Nursing: History, Problems, Suggested Solutions

The history of nursing

Nursing is the ability and science of supporting individuals in learning to care for them whenever possible and of caring for them when they are unable to meet their own needs. Nursing developed into a scientific profession from an unorganized way of caring for the ill, resulting in a change from mystical beliefs to sophisticated technology and caring. Nursing uses a caring manner of acting or controlling themselves, critical thinking skills, and science knowledge. Nursing promoted health and assists clients move to a higher level of wellness, including the activity of contributing to the fulfillment of a need or furtherance of an effort or purpose during a terminal illness with the maintenance of comfort and the quality of being worthy of esteem or respect during the final stage of life (White L. 2004). The development of nursing is traced through its rich history and the social forces that affected it.

Health and social care professions such as nursing, physiotherapy, radiotherapy, and medical social work have all attempted to strive to equal or match, especially by imitating the medical profession’s route to provide professional authority. The long-standing auxiliary activity of professional status is arguably the defining feature of the history of modern nursing:

Nursing has pursued its professional project for over a period of 100 years, attempting by employing effort to achieve some autonomy and jurisdiction of its own. Its professional milieu is one which the powerful forces of medicine and the hospitals constantly seek to control or to change the metaphor, they re[resent the upper and nether millstones between which nursing has always been ground. (Macdonald 1995)

The attempt to construct a ‘new nursing’ framework of theory and practice as the basis for the ‘professionalizing’ of nursing has in many ways been undermined by the reality of practice, where the care provided by nurses has to be coordinated with the needs of the complex organization (Allen 2001).

Goals of nursing, its scope of practice, and its acts under the Ontario Regulated Health professions Act

Nursing just as any other profession has statutory regulations that govern its activities. To prohibit the entire activities of a profession by anyone other than a registered practitioner speaks of a scatter-gun approach to regulation that raises suspicions that the covert intention is to protect the profession, not the public interest. This approach is preferred in the Canadian Province of Ontario under the Regulated Health Professions Act 1991 which described precisely certain controlled acts that may only be performed by specified professions without specifying a broad scope of practice. Competitive but protective means to regulate the professions is to limit the use of specific tasks or procedures that qualify as requiring regulation on the minimum regulation/protection model (Ian R. Freckelton, 2006).

The most competitive but protective means to regulate the professions is to limit the use of specific tasks or procedures that qualify as requiring regulation on the minimum regulation/protection model. This task-based regulation requires the procedures employed to be separated into those with serious health implications and those without serious or nill health implications. This process requires a commonsense assessment of how the day-to-day activities of a practitioner can be separated and an assessment made of the risk it offers to patients.

It is proposed that a scheme similar to the Ontario model under the Regulated Health Professions Act 1991(Ont) be instigated in Australia with the following modifications:

  • That there is no scope of practice for any profession which would limit the broad practice of a particular profession such as the practice of physiotherapy;
  • That there would be a list of controlled acts that could only be performed by specified registrants;
  • That the currently registered health professions would be provided with a registration statute or be mentioned in omnibus legislation with the addition of TCM, acupuncture, naturopathy, and homeopathy (Bensoussan and Myers, 1996).

Strategies that the nursing has used to obtain and maintain its professional statues

A nurse is obligated to participate actively in the patient’s medical management and care decisions to ensure quality healthcare in the most cost-efficient manner. If the case manager’s decisions result in harm to the patient, denial of an essential service, or interference with or corruption of acceptable medical judgment, there may be grounds for professional liability. All health care facilities have a document known as the ‘Against Medical Advice (AMA) form. Patients are asked to sign the AMA form when they decide to refuse or discontinue ordered therapy or intend to leave the facility. The value of the document in countering a claim of negligence should the patient or family late sue will depend in great part on the quality of the nurse’s charting. The nurse’s notes should always reflect the specific advice given to the patient.

Professional nursing practice is governed by an ever-widening circle of federal and state statutes and is constantly evolving in great part because of an accumulating body of nursing case law. The law provides guidance for every aspect of practice and can assist the nurse in managing the complexities of practice in a rapidly changing health care system. Knowledge is power, and the nurse who possesses a sound understanding of the law as it pertains to professional practice is empowered.

If a patient under the nurse’s care refuses treatment, the nurse has a duty to notify the primary provider. The same principles pertaining to the informed consent process apply to the situation when the patient refuses care. The nurse should provide the patient with information about the consequences, risks, and benefits of refusing therapy. The nurse must also explore any alternative treatments that may be available to the patient. One last, but equally important, area of patient rights to be discussed is the right of a competent adult to be free of restraint. Even patients with mental illness cannot be incarcerated or restrained without due process, and the institution must have the treatment and rehabilitation services necessary to reintegrate the individual into society

When a nurse is accused of professional misconduct, the state board of nursing usually investigates the claim by conducting an administrative review. This is a separate appearance from civil action in court. The state board of nursing can take disciplinary action against a nurse for any violation of the state’s nurse practice act.

