Nursing Administration BT Basavanthappa
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Introduction to Nursing Profession1

  • • NATURE OF NURSING
  • • NURSING AS A PROFESSION
  • • CHARACTERISTICS OF PROFESSIONALIZATION
  • • IS NURSING A PROFESSION?
  • • PROFESSIONAL NURSING
  • • PROFESSIONAL SOCIALIZATION OF NURSING
  • • PROFESSIONAL NURSING VALUES
  • • QUALIFICATION OF PROFESSIONAL NURSE
  • • ABILITIES OF PROFESSIONAL NURSE
  • • CHARACTERISTICS OF PROFESSIONAL PRACTICE
  • • CODE OF ETHICS OF A PROFESSION
  • • FUNCTIONS OF PROFESSIONAL NURSING
  • • ETHICO-LEGAL OBLIGATIONS OF NURSES
  • • NEED FOR NURSING ADMINISTRATION
 
NATURE OF NURSING
Nurse means ‘to foster’ or ‘cherish’ (‘to nurse one's meagre talents’); to treat or handle with adroit care (‘to nurse one's egg’); to bring up, train or nurture; to clasp or handle carefully or fondly (‘to nurse a memento’), to preserve (‘to nurse a drink’). So, the term nurse suggests attendance and service. Its antonym is neglect. Accordingly, the nurse is a person, a woman generally, who takes care of the sick or infirm; a woman who has the general care of the child or children; a woman employed to suckle an infant, or any fostering agency or influence. Now, meaning of nurse is a person formally educated in the care of the sick or infirm, especially a registered nurse.
Nurse, nourish, and nurture, all are derived from the same Latin source. These words have been so closely associated through the years that some people label any caregiver a “nurse.” Thus some historians have identified the roots of modern nursing in the care given to the sick by military camp followers or religious sisters, or even in the nurturance of children by their mothers. The assumption that nursing is an art possessed inherently by any female has hindered development of a concept of nursing as a profession with an organized body of knowledge and specialized skills.
Throughout nursing history, there have been many authors who have contributed their thoughts about the nature of Nursing. Nursing has begun as the desire to keep people healthy and provide comfort, care and assurance to the sick. Although the general goals of nursing have been influenced by society's changing needs, and thus nursing has gradually evolved as a modern profession. Nursing is as old as medicine. Throughout the history, nursing and medicine have been interdependent. During the era of Hippocrates, medicine was practised without nursing and during the middle ages, nursing was practised without medicine. In ancient India, Susrutha defines the ideal relations of doctor, patient, nurse and medicine as the four feet upon which a cure must rest (Susrutha Samhitha). There are some references to nurse and patient, found in Charaka-Samhitha also.
Historically, men and women have held the role of nurse. The entry of women into nursing can be traced to approximately AD 300 to improve their social position, by taking care of the sick and infirm.
Various definitions of nursing from the times of Nightingale to the present, which help to know the nature of Nursing are as follows:
Florence Nightingale defined nursing as “the act of utilizing the environment of the patient to assist him in his recovery” (Nightingale, 1860). Nightingale considered a clean, well-ventilated, and quiet environment essential for recovery. Often considered the first nurse theorist, Nightingale raised the status of nursing through education. Nurses were no longer untrained housekeepers but people trained in the care of the sick.
Virginia Henderson was one of the first modern nurses to define nursing. In 1960, she wrote, “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, and to do this in such a way as to help him gain independence as rapidly as possible.” Like Nightingale, Henderson described nursing in relation to the client and the client's environment. Unlike Nightingale, Henderson saw the nurse as concerned with both well and ill individuals, acknowledged that nurses interact with clients even when recovery may not be feasible, and mentioned the teaching and advocacy roles of the nurse.
In the latter half of the twentieth century, a number of nurse theorists developed their own views of nursing. Certain themes are common to many of these definitions: that nursing is caring, adaptive, individualized, holistic, family- and community-interrelated; that it involves teaching and direct/indirect services; and that it is a science as well as an art concerned with health promotion, health maintenance, health restoration, and the care of the dying.2
Table 1.1   Nursing theories and its descriptions of nursing
Nursing Theorist and Theory
Description of Nursing
Hildegard Peplau (1952): Psychodynamic nursing
A therapeutic, interpersonal process. It functions cooperatively with other human processes that make health possible for people in communities. An educative instrument, a maturing force that aims to promote forward movement of the personality in the direction of creative, constructive, productive, personal, and community living.
Faye Abdellah (1960): Twenty-one nursing problems
Service to individuals and families; therefore, to society. An art and science that molds the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs. May be carried out under general or specific medical direction.
Virginia Henderson (1960): Fourteen basic needs
The unique function of the nurse: To assist clients, sick or well, in the performance of those activities contributing to health, its recovery, or peaceful death that clients would perform unaided if they had the necessary strength, will, or knowledge. Also, to do so in such a way as to help clients gain independence as rapidly as possible.
Martha Rogers (1970): Unitary human beings, an energy field
A humanistic science dedicated to compassionate concern with maintaining and promoting health, preventing illness, and caring for and rehabilitating the sick and disabled. Nursing seeks to promote symphonic interaction between the environment and the person, to strengthen the coherence and integrity of the human beings, and to direct and redirect patterns of interaction between the person and the environment for the realization of maximum health potential.
Imogene King (1971, 1981): Goal attainment theory
A helping profession that assists individuals and groups in society to attain, maintain, and restore health. If this is not possible, nurses help individuals die with dignity. Nursing is perceiving, thinking, relating, judging, and acting vis-a-vis the behavior of individuals who come to a nursing situation. A nursing situation is the immediate environment, spatial and temporal reality, in which nurse and client establish a relationship to cope with health states and adjust to changes in activities of daily living if the situation demands adjustment. It is an interpersonal process of action, reaction, interaction, and transaction whereby nurse and client share information about their perceptions in the nursing situation.
Dorothea Orem (1971, 1980,1985):
A helping or assisting service to persons who are wholly or partly dependent–infants, children, and adults–Self-care theorywhen they, their parents, guardians, or other adults responsible for their care are no longer able to give or supervise their care. A creative effort of one human being to help another human being. Nursing is deliberate action, a function of the practical intelligence of nurses, and action to bring about humanely desirable conditions in persons and their environments. It is distinguished from other human services and other forms of care by its focus on human beings.
Myra Levine (1973): Four conservation principles
A human interaction; a discipline rooted in the organic dependency of the individual on relationships with other human beings. A subculture reflecting ideas and values unique to nurses, even though the values mirror the social template that created them.
Sister Callista Roy (1976, 1984):
A theoretical system of knowledge that prescribes a process of analysis and action related to the care of Adaptation theory the ill or potentially ill person. As a science, nursing is a developing system of knowledge about persons used to observe, classify, and relate the processes by which persons positively affect their health status. As a practice discipline, nursing's scientific body of knowledge is used to provide an essential service to people, that is, to promote ability to affect health positively.
Jean Watson (1979, 1985): Science of caring
Nursing is concerned with promoting and restoring health and preventing illness. Caring is a nursing term representing all the factors the nurse uses to deliver health care to the client. In contrast, curing is a medical term that refers to the elimination of disease.
Dorothy E. Johnson (1980): Behavioral system theory
An external regulatory force that acts to preserve the organization and integration of the client's behavior at an optimal level under those conditions in which the behavior constitutes a threat to physical or social health or in which illness is found.
Rosemarie Rizzo Parse (1981): Man-Living-Health
Nursing is a human science that focuses on Man as a living unity and Man's qualitative participation with health experiences. The responsibility to society relative to nursing practice is guiding the choosing of possibilities in the changing health process. Nursing practice is directed toward illuminating and mobilizing family interrelationships in light of the meaning assigned to health and its possibilities as languaged in the co-created patterns of relating.
Betty Neuman (1982): Systems theory
A unique profession in that it is concerned with all of the variables affecting an individual's response to stressors, which are intra-, inter-, and extra-personal in nature. The concern of nursing is to prevent stress invasion, or, following stress invasion, to protect the client's basic structure and obtain or maintain a maximum level of wellness. The nurse helps the client, through primary, secondary, and tertiary prevention modes, to adjust to environmental stressors and maintain client system stability.
Madeleine Leininger (1984): Transcultural care theory
A learned humanistic art and science that focuses on personalized (individual and group) care behaviors, functions, and processes directed toward promoting and maintaining health behaviors or recovery from illness. Behaviors have physical, psychocultural, and social significance or meaning for those being assisted generally by a professional nurse or one with similar role competencies.
3
Table 1.1 shows the definitions or descriptions of nursing by selected nurse theorists.
Professional nursing associations have also examined nursing and developed their definitions of nursing, describes nursing practice as “direct, goal oriented, and adaptable to the needs of the individual, the family, and community during health and illness.” In 1980, the ANA published this definition of nursing: “Nursing is the diagnosis and treatment of human responses to actual or potential health problems.”
Nursing means “to have charge of the personal health of somebody…and what nursing has to do-is to put the patient in the best condition for the nature to act upon him” (Florence Nightingale, 1859). Accordingly, the Nightingale view suggests that the word ‘Nursing’ has been limited to signify a little more than the administration of medicines, it ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet-all at least expense of vital power to the patient. Further, she opined that, “It is often thought that medicine is the curative process. It is no such thing; medicine is the surgery of functions, as surgery proper is that of limbs and organs. Neither of them can do anything but remove obstructions; neither can cure; nature alone can cure.”
Nursing is “both an art and science involving the total patient, as promoting spiritual, mental and physical health; stressing health education and health preservation, ministering to the sick, caring for the patient environment and giving health service to the family, the community and the individual” (Mother Olivia Gowan, 1943).
The practice of professional nursing means the performance for compensation of any act in the observation, care, counsel of the ills, injured or infirm or in the maintenance of health or prevention of illness, or in the supervision and teaching of other personnel of the administration of medications and treatments as prescribed by licensed physician or dentist, requiring substantial specialised judgements and skill and based on knowledge and application of principles of biological, physical, and social sciences. The foregoing shall not be deemed to include acts of diagnosis or prescription of therapeutic or corrective measures (ANA 1955).
The above definitions stress mostly the dependent role of the nurse. Now it is felt nursing has attained the professional status, and presents a fuller definition of nursing and emphasizes nursing as an independent profession. Nursing is a helping profession and as such, provides services, which contribute to the health and wellbeing of people. Nursing is of a vital consequence to the individual receiving services. It fills the needs that cannot be met by the person, family or other persons in the community.
Three essential components of professional nursing are Care, Cure and Coordination.
  1. The care aspect is more than “to take care of”; it is also “Caring for” and “Caring about”. It deals with the human beings under stress frequently over long periods of time. It is providing comfort and support in times of anxiety, loneliness and helplessness. It is listening, evaluating and intervening appropriately.
  2. The promotion of health and healing is the cure aspect of professional nursing. It is assisting clients to understand that health problems and helping them cope. It is the administration of medications and treatments. It is also the use of clinical judgement in determining, on the basis of patient's outcome, whether the plan of care needs to be maintained or changed. It is knowing when and how to use existing and potential resources to help patients towards recovery and adjustment by mobilizing their own resources.
  3. Professional nursing practice is this and more. It is sharing responsibility for the health and welfare of all people in the community, and it is participating in programs designed to prevent illness and maintain health. It is co-ordinating and synchronising medical and other professional and technical services that effect patient care. It is supervising, teaching and directing all those involved in nursing care.
As stated earlier, Virginia Henderson gave her personal concept of the unique function of the nurse as follows:
“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 necessary strength, will or knowledge, and to do this, in such a way as to help him gain independence as quickly as possible.” This unique function is the Core of Nursing from which all other functions spring and which must be protected. None of them should make such heavy demands on other members of the medical team that anyone of them is unable to perform her or his unique function. In a passage so lovely that it is almost poetry, Henderson translates this unique function. “The nurse is temporarily the consciousness of the unconscious, the love of life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant, knowledge and confidence of the young mother, the voice for those too weak or withdrawn to speak.”
Further, in these activities, the nurse should be an independent practitioner and she is able to make independent judgements. It is true, that, now the role of nurses as providers of primary health care as those who diagnose and treat, when a doctor is unavailable, even as the midwife functions in the absence of an obstetrician.4 Nurses may be the general medical practitioners of tomorrow, because it has been recognised by everyone that the majority of health care providers recognise that the nurses are the major providers of primary care, i.e. obstetrical nurses or midwives, have been universally recognised worldwide as the providers of primary care for mothers and newborns. They diagnose and treat as well as “Care”.
ANA (1980) congress defined Nursing as, “the diagnosis and treatment of human responses to actual or potential health problems”. It involves the characteristics of nursing, i.e. phenomena, theory, application nursing action and evaluation of the effects of action. In the same year the Canadian Nurses' Association defined practice of Nursing as follows:
“The nursing profession exists in response to a need of society and holds ideals related to man's health throughout his lifespan. Nurses direct their energies towards the promotion, maintenance and restoration of health; the prevention of illness; the alleviation of suffering, and the assurance of a peaceful death when life can no longer be sustained. Nurses value a holistic view and regard an individual as a biopsychosocial being who has the capacity to set goals and make decisions and who has the right and responsibility to make informed choices congruent with personal beliefs and values. Nursing, a dynamic and supportive profession guided by its code of ethics, is rooted in caring, a concept evident throughout its four fields of activity; practice, education, administration and research.”
The above definitions may differ in terminology and frame of reference, but they convey similar goals; to restore, maintain, and promote optimal health of the individual, family and community. In 1987, International Council of Nurses approved the following definition of Nursing.
“Nursing as an integral part of the health care system, encompasses the promotion of health, prevention of illness, and care of the physically ill, mentally ill, and disabled people of all ages, in all health care and other community settings. Within this broad spectrum of health care, the phenomenon of particular concern to Nurses is individual, family and group response to actual or potential health problems. These human responses range broadly from health restoring reactions to an individual episode of illness to the development of policy in promoting the longterm health of a population.”
The unique function of nurses in caring for individuals, sick or well, is to assess their responses to their health status and to assist them in the performance of those activities contributing to health, recovery or to dignified death, that they would perform unaided if they had the necessary strength, will, or knowledge and to do this in such a way as to help them gain, full or partial independence as early as possible. Within the total health care environment, nurses share with other health professionals and those in other sectors of public service, the functions of planning, implementation, and evaluation to ensure the adequacy of the health system for promoting health, preventing illness and caring for ill and disabled people.
 
