Professional Adjustment in Nursing PDF

LECTURE NOTES ON PROFESSIONAL ADJUSTMENT IN NURSING UNIT ONE INTRODUCTION Before one can fully grasp the nature of nursing or define its practice, it is helpful to understand the roots and influencing...

LECTURE NOTES ON PROFESSIONAL ADJUSTMENT IN NURSING UNIT ONE INTRODUCTION Before one can fully grasp the nature of nursing or define its practice, it is helpful to understand the roots and influencing factors which shaped its growth over time. Nursing today is far different from nursing as it was practiced 50 years ago, and it takes a vivid imagination to envision how the nursing profession will change as we move forward in to the 21st century. To comprehend present-day nursing and at the same time prepare for future, one must understand not only past events but also contemporary nursing practices. DEFINITION OF NURSING Different people have defined nursing differently. However, in this unit we will see some of the common definitions of nursing: Nursing is provision of optimal conditions to enhance the person's reparative processes and prevent the reparative process from being interrupted. The practice of nursing is defined as diagnosing and treating human response to actual or potential health problems through such services as case finding, health teaching, health counseling; and provision of support to or restoration of life and well-being and executing medical regimes prescribed by licensed or otherwise legally authorized physician or dentist. Nursing is directed toward meeting both the health and illness need and man who is viewed holistically as having physical, emotional, psychological intellectual, social and spiritual. Nursing is a humanistic science dedicated to compassionate concern with maintaining and promoting health, preventing illness and caring for and rehabilitating the sick and disabled. Nursing is a deliberate action, a function of the practical intelligence of nurses and action to bring about humanely desirable conditions in persons and their environments. 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. Virginia Henderson defines nursing as assisting an individual sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. HISTORY AND DEVELOPMENT OF NURSING It is difficult to trace the exact origin of the nursing profession. However, moral action is the historical basis for the creation, evolution and practice of nursing. Nursing in ancient civilization The early record of ancient civilization offers little information about those who cared for the sick. During this time, beliefs about the cause of disease were embedded in superstition and magic and thus treatment often involved magical cures. Ancient Egyptians developed community planning and strict hygienic rules to control communicable diseases. The first recorded Nurses were seen in this era. In the Babylonian civilization, there were references to tasks and practices traditionally provided by nurses. Nurses are mentioned occasionally in Old Testament of the Bible (Exodus 2:7-9, Luke 10:30-35, Jeremiah 8:22) as women who provide care for infant, for the sick and dying and as midwives who assisted during pregnancy and delivery. In ancient Rome, care of the sick and injuries was advanced in Mythology and reality. Although medicine as a science was developed there was little evidence of establishing a foundation for nursing. The ancient Greeks gods were believed to have special healing power. In 460 BC Hippocrates born and credited with being the Father of medicine. He proved that illness had natural cause and not to be of a religious or magical cause. Hippocrates first proposed such concepts as physical assessment, medical Ethics, patient – centered care, observation and reporting. He emphasized the importance of patient care that contributed a lot for the groundwork of nursing. In ancient India, male nurses staffed early Hospitals and women served as midwives and nursed ill family members. Nursing in the middle Ages During this time, monasticism and other religious groups offered the only opportunities for men and women to pursue careers in nursing. It was the Christian value of "love thy neighbor as the self" that had a significant impact on the development of western nursing. The principle of caring was established with Christ’ s parable of Good Samaritan providing care for a tired and injured stranger. In the third and fourth centuries several wealthy matrons of Roman empire, including Marcella, Fabiola and Paula, converted to Christianity and used their wealth to provide house of care and healing (the fore runner of hospital) for the poor, the sick and homeless. Women were not the sole providers of nursing service in the third century in Rome. There was an organization of men called the parabola Brotherhood. This group of men provided care to the sick and dying from the great plague in Alexandria. Dark Age of Nursing In this period, Monasteries were closed and the work of women in religious order was nearly ended. The few women who cared for the sick during this time were prisoners or prostitutes who had little or no training in nursing. Because of this, nursing was considered as the most minimal of all tasks, and had little acceptance and prestige. The development of modern Nursing Three images influenced the development of modern nursing. Ursuline Sisters of Quebec organized the first training for nurses. Theodore Flender revived the deaconess movement and opened a School in Kaiserwerth, Germany, which was training nurses. Elizabeth Fry established the institute of Nursing Sisters. But in the latter half of eighteenth century Florence nightingale the founder of modern nursing changed the form and direction of nursing and succeeded in establishing it as a respected profession. She was born to wealthy and intellectual family in 1820. In spite of opposition from her family and restrictive societal code for affluent young English woman to be a nurse Nightingale believed she was "called”by God to help others and to improve the wellbeing of mankind. In 1847 she received three month's training at Kaiserwerth. In 1853 she studied in Paris with sister of charity, after which she returned to England to assume the position of super intendment of a charity hospital. Nightingale worked to free nursing from the bonds of the church. She saw nursing as a separate profession from the church, yet she began her career as the result of the mystic experience. During the Crimean war, Florence nightingale was asked to recruit a contingent of female nurses. The Jamaica nurse Mary Grant was the first nurse recruited to provide care to the sick and injured in the Crimean war. The achievements of Florence nightingale in the war were so outstanding that she was recognized by the queen of England who awarded her the Order of Merit. When she returned to England she established the nightingale school of nursing, which was opened in 1860. The school served as a model for other training schools. Its graduates traveled to other counties to manage hospitals and nursing training programs. History of Nursing Ghana Docia Kisseih, the first Ghanaian Chief Nursing Officer who researched on the history of her profession, states: “ The care of the sick had been the prerogative of the elderly female members of the community before the advent of the professional nurse. Their skill was not acquired in any school of nursing but through long years of housekeeping and child-bearing and practical experience gained in the care of former sick relatives.”(Kisseih 1968). Like in many societies worldwide, the division went along gender lines, men being the healers and women providing the care. Alongside colonialism and Christian conversion, European health care including its principles and convictions was introduced to Africa. The health hazards in the region claimed many lives and required improved health services for the Europeans there. In the early 19th century, the Basel Mission sent a medical doctor to evaluate the health situation in the Gold Coast. Like many men before, he “ succumbed to the ‘ fever’within six weeks of his arrival”(Schweizer 2000). Only few European doctors withstood the challenges for a longer period and Europeans like Africans relied on traditional healers. In 1878 the first two European nurses arrived in the Gold Coast to care for the European officials, but it is not documented how successful their stay was. In 1892 a nursing organization was founded to send British nursing sisters to India to care for the colonial workers. In 1895 the Colonial Nursing Associations followed, being renamed as Overseas Nursing Association (ONA) in 1919. Already in 1896 the first nurses were sent to Madagascar and as second place to West Africa, where they reached Accra to find out how the conditions for a permanent posting were. The objective was caring for the sick and maintaining a healthy living environment for both Europeans and Africans. The journey was successful, and its objectives fitted in the parallel expansion of the curative hospital-based health service in the region (Holden 1991). More nurses arrived by the turn of the century to establish a permanent nursing service in the Crown colony from 1899 onwards. These nurses were carefully selected and given the order to represent their home country and its moral norms and symbolize this order and discipline in their working attitude and spotless white uniform. This ‘ right type of woman’was often compared to a soldier, as Tooley does: “ No pace is too remote, no climate too deadly for the nurse to ply her ministrations. Like the soldier she obeys the call of duty and if need be gives her life for the cause”(in Holden 1991: 68). Their main duty was to work in the hospitals, assist the medical doctors and train local workers. With the formal beginning of medicine in 1878, it became apparent that there were too few British nurses and that locals were needed to support the medical doctors, bathe and feed patients and dress their wounds. Most of the first Africans who were trained were male. Various reasons can be given to explain this fact. Firstly, women were supposed to fulfill the household chores and not expected to leave the compound for work other than farming or selling products in the market. Parents protected their daughters, since caring for strangers was perceived as unacceptable for girls in those days (Sumani 2005). In addition, this work required formal education in English writing and reading, and girls had not yet generally entered the school system. Sending girls to school was an economic risk, as they were supposed to be married and start child-bearing. Thirdly, men were seen as breadwinners to support their families. Sending them to school to acquire formal education was seen as a wise investment. But the nursing work in general had a low status. It is likely women took over the care of the sick and old in the families, but nursing was not yet perceived as a bread-winning lifelong activity. Working in these new institutions, the hospitals, where white doctors practised an unknown healing system appeared unattractive. Another new factor was the content of work, namely dealing with naked bodies, blood, feaces, and smell; it was seen as menial work and not proper. The recruitment of candidates constituted a formidable problem from the start (Addae 1996, Kisseih 1968). Dr. Henderson, the then Chief Medical Officer, reports the same: “ No native of intelligence would like to be a nurse because the pay is low and conditions of service are not good”(Owusu 