Education should be one of the most important values of nurses. Hence the initial piece of advice for nurses to protect themselves from litigation is ‘Never stop learning” other recommendations are as follows:

  • Make it a point to stay abreast of the legislation that impacts healthcare both at the federal and state level.
  • Maintain membership in professional associations. This helps nurses to stay current in their fields and gives them a voice in government and in the eye of the public.
  • Always review the state professional practice act just to bring to mind what the statutes describe as case management.
  • Network with professional colleagues. This may help the nurse with problem-solving and may strengthen the case management profession.
  • Maintain rapport with patients and their families or caregivers.
  • An understanding and appreciation of the legal process, areas of potential liability, and the critical importance of communication support the nurse in giving sound and legitimate care to clients.

Besides this, a nurse can also be a patient’s advocate. They may be presented with conflicting choices. Using the principle of beneficence, the case manager should always select the choice that will advance the best interests of the patient. As an advocate to the patient, the nurse must provide patients and families with the information necessary to help them make better decisions and must support the decisions they make.

In an organizational setting, the nurse is to behave and act responsibly. This requires a shift in perspective from that of an individualist who strives to do all he/she can do for the patients. As the person responsible for coordinating the delivery of care to patients, case managers must also assume responsibility for initiating shared decision-making to resolve ethical problems that may arise (Habermas,1990).

Nursing is specialty a specialty that does not focus on direct patient care but instead focuses on how to improve patient care and safety as well as on improving the workflow and work process of nurses and other healthcare workers.

Understanding change and how it affects people allow nurses to develop strategies to allow the healthcare workers to accept changes and become proficient in informatics solutions that are implemented.

Case Study The Sharma Family’s Story

As a result of a job transfer, Nirit Sharma and his wife, two kids, and elderly mother had recently moved from Montreal to Uniontown. One of his children had diabetes and his mother was beginning to show signs of dementia.

An early task for the family was to find a primary care physician and some supports to help them cope with his mother’s increasing health difficulties.

Nirit asked around at work and was dismayed to find that all the family practices in Uniontown were closed to new patients. There were a few new physicians in a neighboring area but they were mostly serving the Chinese-speaking community. Nirit discovered that few services were available in the community for his Mother, particularly in her first language. He spoke to the local Alzheimer Association chapter but due to budget issues, they could only offer some educational help. She didn’t qualify for home care services, but Senior Help, a non-profit home support agency, was able to provide some respite services and general assistance for a fairly reasonable price.

Nirit had heard that the local hospital – Uniontown General Hospital – could possibly offer some assistance to him.

He called the Hospital and found a number of services were available to meet his family’s needs. To start with, he learned that the Hospital operated a Health and Wellness Centre that included both hospital-run clinics and physician/specialist offices and a range of other health-related services. He learned that located within the Centre was a Family Health Team (FHT). The Family Health Team was run by a group of 20 primary care physicians. They also employed several nurse practitioners.

Between the physicians and staff, the practice had the capability to converse in various languages. The FHT also had an arrangement with the hospital for the provision of nutritional counseling, health promotion services, family and children’s mental health counseling, and other such services within the FHT’s offices.

When he went over to the Health and Wellness Centre he saw that just down the hall from the FHT were many related hospital services such as diagnostic imaging and even several operating rooms for day procedures. It also provided child and adult diabetes programs for educational, consulting, and monitoring services. Upstairs were pediatricians, surgeons, and several other specialists. Also located right within the building was a health food store, a physiotherapy clinic, an alternative medicine clinic, a pharmacy, a home health care store, and the offices for the local CCAC.

He further learned that all the doctors, clinics, and the main hospital were electronically linked to facilitate referrals for consultations and tests, receipt of results, and access by his health care providers to relevant health information. He reasoned this would result in less duplication of tests and better sharing of pertinent health information including allergies, current medications, and upcoming tests. Nirit was even more excited to learn that next door, another facility operated a regional geriatric program (RGP) and that their health records were also electronically linked. The RGP assessment program could do a full work-up on his mother over a 3 day period and then help him locate and coordinate the help they would need including referrals to appropriate community programs, home care services, and services of a number of long-term care services in the area.

At first, his wife was a little hesitant, because when she called to make a doctor’s appointment with a family physician she was told she would have to roster with the FHT, meaning agree to receive all of her primary care within the FHT. She was told she could choose her physician but she would also receive care from the nurse practitioner when appropriate or one of the other doctors if hers wasn’t available. She became more comfortable when she learned all of the staff was affiliated with the hospital and that she could call 24 hours a day for service or advice.

