Home care case management. Perspectives from the home front

Focus groups were held with home care case managers in two cities in Canada which provided information on the role of the case manager, factors that influence decision making, recent changes that have taken place in case management, and the different and positive aspects of home care case management. Factors which influence decision making were grouped into organizational, client, family, other professionals, and case management factors. The differences in case managers' preparation and functions in the two sites are discussed. The difficult aspects of case management included making tough decisions related to client resources, and client, work life, and management issues. The positive aspects included the personal interaction with clients, the opportunity to follow through on services to clients, the diversity of case management work, and the opportunity for relatively independent professional practice.     

An exploration of the relationship between patient autonomy and patient advocacy: implications for nursing practice

The purpose of this article is to examine whether patient/client autonomy is always compatible with the nurse's role of advocacy. The author looks separately at the concepts of autonomy and advocacy, and considers them in relation to the reality of clinical practice from professional, ethical and legal perspectives. Considerable ambiguity is found regarding the legitimacy of claims of a unique function for nurses to act as patient advocates. To act as an advocate may put nurses at personal and professional risk. It may also be deemed arrogant and insulting to other health care professionals. Patient autonomy can be seen as a subcategory of the right of every individual to self-determination, and as such is protected by law. However, it is questionable whether the traditionally paternalistic approach to health care provision truly respects the autonomous rights of each patient. The author considers examples and cases from the literature that resulted in professional and/or personal difficulties for the nurses involved, and also reflects on an incident from her own practice where a positive outcome was achieved that demonstrated compatibility between the concepts under consideration.     

Is the professional code still the cornerstone of clinical nursing practice?*

Although codes of practice for those concerned with the health care of others have always been inherent in the structure of societies, they have been institutionalized within the nursing discipline since the end of the last century. Up until the early 1970s they promulgated subservience to the medical discipline. As a result of the processes of emancipation and professionalization, the philosophy of the nurse has come to contain concepts of autonomy, accountability and patient‐advocacy, based on a personal and individualized care system. Research in recent years has shown that nurses are making morally sound and ethically acceptable choices based on their own decision‐making abilities, whilst having little or no active knowledge of the existing professional codes. Based on the literature, the author discusses ethical codes in relation to their perception by nurses in the clinical situation. The influence of the code in the areas of moral decision‐making, administration and management, and education are likewise discussed and the conclusion is reached that codes remain the cornerstone of nursing practice.     

Who speaks for the children?

• ? It would probably be a truism to say that most professional nurses consider patient/client advocacy to be an essential component of their role—indeed, there is a UKCC Advisory paper (Exercising Accountability, 1989), which categorically states that this is so. ‘The introductory paragraphs of the Code of Professional Conduct, together with several of its clauses, include clearly the expectation that the practitioner will accept a role as an advocate on behalf of his or her patients/clients.’
• ? Some professional nurses, however, consider advocacy to be too altruistic an activity and prefer to leave it to others.

     

Public health nurse perceptions of empowerment and advocacy in child health surveillance in West Ireland

ABSTRACT Objective: The objective of this study was to analyze public health nurses' perceptions of empowerment and advocacy within a child health screening and surveillance program in West Ireland. Design and Sample: This study combined both qualitative and quantitative research methods. A purposive sample of 9 public health nurses (PHNs) (phase 1) participated in 2 focus groups and a purposive sample of 43 clients attending the child health screening service completed a questionnaire (phase 2). Measures: Focus groups and Questionnaires were used. Results: Thematic content analysis revealed that PHNs in the study did not perceive themselves to be empowered in their work. They attributed this to workload, lack of professional advocacy, and restricted access to power and opportunity, while also identifying the need for continued managerial support and feedback. Conclusions: The results suggest that PHNs need to be empowered in order to facilitate client empowerment. PHNs struggled with empowerment and client advocacy. There is a need for professional development for PHNs in order to support them to more critically engage with empowerment and self‐efficacy in their work. This needs to be done within organizational structures that support PHNs to critically analyze the role of advocacy and empowerment in their practice.     

Ethical dilemmas in nursing: the role of the nurse and perceptions of autonomy

This study investigated decision making in ethical dilemmas and attitudes toward professional autonomy. It was based on Murphy's identification of three nurse-patient relationship models. The model identification was the result of Murphy's investigation of the levels of moral reasoning of nurse practitioners, from Kohlberg's theory of moral development. Autonomy is necessary for patient advocacy in Murphy's highest order model of nurse-patient relationship. 109 freshmen, 103 seniors, and 82 graduates (baccalaureate nursing) were examined for model selection, risk-taking, restrictions, and anxiety in the decision-making process in specific situations. Autonomy was measured independently. The most significant results indicated that freshmen were less likely to select the autonomous model of relationship, had lower attitudes toward professional nursing autonomy, and were less willing to take risks. Graduates were lower than either student group in their perceptions of restrictions and anxiety. The responses to each dilemma itself varied by situation in relation to the model preferred.     