NURSING AS A PROFESSION
Historically, only medicine, law and engineering were accepted as professions. Today ‘professional’ is a term commonly used to identify many types of people ranging from wrestlers and rock stars to call as profession. Flexner (1915) believed that professional work:
  • Is basically intellectual (as opposed to physical)
  • Is based on a body of knowledge that can be learned
  • Is practical rather than theoretical
  • Can be taught through a process of professional education
  • Has a strong internal organisation of members
  • Has practitioners who are motivated by altruism (the desire to help others).
Since Flexners original criteria were published, they have been widely used as a benchmate for determining the status of various occupations in terms of professionalism.
Occupation is often used interchangeable with profession, but their definition differ. Webstar defines occupation as, ‘what occupies or engages-one's time; business, employment.’ Profession is defined as, ‘a vocation requiring advanced training and usually involving mental rather than manual work, as teaching, engineering, medicine, law, etc. There are some differences between occupation arid profession in terms of their characteristics as given in Table 1.2.
 
Concepts of a Profession
A profession is an occupation with ethical components that is devoted to the promotion of human and social welfare. The services offered by a profession are based on specialised knowledge and skills that have been developed in scientific and learned manner.
Occupations are principal areas of work classified according to various features such as preparation, skills and knowledge required; the nature of the work itself, supervision, motivation, etc.
Professions are those occupations possessing a particular combination of characteristics: Generally considered to be expertise, autonomy, commitment and responsibility. These characteristics mandate an advanced body of knowledge and skill and an organized value system, developed and transmitted through extensive academic preparation and professional socialisation, along with the occupational structures to assure the required level of education and practice. Some occupation, organised around a professional core, also include an array of personnel, such as assistants, technicians who are not professionals by the accepted standards of preparation and responsibility.5
Table 1.2   Difference between occupation and profession
Occupation
Profession
1
Training may occur in the job
Education takes place in a College or University
2
Length of training varies
Education in prolonged
3
Values, beliefs and ethics are not prominent factors of preparation
Values, ethics, beliefs are an integral part of preparation
4
Commitment and personal identification vary
Commitment and personal identification strong
5
Workers supervised
Workers are autonomous
6
People often change job
People unlikely to change profession
7
Accountability rests with employer
Accountability rests with an individual
So “A profession is an occupation based on specialised intellectual study and training, the purpose of which is to supply skilled service with ethical components to others, for a definite fee or salary”. The economists view is that the profession is a non-competing group. The sociologist view that the professional worker is subject to institutional or normative control.”
 
Criteria of a Profession
In general to be a professional person, the person must:
  • Have a grasp of fundamental truth-a kind of truth that will make him free to think and act,
  • Have the ability to apply truth in dealing with new problem for which there is 110 precise answer at that moment and
  • Be able to remain uninhibited and unafraid under perplexities of changing basic knowledge, demands social conditions or personal upsets.
Many writers have listed the criteria of professiona-lization are as follows:
Abraham Flexner (1915) listed the following criteria of profession:
  1. The profession involves essential intellectual operations accompanied by large undivided responsibility.
  2. They are learned in nature and their members are constantly resorting to the laboratory and seminar for a fresh supply of facts.
  3. They are not merely academic and theoretical however, but are definitely practical in their aims.
  4. They possess a technique capable of communication through a highly specialized educational discipline.
  5. They are self-organised with activities, duties and responsibilities which completely engage their participants and develop group consciousness.
  6. They are likely to be more responsible to public interest than that of unorganised and isolated individuals and they tend to become increasingly concerned with the achievement to social bias.
According to William J, the profession:
  1. Deals with matters of great urgency and significance.
  2. Is directed to human benefit and is guided by ethical standards.
  3. Has no over generalization (is learned).
  4. Undertakes tasks a which require the exercise of judgement in applying knowledge to the solution of problem and accepts responsibilities for the results.
William Shephard (1948) listed following criteria of a profession:
  1. A profession must satisfy an indispensable social need and be based upon well established and socially accepted scientific principle.
  2. It must demand adequate pre-profession and cultural training.
  3. It must demand the possession of a body of specialised and systematized knowledge.
  4. It must give evidence of needed skills which the public does not possess, i.e. skills which are partly native and partly acquired.
  5. It must have developed a scientific technique which is the result of tested experience.
  6. It must require the exercise of discretion and judgement as to time and manner of the performance of duty. This is contrast to the kind of work which is subject to immediate direction and supervision.
  7. It must be a type of beneficial work, the result of which is not subject to standardization in terms of unit performance or time element.
  8. It must have a group consciousness designed to extend scientific knowledge in technical language.
  9. It must have sufficient, self-impelling power to retain its members throughout life. It must not be used as a mere stepping stone to other occupations.
  10. It must recognise its obligations to society by insisting that its members live up to an established code of ethics.
Additional criteria as a basis for determining professional activities are:
  1. A profession has the responsibility for determining its own role and responsibility for meeting society's needs for its services. In deciding its own role,6 consideration must be given to the roles of other related groups.
  2. It needs to decide which functions are its own, which constitute its particular responsibility and which functions overlap with those of professional or other groups in the particular area of activity.
  3. It needs to include in its code of ethics what the particular professional group ought to know in order to have an understanding of moral principles. Another important point to stress in the ethical obligation of the professional person is to give service to the public above all-above personal consideration such as remuneration, although, of course ‘the labor is worthy of his hire’.
Kelly (1981) reiterated and expanded Flexner's criteria in the listing of characteristics of a profession as follows:
  1. The services provided are vital to humanity and the welfare of the society.
  2. There is a special body of knowledge which is continually enlarged through research.
  3. The services involve intellectual activities, individual responsibility (accountability) is a strong feature.
  4. Practitioners are educated in institutions of higher learning.
  5. Practitioners are relatively independent and control their own policies and activities (Autonomy).
  6. Practitioners are motivated by service (altruism) and consider that work on important component of their lives.
  7. There is a code of ethics to guide the decisions and conduct of practitioners.
  8. There is an organization (Association) which encourages and supports high standards of practice.
Moore and Rosenblum (1970) identified six elements of a profession. A profession should (a) have a systematic theory, (b) exert authority, (c) command prestige, (d) have a code of ethics, (e) have a professional culture, and (f) be the major source of income by those who practice it.
Kramer (1974) identified the following characteristics of a profession:
  • Specialized competence having an intellectual component
  • Extensive autonomy in exercising this special competence
  • Strong commitment to a career based on special competence
  • Influence and responsibility in the use of special competence
  • Development of training facilities that are controlled by the professional group
  • Decision-making governed by internalized standards.
Miller (1985) stated that the critical attributes of professionalism in nursing are the following:
  • Gaining a body of knowledge in a university setting and a science orientation at the graduate level in nursing
  • Attaining competencies derived from the theoretical base wherein the “diagnosis and the treatment of human responses to actual or potential health problems” can be accomplished
  • Delineating and specifying the skills and competencies that are the boundaries of expertise.
Bixler and Bixler Criteria for Profession: Genevieve and Roy Bixler (1945) who were against the status of ‘Nursing as a profession’, appraised nursing according to their original seven criterias as follows:
  1. A profession utilises in its practice a well defined and well organised body of knowledge, which is on the intellectual level of the higher learning.
  2. A profession constantly enlarges the body of knowledge, it uses and improves its techniques of education and service by the use of the scientific method.
  3. A profession entrusts the education of its practitioners to institutions of higher education.
  4. A profession applies its body of knowledge in practical services which are vital to human and social welfare.
  5. A profession functions autonomously in the formulation of professional policy and in the control of professional activities thereby.
  6. A profession attracts individuals of intellectuals and personal qualities who exalt service above personal gain and who recognise their chosen occupation as a life work.
  7. A profession strives to compensate its practitioners by providing freedom of action, opportunity for continuous professional growth and economic security.
After examining all the criteria of profession and other related concepts and aspect, ‘World Health Organisation’ has already recognised ‘Nursing as a Profession’. The growth of professionalism in nursing can be viewed in relation to specialized education, knowledge base, ethics, and autonomy.
Nursing as a discipline is “characterized by a unique perspective, a distinct way of viewing all phenomena, which ultimately defines the limits and nature of its inquiry.” Disciplines reflect distinctions among bodies of knowledge; in other words, human knowledge is divided into disciplines. Nursing as a discipline is defined by the essence of nursing. Disciplines are divided into academic disciplines and professional disciplines. Academic disciplines, such as physics and mathematics, use descriptive theories and do basic and applied research. Professional disciplines are directed toward practical aims 7using both descriptive and prescriptive theories and add clinical research along with basic and applied research. The practice of academic disciplines is research and education, whereas the practice of professional disciplines adds a component of clinical practice. Thus, nursing has a better fit as a professional discipline.
 
