Nursing is often pictured as the heart of health care. But being a nurse requires much more. Effective executive skills require efficient decision making and ability to cope situation which can only be achieved through professional. Thus, in this paper I will discuss strategies that allow nurses to be more effective clinical executive and decision makers.
Being an executive has a major collision on the knowledge and competencies of the nurse clinician. Nurse executive practice has been forced to make severe accommodations within this larger societal context as knowledge has continued to increase and attitudes and values have shifted. Nurse executive practice has expanded and extended in both horizontal and vertical directions. This expansion has been too great and that professional growth comes by limiting functions rather than by extending them; they believe that the focus of concentration should be on the functions that are of a professional nature and integral to nursing. Nursing has gone too far and that it has begun to encroach on the medical domain. On the other hand the expanded roles in nursing fulfill a vital need and provide health care services where either none exist or services are limited. In addition, the assumption of additional functions by nurses is viewed as necessary so that the best possible care is rendered. Whatever the case, the changing environment has called for an education to keep pace with the modern world. Yet the struggle for the inclusion of educational programs for nursing in institutions of higher learning still continues at a time when education is needed more than ever to develop individuals who can deal with the problems of adjustment in modern life.
Post grad nurses are well geared up to convene the demands placed on today’s nurse. These nurses are valued for their skills in critical thinking, management, case management, and for their capability to practice across a range of inpatient and outpatient settings.
Moreover, Critical care nursing cannot be understood in isolation from nursing as a professional discipline. While geographical and specialization designations such as the emergency room, the coronary care unit, the Mobile Army Surgical Hospital (MASH) unit, or the intensive care unit may imply critical care, the distinctiveness of critical care nursing awaits description. In fact, critical care nursing represents a concentration of nursing practice as a whole or reflects something innovative and different. Further, the impact of specialization and the rapid influx of technological change on nursing practice have gained the attention of few researchers.
Advanced patient assessment skills held by post grad RN’s particularly those who hold a grad dip in critical care, allow the nurse to improve patient outcomes because the grad dip gives nurses the ability to interpret and act on physiological abnormalities which is a fundamental factor in adverse event prediction and prevention. (Considine, 2004)
Post grad education not only provides nurses with the skill of using latest technology but also educate them to make efficient decision at right time. In the intensive care unit the nurse collects and monitors vast amounts of detailed data. This monitoring is continuous and occurs in rapidly changing situations. These judgments require anticipation of subtle changes and decision making, interpretations, intervention, and evaluation in complex situations. The outcomes of these decisions may have life and death potential for patients. The decision making may occur in units that are inadequately staffed, organized, and managed and have little or no competent medical back-up. Further, the invasive and life-extending procedures that patients may experience may be perceived as dehumanizing by the nurse if they do not have the required proficiency to operate those technologies or to have ability to priorities care that can have serious consequences for patients.
According to Charles Hendry (2004), “skill deficits such as ability to priorities care can have serious consequences for patients, this can be defined as ordering of patient problems using notions of urgency/importance, this is a skill that is difficult for newly qualified nurses to acquire and may not have been addressed sufficiently in their under grad education (Priority setting in clinical nursing practice)”.
Moreover, the best strategies for success in nurse executives are to enhance health care through scientific inquiry, through collaboration with other health professionals, and through client advocacy in the health care system. The School of Nursing programs use a multi-theoretical approach to execute these concepts. Examples of theories used include nursing theories, stress/adaptation theory, physiological theories, and systems theory.
Nursing worldwide has been so confined and controlled by external material, physical reality, found within Westernized medicine and institutions, that it has almost lost its own heritage and purposive existence. It has been so consumed by the modern demand for “technological competencies” it now is faced with having to restore the under developed “ontological competencies” as essential to nursing’s maturity and survival as a distinct caring-healing profession. (Gervais, 1996)
The “American Nurses’ Association” was founded in 1896, according to its charter, “to establish and maintain a code of ethics; to elevate the standard of nurses’ education; to promote the usefulness and honor of nurses; to distribute relief among such nurses as may become ill, disabled or destitute; to disseminate information on the subject of nursing by publications in official periodicals or otherwise; to bring into communication with each other various nurses and associations and federations of nurses throughout the United States.” (Omeri and Ahern, 1999)
Nursing care is holistic care that promotes wellness of the person as a physical, spiritual, emotional, psychological, intellectual being by working directly with the person and by making adjustments to his environment. In order to do this, nurses work through the “nursing process” by which they discover and treat the person’s responses to illness.
Carrying out physicians orders, involves such activities as administering medications (orally, intravenously, subcutaneously, intramuscularly), placing catheters (into veins, stomach, bladder, etc), assisting the physician with medical procedures (surgery, spinal taps, etc), and various kinds of physiological monitoring (taking blood pressure, temperature, fluid intake and output, weight, cardiac output, pulmonary artery wedge pressures, etc.) to keep track of how the person is doing physiologically. If a physiological crisis occurs, the nurse notifies the physician and receives further orders to rectify the situation. Rarely, the physician will have to go to the hospital to deal with the situation in person.
