Profesional Nursing in A Changing Environmnet Final

PROFESSIONAL NURSING IN A
CHANGING HEALTH
ENVIRONMENT
1
INTRODUCTION
• Trends in the delivery of health care are providing

opportunities for nurses to create new roles and
expand their current roles and duties.
– C/S
– CPAR
– FP surgical (TL & VS
• This has led to changes in nursing’s environment
2
The changes:
1. Increasing emphasis on Primary Health Care.
2. A shift from institutional care (health centre) to

community care (home-based).
e.g. home deliveries.
mobile nursing teams that take care to homes
3. New developments in technology.

computerized health environment
4. Demand and supply for various health care providers of

particular skills.
anesthesia nurses
3
advanced Nurse Practitioners
The changes: contd…
5. Influence of economics requiring a cut down on costs.
removal of evening duty (ended as a win- win situation)
6. Diverse and sicker population
7. New illnesses & increasing violence.

Ebola, HIV, swine flu, etc
8. Some existing diseases becoming unmanageable

increasing incidence e.g. cancer,
drug resistance e.g. malaria and chloroquine
8. Nursing and the health care system are increasingly being influenced by
various political and economic factors
4
Can nursing remain static in a changing
environment?
• The roles and practices of nursing in a changing

environment can never remain static.
• Nurses have had to introduce more levels of

education, the advent of BSN, MSN & PhD
programs.
– They thus have increased their ability to offer
more skilled & specialized care and services.
5
Contn…
– From this have developed new roles e.g.

Advanced Nurse Practitioner/Clinical Nurse
specialist capable of performing at the level of
the general practitioner.
• Critical care nurses.
• Nurse anesthetists.
• Community health nurse.
• Nurse researchers
• Etc. 6
Contn…
• Nursing research to:

– Expand the body of knowledge
– Maintain accountability to the public
– Enhance evidenced practice and learning.
7
Introduction…
• This has taken place at different levels e.g. as

educational requirements, government and
NGO research initiatives e.g. AMRN.
• Theories of nursing, literature and empirical

evidence that guide practice and education
are the outcomes.
8
Professional Nursing In A Changing
Health Environment…
• Nursing Administration and Leadership:

– The nurse has taken up various important and
significant positions to influence health policies
and the decision-making process.
– Watch out for the devil

• Many nurses upon acquiring these positions are taken
up by the money and workshop syndrome.
• Some use influence to get to these positions without
having the capacity to deliver.
9
• Technological advances:
– Need for updating knowledge and skill
– Need for specialization to be able to work in the
computerized health environment.
– Increased accessibility to information.
• HINARI
– Enhanced possibilities for education and clear
career path
• RM BSM MSM PhD M
• RN BSN MSN PhD N 10
• Nursing politics:
– Increasing need to influence policy making for a change
in the profession
– Nurses must be well informed about current issues of

nursing locally and globally so as to influence them in
their favor.
“A powerful voice for nurses is a powerful voice for the health

care consumers, the profession and the nation.”
11
• Nursing, Litigation and ethics:

– The numbers of legal suits are increasing daily, for even
the most ‘minor’ errors.
– Nurses testifying in legal suits. The
• mityana story
• The mbale story
• The mulago story
• etc
12
Nursing, Litigation and ethics:
contd..
• The ethical considerations & dilemmas increase with
the increasing levels of literacy & awareness of
rights.
• Breaking / concealing info
– Patient is HIV +ve, has not informed partner, and is continuing to
marry and be promiscuous.
» The hoima DJ story
– You your patient wont make it. Family members ask, will the
patient recover?
• Assisting in death (euthanasia)
13
• ethical considerations & dilemmas case.
• A 34year old with possible terminal cancer and 3 children under 4 was undergoing tests to locate the primary.
At this point there was a lot of suspison that the CA was terminal, but without finding the primary tumour the
doctors didn't want to make a solid statement.
The patient had presented to the A&E several months piror with serious back pain, and after Xray was found to
have several tumours on a number of vertabrae. The pt's medical history was four elective termination of
pregnancies, one when she was 18 and another at age 20, 21 and 24. Post the second termination she suffered
complications relating to retained foetal parts, and post the fourth termination had suffered a serious of
ovarian cysts.
Her children were born after the fourth termination.
Anyway, long story short, the doctors eventually found the primary - it was located on utuerine scaring, the
doctors were all in agreement the primary cancerous growth was caused by the terminations. (It was a lot
more complicated and lengthy explanation).
Here's the ethical problem - the pt had suffered post abortion depression and had made 3 suicide attempts
within months of the first three terminations. The pt explained that she'd continued to have TOP because she
had wanted to get pregnant again after each TOP because she felt "empty" and was hoping the soul of the
babies she'd "murdered" would return to her, but each time she got pregnant the circumstances which
"required" the TOP still existed.
Anyway, she had made comment to myself, and several other nurses and doctors that she beleived her cancer
was a punishment from her dead babies for killing them.
So, the doctors told her they had found the primary on her verabrae and it was no where near her uterus to
ensure she didn't get "depressed" or blame her TOPs for her "death sentance". However, the pt asked on
occasion to check the uterus for cancer, as she thought it might have been there, because of all her TOPs.
She wasn't an adherant to any major religion, but was very "spiritiual" and followed a bunch of varying beleifs
she had taken from a lot of Asian and Pagan religions.
Sadly, the woman died several months after 14
• There is need for nurses to protect themselves yet be

able to provide care.
– Without looking dehumanizing
• The nurse must understand the laws that regulate and
affect practice.
• Risk taking is limited for fear of litigation, thereby
compromising the art of nursing.
15
• The nurse as the clients’ advocate is an

important role in this era of medical
malpractice and profit-making.
• There are many things at stake!!!!!!!!!
16
• A diverse population requiring more knowledge

about cultural & social influences on health for
holistic care.
• Cultural and spiritual diversity requires that the

nurse exhibits sensitivity and knowledge in relation
to personal beliefs.
17
• The importance of appropriate communication

skills including computer knowledge
– i.e. emailing has become even more important.
18
• Nursing informatics i.e. the relationship between

information science and nursing science.
– Is important as the nurse must be able to
utilize the internet.
– Literature reviews.
– Reading journals and magazines online.
• Remember on
19
• A sicker population with new diseases
related to social & environmental
problems.
– Thus a greater need for integrated
knowledge from biological,
psychosocial sciences for health
promotion, illness and injury
prevention and care provision.
20
– The levels of violence and abuse have

increased, increasing the demand for health
care and services.
– The role of nursing in dealing with man-

made and natural disasters i.e. wars, floods,
earthquakes etc is never understated.
21
stereotypes
• The historical stereotypes are being shade.

– The handmaiden; women’s profession
• Due to the influx of men into the profession;
• A decline in the use of identifying symbols i.e. caps and

symbolic white uniforms.
• Increase in the number of married nurses (ANA,2000).

– 72% married & >half have children.
– Are many nurses single parents?!!!!!!!! Why
22
stereotypes …
• The modern
nursing
uniforms
23
stereotypes …
• The
archaic
Sex Symbol
is fading
24
stereotypes …
• This has all resulted in an image change

toward the positive thus increasing the
status of the profession.
25
Specialization …
• Has necessitated the modification of the traditional
roles.
• Nurses have to cooperate, thus they are colleagues
and collaborators in a health care team i.e.
teamwork.
• Nurses’ responsibility and accountability for actions
taken and not taken has increased.
– But this is the biggest problem at home….
We haven't seen much of accountability for actions not taken
26
Economics:
– The competitive economic world necessitates

cost-cutting for profits & cost-effective business.
Health care has not been an exception.
• There has been a worsening of the nurse-patient
ratio
• laying off nurses and employing UAP’s.
• Less time for nursing thus less quality.
27
media
• The impact of the media in shaping the profession