CHARACTERISTICS OF PROFESSIONALIZATION
Although nursing has been called a profession for many years, an assessment of the characteristics of a profession indicates that it should more accurately be considered an “emerging profession.” Houle (1980) identified characteristics of professionalization, including:
  • A concept of mission open to change
  • Mastery of theoretical knowledge
  • Capacity to solve problems
  • Use of theoretical knowledge
  • Continued seeking of self-enhancement by its members
  • Formal training
  • Credentialing system to certify competence
  • Creation of a subculture
  • Legal reinforcement of professional standards
  • Ethical practice
  • Penalties against incompetent or unethical practice
  • Public acceptance
  • Role distinctions that differentiate professional work from that of other vocations and permit autonomous practice
  • Service to society.
These characteristics of a profession can be categorized into intellectual characteristics, personal and interpersonal characteristics, commitment to service to society, autonomy, and shared personal values. Personal values that characterize professional practice will be discussed later in this chapter. Intellectual characteristics really has three components: (1) a body of knowledge on which professional practice is based, (2) specialized education to transmit the body of knowledge, and (3) use of knowledge in critical and creative thinking.
  • Body of Knowledge: Professional practice is based on a body of knowledge derived from experience (leading to expertise) and research (leading to theoretical foundations for knowledge). This knowledge base contributes to judgment and a rationale for modifying actions according to a specific situation. However, nursing education has often emphasized proven methods for responding in particular kinds of situations. This approach to education may explain why many nurses seem unwilling or unable to apply knowledge in clinical problem solving, contributing to dependence in practice. They seek the “right” answer and do things the way they always have been done. Thus, for example, clients are still discharged without self-care teaching because “the doctor didn't write an order,” and pain medication is withheld because “it isn't 4 hours yet.”
An important component of professional education is liberal studies in the arts, sciences, and humanities. Liberal education “leads to a greater personal and professional contribution to nursing and society” and to the continued development of personal values and coherence of knowledge. Desired outcomes of baccalaureate education in any major toward which liberal components contribute include the development of thinking and communication skills, historical consciousness, understanding of what science is, exploration of personal values, appreciation of fine art, and appreciation of ethnic diversity. In the past, it has been debated whether nursing's body of knowledge was unique to nursing or was an application of knowledge borrowed from behavioral and physical sciences and medicine. Previously, nursing derived its knowledge base through intuition and experience and by borrowing from other disciplines. But in recent years nursing theorists have developed frameworks, or models, that are uniquely relevant for nursing. Because nursing now has research that provides a basis for practice and knowledge derived from theory-building research, this debate is no longer relevant.
  • Specialized Education: Nursing transmits knowledge through specialized education. However, there are five levels of basic education for registered nursing. Three of the five levels certificate courses (Diploma and Bachelor degree) accept high school graduates, whereas the other two (masters degree and doctoral degree), accept college graduates with liberal arts majors.
To differentiate practice for diploma and bachelor degree-prepared nurses agreed on the following role components (Table 1.3).
Power, authority, and professional status usually are associated with a postgraduate educational base. Nursing can be considered a true profession when much controversy has focused on presumed quality of the various education patterns rather than on their differences of purpose. The time is long overdue for the profession to move from having nurses with various levels of preparation doing the same thing, or nurses with one level of preparation doing everything, to practitioners with different levels of preparation doing different, interrelated things. It has been proposed a trilevel model with three different practice roles, each with different educational preparation:
  1. Professional nursing clinician, who has “direct responsibility to clients over time for the determination of both short- and long-term nursing care across multiple practice settings… Educational preparation needed for this role is a postbaccalaureate professional degree based on a curriculum that is person-centered and focused on health.8
    Table 1.3   Difference between diploma and bachelor degree level nurses
    Diploma Level Nurse (DLN)
    Bachelor degree Level Nurse (BLN)
    The DLN is a licensed registered nurse who provides direct care based on the nursing process and focused on individual clients who have common, well defined nursing diagnoses.
    The BLN is a licensed registered nurse who provides direct care based on the nursing process and focused on clients with complex interactions of nursing diagnoses.
    Consideration is given to the client's relationship within the family. The DLN functions in a structured health care setting that is a geographical or a situational environment where the policies, procedures, and protocols for provision of health care are established. In the structured setting there is recourse to assistance and support from the full scope of nursing expertise.
    Clients include individuals, families, groups, aggregates, and communities in structured and unstructured health settings. The unstructured setting is a geographical or a situational environment that may not have established policies, procedures, and protocols and has the potential for variations requiring independent nursing decisions.
    The DLN uses basic communication skills with focal clients and needs.
    The BLN uses complex communication skills with focal clients, collaborates coordinates with other health team members to meet focal client's with other health team members, and assumes an accountable role in change.
    The DLN recognizes the focal client's need for information and modifies a standard teaching plan.
    The BLN assesses the need for information and designs comprehensive teaching plans individualized for the focal client.
    The DLN recognizes that nursing research influences nursing practice and assists in standardized data collection.
    The BLN collaborates with nurse researchers and incorporates research findings into nursing practice.
    The DLN organizes for focal clients those aspects of care for which the nurse is responsible.
    The BLN manages comprehensive nursing care for focal clients.
    The DLN maintains accountability for her own practice and for nurses, and ancillary nursing personnel.
    The BLN maintains accountability for her own practice and for aspects of aspects of nursing care delegated to peers, licensed practical nursing care delegated to other nursing personnel consistent with their levels of education and expertise.
    Within a specified work period, the DLN plans and implements' nursing care that is consistent with the overall admission to post-discharge plan.
    The BLN plans for nursing care based on identified needs of the focal client from admission to postdischarge.
    The DLN practices within accepted ethical and legal parameters of nursing.
    The BLN practices within accepted ethical and legal parameters of nursing.
  2. Team leader, who “provides clinical leadership within institutional settings… and is responsible around the clock for the quality of nursing care administered by a team of staff nurses and auxiliary personnel… Preparation needed for this role is a baccalaureate in nursing.”
  3. Staff nurse, who is “responsible for the implementation of delegated medical and nursing care for designated clients within a specified setting and who function as members of a nursing team… Preparation needed for this role is the associate degree in nursing.”
Here there is no competition between the practice roles, because all three roles are essential. Because the practice roles are different, the educational preparation for each role must be different, as must the credentialing and titling process. It is one way that nurses can refute the persistent assumption that “a nurse is a nurse” and move toward unambiguous acceptance of the differentiation between professional practice and supporting practice in nursing roles.
  • Critical and Creative Thinking: A logical and critical thinking process is one essential component of professional practice. The nursing process is a problem-solving approach, a system to:
  • Collect and organize information derived from multiple sources
  • Decide what is needed, based on that information
  • Select and implement one approach from among many possible approaches
  • Evaluate the results of the process.
Most nurses solve problems every working day. The main weakness in this approach, however, seems to be the tendency to act hastily on the basis of both inadequate information and insufficient brainstorming for alternative approaches.
There is no question that nursing involves “specialized skills essential to the performance of a unique, professional role,” although the skills that comprise nursing practice have changed over the years. Skills required for present-day professional responsibilities include:
  • Coordination of care given by various allied health workers
  • Critical thinking and judgment in ambulatory, home, and acute care settings
  • Communication and collaboration with clients, their families, and members of the health care delivery team
  • Advocacy and leadership to bring about needed changes in the health care delivery system
  • Expanded assessment skills to establish baseline data for the nursing process
  • Competence in diagnostic and therapeutic nursing techniques9
  • Caring manifested in interpersonal interactions and therapeutic interviews.
Service to Society: Nursing has been associated with service to others. Many aspirants still enter nursing “to help people,” an image of the nurse shared by the public. But the intrinsic motivation “to care” is only one conceptualization of caring currently receiving much attention in the nursing literature. Morse et al (1991) have identified five conceptualizations of caring: (1) caring as a human trait, (2) caring as a moral imperative, (3) caring as an affect, (4) caring as an interpersonal interaction, and (5) caring as a therapeutic intervention. It is clear that caring is much more complex than just intuitive concern for others. Several nurse theorists have even developed conceptual models for nursing that include caring as a major concept.
Professional service to society requires integrity and responsibility for ethical practice and a lifelong commitment. Nursing has been viewed by many of its practitioners as a job rather than a career. Many nurses either leave the profession (at least temporarily) to raise a family or work primarily to supplement family income. Because professional commitments may be secondary to other concerns, these nurses may tend to seek job security and avoid “rocking the boat.” This attitude is easily exploited by the employing agency Regardless of such difficulties as high client-nurse ratio, rotating shifts, reassignment to provide adequate coverage of other units (floating), and constant change in client assignments, some nurses will make do and maintain the status quo. For those nurses, the service orientation has shifted from the responsibility to an individual client and the welfare of all clients to the welfare of the employing institution.
Service to people involves ethical responsibility. In other words, the nurse must have the integrity to do what is right, often in situations that cause real moral dilemmas. Codes for nurses have been developed by the International Council of Nurses and others. Intrinsic to these codes is the belief that the recipient of nursing care has basic rights and that a nurse's primary responsibility is to the client.
Service to society also requires legal assurances that practitioners are competent. A credentialing system, such as licensure, provides a system for certifying minimal safe practice by a person legally permitted to be called a “registered nurse.” Nurse practice acts also provide legal reinforcement against incompetence by providing for penalties against unethical or negligent practice.
Service to society requires nurses to have autonomy in their dealings. Autonomy means that practitioners have control over their own functions in the work setting. Autonomy involves independence, a willingness to take risks, and responsibility and accountability for one's own actions, as well as self-determination and self-regulation. Most nurses work in institutional settings where authority is vested in administrative positions in a hierarchical organization. This is in contrast to medicine, which has maintained political power and professional credibility through technical competence and specialized knowledge. Nurses seek status through increased rank in the hierarchy rather than through expert practice.
Nursing lacks a collective professional identity. Though united action by over two million potential practitioners represents enormous potential power, nursing has been fragmented by internal dissension and rivalry. Instead of presenting a united front, each subgroup maintains its own turf. The result is political impotence and professional powerlessness. A major goal for nursing must be the development of strength that can be translated into legislative power to increase legal autonomy and provide for third party reimbursement for nursing services.
 
