CHAPTER 1

Nursing

As A

Profession

LEARNING OBJECTIVES

• Define nursing
• Describe nature & meaning of nursing
• Explain the ethics, principles and scope career in nursing
• Enumerate the qualities of professional nurse
• Describe the holistic approach in nursing
• Explain the determinants of health
• Describe the effects of illness
• Explain the historical perspective in nursing

CHAPTER OUTLINE

Section A: Introduction to nursing ( concept, meaning , definition scope and functions)

• Section B: History of nursing in India
• Section C: Nursing as profession
• Section D: Nursing professional – qualities of a nurse
• Section E: Ethics in nursing

• Section F: Health care agencies – hospital and community services
• Section G: Modern approaches to nursing care including holistic nursing care
• Section H: Health and disease

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INTRODUCTION

Definition : “The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or

knowledge.”

—Virginia Henderson

Concept:

Nursing is considered as an art and a science.

Professional nurse deliver the health care artfully with sympathy, mindfulness, and respect for each patient’s dignity

and personhood

ASPECTS OF NURSING

Aspect

Description

Spiritual

When an individual is physically unwell, the belief system, religious/spiritual rituals and practices are challenged. Nurse do provide spiritual care and while doing so she encourages patient to keep the faith and helps to perform the routine or rituals related to spiritual beliefs of the patient.

Purpose is to provide a support to patient and help to cope up with illness, loss or grief or pain

Emotional

Emotional care includes acceptance of the patient as an individual being empathetic and compassionate towards the individual in sickness, loss or grief or pain. Nurse need to be emotionally stable and possess emotional intelligence to provide effective care.

Social

Social care is related to the interpersonal relationships patient has and empowering the patient to maintain them in a healthy way is providing social care. Nurse need to be free from personal prejudices and bias in order to incapacitate the patient for better understanding of others’ mind set so that empathetic approach is developed and conflict resolution occurs,

Physical

Physical care is the most important and responsible for disturbance of other dimensions of health. Patients are mainly focussed on the physical (bodily) sickness, due to which the other aspects are affected therefore nurse provides care catering to all the aspects leading to provision of holistic care.

CONCEPTS OF NURSING

Fair and justice

• The delivery of care should be impartial regardless of physical and psychological condition of individual, their age, gender, race, belief and status in society.

Respect

• Respect fundamental human rights while providing health care to individual.

Therapeutic

• Build a helping relationship with the patient, his family and society.

Collaboration

• Ability to walk independently and in collaboration with the multidisciplinary team in view of

developing her skills and professional knowledge.

Judicious

• Timely and thoughtful implementation of health policies.

Evidence based practice

• Participate in research-based nursing and evaluation of research to propose evidence-based practices.

Patient autonomy

• Respect the rights of patient to accept and refuse the treatment.

Informed practices

• Disseminate appropriate information to patients and his family members about health status, investigations and procedures done, diagnosis, treatment and prognosis of patient

FUNDAMENTAL NURSING CONCEPTS

The art and science of modern nursing encompasses fundamental nursing concepts that include health, illness, and stress and health promotion.

Nurses work with physicians and other medical staff in a wide variety of medical and community settings. Nursing care focuses on protecting and promoting physical and mental health for patients and for the community.

NURSING METAPARADIGM

PHILOSOHY OF NURSING

Philosophy of nursing care states our thoughts that what we believe to be true about the nature of the profession of nursing and provide a basis for nursing activities.

According to philosophy, nursing is

considered as ’profession of charity’. It covers

following aspects:

PHILOSOPHY OF NURSING BARRIERS

Spiritual:- spirituality provides the motives for the nurse influenced by spiritual principles. It focus on developing a sense of meaning, purpose, and hope for the person in their current life experience. Spiritual interventions involve listening to the person's story and facilitating the person to connect to God

using meditation or prayer.

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Moral: Understanding of moral principles and actions lead the nurses to study ethics. Nurse has to apply the right conduct in various situations of daily life, based on moral character, adequate understanding and application of moral standards.

Intellectual: Nurse should be intellectually sound. Nursing education should give training in memory development, communication skills, acting reasonably, judging wisely, strengthening and expansion of capacity.