1980). Those few men who were curious and courageous to work in the clinics were to be trained by the British sisters. This took place in the hospitals in Accra (Korle Bu), Cape Coast, Sekondi and Kumasi. The in-service education given to those candidates were practical instructions on the ward and theoretical lessons in anatomy and physiology, surgical and medical nursing and first aid techniques. Tutors assessed the students on the ward. There were no general standards in the training school yet, and also the educational standard of the trainees differed from a few year of schooling to Middle School Leaving Certificate. After a successful training of three years, a certificate was handed over and the men were appointed as Second Division Nurses in the Civil Services. They worked in the ‘ ; all senior posts like ‘ junior service’ sister’and ‘ matron’were held by expatriates, and due to the limited training, there was no prospect of promotion for the African nurses (Kisseih 1968,Akiwumi 1994). In addition there were orderlies for simple tasks like cleaning the floor and carrying messages. The differences in expectations and the religious and cultural background of the medical doctors, British and African nurses led to regular conflicts and frustrations. A surgeon complained in 1901: “ I would strongly recommend that some steps be taken to encourage a better class of men to join this branch of the service, for really the type of boys we have applying recently are too bad for anything. They are all ‘ bush boys’who have had little education, so called, in a way of book work, otherwise they are absolute savages and quite untouchable”(Owusu 1981). The work was tediously divided in day and night shift with few free days and a strict disciplinary regime. This all resulted in difficulties in retailing the trained nurses and recruiting enough new workers. At that time, the mining industry and cocoa farming had started to grow in the territories and many young men had migrated to those professions that promised a higher salary and less strict working conditions; the shortage of healthcare givers thus can be dated back to this very beginning. The British and African nurses worked together on the wards; while the British sisters supervised the work, dealt with the administrative writings and administered the medications, the nurses’work was to clean and feed the patients, wash the bandages and clean the instruments. Bedsores were an indication for poor care rendered and its cause had to be explained to the matrons. Punishments and warnings were given. Soon, plans were made to rethink the nursing activities and improve the training. The First World War delayed the development of the nursing education and reduced the number of British nurses from 64 to 15 by 1925, while there were about 100 male Second Division Nurses. Under Governor Guggisberg, the health delivery regained importance and new plans were made to reform the training and also attract women into the nursing profession. At this time, there was also another supporting profession at the hospitals, that of the dispenser: He was to performed sanitary inspection, treat complicated wounds and administer drugs. Indeed, the status of such dispensers was higher than that of nurses and many motivated men changed into that profession, creating a shortage. Parallel to this, health visiting nurses took up work in Accra to help in the starting health welfare clinics. They can be seen as forerunners to today’ s public health nurses (Otoo 1968). The first midwifery school opened at the maternity block in Korle Bu, Accra, in 1928, and many girls who had passed through secondary education opted to enter into this considered female and accepted profession. The growing demand for Western healthcare demanded more nurses and a solution needed to be found to meet the need. In 1944 plans were made to establish a nursing education in the country, standardize the training and establish recognition with the British Nursing Society. It is suggested that nursing started in most societies as a female activity, as caring for the sick family members in the houses was the duty of house-helps, wives and daughters. Healers and doctors needed assistants but organized the work distribution so that the glory of a successful healing was given to them, and the nursing activities were subordinate to them. In European hospitals, developing in the 17th century, the first nurses were nuns caring for the poor and sick brought there. Doctors emerged and displayed their knowledge there and the nurses were to support the medical treatment leading to healing or to give comfort to the dying with prayers on their last journey. Nurses were female and of unquestionable religious and moral status. Their devoted and endless commitment symbolized control over health threats and they were seen as perfect women and Christians. The first British nurses transported this image and expectations to the African colonies at the turn to the 20th century. In conclusion, the start of formal nursing in Ghana shows an interesting development. While caring in the homes and compounds was the domain of women, nursing in health institutions was a new phenomenon. Cultural barriers forbade women to join the nursing profession, and it was male school-leavers who were trained as first nursing assistants. The European perception of the good woman caring for the sick could not be translated immediately into this context. Although working outside the house was possible for women, for example as market women or traders, dealing with sick strangers was initially regarded as inappropriate. It took time till formal school education was introduced and girls were admitted to secondary education. Secretarial work, teaching, and midwifery became options for those girls, professions that were imported from Europe and labeled as ‘. Nursing was added to that group of ‘ typical female activities’ female professions’a slightly later. It underwent a change in perception and since it meant direct work under and with the colonial power, it was perceived as respected and venerable. The white nursing uniform intensified this idea. Some 45 years after arrival of the first nurses in the country, the nursing profession became attractive and accepted for women to choose after school education. It has to be seen that Western thought and standard dominated nursing in the Gold Coast. In the past hundred and fifty years, the industry and profession of nursing has changed tremendously. A profession that was at one point thought to be demeaning and undesired has turned into a profession that thousands of people in the United States are coveting. How did the field of nursing go from a criminals' career to a modern-day hero's career? There were many women (and men) who have helped in facilitating the improvements and great strides toward success in the field of nursing in the past one hundred and fifty years. But just who were these great men and women nurses, and how did they aid in the institutionalization of nursing as we know it today? I'm sure you've heard of Florence Nightingale, but how about Dorothea Dix or Sojourner Truth? Read on to learn about the most influential Pioneers of Nursing in the past two centuries. NURSING AS A DEVELOPING PROFESSION Profession and professionalism Nursing is a profession. A profession is a calling that requires special knowledge and skilled preparation. A profession is generally distinguished from other kinds of occupation by: a) Its requirement of prolonged specialized training acquiring a body of knowledge pertinent to the role to be performed and also an orientation of the individual to ward service, ether to community or organization. Criteria of a profession Professional status is achieved when an occupation involves practice, A profession carries great individual responsibility and based up on theoretical Knowledge. The privilege to practice is granted only after the individual was completed a standardized program of highly specialized education and has demonstrated an ability to meet the standards for practice  The body of specialized knowledge is continually developed and Evaluated through research. The members are self-organized and collectively assume the responsibility of establishing standards for education and practice. COMPARISON BETWEEN PROFESSION AND OCCUPATION OCCUPATION PROFESSION 1. Training may occur on job 1. Education takes place in College and university Length of training varies 2.Education is definite and prolonged Value, 2. Ethics are integral part of preparation beliefs and Ethics are not Prominent features Commitment & personal identification are of preparation Value beliefs, strong Commitment & personal Identification vary 3.Works are autonomous 3.Works are supervised People unlikely to change jobs Peoples often change Jobs 4.Accountability rests with individual 4.Accountability rests with employees PROFESSIONAL DEVELOPMENT Professional development in Nursing can be viewed in relation to specialized education, Knowledge base, Ethics, and autonomy. ROLE OF THE PROFESSIONAL NURSE 1. Care provider: caring /comforting involve knowledge and sensitivity to what matter and what is important to the client. 2. Communicator / Helper: Effective communication is an essential element of all helping profession, including nursing. It helps the client to explain the internal feeling. 3. Teacher/educator: teacher refers to activities by which the teacher helps the student to learn. The client also need education based on the case. 4. Counselor: counseling is a process of helping a client to recognized and cope with stressful psychological or social problem, to develop improved interpersonal relationships and promote personal growth. 5. Client advocate: An advocate pleads the cause of others or argues or pleads for a cause or proposal 6. Change agent: a change agent is a person or group who initiates changes or who assists others in making modification in themselves or in the system. 7. Leader: leader ship is defined as mutual process of inter personal influence through which the nurse helps a client make decision in establishing and achieving goals to improve the client wellbeing. 8. Manager: management defines manager as who plans, gives direction, developing staff, monitoring operations, giving rewards fairly and representing both staff member and administration as needed. 9. Researcher: majority of researchers in nursing are prepared at doctoral and post-doctoral level. Although an increasing number of clinicians and nurses with degree and master’ s degree are beginning to practice it. NURSING EDUCATION 1. Practical Nurse Education: Practical nursing has been in existence for many years. In the past the practical nurse was the family, friends or community members who was called to the home during emergencies. These were lay people who gained the experience through self-taught. The first formal education in practical nursing was started in 1892. The duration of training was 3 months and students were called attendants. The curricula of practical nursing includes child and elderly care, cooking and care of the sick at home. 2. Licensed practical nursing: This program provided by high school, community colleges, vocational schools, hospitals, and a variety of health agents. These programs usually last one year and provide both classroom and clinical experiences. At the end, the graduate takes national council licensing examination to obtain a license as a practical or vocational nurse. In Ethiopia the international licensed examination was given up to 1977. Later on national was given and stopped 1997. 