IS NURSING A PROFESSION?
Nursing today is far different from nursing as it was practiced 60 years ago, and it takes a vivid imagination to envision how the nursing profession will change in the next 60 years in an ever-changing world. To comprehend present-day nursing and at the same time prepare for nursing in tomorrow's world, one must understand not only past events but also contemporary nursing practice and the sociologic factors affecting it. At the core of the controversy over level of entry into professional nursing is the definition of profession. Six different conceptualizations of the criteria, qualities, and behaviors for a profession. Educational preparation at the baccalaureate level provides a broader education to better address the body of knowledge. Although nursing meets each of the criteria to some extent, some are more adequately addressed than others. The autonomous practice of nursing has been a source of political activism on behalf of nurses. Whether nursing has a sufficiently developed, unique body of knowledge is also in dispute. It may be concluded that nursing has not yet achieved full professional status but is emerging as a profession the following.
Discussion helps that how well contemporary nursing fulfills these criteria.
  1. “The services provided are vital to humanity and the welfare of society.” If ten students were asked why they chose nursing, most would reply, “To help people.” Certainly nursing is a service that is essential to the well-being of people and to society as a whole. Nursing promotes the maintenance and restoration of health of individuals, groups, and communities. Assisting others to attain the highest level of wellness of which they are capable is the goal of nursing. Caring, meaning nurturing and helping others, is a basic component of professional nursing.
  2. “There is a special body of knowledge which is continually enlarged thro research.” In the past, nursing was 10based on principles borrowed from the physical and social sciences and other disciplines. Today, however, there is a body of knowledge that is uniquely nursing's. While this was not always so, the amount of investigation and analysis of nursing care has expanded rapidly in the past 50 years. Nursing is no theory development is also proceeding swiftly. Nursing is longer based on task orientation, intuition, or trial and error but increasingly relies on research as a basis for practice.
  3. “The services involve intellectual activities; individual responsibility (accountability) is a strong feature.” Nursing has developed and refined its own unique approach to practice, called the nursing process. The nursing process is essentially a cognitive (mental) activity that requires both critical and creative thinking and serves as the basis for providing nursing care. Individual accountability in nursing has become the hallmark of practice. Accountability is “being answerable to someone for something one has done. It means providing an explanation to self, to the client, to the employing agency, and to the nursing profession,” Organized nursing has also demonstrated a commitment to accountability in the Standards of Nursing Practice. Through legal opinions and court cases, society has demonstrated that it, too, holds nurses individually responsible for their actions as well as for those of personnel under their supervision.
  4. “Practitioners are educated in institutions of higher learning.” The first university-based nursing program began in 1909 at the University of Minnesota. Several studies, reported for nursing education to be based in universities and colleges and called for all nursing education to take place in institutions of higher education. The majority of programs offering basic nursing education are now degree and baccalaureate programs located in colleges and universities. There are master's and doctoral programs in nursing, although the number of graduates is small compared with other health professions. Since professional status and power increase with postgraduate education, a legitimate question is, “How can nursing take its place as a peer among the professions when most nurses currently in practice hold less them a bachelor degree?” The differentiation between professional nursing and technical nursing is a challenging issue that nursing has not yet resolved. Diversity within the ranks of nursing has slowed the progress toward acceptance of the bachelor or higher degree as the prerequisite for professional practice. Lack of resolution of these differences threatens to undermine nursing's development as a profession.
  5. “Practitioners are relatively independent and control their own policies and activities (autonomy).” Autonomy, or control over one's practice, is another controversial area for nursing. While many nursing actions are independent, most nurses are employed in organizations where authority resides in one's position. One's place in the hierarchy, rather than expertise, confers or denies power and status. Physicians are widely regarded as gatekeepers, and their authorization or supervision is required before many activities can occur. Nurse practice acts in most states reinforce nursing's lack of self-determination by requiring that nurses perform certain actions only when authorized by supervising physicians or hospital protocols. There are at least three groups who wish to control nursing practice: organized medicine, health service administration, and organized nursing. Both the medical profession and health service administration are attempting to maintain control of nursing because they believe it is in their best interest to keep nurses dependent on them. Both are well organized and have powerful lobbies at state and national levels. Organized nursing, on the other hand, promotes independence and autonomy, but its power is fragmented by subgroups and dissension. Rivalry between diploma-educated, associate degree-educated, and baccalaureate-educated nurses saps the energy of the profession. The proliferation of nursing organizations and competition among them also diminish nursing's potential. The fact that most nurses are not members of any professional organization impairs nursing's ability to lobby effectively. These are major challenges for nursing if it is to realize its potential collective professional power and autonomy.
  6. “Practitioners are motivated by service (altruism) and consider their work an important component of their lives.” As a group, nurses are dedicated to the ideal of service to others, which is also known as altruism. This ideal has sometimes become intertwined with economic issues and historically has been exploited by employers of nurses. No one questions the right of other professionals to charge reasonable fees for the services they render; when nurses want higher salaries, however, others sometimes call their altruism into question. Nurses must take responsibility for their own financial well-being and for the health of the profession. This will, in turn, assure its continued attractiveness to those who might choose nursing as a career. If there are to be adequate numbers of nurses to meet society's needs, salaries must be comparable with those in competing occupations. Being concerned with salary issues does nothing to diminish a nurse's altruism. Another issue, consideration of work as a primary component of life, has been a thornier problem for nurses. Commitment to a career is not a value equally shared by all nurses. Some still regard nursing as a job and drop in and out of practice depending on economic and family needs. This approach, while appealing to many nurses and conducive to traditional family management, has retarded the development of professional attitudes and behaviors for the profession as a whole.
  7. “There is a code of ethics to guide the decisions and conduct of practitioners.” An ethical code does not 11stipulate how an individual should act in a specific situation; rather, it provides professional standards and a framework for decision making. The trust placed in the nursing profession by the public requires that nurses act with integrity. To aid them in doing so, both the International Council of Nurses (ICN) and the ANA have established codes of nursing ethics through which standards of practice are established, promoted, and refined. In India we are following ICN guidelines.
  8. “There is an organization (association) which encourages and supports high standards of practice.” Nursing has a number of professional associations that were formed to promote the improvement of the profession. The purposes of which are to foster high standards of nursing practice, promote professional and educational advancement of nurses, and promote the welfare of nurses to the end that all people have better nursing care. The Associations are the official voice of nursing and therefore is the primary advocate for nursing interests in general. The political power that could be derived from the unified efforts of million nurses nationwide would be impressive; that goal has not yet been realized. In India we have TNAI and State Government Nurses Association. Example, Govt. Nurses Association, Karnataka.
 
