Delivering Health Care in America: A Systems Approach (3rd Edition)

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Who that person is and how she or he best exemplify in their own person and role the character and content of the profession is the only realistic window the observer has into the character and value of the profession. All of the descriptors, principles, standards, codes, and behavioral protocols will serve as naught if the individual nurse does not represent them in her or his consciousness, attitude, behavior, and action. To do so or to fail to do so reflects a lasting image, difficult, if not impossible, to extinguish, seared into the consciousness of other colleagues, disciplines, and patients with regard to what Nursing is or is not Johns, The profession simply cannot take the risk that emerges when individual nurses are not fully prepared to understand and exemplify in their own practice the character, obligations, and appropriate expressions of the nursing professional.

The profession has a right to expect that those identifying themselves as members of the profession understand what that means, embody that ownership in their own patterns of behavior and represent a strongly identified internal locus of control with regard to their representation of the profession to themselves and others Arnold, Job oriented language has the potential for removing the professional overlay to the work of the nurse and reducing it to a set of functions, processes, and procedures.

Here the language shift implies a significantly different approach to identifying professional nurse expectations. Nursing professionals will not be perceived equitably with other disciplines unless two conditions are met. First, the academic delineations for professional practice must operate at a level of comparability with those same definitions accepted almost universally by other professional disciplines. Here clinical and management leadership plays a critical role in providing both the expectation and patterns of behavior that exemplify equity-based activities and expressions.

In short, if one seeks to be treated equitably one must live within the context of the expectation of equity. This is a learned process and the skills attendant to the expression of equitable behavior have been well enumerated. Nurses cannot adequately advocate for patients and healthcare if it is perceived that they have no right to do so.

In contemporary thinking, patients have primary obligation for decisions and actions which affect what happens to them Osborne, It is no longer optional for nurses not to see themselves as a key coordinator of this effort, and the driving force for assuring the broadest range of access and partnership in a way that advances patient service.

Increasingly, the human dynamic partnership and interaction is accelerated by newer realities of patient data management and integration Maysys, The expanding efficacy of digital and virtual technologies now makes it a requisite for nurses to understand and utilize new tools for practice in ways that fundamentally alter the mechanisms with which nurses and others communicate, interact, and apply practice skills Ball, The following issues of individual nursing capacity and competence are now the requisites for every individual professional nurse in the exercise of her or his role:.

Professional nurses at all levels of practice must now see themselves as equal partners with other disciplines in creating a new template and landscape for the future of health care in the United States. However, nurses must accept the elemental political reality that others do not make space at the broader table within the context of an invitational scenario.

Because of their predominance and centrality of role, nurses, often unknowingly, exert a powerful influence over what initiatives in their health systems will succeed or fail. Clinical and management leaders must come to more fully understand this dynamic, validate and enumerate its significance with greater clarity, and positively harness it in partnership with others in the organization in ways which best advance the interests of patient care and the integrity and viability of the organization AONE, ; M.

Nursing work is not easy. The particular and unique demands of nursing practice require individuals who are knowledgeable, competent, and committed. The one constant in the history of the nursing profession has been the consistent presence of these challenging and often conflicting forces. They have not diminished and will remain constituents of nursing practice for the foreseeable future.

Individuals not prepared to confront and embrace these realities need not seek entry here. Those who do become members of the nursing profession will find that their being available to these prevailing conditions and circumstances will yield to them levels of challenge, satisfaction, accomplishment, meaning, and value not as readily available to other pursuits Katz, The Patient and Community.

There is perhaps no greater arena of change and transformation for the nursing profession than that related to direct patient care. The shift in therapeutics and technology has created a contextual framework for practice that is so unique and different that it represents a radical alteration from the historic and traditional practices associated with nursing. This shift has done more than simply change the conditions of healthcare work and the processes and activities associated with it.

What has occurred as a result of these changes is a complete paradigm shift for both provider and patient. In fact, the shift has been so transformative that practices, roles, and behaviors have been dramatically altered. Systematically affecting the nature of this interaction is the clinical and therapeutic shift from residency-based, long term, institutional, and patient-passive care Maysys, ; McKenna, ; Stock, Today the majority of therapeutic services are short-term, minimally invasive, early recovery, and mobility-facilitating experiences.

Increasingly, the issue for the user is not so much the interruptive conditions and circumstances of the institution and health service setting, but more, what resources patients have to facilitate the healing experience in their own circumstances Schermer, Nurses simply do not have the same time content and conditions in the digital, virtual, portable, and mobility-based clinical environment. Currently and for the foreseeable future, users will spend a shorter period of time in the intervention process where the majority of nurses have historically been located.

The principles of caring which underpin the very character of the profession clearly need to be reaffirmed and reconfigured in a way that represents inclusion of newer knowledge and technology in the expression of that care Cassey, Reconnecting with the fundamental obligation of the nurse to ensure the safety of the user will need to be reaffirmed in a much more fluid context.

In addition, continuity of care can no longer be attained or maintained simply through the action of the nurse and the communication across disciplines. Continuity is now embedded in the human-technology infrastructure and the interface between practitioner, user, and technology and is essential to build and sustain an effective continuum of care Gandhi, Smith, It is the end of the medical model as it has been historically configured. The multifocal nature of healthcare delivery and the complex intersection of roles, relationships, and practices have now overwhelmed the notion of a unilateral locus of control and compartmental decision-making Thomson, It is no secret that the physician is not prepared by role or by disposition to the presence, time, and intensity of activities necessary to the investment required to coordinate, integrate, and facilitate the continuum of interdisciplinary activities necessary to effective patient care Moanojovich, The role of the physician is primarily as interventionist, as clearly delineated both by preparation and performance.