is also growing due to the publicity of health care.
– The nurse still remains subjective, the doctor

dominant.
28
CHANGING HEALTH ENVIRONMENT:
The Ugandan perspective.
29
Introduction
• Uganda, though lagging behind, has seen

the development that has been described
above
• The major leaps in development of nursing
as a profession have been due to the fact
that drastic measures have been taken to
achieve the changes.
30
Nursing Education.
– Competitiveness has ensured that the profession

catches up with others. Thus the BSN, MSN &
PhD programs are being established.
– The lower certificate and diploma levels may be

an issue of the past soon.
• Some set backs still present.
31
Administration:
– The commissioner at the MOH level.

– Assistant commissioners at the national referral hospitals.
– At district levels, for positions of authority a BSN is required.
– In some NGOs a BNS is a must for positions of administration
– Assistant DDHS
– Nursing schools are still adamant in this matter but change will
eventually come, whether they like it or not.
32
Administration: …
• However, in spite of these

developments, the nurses are still poorly
represented at the levels necessary to
influence policy and the decision-making
process.
33
Research
• There is need to build the body of nursing

knowledge which is not being done
significantly.
34
Nursing Practice:
– The focus is on preventive care i.e. PHC.

– Curative care as well.
• Nursing seems to exist in a “physicians world.”

» or
• Nursing systems to exist in a health care world?!!
– hhhhhhmmmmm paradoxical!!##***
35
CHANGING HEALTH
ENVIRONMENT
Issues
And
Way Forward
36
• Nursing is the largest work force in the health

care setting.
• The health care system has changed, and nurses
feel they are unable to fulfill their historic
mission of caring for the sick.
• So what do we do??
37
• However, health care cost cutting and competition

are having an ever-more damaging impact not just
on doctors but on the nursing fraternity.
• Hospital restructurings and downsizings have

slashed bedside nursing staff--the backbone of the
hospital--and have replaced RNs with poorly
trained and poorly paid nursing assistants/UAP’s.
38
Professional Nursing In A Chan…
• Nurses who remain at the bedside must now care for

greater numbers of sicker patients, assembly-lined
through the hospital in shorter periods of time.
39
• The consequences of cuts in nursing care are extremely

serious:
– Patients who could recover, don't.
– Preventable complications escalate.
– Some patients die.
– As nurses are stretched too thin in the hospital & as
patients are denied expert nursing care at home, the
burden of care is shifted to unpaid, ill-prepared family
caregivers.
40
• Cost cutting is moving more and more money away

from the bedside.
• Since RNs represent 23 percent of the hospital work

force and are the biggest share of labor costs (and
are only 10 percent unionized), downsizing RN staff
has become an irresistible cost-reduction strategy.
41
• Economy consultants say

“Change the production process, make operations
more efficient,
replace expensive employees with cheaper ones, and
help those who remain to be
more productive--you'll save money without
sacrificing quality.”
• The nurse heads this list, no way to protest.
42
• No regulation for the education of nurse

assistants.
• Someone with no high school diploma and a
few hours of on-the-job training may change
sterile dressings, insert urinary catheters, or
clean tracheostomy tubes.
43
• These nursing assistants are actually practicing

under the supervising RN's license;
– This means that the nurse can be held
responsible for any mistakes made by aides
working under his or her direction--and can lose
his or her license as a result of those mistakes.
44
Professional Nursing In A
Changing Health Environment…
• Hospitals now have a cadre of RNs who are taking

care of the charts, not the patients.
• The nurse-patient ratio thus spirals upwards.
• The quality of nursing care is compromised:
– Medication cannot be given on time
– Adequate time is not given to the patients
45
How do we summarize what we
have seen so far?
• Sicker patients, being attended to by busier nurses.

