increase being seen after 3 or 5 years since publication [ 35 ]. Therefore, when analysing citation frequencies, the temporal dimension is important too.

Furthermore, the nationality of the authors is important. This can show that a specific research culture that is associated with a certain geographical area can influence the progress of research in a certain field and the number of citations received.

Giving this context, we want to consider those factors identified in the research literature and to verify if those results are also the same in our case. Therefore, one of our research objectives is to identify the factors associated with obtaining citations so that we can explain their effect and offer useful suggestions for increasing citations. To do this, the following variables will be considered for analysis: journal name, number of title words, number of authors, time since each article was published, the paper length (pages number), the number of references in each article, and the country of the affiliated institution of the first author. The characteristics of those variables are presented in Table 2 .

Studied variables and their characteristics.

Data Analysis Methods

A multilevel regression model was used to study the influence of factors, such as article author number, article topic, researcher affiliation, or the number of words in the title, on the number of citations of the considered articles. Multilevel models describe hierarchical structures referring to quantifications taken on the same unit at various moments, e.g., physical characteristics that are strongly correlated compared to previous assessments from different units. Multilevel models are used for the analysis of such dependency.

Multilevel modelling allows us to analyse the type of between-group variability and the outcomes of a group-level attribute on single outcomes. To offer an answer to our research questions, we opted for a two-level pattern with articles at level 1, nested with groups at level 2. Moreover, in a two-level model, residuals are divided into two parts, suitable for the two levels in the data frame. The random effects (group-level residuals) are noted by u i and the individual residuals group is noted by e ij . The two-level extensions that allow for group effects are given by

where β 0 is the gross average of Y (through all groups). The average of Y for group j is β 0 + u j . The residual u j is the difference between the average of group j and of the total. The individual-level residual e i j is the difference between the Y value for the i unit and that unit’s mean group e i j = Y i j − ( β 0 + u j ) . Residuals for both levels are assumed to be normally distributed with 0 means: u j ~ N ( 0 , σ u 2 ) and e i j ~ N ( 0 , σ e 2 ) . The simplest multilevel model with one explanatory variable is

In this model, the relationship between Y and X is expressed by a direct line with intercept β 0 and slope β 1 .

3.1. Results Regarding the Dynamic of Scientific Production Related to the Healthcare Management Field

The 250 articles included in the analysis come from 139 different journals in the field of healthcare management, and they have a varied impact. Table 3 presents the journals in which the most articles in this field were published.

The first 15 journals in which healthcare management articles have been published.

The results show that the journal in which the highest number of articles in the field of healthcare management was published is JAMA (n = 34), followed by Health System in Transition (n = 11) and Libyan Journal of Medicine (n = 7).

Regarding the affiliation of the main author, it was observed that the analysed articles are from 48 countries. The United States 47% (n = 117), the United Kingdom 6% (n = 16), Australia 0.5% (n = 13), and Canada 4% (n = 9) together accounted for 62% of the total items included in the analysis, as can be seen in Figure 2 . Other countries with a higher contribution are India, China, Iran, Italy, and Libya (all with six published articles. each with a contribution of 2%).

Distribution of published articles in the domain of healthcare management worldwide.

Although most of the articles have been published by authors who are affiliated with universities in only a few countries, the results show that there has been significant growth in recent years, especially in the early period of the pandemic ( Figure 3 ). This result can show an increasing speed regarding the dissemination of research findings, many journals prioritising the processing of articles involving COVID-19. Related to this aspect, an analysis of a limited number of journals showed that the number of days between an article submission and article publication during the pandemic was decreased by almost half compared to that before the pandemic.

The number of articles and number of citations according to year.

Before 2000, the only countries that published literature on healthcare management were the United States, the United Kingdom, or Germany; since 2015, the articles have come from 19 different countries. The published articles also come from authors affiliated with universities from Finland, Norway, the Netherlands, Denmark, Spain, Switzerland, Romania, China, the Philippines, Pakistan, and Nigeria.

3.2. Results Regarding Articles Topic

All articles included in the analysis could be classified with full and accessible text. Around 12.4% of them ( n = 31) treated the conceptual elements regarding healthcare management as well as elements of “literature review” ( Table 4 ).

Number articles and citations according to topic.

Around 44.5% of the articles deal with management systems in terms of healthcare and the encountered challenges and the quality of these services. Both topics are addressed mainly in works by researchers from the United States (n = 46), Canada (n = 7), Australia (n = 5), and the United Kingdom (n = 4).

The results of such studies were obtained by large groups of researchers, with the number of authors of the articles exceeding 10 (in the case of articles published by authors in the United States or Canada). This result shows that there are many researchers who also contributed to the article, and these results are often being obtained because of large research projects that require multidisciplinary teams.

Moreover, as the field of healthcare management develops, its magnitude is reflected in the number of authors who publish their scientific papers. Lately, more and more often, the research is based on the efforts of larger groups of researchers. There is also a disadvantage of having many authors since there have been cases in which the article cannot be reviewed because almost all the experts in a certain field were among its authors.

Another important aspect highlighted by the analysed articles is the fact that in the last 2 years, the number of articles that were published in the domain of healthcare management has greatly increased. Most of the articles published in these 2 years refer to healthcare management systems and their challenges, the quality of these services, or access to them.

This result is not accidental, as more and more countries are facing many problems caused by the COVID-19 pandemic. For decisions to be made about healthcare for individual patients and public health policies, the best confirmations available based on research are needed. This creates the framework for ensuring best practices and reducing variations in the provision of healthcare. For this reason, the large number of articles is justified, requiring the latest and most reliable information.

