Autonomous Practice and Knowledge
The role of nursing leaders is important within the healthcare delivery system although there has been growing concerns on how to encourage nurses to accept greater challenging roles and more autonomy in nursing practice within the healthcare system.
Wheeldon (2005) emphasizes that the role of nurse is continuing to change and the line between nursing and medicine has become blurred so much that the responsibilities of nurses and clinicians have overlapped. There has been a reduction in the working hours of junior doctors as modern nurses are taking innovative roles and more tasks and responsibilities that were traditionally part of the doctors’ remit (Wheeldon, 2005). The analysis of utilization of physical assessment in the respiratory unit indicates that nursing training and legal issues are important as also physical assessment, adoption of tasks, role extension, and Wheeldon discusses whether taking up extended role of nurses as physician’s assistants or giving them new roles as autonomous practitioners can be more effective for the nursing profession.
Nurses are increasingly taking up more responsibilities from surgery to prescribing and several studies report on controversies surrounding nurse prescriptions. However the changing role of nurses is a fact and the medical setting has to increasingly appreciate and recognize the need for greater and more important roles of nurses.
In this essay we discuss the extended and enhanced role of nurses from several perspectives highlighting many aspects of nursing, focusing mainly on Accident and Emergency departments and the quality of care provided.
Nursing Profession – New Roles?
Macleod and Freeland (1992) describe a study carried out in the Accident and Emergency Department of a clinical setting and assess the extended role of the A&E nurse and their ability to request X-Rays prior to patients being actually seen by a doctor. 579 patients have been selected for the study from the A&E departments and three fourths of these patients were X-rayed at the request of nurses although 7% of these X-rays were considered unnecessary by the doctors who later took up the case. However 90% of the patients fell within the X-ray criteria but did not have an X-ray requested by the nurse. Yet the study do suggest that independent decisions by nurses, especially in the Accident and Emergency Departments and their requests for X-rays from patients without medical back up actually were successful as patients had to spend less time in the A&E department of the hospital.
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In this context, Walsh (1999) differentiates between the nurse practitioner and the general nurses. He emphasizes that there has been a recent growth of nurse practitioner (NP) movements, the importance of the nurse as a practitioner that has coincided with a growing interest in professional development of nurses. There has been a lot of controversy on the role of nurses as nurses have been criticized for moving away from traditional nursing and becoming ‘mini-doctors’ (Walsh, 1999) and performing X-rays, surgery and prescribing medicines. However, as Walsh suggests nurses deny these charges of their attempts to replace doctors or take up doctors’ role and insist that they are only trying to expand nursing roles, learn more skills to help patients and improving their attempts to become ‘maxi-nurses’ or nurses with complete and maximum knowledge in their field. Walsh tends to question how nurses view their professional and future development. And also ask whether nurse practitioners are really intent on becoming mini-doctors and whether this suggests a different kind of aspiration in their professional development? Walsh directly contrasts nurse with nurse practitioners and analyze the path of professional development of NPs in future nursing practice.
Thus extended role of nurses is thus, also an ethical issue as it brings into question the fine line blurring clinical practice from nursing profession. Ulrich and Soeken (2005) bring out the ethical conflict of practice and autonomy within the nursing profession and study a sample of 254 nurse practitioners working in primary care areas of pediatrics, family health and gynecology. According to the study, 45% of total variance in ethical conflict was explained by variables of ethical environment and ethical concern. Ethical concern, idealistic philosophy, ethics education, and percentage of clients enrolled in care explained variance in autonomy. Thus the authors successfully highlight that ethical conflicts play a significant role in nursing practice and autonomy and also focuses on the fact that proper clinical decision making is associated with nursing practice in a managed care environment. The conceptual framework for nursing practice and autonomy influencing decision making can be divided into individual, organizational and societal or market variables that seem to influence ethical concerns as well as practice.
Marshall et al (1997) also studied the legal and professional issues related to nurse administration of drugs according to protocols, within the Accident and Emergency departments and describe the implementation and initial audit findings of such a scheme. The authors studied cases within the A&E department of a district general hospital and analyzed the legal and professional opinions of the nurses, the protocols acceptable to the medical, nursing and pharmacy professions which were developed for a wide range of drugs appropriate for administration by accident and emergency nurse practitioners or ENP. The audit done of the professionals’ opinions addressed general compliance with protocols on drug administration and the nurses’ roles although specific areas such as tetanus immunization, emergency contraception were also addressed. In this study the ENPs assessed 2925 patients in six months and 15.5% of the patients were given drugs according to protocols with no breaches of the protocols. The results indicated more than 94% compliance with protocol standards and more than 71% compliance with emergency contraception. Marshall et al concluded that there are no legal or professional obstacles towards the development of protocols for administration of drugs to patients by nurses without referring to medical doctors as long as protocols met all legal requirements and had support of consultant medical staff. Thus administration of drugs to patients by nurses has to have wider legal, social and managerial support and can consequently be a completely accepted practice. The authors however maintain that such systems may be subject to regular audits to promote a dynamic approach to protocols and training to enhance the system of quality of care of patients who are treated with medicines by ENPs within the Accident and Emergency departments.