The content of advocacy in procedural pain care – patients’ and nurses’ perspectives

Title. The content of advocacy in procedural pain care ‐ patient’ and nurses’ Perspectives. Aim. This paper is a report of an exploration of the content of nursing advocacy from the point of view of patients and nurses in the context of procedural pain care. Background. Nursing advocacy is every nurse’s professional duty, grounded in patients’ legal and moral rights. Nevertheless, earlier research has approached advocacy as a whistle‐blowing event from the nurse’s perspective. Method. This cross‐sectional study was conducted with a cluster sample of otolaryngology patients (n = 405) and nurses (n = 118) in 11 hospital units in Finland during 2007. The data were collected using an instrument measuring the content of advocacy and analysed statistically. Results. Advocacy in procedural pain care is a process which takes place in the patient–nurse relationship through role identification in decision‐making about pain care. This prompts counselling and responding activities, which in turn lead to some degree of empowerment on the part of both patient and nurse. However, advocacy is partly dependent on the nurse’s own role identification: in the context of pain care it seems that the nurse’s pain care skills and influence over pain care plans are important factors in the decision to advocate or not. At best, patients have some role in decision‐making about their care; at worst, they are subjected to paternalism. Conclusions. Advocacy is an integral part of the nursing care process. It is important that this key ethical aspect of professional nursing is discussed in nursing education and systematically applied in nursing practice through on‐the‐job training, feedback and collaboration.     

Health ‘care’ interventions: making health inequalities worse,not better?

AIM: The aim of this paper is to present a model, the 'Effect of the Professional Ego', which provides a psychodynamically informed analytical framework for examining professional practice in arenas where issues of inequalities need to be addressed. BACKGROUND: There is a great deal of literature on the psychosocial aspects of inequalities in health care provision. However, the impact of intrapsychic and professional cultural elements has not been explored in this context. Moreover, the body of work which does explore these elements in relation to health care workers does not address how they might impact on health inequalities. DISCUSSION: Drawing on empirical work, we discuss ways in which intrapsychic and professional cultural elements feed into the dynamic between clients and health care professionals in a way which can subvert espoused, positive client health outcomes. Based on this discussion, we propose the Effect of the Professional Ego model, which identifies two main aspects of the professional ego - the grandiose self and self-preservation - and how they influence the professional/client dynamic. CONCLUSION: Systematic self-reflection on the part of professionals would be a valuable contribution to the development of professional practice. This applies particularly to conceptualizing the links between the actions of service providers and the adverse health of clients.     

Reflecting on forced medication

There are multiple concerns regarding the practice of forced medication of clients with mental illness. Clients often report that side effects outweigh the benefits of psychotropic medication, while mental health clinicians often think the client may become dangerous without medication. Who should have the right to decide whether a client takes medication? Nursing plays an integral role in the decision making by considering alternative therapies and current research, addressing the diversity among our clients, and ensuring comprehensive assessments. This article presents circumstances that may lead to forced medication and explores beliefs of clients, mental health clinicians, and mental health advocacy groups.Building upon Johns' (2008) model for structured reflections of clinical experiences, this article reflects upon the experience of forced medication in psychiatric nursing practice. First, the process and consequences of forced medication are explored. Next, the factors influencing the thoughts and responses of psychiatric clinicians, clients, and advocacy groups is discussed. Finally, possible alternative actions are presented.     

Effective ergonomic teaching for positive client outcomes. Implications for practice.

Teaching and intervention are integral aspects of professional nursing practice. Numerous publications encourage the use of specific teaching intervention techniques, but few are validated by studies conducted to assess actual teaching behaviors of nurses who administer successful teaching intervention programs. This is a case study of one occupational health nurse who administers a highly effective ergonomic program for employees in a large urban hospital. Themes identified during observation of nurse and client interactions include mindfulness on the part of the nurse, respect for client autonomy, nurse effort, nurse accessibility, and professional distance. A consistent teaching process identified during observation consists of six steps: inquiry, invitation, assessment, synthesis, validation, and progression. This six step process is embedded within identified themes. Teaching and intervention methods identified in the study are a synthesis of caring behaviors and nursing process. This integrated method is entitled "Effective Teaching Through Unified Process and Caring Interpersonal Behavior." It may represent a valid teaching and intervention method supporting compliance and positive client outcome when interacting with clients requiring ergonomic teaching and intervention.     

Social media and professional boundaries in undergraduate nursing students

Social media use and professional boundaries are growing challenges for nurse educators. The current undergraduate nursing student population is a technology savvy generation that enjoys the constant stimulation and social connections created by social media. Professional standards in nursing are dictated by the ANA's Code of Ethics, and educators are responsible for instilling professional values into impressionable nursing students. Professional boundaries have become blurred with increased use of social media as students struggle to differentiate between personal and professional identities. Increased exposure to professional expectations along with clearly defined policies and procedures regarding social media use can foster the development of an ethical conscience in students that can be carried into future practice. The establishment of clear professional boundaries upon entry into nursing programs can support safe use of social media and promote a positive image for the future of the nursing profession.     