Going deeper into the content of the selected articles, it was possible to develop broader categories in terms of the addressed topic, with several topics being frequently prominent. These topics are listed in Table 3 and refer to “Characteristics of health systems in healthcare management”, “Impact of factors on healthcare management”, “Healthcare legislation”, or “Good management practices”.

Although health professionals have addressed various topics dealing with healthcare management since 1967, it was only in 2015 that articles began to focus on change, growth, and implementation, research, and policy.

3.3. Influential Articles and the Effect of Factors on Which the Citation of Analysed Articles Depend

The number of citations of an article in a certain period, regardless of the field, can show the importance and appreciation given to the results obtained by members of the medical, scientific community.

The number of citations of each article was used to highlight the influence of the analysed articles. In total, the average number of citations is 101, although the degree of asymmetry is high (median = 20.5, min. = 3, max. = 1752).

The most influential article in our database was published in Nursing Outlook, which was cited 1752 times. The article deals with the effect of exhaustion, the high degree of dissatisfaction with the workplace among nurses, and the organisational support they receive on the quality of healthcare. Another article with a high number of citations (1612) was published in JAMA. In this study, the authors aimed to identify issues related to the quality of healthcare in the United States, including measuring, evaluating, and improving it in healthcare facilities both in the public and private sectors.

Articles published in journals, such as Nursing Outlook, Journal of Service Research, Operations Research, Medical Care, The Lancet, or Environment and Behaviour, have a high number of citations. In addition, articles written by American, Greek, and Dutch authors recorded a high number of citations, while authors from countries such as Jamaica, Qatar, or Romania had a low number of citations.

The evolution over time of the distribution of the mean number of citations can be observed in Figure 3 . It can be easily seen that the articles that were most often cited are those published in the first half of the analysed period (between 1975–2013). This result may show that articles that have recorded more citations have a higher intensity of impact on the volume of knowledge. Furthermore, from Figure 3 , it can be observed that a high number of articles appeared in the early period of the pandemic. Comparing the number of published articles and the number of citations received, we can believe that research topics from the healthcare management field became more actual and diverse. Regarding this, some inherent risks can be identified. One of the highest risks can be the dissemination of poor-quality research and rapid scientific publication, the quantity of information and processing speed being at an impressive level in this period.

To evaluate the effects of some factors on article citation, a multilevel model was used. Initially, a multilevel model that allows for estimating the journal effects on citation number and with explanatory variables was used. The obtained results are presented in Table 5 .

The effect of different factors on article citations and a coefficient of random effects according to journal.

From Table 5 , article citation is strongly affected by the time since that article was published. This effect is statistically significant because the estimated coefficient is more than five times its standard error.

Another factor that has a high effect on article citations is the article topic. Our results show that, for topics such as “Impact of different factors on healthcare management” and “Challenges of healthcare management”, the obtained coefficients were higher than the standard error.

However, we have considered only the main effects of these variables, and the relationship between the number of article citations and the explanatory variables may depend on an interaction effect between some explanatory variables. We added those interactions to the model, with estimates presented in Table 6 . For the results presented in Table 6 , the estimated coefficients for the interaction between variables are higher than their standard errors. However, the addition of those interaction effects does little to explain the differences between journals: the journal-level variance has only increased from 10,643 to 10,752.

The effect of different factors on article citations with the interaction effect of explanatory variables and a coefficient for random effects according to journal.

To compare the two estimated models, the likelihood ratio test statistics were calculated ( Table 7 ).

Likelihood ration test statistics.

Signif. codes: 0 ‘***’ 0.001.

From the low Pr (>χ 2 ) value, we conclude that there is evidence that the second model (Model 2) can more adequately explain the data structure and the effect of interaction between variables, which differs across journals.

4. Limitations

The limitation of our study arises from the use of quantitative methods to review the papers published in the healthcare management field. The review relied on the analysis of bibliographic data associated with the documents rather than an examination of the research findings. Thus, the review’s implications are limited to the general directions of the studied field rather than the synthesis of article results. Thus, our results can be used as a starting point for future analyses aimed at the development of this field.

5. Discussions

In our study, we aimed to perform a bibliometric analysis of the research literature of articles that treated topics in the healthcare management field. We identified trends in the publication of analysed articles, with an evident global spreading of ideas and into specific topic themes. In addition, we found substantial evidence leading us to make the following statement: a responsible author will publish the results of high-quality research in a way that is easy to understand and attractive, guaranteeing that it will be widely read by several categories of audience and thus accumulating more citations.

Our study delivered additional types of results. Thus, from the results regarding article publication, we saw that the journals in which most of the analysed articles were published are JAMA, Health System in Transition, and Libyan Journal of Medicine.

Regarding the affiliation of the main author, we found that most of the analysed articles are written by researchers from the United States, United Kingdom, Australia, and Canada. This result shows that a high number of analysed articles were published by researchers from developed countries. Similar results were reported for studies in other branches of medicine, such as general medicine [ 36 ] and neurology [ 37 ]. Regarding the small number of articles published by authors from developing countries, it can be considered that both their quantity and quality may be affected by several barriers, such as poor funding, lack of facilities to support research activities, lack of government incentives, or inadequate support. These issues can contribute to maintaining a scientific environment and research conditions that do not meet the competitive standards of prestigious journals. Certainly, journals can publish research results that are of interest to their readers. However, where possible, journals could support the dissemination of healthcare research conducted in the developing world by setting up international advisory boards to help ensure a greater degree of diversity.