The autonomy of the nursing profession should however begin at the level of training as emphasized by Reveley and Walsh (2000) who focus on the role of education of nurses and propose a curriculum for primary health care that can equip nurses to meet the challenges of future healthcare systems. The authors claim that only a radical approach to post-registration education can prepare nurses for working across traditional healthcare boundaries and to a higher level of practice, including taking up greater responsibilities and managerial roles.
A further evaluation of nurse led inpatient care has been done by Walsh and his colleagues in 2003 and the authors emphasize that the ‘black box’ of nurse-led care has to be opened to examine thoroughly this form and model of treatment. The paper presents the processes of care in one nurse-led unit in a hospital ward and compares it with the workings of a clinician led acute ward. Type, frequency and duration of nursing activities were quantified using bar-code technology to measure type, frequency and duration of nursing activities and Quality Patient Care scale was used to measure the quality of care. The results indicated that quality of care provided by Nurse led units matched those provided in the acute clinician controlled wards. Although the patterns of care differed between the wards, activities associated with therapeutic nursing were equally frequent in both the units. The paper points out that disappointing outcomes in patient evaluations may be linked not to nurse led care or clinician care but to a failure to implement a proper therapeutic model of nursing.
Relating how nurse led intermediate care units are being set up across the UK as potential solutions to hospital bed crises, Wiles et al (2001) draws on data collected from an evaluation of a 10 bedded nurse led unit in the South of England and explores the potential of enhanced nursing roles by focusing on the views of nursing staff, especially involved in nurse led units and other healthcare professionals. 38 audio taped qualitative interviews were conducted with NLU nursing staff and other health professionals such as acute ward nurses, doctors and managers. Wiles et al point out that although nurses derived considerable on their work in NLU, this model of treatment was often seen by junior and middle grade nurses as well as doctors as of lower status and quality. Senior nurses however gave a different view and equated working in NLU as part of professionalization of nursing suggesting that involving nurses on the NLU represented extended roles of nurses as doctor substitutes rather than working in complementary therapeutic domains with enhanced roles. The NLUs provide opportunities for nurses to develop enhanced roles and allow them to work autonomously providing elements of therapeutic nursing aimed at improving patient outcomes at and after discharge. To optimize such opportunities proper education, training and leadership are necessary to ensure that both nurses and patients benefit from these programs. Wiles et al thus makes it obvious that nurse led intermediate care not only hands over autonomy to the nurses but by providing opportunity to develop enhanced roles in the nursing profession, can be beneficial to both nurses and patients.
A further study by Currie et al (2005) examine the relationship between staffing levels, quality of care, skills in clinical setting and nursing autonomy. The paper reports on a literature review and uses selected organizational variables to explore whether perceptions of quality are affected by changes in staffing, skill mix or autonomy. According to the report, quality of care is considered as a complex and multidimensional concept and any attempt to evaluate quality of care is challenging to researchers. Traditional nursing assessment tools have failed to provide opportunities to access views of patients or nurses regarding quality of care, also patient satisfaction is still considered as one of the primary indicators of quality. Nurse and patients may have completely different and opposing views on quality and many organizational variables could be related to the perception of quality of care. Thus there is a requirement for a more patient centered research to explore perceptions on the quality of care received and how this is affected by differences in nurse staffing, skill mix and nursing autonomy. The focus of this study definitely indicates a strong link between nursing autonomy, staffing levels and the perception of the quality of care provided both by patients and by nurses.
In a related study, Wiles and his team study nurse autonomy from the patients’ perspective and suggest that intermediate care currently forms the main initiatives of the NHS in improving the quality of post-acute care. Wiles et al studied patients’ and carers’ experiences of a nurse led unit that provided intermediate care to people no longer acutely ill in a UK hospital. From qualitative interview data taken, patients viewed the model of nurse led care as entirely acceptable although there have been reports if inconsistent experiences of care and considerable variations of their perceptions on the purpose of care given in the nurse led unit with the patient outcomes and objectives being ill-defined ion these units. The paper highlights this point and explores the implications of development of good-quality nurse-led intermediate care.
All these studies point out to the developing roles of nurses and the various aspects of nursing in nurse led units providing greater autonomy as well increased responsibilities of nurses in A&E departments. The controversies of nurse led care, patient perceptions and aspects of the nursing profession have been highlighted in the study.
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Nurses and nurse practitioners. Part 2: Perspectives on care. Nurs Stand. 1999 Mar 10-16;13(25):36-40.
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