Postgrad Education for Nurses in Effective Clinical Decision-Making - Essay Example

Postgrad education allows nurses to be more effective clinical decision makers In the beginning, God created nursing. He (or She) said, I will take a solid, simple, significant system of education and an adequate, applicable base of clinical research, and On these rocks, will I build My greatest gift to Mankind-nursing practice. On the seventh day, He-threw up His hands. And has left it up to us. - MARGRETTA M. STYLES Outline of essay Nursing is often pictured as the heart of health care. But being a nurse requires much more. It requires efficient decision making and ability to cope situation which can only be achieved through postgrad education. Thus, in this paper I will discuss that how postgrad education allows nurses to be more effective clinical decision makers. Introduction Education has a major collision on the knowledge and competencies of the nurse clinician. Nursing 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. Nursing 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. Postgrad 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 (Julie Considine, 2004). Postgrad 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". Outline of search strategy and findings: To prove my point that post grad education allows nurses to be more effective clinical decision makers in critical care setting, I have reviewed different researches that shows the central features of the contemporary critical 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. Scholars explore that how distinctive critical care nursing is as a specialty and how representative it is of the discipline as a whole remain questions to be tested relative to traditional roles and to changes affecting nursing and contemporary practice due to post grad education. Malloch, K.M., Milton, D.A. & Jobes, M.O. (1990) study that nursing post grad education prepare professionals to make decisions at the individual client level, much less attention is given to identifying problems/needs and proposing solutions at the aggregate or group level. Sinclair (1988) shows that the new technology imposes both benefits and problems on critical care nurses. Phillips, C.Y., Palmer, C.V., Zimmerman, B.J. & Mayfield, M. (2002) shows nurses' professional development. They define nursing functions in critical care as interpretive and anticipatory functions. Thus professional grad nurse can focus time and attention on mechanical aspects of treatment, anticipate subtle changes in patient status, and make quick decisions in emergency situations. Literature review Malloch, K.M., Milton, D.A. & Jobes, M.O. (1990) study the characteristics of nursing practice in ICU settings reveals information about the ways in which nurses, patients, and others respond to the complex, stressful, and highly technical critical care environment. Education of critical care nursing is also a valuable source of information about the interactions between nurses and patients and their families, physicians, and others; the actual nursing care delivered; and the ethical dimensions of critical care practice. In their study on nursing, Malloch et al, focused primarily on the need for graduate nursing education to include clinical experiences in working with aggregates. Postgrad nurses Especially in directing patient care, suggesting everything from treatments to medications to protocols and also being patient advocates at the same time. What is and isn't appropriate for a physician to prescribe not just in terms of what the patient's medical condition is but also what may or may not be necessary at that time. Whether an inappropriate test is going to be real expensive for the patient, that kind of thing. Especially in ICU the postgrad nurses are really the trouble shooters. They are the ones that see it first. They have to know what they are seeing and know that they are seeing something and call the doctor. The ICU nurses, are incredible in their ability to really see the forest and the trees. They can really pick up on things. They are sort of the integrated masters there, because in a way that it really is not the doctors, it really is the nurses that pull it all together and tie it together in a pie. The doctor sort of fits into that pie, but it is the nurses that not only run the show behind the scene but through it all. They are just the fabric of the care of the patient that holds it together. Sinclair shows that Sophisticated computerized systems provide nurses with highly accurate and precise physiologic measurements, giving a timely picture of the patient's status and facilitating rapid intervention if complications develop. Nurses may receive automatic assessments of chest drainage, urine output, and hemodynamic measures every two minutes. Some computer systems can be programmed to administer blood, fluids, or drugs to patients in small increments based on the computer's frequent assessment of measures of volume loss or changes in blood pressure. Some new technologies replace very invasive, high-risk techniques with less costly and problematic ones. Thus, postgrad nursing education help to cope automation that help the nurse accomplish timely interventions, because critical changes in patient status may occur very quickly and require rapid and accurate decision making. The literature in critical care nursing reflected concerns about the particular outcomes of high technology on both nurses and patients in the critical care setting. Specialty and general nursing literature have reported frequently on strategies for coping, monitoring, or adopting new technologies such as dialysis, coronary care, computers, and new machines and monitors. As critical care units have become more common, the specific issues of touch, empathy, and stress, and human problems caused by the highly technical critical care environment, have become more apparent in the literature. V. Sinclair ( 1988) notes that the constant introduction of new technology into critical care units