PROFESSIONAL NURSING
Professional nursing is an art and science dominated by an ideal service in which certain principles are applied in the skillful care of the such an appropriate relationship with the physician and with others who have related responsibilities. It is concerned equally with the prevention of disease and the conservation of health. Skillful care embraces the person body as a whole, his mind and soul, his physical, mental and spiritual well-being. Nursing encompasses:
  1. Caring for sick and injured, bringing to bear the resources of patient, his family and environment and the services of available co-operating personnel to facilitate his recovery and rehabilitation in accordance to the diagnosis made and treatment prescribed by a licensed physician.
  2. Helping an individual and his family to take positive action in relief of illness and improvement of his individual, family and community health needs.
  3. Training students and auxiliary personnel to function as members of the team.
  4. Adapting nursing service to co-operate with responsible planning authorities in emergencies due to disasters caused by disease and natural causes or war.
  5. Evaluating and conducting research to continually improve methods whereby nursing in particular and health medical care adequately met society's needs.
  6. Sharing with others in the dissemination of general health information to individuals and community groups to further the cultivation of health.
 
Growth of Professionalism
The profession of nursing has evolved over centuries. The traditional nursing role was one of humanistic caring, nurturing, comforting, and supporting. To these must be added specific characteristics of true professionalism, including education, a code of ethics, mastery of a craft, an informed membership involved in the organized profession, and accountability for actions.
There are a number of ways to differentiate a profession from an occupation (Table 1.2). A profession is a calling that requires special knowledge, skill, and preparation. Medicine and law have consistently been recognized as learned professions. The terms vocation and occupation are often used synonymously. A vocation is the work that a person regularly performs or the work that especially suits him or her. An occupation is an activity in which one engages, e.g. a business. Thus, an occupation does not necessarily hold a special interest for the person and may be temporary, whereas a vocation often denotes employment in an area of interest on a regular basis. In this chapter, the more commonly used term occupation will be used to denote nonprofessions.
A profession is generally distinguished from other kinds of occupations by (a) its requirement of prolonged, specialized training to acquire a body of knowledge pertinent to the role to be performed and (b) an orientation of the individual toward service, either to a community or to an organization. The standards of education and practice for the profession are determined by the members of the profession, rather than by outsiders. The education of the professional involves a complete socialization process, more far-reaching in its social and attitudinal aspects and its technical features than is usually required in other kinds of occupations. In 1915, Abraham Flexner stated that professions are organized primarily for the achievement of social ends and secondarily for the assertion of rights and the protection of special interests.
Styles (1983) writes that nursing organizations must perform the following five functions for the preservation and development of the profession:
  1. Professional definition and regulation through the setting and enforcing of standards of education and practice for the generalist and the specialist. Regulation is also achieved through the adoption of codes of ethics and norms of conduct.
  2. Development of the knowledge base for practice in its broadest and narrowest components. Major contributions to the development of nursing knowledge have been made by various theorists. The primary purpose of nursing theories is to generate nursing knowledge. The challenge for nurses in the future is to generate 12questions and formulate hypotheses from these published theories and then test the hypotheses through nursing research. Since only research can determine the usefulness of a theory, research makes a major contribution to the development of nursing knowledge. Another significant contribution to nursing knowledge is the work of the North American Diagnosis Association (NANDA). This group is generating and expanding a taxonomy of nursing diagnoses. Research is required to determine the validity and reliability of these diagnoses.
  3. Transmission of values, norms, knowledge, and skill to neophytes and members of the profession for application in practice. This function is largely performed through the education of nurses and the socialization processes. Socialization is the development in the individual of those qualities (skills, beliefs, habits, requirements) necessary to belong to and function in a group.
  4. Communication and advocacy of the values and contributions of the field to several publics and constituencies. This function requires that nursing organizations speak for nurses from a position of broad agreement. It is essential for nurses to participate actively in the formulation of health legislation and policy.
  5. Attendance to the social and general welfare of their members. This function is carried out by the professional nursing organizations of the country. Professional associations give their members social and moral support to perform their roles as professionals and to cope with their professional problems. Nursing organizations, association journals, for example, disseminate updated knowledge, new ideas, and professional concerns. By participating in the collective bargaining process, nurses can improve their economic and working conditions.
 
Professional Socialization of Nursing
People's work identities can be one of the most important parts of their social identities, since they are often judged by the ways in which they do their jobs and by how successful they are at achieving their goals. Professional socialization is “the process whereby the values and norms of the profession are internalized into one's own behavior and concept of self; it is the process whereby the knowledge, skills, and attitudes characteristic of a profession are acquired.” In other words, socialization as “the process of learning new roles and the adaptation to them, and as such, continual processes by which individuals become members of a social group.” It points out that from the perspective of professional nursing, the adult socialization/resocialization process focuses on the provision of values and behaviors basic to the delivery of quality client care. Standards for this process are derived from the norms of service professions and guide the specific role of professional nurses. Obviously, each person enters a nursing education program with many personal values that reflect the person's culture. Some of these values influence the person's choice of nursing as a career and during ongoing professional development through life-long learning. The professional educational concept of the nurse is one who does the following:
  • Defines clients in terms of health and promoting and maintaining health
  • Views the relationship between the nurse and clients as a therapeutic and analytic process
  • Learns technical mastery of procedures and tools from the aspect of principles guiding their use
  • Uses critical inquiry and creativity processes to manipulate knowledge in relation to the client's concerns
  • Accepts responsibility and accountability for client care decisions.
The socialization process therefore involves changes in knowledge, skills, attitudes, and values–changes that are often associated with strong emotional reactions and conflict. It is within the nursing educational program that professional values are developed, clarified, and internalized. Specific professional nursing values are stated in nursing codes of ethics, in standards of nursing practice, and in the legal system itself. Four values critical for the profession of nursing includes:
  1. A strong commitment to the service that nursing provides for the public
  2. Belief in the dignity and worth of each person
  3. A commitment to education
  4. Autonomy.
  • A strong commitment to the service that nursing provides for the public, is considered essential. Nursing is a helping, humanistic service directed to the health needs of individuals, families, and communities. The nurse's role is therefore focused on health and care. Nurses, being responsible for assessing and promoting the health status of all humans, need to value their contribution to the health and well-being of people. Since “care and caring is the central core and essence of nursing,” nurses also need to value the caring aspect of nursing.
  • The dignity and worth of each person is based on philosophy of the sacredness of human life and the worth of the individual. Because nursing is a person-oriented profession, a basic value of the worth of each person regardless of nationality, race, creed, color, age, sex, politics, social class, and health status is basic to nursing. Applied to nursing practice this value means that the nurse always acts in the best interest of the client.13
  • Commitment to education, the third value, reflects the lifelong value of learning in any society. In terms of professional nursing, continuous education is needed for graduates to maintain and expand their level of competencies to meet professional criteria, to anticipate the role of the nurse in the future, and to expand the body of professional knowledge. Nurses need to question nursing knowledge and practice critically, to contribute to nursing's theoretical base, and to test theories in nursing practice.
  • Autonomy, or the right of self-determination as a profession–is “the one where the greatest emphasis should be placed at this time.” Nurses must have freedom to use their knowledge and skills for human betterment and the authority and ability to see that nursing service is delivered safely and effectively.” A future challenge for nurses is to become more assertive in promoting nursing care and to develop the ability for independent behavior.
 
Professional Nursing Values
The values related the professional nursing are under three aspects, i.e.
  1. Values covering the professional nurse
  2. Values covering the nurse-patient relationship
  3. Values covering the relationships of the nurse to colleagues and to the community as follows:
 
Professional Nurse
  1. The nurse should enter the profession with a strong moral character and during the years that she/he engaged in her/his profession he/she should continue to develop ethical and moral principles essential to gain the confidence and trust of those with who he/she works. But he/she must avoid passing moral judgements on patients and co-worker.
  2. The nurse should be eager to secure more knowledge of experience in nursing. But this knowledge should be gained to help people rather than merely to satisfy her own intellectual curiosity.
  3. The nurse, when engaged in the practice of her/his profession should have the primary obligation to make as much time as possible available for the study and care of patients. But she/he should also continue to keep her/his outside Interest alive, varied and growing and to maintain worth while relationships with home community, temple, church, school and friends.
  4. The nurse should make available as much time as possible for her/his work. But she/he should continue her/his self education to gain greater breadth and depth of preparation in nursing and more content dealing with the world around her/his and to strengthen values which should guide her/his action as a citizen, as a professional nurse and as an individual.
  5. The nurse should be willing to share her/his research findings in nursing with others. But she/he should be willing to let other researchers, validate her/his research results and further develop knowledge which may be helpful to people.
  6. The nurse should be interested and willing to add to his/her nursing responsibilities as she/he progresses in her/his profession. But she/he must not prematurely accept a responsibility for which she/he is not adequately prepared through education and related experience.
 
Nurse-patient Relationship
  1. It is important that the nurse have friendly, cheerful and pleasant relationships with the patient and his family. But it is equally important she/he should not be familiar.
  2. The nurses should show appropriate concern for their patients without becoming too involved emotionally. But they must avoid becoming callous and should have compassionate concern for the patient.
  3. The nurses must provide adequate and unhurried care for each patient. But they should not allow any patient to use up so much of their limited time as to have this be at the expense of the welfare of other patients.
  4. The nurse should do whatever is needed for the patients physical, mental and spiritual comfort. But she/he too has a right to a normal life, which she/he shared with her/his family and friends.
  5. The nurses should be concerned with the patients emotional needs as well as with his physical needs. But they should respect the patients confidences and should not repeat them unless necessary for his better care.
  6. The nurses must know their patient as a person and give substantial attention to their psychologic and social circumstances. They must know themselves and not become too subjective in their relationships to any patient.
  7. The nurses should be good listeners but not to the extent that they start offering nothing of value to the conversation when it is needed.
 