3. Registered nursing: In the United States, most basic education for registered nurses is provided in three types of programs, Diploma, Associate degree, and baccalaureate programs in Canada, the 2-years, 3- years or more diploma and baccalaureate programs prepare registered nurses. 4. Diploma: today’ s diploma nursing program have changed markedly from the original nightingale model, becoming hospital-based education programs that provide a rich clinical experience for nursing students these programs programs may last two or more years and are often associated with colleges or universities. NURSING EDUCATION IN GHANA SOCIALIZATION IN NURSING The student Nurse internalize, or takes in, the knowledge, skills, attitudes beliefs, norms culture, values and ethical standards of nursing and make them a part of their own self-image and behavior. The process of internalization and development of an occupation identity is known as professional socialization. Socialization is a process by which a person learns the way of a group or society in order to become a functioning participant. Socialization is a reciprocal learning process that occurs through interaction with other people. Professional socialization in nursing is believed to occur largely, but not entirely, during the periods students are in basic nursing programs. It continues after graduation when they enter nursing practice. Learning any new role is derived from a mixture of formal and informal socialization E.g. Little boys learn how to assume the father role by what their own fathers purposely teach them (formal socialization) and how they observe their own and other fathers behaving (informal socialization). In Nursing, formal socialization includes lessons the faculty intends to teach- such as how to plan nursing care, how to perform a physical examination on healthy child, or how to communicate with psychiatric patient. Informal socialization includes lessons that occur incidentally such as over hearing a nurse teach a young mother how to care for her premature infant, participating in the students nurse association or sitting in on nursing ethics committee meeting part of professional socialization in simply absorbing the culture of nursing that is the rites, rituals, and valued behavior of the profession. This requires that students spend enough time with nurses in working setting for adequate exposure to the nursing culture to occur. Most nurses agree that informal socialization is often more power full and memorable than formal socialization. Learning any new role creates some degree of anxiety. Disappointment and frustration sometimes occurs when student's learning expectations come in to conflict with educational realities. Students' ideas of what they need to learn, when they need to learn may differ from what actually occurs. They sometimes become disillusioned when they observe nurses behaving in ways that differ from their ideas about how nurses should behave. Knowing in Advance that these things may happen can help students accurately assess the sources of their anxiety and manage it more effectively. Socialization is much more than the transmission of knowledge and skills. It serves to develop a common nursing consciousness and is the key to keeping the profession vital and dynamic. It is not surprising there for that a good deal of attention has been paid to this important process. During socialization the nurse should: Value her/his own beliefs and practice while respecting the belief and practice of others. - Respect the culture and religious beliefs of individuals. Become aware of the client’ s culture as described by the client and know client’ s cultural values, beliefs, and behavior. Know what is right or wrong The socialization process therefore involves changes in perception, knowledge, skill, attitudes, and values. There are five levels of proficiency the nurse passes as the nurse progress and acquires the knowledge, skill, attitudes, and values of nursing. These levels are novice, advanced beginner, competent, proficient and expert. Novice: A novice may be a nursing student/ any nurse entering a clinical setting where that person has no experience and governed by structured rules and protocols. Advanced beginner: can demonstrate marginally accepted performance. The beginner has had experience with enough real situations to be aware of meaningful aspect of situation. Competent: the nurse who has been on the job in similar situation for 2or 3 years manifests Competence. Competence develops when the nurse consciously and deliberately plans nursing care and coordinates multiple complex care demands. Nursing competence provide a broad specification of nursing to cover the physical, psychological and spiritual care fields and serves as a bias for considering the objectives of training. The major components of competency include observation, interpretation, planning, action and evaluation. Proficient: The proficient nurse perceives a situation as a whole rather than just its individual aspects. The nurse focuses on long-term goals and is oriented toward managing the nursing care of a client rather than performing specific task. Expert: The expert nurse not only relies on rules, guidelines, or maxims but also uses her/his understanding of situation to an appropriate action. UNIT TWO MODELS OF PROFESSIONAL SOCIALIZATION COHEN'S STAGES OF PROFESSIONAL SOCIALIZATION Unilateral dependence: Reliant on external authority, limited questioning or critical analysis. Students are unlikely to question or analyze critically the concepts teachers present because they lack the necessary background to do so. Negatively/independence: Cognitive rebellion, diminished reliance on external authority. Student’ s critical thinking abilities and knowledge bases expand. Dependence/mutuality: Reasoned appraisal, beings integration of facts and opinions following objective testing. Students evaluate the ideas of others. They develop an increasingly realistic appraisal process and learn to test concepts facts, ideas and models objectively. Interdependence collaborative decision making: commitment to professional role; self-concept now includes professional role Identify. Student's needs for both independence and mutually (sharing jointly with others) come together. Organization socialization: Organization socialization is the process by which an individual comes to appreciate the values, abilities, expected behaviors and social knowledge essential for assuming an organizational role and for participating as an organization member. The organization seeks through socialization to achieve high levels of individual performance with positive impact on group and organization output. Each organization is an ongoing social system that has evolved a unique set of values, ideas, frictions, conflicts, friend ships coalitions. It is the goal of orientation to enable the new person to enter this new system intelligently and to cope successfully. Socialization includes an introduction to group norms, the values and modes of behavior that are respected. Group norms are established as nurse’ s attempt at resaving a potentially explosive conflict of interest" the two conflicting interests are 1. A desire for companion ship and peer recognition 2. A human desire for autonomy and individuality group norm can be positive (supportive), negative (obstructing) or neutral (ineffectual) The student nurses need orientation of the organization. The function of the organization is to integrate individual and organizational needs which maintain the integrity and self-confidence of the individual as well as the effectiveness and unity of the organization. As each individual is unique so each organization is unique. The blending of these match less entities without sacrificing either, and augmenting both of them, make up the special goal of orientation.  INTERNATIONAL AND NATIONAL NURSING ASSOCIATION Associations are organizations of persons with common interests. As the number of nurses increased the activities and problem in connection with work also increased. A professional association is an association of practitioners who judge one another as professionally competent and who banded together to perform social function’ s which they cannot perform in their separate capacities as individual. NURSING ASSOCIATION The nursing association must perform the following five functions for the preservation and development of its profession 1. Defining and regulating the profession through setting and enforcing standard of education and of education and practice for generalist and specialist. 2. Developing the knowledge base for practice in its broadest and narrowest components. 3. Transmitting values norms, knowledge, and skill to nursing students, new graduates and members of the profession for application in practice. 4. Communicating and advocating the value and contribution of field to several publics and constituencies. 5. Attending to social and general welfare of their member. Professional associations give their member social and moral support to perform their roles as professionals and cope with professional problems. INTERNATIONAL COUNCIL OF NURSES (ICN) The international council of Nurses (ICN) was established in 1899. Nurses from Great Britain, the United States, and Canada were among the founding members. The Council is a federation of national Nurses ’association, Such as the American Nursing Association (ANA) and Canadian Association for Nurses (CAN). In 1993, 111 national Nurses Associations representing 1.4 Million Nurses worldwide were affiliated with the ICN. The ICN provides an organization through which member of national Nursing Association can work together to promote the health of people and the care of the sick. The Objectives of ICN are: 1. To improve the standers and states of Nursing 2. To promote the development of strong National Nurses’Association 3. To serve as the authoritative voice for Nurses and the nursing profession worldwide. WEST AFRICAN COLLEGE OF NURSING The first African Commonwealth Nurses Seminar held in Ghana at the University of Ghana in January, 1974, served as a very useful forum for participants who were top nurses representing National Nurses Associations from The Gambia, Ghana, Nigeria and Sierra Leone. There were observers from Liberia, East, Central and Southern Africa. Issues related to Nursing were discussed with particular reference to the West Africa sub-region. Commonwealth Nurses Federation sponsored the seminar while Ghana hosted it. "Educating Nurses for Community Health Services" was the Theme for the seminar. Participants stressed very much on the need for more contact and collaboration among nurses in the Sub-Region, the formation of the West African Branch of the Federation and the need to marshal resources for the improvement and advancement of Nursing in its totality. There were resource persons from the sponsors, ie. Britain, Canada and W.H.O. In May 1977, there was a meeting for Nurse Administrators from the five member countries of the College, viz The Gambia, Ghana, Liberia, Nigeria and Sierra Leone. The objective was to discuss Nursing Education. Visits to Nursing institutions in the member countries followed later, and a report was submitted to the Conference of Directors of Medical Services (CDMS) and the Interim Executive Board of the West African Health Community (WAHC). On the basis of the recommendations made