PHILOSOPHY OF NURSING

Emotional needs: Nurse must be able to function as mature, self-depending personality. She

must also be able to relate well to other people

Physical: Nurse should have knowledge, ability and skills to guide and assist others in carrying out their physical activities. Nurse must have knowledge of, how to keep well and improve health.

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Social: Nursing is linked to social culture, in which nursing is carried out. Nurse is a social being, who passes her life in society in relation to which she has privilege and obligations. Nursing is a support of individual, family and society. It depends on art and science, which form the position, intellectual fitness and showing abilities of the individual nurse, to help individuals, debilitated or well, to meet their wellbeing needs in clinical way.

PHILOSOPHY OF NURSING BARRIERS

OTHER ASPECTS OF PHILOSOPHY OF NURSING

1. Genuineness:- Professional nurse should be sincere and honest in therapeutic relation. She must have clear and concrete in communications with patient.

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• Respect:- Nursing is based on unconditional positive regard to the patients. Nurse

behaviour towards patients should not depend on the patient's behaviour.

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3. Concreteness:- Communicating a message in a clear language using specific terms,

according to the patient’s level of understanding is the vital aspect of nursing.

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4. Immediacy:- Nursing encourages immediacy that involves sensitivity to the patient's feelings and a willingness to deal with these feelings rather than ignore them. (Focus on here and now).

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• Advocacy:- Nurse protect the fundamental rights of the patients.

Apply principles of philosophy in nursing interventions.

OBJECTIVES OF NURSING

Apply scientific knowledge from nursing, natural sciences and general education courses as a source for making decisions in nursing.

Use the nursing process to identify health potential of individuals, groups, families and communities and to meet their health needs.

Provide comprehensive nursing care without any discrimination related to race, sex, and religion and culture in a variety of settings.

Use community resources to achieve the goals of nursing.

Demonstrate utilization, integration and application of knowledge generated through research as evidence in practice.

Assume individual responsibility for decisions made and actions taken related to nursing intervention.

Use information and communication technologies to care for the patient and to enhance one's own professional knowledge.

Apply principles of scientific investigation in testing nursing intervention as hypothesis for the improvement of nursing practice.

Employ appropriate actions to enhance personal and professional growth in order to cope with changes within the health care system

Evaluate therapeutic nursing care according to accepted standards of practice.

Develop goals for continued professional development, self-care, and lifelong learning.

CHARACTERISTICS OF NURSING PRACTICE

Nursing practice respects the diversity and is individualized to meet the unique needs of the patient, family and group or community. All these are health

Respects the diversity

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COORDINATION

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The nurses establish coordination with the heath care team and address the needs of the patients and achieve the goals to deliver the quality health care.

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SYSTEMATIC AND SCIENTIFIC APPROACH

Nurses use nursing process (cognitive skills and evidence- based practice) to make diagnosis, identify objectives, plan and implement and evaluate the care.

Critical thinking underlines each step of nursing process.

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HEALING ENVIRONMENT

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Nursing practice is a strong link between the professional work and environment to provide optimal level of health care services and to achieve optimal outcomes.

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CONTINUUM OF CARE

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• Professional nurse provides hospital or community based specialized care to the patients experiencing health problems.

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THERAPEUTIC COMMUNICATION

• It is a process of interacting with the patients that focuses on advancing their physical and emotional well-being.
• With therapeutic communication, the nurse understands the response of the patient that is beneficial to

the patient’s mental and physical

health.

• Therapeutic communication is the backbone of the nursing.

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PHYSICAL AND BIOLOGICAL INTERVENTIONS

Nursing involves delivering or assisting in various psychical and biological interventions such as medications, surgery and direct physical care (personal hygiene, nutrition, sleep, etc) of the patients having illness.

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PSYCHOSOCIAL INTERVENTIONS

• Psychosocial interventions are increasingly used in health care settings.
• It includes psychotherapy interventions, such as cognitive behavioral

therapy, family therapy, milieu therapy and psychodynamic approaches.