Relationship of the Nurse to Colleagues and to the Community
  1. The nurse must be conscientious in carrying out the physicians instructions relating to the proper care of the patient. But she/he must question the instructions if the situation warrants it.
  2. The nurse must respect the reputation of her/his colleagues and not hold them up to ridicule before associates or patients. But she/he is obliged to see to it that high standards are maintained by others in the profession as well as by herself/himself.14
  3. The nurse must collaborate with nursing team rather than dominate them. But she/he has responsibility for supervision of these workers and must see that they meet high standards.
  4. The nurse should be an active participant in nursing organisations. But she/he should not spend too much time away from her/his job.
  5. The nurse must do all she/he can to prevent illness and promote health. But she/he must not be disappointed or discouraged if she/he is not rewarded by the public as readily for the prevention of illness, since it is not as readily recognised by patients who do not know that they remain healthy because of preventive means.
  6. The nurse must seek better ways of carrying out professional responsibilities. But she/ he must welcome supervision and evaluation by others who are willing and qualified to help her/his improve.
  7. The nurse should develop self-confidence and trust, in emergencies, make quick decisions and judgement. But she/he must not assume the attitude that everything she/he does is right.
 
Qualification of Professional Nurse
Arthur Corey (1955) stated that “No group of specialized workers can done to dream of making its calling pre-eminent unless the significance of its social contribution is so compelling that pre-eminence is imperative”.
Since nurses also come under specialised group, the good nurse should:
  1. Have faith in the fundamental values that underlie the democratic way of life, e.g. the nurse should have respect for the individual dignity of every human being, practicing self sacrifice for the common good, participating and allowing participation of others in matters affecting both the individual and the group and having a strong sense of responsibility for bearing full share in solving problem of the society.
  2. Have a sense of responsibility for understanding those with whom they (Nurse) work or associate through use of the following skills:
    1. Skill in utilizing pertinent basic concept of psycho logy and
    2. Skill in handling themselves so that they and others may work effectively together.
  3. Have faith in the reality of spiritual and aesthetic values and awareness of the value and pleasure of self development through the pursuit of some aesthetic interest.
  4. Have the basic skills and knowledge necessary to apply to present day social problems realistic, incisive and well ordered through use of the following skills:
    1. Skill in securing, appraising and organizing evidence.
    2. Skill in inductive analysis of social problem in terms of their origins and
    3. Skill in using basic concepts and generalization for deductive analysis.
  5. Have skill in using written and spoken language, both to develop their (Nurses) own thoughts and to communicate them to others.
  6. Understand and appreciate the importance of good health.
  7. Like hard work and possess a capacity for it.
  8. Appreciate high standards of workmanship.
  9. Really try to accept and understand people of all sorts, Regardless of race, religion or color.
  10. Know nursing so thoroughly that every person will receive excellent care.
 
Abilities of Professional Nurse (Arthur Corey 1955)
All nurses, regardless of the special field in which they elect to practice, should:
  1. Be able to give expert bed side care and have such knowledge of the household arts as will enable them to deal effectively with domestic emergencies arising out of illness.
  2. Be able to observe and to interpret the physical manifestations of the patient's condition and also the social and the environmental factors which may hasten or delay his recovery.
  3. Possess the special knowledge and skill required in dealing effectively with situations peculiar to certain common types of illness.
  4. Be able to apply in nursing situations those principles of mental health which make for a better understanding of the psychologic factor in illness.
  5. Be capable of taking part in the promotion of health and prevention of disease.
  6. Possess the essential knowledge and the ability, to teach measures to conserve and restore health.
  7. Possess the required knowledge about legal aspects of nursing.
  8. Be able by means of the practice of nursing profession to attain a measure of economic security and to provide for sickness and old age.
So, as a professional nurse, all will need to:
  1. Develop sound study habits.
  2. Assume responsibility for advantage our own learning.
  3. Participate actively in professional associations.
  4. Help interpret nursing needs and the role of the nurse to persons, to the community, to members of other health professions and to personnel in institutions of higher education.
  5. Be able to teach practical nurses and auxiliary workers.
  6. Be able to function as a leader of a nursing team and to direct the activities of allied nursing personnel.15
  7. Arrive at decisions by utilizing the problem-solving approach and not be dependent upon specific rules as a guide to all actions.
 
Characteristics of Professional Nursing Practice
For some nurses, work is a job that provides financial return and some degree of satisfaction. Professional practice, on the other hand, requires a “deep and abiding awareness of purpose and direction in place of a specific set of objectives or standards.” For a professional, work is a component of a career plan and an integral part of the person's being.
Experts explored the idea that involvement, motivation, and commitment are separate components of a person's sense of vocation. Involvement is viewed as a quantitative measure; for example, how much time or energy does the person devote to nursing? Motivation is the driving force suggested by the question “what's in it for met” Motives might include prestige, financial gain, or even just keeping busy, or they might include the opportunity for self-expression and achievement of excellence. Commitment is defined as the “intimacy of the perceptions about nursing to the very core of the self.” It is unlikely that a person could achieve a professional self-identity without great involvement and a sense that nursing is a major component of her or his life. It is time to “reinstate the service ideal in its proper primary relationship to our science and practice on the one hand, and to our legitimate claims to self-determination and reward on the other.” Components of this service ideal include a sense of purpose, a sense of capability, and a concern for others demonstrated as caring. Caring includes interpersonal valuing and involvement; experiencing with the other; instillment of faith, concern, and love for another; and actualization. This concern for others, although by itself not sufficient to form a professional purpose, is basic to a service ideal. Whether a person could be a professional nurse without possessing genuine warmth and caring for others is questionable.
The concept of a professional includes accountability and autonomy for personal actions. Accountability means that the nurse is answerable for her own behavior. Autonomy means the freedom and the authority to act independently However, “the right to autonomy refers specifically to control of one's own life-not the lives of others.” For example, an autonomous nurse would make a judgment about a client's possible health problem but would work with the client to identify the client's views about the “problem.” Unfortunately, nurses collectively have been characterized by feelings of inadequacy, powerlessness, and frustration, and avoidance of accountability for autonomous practice. Competition for status has interfered with a spirit of collegiality and shared respect. As a result, nursing has been largely a labor force rather than a significant influence on the health care delivery system.
Collaboration with members of the health professions, especially physicians, has been promoted as an appropriate approach to teamwork. True collaboration involves the potential for equally valued contributions by the parties. Yet the typical medical curriculum provides physicians with little experience with or knowledge of the potential contributions of colleagues in other disciplines. Most nurses have much less education than do physicians and thus usually are not viewed as physicians' equal colleagues. Under such circumstances, “coordination, cooperation or collaboration, however desirable, do not provide lasting solutions in power struggles.” By emphasizing cooperation and collaboration, nurses have used their potential power to “maintain the very system which has oppressed… rather than change the system.”
As the health care delivery system has changed under pressure to contain cost increases, the concept of managed care has received renewed attention. In principle, managed care provides for planned organization and coordination of client care across delivery settings. Unfortunately, in practice, managed care largely has been incorporated into case management, which is usually limited to the hospital setting, and to management of medical care to provide “a controlled balance between quality and cost.” Large numbers of nurses have not been ready risk takers. Seeking to cooperate with other health professionals may represent less risk than autonomous practice, but professionals need the ability to manage ambiguity and diversity to make sound judgments and decisions in practice. They also need knowledge and skills to use the political process for power. The unwillingness to take risks (based on sound knowledge) and use political power are the greatest barriers to autonomous and assertive nursing practice.
 
Professional Behaviors of Nurses
Miller (1985) states that the degree to which a nurse behaves as a professional is reflected in the following five behaviors. The professional:
  1. Assesses, plans, implements, and evaluates theory, research, and practice in nursing. These behaviors are reflected in the entire nursing process.
  2. Accepts, promotes, and maintains the interdependence of theory, research, and practice. These three elements make nursing a profession and not a task centered activity.
  3. Communicates and disseminates theoretical knowledge, practical knowledge, and research findings to the nursing community. Professionalism must be demonstrated by supporting, counseling, and assisting other nurses.
  4. Upholds the service orientation of nursing in the eyes of the public. This orientation differentiates nursing from an occupation pursued primarily for profit. Many consider altruism the hallmark of a profession.16 Nursing has a tradition of service to others. This service, however, must be guided by certain rules, policies, or a code of ethics. The nursing code of ethics is formulated by national nursing associations. In addition, society is protected by licensure and certification of nurses. These self-regulatory provisions give nurses the autonomy to function in the public's best interests rather than in the best interests of an institution or other profession.
  5. Preserves and promotes the professional organization as the major referent. Operation under the umbrella of professional organization differentiates a profession from an occupation.
 
Code of Ethics of a Profession
Ethics is the philosophical study of morality. Morals are defined as the “shoulds and oughts of life, and, ethics as the reasons behind the morals.” Ethics are standards for determining right or wrong and for making judgments about what should be done to or for other human beings. Because there is no arbitrary standard of right and wrong, the study of ethics helps each individual nurse identify her own moral positions and biases, in preparation for decision making in ethical dilemmas.
Because there often is no clear-cut single answer for a given moral dilemma, and because people may disagree as to the best decision, many moral decisions require an agonizing personal choice among imperfect alternatives. “The basic categories of moral life are conflict, choice, and conscience. Conflict and choice constitute the two interdependent factors of the moral process in its developed stage. Neither factor can function properly without the other, the moral process itself being precisely the product of the two.”
It is important to remember that the “basic moral concern (of nursing) is with the welfare of other humans.” “One of the central goals of nursing is to care for people with respect and dignity, supporting the client's right to self determination.” This principle may be helpful in considering controversial moral decisions that arise in relation to institutional policies and physician orders regarding medical care. It is a part of the Code for Nurses. This code “serves to inform both the nurse and society of the profession's expectations and requirements in ethical matters. One of the criterion of a profession is that the profession “must recognise its obligations to society by insisting that its members live up to an established code of ethics”. Ethic has always been an integral part of nursing. Throughout history one can find codes of ethics, statements of moral principles, treatises on maintaining high ideals, and recorded discussions on moral and ethical issues. Caring for and comforting sick and protecting the suffering the human activities of nurses. These human activities and how society views them directly affect the more privilege customs and beliefs of human kind.
Code of ethics serve a variety of purposes as follows:
  1. They serve as one basis for developing pre-service curriculum for the particular professional group.
  2. They help to orient the new practitioner to his professional responsibilities, rights and privileges.
  3. They furnish the basis for distinguishing scrupulous and unscrupulous conduct.
  4. They serve as a basis for regulating the relationship of the practitioners to consumers of the professional services, to the professional itself, to society and to co-workers within the outside the profession.
  5. They provide the profession with a basis for excluding the unscrupulous or the incompetent practitioner, for defending the practitioner who is wrongly accused of wrong doing.
  6. They serve as a guide to the public for understanding the characteristics of professional conduct.
 