Another result of the study was that before 2000, the only countries that published articles on healthcare management were the United States, United Kingdom, or Germany, and since 2015, articles have come from 19 different countries. This result shows that researchers from different countries have started to be more active since 2000. One possible explanation is that international cooperation in healthcare research between different countries has varied significantly, with the interest in research being gradually spread across multiple aspects of this field. Moreover, after 2000, an increasing trend of scientific production on healthcare management topics can be observed. The geographical distribution of analysed articles reveals that in the last two decades, the research has spread in countries from continents, such as North America and Europe. This result is not surprising, taking into consideration that the developed countries in North America and Europe have a stronger academic research infrastructure in healthcare management than less developed nations since they have more research institutes, well-established data management systems, and more assets allocated for research. The number of authors who are affiliated with research institutions in regions such as Asia, South America, or Africa was lower, and the dissemination of the results of their inquiry manifested later (after 2000).

The interest shown in healthcare management research can, however, also be affected by the healthcare system model specific to each nation or region. Healthcare systems in developed nations (for example, Regional Health Systems (RHS) in Singapore, Managed Care in the United States, or National Health Services (NHS) in the United Kingdom) have implemented several systematised medical lines of action [ 38 , 39 , 40 ]. The requirement for high-quality healthcare services has elevated many inquiries about health systems. For example, about 10 years ago, China and India deployed health reformation, setting out a set of policies to integrate healthcare services to improve their quality [ 41 ]. The objectives of healthcare reformation have made research topics catchier, and research can be more substantially supported and for longer, including through data availability and funding. In addition, the ways for cooperation between academic institutions have also influenced local research productivity [ 42 , 43 ].

Given our results and the results of other studies [ 44 , 45 ], we consider that the degree of economic development of a country or region can influence the production of scientific articles, with our analysis reporting a high growth in scientific production in more developed countries. Regarding this result, we also found evidence of countries with a lower level of GDP per capita for which the scientific production is high ( Table 8 ). This can suggest that there is not a clear link between economic development and scientific production in this field. Instead, this may show an effort made by governments in those countries in terms of investments in healthcare or the interest manifested by their scientific community for this field.

Countries with the highest scientific production in our analysis in relation to GDP per capita and heath expenditure per capita.

Source: World Bank and OECD Health Statistics 2021, WHO Global Health Expenditure Database.

Further, these results suggest that there may be a dilemma between healthcare ethics and financial constraints. In the literature, many empirical studies describing health employees’ dilemmas and decision-making processes can be identified [ 46 , 47 , 48 , 49 ]. These studies have, however, focused on developed countries, with a limited number of studies presenting results for the case of low and middle-income countries. Furthermore, the available studies are small qualitative studies [ 50 , 51 , 52 , 53 , 54 , 55 ].

In our paper, we also aimed to analyse the relationship between the number of articles citations and several factors. Some of those factors were number of authors of an article and the country with which the principal author is affiliated. We assumed that we could identify a correlation between these factors and the number of citations, with a higher number of authors bringing more information as well as personal grid contacts or research infrastructure. Even if authors such as [ 56 , 57 ] reported such effects in their papers, our results showed that there is an effect of author number but not author affiliation. Statistically significant effects were identified regarding the time since an article was published, showing that the temporal dimension is important. Articles that were recently published have not yet been cited, and the number of citations grows with time. In other words, the older an article, the more likely it is to be cited more than once [ 58 ].

Another important factor that has a significant effect on the number of articles citations is the title length (number of words in the title). We found that this factor has a negative effect on article citations. Similar results were also found by other researchers [ 59 , 60 ], with their argument being that the shortest titles generate the most citations. However, this effect could depend on differences between fields or research topics. Regarding this, the authors of [ 61 ] showed that in medicine, shorter titles often have less citations. On the other hand, the authors of [ 62 ] argued that this relationship became inverted around the year 2000 from negative to positive. This situation is explained by the growing volume of online search engines (for example, Web of Knowledge was released in 2002, Scopus in 2004, and Clarivate in 2016). It seems that short titles perform better when the search is made manually, while longer titles produce more hits in online searches, ensuring a higher degree of discoverability and a higher number of citations.

Another important effect on article citations is due to the interaction between the number of pages in an article and the time since it was published. Considered alone, the variable representing the number of pages does not seem to influence the number of citations. Regarding those results, the authors of [ 63 , 64 , 65 , 66 , 67 , 68 ] showed that the pagination affects the number of article citations depending on the discipline. In general, in the field of medicine, longer articles have more content, and the readers have a greater opportunity to find and access important info, which is conducive to a higher number of citations.

6. Conclusions

This paper provides an overview of research tendencies, challenges in healthcare management research, and possible future research perspectives. Healthcare research has grown significantly since 2000. Our results show that there are regional disparities in scientific output that are related to some aspects of economic development, specificities of healthcare systems, and academic association models.

In the paper, we also evaluated the factors influencing the number of citations of the analysed articles published in journals from the healthcare management field. We assume that the significance of identified factors will be sensitive to the growth of other approaches regarding impact quantification.