• These interventions are used by the nurses to a broad range of psychological problems

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SPIRITUAL INTERVENTIONS

It focus on developing a sense of meaning, purpose, and hope for the person in their current life experience. Spiritual interventions involve listening to the person's story and facilitating the person to connect to God

using meditation or prayer

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THERAPEUTIC RELATIONSHIP

The fundamental elements of nursing care revolve around the interpersonal relations and interactions established between nurses and patients. Caring for people demands an intensified presence and a strong desire to be supportive

nurse try to Understand patient’s perspective. Empathy reinforces a positive psychological and enhances patient’s sense of importance.

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EMPATHETIC NURSING

• It is the core of nursing where

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SUPPORTIVE CARE

• Successful therapeutic relationships between nurses and patients need to have positive support. Minor activities, such as sitting with the patients or reading the newspaper together can improve the quality of support provided. Therapeutic touch is intended to comfort and console patients.

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LEGAL AND ETHICAL PARAMETERS

• Professional nursing take place in legal and ethical boundaries. Nurse must have clear sense of professional ethics, one's own values that helps her to be honest and committed nursing professional

SCOPE OF NURSING PRACTICE

The scope of nursing practice is defined as the range of roles, functions, responsibilities, and activities which registered nurses are educated and authorized to perform.

The broad scope of nursing practice reflects all of the roles and activities undertaken by the nurses to address the full range of human experiences and responses to health and illness.

Nursing practice is accomplished through the following:

FUNCTIONS OF A NURSE

ROLE AND FUNCTIONS OF NURSE IN VARIOUS SETTINGS

HISTORY OF NURSING IN INDIA

Nursing has a long and rich international heritage filled with colourful events and people. Nurses with their unique divergent opinions and talents have made many valuable individual and collective contribution to societies.

A review of historical nursing literature reveals significant linkages between social events the development of nursing and the status of nursing.

HISTORY OF NURSING IN INDIA

HISTORY OF NURSING IN INDIA

HISTORY OF NURSING IN INDIA

PROFESSION- DEFINITION AND CHARACTERISTICS

• A profession is a paid occupation especially one that involves prolonged training and formal education.

~ Oxford dictionary

• A profession requires extensive education, knowledge, skill and preparation.
• Profession is defined as job and practice which requires mastery of a complex set of knowledge and specific skills through formal education and practical experience.

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PROFESSION-

CHARACTERISTICS

NURSING AS A PROFESSION

Changing needs of the society, the general goals of nursing have changed over time and in today’s world the nursing has gradually evolved as a modern profession. Nursing is an art and science and it is caring, adaptive, individualized, holistic and family and community centred and is concerned with health promotion, maintenance and restoration.

Today, nursing has also attained the professional status as it fulfils the following criteria :

CRITERIA FOR A NURSING PROFESSION

NURSING AS A PROFESSION

Body of Knowledge-

Nursing requires a specific body of knowledge that is derived from experiences and researches. Judgement made by a nurse and a rationale for modifying actions according to a specific situation is based on this body of knowledge. This knowledge orderly and exact.

A nurse keeps on constantly expanding this body of knowledge to improve her techniques and skills for rendering nursing care.

Specialized education-

Being a nurse requires specialized education as well as training and it is an important aspect of professional status. Various schools and colleges have been set up to provide specialized education and training.

Service to the society -

Nursing means to care. It is a service that is essential for the wellbeing of the person and of the society as a whole. It is concerned with health promotion, maintenance and restoration. The goal of nursing is to help others and attain the highest level of wellness of which they are capable. It is an altruistic profession in which an individual puts the life and well-being of patient above theirs.

NURSING AS A PROFESSION

Accountability - Being accountable means being answerable to oneself and to others for one own actions. A nurse is accountable for making judgements, taking actions, maintaining competency and upholding quality patient care.

Autonomy and Independence - Nurses deals with various patients and provide care. Nursing has developed and refined its own approach to practice which is called nursing process that requires logical, critical and creative thinking and serves as the basis for providing nursing care. Therefore, nursing is an interdependent and independent practice.