compounds the problem of under trained personnel. Sinclair does not consider another complicating factor that contributes to the hazard of new equipment -- the lack of uniformity in the equipment of the new technologies. Free market competition by companies and cost containment efforts by hospitals add to the constant change in critical care settings. Phillips, C.Y., Palmer, C.V., Zimmerman, B.J. & Mayfield, M. (2002) shows Nursing functions in critical care have been defined by legal experts as including "interpretive and anticipatory functions of the nurse involving decision making and action with regard to a patient in biophysical and/or psychological crisis, close monitoring of patients in life threatening situations...and rendering of life supporting treatment to patients who could not otherwise monitor the functional mechanisms underlying the life processes. Thus professional grad nurse can focus time and attention on mechanical aspects of treatment, anticipate subtle changes in patient status, and make quick decisions in emergency situations" The critical care nurses interviewed for this study spoke openly and often passionately about their beliefs and commitments about nursing and the rewards and frustrations of patient care. This study provides a forum for those nurses to speak about their perceptions of the essence of nursing practice. Many factors contribute to the nurses' perceptions about themselves and their practice. Several of these that have particular impact on the practice setting were selected for discussion: the roles that nurses assume; the values that permeate nursing education and practice; the accepted model of decision making in nursing; the ways that nursing has been defined by nursing leaders and others (because of the influence these definitions have on the formation of a professional self-image); and, finally, a research study examining clinical nursing practice from the perspective of practicing nurses. Various disciplines have described the role of the nurse in critical care settings in relation to the medical, nursing, administrative, legal, historical, ethical, and even architectural dimensions of critical care. The nurse has been described as coordinator of patient care, collaborator with physicians and all other health team members, and promoter of activities to help the patient regain or maintain health (Phillips, C.Y., Palmer, C.V., Zimmerman, B.J. & Mayfield, M. 2002). Both Phillips et al and Sinclair in their study shows not only awareness of technology but ability to priorities care can have serious consequences for patients. These practices should permeate all aspects of health care practice, not just life and death dilemmas but the mundane, everyday routines which may go unexamined. Sinclair emphasized those professional nurses ethical behavior is not: '... a display of moral rectitude in time of crises, but a day-by-day expression of one's commitment to other persons, and they ways in which human beings relate to one another in their daily interactions' (1988). 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, K.M., Milton, D.A. & Jobes, M.O. (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. The practitioner is required to engage in moral reasoning at four different levels, that is, in relation to the principles behind health work (respect for and creation of autonomy), duties of the health professional (truth telling, non-maleficence), beneficial outcomes for the recipients of care, and external considerations (resources, the law, risks, codes of practice and certainty of evidence available). 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. Discussion Thus, Nursing postgrad education has 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. All the studies describe the impact of increasingly complex technology and environments on the practice of critical care nursing, particularly the decision making associated with critical care practice. Nurses may describe their experiences as stressful and yet satisfying. Technology may be perceived as a blessing, yet the actual and potential outcomes may be painful and dehumanizing. Some of their experiences parallel findings in the literature; others reveal previously unknown dimensions. Increasing specialization, knowledge, and technology precipitated a need for bringing together nurses who had specialized knowledge with patients. Many of the earlier ICUs opened even without cardiac monitors, now considered one of the most fundamental elements of ICU care. The nurse was the monitor in the early units, using traditional hands-on nursing skills, such as taking the pulse and temperature and providing constant surveillance and observation of patient condition and status. Both medicine and nursing were less complex then and often involved more touch and personal, hands-on ministrations and care, such as alcohol baths for persistent high fevers. 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 postgrad 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. Conclusion 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 postgrad 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. Postgrad 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. Work Cited Julie Considine; who, when, where identification of patients at risk of an in hospital adverse event: implications fore practice. Into Jour of Nursing Practice volt 10 issue 1 pg 21 fibs 2004 Charles Hendry, Priority setting in clinical nursing practice: literature review. Jour of advanced Nursing volt 47, issue 4 pg 427 agues 2004. Sinclair Vaughn ( 1988). "High Technology in Critical Care: Implications for Nursling's Role and Practice." Focus on Critical Care 15 ( 4): 36-41. Malloch, K.M., Milton, D.A. & Jobes, M.O. (1990). A model for differentiated nursing practice. Journal of Nursing Administration, 20(2), 20-26. Phillips, C.Y., Palmer, C.V., Zimmerman, B.J. & Mayfield, M. (2002). Professional development: Assuring growth of RN-to-BSN students. Journal of Nursing Education, 41(6), 282-283. Read More