Thus, our results are useful in providing evidence related to the researched issues. Moreover, they can be used before planning or deciding a strategy for researching various aspects related to healthcare management. Thus, the awareness of the existence of a solid fund of knowledge increases, and the existing gaps can be identified, or some conceptual and methodological inconveniences can be avoided. On the other hand, exploring these data sources can help pave the way for future knowledge management (including science policy), as well as social policy decisions. In addition, our analysis is helpful in identifying unsatisfied challenges in the studied field that can trigger new ideas for further research.

Acknowledgments

This research is part of the doctoral research project “Healthcare management in hospitals from the North-East Region of Romania”, endorsed by the Research Ethics Commission (Registration No. 128/24.11.2021) from Grigore T. Popa University of Medicine and Pharmacy, Iași, Romania.

Author Contributions

For this article, the following describes the contribution of each author: conceptualisation, O.P., E.M.C. and C.Ș.P.; methodology, A.M.; validation, E.M.C., O.P. and C.Ș.P.; formal analysis, A.M.; investigation, A.M.; resources, A.M.; data curation, A.M.; writing—original draft, A.M.; writing—review and editing, O.P. and C.Ș.P.; supervision, E.M.C. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

EDITORIAL article

This article is part of the research topic.

Positive Psychology in Health Management

Editorial: Positive Psychology and Health Management

• 1 School of Nursing, Fudan University, China
• 2 School of Nursing, Southern Medical University, China
• 3 School of Nursing and Rehabilitation, Shandong University, China
• 4 University of Minnesota Twin Cities, United States
• 5 School of Nursing, Qingdao University, China

The final, formatted version of the article will be published soon.

Health management is a broad topic encompassing various aspects of health-related issues, involving policy-making, legal regulation, workforce management, healthcare quality and specific disease management. There has been a noticeable increase in research applying positive psychology to health management [2]. The growing body of theoretical and empirical studies demonstrates that positive psychological theories have positive effects on the patients' physical and mental health, quality of life, as well as on healthcare workers' job satisfaction, burnout, and quality of work life [2][3][4]. Over the past decade, disease management and health workforce management have emerged as two major subjects extensively investigated in the context of positive psychology [5]. By integrating positive psychology and health management together, this is field seeks to foster cutting-edge ideas and research to explore multidisciplinary approaches of positive psychology in disease management and health workforce management. This call for submissions on Positive psychology and health psychology has received an excellent response. The collection comprises 16 studies involving over 10 thousands participants, which have garnered a total of 26,525 total views and 7,102 downloads worldwide until drafting this editorial. The studies encompass a diverse range of populations, including patients with conditions such as breast caner (Ma et al. 5) Finally, the findings contribute to the development of culturally sensitive and contextually innovative theories and instruments . Notably, they aid in the conceptualizing of mental wellness among adolescents living with HIV (Orth and Wyk, 2023). These findings hold significant potential for advancing future theoretical and empirical studies in this field.However, several limitations should be emphasized here. First, a majority of the articles employed an observational cross-sectional design, primarily focusing on examining mediation or moderation effects. Consequently, the full potential of positive constructs in enhancing long-term adaptation outcomes under stress remains incompletely elucidated [6]. Secondly, one of our aims was to discern distinct adaptation trajectories under stress, where positive psychological resources could exert an effect. Regrettably, this goal was realized in the current collection. Third, there is a notable scarcity of articles dedicated to theory and instrument development. Future research endeavors should be directed towards formulating novel theories and instruments to delve deeper into the construct within positive psychology [7]. Fourthly, the examination of the efficacy, sustainability and implementation challenges of complex intervention programs targeting various health-related stressful population should be the nextstride in advancing our understanding [3,8].

Keywords: POSITIVE PSYCHOLOG, Health management, resilience, Workforce, intervention

Received: 06 Nov 2023; Accepted: 13 Nov 2023.

Copyright: © 2023 Wang, Huang, Guo, Lei and Song. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Anni Wang, School of Nursing, Fudan University, Shanghai, China

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‘I’d Love to See BU Become a National Leader in College-in-Prison Programming and Collegiate Recovery’

What’s Next for Health Law, Policy & Management?

What’s Next for Health Law, Policy & Management ?

What’s next for health law, policy & management, in the second segment of our “what’s next for health” series, michael stein, chair and professor of health law, policy & management, discusses several emerging directions for the fields encompassed within that department., michael stein, md.

On the multiple disciplines represented by health law, policy & management

As you can see from the name of our department , our work involves three fields: we are heterogeneous. So what is changing across law, policy, and management, our three overlapping disciplines?

1. The ever-increasing influence of politics in the workings of public health. Departments encompassing these fields should study national affairs, state laws, and the inequities that too often limit large swathes of our population.

2. Growing distrust not only in government public health agencies, but also in private markets. Combatting health misinformation is an urgent matter for all. Health services research increasingly deals with the absence of price transparency, market distortions, and a declining quality of care.

3. COVID-19 and overlapping crises . COVID-19 and the social upheavals of the past three years have highlighted new topics that are important to analyze and critique: telemedicine, lack of abortion access, and the seemingly unstoppable epidemic of opioids.

4. Climate change. Looming over all, climate change and its effect on health and healthcare necessitates that we uncover new data that can drive policy in this area.

Areas of innovation

Those of us working across health law, policy, and management must commit to leading the public conversation about the most pressing health and social policy concerns of the day.  At BUSPH, HLPM has national prominence in five arenas: Medicaid policy, health economics, social policy, substance use, and health law.