Things were looking better. But one big problem remained. With only one car, getting to the hospital campus was not easy and her child with diabetes would need frequent visits to the hospital to monitor his blood sugar and teach him the life skills he would need. Her mother-in-law could not be left alone for long periods of time and was a real handful to take on public transportation.

So Mina became ecstatic when she learned that the hospital and the FHT had established a joint tele-home care program that enabled blood sugar levels to be sent via the internet to the hospital lab and the FHT and that through the hospital’s videoconferencing abilities, if necessary, the FHT or hospital could do a remote conference with them.

So the Sharmas took the plunge and joined the FHT. They were very satisfied with the care they received from the team and the easy access to and better coordination of their care, particularly for Nirit’s mother.

They also began to take advantage of the weekend hours at the FHT. Nirit even signed up his kids for Saturday programs at the community center that was co-located with the Health and Wellness Centre. While his daughter was in swimming class, his son would be playing hockey, and Nirit could go and see the nutritional counselor about coping with his newly diagnosed diabetes – all in the same building at the same time.

Unfortunately, Mina was diagnosed with a neurological disorder which was diagnosed very expeditiously as a result of the facilitated electronic exchange of information between all members of the health care team.

Unfortunately, Uniontown General Hospital did not have the specialists to deal with her disease, so she was referred to the regional health center. As a result, the coordination and communication Mina had become used to began to break down. She had some blood work done and an MRI at Uniontown, but because the information systems weren’t linked, the results didn’t get to the Regional specialist before her appointment. The tests were redone which resulted in a two-month wait for an appointment.

Thankfully, the problem wasn’t serious and she was told she could be followed by her family doctor but when she saw her physician he had not yet received the consultation report.

As a result of this experience, the Sharma family realized the advantages of being in a community where their acute care hospital/ CCC/rehab hospital, specialists, family practice group, and community health care providers had come together and developed an integrated approach to providing coordinated care along the entire continuum.

They further learned at a public meeting held by the hospital and through the local paper that the plans to expand the extent of their partnership within the community by establishing formal partnership and service arrangements with other providers in the community including other FHTs, pharmacies, public health, and the CCAC.

They also came to truly appreciate the efforts of the hospitals and the providers to develop this integrated system when Nirit inquired about becoming a member of the Hospital Board. He learned that each organization remains autonomous with its own governance structures and separate funding, but that through voluntary agreements, money is shared and substantial collaborative efforts are put towards establishing and nurturing the relationships.

Questions to be considered

The types of integration are described in the case study

The types of action of incorporating a racial or religious group into a community discussed in this case study are that Nirit Sharma:

  1. Found a number of services were available to meet his family’s needs.
  2. He learned that the Hospital operated a Health and Wellness Centre that included both hospital-run clinics and physician/specialist offices and a range of other health-related services.
  3. They also employed several nurse practitioners with the capability to converse in various languages.

The benefits derived from the integration and for whom

The Sharmas benefited from the integration in that they were very satisfied with the care they received from the team and the easy access to and better coordination of their care, particularly for Nirit’s mother. They also began to take advantage of the weekend hours at the FHT.

Nirit even signed up his kids for Saturday programs at the community center that was co-located with the Health and Wellness Centre. While his daughter was in swimming class, his son would be playing hockey, and Nirit could go and see the nutritional counselor about coping with his newly diagnosed diabetes – all in the same building at the same time.

The key issues involved in successfully implementing the integration described

In order to successfully implement the described integration, the Sharmas took the plunge and joined the FHT, access to and better coordination of their care, particularly for Nirit’s mother.

From my perspective and the information discussed in the course, what I think is needed to make these approaches reality and what needs to be done to get there are:

The entire community needs to have an acute care hospital/ CCC/rehab hospital, specialists, family practice group, and community health care providers to come together and develop an integrated approach to providing coordinated care along the entire continuum.

Reference List

Allen D. (2001). The changing shape of nursing practice. Routledge, London.

Bensoussan, A and SP Myers (1996). Towards a Safer Choice: The practice of Traditional Chinese Medicine in Australia Victorian Department of Human Services, New South Wales Department of Health and Queensland Department of Health.

Freckelton, I. R. (2006). Regulating health practitioners. .Leichhardt. NSW: Federation Press.

Habermas, J: (1990). Moral consciousness and communicative action. Cambridge. Mass. MIT Press.

Macdonald K (1995). The sociology of the professions. Sage. London.

White L. (2004). FOUNDATIONS OF NURSING. New York. NY: Cengage Learning.