Code of ethics - According to Webster, “ethics are the morals concerned with or relating to what is right or

wrong” in matters of human behavior. Codes of ethics provide professional standards and framework based on which a nurse should render the care

NURSING AS A PROFESSION

Professional License - Beside having a specialized education and advanced body of knowledge, a nurse must have a professional license to practice.

Granting a license is a legal activity which states that the

individual has passed a national licensure examination and is now

qualified to practice nursing.

Representative organization- Various international and national professional associations have been formed for the improvement of nursing profession. The purpose is to promote and maintain the standards of nursing, promote educational advancements and research in nursing and promote the welfare of nurses. In India, TNAI (Trained Nurses Association of India) and SNRC (State Nurses Registration Council) are the representative organizations of nurses.

Evidence- Based Nursing Practice- All interventions and care rendered by nurses are based on some evidence and data collected from various researches that have proven to be successful and appropriate.

QUALITIES OF NURSE

Qualities of Nurse

Communication

skills

Emotional stability

Empathy

Flexibility

Physical endurance

Problem solving skills

Quick response

Respect and patience

Economic

Sense of responsibility

Honesty and loyalty

Discipline and obedience

Cooperative and considerate

Observant & Confident

Knowledgeable

CATEGORIES OF NURSING PERSONNEL:�

ETHICS

“Ethics refers to moral code for

nursing and is based on the obligation to service and respect to human life. —Melanie and Evelyn

ETHICAL PRINCIPLES

ETHICAL PRINCIPLES

• Autonomy is the right of self determination or freedom to make choices. It refers to patient’s right to make decision concerning his/her healthcare.

Autonomy

• Beneficence refers to doing good and right things for the patient. It includes taking positive actions to help others.

Beneficence

• Justice refers to treating all patients fairly and equally. Nurses must be fair when they render their services and care to patients

Justice

• Nonmaleficence is avoiding harm to patients. Harm can be either intentional or unintentional

Nonmaleficence

Fidelity

• Fidelity: It involves faithfulness, loyalty, and honouring commitments. It basically means healthcare professionals loyalty and faithfulness to their professional responsibilities and agreements to provide quality care to patients

• This principle is concerned with being honest and telling truth.

Nurses must honestly represent client’s perspective and wishes.

Veracity

• It is defined being answerable to oneself and others for one’s own actions. It means being accountable for our practice, work environment, and patient safety

Accountability

• It is the obligation to perform duties and role assigned using

scientific knowledge and professional judgment

Responsibility

• It is the right of the patient to have all personal and heathcare information to be kept in confidence. Nurses have the responsibility to maintain confidentiality while providing care to patients.

Confidentiality

Expanded roles of nurses :

Extended roles of nurses :

HEALTH CARE SERVICES

HEALTH CARE SERVICES

• These are the services provided to individuals/families or communities by health care professionals for health promotion, maintenance, monitoring, or restoration of health. The institution providing such services are called as health care agencies.

Types of health care agencies

Clinics/day care centers

A department of the hospital which provides medical care on an OPD basis or without hospitalization, for example, Chemo Day Care Clinic or Pain Clinic

Ambulatory Care Centers and Clinics

(Mobile Clinics)

Ambulatory Care Centers and clinics (facilities that deliver outpatient medical care) may be located in hospitals or they may be freestanding services provided by a group of health care providers who work together. Many ambulatory care centers and clinics offer walk-in services and many are also open at times other than traditional office hours. Nurses in Ambulatory Care Centers and clinics provide technical services (e.g., administering medications), determine the priority of care needs, and provide teaching about all aspects of care.

Extended-Care

Agencies

These services provide medical and nonmedical care for people with chronic illnesses or disabilities. Through a variety of facilities and in conjunction with family members and other caregivers, extended- care services assist with activities of daily living for people of any age who are physically or mentally unable to care for themselves independently. It is always helpful for nurses to be sensitive to the needs of family caregivers, who often labor at great health and financial costs to themselves.

Hospice services

Hospice is a program of palliative and supportive care services providing physical, psychological, social, and spiritual care for dying people, their families, and other loved ones.

Rehabilitation

centers

Rehabilitation centers specialize in services for patients requiring physical or emotional rehabilitation and for treatment of chemical dependency. These centers may be freestanding or associated with a hospital. The goal is to return patients to optimal health and to the community as independent members of society.