• Our Medicaid Policy Lab —led by Professors Cole, Gordon and Shafer—is one-of-a-kind. The unit evaluates the impacts of policy changes and innovative care delivery models on health insurance coverage, access to care, quality of care, and health outcomes using a health equity lens. 
• The  Partner Evidence-based Policy Resource Center  (PEPReC) for the Veterans Hospital Administration—led by Professors Frakt, Garrido, and Pizer—uses the discipline of economics to evaluate studies about access to and quality of care for veterans. The unit serves as a home base for many of our doctoral students.
• The  Healthy Minds Study , the largest, most comprehensive study of mental health, health behaviors, and health service use on U.S. college campuses, is led by Professor Lipson.
• The historic $345 million four-state  Healing Communities Study , which addresses opioid overdose deaths in Massachusetts and beyond working with 67 communities is driven by HLPM faculty—Professors Stein, Morgan, and Rosenbloom– who are among the lead investigators.
• Our Center for Health Law, Ethics and Human Rights faculty—Professors Annas, Huberfeld, McCuskey and Ulrich, lawyers all–have been leaders in public health law in the areas of human rights, informed consent, insurance, the Second Amendment and gun violence, reproductive justice, mental health,  and contagious disease control. Their work is practical: explaining the divide between constitutional theory and the real-world health implications of courts’ decisions.

Impact beyond academic papers

Public health schools must ensure that there are diverse scholars and voices focused on diverse topics. Minoritized communities must be engaged in the research that impacts them, the policy solutions that affect them.

We also need to measure our impact beyond academic papers. We believe that there are three forms of extramural activities that are central to our mission and the work of HLPM faculty:  activities through their disciplines, activities through public media, and activities of assisting government agencies when asked.

First, faculty are engaging with their relevant disciplines, seeking out leadership positions in their professional organizations and through direct involvement in state and national policy work. This helps keep faculty at the cutting edge of what is new for their field while also promoting the BUSPH.

Public health needs to be held in high regard, built on a foundation of trust within the communities in which we work. Michael Stein

Second, we encourage faculty to engage with the media, and we provide training and resources to support this activity.  By engaging, we can help fulfill the “Do” of BUSPH’s purpose, “Think. Teach. Do. For the health of all” by helping journalists inform the public about important health policy issues.

Third, we believe that faculty should engage in extramural service by helping local, state and federal governments when called upon. We have a responsibility to enhance collaboration with public health organizations and healthcare systems near us to inform and implement the findings from our research. Those of us working in urban academic centers are almost always located near our state governments and/or a large hospital system—we must interact with them more, and find areas for collaboration. Recently, BUSPH hosted a day-long briefing for Massachusetts elected officials to answer their public health questions, and suggest levers to pull for the health of all their residents.

On optimism

I am optimistic about the work that is being conducted across the fields of health law, policy and management:

• Our research is helping to explain the causes of inequities in health and healthcare, and providing recommendations for interventions, laws and policies to reduce them.
• Our teaching is preparing public health professionals, researchers, and activists to advance social justice and health.
• Our advocacy is contributing to efforts to improve health and healthcare locally, nationally and around the world.

We will keep pushing in all of these aspects of our work. Public health needs to be held in high regard, built on a foundation of trust within the communities in which we work. This is essential if we are to continue attracting talented students, the future public health leaders we need.

It is a privilege to welcome new students each year, who provide a continuous social transformation. The next generation moves us toward equity—through the slow accretion of structural level change, reaching new communities, and using the new communication modes the next generation always invents. It is incumbent on us to embrace and evolve with them.

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Michael Stein, MD is professor and chair of health law, policy, and management. Recognized among the top one percent of NIH grant recipients over the past two decades, Dr. Stein works at the intersection of behavioral medicine and primary care. Profile

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Ai ethics essentials: lawsuit over ai denial of healthcare.

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AI ethics or AI Law concept. Developing AI codes of ethics. Compliance, regulation, standard , ... [+] business policy and responsibility for guarding against unintended bias in machine learning algorithms.

UnitedHealthcare, the largest health insurance provider in the US, is currently embroiled in a class-action lawsuit alleging the wrongful denial of extended care claims for elderly patients through the use of an artificial intelligence (AI) algorithm called nH Predict.

The lawsuit, filed in the US District Court for the District of Minnesota, accuses UnitedHealthcare of utilizing the nH Predict algorithm to make health-care determinations, leading to the premature and bad-faith discontinuation of payment for healthcare services. The plaintiffs, representing the estates of deceased individuals covered by Medicare Advantage plans provided by UnitedHealthcare, claim that they were forced to pay out of pocket for medically necessary care due to claim denials by the insurer. This suit potentially involve thousands of individuals and billions of dollars of damages, according to a lawyer for the plaintiffs.

The lawsuit alleges that the nH Predict algorithm, developed by NaviHealth, a company acquired by UnitedHealth in 2020, systematically denied elderly patients' claims for extended care, including stays in skilled nursing facilities and in-home care. It is claimed that when these denials are appealed to federal administrative law judges, approximately 90% are reversed, highlighting the alleged inaccuracy of the algorithm. The plaintiffs also argue that UnitedHealth's use of the technology is illegal and violates contracts with patients and insurance laws in various states.

The Future of Responsible AI

The recent presidential executive order on AI could potentially have implications for cases such as this in the future. The order emphasizes the need for transparency and accountability in AI systems, particularly in sectors such as healthcare, where the decisions made by AI algorithms can have significant life-and-death impacts. By promoting the responsible use of AI and ensuring that AI systems are designed and deployed in a manner that upholds fairness and prevents discrimination, the executive order aims to mitigate situations where AI algorithms are wrongfully denying essential care to vulnerable populations, such as the elderly.