by The Conference of The Directors of Medical Services (CDMS) and the Interim Executive Board, The Assembly of Health Ministers (AHIM) in October, 1978 decided that: A Provisional Council should be set up for a period of two years to work towards the establishment of a West African College of Nursing. A Nurse should be appointed in the Office of the Executive Director and designated Coordinator for Nursing Affairs. GHANA COLLEGE OF NURSES AND MIDWIVES The Ghana College of Nurses and Midwives (GCNM) is a body corporate with perpetual succession established by the provisions of the SPECIALIST HEALTH TRAINING AND PLANT MEDICINE RESEARCH ACT 2011, PART THREE (ACT 833). Which mandate is to; Promote specialist education in nursing, midwifery and related disciplines Promote continuous professional development in nursing, midwifery and related disciplines Promote postgraduate nursing, midwifery and related disciplines for the College Contribute to the formulation of policies to improve health outcomes and public health generally. The Ghana College of Nurses and Midwives is established to: Organize and supervise specialist training, continuous professional development and support postgraduate or post diploma research in nursing, midwifery and related disciplines Conduct and organize specialist examinations in nursing, midwifery and related disciplines Publish journals and pamphlets Award diplomas and certificates on completion of specialist training and confer professional distinctions Foster cooperation with other institutions with similar objectives Initiate and participate in actions and discussions aimed at improving health outcomes, and formulation of public health policies in collaboration with other relevant institutions Perform other functions that are ancillary to the objectives of the College Professional academic institutions aim at further nurturing a cohort of nurses and midwives with a capacity to provide specialist services for health improvements in Ghana and beyond.The details below describe the criteria for the categories of potential members of the College and their eligibility criteria. The descriptions take cognizance of the various levels of training of nurses and midwives in Ghana and their rights to access to career advancement through academic structures that recognize previous learning. Also described are the emblems and colours of the College and their significance; backgrounds to the College and interlink ages. Governing Council. The GCNM by the provisions of ACT 833 has a Governing Council comprising a Chairperson, President of College and representations from educational, regulatory and leadership arms of Nursing, Midwifery and related professional backgrounds with the core responsibilities to ensure proper and effective performance of the functions of the College. EDUCATIONAL PROGRAMES IN NURSING Nursing programs offered in Health Training Institutions 1. Basic Programs 2. Registered General Nursing; 3. Midwifery 4. Registered Community Nursing 5. Registered Mental Nursing 6. Health Assisted Clinical 7. Community Health Nursing 8. Post basic programs 9. Perioperative Nursing 10. Public Health Nursing 11. Ophthalmic Nursing 12. Ear Nose and Throat 13. Critical Care Nursing 14. Post Basic Midwifery MEDICAL AND ALLIED HEALTH PROGRAMS 1. Anesthetist Assistant 2. Community Oral Health and Medicine 3. Environmental Health Assistant 4. Environmental Health Officer 5. Health Record Management 6. Community Medicine and Health 7. Community Health Nursing  GHANA REGISTERED NURSES’AND MIDWIVES’ASSOCIATION (GRNMA) The Ghana Registered Nurses’and Midwives association (GRNMA), formerly Ghana Registered Nurses’association (GRNA) is a professional association for all categories of nurses in Ghana. The association was founded in 1960 as a result of a merger of two professional nursing associations, the qualified nurses’association and the state Registered Nurses Association with the mission to provide a central organization that would advance the interest of the nursing profession in Ghana and internationally. Vision To become leaders of frontline health service providers and formidable team players in the health care continuum. Mission To develop the nurse professionally to cope with contemporary challenges of the profession towards the promotion of the health of our client and their socio-economic status. Members Membership of GRNMA is open to all nurses/midwives in Ghana, registered or enrolled by the Nurses’and Midwives council of Ghana. Membership is acquired and maintained through registration and payment of monthly and other dues instituted by the GRNMA. Life membership is open to retired, or disabled and maimed nurses who can never return to active service: upon payment of prescribed fees. Objectives of the Association Advance the interest of the nursing/midwifery profession Promote a better understanding and dignity of the profession Maintain the honour and independence of the profession with special reference to professional standard, conduct, discipline and etiquette. Promote nursing/ midwifery research Affiliate and promote good relations with the international council of Nurses, commonwealth Nurses federation and similar organizations of Nurses in other countries. Promote and support law reforms on matters affecting the nursing/midwifery profession  COMMONWEALTH NURSES AND MIDWIVES FEDERATION (CNMF) The Commonwealth Nurses and Midwives Federation (CNMF), founded in 1973, is a federation of national nursing and midwifery associations in Commonwealth countries. The CNMF has regular and constructive contact with major Commonwealth bodies in London including the Commonwealth Secretariat and the Commonwealth Foundation. The CNMF is an accredited Commonwealth body, which allows involvement in annual Health Ministers' meetings, the biennial Commonwealth Peoples Forum held prior to the Commonwealth Heads of Government meeting and other Commonwealth meetings such as the civil society consultations. Management The CNMF is managed by an elected Board, which consists of a President, a Vice-President, and a member from each of its six regions. The Federation has two appointed officers - an Executive Secretary and a Treasurer. Board Meetings and General Meetings are held every two years. Objectives The CNMF's current Constitution was agreed in 2014. It exists to: Influence health policy throughout the Commonwealth, develop nursing networks, enhance nursing education, improve nursing standards and competence, and strengthen nursing leadership. Historic Constitutional changes in 2014 included a change of name to the Commonwealth Nurses and Midwives Federation, the insertion of a clause on the values of the organization, and an expansion of membership categories. The CNMF is committed to fostering active participatory membership and collaborating with Commonwealth and international organizations such as the International Council of Nurses, the International Confederation of Midwives and the World Health Organization. Work Programme The CNMF’ s current work programme includes the following: membership development,  Conducting in-country projects with national nursing organizations involving capacity building and training, communicating with member organizations through a newsletter and the website, Conducting and facilitating research on nursing and midwifery within Commonwealth countries Participating in and contributing to Commonwealth Health Ministers’and Heads of Government meetings participating in and contributing to Commonwealth Health Ministers and other Commonwealth meetings, promoting Commonwealth Day. HEALTH ILLNESS AND HEALTH CARE SYSTEM Health and illness The World Health Organization defines health as “ a state of complete physical, mental and social well-being, not merely the absence of disease and infirmity. This definition considers the total persons state of health and wellness as essential component. Health and illness is a relative concept, which is perceived differently by different individuals. Wellness is not only the absence of disease; therefore, any definition of health should consider the different dimensions influencing health. The concept of health and wellness must allow for an individual variability. Health is a dynamic state in which the person is constantly adapting to changes in the internal and external environment. Various models on the concept of health and wellness exist. Some are based on the presence and absence of disease and others on holism, health beliefs and wellness. Models of Health and illness Health models have been developed to help describe the concepts and relationships involved in health and illness. a. Host - agent-environment model According to this model health is an ever-changing state and health and illness depends on interaction of host, agent and environmental factors. These factors are constantly in interaction and a combination of factors increases the possibility of illness. When the agent, host and environment variables are in equilibrium health is maintained. On the other hand when the balance is disrupted disease occurs. b. The Health illness continuum model According to this model, health is a constantly changing state, with high level wellness and death being in the opposite ends of a graduated scale, or continuum. The nurse must be aware that a client may place himself/herself at different points on the continuum at any given time depending on how well he/she believes himself to be functioning for his illness c. High-level wellness model This model describes high-level wellness as functioning to one's maximum potential while maintaining balance and purposeful direction in the environment. The concept of high level of wellness can be applied to the individual, family, community, environment, and society. In High-level wellness model human beings are viewed as having five aspects 1. Each individual is functioning as a total personality 2. Each person possess dynamic energy 3. Each person is at peace with inner and outer worlds 4. Each person has a relationship between energy use and self-integration 5. Each person has an inner world and an outer world These five processes help the person know who and what he/she is. This model is holistic, allowing the nurse to care for the total person with regard for all dimensional factors affecting the person's state of being as he/she strives to reach maximum potential. d. Health Belief Model The health belief model is based on what people perceive, or believe, to be true about them in relation to health. This model is based on three components: perceived susceptibility to a disease, perceived seriousness of a disease and perceived value of action. This model states that whether or not a person practices a particular health behavior can be understood by knowing two factors: the degree to which the person perceives a personal health threat and the perception that a particular health practice will be effective in reducing that threat. The perception of a personal health threat is itself influenced by at least three factors: general health values, which include interest, and concern about health; specific beliefs about vulnerability to a particular health problem; and beliefs about the consequence of the health problem. Whether or not the perception of a threat leads to changing health behavior also depends on whether a person thinks a particular health practice will be effective against the health problem in question and whether or not the cost of undertaking that measure exceeds the benefits of the measure. The health belief model enable nurses to understand why people practice health behavior and also to predict some of the circumstances under which people’ s health behavior will change. FACTORS AFFECTING HEALTH AND ILLNESS 1. Physical dimension-genetic makeup, age, developmental level, race and sex 2. Emotional dimension-how the mind and body interact to affect to body function and to respond to body conditions also influence s health. E.g. long term stress affects the body systems, anxiety affects health habits and conversely calm acceptance and relaxation can actually change body responses to illness. 