Rehabilitation centers often use a multidisciplinary team composed of health care providers, nurses, physiotherapist, occupational therapists, and counselors.

The role of the nurse includes direct care, teaching, and counseling.

De-addiction

centres

De-addiction centres are specialized clinics where patients with addiction are treated and helped to come out of addiction.

HOSPITALS: TYPES, ORGANIZATION, AND FUNCTIONS

Hospital

• The word hospital is derived from the Latin word “hospital,” which is in turn derived from the French word “hospes” that means “a host or a guest.” The hospital is a health care institution providing treatment to patients with specialized staff and equipment. Hospitals are licensed institutions, whose primary function is to provide diagnostic and therapeutic services for medical and surgical conditions by an organized physician staff and have continuous nursing services under the supervision of registered nurses.

Types of hospitals

Hospitals based on objective

General Hospitals

Special Hospitals

Teaching cum research hospital

Types of hospitals

Based on Administration, Ownership, Control, or Financial Income

Governmental or

public hospital

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Private Hospital

Semi-Government

Hospital

Voluntary agency

hospital

Types of hospitals

Based on Length of Stay

Short-term or short-stay hospitals

Long-term or long-stay hospitals

Types of hospitals

Based on Type of Medical Staff

Closed-staff hospital

Open-staff hospital

Types of hospitals

Based on WHO Classification

Regional Hospital

Intermediate/ District Hospital

Rural Hospital

Functions of Hospital

HEALTH CARE TEAMS IN HOSPITALMEMBERS AND THEIR ROLE

Health care team

Physician Nurse

Physical therapist

Occupational/ speech therapist

Social

worker

Pharmacist

Respiratory Therapist

Dietician

Assistive personnel

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Nurses provide care to clients while working under a variety of care models . A care model is a philosophy of care delivered and a system for organizing the relationship and roles of all nursing care personnel .

Historically several delivery of approaches have been used in nursing. Each differs in regards to the types of responsibilities assumed by registered nurses and other personnel. The approaches also differs in the extent to which a registered nurse directly coordinates the care of all clients need is matched with staff abilities .

The traditional approaches:

• Case method
• Functional method
• Modular nursing
• Primary nursing method

The advanced method:

• Case management
• Critical thinking

These approaches are classified into :

MODERN APPROACHES TO NURSING CARE INCLUDING HOLISTIC NURSING CARE

TRADITIONAL APPROACHES OF NURSING

Case method

• Oldest mode of organizing patient care.
• It involves the assignments of one or more clients to a nurse for a specific period of time such as shifts.
• It provides nurses with great high autonomy and responsibility.
• Widely used in hospital and in nursing homes.

Functional nursing

• Emerged during 1950s , due to shortage of nurses . This method focuses on getting the greatest amount of tasks in the least time
• In this method , the nursing care is divided into tasks and each staff member is assigning to perform one or two tasks for all the patients in the unit according to the level of skill required .

Team method

• This concept was introduced in early 1950s.
• It is a method of nursing assignments that binds professional , technical and nurses aides into small teams

Modular Nursing

• This assignment is used when the nursing staff includes technical and nurse aides, as well as professional nurses.
• It is the modification of team nursing and was developed by Magargal in 1987.
• Two or three person are assigned to each module and the professional nurse is responsible for guiding and teaching the non-professional nurse.

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Primary nursing methods

• It was developed by Manthey at al in 1970.
• This method is based on the concept of ‘my patient-my nurse’.
• In this nursing care delivery system , each registered nurse is assigned to the care of group of patients for which she plans complete 24hrs care and writes the nursing care plan.

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ADVANCED METHODS OF NURSING

Case management

• It was developed in 1985 as an outgrow of primary care.
• It is process of monitoring an individual patients health care by the case manager, for the purpose of maximizing positive outcomes and containing costs.
• It is a collaborative activity that focuses on comprehensive assessment and intervention and holistic care planning with appropriate referrals to meet the health care needs of the patient and family.