The allegations against UnitedHealthcare underscore the importance of ethical and responsible AI implementation, particularly in the healthcare industry. As AI continues to play an increasingly prominent role in decision-making, it is crucial for organizations to prioritize the ethical considerations surrounding AI utilization. This includes ensuring that AI algorithms are accurate, transparent, and aligned with the best interests of patients, especially when it comes to critical decisions regarding healthcare coverage and treatment.

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"In AI regulation, there's a fine line between effective oversight and misconceptions of the technology," says Ryan Elmore, AI Innovation Fellow with West Monroe. "Even well-intentioned governance can be hampered by a lack of technical knowledge and conflicting financial interests."

The Role of Data Management and Governance in AI Decision-Making

In the context of this lawsuit, attention to data management and governance practices is of paramount importance. Data governance defines how an organization manages its data assets and ensures the availability, integrity, security, and usability of an organization’s structured and unstructured data assets. Organizations that mismanage their data as an actual asset are poised to misuse those assets.

Here's why it is crucial in this context:

• Patient Safety and Privacy: Data governance in healthcare is crucial for ensuring patient safety and privacy by maintaining the accuracy and security of patient data. In the case of AI-driven decision-making in healthcare, accurate and secure patient data is essential to ensure that AI algorithms make informed and ethical decisions regarding patient care.
• Data Integrity and Usability: By establishing standards and policies for data management, organizations can ensure the integrity and security of their data, while also maintaining compliance with regulatory requirements. This is particularly important when AI algorithms are used to make critical decisions about patient care, as the accuracy and integrity of the data used by these algorithms directly impact the outcomes for patients.
• Transparency and Accountability: Data governance provides a framework for managing data throughout its lifecycle, including how data is collected, stored, processed, analyzed, and shared. This level of transparency and accountability is essential when AI algorithms are involved in healthcare decision-making, as it ensures that the decisions made by these algorithms are based on accurate and reliable data.
• Shared Responsibility and Collaboration: Data governance creates a shared responsibility for staff members by actively engaging them in creating policies, best practices, procedures, and work products that improve the quality of patient demographic data. In the context of AI-driven decision-making, this shared responsibility ensures that the data used by AI algorithms is of high quality and reflects the collective expertise and collaboration of healthcare professionals.
• Informed Decision-Making: Governance ensures that the right people can use data at the right time for the right reasons, supporting decision-making and ensuring that the organization successfully realizes its desired outcomes and receives business value from data management activities. This is particularly relevant when AI algorithms are utilized in healthcare, as informed decision-making is crucial to ensure the well-being of patients.

Ethics as an Enterprise Priority

The lawsuit against UnitedHealthcare serves as a stark reminder of the potential consequences of AI misuse (whether intentional or unintentional) in the healthcare sector. The recent executive order on AI underscores the need for ethical and accountable AI practices, particularly in critical areas such as healthcare, to prevent situations where AI algorithms may wrongfully deny essential care to vulnerable populations. Regardless, it is imperative for healthcare organizations to prioritize the ethical deployment of AI, reduce bias in the algorithms and data, and uphold high standards of transparency and fairness in all manner of automated decision-making processes.

“This is one more emerging concern to add to the growing list of emerging existential business challenges for data and analytics leaders,” says Keyur Desai, a healthcare industry data executive. “However, with strong relationships and collaboration among data-, technology-, and business executives, it is certainly not insurmountable. Human advancement has never paused for us to play ethical catch-up, nor should we expect it to do so.”

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End of life: providing physical comfort, end of life: managing mental and emotional needs, spiritual needs at the end of life, providing support for practical tasks.

Not all end-of-life experiences are alike. Death can come suddenly, or a person may linger in a near-death state for days. For some older adults at the end of life, the body weakens while the mind stays clear. Others remain physically strong while cognitive function declines. It's common to wonder what happens when someone is dying. You may want to know how to provide comfort, what to say, or what to do.

In this article, you will read about ways to help provide care and comfort to someone who is dying. Such care often involves a team: Always remember to check with the person’s health care team to make sure these suggestions are appropriate for the situation.

End-of-life care is the term used to describe the support and medical care given during the time surrounding death. This type of care does not happen only in the moments before breathing ceases and the heart stops beating. Older people often live with one or more chronic illness and need significant care for days, weeks, and even months before death.

The end of life may look different depending on the person’s preferences, needs, or choices. Some people may want to be at home when they die, while others may prefer to seek treatment in a hospital or facility until the very end. Many want to be surrounded by family and friends, but it’s common for some to slip away while their loved ones aren’t in the room. When possible, there are steps you can take to increase the likelihood of a peaceful death for your loved one, follow their end-of-life wishes, and treat them with respect while they are dying.

Generally speaking, people who are dying need care in four areas: physical comfort , mental and emotional needs , spiritual needs , and practical tasks . Of course, the family of the dying person needs support as well, with practical tasks and emotional distress.

Discomfort during the dying process can come from a variety of sources. Depending on the cause of the discomfort, there are things you or a health care provider can do to help make the dying person more comfortable. For example, the person may be uncomfortable because of:

• Breathing problems
• Skin irritation, including itching
• Digestive problems
• Temperature sensitivity

Pain. Not everyone who is dying experiences pain. For those who do, experts believe that care should focus on relieving pain without worrying about possible long-term problems of drug dependence or abuse.