3. Intellectual dimension-encompasses cognitive abilities, educational background and past experiences. 4. Environmental dimensions-the environment has many influences on health and illness. Housing sanitation, climate, pollution of air, food and water are aspects of the environmental dimension. 5. Sociocultural dimensions- health practices are strongly influenced by a person's economic level, life style, family and culture. 6. Spiritual dimensions- spiritual and religious beliefs and values are important components of how a person behaves in health and illness. DIMENSIONS OF HEALTH AND ILLNESS Nursing in wellness and holistic health care Nurses carry out wellness promotion activities on primary, secondary and tertiary levels. PREVENTIVE ACTIVITIES Primary prevention: Is a care directed toward health promotion and specific protection against illness. E.g. Immunization, family planning and health education Secondary Prevention: Focuses on health maintenance for clients experiencing health problems on prevention of complication or disabilities. E.g. nursing care for hospitalized clients, early detection and treatment of health problems Tertiary prevention: Is aimed at helping rehabilitate clients and restore them to a maximum level of functioning following an illness. E.g. teaching a diabetic client how to recognize and prevent complications UNIT THREE  ETHICAL ISSSUES IN NURSING UNDERSTANDING THE CONCEPT OF ETHICS Ethics versus Morality. Ethics is derived from the Greek word ethos, meaning custom or character. Ethics can be defined as the branch of philosophy dealing with standards of conduct and moral judgment. It refers to a method of inquiry that assists people to understand the morality of human behavior. (I.e. it is the study of morality). When used in this sense, ethics is an activity; it is a way of looking at or investigating certain issues about human behavior. Ethics refers to the practices or beliefs of a certain group (i.e. nursing ethics, Physicians' ethics). It also refers to the expected standards as described in the group's code of professional conduct. Ethics is concerned what ought to be, what is right, or wrong, good or bad. It is the base on moral reasoning and reflects set of values. It is a formal reasoning process used to determine right conduct. It is professionally and publicly stated. Inquiry or study of principles and values. It is process of questioning, and perhaps changing, one's morals. Moral: is principles and rules of right conduct. It is private or personal. Commitment to principles and values are usually defended in daily life. TYPES OF ETHICS Descriptive: It is the description of the values and beliefs of various cultural, religious or social groups about health and illness. Normative: a study of human activities in a broad sense in an attempt to identify human actions that are right or wrong and good and bad qualities. In nursing normative ethics addresses: scope of practice of different categories of nurses and, level of competence expected. Analytical: analyzes the meaning of moral terms. It seeks the reasons why these action or attitudes are either wrong or right.  COMMON ETHICAL THEORIES Ethical theories may be compared to lenses that help us to view an ethical problem. Different theories can be useful because they allow us to bring different perspectives in to our ethical discussions or deliberations. There are four ethical theories: 1. Deontology 2. Teleology 3. Intuitionism 4. The ethic of caring Deontology (Duty or rule-Based theory) This theory proposes that the rightness or wrongness of an action depends on the nature of the act rather than its consequences. This theory holds that you are acting rightly when you act according to duties and rights. Responsibility arises from these moral facts of life. The theory denotes that duties and rights are the correct measuring rods for evaluating action. One place where such factors are presented is in codes of professional ethics. E.g. informed consent, respect of patient⋯ Teleology (utilitarian or end based theory).This theory looks to the consequences of an action in judging whether that action is right or wrong. According to the utilitarian school of thought right action is that which has greatest utility or usefulness. Utilitarian hold that no action in itself is good or bad, the only factors that make actions good or bad are the outcomes, or end results that are derived from them. Types of Utilitarian Theories Act utilitarianism: suggests that people choose actions that will in any given circumstances increase the over all-good. Rule utilitarianism: suggests that people choose rules that when followed consistently will maximize the overall good Intuitions The notion that people inherently know what is right or wrong; determining what is not a matter of rational thought or learning. For example, nurse inherently known it is wrong to strike a client, this does not need to be taught or reasoned out. The ethic of caring (case based theory).Unlike the preceding theories which are based on the concept of fairness (justice) an ethical caring is based on relationships. It stresses courage, generosity, commitment, and responsibility. Caring is a force for protecting and enhancing client dignity. ETHICAL PRINCIPLES Principles are basic ideas that are starting points for understanding and working through a problem. Ethical principles presuppose that nurses should respect the value and uniqueness of persons and consider others to be worthy of high regard. These principles are tents that are important to uphold in all situations. The major principles of nursing ethics are: 1. Autonomy 2. Beneficence 3. Non-maleficence 4. Justice 5. Veracity 6. Fidelity 7. Confidentiality Autonomy Autonomy is the promotion of independent choice, self-determination and freedom of action. Autonomy means independence and ability to be self-directed in healthcare. Autonomy is the basis for the client's right to self-determination. It means clients are entitled to make decision about what will happen to their body. The term autonomy implies for basic elements. The autonomous person is respected The autonomous person must be able to determine personal goals. The goals may be explicit or may be less well defined The autonomous person has the capacity to decide on a plan of action. The person must be able to understand the meaning of the choice to be made and deliberate on the various options, while understanding the implications of possible outcomes. The autonomous person has the freedom to act upon the choices. Competent adult clients have the right to consent or refuse treatment even if health care providers do not agree with clients' decisions; their wishes must be respected. However, in most instances patients are expected to be dependent upon the health care provider. Often time’ s health  care professionals are insensitive to ways by which they dehumanize and erode the autonomy of consumers. For example: Right after admission patients are asked about personal and private matters Workers who are new to patients may freely enter and leave the patients’room making privacy impossible. Four factors for violations of patient autonomy Nurses may assume that patients have the same values and goals as themselves Failure to recognize that individuals’thought processes are different Assumptions about patients’knowledge base Focus on work rather than caring Infants, young children, mentally handicapped or incapacitated people, or comatose patient do not have the capacity to participate in decision making about their health care. If the client becomes unable to make decisions for himself/ herself, this “ surrogate decision maker”would act on the client's behalf. Autonomy of clients is more discussed in terms of larger issues such as: informed consent, paternalism, compliance and self-determination. Informed consent: is a process by which patients are informed of the possible outcomes, alternative s and risks of treatments and are required to give their consent freely. It assures the legal protection of a patient’ s right to personal autonomy in regard to specific treatments and procedures. Informed consent will be discussed in detail in selected legal facts of nursing practice. Paternalism: Restricting others autonomy to protect from perceived or anticipated harm. The intentional limitation of another’ s autonomy justified by the needs of another. Thus, the prevention of any evil or harm is greater than any potential evils caused by the interference of the individual’ s autonomy or liberty. Paternalism is appropriate when the patient is judged to be incompetent or to have diminished decision-making capacity. Non-compliance: Unwillingness of the patient to participate in health care activities. Lack of participation in a regimen that has been planned by the health care professionals to be carried out by the client. Noncompliance may result from two factors: When plans seem unreasonable to the patient, Patients may be unable to comply with plans for a variety of reasons including resources, lack of knowledge, psychological and cultural factors that are not consistent with the proposed plan of care Beneficence Beneficence is doing or promoting good. This principle is the basis for all health care providers. Nurses take beneficent actions when they administer pain medication, perform a dressing to promote wound healing or providing emotional support to a client who is anxious or depressed. This principle provides nursing’ s context and justification. It lays the groundwork for the trust that society places in the nursing profession and the trust that individuals place in particular nurses or health care agencies. The principle of beneficence has three components: 1. Promote good 2. Prevent harm 3. Remove evil or harm Non-maleficence Non-maleficence is the converse of beneficence. It means to avoid doing harm. When working with clients, health care workers must not cause injury or suffering to clients. It is to avoid causing deliberate harm, risk of harm and harm that occurs during the performance of beneficial acts. E.g. Experimental research that have negative consequences on the client. Non-maleficence also means avoiding harm as a consequence of good. In that cases the harm must be weighed against the expected benefit. Justice Justice is fair, equitable and appropriate treatment. It is the basis for the obligation to treat all clients in an equal and fair way. Just decision is based on client need and fair distribution resources. It would be unjust to make such decision based on how much he or she likes each client. Veracity Veracity means telling the truth, which is essential to the integrity of the client-provider relationship. Health care providers obliged to be honest with clients. The right to self- determination becomes meaningless if the client does not receive accurate, unbiased, and understandable information Fidelity Fidelity