The persistent problems that plaque nursing have been explored in the literature throughout the period of the 20th century feminism. Gervais (1996) in her critical social analysis of nursing’s sex-segregated occupational status, called for health policy change. Rather than advocating the superficial remedy of more men in nursing, Greenleaf’s analysis showed the potential for broad social policy change that values work typically relegated to women. More recently, Lazure et al 1997 challenged the adequacy of equity as a principle for developing health policy, and argued that policy needs to be developed from broad feminist criteria that bridge ethical, political and scientific concerns for the benefit of women. The image of the nurse in both the general public and in the women’s movement was analyzed by Lazure, G., Vissandjee, B., Pepin, J., ; Kerouac, S. 1997. These analyses offered broad suggestions for change in health policy and social relationships. They emphasize the need for public and self-education. However, as compelling as these analyses seem, they have not offered substantial guidance for nurses to use in creating change in their work lives.
Education always allows nurses to be more effective clinical decision makers in health care setting; I have reviewed different researches that show the central features of the contemporary health care setting include constant nursing care of complicated patients in highly technical, increasingly specialized, rapidly changing, and complex environments. The moral, social, and ethical dimensions of decision making in these environments are not clear, and the nurse is bound through interpersonal and professional role functions in a pivotal relationship with patient, family, physician, and hospital.
If health care professionals are to participate in the enabling, enhancing and empowering interventions which will preserve patient or client autonomy, a number of factors must inform approaches to decision making. These include a sound understanding of priority principles and frameworks; an up-to-date knowledge, research-based practice in the particular professional discipline, aligned to competent judgment. Commitment to professional codes of conduct and the possession of qualities which foster critical scrutiny of the self in relation to values and attitudes, linked to a capacity for honest reflection, are vital. The development of skill in ethical analysis is a prerequisite for the delivery of high-quality health care.
Cognitive processes of deliberation and reflection, which incorporate a number of stages, have been identified as precedents to moral decision making. These include appreciation of the situation and possible outcomes; review of courses of action; selection and application of principles in the final weighing of practical considerations preceding the decision. At consecutive stages, the following points should be borne in mind:
Each situation should be viewed as unique, pertaining to the individual who is the recipient of care.
Factual information relevant to the situation should be gathered; disputed facts identified; supporting evidence for the facts critically appraised.
Courses of action should be formulated and potential outcomes predicted.
Consideration should be given to resources which could support courses of action; to precedent situations which could illuminate a decision: and to the quantification of risks in relation to harm.
Moral principles significantly relevant to the particular situation should be identified, that is, rights, duties, benefits, minimizing harm and respecting autonomy.
The interface with the law must be considered and guidance sought from codes of professional conduct.
Reflection and weighing of principles and consequences which create the most moral outcome should precede the decision to act.
Malloch et al (1990) developed a model of decision making based on general systems theory which incorporates concepts and definitions of nurses, clients and the process of nursing. The model is concerned with the potential for psychosociocultural variables on the part of the recipient of care or nurse to inhibit or enhance interactions with others and which may affect the ‘rightness’ of health care given and received. The ethical framework for this model, which is deontological, is based on the ICN code and ANA professional code, which emphasize autonomy, beneficence, non-maleficence, justice and professional accountability. The framework does not incorporate stages in the process of moral deliberation.
In contrast, the ethical grid developed by Sinclair (1988) to teach practical decision -making methods to nurses covers a range of considerations which might affect moral deliberation. Its use requires the identification of significant principles relevant to the situation and justification of a course of action. An algorithm subsequently derived from the grid describes five pathways to assist decision making, incorporating external considerations, moral duties, central conditions of health work and consequences, leading into a final common pathway. Necessary decision steps include the assessment of priorities and conflicts. Used in the context of case-study analysis, this is an invaluable approach to the development of decision -making skills.
Thus, nurse executives have increasingly moved to collegiate settings, and changes in nursing practice include performance of comprehensive physical and psychosocial patient assessments. The practice of critical care nursing is increasingly complex and sophisticated.
As technology and specialized equipment emerged rapidly, the pace of change accelerated. This rapid change had several outcomes. Nurses were eager to learn new skills, but did not forfeit older methods. Nursing incorporated technical expertise into the traditional constant caretaking considered essential to nursing practice. Both medicine and nursing often experienced an over-reliance on technology that at times resulted in a diminished capacity for manual assessment.
The existence of technology rather than decisions based on individual need often seemed to dictate its use. Competency and quality assurance with regard to technology both were assumed by nursing, but often very rapidly and with little time for preparation. Finally, technology was seen as stressful, because of complexity, rapid change, the demand for autonomy and responsibility with minimal authority for decision-making, and the general perception that technology often inflicts pain and unnecessarily prolonged suffering on patients when the timing of decision-making is awry.
The traditional post grad nursing characteristics of caring, skill, and continual presence are augmented by a new aggressiveness as critical care settings became increasingly complex. The nursing role is greatly amplified as nurses assumed responsibility for increasing numbers of technical skills.
Nurses embraced the technology and became proficient in it. Indeed, the nurse became the major treatment modality at the bedside. However, nursing incorporated that skill level into traditional roles. While nurses learned to generate and use the increased amounts of data available for patient care and appreciated the positive outcomes for patients, many conflicts emerged in the care setting as a result of high technology. Decision-making and the uses of technology can be easily handled by post grad nursing education. Thus, the education of nurses for the future must provide for the society of the future. At the same time, the full potentialities of individual nurses and nursing at large must not be sacrificed. Post grad educations have had a significant effect on the development of health care and on the direction of nursing services especially in intensive care. A wide spectrum of change has occurred and catapulted society from the horse-and-buggy era to the space age.
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