Struggling with severe pain can be draining and make the dying person understandably angry or short-tempered. This can make it even harder for families and other loved ones to communicate with the person in a meaningful way.

Caregivers and other family members can play significant roles in managing a dying person’s pain. But knowing how much pain someone is in can be difficult. Watch for clues, such as trouble sleeping, showing increased agitation, or crying. Don’t be afraid of giving as much pain medicine as is prescribed by the doctor.

Pain is easier to prevent than to relieve, and severe pain is hard to manage. Try to make sure that the level of pain does not get ahead of pain-relieving medicines. Tell the health care professionals if the pain is not controlled because medicines can be increased or changed. Palliative medical specialists are experienced in pain management for seriously ill patients; consider consulting with one if they’re not already involved (see What Are Palliative Care and Hospice Care? ).

Breathing problems. Shortness of breath or the feeling that breathing is difficult is a common experience at the end of life. The doctor might call this dyspnea. To help ease breathing for your loved one, try raising the head of the bed, opening a window, using a humidifier, or using a fan to circulate air in the room. Sometimes, morphine or other pain medications can help relieve the sense of breathlessness.

There may be times when a dying person has an abnormal breathing pattern, known as Cheyne-Stokes breathing. The person’s breathing may alternate between deep, heavy breaths and shallow or even no breaths. Some people very near death might have noisy breathing, sometimes called a death rattle. In most cases, this noisy breathing does not upset the dying person, though it may be alarming to family and friends. You may try turning the person to rest on one side or elevating their head. Prescription medicine may also help.

Skin irritation. Skin problems can be very uncomfortable for someone when they are dying. Keep the person’s skin clean and moisturized. Gently apply alcohol-free lotion to relieve itching and dryness.

Dryness on parts of the face, such as the lips and eyes, can be a common cause of discomfort near death. These tips may help:

• Apply a balm or petroleum jelly to the lips.
• Gently dab an eye cream or gel around the eyes.
• Try placing a damp cloth over the person’s closed eyes.
• If the inside of the mouth seems dry, giving ice chips (if the person is conscious) or wiping the inside of the person’s mouth with a damp cloth, cotton ball, or specially treated swab might help.

Sitting or lying in one position can put constant pressure on sensitive skin, which can lead to painful bed sores (sometimes called pressure ulcers). When a bed sore first forms, the skin gets discolored or darker. Watch carefully for these discolored spots, especially on the heels, hips, lower back, and back of the head.

Turning the person in bed every few hours may help prevent bed sores and stiffness. Try putting a foam pad under the person’s heel or elbow to raise it off the bed and reduce pressure. Ask a member of your health care team if a special mattress or chair cushion might also help.

Digestive problems. Nausea, vomiting, constipation , and loss of appetite are common issues at the end of life. Swallowing may also be a problem. The causes and treatments for these symptoms vary, so talk to a doctor or nurse about what you’re seeing. Medicines can control nausea or vomiting or relieve constipation, all of which are common side effects of strong pain medications.

If the person loses their appetite, try gently offering favorite foods in small amounts. Serve frequent, smaller meals rather than three larger ones. Help with feeding if the person wants to eat but is too tired or weak.

But don’t force a dying person to eat. Losing one’s appetite is a common and normal part of dying. Going without food and/or water is generally not painful, and eating and drinking can add to a dying person’s discomfort. A conscious decision to give up food can be part of a person’s acceptance that death is near.

Temperature sensitivity. When a person is closer to death, their hands, arms, feet, or legs may be cool to the touch. Some parts of the body may become darker or blueish. People who are dying may not be able to tell you that they are too hot or too cold, so watch for clues. For example, someone who is too warm might repeatedly try to remove a blanket. You can remove the blanket and place a cool cloth on the person’s head.

Hunching their shoulders, pulling the covers up, and shivering can be signs the person is cold. Make sure there is no draft, raise the heat, and add another blanket. Avoid electric blankets because they can get too hot.

Fatigue. It is common for people nearing the end of life to feel tired and have little or no energy. Keep things simple. For example, a bedside commode can be used instead of walking to the bathroom. Providing a stool so the person can sit in the shower, or sponge baths in bed can also help.

End-of-life care can also include helping the dying person manage mental and emotional distress. Someone who is alert near the end of life might understandably feel depressed or anxious. It is important to treat emotional pain and suffering. You might want to contact a counselor, possibly one familiar with end-of-life issues, to encourage conversations about feelings. Medicine may help if the depression or anxiety is severe.

The dying person may also have some specific fears and concerns. He or she may fear the unknown, or worry about those left behind. Some people are afraid of being alone at the very end. These feelings can be made worse by the reactions of family, friends, and even the medical team. For example, family and friends may not know how to help or what to say, so they stop visiting, or they may withdraw because they are already grieving. Doctors may feel helpless and avoid dying patients because they cannot help them further.

And some people may experience mental confusion and may have strange or unusual behavior, making it harder to connect with their loved ones. This can add to a dying person's sense of isolation.

Here are a few tips that may help manage mental and emotional needs:

• Provide physical contact . Try holding hands or a gentle massage.
• Set a comforting mood . Some people prefer quiet moments with less people. Use soft lighting in the room.
• Play music at a low volume . This can help with relaxation and lessen pain.
• Involve the dying person . If the person can still communicate, ask them what they need.
• Be present . Visit with the person. Talk or read to them, even if they can’t talk back. If they can talk, listen attentively to what they have to say without worrying about what you will say next. Your presence can be the greatest gift you can give to a dying person.