means being faithful to one's commitments and promises. Nurses’commitments to clients include providing safe care and maintaining competence in nursing practice. In some instances, a promise is made to a client in an over way. Nurse must use good judgment when making promises to client. Fidelity means not only keeping commitment but also keeping or maintaining our obligation. Confidentiality Confidentiality comes from Latin fide: trust, confide as to “ ;“ show trust by imparting secrets” tell ;“ in assurance of secrecy” entrust; commit to the charge, knowledge or good faith of another” ; while confidential or in confidence is “ a secret or private matter not to be divulged to others” Confidentiality in the health care context is the requirement of health professionals (HPs) to keep information obtained in the course of their work private. Professional codes of ethics (and conduct) will often have statements about professions maintaining confidentiality, but confidentiality is often qualified. Confidentiality is non- disclosure of private or secret information with which one is entrusted. Legally, this requirement applies to HPs and others, who have access to information about patients, and continues after the patient’ s death Nurses hold in confidence any information obtained in a professional capacity, and use professional judgment in sharing such information. Each nurse will treat as confidential personal information obtained in a professional capacity. The nurse uses professional judgment regarding the necessity to disclose particular details, giving due consideration to the interests, wellbeing and safety of the patient and recognizing that the nurse is required by law to disclose certain information. Ethical Arguments for Maintaining Patient Confidentiality (i) Utilitarian argument Patients’assurance of confidentiality helps ensure they will seek treatment (e.g., for complaints that may be personally embarrassing, or related to socially denigrated, or illegal activities, etc.). This helps to ensure that patients will be properly diagnosed and treated. This in turn helps to minimize harm, and maximize good. (ii) Respect for autonomy (may be a deontological or utilitarian justification) Respect for autonomy requires allowing individuals to control any disclosure of information about them. Such control is essential for personal freedom (e.g., from coercion, or to pursue one’ s goals/values). (iii) Promise keeping: There is an implicit promise between HPs and patients that information will not be disclosed to third parties. Hence, breach of confidentiality breaks a promise. The notion of confidentiality draws upon the principle of privacy, which may derive from the concept of autonomy or be conceptually separate. PRIVACY Bodily privacy: An ethical concept of bodily privacy can be derived from respect for autonomy, where autonomy includes the freedom to decide what happens to one’ s body. Bodily privacy is recognized in law: actions in assault, battery and false imprisonment may be available to the person who does not consent to health care. Decisional privacy: Decisional privacy is distinguished as control over the intimate decisions one makes (e.g., about contraception, abortion, and perhaps health care at the end of one’ s life). Informational privacy: This type of privacy underlies the notion of confidentiality.  ARGUMENTS FOR RESPECTING PRIVACY (i) Privacy and property Personal information is regarded as a kind of property, something one owns. (ii) Privacy and social relationships Privacy is a necessary condition for the development and maintenance of relationships, including those between HPs and patients. (iii) Privacy and the sense of self. The notion that one is a separate self includes the concept of one’ s body and experiences as one’ s own. Privacy is to be valued for its role in developing and maintaining our sense of individuation. Limits of confidentiality: Should the principles of confidentiality be honored in all instances? There are arguments that favor questioning the absolute obligation of confidentiality in certain situations. These arguments include theories related to the principles of harm and vulnerability. The harm principle can be applied when the nurse or other professional recognizes that maintaining confidentiality will result in preventable wrongful harm to innocent others. Foresee ability is an important consideration in situations in which confidentiality conflicts with the duty to warn. The nurse or other health care professional should be able to reasonably foresee harm or injury to an innocent other in order to violate the principle of confidentiality in favor of a duty to warn. The harm principle is strengthened when one considers the vulnerability of the innocent. The duty to protect others from harm is stronger when the third party is dependent on others or in some way especially vulnerable. This duty is called the vulnerability principle. Vulnerability implies risk or susceptibility to harm when vulnerable individuals have a relative inability to protect themselves. Actions that are considered ethical are not always found to be legal. Though there is an ethical basis for subsuming the principle of confidentiality in special circumstances, and there is some legal precedent for doing so, there is legal risk to disclosing sensitive information. There is dynamic tension between the patient’ s right to confidentiality and the duty to warn innocent others. Nurses need to recognize that careful consideration of the ethical implications of actions will not always be supported in legal systems.  DISCLOSURE OF INFORMATION Disclosure of information is not necessarily an actionable breach of confidence. Disclosure may be allowed, under certain circumstances, when it is requested by: the patient, and where it applies, freedom of information can be used by patients to obtain health care information; Other health practitioners (with the patient’ s consent, and where the information is relevant to the patient’ s care); Can Nurses Violate Confidentiality? Think About the two given scenarios and discuss about it 1. If a relative contracted HIV from a source who the nurse knew was infected, and had reason to believe would infect others, but neglected to warn. What do you do? 2. If Ato Abebe is HIV infected and the health provider violated his right to confidentiality. What do you think about the act? Relatives in limited circumstances (e.g., parents when it is in the interests of the child); Researchers with ethics committee approval (and where the approved process is followed); The court; The media, if the patient has consented; and The police, when the HP has a duty to provide the information. Unless there is a warrant or a serious crime has been committed, the information provided to the police is normally limited to the patient’ s identity, general condition and an outline of injuries. If in doubt, refer the issue to management and/or seek legal advice. When a patient has consented to the release of information to the media, management authorization is usually required. Confidentiality is the ethical principle that requires non-disclosure of private or secret information with which one is interested. 8 RULES The principles of health care ethics must be upheld in all situations. Rules are guidelines for the relationship between clients and health care Providers. They are the foundations for the ethical rules veracity, fidelity and confidentiality Ethical Dilemmas & ethical decision making in Nursing A dilemma is a situation in which two or more choices are available; it is difficult to determine which choice is best and the needs of all these involved cannot be solved by the available alternatives. The alternatives in a dilemma may have favorable and unfavorable features. Ethical dilemmas in health care involve issues surrounding professional actions and client care decisions. They can lead to discomfort and conflict among the members of the health care team or between the providers and the client and family, MODELS FOR ETHICAL DECISION-MAKING. Ethical issues are real life issues. There is no one way of resolving such situations. Each situation will be different, depending on the people involved and the context. However, ethical decision- making models provide mechanisms or structures that help you think through or clarify an ethical issue. There are a number of models from which to choose from, but there is no one best way to approach ethical decision-making. Ethical decision making models are not formulas and they do not ensure that the decision you take will be the right one. Model 1 Is a guide to moral decision-making. It outlines a step-by step process that considers the many aspects of ethical decision-making: 1. Recognizing the moral dimension Is recognizing the decision as one that has moral importance Important clues include conflicts between two or more values or ideals Consider here the levels of ethical guidance of the code of Ethics for registered nurses. 2. Who are the interested parties? What are their relationships? Carefully Identify who has a stake in the decision in this regard, be imaginative and sympathetic  Often there are more parties whose interests should be taken in to consideration than is immediately obvious. Look at the relationships between the parties look at their relationship with yourself and with each other, and with relevant institutions. 3. What values are involved? Think through the shared values that are at stake in making this decision. Is there a question of trust? Is personal autonomy a consideration? Is there a question of fairness? Is anyone harmed or helped? Consider your own and others personal values & ethical principles 4. Weight the benefits and burdens Benefits might include such things as the production of goods (physical, emotional, financial, and social, etc.) for various parties, the satisfaction of preferences and acting in accordance with various relevant valves (such as fairness). Burdens might include causing physical or emotional pain to various parties imposing financial costs and ignoring relevant values. 5. Look for analogous cases Can you think of similar decisions? What course of action was taken? Was it a good one? How is the present case like that one? How is it different? 6. Discuss with relevant other The merit of discussion should not be underestimated. Time permitting discusses your decision with as many people as have a take in it. Gather opinions and ask for the reasons behind those opinions. 7. Does this decision according with legal and organizational rules. Some decisions are appropriately based on legal considerations. If an option is illegal, one should think very carefully before thanking that option  Discussion may also be affected by organizations of which we are members. For example, the nursing profession has a code of ethics and professional standards that are intended to guide individual decision-making. Institutions may also have policies that limit the options available. 8. Am I comfortable with this decision? Question to reflect up on include: If I Cary out this decision, would I be comfortable telling my family about it? My clergy? My mentors? Would I want my children to take my behavior as an example? Is this decision one that a wise, informed, virtuous person would make? Can I live with this decision? MODEL 2 Clinical Ethics grid System: This grid system helps construct a summary of the facts that must be considered along with ethical principles to guide ethical decisions in a clinical setting out lined as follows. 