• Skilled nurses being systematically replaced by
poorly trained & poorly paid aides.
• The nurses are chronically silent by a weaker voice,
internal strife.
• Recruitment of nurses is even more difficult. So is
keeping those who are already there.
46
• These trends are worrying but true
47
Professional Nursing In A Changing Health
Environment…
• The media perpetually presents an erroneous

picture to the public; that the nurses do
nothing to change.
• The global media's relentless linking of sexual
images to the profession of nursing reinforces
long-standing stereotypes.
• Even though those images are often "jokes" or
"fantasies," the stereotypes they promote
discourage practicing and potential nurses,
foster sexual abuse in the workplace, and
contribute to a general atmosphere of
disrespect for nursing.
48
hmm
• The global media's relentless linking of sexual

images to the profession of nursing reinforces
long-standing stereotypes. Even though those
images are often "jokes" or "fantasies," the
stereotypes they promote discourage practicing
and potential nurses, foster sexual abuse in the
workplace, and contribute to a general
atmosphere of disrespect.
49
• The media says the doctors remain honorable,

hardworking etc etc…
• And the nurse?!!!##**
• The nurses are doing themselves no favours:

• Nothing to prove that we do an honorable Job.
• Doing nothing about it is tantamount to allowing the
worst to happen.
– And that’s what we get
50
References
• Blais, K.K. Hayes, J.S. Kozier, B. & Erb, G. (2002) Professional nursing
practice. 4th Ed, Practice Hall New Jersey.
• Gordon S. Nursing Interrupted
available at www.prospect.org/org/web [accessed 10th July 2006].
• Gordon, S. (2005) Nursing Against the Odds: How Health Care Cost-
Cutting, Media Stereotypes, and Medical Hubris Undermine Nursing
and Patient Care available at
www.nursingadvocacy.org/media/book/nursing_against the odds.
51

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PROFESSIONAL NURSING IN A

• Trends in the delivery of health care are providing

2. A shift from institutional care (health centre) to

3. New developments in technology.

4. Demand and supply for various health care providers of

7. New illnesses & increasing violence.

8. Some existing diseases becoming unmanageable

• The roles and practices of nursing in a changing

• Nurses have had to introduce more levels of

– From this have developed new roles e.g.

• Nursing research to:

• This has taken place at different levels e.g. as

• Theories of nursing, literature and empirical

• Nursing Administration and Leadership:

– Watch out for the devil

– Nurses must be well informed about current issues of

“A powerful voice for nurses is a powerful voice for the health

• Nursing, Litigation and ethics:

• There is need for nurses to protect themselves yet be

• The nurse as the clients’ advocate is an

• There are many things at stake!!!!!!!!!

• A diverse population requiring more knowledge

• Cultural and spiritual diversity requires that the

• The importance of appropriate communication

• Nursing informatics i.e. the relationship between

– The levels of violence and abuse have

– The role of nursing in dealing with man-

• The historical stereotypes are being shade.

• A decline in the use of identifying symbols i.e. caps and

• Increase in the number of married nurses (ANA,2000).

• This has all resulted in an image change

– The competitive economic world necessitates

• The impact of the media in shaping the profession

– The nurse still remains subjective, the doctor

CHANGING HEALTH ENVIRONMENT:

The Ugandan perspective.

• Uganda, though lagging behind, has seen

– Competitiveness has ensured that the profession

– The lower certificate and diploma levels may be

– The commissioner at the MOH level.

• However, in spite of these

• There is need to build the body of nursing

– The focus is on preventive care i.e. PHC.

• Nursing seems to exist in a “physicians world.”

• Nursing is the largest work force in the health

• However, health care cost cutting and competition

• Hospital restructurings and downsizings have

• Nurses who remain at the bedside must now care for

• The consequences of cuts in nursing care are extremely

• Cost cutting is moving more and more money away

• Since RNs represent 23 percent of the hospital work

• Economy consultants say

• No regulation for the education of nurse

• These nursing assistants are actually practicing

• Hospitals now have a cadre of RNs who are taking

• Sicker patients, being attended to by busier nurses.

• These trends are worrying but true

• The media perpetually presents an erroneous

• The global media's relentless linking of sexual

• The media says the doctors remain honorable,

• The nurses are doing themselves no favours:

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