Certainly, new definitions and scripts for the role of the physician must also unfold in this new age for healthcare. More delineations of the role need yet to be defined in relationship to equilateral clinical partnerships, inclusionary decision-making, and the leadership role of other clinicians in guiding the therapeutic team and clinical activities at different points across the continuum of service A.

All of this will directly impact the role of nursing professionals.

This will require from the nurse a degree of facility in articulating multiple roles, bridging the activities of other professionals, managing the integration of communication and documentation technology, and ultimately, evaluating impact and effectiveness. Failure to adequately address this critical emphasis on the evolving role of the nurse will ultimately diminish the value of that role and increase the requisite of the assumption of that role by another or new player in the healthcare system.

Indeed, this role is becoming so important to the effectiveness of the system that many of the contemporary failures in the clinical continuum of services can be related to the paucity of coordination, integration, and facilitation of the process Mittelstaedt, Emphasis on the evolution and transformation of nursing practice and practitioner will need to include focus on the following priorities:. Clinical leadership development which leads to leadership roles exemplifying the capacity to incorporate the above circumstances and skills into nursing practice roles and to reflect their exercise in the normative course of rendering care.

Clinical leaders, advanced practice nurses and others which represent the evolution to advanced or expert practice must not only be able to articulate these shifting role characteristics but to exemplify them within the character and content of their own practice. Leadership in this age increasingly will mean modeling, demonstration, and actualizing the principles, character, and content of these shifting professional practice roles. Evidence-driven practice approaches represent an entirely different foundation for provider practices and healthcare delivery.

Evidence is not the domain of any single discipline and cannot be successfully undertaken within their unilateral contextual framework. Evidence-based practice is fundamentally interdisciplinary, requiring the interface of all relevant clinical providers and activities. It is the congruence and consonance as well as the fusion among the activities of these various stakeholders that, when synthesized, presents evidence of excellence and best practices. Professional nursing practice operates on a continuum of knowledge and practice. Delineating differentiation in practice and clinical expectations continues to be an important mechanism for distinguishing performance, clarifying expectations, and measuring clinical outcomes.

Clinical advancement programs which differentiate and articulate various categories of practice expectation moving from novice and advancing along stages of enumerated expertise remains the best mechanism for ensuring accountability and establishing the relationship between competence and performance. While competence, action, and performance expectations are being transformed in this new age for practice, the requisites for delineating outcomes aligned with competence and the maturity of knowledge remains essential to good practice.

Within the context of an advancing socio-technical reality, users are now able to more fully participate in accessing, interpreting, using, and evaluating clinical options in relationship to their health and life choices. This primary source of access changes the equation of knowledge management and the locus of control between provider and user. No longer is the user held hostage to the knowledge capacity of the provider without access to resources not controlled by providers.

In addition, provider performance measures, grades, evaluations and interpretations are becoming increasingly refined and useful tools for users to make decisions with regard to provider choices. In the United States, changing data and demographic realities related to citizens health strongly indicate that for all our interventional science, technology, talent, and applications, the health of the nation is not comparable with other first world nations in almost all the measures of the status of societal health save one, the cost of health care.

When compared with other first world nations, American health indicators generally place the nation in the bottom categories of measure. One of the ethical characteristics of professions is that they operate in a way that acts in the best interests of a larger community. If the health of America is to be advanced and the quality of life improved, the commitment of every nursing professional must be broader than the personal quality of good patient care and clinical excellence. The outcome of the work of the profession should ultimately be an improvement in the health of the larger community.

Nursing certainly plays a major role in addressing national, regional, and local health needs. Just as clearly in the language and armamentarium of every individual nurse is a requirement that she or he be able to identify work and role with the advancement of health and the improvement of the quality of life in the greater community. Individual and local practices must be clearly linked with the broader script for healthcare and a direct relationship established between the practices of the individual and the health status of the community.

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It is only when this connection is well established will the true value of nursing advocacy be evidenced, not as an exception to the normative work of daily practice, but as evidence of the impact of the work of each practicing nurse on the health status and quality of life of the community and, ultimately, of the nation. Nurses continually articulate the commitment of the profession and its practitioners to the needs and interests of the patients in the communities nurses serve. If this is not to remain simply a vacuous statement, empty of evidence, it must be translated into a living presence and verified by a clearly articulated and discernible impact on person and community McNamara, By all measures of comparison on the global stage, with nations comparable to the American standard of living, we simply do not meet the outcomes of the promises we make.

From measures of access, quality, safety, clinical outcome, satisfaction, and cost-benefit, the United States simply does not favorably compare with our international partners Commonwealth Fund, If nursing is to fulfill its professional mandate to act in the best interests of the society it serves, the formation of this new script and the performance against its requisites is not an option Parker, It is a new age for health care and for the nursing profession.

It is early in its formation. The opportunity to write the new script and the transformative impact of living it presents an exceptional potential and opportunity for improving health and advancing the quality of human life. Will we do this work? Urgency is critical; time is of the essence.

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