1. Medical indications: What is the patient medical problem? History? Diagnosis? Is the problem acute? Chronic? Critical? Emergent? Reversible? What are the goals of treatment etc? 2. Patient preference: What has the patient experienced about preferences for treatment? Has the patient been informed of benefits and risk, understood, and given consent? Etc. 3. Quality of life: What are the prospects with or without treatment, for a return to the patient's normal life? Are there biases that might prejudice the provider's evaluation of a patient's quality of life etc? 4. Contextual factors:  Are there family issues that might influence treatment decisions? UNIT FOUR THE NURSES’PLEDGE 1. I acknowledge that the special training I have received has prepared me as a responsible member of the community. 2. I promise to care for the sick with all the skill I possess, no matter their race, creed, color, political, or social status, sparing no effort to conserve life, alleviate pain and promote health. 3. I promise to respect at all times the dignity of the patient in my charge. 4. I promise to hold in confidence all personal information entrusted to me.  5. I promise to keep my knowledge and skill at the professional level and to give the highest standard of nursing care to my patients. 6. I promise to carry out intelligently and loyally medical instructions given to me. 7. I promise that my personal life shall at all times bring credit to my profession. 8. I promise to share in the responsibility of other professions and citizens for promoting health locally, nationally and internationally. So help me God MIDWIVES PRAYER · Have mercy on me, oh Lord · And in all my actions · Let me have thy fear before my eyes · That I may be careful for both rich and poor · To do good and not to hurt · To save lives and not to destroy · Help my infirmities and imperfections · And grant me skill and judgment · Happily to finish every work So help me God Amen EXPECTED BEHAVIOR AND ATTITUDE OF THE REGISTERED GENERAL NURSE Nursing practitioners, much like other professionals, have unique binding values, attitudes and behaviors. Nursing theories are important since despite the evolving nature of the nursing profession over time due to technological advancements, the underlying principle of caring still serves as the major motivation for all nursing practitioners. In addition, professional values form the basis for acceptable behavior and attitude in the nursing profession. The development of these values is critical for every nurse in making important decisions in healthcare. Nursing practitioners must also exhibit certain attitudes and behaviors in their profession to carry out their major role of caring. It is evident that nursing is highly dependent on one's morals and a sense of responsibility to the client. Nurses belong to associations that support and regulate their activities. Some major values of the nursing profession are altruism, accountability, commitment and human dignity. These professional values develop in response to culture, society and individual personality traits. QUALITIES OF A NURSE Amidst the numerous good qualities, a nurse must exhibit the following qualities. (List not exhaustive). A nurse must be: 1. Humble 6. Sympathetic 2. Compassionate 7. Competent 3. Knowledgeable 8. Empathetic 4. Obedient 9. Smart 5. Kind 10. Respectful. Etc. Assertive Behavior s Medical Dictionary defines it as “ Assertiveness is a mode of communication. Dorland’ a form of behavior characterized by a confident declaration or affirmation of a statement without need of proof; this affirms the person’ s rights or point of view without either aggressively threatening the rights of another (assuming a position of dominance) or submissively permitting another to ignore or deny one’ s rights or point”. Many of us don’ t like having to tell people that they can’ t do something, or feel obligated when a colleague asks for a favor or pressurized when someone senior needs something done. In some workplaces, saying “ no”is frowned upon. Assertiveness skills are essential, as they will enable you to look after yourself and work more effectively. Sometimes, it involves finding ways of saying no without having to use the “ n”word. There is a lot of anxiety around the consequences of saying no. To ensure assertiveness, if you feel you will be at an unfair disadvantage, stand back and assess the situation, check your understanding: “ when you ask me to do⋯do you mean⋯?” , use the I-statement, then consider a way forward (fogging, asking for information, suggesting a solution), be reasonable and work with integrity; looking after yourself without being selfish will lead to positive outcomes all round. Unassertive individuals don’ t say anything, agree to things they’ d rather not and get landed with work that isn’ t theirs. Assertiveness can help people to be more efficient in their own work, and act as role models, showing a way of working that supports others to do the same and promote a fairer distribution of work. Also being assertive can make a real difference to the working environment. Assertive communication consists of sharing wants and needs honestly in a safe manner and focuses on the issue, not the person. Aggressive and/or passive communication, on the other hand, may mark a relationship’ s end and reduce self-respect. A person communicates assertively by not being afraid to speak his or her mind or trying to influence others, but doing so in a way that is respectful and appropriate. An individual who is assertive is also willing to defend themselves against aggressive incursions or affronts by others. Respect for your fellow team members is the key to understanding how to speak and act assertively. Assertiveness is the ability to express one’ s feelings and assert one’ s rights while respecting the feelings and rights of others. Assertive communication is appropriately direct, open and honest, and clarifies one’ s needs to the other person. Assertiveness comes naturally to some, but is a skill that can be learned. People who have mastered the skill of assertiveness are able to greatly reduce the level of interpersonal conflict in their lives, thereby reducing a major source of stress and increasing levels of safety and awareness of both themselves and others. An assertive style of behavior is to interact with people while standing up for your rights. Being assertive is to one’ s benefit most of the time but it does not mean that one always gets what he/she wants. The result of being assertive is that (1) you feel good about yourself, and (2) other people know how to deal with you because you are direct and to the point, but respectful. Not Aggressive As a communication style and strategy, assertiveness is distinguished from aggression and passivity. How people deal with personal boundaries (both their own and those of other people) helps to distinguish between these concepts. Passive communicators do not defend their own personal boundaries and thus allow aggressive people to abuse or manipulate them. They are also typically not likely to risk trying to influence anyone else. Aggressive people do not respect the personal boundaries of others and thus are liable to harm others while trying to influence them. One way to practice being assertive is to use “ I statements.”These can be used to voice one's feelings and wishes from a personal position without expressing a judgment about the other s feelings or concerns on them. Rather than saying things like, “ person or blaming one’ You really messed up here,”begin statements with “ I”, and make them about yourself and your feelings, like, “ I feel frustrated when this happens.”It’ s less accusatory, sparks less defensiveness, and helps the other person understand your point of view rather than feeling attacked. Best Practices There are two models that many healthcare professionals, organizations and hospitals use to teach individuals and teams about assertive behavior. The first model in widespread use is the “ See it, say it, Fix it.”This three step process is a simple method that allows individuals to identify a problem or issue, speak-up about it and work resolve it. The second model used to teach assertiveness is the five step assertion Model. The five steps included in this approach consist of: 1. Getting the Person’ s Attention: Use a first name and establish eye contact. 2. Expressing Concern: Be direct and unambiguous. 3. Stating the Problem: Be succinct; explain as needed. 4. Proposing Action: Suggest a plan or action. 5. Reaching a Decision: Team leader makes final call. MANAGING CHALLENGING BEHAVIORS Challenging behavior manifests in various ways and it is vital that care givers know the appropriate method of dealing with each manifestation. It is important to understand not only the means of restraint, but also to understand the reasons behind such behavior. They are behaviors that could lead to the person being denied access to public facilities. This could include aggressiveness and agitation (for example, shouting, screaming and self-injury; such as people banging their heads hard or taking off cloths in public). The more clearly the challenging behavior is described and understood, the more obvious is the intervention required. Family, friends and cares usually know the person well and can provide valuable opinions on the meaning of the behavior and the best approach to management. The first approach should always be non-pharmacological treatment together with dealing with the environmental and career factors that may be contributing to the problem. The use of drugs to control challenging behavior has to be approached cautiously. It has to be considered on the background of a person’ s physical health and the frequency and severity of their behavioral problems. Many challenging behaviors will run a course and stop spontaneously, so watchful waiting may be useful in situations where symptoms are less severe. HANDLING CLIENTS’COMPLAINS Listening and attending isn’ t important just when patient/clients are telling you something about their health, or when they’ re complimenting you for doing a good job. It’ s also very important that we listen and attend well when patients/clients or their families are unhappy about something or want to complain. It’ s never easy nor pleasant to be on the receiving end of a complaint, particularity if the person doing the complaining is upset, angry or even abusive. There are three important things we have to recognize in this situation: In all likelihood, the complaint is not about you: you just happen to be the person who is hearing it –do not take it personally if the person is upset or angry, you becoming upset or angry will not help the situation –it could, in fact, make it worse; keep clam and composed while it might not seem pleasant at the time, we can learn a great deal from complaints, giving us an opportunity not only to put whatever is wrong right for the patient/client or family member, but also to make sure that if possible, it doesn’ t happen again; complaints also help you to develop your own understanding and knowledge of what is important for patients/clients and families. Compose yourself: relax and remember about good body posture –keep good eye contact with the person, don’ t cross your arms in front of you or raise your eyes to the ceiling. Show by your posture that you’ re interested and ready to listen. Attend: give the person your undivided attention. Don’ t be distracted by