Sphere of Nursing Advocacy Model

The Sphere of Nursing Advocacy (SNA) model explains and depicts nursing advocacy on behalf of a client. The SNA model views the client as continually protected from the external environment by a semipermeable sphere of nursing advocacy that allows clients to self advocate if the client is emotionally and physically able or to be advocated for by the nurse if the patient is unable to advocate for him- or herself. The SNA model can be used to guide research or it can provide the basis for instruction on the subject of nursing advocacy.     

Rural Nurse Practitioners: Perceptions of Ethical Dilemmas

The purposes of this study were to identify ethical dilemmas encountered by rural nurse practitioners in primary practice and to identify constraints or enhancers that influenced ethical decision making. Nine nurse practitioners from Wyoming and Colorado responded to in-depth interviews. Six categories of ethical dilemmas and a list of constraints and enhancers were identified. One central concept, conflict between personal values and professional responsibility, emerged. Beneficence, nonmaleficence, justice, and patient autonomy, as core ethical principles, were related to this central conflict.     

国外护士职业社会化与职业认同的研究

职业认同是职业社会化过程的结果之一,它既指一种过程,也指一种状态。职业社会化文献已经从个体的被动或反应性角色转变为社会互动和建构主义观点。护士职业认同的概念包括个人、人际方面与社会历史方面,也是一个多维度的现象,包括结构成分、社会成分和个体心理成分。家庭、社会、教育经验,工作社会化过程中现实打击、师徒关系、职业枯竭都对职业认同的形成与发展产生巨大影响。对护士职业认同的感知研究是这一领域内的另一研究主题。从社会化的角度探讨护士职业认同,可以为改善护理教育和护理管理提供参考。     

On being a good nurse: reflections on the past and preparing for the future

The objectives of this paper include reflecting on the attributes of the 'good' nurse in the past, outlining thematically the essential attributes (virtues) required by the 'good' nurse today and presenting an original 4-point framework for ethics in practice. Although there is no doubt that nurses in the past were highly professional, the culture within which they practiced tended to stifle the emergence of autonomy, assertiveness, advocacy and accountability. An original table of contemporary attributes, which is congruent with a neo Aristotelian virtue ethical approach, is arranged in themes of Intellectual and Practical Attributes, Dispositional Attributes and Moral Attributes. A framework for professional practice, the 'Four As' is then extrapolated from these themes. These four key professional attributes, autonomy, advocacy, accountability and assertiveness, along with the virtues listed in the themes, exemplify the 'good' nurse and are identified as the linchpins of modern professional ethics and good conduct.     

Reflecting on Forced Medication

There are multiple concerns regarding the practice of forced medication of clients with mental illness. Clients often report that side effects outweigh the benefits of psychotropic medication, while mental health clinicians often think the client may become dangerous without medication. Who should have the right to decide whether a client takes medication? Nursing plays an integral role in the decision making by considering alternative therapies and current research, addressing the diversity among our clients, and ensuring comprehensive assessments. This article presents circumstances that may lead to forced medication and explores beliefs of clients, mental health clinicians, and mental health advocacy groups.Building upon Johns’ (2008) model for structured reflections of clinical experiences, this article reflects upon the experience of forced medication in psychiatric nursing practice. First, the process and consequences of forced medication are explored. Next, the factors influencing the thoughts and responses of psychiatric clinicians, clients, and advocacy groups is discussed. Finally, possible alternative actions are presented.     

Professional Autonomy: Essential for Nurse Practitioner Survival in the 21st Century

This article examines nurse practitioners' (NPs) professional autonomy as a critical component of future practice success and survival. Professional autonomy provides the basis for defining and negotiating NPs' work and worth in primary care. Outcome data and analyses that delineate the unique and overlapping practice roles and responsibilities of physicians and NPs will help determine the relative value of their work. Nurse practitioners practicing as physician "substitutes" risk professional survival. Nurse practitioners need to identify nursing as their practice paradigm and nurses as their professional identity.     

Critical incident: reflection on the process of terminal weaning

The article uses critical incident analysis to reflect on the process of terminal weaning. Terminal weaning is defined in the context of withdrawing ventilatory support when the expected outcome is the patient's death. Basic ethical concepts are identified, and the role of the nurse in ethical decision making is discussed in relation to the associated professional and legal issues. Conflict exists between professional and legal accountability in relation to advocacy. Caution is advised with regard to nurses becoming involved in the decision to terminally wean, and its practice.     

Spiritual care, ethical choices, and patient advocacy

Each of the nurses in these examples demonstrates an understanding of patient advocacy. Patient advocacy may involve the nurse in political action or negotiation for change. Perhaps more frequently, however, it is a quiet, private function of support and intuition as patients (or clients) seek to come to a personal awareness of the meaning of illness. Advocacy exhibits a sensitivity to personal values, hopes, and even unspoken prayer that shape an atmosphere of caring. Patient advocacy enhances all that is life giving.