Criteria of Good Codes
Lieberman has identified seven criteria for good codes as follows:
  1. A code must be clear. Just as a good law differentiates clearly between legal and illegal conduct, so a good code differentiates clearly between ethical and unethical conduct. A code cannot possibly specify everything a person might to do that would be unprofessional, but it should avoid mere exhortation or platitudinous injunctions. The code must lay down principles which are specific and clear enough to be applied in a variety of concrete cases.
  2. Although a code must aim at the rendering of efficient service, it must avoid insisting upon unreasonable standards of behavior on the part of the practitioners. This does not mean that altruistic behavior is unreasonable or that the code cannot require service to be performed at great sacrifice to the professional worker himself. Doctors are required to provide medical services in emergencies even when there is no chance that they will receive any compensation for such service. Nevertheless, the medical code is not unrealistic at this point, because it authorizes doctors to charge others a sufficient amount to defray the doctors expenses in serving those unable to pay.
  3. A good code will not assume agreement on professional policy or purpose where none exists. It will not unwillingly commit the entire profession to a policy about which reasonable professional mean can or do differ.
  4. A code should deal only with professional conduct or with non-professional conduct that bears a clear and correct relationship to professional conduct. Professional code should not be used to regulate the personal and non-professional lives of the 17practitioners. Conduct which is irrelevant to the rendition of efficient service must not be included in the code.
  5. A code must not confuse undesirable patterns of behavior with unethical ones. This is very important. A code must contemplate enforcement or it is useless. Every provision in the code must meet this test. It would be violation of this provision to justify same kind of penalty, disciplinary action by the profession against the violator. If not, then the provision in question should not be in the code.
  6. A code should protect the competent practitioners by a straight forward recognition of the various situations in which the practitioner may be become the object of unjustified lay criticism and abuse, therefore, it will not regard lay popularity as the test of professional integrity and competence.
  7. A code should keep the concept of efficient service as the controlling consideration in all cases. It will not compromise this and for professional advantage, whether professional advantage be regarded as the advantage of the individual practitioner or the professional group as a whole.
Within any given profession, a code of ethics serves as a means of self regulation and a source of guidelines for individual behavior and responsibility. Ideally, code of ethics is a response to a society's needs for trustworthy, competent and accountable practitioner. Professional code of ethics are a system of rules and principles by which that profession is expected to regulate its members and demonstrate its responsibility to society. They provide an enforceable standard of minimal conduct and indicate the ethical consideration of professional conduct.
A code of ethics provides a standard of behavior that serves as guide for:
  1. Education and practice of nurses
  2. Legislation affecting nurses
  3. Licensing of nurses, and
  4. Public participation of nurses.
The Nightingale pledge, prepared by Greater, included the basic principles of governing ethical practice.
 
Nurses Pledge
 
The Florence Nightingale Pledge
I solemnly pledge myself before God and in the presence of this assembly; to pass my life in purity and to practice my profession faithfully;
I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug;
I will do all in my power to maintain and elevate the standards of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling;
With loyalty will endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.
 
The Practical Nurse Pledge
Before God and those assembled here, I solemnly pledge;
To adhere to the code of ethics of the nursing profession;
To cooperate faithfully with the other members of the nursing team and do carryout faithfully and to the best of my ability the instructions of the physician or the nurse who may be assigned to supervise my work;
I will not do anything evil or malicious and I will not knowingly give any harmful drug or assist in malpractice.
I will not reveal any confidential information that may come to my knowledge in the course of my work.
And I pledge myself to do all in my power to raise the standards and prestige of practical nursing;
May my life be devoted to service and to the high ideals of the nursing profession.
 
Code for Nurses as Approved by CNR: 1982
 
Ethical Concepts Applied to Nursing
The fundamental responsibility of the nurse is fourfold; to promote health, to prevent illness, to restore health and to alleviate suffering.
The need for nursing is universal, inherent in nursing is respect for life, dignity and rights of man. It is unrestricted by consideration of nationality, race, creed, color, age, gender politics or social status.
Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups.
 
Nurses and People
The nurse's primary responsibility is to those people who require nursing care.
The nurse, in providing care, promotes an environment in which the values, customs and spiritual beliefs of the individual are respected.
The nurse holds in confidence personal information and uses judgement in sharing this information.
 
Nurses and Practice
The nurse carried personal responsibility for nursing practice and for maintaining competence by continual learning.
The nurse maintains the highest standards of nursing care possible within the reality of a specific situation.
The nurse uses judgement in relation to individual competence whom accepting and delegating responsibilities.18
The nurse when acting in a professional capacity should at all times maintain standards of personal conduct which reflect credit upon the profession.
 
Nurses and Society
The nurse shared with other citizens the responsibility for initiating and supporting action to meet the health and social needs of the public.
 
Nurses and Co-workers
The nurse sustains co-operative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard the individual when his care is endangered by a co-worker or by any other person.
 
Nurses and the Profession
The nurses plays the major role in determining and implementing desirable standards of nursing practice and nursing education.
The nurse is active in developing a core of professional knowledge.
The nurse acting through the professional organization participates in establishing and maintaining equitable social and economic working conditions in nursing.
Suggestions for application by nursing educators, practitioners, administrators and nurses' association of concepts of the code for Nurse.
The code for nurses is a guide for action based in values and needs of society, it will have meaning only if it becomes a living document applied to the realities of human behavior in a changing society.
In order to achieve its purpose of code must be understood, internalized and utilized by nurses in all aspects of their work, it must be put before and be continuously available to students and practitioners in their mother tongue, throughout their study and working lives. For practical application in the local setting, the code should be studied in conjunction with information relevant to the specific situation which would guide the nurse in selecting priorities and scope for action in nursing.
 
Code for Nurses (ANA)
The ANA code for nurses is as follows:
  1. The nurse provides services with respect for human dignity and the uniqueness of the client unrestricted by considerations of social or economic status, personal attributes, or the nature of the health problems.
  2. The nurse safeguards the client's right to privacy by judiciously protecting information of a confidential nature.
  3. The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.
  4. The nurse assumes responsibility and accountability for individual nursing judgments and actions.
  5. The nurse maintains competence in nursing.
  6. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others.
  7. The nurse participates in activities that contribute to the ongoing development of the professions body of knowledge.
  8. The nurse participates in the professions efforts to implement and improve standards of nursing.
  9. The nurse participates in the profession's efforts to establish and maintain conditions of employment conducive to high-quality nursing care.
  10. The nurse participates in the profession's effort to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing.
  11. The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.
The “Interpretive Statements” distributed with the code emphasize clients' rights and nurses' responsibilities. Clients' rights include:
  1. Respect for human dignity, and adequately informed consent.
  2. Full involvement in the planning and implementation of health care.
  3. Nursing care based on need, irrespective of social and economic status, personal attributes, or the nature of the health problem.
  4. Privacy and confidentiality of information.
  5. Protection from unsafe or unethical health care practices.
Nurses' responsibilities include:
  1. Assuming accountability and responsibility for giving safe and competent care, delegating activities to others, and maintaining the integrity of nursing.
  2. Participating in research while protecting the rights of human subjects.
  3. Establishing and maintaining employment conditions conducive to high-quality nursing care.
  4. Promoting collaborative planning for availability and accessibility to quality health services for all citizens.
 
Functions of Professional Nursing
A function is a nucleus of activities, responsibilities or duties so homogenous in character as to fall logically into a unit for purposes of execution.
Professional groups have distinctive function to perform. It has not been easy to identify functions for the nursing profession. However, Lesnik and Anderson have identified 19and linked seven areas of function in professional nursing, based upon legislative and judicial decisions. Six of these are classified as independent areas and one as a dependent area.
 
Independent Functions
  1. The supervision of a patient involving the whole management of care, requiring the application of principles based upon the biological, the physical and social sciences.
  2. The observation of symptoms and reactions, including symptomatology of physical and mental conditions and needs, requiring evaluation or application of principles based upon the biological, the physical and the social sciences.
  3. The accurate recording and reporting of facts, including evaluation of the whole care of the patient.
  4. The supervision of others, except physicians, contributing to the care of the patient.
  5. The application and the execution of nursing procedures and techniques.
  6. The direction and education to secure physical and mental care.
 
Dependent Function
The application and the execution of legal orders of physicians concerning treatments and medications with an understanding of cause and thereof.
 
Ethico-legal Obligation of Nurses
The Code and the Interpretive Statements “provide a framework within which nurses can make ethical decisions and discharge their responsibilities to the public, to other members of the health team, and to the profession.” An ethical code defines a professional standard but it does not provide specific guidelines for how the nurse should act in a given situation, nor is it legally binding. Individual decisions, if moral, are based on ethical principles and can be enforced only by the nurse's conscience.
 
