New flexible healthcare roles and the purpose of nursing

The meaning of autonomy in nursing practice

AIM

To illuminate the meaning of nurses' experiences of autonomy in work situations.

BACKGROUND

Professional autonomy means having the authority to make decisions and the freedom to act in accordance with one's professional knowledge base. An understanding of autonomy is needed to clarify and develop the nursing profession in rapidly changing health care environments and internationally there is a concern about how the core elements of nursing are taken care of when focusing on expansion and extension of specialist nursing roles.

DESIGN

Qualitative study.

METHODS

This paper reports part of a project aimed at exploring the education and work qualifications required by the nursing profession. Eleven Norwegian nurses, each with 2-3 years of work experience since graduation, participated in both in-depth interviews and focus group interviews in 2006. A qualitative hermeneutic approach, inspired by Gadamer's philosophy, guided the research process and the analysis and interpretation of the transcribed interview-texts.

RESULTS

The nurses' descriptions of their experiences of autonomy in work situations emerged as four themes: 'to have a holistic view', 'to know the patient', 'to know that you know' and 'to dare'. To be knowledgeable and confident was found to be the coherent meaning of autonomy in nursing practice.

CONCLUSIONS

Authority of total patient care, the power to make decisions in a relationship with the patient and next of kin and the freedom to make clinical judgements, choices and actions seem to be connected to the meaning of autonomy in nursing practice.

RELEVANCE TO CLINICAL PRACTICE

To gain autonomous practice, nurses must be competent and have the courage to take charge in situations where they are responsible. This study shows the challenges in handling this autonomous practice.

From expert to tasks, expert nursing practice redefined?

AIM

The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas.

BACKGROUND

Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the 'expert nurse' to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care.

METHOD

The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role.

CONCLUSION

Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating.

RELEVANCE TO CLINICAL PRACTICE

The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.

New roles in rehabilitation--the implications for nurses and other professionals

RATIONALE, AIMS AND OBJECTIVES

The development of rehabilitation and intermediate care services, and roles therein, is part of current UK health policy to meet the demands of the ever-growing older population. One new role is the rehabilitation assistant (RA). This is a generic support worker trained at a basic level in nursing, physiotherapy, occupational therapy and social work who works under the supervision of the referring professionals, to deliver integrated rehabilitation programmes. RAs were introduced in one region in the north-west of England to increase the rehabilitation activity for patients. An empirical qualitative study was recently undertaken to evaluate the impact of the RAs from the perspectives of patients and associated nurses, therapists, managers and the RAs.

METHODS

Fifty-five semi-structured interviews were used to collect data, which was then inductively analysed into categories and then themes. The categories included variations in role, benefits of role, acceptance and integration of role, difficulties with role, training and retention. This paper focuses on the benefits and difficulties of the role.

RESULTS

It was found that patients, professionals and the RAs expressed great satisfaction with the new role. However, barriers to effective rehabilitation were reported owing to ward routines and organizational systems that interrupted and caused inconsistencies with the rehabilitation care programmes for patients.

CONCLUSIONS

If it is agreed that the majority of patients (unless end stage terminally ill, unwilling or unable) could benefit from some degree of rehabilitation, then there is an issue around how such skills could be widely implemented. This paper discusses the barriers to effective rehabilitation, the benefits and drawbacks of looking at new ways of working and the need for a unified approach by all care workers in rehabilitative care.

Defining the expert ICU nurse

This paper explores the concept of expertise in intensive care nursing practice from the perspective of its relationship to the current driving forces in healthcare. It discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. It argues that nursing expertise which focuses on the provision of individualised, holistic care and which is based largely on intuitive decision-making cannot and should not be reduced to being articulated in positivist terms. The principles of abduction or fuzzy logic, derived from computer science, may be useful in assisting nurses to explain in terms, which others can comprehend, the value of nursing expertise.

Micro-pigmentation: implications for patients and professionals

In the UK, reconstructive breast surgery is routinely offered to patients undergoing surgery for breast cancer. The results can be excellent, but without a nipple-areola complex the patient can feel incomplete. In response to patient need, an innovative nurse-led micro-pigmentation service has been developed in the authors' NHS trust, which provides women (and men) an opportunity to complete their reconstruction process. With the use of coloured pigments, micro-pigmentation creates a permanent image of a nipple-areola complex, which improves the aesthetic appearance of the surgically-created breast. As with the development of any new nurse-led innovation, the micro-pigmentation service has professional and client implications. Breast cancer can be devastating and may induce many psychological concerns, not least about body image and sexuality. This article addresses these issues, along with professional matters, such as autonomous practice, role expansion and the blurring of clinical boundaries. These factors are considered in relation to the nursing management of the micro-pigmentation service, where patient autonomy is encouraged to promote acceptance of self-image and closure on the breast cancer experience.

The issues for nurses involved in implementing evidence in practice

Evidence-based practice (EBP) is currently high on political and professional agendas. However, there is a suggestion that despite apparent enthusiasm for EBP, it is not becoming a reality. A variety of reasons for evidence not being implemented in practice exist, including the way in which evidence is communicated, how staff are involved in changes in practice, the availability of resources, patient expectations and the priority afforded to EBP by individuals and organizations. These issues must be addressed if EBP is to succeed.