For people nearing the end of life, spiritual needs may be as important as their physical concerns. Spiritual needs may include finding meaning in one's life, ending disagreements with others, or making peace with life circumstances. The dying person might find comfort in resolving unsettled issues with friends or family. Visits from a social worker or a counselor may help.

Many people find solace in their faith. Others may struggle with their faith or spiritual beliefs. Praying, reading religious texts, or listening to religious music may help. The person can also talk with someone from their religious community, such as a minister, priest, rabbi, or imam.

Family and friends can talk to the dying person about the importance of their relationship. For example, adult children may share how their father has influenced the course of their lives. Grandchildren can let their grandfather know how much he has meant to them. Friends can share how they value years of support and companionship. Family and friends who can't be present in person can send a video or audio recording of what they would like to say, or a letter to be read out loud.

Sharing memories of good times is another way some people find peace near death. This can be comforting for everyone. Some doctors think that dying people can still hear even if they are not conscious. Always talk to, not about, the person who is dying. When you come into the room, identify yourself to the person. You may want to ask someone to write down some of the things said at this time — both by and to the person who is dying. In time, these words might serve as a source of comfort to family and friends.

There may come a time when a dying person who has been confused suddenly seems to be thinking clearly. Take advantage of these moments but understand that they are likely temporary and not necessarily a sign of getting better. Sometimes, a dying person may appear to see or talk to someone who is not there. Resist temptation to interrupt or correct them, or say they are imagining things. Give the dying person the space to experience their own reality. Sometimes dying people will report having dreams of meeting deceased relatives, friends, or religious figures. The dying person may have various reactions to such dreams, but often, they are quite comforting to them.

Many practical jobs need to be done at the end of life — both to relieve the person who is dying and to support the caregiver . A person who is dying might be worried about who will take care of things when they are gone. A family member or friend can offer reassurance — "I'll make sure your African violets are watered," "Jessica has promised to take care of Bandit," "Dad, we want Mom to live with us from now on" — which may help provide a measure of peace. You also may remind the dying person that their personal affairs are in good hands.

Everyday tasks can also be a source of worry for someone who is dying and can overwhelm a caregiver. A family member or friend can provide the caregiver with a much-needed break by helping with small daily chores around the house such as picking up the mail, writing down phone messages, doing a load of laundry, feeding the family pet, or picking up medicine from the pharmacy.

Caregivers may also feel overwhelmed keeping close friends and family informed. A family member or friend can help set up an outgoing voicemail message, a blog, an email list, a private Facebook page, or even a phone tree to help reduce the number of calls the caregiver must make. Listed at the end of this article are some organizations that make setting up such resources easy and secure.

Providing comfort and care for someone at the end of life can be physically and emotionally exhausting. If you are a primary caregiver, ask for help when you need it and accept help when it's offered. Don't hesitate to suggest a specific task to someone who offers to help. Friends and family are usually eager to do something for you and the person who is dying, but they may not know what to do.

In the end, consider that there may be no “perfect” death so just do the best you can for your loved one. The deep pain of losing someone close to you may be softened a little by knowing that, when you were needed, you did what you could.

You may also be interested in

• Learning what steps to take after someone dies
• Reading about making decisions for someone at the end of life
• Exploring different care settings at the end of life

Sign up for caregiving tips from NIA

For more information about comfort care.

National Institute of Nursing Research 301-496-0207 [email protected] www.ninr.nih.gov/end-of-life

American Music Therapy Association 301-589-3300 [email protected] www.musictherapy.org

CaringBridge 651-789-2300 [email protected] www.caringbridge.org

CaringInfo National Hospice and Palliative Care Organization 800-658-8898 [email protected] www.caringinfo.org

Hospice and Palliative Nurses Association 412-787-9301 [email protected] https://advancingexpertcare.org

National Alliance for Caregiving 301-718-8444 [email protected] www.caregiving.org

What Matters Now 877-365-5533 [email protected] www.whatmattersnow.org

This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.

Content reviewed: November 17, 2022

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An official website of the National Institutes of Health

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• The “Élektrostal’” Metallurgical Plant: Past and Present
• Published: September 2007

Advancement of the process of production of rolled stock from steel R6M5 at the “Élektrostal’” Metallurgical Plant JSC

• I. V. Kabanov 1 ,
• M. V. Girusova 1 &
• A. A. Gorbushkin 1  

Metal Science and Heat Treatment volume  49 ,  pages 465–470 ( 2007 ) Cite this article

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Results of advancement of the process of production of rolled stock from steel R6M5 are considered. The effect of various process factors on the quality parameters of the steel is discussed. An analysis of actual data and of industrial experiments is presented.

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A. P. Gulyaev, High-Speed Steels with Low Additives of Tungsten and Molybdenum [in Russian], GNTI Mashinostr. Literatury, Leningrad (1941).

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M. Ya. Dzugutov, Plastic Deformation of High-Alloy Steels and Alloys [in Russian], Metallurgiya, Moscow (1971).

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Kabanov, I.V., Girusova, M.V. & Gorbushkin, A.A. Advancement of the process of production of rolled stock from steel R6M5 at the “Élektrostal’” Metallurgical Plant JSC. Met Sci Heat Treat 49 , 465–470 (2007). https://doi.org/10.1007/s11041-007-0087-5

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