Ethical Obligations
  • Autonomy is a basic ethical principle. An autonomous person is capable of making rational and unconstrained decisions and acting on those decisions. Belief in autonomy means that the nurse respects the client and the choices that the client may make as a rational person.
A person is considered rational when capable of choosing the best means to some chosen end. A person's rationality may be diminished by numerous factors, including fear, laziness, lack of intelligence, pain, drugs that affect reasoning ability, and disease. Regardless of a person's rationality, several situations seem to justify constraints on autonomy. Some of the most widely accepted of these situations include preventing harm to others (private harm principle), preventing offense to others (offense principle), and preventing impairment of institutional practices that are in the public interest (public harm principle). Some situations in which moral legitimacy is a matter of dispute include preventing self-harm (principle of paternalism), providing benefit for the person being constrained (principle of extreme paternalism), and providing benefit to others (social welfare principle). Interference with a person's autonomy, whatever the reason, is paternalism.
A person can be constrained from acting autonomously through lack of knowledge just as well as by coercive force. Thus, the nurse is obligated to share all relevant information and alternatives for action with the client so that informed choices can be made. The nurse also is obligated to respect the client's decisions, even when disagreeing with them. This may mean that the nurse is forced to choose between doing something she believes to be in the client's best interests and respecting the client's decision to do otherwise.
  • Beneficence and justice: Beneficence, relates to the nurse's duty to help clients further their legitimate interests within the boundaries of safety. This principle is closely related to the principle of justice, which specifies that all clients be provided with high-quality nursing care irrespective of social conditions, economic status, personal attributes, or the nature of health problems.
The preceding principles are based on the assumption that all persons have certain ethical rights. Three types of ethical rights includes:
  • A conventional ethical right is a claim derived from customs, traditions, and expectations. An example is the right of the client to confidentiality of information.
  • An ideal ethical right is a claim of what ought to be, but it may not actually exist. An example is the right of all citizens to equal access to excellent health care.
  • A conscientious ethical right is a claim based on principles of conscience. Such claims may not be recog nized as valid by others (e.g. terminating life-support systems in a person with brain death).
Individual rights are associated with a number of concerns. For example, what kinds of entities have rights and what kinds do not? Does a fetus have rights? When there is a conflict of rights, how should the conflict be resolved? Obligations to clients may seem to conflict with obligations to the physician or to the institution. This is not really a moral dilemma, although the decision may be an agonizing one. There is an important distinction between doing what is morally right and what is least difficult practically. As a professional, the nurse's primary ethical obligation is to the client.20
 
Legal Obligation
However, the nurse may have legal obligations to both the client and the institution. These legal obligations are given below:
Licensure: The licensure is “the process by which an agency of government grants permission to persons to engage in a given profession or occupation by certifying that those licensed have attained the minimal degree of competency necessary to ensure that the public health, safety, and welfare will be reasonably well protected.” Thus, a license is a legal document that certifies that minimal standards for qualified practitioners have been met. Requirements for licensure as a registered nurse are included in each state's nurse practice act. Each act “contains a definition of professional nursing; outlines requirements for licensure and provides for endorsement for persons licensed in other states; specifies exemptions from licensure; lists grounds for revocation of licensure; provides for a board of examiners and outlines its responsibilities; and sets penalties for practicing without a license.”
Legal responsibility: Licensure as a registered nurse carries with it the responsibility for safe and competent practice. If injury, unnecessary suffering, or death should occur as a result of care given by a nurse, the nurse legally may be held responsible for malpractice or negligence. Malpractice has been defined as “any professional misconduct, unreasonable lack of skill or fidelity in professional or judiciary duties, evil practice, or illegal or immoral conduct.”
Negligence, on the other hand, is “the omission to do something that a reasonable person, guided by those ordinary considerations that ordinarily regulate human affairs, would do, or as doing something that a reasonable and prudent person would not do.” Some of the most common acts of negligence by nurses involve burns; falls; wrong dosage, concentration, or kind of medication; mistaken identity; blood administration; failure to communicate effectively with the client, the client's family, or health team members; failure to observe and take appropriate action; failure to observe defects in equipment; and failure in reasonable judgment.
The nurse is legally responsible for her own actions. But because in most cases the nurse also is an employee of an institution, the question may arise as to whether the institution and the client's physician also are legally responsible. This is due to the legal “respondent superior” (master-servant) rule, which states that the master is responsible for the acts of the servants. Based on this rule, the nurse's employer also is held responsible for the nurse's acts.
A person becomes an employee “when he performs services for another who has the ‘right to control’ what is done and how it is to be done. An employee is one who works for wages or salary in the service of an employer.” The registered nurse who also is a student is considered an employee if she usually works for pay in that institution. On the other hand, the contract between the nursing school and the clinical agency usually specifies that basic students are not employees of the agency and must carry their own liability insurance. However, precedent cases have held institutions (as well as the students and possibly the faculty) responsible for the actions of nursing students acting as agents of the institution in the provision of care.
Nursing students are accountable and personally liable for their actions. In cases involving alleged negligence, the court will try to establish the standard of care against which the student's actions will be evaluated. The court will usually examine the following:
  1. The practice of the clinical agency and school to allow a student at a certain point in studies to give this particular treatment to a client, by asking [whether] this student was appropriately allowed to carry out this activity
  2. The student's knowledge, by asking whether there had been proper instruction in all related subjects in school and whether adequate knowledge and sufficient ability as a student nurse had been demonstrated to be entrusted with such tasks.
The actions of nursing students will be judged by their experience and the amount of their education. This is based on the standard of reasonable care, which is concerned with the degree of skill and knowledge customarily used by a competent practitioner of similar education and experience in the community. However, if students perform duties within the scope of professional nursing “these acts must be carried out with the same degree of competence as if done by a registered professional nurse.” Thus, individual limits of experience and education must be known by the student, who must be adequately prepared for clinical assignments. If questions arise about how to proceed with an activity, the faculty must be contacted.
Ethical and legal considerations may at times overlap. The nurse must know and function within the legal parameters of practice in her state. If the nurse has moral or legal concerns about medical treatment, she must share those concerns and the reasons for them with the physician and, if necessary, with nursing, medical, or hospital authorities. The nurse may refuse to carry out a treatment, but must not attempt to circumvent the physician by interfering with treatment without the physician's knowledge. The goal should be collaboration, not competition.
 
NEED FOR NURSING ADMINISTRATION
Nursing is a major component of the health care delivery system, and nurses make up the longest employment group within the system. Nursing services are necessary for virtually every client seeking care of any type, including 21health promotion, diagnosis and treatment, and rehabilitation. Because nursing is such an important part of the health care delivery system and because the delivery of nursing services is tied to other components of the health care delivery system, the nurse needs to understand the system to effectively deliver quality care within it. Every nurse practicing today needs to appreciate that health care is a business. The success of health care business depends on nursing participation in changing the systems for delivering cost-effective care and creating strategies to ensure that clients receive quality care.
Since ancient times, nursing has been required to respond to changing technological and social forces, e.g. managerial responsibilities evolved in response to an increased emphasis on the business of health care, thus requiring managerial expertise in the financial and marketing aspects of their departments. Because the trends in the health care delivery the nurse supervisor/administrator manager role is becoming critical to effective, quality, patient care; to confronting these expanding responsibilities, and demands the nurse manager must taken on new dimensions to facilitate quality outcomes in patient care and meet other strategic institution goals and objectives.
There is need to develop managerial skills and leadership skills. Two of the foremost tasks of a new nursing leadership will be to raise the consciousness of nurses through an ongoing critique of the present system and to offer philosophical and practical rationales for fundamental change, based on nursing values and the control role that nursing plays in the health care process. These skills are also necessary for team building at the organizational level, ensuring success in all aspects of nursing administration and maintaining high quality in the areas of nursing service, nursing education and nursing administration as a whole.
The nursing administrator historically has been the nurse who endured, who followed the administrators and physicians directions well, and who characteristically was seen as having less power and competence than other administrators. With today's pressures, that nursing administrators cannot exist long. Trends in the nursing community have produced nursing administrators who can think independently and can solve problems as well as direct others in goal setting and achievement. Unfortunately, the issues facing nursing today and in the nearing future are extremely complex and involve more than just nursing.
The present nursing administrators have been ill prepared to face those issues in all level of their administration. So there is a need for all nurses irrespective of their primary job, must assume responsibility for the management or administrative functions that are inherent in every nursing job. It is often said that the role of the professional nurse is becoming increasingly bureaucratic. If bureaucracy includes managing others, managing proper work and managing multiple program or agendas of the health care delivery system/enterprise, then there is truth in that statement. The increasing complexity of delivering patient care requires a multifaceted role for the professional nurse and includes managerial responsibilities.
These managerial activities differ depending on the specific job and situation, but they always include effective communication, delegation, human relations and the management of people, time and resources. The professional nurse also plays an important role in managing change, resolving conflicts and making organisational goals. The role of the nurse is composed of a multidimensional set of activities that focus on care of the patient, support of the organisation, and support of the profession and oneself as a professional.
Since many years, nursing has rigidly adhered to categorisation of nurses as clinicians, educators, managers or researchers. There role categories have referred to primary focus of the job. Now there is a need for every nurse to have a sound management base from which to operate. This aspect of the clinical work role cannot be delegated or relegated as a low priority. Management is a key to success in the professional nursing job. The issue has become one of the many aspects of job-clinical, managerial, educational and research with overall consistency. As with most learning it is easier to start with simple and move to the complex. The new nurse can identify the basic managerial behaviors necessary for success and practice these until mastery is achieved. She/he can move towards the more complex managerial activities that ultimately may result in a change in her/his primary role from clinical nurse to manager.
Nurses in managerial roles must be able to understand the conditions promoting and innovating the expression of talent among team members. This understanding requires a close look at the new responsibilities and activities with which managers should be involved and an equally close look at which of the traditional roles must be modified to accommodate the every evolving changes. As the health care industry/system has changed dramatically in the past few years, so have the roles of nurses. These changes have led to role ambiguity as nurses search for models that will meet changing demands.
The managerial roles being assumed by clinical nurses are the result of requirements to push decision making to lower of the organization and encourage nurses to determine the ways in which the delivery system can best function. The contemporary manager is finding that the pure managerial role is changing. No longer an authoritarian order gives, today's manager a concentration on providing a climate in which individuals have a sense of working for themselves. Thus, role of the manager should be able to:22
  • Provide visibility for organisation goals
  • Provide resources and define constraints
  • Mediate conflict
  • Serve as a coach or member
  • Monitor results
  • Stay out of the way so that individuals can manage their work.
This redefines of the managers role to provide opportunities for persons to manager their own work gives clear direction to the nursing personnel to assume responsibility, whether clinical or managerial.
For all the above reasons, the nurses must be prepared to look into the matters of all types of management. So, managerial concepts or concepts of administration needed by the nurses at all level, focus on how to deal with people, how to manage resources, and how to manager ones job. This preparation is important in making that first job more meaningful and understandable.
Nursing administration describes the managerial role of the nurse in complex organisation, the management of one's professional career, and the issues related to contemporary professional nursing practice.