Critical pathway

• Also known as care pathway, integrated pathway , or care maps .
• It is used to manage the quality in healthcare concerning the standardization of care processess.
• It promotes organized and efficient patient care based on evidenced based practice.

Holistic Nursing

• This approach was adopted to provide nursing care while considering the patient as whole – not focusing only on physical illness or care.
• Holistic approach is the heart if nursing care where mind body and spirit works together.
• It also utilizes the alternative modalities of care.

MEANING OF HEALTH

Health is more than just the absence of illness; it is an active process in which a person moves toward his or her maximum potential.

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Definition of Health

MASLOW’S HIERARCHY OF NEEDS

Physiological Needs

• Physiological needs are the physical requirements for human survival. If these requirements are not met, the human body cannot function properly and will ultimately fail.
• Physiological needs are thought to be the most important and they should be met first. They are the basic needs such as air, water and food which are metabolic requirements for survival in all animals, including humans.

Safety and Security

• Once a person’s physical safety needs are relatively satisfied, their safety needs take precedence and dominate behavior. In the absence of physical safety due to war, natural disaster, family violence, childhood abuse etc. – people may (re)experience post-traumatic stress disorder or transgenerational trauma.

Love and Belongingness

• After physiological and safety needs are fulfilled, the third level of human need is interpersonal and involve seelings of belongingness. This need is especially strong in childhood and can override the need for safety as witnessed in children who cling to abusive parents.

Self-esteem

• All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Esteem presents the typical human desire to be accepted and valued by others. People often engage in a profession or hobby to gain recognition.

Self-actualization

• “What a man can be, he must be”. This quotation forms the basis of the perceived need for self-actualization. This level of need refers to what a person’s full potential is and the realization of that potential. Maslow

describes this level as the desire to accomplish everything that one can, to become the most that one can be. Individuals may perceive or focus on this need very specifically.

Determinants of health

Health is multifactorial . The factors which influence health lie within the individual ( internally ) and externally in the society in which he/ she lives. Factors interacts and these interactions may be health promoting or deteriorating. Determinants of health are :

Biological Determinants

Behavioral and Socio-cultural Conditions

Physical and mental traits of every human beings are dependent on genetic makeup and cannot altered thereafter . A number of diseases are known to be of genetic origin e.g., Chromosomal , metabolic and structural .This state of health depends partly on genetic constitution of man.

The term ‘lifestyle’ reflects the whole range of social values , attitude and activities. It is composed of cultural , behavioral and lifelong personal habits (e.g., Smoking , alcoholism).Health requires the promotion of lifestyle and there is association between health and lifestyle.

Environment

Socio-economic Status

Health Services

Environment has a direct impact on physical, mental , and social well being of persons living in it. Environmental factors ranges from housing, water supply , psychological stress and family structures through social and economical support systems to organization of health in the community.

Socioeconomic conditions have a long been known to influence human health . Main conditions that influence health are :

1.Economic status

2.Education

3.Occupation

4.Political system

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The purposes of health services are to improve health status of population . For e.g., immunization , provision of safe water , care in pregnancy .Health services must be equitable ( equally distributed ) , accessible to country at affordable rates and socially acceptable.

ILLNESS

• An illness is the response of a person to a disease; it is a process in which the person’s level of functioning is changed when compared with the previous level. Illness is not synonymous with diseases.

Type of Illness

• Acute illness: An acute illness usually has a rapid onset of symptoms and lasts only a relatively short time. Although some acute illnesses are life threatening, simple acute illnesses, such as common cold or diarrhea, do not usually require medical treatment.
• Chronic Illness: Chronic illness the one which persists, usually longer than 6 months. It is a broad term that encompasses a number of different physical and mental alterations in health.

IMPACT OF ILLNESS ON PATIENT AND FAMILY

• Impact on behavior

Individual reacts differently to illness or threat of illness. An individual’s behavioral and emotional response is influenced by duration and nature of illness. Short term illness leads to behavioral changes.

• Impact on body image

Illness may result in the loss of body part or change in physical appearance. Every individual responds to the changes differently.

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• Impact on family roles

Every individual has varied roles and responsibilities to play. These roles and responsibilities change with illness.

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