thoughts of the other things you should be doing right now –this is important, so be there. Listen: really listen to what the person is saying. Many patients/clients who are unhappy about the way their complaint has been handled tell us that no one really listened to them. Try to identify the key words –angry, disappointed, disgusted, hurt –these emotional responses need to be addressed just as much as the initial situation that caused them. And please, don’ t interrupt or talk over the person –hold your response until the person has finished what he or she wants to say. Moving on: respond positively to what the person has told you and lay the foundations for moving on towards a solution. First and foremost, say you’ re sorry. That doesn’ t necessarily re apologizing for a failure of service –simply that you’ mean you’ re sorry that whatever has happened has made the person so upset. If you can deal with the situation easily and quickly, by all means do so. If the situation is more complicated, explain to the person that you will let your manager/supervisor know as soon as possible so that he or she can take time to agree a way forward with the person to identify exactly what went wrong, whether there is any explanation for its occurrence, and what can be done to remedy it. As was said earlier, it’ s probably not you personally who is being criticized, but occasionally, a person might raise a complaint that is down to a mistake you have made. No one is infallible, and everyone makes mistakes. What’ s important is how you respond to them. Instead of feeling that you’ ve somehow failed in this situation, try to see it as an opportunity to learn and to improve your practice. Think through what happened, initially by yourself but also with your manager/supervisor. Going through this with your manager/supervisor will give you a deeper understanding of the situation and a clear plan on how to deal with similar situations in future. Your organization will have guidance and protocols on how to report and record comments and complaints received –you should familiarize yourself with these, discussing any emerging training issues with your manager or supervisor. HOSPITAL ETIQUETTE Etiquette is the formal rules for polite behavior in a society. Etiquette is more than good manners; it's a tool for cultivating good relationships. More than most careers, nursing is characterized by professional relationships among different people in numerous settings. Based on the guiding principles of kindness, consideration, and common sense, professional etiquette can help you form new alliances and enhance established ones. 1. Introduce yourself You won't feel awkward during introductions if you're always ready to introduce yourself. Don't just stand next to someone waiting to be introduced; take the initiative. Put out your hand for a handshake and say your name in a confident voice. Example: "Hello, I'm Margie Mensah, the new perioperative nurse educator." Be ready to introduce colleagues to others as well. Mention the name of the person you're making the introduction to first, then say the name of the person being introduced and say something about her. Then come back to the first person and say something about her.1 Example: "Sharon, I'd like to introduce Jack Brown. Jack is our new staff nurse with two years' experience in the PACU. Jack, Sharon Jones has been our vice president of nursing since 2002." A good rule of thumb is to mention the higher-ranking person in the organization first. In the example above, the vice president (Sharon) is mentioned first and the new nurse (Jack) is introduced to her. Note that your book-ending the introductions to include both people. 2. Have a confident handshake A strong handshake creates a positive first impression. Many people judge others by the quality of their handshake, so make sure it's confident and firm (but not too firm-don't overdo it). Stand up, lean forward, make eye contact, and smile. However, take into consideration cultural preferences and sensitivities that can impact a handshake. Example: In the Hindu culture, men don't shake hands with women.1 If someone ignores your attempt to shake hands, don't take it personally-someone may avoid shaking hands because of arthritic pain. Gently drop your hand to your side and continue as if nothing happened. 3. Keep conversations on track The ability to connect with colleagues and patients by making conversation is essential for success. To avoid inadvertently offending someone, stay away from controversial topics. Topics to avoid include religion, politics, salaries, jokes of questionable taste, medical problems, and gossip. Topics that are usually safe to talk about include weather, traffic, sports, travel, books, and TV programs. When talking with a patient, remember that you're the caretaker. Don't discuss personal problems with a patient. If you have trouble getting a conversation started, try using the acronym OAR to help. Here's an example with a patient in a clinical setting. Observe. Make an observation. ("It looks like you're ready for your surgery."). Ask questions. ("Is this the first time you've been a patient in this hospital?") Reveal something about yourself, but avoid getting too personal. ("After years of working in a large medical center, I like the friendly atmosphere of this community hospital.) 4. Watch your body language Your body language is an essential component of communication. When making conversation, don't forget that the care you invest in your words can be undone by nonverbal communication. Example: Suppose while talking with a patient, you're slouching and not looking directly at him. You're sending the message that you're not interested in what he has to say. Tune in and be aware of what image your body language is sending. Here are some body language tips to follow: Stand tall with your shoulders back and your chin up; avoid slouching. Keep your hands out of your pockets. Don't put your hands on your hips or cross them over your chest. Use a sincere smile to denote warmth and friendliness. Look at the eyes of the person you're talking with to show your interest. Don't wring your hands or make a fist. Move with confidence and purpose. Don't drag or shuffle your feet. As a healthcare provider, you interact with patients and providers from diverse cultural backgrounds. Be sensitive to the fact that your body language could unknowingly offend someone; in some cultures, direct eye contact is considered aggressive. Your mistake may be obvious from someone's comments, expression, or body language. Apologize immediately. If you don't know what you did, adopt a humble and respectful attitude and ask. Some gestures may be misunderstood and considered offensive to people from other cultures. 5. Cultivate a positive work environment The kindness, consideration, and common sense that characterize etiquette are also essential for nurse-to-nurse collaboration. Be polite and courteous to your colleagues, no matter how stressful the situation. When you show respect for others and make others feel valued, you contribute to effective communication and team building. Example: Greet colleagues with a smile and a "hello" when you arrive at work, and say "good-bye" when you leave. Offer to help others, and thank others for helping you. Use good manners and polite language, and avoid listening to gossip or complaining with colleagues. Participate in department events to show your colleagues that you're a part of the team. 6. Dress for success Although informality is a trend in many workplaces, remember that the workplace isn't your home. It may not be completely fair, but people do judge you by the way you dress. What you wear supports or detracts from your professional image and sends a clear message to others about how you see yourself and how you want to be perceived by others. Most nurses would agree that they want to be viewed as professional, intelligent, and competent. You need to ask yourself if your appearance mirrors that image. If you dress too casually, patients may question your professionalism and attention to detail. Example: Does a nurse dressed in cartoon-print scrubs establish immediate trust, authority, and credibility? Cartoon prints may be appropriate for the pediatric surgical unit or the nursery, but nowhere else. Many patients complain that everyone in the clinical setting looks the same. This can be a safety issue if patients can't quickly identify a nurse in an emergency. 7. Present a positive, professional image Address all patients as Mr., Mrs., or Ms. Use a first name or nickname only if the person gives your permission. Never use terms like "honey" or "sweetie." Before going to meet the patient, take a few seconds to compose yourself and put a smile on your face. Knock or speak softly, and wait for permission before approaching the patient's bedside. Greet patients in a manner similar to the following: "Welcome to ______ (if this is your first patient encounter). My name is (first and last), and I'm the registered nurse who'll be coordinating your care until (time)."  Review the patient's plan of care. Explain to the patient what to expect preoperatively, intra-operatively, and postoperatively. Use open-ended questions. Ask the patient for input. When leaving the patient's bedside, ask, "Is there anything else you need?" Make sure that important items such as the call bell are within the patient's reach. When a patient thanks you, replace the phrase "No problem" with "You are welcome" or "My pleasure." UNIT FIVE COMMUNICATION AND INTERPERSONAL RELATIONSHIPS IN NURSING Communication: Communication is a complex process of sending and receiving verbal and nonverbal messages. Allows for exchange of information, feelings, needs, and preferences. The process of creating common understanding. The process of sharing information. The process of generating and transmitting meanings Purposes of communication are; Information Education Persuasion Entertainment Goals of communication: 1. Mutual understanding of the meaning of the message. 2. Feedback/response indicates if the meaning of the message was communicated as intended Types of Communication People Communicate in a variety of ways. 1. Verbal Communication-is an exchange of information using words and includes both the spoken and the written word. Verbal communication depends on language. Language is a prescribed way of using words so that people can share information effectively. Both spoken and written communication reveal a great deal about a person. Conscious use of spoken or written word. Choice of words can reflect age, education, developmental level, and culture. Feelings can be expressed through tone, pace, etc The verbal form of communication is used extensively by nurses when speaking with clients, giving oral reports to other nurses, writing care plans and recording in nursing progress reports. Characteristics: Simple, brief, clear, well timed, relevant, adaptable, and credible. 2. Non- verbal communication-is the exchange of information without the use of words. It is communication through gestures, facial expressions, posture, body movement, voice tone, rate of speech, eye contact. It is generally accepted that non-verbal communication expresses more of true meaning of a message than dose verbal communication. Therefore, nurses must be aware of both the non- verbal messages they send and receive from clients. Non -verbal is less conscious than verbal, requires systematic observation and valid interpretation 3. Meta-communication: